Gloria D Coronado

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• Franklin, I. R., Gambatese, R., Duggan, M. C., Green, B. B., Nocon, R. S., Coronado, G. D., Hahn, E. E., Honda, S. A., Koplan, K., Levin, T. R., Steiner, C. A., & Ngo-Metzger, Q. (2025). Colorectal Cancer Screening and Social Needs. Journal of the American Board of Family Medicine : JABFM.
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  Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. While patient-reported barriers have been previously described, few studies have analyzed how patients' social needs affect screening rates.
• Nascimento de Lima, P., Matrajt, L., Coronado, G., Escaron, A. L., & Rutter, C. M. (2025). Cost-Effectiveness of Noninvasive Colorectal Cancer Screening in Community Clinics. JAMA network open, 8(1), e2454938.
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  Several noninvasive tests for colorectal cancer screening are available, but their effectiveness in settings with low adherence to screening and follow-up colonoscopy is not well documented.
• Tong, G., Coronado, G. D., Li, C., & Li, F. (2025). Randomized in error in pragmatic clinical trials. Contemporary clinical trials, 148, 107764.
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  Pragmatic trials that combine electronic health record data and patient-reported data may be subject to selection bias due to the differential post-randomization exclusion of participants who are randomized in error. Such situations are often caused by inevitable reasons, such as incomplete patient medical records at the pre-randomization stage. This can lead to participants in the intervention arm being identified as ineligible after randomization, while randomized-in-error participants in the usual care are often not discernable. The differential exclusion can present analytic challenges and threaten result validity.
• Tong, G., Coronado, G., Li, C., & Li, F. (2025). Randomized in error in pragmatic clinical trials. Contemporary Clinical Trials, 148. doi:10.1016/j.cct.2024.107764
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  Background: Pragmatic trials that combine electronic health record data and patient-reported data may be subject to selection bias due to the differential post-randomization exclusion of participants who are randomized in error. Such situations are often caused by inevitable reasons, such as incomplete patient medical records at the pre-randomization stage. This can lead to participants in the intervention arm being identified as ineligible after randomization, while randomized-in-error participants in the usual care are often not discernable. The differential exclusion can present analytic challenges and threaten result validity. Methods: Under the potential outcomes framework, we developed a Bayesian model that jointly identifies the randomized-in-error status and estimates the average treatment effect among participants not randomized in error. We designed simulation studies with hypothesized proportions of 5 %–15 % randomization in error to evaluate the performance of our model across scenarios where the outcomes of participants randomized in error were either measured or unmeasured. Comparisons were made to intention-to-treat and covariate-adjusted estimators. Results: Simulation results show satisfactory performance of our proposed models, where the estimated average treatment effects among participants not randomized in error have low bias (
• Badicke, B., Coury, J., Myers, E., Petrik, A. F., Hiebert Larson, J., Bhadra, S., Coronado, G. D., & Davis, M. M. (2024). Effort Required and Lessons Learned From Recruiting Health Plans and Rural Primary Care Practices for a Cancer Screening Outreach Study. Journal of primary care & community health, 15, 21501319241259915.
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  Recruiting organizations (i.e., health plans, health systems, or clinical practices) is important for implementation science, yet limited research explores effective strategies for engaging organizations in pragmatic studies. We explore the effort required to meet recruitment targets for a pragmatic implementation trial, characteristics of engaged and non-engaged clinical practices, and reasons health plans and rural clinical practices chose to participate.
• Badicke, B., Coury, J., Myers, E., Petrik, A., Hiebert Larson, J., Bhadra, S., Coronado, G., & Davis, M. (2024). Effort Required and Lessons Learned From Recruiting Health Plans and Rural Primary Care Practices for a Cancer Screening Outreach Study. Journal of Primary Care and Community Health, 15. doi:10.1177/21501319241259915
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  Introduction: Recruiting organizations (i.e., health plans, health systems, or clinical practices) is important for implementation science, yet limited research explores effective strategies for engaging organizations in pragmatic studies. We explore the effort required to meet recruitment targets for a pragmatic implementation trial, characteristics of engaged and non-engaged clinical practices, and reasons health plans and rural clinical practices chose to participate. Methods: We explored recruitment activities and factors associated with organizational enrollment in SMARTER CRC, a randomized pragmatic trial to increase rates of CRC screening in rural populations. We sought to recruit 30 rural primary care practices within participating Medicaid health plans. We tracked recruitment outreach contacts, meeting content, and outcomes using tracking logs. Informed by the Consolidated Framework for Implementation Research, we analyzed interviews, surveys, and publicly available clinical practice data to identify facilitators of participation. Results: Overall recruitment activities spanned January 2020 to April 2021. Five of the 9 health plans approached agreed to participate (55%). Three of the health plans chose to operate centrally as 1 site based on network structure, resulting in 3 recruited health plan sites. Of the 101 identified practices, 76 met study eligibility criteria; 51% (n = 39) enrolled. Between recruitment and randomization, 1 practice was excluded, 5 withdrew, and 7 practices were collapsed into 3 sites for randomization purposes based on clinical practice structure, leaving 29 randomized sites. Successful recruitment required iterative outreach across time, with a range of 2 to 17 encounters per clinical practice. Facilitators to recruitment included multi-modal outreach, prior relationships, effective messaging, flexibility, and good timing. Conclusion: Recruiting health plans and rural clinical practices was complex and iterative. Leveraging existing relationships and allocating time and resources to engage clinical practices in pragmatic implementation research may facilitate more diverse representation in future trials and generalizability of research findings.
• Coronado, G. D., Anyane-Yeboa, A., Byhoff, E., Escaron, A. L., Sonik, R., Talamantes, E., & Neslund-Dudas, C. (2024). Greater Investments in Safety Net Health Systems Can Help Diversify Participation in Clinical Trials and Research. Journal of general internal medicine, 39(2), 312-315.
• Coronado, G. D., Bienen, L., Burnett-Hartman, A., Lee, J. K., & Rutter, C. M. (2024). Maximizing scarce colonoscopy resources: the crucial role of Stool-Based tests. JNCI: Journal of the National Cancer Institute. doi:10.1093/jnci/djae022
• Coronado, G. D., Bienen, L., Burnett-Hartman, A., Lee, J. K., & Rutter, C. M. (2024). Maximizing scarce colonoscopy resources: the crucial role of stool-based tests. Journal of the National Cancer Institute, 116(5), 647-652.
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  During the COVID-19 pandemic, health systems, including federally qualified health centers, experienced disruptions in colorectal cancer (CRC) screening. National organizations called for greater use of at-home stool-based testing followed by colonoscopy for those with abnormal test results to limit (in-person) colonoscopy exams to people with acute symptoms or who were high risk. This stool-test-first strategy may also be useful for adults with low-risk adenomas who are due for surveillance colonoscopy. We argue that colonoscopy is overused as a first-line screening method in low- and average-risk adults and as a surveillance tool among adults with small adenomas. Yet, simultaneously, many people do not receive much-needed colonoscopies. Delivering the right screening tests at intervals that reduce the risk of CRC, while minimizing patient inconvenience and procedural risks, can strengthen health-care systems. Risk stratification could improve efficiency of CRC screening, but because models that adequately predict risk are years away from clinical use, we need to optimize use of currently available technology-that is, low-cost fecal testing followed by colonoscopy for those with abnormal test results. The COVID-19 pandemic highlighted the urgent need to adapt to resource constraints around colonoscopies and showed that increased use of stool-based testing was possible. Learning how to adapt to such constraints without sacrificing patients' health, particularly for patients who receive care at federally qualified health centers, should be a priority for CRC prevention research.
• Coronado, G. D., Jenkins, C. L., Shuster, E., Johnson, C., Amy, D., Cook, J., Sahnow, S., Zepp, J. M., & Mummadi, R. (2024). Blood-based colorectal cancer screening in an integrated health system: a randomised trial of patient adherence. Gut, 73(4), 622-628.
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  We evaluated whether people who had not completed a faecal immunochemical test (FIT) for colorectal cancer (CRC) screening would complete a blood-based testing option if offered one during health encounters. Blood-based screening tests for CRC could add to the total number of people screened for CRC by providing another testing alternative.
• Coronado, G. D., Nyongesa, D. B., Petrik, A. F., Thompson, J. H., Escaron, A. L., Pham, T., & Leo, M. C. (2024). The Reach of Calls and Text Messages for Mailed FIT Outreach in the PROMPT Stepped-Wedge Colorectal Cancer Screening Trial. Cancer Epidemiology, Biomarkers & Prevention, 33(4), 525-533. doi:10.1158/1055-9965.epi-23-0940
• Coronado, G. D., Nyongesa, D. B., Petrik, A. F., Thompson, J. H., Escaron, A. L., Pham, T., & Leo, M. C. (2024). The Reach of Calls and Text Messages for Mailed FIT Outreach in the PROMPT Stepped-Wedge Colorectal Cancer Screening Trial. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 33(4), 525-533.
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  Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening participation. We assessed the reach and effectiveness of adding notifications to mailed FIT programs.
• Coronado, G. D., Rivelli, J. S., Serrato, V., Thompson, J., Shafer, A., Tracy-Carter, D., Warner, K., & Shannon, J. (2024). Improving representation of Hispanic adults in a population-based cancer genetics cohort: Qualitative findings from the Healthy Oregon Project. Journal of clinical and translational science, 8(1), e99.
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  Members of many racial and ethnic population subgroups are underrepresented in clinical trials and research. We present perspectives on barriers and facilitators to study participation gathered from Hispanic participants in a population-based genetic screening study.
• Coronado, G., Anyane-Yeboa, A., Byhoff, E., Escaron, A., Sonik, R., Talamantes, E., & Neslund-Dudas, C. (2024). Greater Investments in Safety Net Health Systems Can Help Diversify Participation in Clinical Trials and Research. Journal of General Internal Medicine, 39(2). doi:10.1007/s11606-023-08489-6
• Coronado, G., Jenkins, C., Shuster, E., Johnson, C., Amy, D., Cook, J., Sahnow, S., Zepp, J., & Mummadi, R. (2024). Blood-based colorectal cancer screening in an integrated health system: a randomised trial of patient adherence. Gut, 73(4). doi:10.1136/gutjnl-2023-330980
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  Objective We evaluated whether people who had not completed a faecal immunochemical test (FIT) for colorectal cancer (CRC) screening would complete a blood-based testing option if offered one during health encounters. Blood-based screening tests for CRC could add to the total number of people screened for CRC by providing another testing alternative. Design Study participants were patients aged 45-75 years at a large, integrated health system who were offered but did not complete an FIT in the prior 3-9 months and were scheduled for a clinical encounter. Individuals were randomised (1:1) to be offered a commercially available CRC blood test (Shield, Guardant Health) versus usual care. We compared 3-month CRC screening proportions in the two groups. Results We randomised 2026 patients; 2004 remained eligible following postrandomisation exclusions (1003 to usual care and 1001 to blood draw offer; mean age: 60, 62% female, 80% non-Hispanic white). Of the 1001 allocated to the blood test group, 924 were recruited following chart-review exclusions; 548 (59.3%) were reached via phone, of which 280 (51.1%) scheduled an appointment with the research team. CRC screening proportions were 17.5 percentage points higher in the blood test group versus usual care (30.5% vs 13.0%; OR 2.94, 95% CI 2.34 to 3.70; p
• Coronado, G., Nyongesa, D., Petrik, A., Thompson, J., Escaron, A., Pham, T., & Leo, M. (2024). The Reach of Calls and Text Messages for Mailed FIT Outreach in the PROMPT Stepped-Wedge Colorectal Cancer Screening Trial. Cancer Epidemiology Biomarkers and Prevention, 33(4). doi:10.1158/1055-9965.epi-23-0940
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  Background: Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening participation. We assessed the reach and effectiveness of adding notifications to mailed FIT programs. Methods: We conducted secondary analyses of a stepped-wedge evaluation of an enhanced mailed FIT program (n = 15 clinics). Patients were stratified by prior FIT completion. Those with prior FIT were sent a text message (Group 1); those without were randomized 1:1 to receive a text message (Group 2) or live phone call (Group 3). All groups were sent automated phone call reminders. In stratified analysis, we measured reach and effectiveness (FIT completion within 6 months) and assessed patient-level associations using generalized estimating equations. Results: Patients (n = 16,934; 83% Latino; 72% completed prior FIT) were reached most often by text messages (78%), followed by live phone calls (71%), then automated phone calls (56%). FIT completion was higher in patients with prior FIT completion versus without [44% (Group 1) vs. 19% (Group 2 + Group 3); P < 0.01]. For patients without prior FIT, effectiveness was higher in those allocated to a live phone call [20% (Group 3) vs. 18% (Group 2) for text message; P = 0.04] and in those who personally answered the live call (28% vs. 9% no call completed; P < 0.01). Conclusions: Text messages reached the most patients, yet effectiveness was highest in those who personally answered the live phone call. Impact: Despite the broad reach and low cost of text messages, personalized approaches may more successfully boost FIT completion.
• Coronado, G., Rivelli, J., Serrato, V., Thompson, J., Shafer, A., Tracy-Carter, D., Warner, K., & Shannon, J. (2024). Improving representation of Hispanic adults in a population-based cancer genetics cohort: Qualitative findings from the Healthy Oregon Project. Journal of Clinical and Translational Science, 8(1). doi:10.1017/cts.2024.544
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  Background: Members of many racial and ethnic population subgroups are underrepresented in clinical trials and research. We present perspectives on barriers and facilitators to study participation gathered from Hispanic participants in a population-based genetic screening study. Methods: Seven focus groups (five in English and two in Spanish) were conducted with self-identified Hispanic participants of the Healthy Oregon Project (HOP), a large population-based cohort of adults residing in Oregon. HOP study participants complete surveys about cancer and chronic disease risks with the option to donate a saliva sample for no-cost genetic risk screening for inherited disorders. HOP invited Hispanic participants via email to join a focus group about their experiences. Focus groups, generally lasting 60-90 minutes, occurred in person and virtually. Notes were coded and content-analyzed. Findings: 49 Hispanic adults participated in the focus groups (37 women; 9 men; 3 non-binary people). Identified facilitators for HOP study participation were trust in the academic medical center leading the study, having a family member who was impacted by cancer, and receiving free genetic screening. Identified barriers were difficulty completing the family history survey, lack of understanding or familiarity with research, immigration status, and navigating technology challenges. Recommendations to improve recruitment of Hispanic populations included promoting the study at community events, clinics, or schools, simplifying the consenting process and providing patient-focused videos to demonstrate study tasks, providing real-time sample tracking, and offering monetary incentives. Discussion: Our findings can inform strategies for bolstering recruitment of Hispanic adults in biomedical research studies.
• Coury, J., Coronado, G. D., Myers, E., Patzel, M., Thompson, J., Whidden-Rivera, C., & Davis, M. M. (2024). Engaging with Rural Communities for Colorectal Cancer Screening Outreach Using Modified Boot Camp Translation. Progress in community health partnerships : research, education, and action, 18(1), 47-59.
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  Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents and Medicaid enrollees.
• Coury, J., Coronado, G., Currier, J. J., Kenzie, E. S., Petrik, A. F., Badicke, B., Myers, E., & Davis, M. M. (2024). Correction: Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas. Implementation science communications, 5(1), 11.
• Coury, J., Coronado, G., Currier, J. J., Kenzie, E. S., Petrik, A. F., Badicke, B., Myers, E., & Davis, M. M. (2024). Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas. Implementation science communications, 5(1), 6.
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  Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings.
• Coury, J., Coronado, G., Currier, J., Kenzie, E., Petrik, A., Badicke, B., Myers, E., & Davis, M. (2024). Correction: Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas (Implementation Science Communications, (2024), 5, 1, (6), 10.1186/s43058-023-00540-1). Implementation Science Communications, 5(1). doi:10.1186/s43058-024-00550-7
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  Following the publication of the original article [1], the authors reported an error in the Competing Interest statement which reads “Dr. Coronado serves as a member of the Board of Scientifc Advisors for the National Cancer Institute (NCI). The rest of the authors declare they have no competing interests.” The correct Competing Interest statement should have read “From 2020- 2022, Dr. Coronado served as a scientific advisor for Exact Sciences, through a contract with the Kaiser Permanente Center for Health Research. From 2021 – 2023, Dr. Coronado served as Principal Investigator on a study funded by Guardant Health, through a contract with Kaiser Permanente Center for Health Research, to assess the adherence to a commercially available blood test for colorectal cancer. The rest of the authors declare they have no competing interests.” The original article [1] has been updated.
• Coury, J., Coronado, G., Currier, J., Kenzie, E., Petrik, A., Badicke, B., Myers, E., & Davis, M. (2024). Methods for scaling up an outreach intervention to increase colorectal cancer screening rates in rural areas. Implementation Science Communications, 5(1). doi:10.1186/s43058-023-00540-1
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  Background: Mailed fecal immunochemical test (FIT) outreach and patient navigation are evidence-based practices shown to improve rates of colorectal cancer (CRC) and follow-up in various settings, yet these programs have not been broadly adopted by health systems and organizations that serve diverse populations. Reasons for low adoption rates are multifactorial, and little research explores approaches for scaling up a complex, multi-level CRC screening outreach intervention to advance equity in rural settings. Methods: SMARTER CRC, a National Cancer Institute Cancer Moonshot project, is a cluster-randomized controlled trial of a mailed FIT and patient navigation program involving 3 Medicaid health plans and 28 rural primary care practices in Oregon and Idaho followed by a national scale-up trial. The SMARTER CRC intervention combines mailed FIT outreach supported by clinics, health plans, and vendors and patient navigation for colonoscopy following an abnormal FIT result. We applied the framework from Perez and colleagues to identify the intervention’s components (including functions and forms) and scale-up dissemination strategies and worked with a national advisory board to support scale-up to additional organizations. The team is recruiting health plans, primary care clinics, and regional and national organizations in the USA that serve a rural population. To teach organizations about the intervention, activities include Extension for Community Healthcare Outcomes (ECHO) tele-mentoring learning collaboratives, a facilitation guide and other materials, a patient navigation workshop, webinars, and individualized technical assistance. Our primary outcome is program adoption (by component), measured 6 months after participation in an ECHO learning collaborative. We also assess engagement and adaptations (implemented and desired) to learn how the multicomponent intervention might be modified to best support broad scale-up. Discussion: Findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. Trial registration: Registered at ClinicalTrials.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP no.: NCI-2021–01032) on May 11, 2021.
• Coury, J., Coronado, G., Myers, E., Patzel, M., Thompson, J., Whidden-Rivera, C., & Davis, M. (2024). Engaging with Rural Communities for Colorectal Cancer Screening Outreach Using Modified Boot Camp Translation. Progress in Community Health Partnerships: Research, Education, and Action, 18(1). doi:10.1353/cpr.2024.a922329
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  Background: Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents and Medicaid enrollees. Objectives: To address disparities, we used a modified community engagement approach, Boot Camp Translation (BCT). Research partners, an advisory board, and the rural community informed messaging about CRC outreach and a mailed fecal immunochemical test program. Methods: Eligible rural patients (English-speaking and ages 50–74) and clinic staff involved in patient outreach partici-pated in a BCT conducted virtually over two months. We applied qualitative analysis to BCT transcripts and field notes. Results: Key themes included: the importance of directly communicating about the seriousness of cancer, leveraging close clinic-patient relationships, and communicating the test safety, ease, and low cost. Conclusions: Using a modified version of BCT delivered in a virtual format, we were able to successfully capture community input to adapt a CRC outreach program for use in rural settings. Program materials will be tested during a pragmatic trial to address rural CRC screening disparities.
• Gautom, P., Rosales, A. G., Petrik, A. F., Thompson, J. H., Slaughter, M. T., Mosso, L., Hussain, S. A., Jimenez, R., & Coronado, G. D. (2024). Evaluating the Reach of a Patient Navigation Program for Follow-up Colonoscopy in a Large Federally Qualified Health Center. Cancer prevention research (Philadelphia, Pa.), 17(7), 325-333.
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  Patient navigation (PN) has been shown to improve participation in cancer screening, including colorectal cancer screening, and is now a recommended practice by the Community Preventive Services Task Force. Despite the effectiveness of PN programs, little is known about the number of contacts needed to successfully reach patients or about the demographic and healthcare utilization factors associated with reach. PRECISE was an individual randomized study of PN versus usual care conducted as a partnership between two large health systems in the Pacific Northwest. The navigation program was a six-topic area telephonic program designed to support patients with an abnormal fecal test result to obtain a follow-up colonoscopy. We report the number of contact attempts needed to successfully reach navigated patients. We used logistic regression to report the demographic and healthcare utilization characteristics associated with patients allocated to PN who were successfully reached. We identified 1,200 patients with an abnormal fecal immunochemical test result, of whom 970 were randomized into the study (45.7% were female, 17.5% were Spanish-speaking, and the mean age was 60.8 years). Of the 479 patients allocated to the PN intervention, 382 (79.7%) were reached within 18 call attempts, and nearly all (n = 356; 93.2%) were reached within six contact attempts. Patient characteristics associated with reach were race, county of residence, and body mass index. Our findings can guide future efforts to optimize the reach of PN programs. Prevention Relevance: The findings from this large study can inform clinic-level implementation of future PN programs in Federally Qualified Health Centers to improve the reach of patients needing cancer screenings, optimize staff resources, and ultimately increase cancer screenings.
• Gautom, P., Rosales, A., Petrik, A., Thompson, J., Slaughter, M., Mosso, L., Hussain, S., Jimenez, R., & Coronado, G. (2024). Evaluating the Reach of a Patient Navigation Program for Follow-up Colonoscopy in a Large Federally Qualified Health Center. Cancer Prevention Research, 17(7). doi:10.1158/1940-6207.capr-23-0498
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  Patient navigation (PN) has been shown to improve participation in cancer screening, including colorectal cancer screening, and is now a recommended practice by the Community Preventive Services Task Force. Despite the effectiveness of PN programs, little is known about the number of contacts needed to successfully reach patients or about the demographic and healthcare utilization factors associated with reach. PRECISE was an individual randomized study of PN versus usual care conducted as a partnership between two large health systems in the Pacific Northwest. The navigation program was a six–topic area telephonic program designed to support patients with an abnormal fecal test result to obtain a follow-up colonoscopy. We report the number of contact attempts needed to successfully reach navigated patients. We used logistic regression to report the demographic and healthcare utilization characteristics associated with patients allocated to PN who were successfully reached. We identified 1,200 patients with an abnormal fecal immunochemical test result, of whom 970 were randomized into the study (45.7% were female, 17.5% were Spanish-speaking, and the mean age was 60.8 years). Of the 479 patients allocated to the PN intervention, 382 (79.7%) were reached within 18 call attempts, and nearly all (n = 356; 93.2%) were reached within six contact attempts. Patient characteristics associated with reach were race, county of residence, and body mass index. Our findings can guide future efforts to optimize the reach of PN programs. Prevention Relevance: The findings from this large study can inform clinic-level implementation of future PN programs in Federally Qualified Health Centers to improve the reach of patients needing cancer screenings, optimize staff resources, and ultimately increase cancer screenings.
• Green, T., Bosworth, H. B., Coronado, G. D., DeBar, L., Green, B. B., Huang, S. S., Jarvik, J. G., Mor, V., Zatzick, D., Weinfurt, K. P., & Check, D. K. (2024). Factors Affecting Post-trial Sustainment or De-implementation of Study Interventions: A Narrative Review. Journal of general internal medicine, 39(6), 1029-1036.
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  In contrast to traditional randomized controlled trials, embedded pragmatic clinical trials (ePCTs) are conducted within healthcare settings with real-world patient populations. ePCTs are intentionally designed to align with health system priorities leveraging existing healthcare system infrastructure and resources to ease intervention implementation and increase the likelihood that effective interventions translate into routine practice following the trial. The NIH Pragmatic Trials Collaboratory, funded by the National Institutes of Health (NIH), supports the conduct of large-scale ePCT Demonstration Projects that address major public health issues within healthcare systems. The Collaboratory has a unique opportunity to draw on the Demonstration Project experiences to generate lessons learned related to ePCTs and the dissemination and implementation of interventions tested in ePCTs. In this article, we use case studies from six completed Demonstration Projects to summarize the Collaboratory's experience with post-trial interpretation of results, and implications for sustainment (or de-implementation) of tested interventions. We highlight three key lessons learned. First, ineffective interventions (i.e., ePCT is null for the primary outcome) may be sustained if they have other measured benefits (e.g., secondary outcome or subgroup) or even perceived benefits (e.g., staff like the intervention). Second, effective interventions-even those solicited by the health system and/or designed with significant health system partner buy-in-may not be sustained if they require significant resources. Third, alignment with policy incentives is essential for achieving sustainment and scale-up of effective interventions. Our experiences point to several recommendations to aid in considering post-trial sustainment or de-implementation of interventions tested in ePCTs: (1) include secondary outcome measures that are salient to health system partners; (2) collect all appropriate data to allow for post hoc analysis of subgroups; (3) collect experience data from clinicians and staff; (4) engage policy-makers before starting the trial.
• Ingram, M., Wilkinson-Lee, A., Mantina, N., Velasco, M., Coronado, G., Gallegos, M., & Carvajal, S. (2024). A Community-Based Participatory Approach in Applying the Sociocultural Resilience Model in U.S–Mexico Border Communities. Progress in Community Health Partnerships: Research, Education, and Action, 18. doi:10.1353/cpr.2024.a922337
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  Background: Behavioral models play a key role in identifying pathways to better health and provide a foundation for health promotion interventions. However, behavioral models based in epidemiological research may be limited in relevance and utility in practice. Objectives: We describe a participatory approach within a community-based participatory research partnership for integrating epidemiological and community perspectives into the application of the sociocultural resilience model (SRM). The SRM posits that cultural processes have a sym-biotic relationship with health-promoting social processes, which contribute to the health advantages among Mexican-origin and other Latinx populations. Methods: Community action board members engaged with academic partners to interpret and apply the SRM to a community-clinical linkages intervention implemented in the context of three U.S.–Mexico border communities. In a two-day workshop, partners engaged in a series of iterative discussions to reach common definitions and measures for SRM constructs. Results: Partners described daily cultural processes as the food they eat, how they communicate, and a collectivist approach to getting things done. For intervention activities, the partners opted for intergenerational storytelling, sharing of food, and artistic forms of expression. Partners included measures of cultural nuances such as border identity and the complexities that often arise from navigating bicultural norms. Conclusions: Collaborative approaches within community-based participatory research partnerships can facilitate the adaptation and measurement of conceptual health behavior models in community practice.
• Petrik, A. F., Henrikson, N. B., Coronado, G. D., Keast, E., & Banegas, M. P. (2024). A roadmap for improving representation in clinical trials. Contemporary clinical trials communications, 42, 101374.
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  Clinical trials continue to struggle with recruiting diverse participants that include historically underrepresented and minoritized patients, who are typically patients in non-white racial and ethnic groups and have low income (Medicaid). Enrolling diverse participants will benefit the health sciences by providing more generalizable findings. The Cancer Financial Experience project (CAFÉ) study sought to improve financial distress by providing financial navigation for newly diagnosed cancer patients, and intentionally recruited diverse participants. All diverse participants consented at slightly higher rates than non-diverse participants (21.3 % vs. 20.1 %). Spanish-speaking patients consented at a much higher rate than non-Spanish speakers (36.4 % vs. 20.2 % respectively). Here we discuss how we increased our recruitment of diverse participants. Obtaining diverse participation is achievable and will provide more meaningful findings.
• Petrik, A., Henrikson, N., Coronado, G., Keast, E., & Banegas, M. (2024). A roadmap for improving representation in clinical trials. Contemporary Clinical Trials Communications, 42. doi:10.1016/j.conctc.2024.101374
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  Clinical trials continue to struggle with recruiting diverse participants that include historically underrepresented and minoritized patients, who are typically patients in non-white racial and ethnic groups and have low income (Medicaid). Enrolling diverse participants will benefit the health sciences by providing more generalizable findings. The Cancer Financial Experience project (CAFÉ) study sought to improve financial distress by providing financial navigation for newly diagnosed cancer patients, and intentionally recruited diverse participants. All diverse participants consented at slightly higher rates than non-diverse participants (21.3 % vs. 20.1 %). Spanish-speaking patients consented at a much higher rate than non-Spanish speakers (36.4 % vs. 20.2 % respectively). Here we discuss how we increased our recruitment of diverse participants. Obtaining diverse participation is achievable and will provide more meaningful findings.
• Petrik, A., Johnson, E., Slaughter, M., Leo, M., Thompson, J., Mummadi, R., Jimenez, R., Hussain, S., & Coronado, G. (2024). The recalibration and redevelopment of a model to calculate patients’ probability of completing a colonoscopy following an abnormal fecal test. Journal of Medical Screening, 31(1). doi:10.1177/09691413231195568
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  Objectives: Fecal immunochemical testing (FIT) is an effective screening tool for colorectal cancer. If an FIT is abnormal, a follow-up colonoscopy is necessary to remove polyps or find cancers. We sought to develop a usable risk prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test. Methods: We recalibrated and then redeveloped a prediction model in federally qualified health centers (FQHCs), using a retrospective cohort of patients aged 50–75 with an abnormal FIT test and clinical data. Logistic and Cox regressions were used to recalibrate and then redevelop the model. Results: The initial risk model used data from eight FQHCs (26 clinics) including 1723 patients. When we applied the model to a single large FQHC (34 clinics, 884 eligible patients), the model did not recalibrate successfully (c-statistic dropped more than 0.05, from 0.66 to 0.61). The model was redeveloped in the same FQHC in a cohort of 1401 patients with a c-statistic of 0.65. Conclusions: The original model developed in a group of FQHCs did not adequately recalibrate in the single large FQHC. Health system, patient characteristics or data differences may have led to the inability to recalibrate the model. However, the redeveloped model provides an adequate model for the single FQHC.
• Ramalingam, N., Coury, J., Barnes, C., Kenzie, E. S., Petrik, A. F., Mummadi, R. R., Coronado, G., & Davis, M. M. (2024). Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association, 40(2), 272-281.
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  Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion.
• Ramalingam, N., Coury, J., Barnes, C., Kenzie, E., Petrik, A., Mummadi, R., Coronado, G., & Davis, M. (2024). Provision of colonoscopy in rural settings: A qualitative assessment of provider context, barriers, facilitators, and capacity. Journal of Rural Health, 40(2). doi:10.1111/jrh.12793
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  Purpose: Colonoscopy can prevent morbidity and mortality from colorectal cancer (CRC) and is the most commonly used screening method in the United States. Barriers to colonoscopy at multiple levels can contribute to disparities. Yet, in rural settings, little is known about who delivers colonoscopy and facilitators and barriers to colonoscopy access through screening completion. Methods: We conducted a qualitative study with providers in rural Oregon who worked in endoscopy centers or primary care clinics. Semistructured interviews, conducted in July and August, 2021, focused on clinician experiences providing colonoscopy to rural Medicaid patients, including workflows, barriers, and access. We used thematic analysis, through immersion crystallization, to analyze interview transcripts and develop emergent themes. Findings: We interviewed 19 providers. We found two categories of colonoscopy providers: primary care providers (PCPs) doing colonoscopy on their own patients (n = 9; 47%) and general surgeons providing colonoscopy to patients referred to their services (n = 10; 53%). Providers described barriers to colonoscopy at the provider, community, and patient levels and suggested patient supports could help overcome them. Providers found current colonoscopy capacity sufficient, but noted PCPs trained to perform colonoscopy would be key to continued accessibility. Finally, providers shared concerns about the shrinking number of PCP endoscopists, especially with anticipated increased screening demand related to the CRC screening guideline shift. Conclusions: These themes reflect opportunities to address multilevel barriers to improve access, colonoscopy capacity, and patient education approaches. Our results highlight that PCPs are an essential part of the workforce that provides colonoscopy in rural areas.
• Schneider, J., Rivelli, J., Vaughn, K., Thompson, J., Petrik, A., & Coronado, G. (2024). Acceptability of Patient Navigation to Promote Follow-up Colonoscopy. American Journal of Health Behavior, 48(3). doi:10.5993/ajhb.48.3.8
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  Objectives: Patient navigation can improve participation in colorectal cancer (CRC) screening, but little is known about patients’ experiences with navigation. Here we report patients’ experience with navigation for colonoscopy following an abnormal stool-test result. Methods: We conducted qualitative interviews among patients due for follow-up colonoscopy after an abnormal stool-test result, and who received patient navigation. Patients were enrolled in PRECISE, a randomized clinical trial comparing patient navigation versus usual care in a large federally qualified health center. Telephone interviews were in English or Spanish in a sub-sample of patients. Recordings were transcribed, coded, and analyzed using a constant comparative approach. Results: We completed 25 interviews (12 in Spanish and 13 in English). All patients perceived navigation as helpful. Spanish-preferring respondents had more barriers and needed support through the colonoscopy process. Navigated patients valued assistance with scheduling and having a single point of contact for bowel preparation questions. Patients suggested making sure navigators are well-versed in the colonoscopy experience, timely with calls, have access to local resources to help resolve barriers, and expand outreach to weekends and evenings. Conclusions: Patients who received navigation for follow-up colonoscopy perceived it as acceptable, helpful, and reassuring. Patients recommended the service continue and suggested improvements.
• Thompson, J. H., Rivelli, J. S., Escaron, A. L., Garcia, J., Ruiz, E., Torres-Ozadali, E., Gautom, P., Richardson, D. M., Thibault, A., & Coronado, G. D. (2024). Developing Patient-Refined Messaging for Follow-Up Colonoscopy After Abnormal Fecal Testing in Hispanic Communities: Key Learnings from Virtual Boot Camp Translation. Hispanic health care international : the official journal of the National Association of Hispanic Nurses, 22(4), 216-224.
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  Colorectal cancer (CRC) is a leading cause of cancer death in the US. Screening by fecal immunochemical test (FIT) is a strategy to lower CRC rates. Unfortunately, only half of patients with an abnormal FIT result complete the follow-up colonoscopy, an essential component of screening. We used virtual Boot Camp Translation (BCT), to elicit input from partners to develop messaging/materials to motivate patients to complete a follow-up colonoscopy. Participants were Hispanic, ages 50 to 75 years, and Spanish-speaking. All materials were developed in English and Spanish. The first meeting included expert presentations that addressed colorectal health. The two follow-up sessions obtained feedback on messaging/materials developed based on themes from the first meeting. Ten participants attended the first meeting and eight attended the follow-up sessions. The two key barriers to follow-up colonoscopy after abnormal FIT noted by participants were (a) lack of colonoscopy awareness and (b) fear of the colonoscopy procedure. We learned that participants valued simple messaging to increase knowledge and alleviate concerns, patient-friendly outreach materials, and increased access to health information. Using virtual BCT, we included participant feedback to design culturally relevant health messages to promote follow-up colonoscopy after abnormal fecal testing among Hispanic patients served by community clinics.
• Thompson, J. H., Rivelli, J. S., Schneider, J. L., Kenzie, E. S., Myers, E., Coury, J., Davis, M., Gautom, P., & Coronado, G. D. (2024). Adaptations to a patient navigation program for follow-up colonoscopy in rural primary care practices. Journal of evaluation in clinical practice, 30(7), 1457-1466.
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  Patient navigation is a recommended practice to improve cancer screenings among underserved populations including those residing in rural areas with care access barriers. We report on patient navigation programme adaptations to increase follow-up colonoscopy rates after abnormal fecal testing in rural primary care practices.
• Thompson, J., Gautom, P., Rivelli, J., Johnson, C., Burns, M., Levell, C., Hayes, N., & Coronado, G. (2024). Faith-based Messaging and Materials for Colorectal Cancer Screening in the United States: Application of Boot Camp Translation within the African Methodist Episcopal Church. Journal of Religion and Health. doi:10.1007/s10943-024-02180-8
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  The Black Church has long been an institution of refuge, mobilization, and healing in Black or African American communities. While health promotion interventions have been implemented in the Black Church, little is known about ways to incorporate faith into colorectal cancer (CRC) screening messages. Using modified boot camp translation, a community-based approach, we met with 27 members of the African Methodist Episcopal Church in Atlanta, Georgia, for in-person and virtual sessions to co-create faith-based CRC screening messages and identify channels for sharing information within the church community. Examples of messages developed included “Faith over fear” and “Honor God by taking care of your body.” Identified dissemination channels included Sunday service, community events, and social media. Churches serve as key partners in delivering health information, as they are among the most trusted institutions within the Black or African American community.
• Thompson, J., Gautom, P., Rivelli, J., Johnson, C., Burns, M., Levell, C., Hayes, N., & Coronado, G. (2024). Faith-based Messaging and Materials for Colorectal Cancer Screening in the United States: Application of Boot Camp Translation within the African Methodist Episcopal Church. Journal of religion and health.
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  The Black Church has long been an institution of refuge, mobilization, and healing in Black or African American communities. While health promotion interventions have been implemented in the Black Church, little is known about ways to incorporate faith into colorectal cancer (CRC) screening messages. Using modified boot camp translation, a community-based approach, we met with 27 members of the African Methodist Episcopal Church in Atlanta, Georgia, for in-person and virtual sessions to co-create faith-based CRC screening messages and identify channels for sharing information within the church community. Examples of messages developed included "Faith over fear" and "Honor God by taking care of your body." Identified dissemination channels included Sunday service, community events, and social media. Churches serve as key partners in delivering health information, as they are among the most trusted institutions within the Black or African American community.
• Thompson, J., Rivelli, J., Schneider, J., Kenzie, E., Myers, E., Coury, J., Davis, M., Gautom, P., & Coronado, G. (2024). Adaptations to a patient navigation program for follow-up colonoscopy in rural primary care practices. Journal of Evaluation in Clinical Practice, 30(7). doi:10.1111/jep.14068
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  Purpose: Patient navigation is a recommended practice to improve cancer screenings among underserved populations including those residing in rural areas with care access barriers. We report on patient navigation programme adaptations to increase follow-up colonoscopy rates after abnormal fecal testing in rural primary care practices. Methods: Participating clinics delivered a patient navigation programme to eligible patients from 28 affiliated clinics serving rural communities in Oregon clustered within 3 Medicaid health plans. Patient navigation adaptations were tracked using data sources including patient navigation training programme reflections, qualitative interviews, clinic meetings, and periodic reflections with practice facilitators. Findings: Initial, planned (proactive) adaptations were made to address the rural context; later, unplanned (reactive) adaptations were implemented to address the impact of the COVID-19 global pandemic. Initial planned adaptations to the patient navigation programme were made before the main trial to address the needs of the rural context, including provider shortages and geographic dispersion limiting both patient access to care and training opportunities for providers. Later unplanned adaptations were made primarily in response to COVID-19 care suspension and staff redeployments and shortages that occurred during implementation. Conclusion: While unplanned adaptations were implemented to address the contextual impact of the COVID-19 pandemic on care access patterns and staffing, the changes to training content and context were beneficial to the rural setting overall and should be sustained. Our findings can guide future efforts to optimise the success of such programmes in other rural settings and highlight the important role of adaptations in implementation projects.
• Coronado, G. D., Ferrari, R. M., Barnes, A., Castañeda, S. F., Cromo, M., Davis, M. M., Doescher, M. P., English, K., Hatcher, J., Kim, K. E., Kobrin, S., Liebovitz, D., Mishra, S. I., Nodora, J. N., Norton, W. E., Oliveri, J. M., Reuland, D. S., Subramanian, S., Thompson, J. H., & Paskett, E. D. (2023). Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative. Journal of the National Cancer Institute, 115(6), 680-694.
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  Although patient navigation has shown promise for increasing participation in colorectal cancer screening and follow-up, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative.
• Coronado, G. D., Nyongesa, D. B., Escaron, A. L., Petrik, A. F., Thompson, J. H., Smith, D., Davis, M. M., Schneider, J. L., Rivelli, J. S., Laguna, T., & Leo, M. C. (2023). Effectiveness and Cost of an Enhanced Mailed Fecal Test Outreach Colorectal Cancer Screening Program: Findings from the PROMPT Stepped-Wedge Trial. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology, 32(11), 1608-1616.
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  Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening rates, yet little is known about how to optimize these programs for effectiveness and cost.
• Coronado, G. D., Petrik, A. F., Slaughter, M., Kepka, D., & Naleway, A. L. (2023). Adolescents Who Have Undergone Human Papillomavirus Vaccination Are More Likely to Get a COVID-19 Vaccine. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 72(6), 985-988.
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  Human papillomavirus (HPV) and COVID-19 vaccination are both recommended for adolescents of ages 12-17. In May 2021, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices allowed the two vaccines to be administered concurrently.
• Coronado, G. D., Ruiz, E., Torres-Ozadali, E., Thompson, J. H., Rivelli, J. S., Thibault, A., & Escaron, A. L. (2023). Video text messaging is needed to deliver patient education about preventive care in the United States. PLOS digital health, 2(5), e0000258.
• Coronado, G., Dickerson, J., Burnett-Hartman, A., Carethers, J., Lee, J., & McBurnie, M. (2023). Reduced Implementation and Completion of Average-Risk Annual Fecal Immunochemical Test Colorectal Cancer Screening in Black Patients Aged 45–49 Years. Clinical Gastroenterology and Hepatology, 21(7). doi:10.1016/j.cgh.2022.05.009
• Coronado, G., Ferrari, R., Ferrari, R., Barnes, A., Cromo, M., Davis, M., Doescher, M., English, K., Hatcher, J., Kim, K., Kobrin, S., Liebovitz, D., Mishra, S., Nodora, J., Norton, W., Oliveri, J., Reuland, D., Subramanian, S., Thompson, J., , Paskett, E., et al. (2023). Characteristics of patient navigation programs in the Cancer Moonshot ACCSIS colorectal cancer screening initiative. Journal of the National Cancer Institute, 115(6). doi:10.1093/jnci/djad032
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  Background: Although patient navigation has shown promise for increasing participation in colorectal cancer screening and followup, little evidence is available to guide implementation of patient navigation in clinical practice. We characterize 8 patient navigation programs being implemented as part of multi-component interventions of the National Cancer Institute's Cancer Moonshot Accelerating Colorectal Cancer Screening and Follow-Up Through Implementation Science (ACCSIS) initiative. Methods: We developed a data collection template organized by ACCSIS framework domains. The template was populated by a representative from each of the 8 ACCSIS research projects. We report standardized descriptions of 1) the socio-ecological context in which the navigation program was being conducted, 2) navigation program characteristics, 3) activities undertaken to facilitate program implementation (eg, training), and 4) outcomes used in program evaluation. Results: ACCSIS patient navigation programs varied broadly in their socio-ecological context and settings, the populations they served, and how they were implemented in practice. Six research projects adapted and implemented evidence-based patient navigation programs; the remaining projects developed new programs. Five projects began navigation when patients were due for initial colorectal cancer screening; 3 projects began navigation later in the screening process, when patients were due for follow-up colonoscopy after an abnormal stool-test result. Seven projects relied on existing clinical staff to deliver the navigation; 1 hired a centralized research navigator. All project researchers plan to evaluate the effectiveness and implementation of their programs. Conclusions: Our detailed program descriptions may facilitate cross-project comparisons and guide future implementation and evaluation of patient navigation programs in clinical practice.
• Coronado, G., Nyongesa, D., Escaron, A., Petrik, A., Thompson, J., Smith, D., Davis, M., Schneider, J., Rivelli, J., Laguna, T., & Leo, M. (2023). Effectiveness and Cost of an Enhanced Mailed Fecal Test Outreach Colorectal Cancer Screening Program: Findings from the PROMPT Stepped-Wedge Trial. Cancer Epidemiology Biomarkers and Prevention, 32(11). doi:10.1158/1055-9965.epi-23-0597
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  Background: Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer screening rates, yet little is known about how to optimize these programs for effectiveness and cost. Methods: PROMPT was a pragmatic, stepped-wedge, cluster-randomized effectiveness trial of mailed FIT outreach. Participants in the standard condition were mailed a FIT and received live telephone reminders to return it. Participants in the enhanced condition also received a tailored advance notification (text message or live phone call) and two automated phone call reminders. The primary outcome was 6-month FIT completion; secondary outcomes were any colorectal cancer screening completion at 6 months, implementation, and program costs. Results: The study included 27,585 participants (80% ages 50–64, 82% Hispanic/Latino; 68% preferred Spanish). A higher proportion of enhanced participants completed FIT at 6 months than standard participants, both in intention-to-treat [+2.8%, 95% confidence interval (CI; 0.4–5.2)] and per-protocol [limited to individuals who were reached; +16.9%, 95% CI (12.3–20.3)] analyses. Text messages and automated calls were successfully delivered to 91% to 100% of participants. The per-patient cost for standard mailed FIT was $10.84. The enhanced program’s text message plus automated call reminder cost an additional $0.66; live phone calls plus an automated call reminder cost an additional $10.82 per patient. Conclusions: Adding advance notifications and automated calls to a standard mailed FIT program boosted 6-month FIT completion rates at a small additional per-patient cost. Impact: Enhancements to mailed FIT outreach can improve colorectal cancer screening participation. Future research might test the addition of educational video messaging for screening-naïve adults.
• Coronado, G., Petrik, A., Slaughter, M., Kepka, D., & Naleway, A. (2023). Adolescents Who Have Undergone Human Papillomavirus Vaccination Are More Likely to Get a COVID-19 Vaccine. Journal of Adolescent Health, 72(6). doi:10.1016/j.jadohealth.2022.12.022
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  Purpose: Human papillomavirus (HPV) and COVID-19 vaccination are both recommended for adolescents of ages 12–17. In May 2021, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices allowed the two vaccines to be administered concurrently. Methods: We identified adolescents of ages 12–17 using electronic health records from a large integrated delivery system. We assessed associations between socio-demographic characteristics and uptake of HPV vaccination and COVID-19 vaccination, as well as the cumulative proportion of adolescents who obtained a COVID-19 vaccine over time by HPV vaccination status. Results: We identified 40,819 adolescents; 65% had received any COVID-19 vaccination, and 79% had received any HPV vaccination. Adolescents who had initiated HPV vaccination had about 4-fold greater odds of having obtained a COVID-19 vaccine than those who had not (odds ratio = 4.02, 95% confidence interval = 3.81, 4.24). Discussion: Patterns of vaccination uptake suggest possible advantages to co-promotion of adolescent vaccines.
• Coronado, G., Ruiz, E., Torres-Ozadali, E., Thompson, J., Rivelli, J., Thibault, A., & Escaron, A. (2023). Video text messaging is needed to deliver patient education about preventive care in the United States. PLOS Digital Health, 2(5). doi:10.1371/journal.pdig.0000258
• Davis, M., Coury, J., Larson, J., Gunn, R., Towey, E., Ketelhut, A., Patzel, M., Ramsey, K., & Coronado, G. (2023). Improving colorectal cancer screening in rural primary care: Preliminary effectiveness and implementation of a collaborative mailed fecal immunochemical test pilot. Journal of Rural Health, 39(1). doi:10.1111/jrh.12685
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  Background: Mailed fecal immunochemical test (FIT) outreach can improve colorectal cancer (CRC) screening rates. We piloted a collaborative mailed FIT program with health plans and rural clinics to evaluate preliminary effectiveness and refine implementation strategies. Methods: We conducted a single-arm study using a convergent, parallel mixed-methods design to evaluate the implementation of a collaborative mailed FIT program. Enrollees were identified using health plan claims and confirmed via clinic scrub. The intervention included a vendor-delivered automated phone call (auto-call) prompt, FIT mailing, and reminder auto-call; clinics were encouraged to make live reminder calls. Practice facilitation was the primary implementation strategy. At 12 months post mailing, we assessed the rates of: (1) mailed FIT return and (2) completion of any CRC screening. We took fieldnotes and conducted postintervention key informant interviews to assess implementation outcomes (eg, feasibility, acceptability, and adaptations). Results: One hundred and sixty-nine Medicaid or Medicare enrollees were mailed a FIT. Over the 12-month intervention, 62 participants (37%) completed screening of which 21% completed the mailed FIT (most were returned within 3 months), and 15% screened by other methods (FITs distributed in-clinic, colonoscopy). Enrollee demographics and the reminder call may encourage mailed FIT completion. Program feasibility and acceptability was high and supported by perceived positive benefit, alignment with existing workflows, adequate staffing, and practice facilitation. Conclusion: Collaborative health plan-clinic mailed FIT programs are feasible and acceptable for implementation in rural clinics and support CRC screening completion. Studies that pragmatically test collaborative approaches to mailed FIT and patient navigation follow-up after abnormal FIT and support broad scale-up in rural settings are needed.
• Gautom, P., Escaron, A. L., Garcia, J., Thompson, J. H., Rivelli, J. S., Ruiz, E., Torres-Ozadali, E., Richardson, D. M., & Coronado, G. D. (2023). Developing patient-refined colorectal cancer screening materials: application of a virtual community engagement approach. BMC gastroenterology, 23(1), 179.
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  In partnership with a federally qualified health center (FQHC), an adapted virtual version of boot camp translation (BCT) was used to elicit input from Spanish-speaking Latino patients and staff to develop messaging and patient education materials for follow-up colonoscopy after abnormal fecal testing. We describe how we adapted an existing in-person BCT process to be delivered virtually and present evaluations from participants on the virtual format.
• Gautom, P., Escaron, A., Garcia, J., Thompson, J., Rivelli, J., Ruiz, E., Torres-Ozadali, E., Richardson, D., & Coronado, G. (2023). Developing patient-refined colorectal cancer screening materials: application of a virtual community engagement approach. BMC Gastroenterology, 23(1). doi:10.1186/s12876-023-02774-8
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  Introduction: In partnership with a federally qualified health center (FQHC), an adapted virtual version of boot camp translation (BCT) was used to elicit input from Spanish-speaking Latino patients and staff to develop messaging and patient education materials for follow-up colonoscopy after abnormal fecal testing. We describe how we adapted an existing in-person BCT process to be delivered virtually and present evaluations from participants on the virtual format. Methods: Three virtual BCT sessions were facilitated by bilingual staff and conducted via Zoom. These sessions included introductions and discussions on colorectal cancer (CRC), CRC screening, and gathered feedback from participants on draft materials. Ten adults were recruited from the FQHC. A research team member from the FQHC served as the point of contact (POC) for all participants and offered Zoom introductory sessions and/or technology support before and during the sessions. Following the third session, participants were invited to complete an evaluation form about their virtual BCT experience. Using a 5-point Likert Scale (where 5 = strongly agree), questions focused on session utility, group comfort level, session pacing, and overall sense of accomplishment. Results: Average scores ranged from 4.3 to 5.0 indicating strong support towards the virtual BCT sessions. Additionally, our study emphasized the importance of a POC to provide technical support to participants throughout the process. Using this approach, we successfully incorporated feedback from participants to design culturally relevant materials to promote follow-up colonoscopy. Conclusion: We recommend ongoing public health emphasis on the use of virtual platforms for community engaged work.
• Gupta, S., Barnes, A., Brenner, A. T., Campbell, J., Davis, M., English, K., Hoover, S., Kim, K., Kobrin, S., Lance, P., Mishra, S. I., Oliveri, J. M., Reuland, D. S., Subramanian, S., & Coronado, G. D. (2023). Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science. Preventing chronic disease, 20, E112.
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  Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated.
• Gupta, S., Barnes, A., Brenner, A., Campbell, J., Davis, M., English, K., Hoover, S., Kim, K., Kobrin, S., Lance, P., Mishra, S., Oliveri, J., Reuland, D., Subramanian, S., & Coronado, G. (2023). Mail-Based Self-Sampling to Complete Colorectal Cancer Screening: Accelerating Colorectal Cancer Screening and Follow-up Through Implementation Science. Preventing Chronic Disease, 20. doi:10.5888/pcd20.230083
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  Introduction Leveraging cancer screening tests, such as the fecal immunochemical test (FIT), that allow for self-sampling and postal mail for screening invitations, test delivery, and return can increase participation in colorectal cancer (CRC) screening. The range of approaches that use self-sampling and mail for promoting CRC screening, including use of recommended best practices, has not been widely investigated. Methods We characterized self-sampling and mail strategies used for implementing CRC screening across a consortium of 8 National Cancer Institute Cancer Moonshot Initiative Accelerating Colorectal Cancer Screening and Follow-up through Implementation Science (ACCSIS) research projects. These projects serve diverse rural, urban, and tribal populations in the US. Results All 8 ACCSIS projects leveraged self-sampling and mail to promote screening. Strategies included organized mailed FIT outreach with mailed invitations, including FIT kits, reminders, and mailed return (n = 7); organized FIT-DNA outreach with mailed kit return (n = 1); organized on-demand FIT outreach with mailed offers to request a kit for mailed return (n = 1); and opportunistic FIT-DNA with in-clinic offers to be mailed a test for mailed return (n = 2). We found differences in patient identification strategies, outreach delivery approaches, and test return options. We also observed consistent use of Centers for Disease Control and Prevention Summit consensus best practice recommendations by the 7 projects that used mailed FIT outreach. Conclusion In research projects reaching diverse populations in the US, we observed multiple strategies that leverage self-sampling and mail to promote CRC screening. Mail and self-sampling, including mailed FIT outreach, could be more broadly leveraged to optimize cancer screening.
• Gustavson, A. M., Lewinski, A. A., Fitzsimmons-Craft, E. E., Coronado, G. D., Linke, S. E., O'Malley, D. M., Adams, A. S., Glasgow, R. E., & Klesges, L. M. (2023). Strategies to Bridge Equitable Implementation of Telehealth. Interactive journal of medical research, 12, e40358.
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  During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.
• Kenzie, E. S., Seater, M., Wakeland, W., Coronado, G. D., & Davis, M. M. (2023). System dynamics modeling for cancer prevention and control: A systematic review. PloS one, 18(12), e0294912.
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  Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.
• Kenzie, E., Seater, M., Wakeland, W., Coronado, G., & Davis, M. (2023). System dynamics modeling for cancer prevention and control: A systematic review. PLoS ONE, 18(12). doi:10.1371/journal.pone.0294912
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  Cancer prevention and control requires consideration of complex interactions between multilevel factors. System dynamics modeling, which consists of diagramming and simulation approaches for understanding and managing such complexity, is being increasingly applied to cancer prevention and control, but the breadth, characteristics, and quality of these studies is not known. We searched PubMed, Scopus, APA PsycInfo, and eight peer-reviewed journals to identify cancer-related studies that used system dynamics modeling. A dual review process was used to determine eligibility. Included studies were assessed using quality criteria adapted from prior literature and mapped onto the cancer control continuum. Characteristics of studies and models were abstracted and qualitatively synthesized. 32 studies met our inclusion criteria. A mix of simulation and diagramming approaches were used to address diverse topics, including chemotherapy treatments (16%), interventions to reduce tobacco or e-cigarettes use (16%), and cancer risk from environmental contamination (13%). Models spanned all focus areas of the cancer control continuum, with treatment (44%), prevention (34%), and detection (31%) being the most common. The quality assessment of studies was low, particularly for simulation approaches. Diagramming-only studies more often used participatory approaches. Involvement of participants, description of model development processes, and proper calibration and validation of models showed the greatest room for improvement. System dynamics modeling can illustrate complex interactions and help identify potential interventions across the cancer control continuum. Prior efforts have been hampered by a lack of rigor and transparency regarding model development and testing. Supportive infrastructure for increasing awareness, accessibility, and further development of best practices of system dynamics for multidisciplinary cancer research is needed.
• Petrik, A. F., Johnson, E. S., Mummadi, R., Slaughter, M., Coronado, G. D., Lin, S. C., Savitz, L., & Wallace, N. (2023). The use of individual and multilevel data in the development of a risk prediction model to predict patients' likelihood of completing colorectal cancer screening. Preventive medicine reports, 36, 102366.
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  Promotion of colorectal cancer (CRC) screening can be expensive and unnecessary for many patients. The use of predictive analytics promises to help health systems target the right services to the right patients at the right time while improving population health. Multilevel data at the interpersonal, organizational, community, and policy levels, is rarely considered in clinical decision making but may be used to improve CRC screening risk prediction. We compared the effectiveness of a CRC screening risk prediction model that uses multilevel data with a more conventional model that uses only individual patient data. We used a retrospective cohort to ascertain the one-year occurrence of CRC screening. The cohort was determined from a Health Maintenance Organization, in Oregon. Eligible patients were 50-75 years old, health plan members for at least one year before their birthday in 2018 and were due for screening. We created a risk model using logistic regression first with data available in the electronic health record (EHR), and then added multilevel data. In a cohort of 59,249 patients, 36.1% completed CRC screening. The individual level model included 14 demographic, clinical and encounter based characteristics, had a bootstrap-corrected C-statistic of 0.722 and sufficient calibration. The multilevel model added 9 variables from clinical setting and community characteristics, and the bootstrap-corrected C-statistic remained the same with continued sufficient calibration. The predictive power of the CRC screening model did not improve after adding multilevel data. Our findings suggest that multilevel data added no improvement to the prediction of the likelihood of CRC screening.
• Petrik, A., Coury, J., Larson, J., Badicke, B., Coronado, G., & Davis, M. (2023). Data Challenges in Identifying Patients Due for Colorectal Cancer Screening in Rural Clinics. Journal of the American Board of Family Medicine, 36(1). doi:10.3122/jabfm.2022.220216r1
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  Introduction: Colorectal cancer (CRC) incidence and mortality are disproportionately high among rural residents despite the availability of effective screening methods. Outreach activities can improve CRC screening rates but rely on accurate identification of patients due for screening. We report on data challenges in rural clinics and Medicaid health plans in Oregon in identifying patients eligible for CRC screening, in a large project implementing mailed fecal immunochemical tests (FIT) and patient navigation. Methods: We analyzed data from clinic intake surveys and administrative claims. Clinics were asked to identify total population numbers relevant to CRC screening and follow-up. Health plans also identified enrollees eligible for CRC screening in Spring, 2021. Clinic staff validated patient lists for eligibility using their electronic health records (EHR). Results: EHR features varied across the 29 participating and 28 responding clinics. Among the 28 responding clinics, 21 were able to report their Medicaid population (75%), 19 reported the number of patients aged 50 to 75 (68%) and the number screened for CRC in the last year (68%). Only 8 (29%) were able to report screening details such as number screened by FIT and 9 were able to report on patients with an abnormal FIT or colonoscopy completed after FIT (32%). Health plans had challenges properly identifying where enrollees received care and had missing data for race and ethnicity (range 22 to 34% unknown race,
• Petrik, A., Johnson, E., Mummadi, R., Slaughter, M., Coronado, G., Lin, S., Savitz, L., & Wallace, N. (2023). The use of individual and multilevel data in the development of a risk prediction model to predict patients’ likelihood of completing colorectal cancer screening. Preventive Medicine Reports, 36. doi:10.1016/j.pmedr.2023.102366
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  Promotion of colorectal cancer (CRC) screening can be expensive and unnecessary for many patients. The use of predictive analytics promises to help health systems target the right services to the right patients at the right time while improving population health. Multilevel data at the interpersonal, organizational, community, and policy levels, is rarely considered in clinical decision making but may be used to improve CRC screening risk prediction. We compared the effectiveness of a CRC screening risk prediction model that uses multilevel data with a more conventional model that uses only individual patient data. We used a retrospective cohort to ascertain the one-year occurrence of CRC screening. The cohort was determined from a Health Maintenance Organization, in Oregon. Eligible patients were 50–75 years old, health plan members for at least one year before their birthday in 2018 and were due for screening. We created a risk model using logistic regression first with data available in the electronic health record (EHR), and then added multilevel data. In a cohort of 59,249 patients, 36.1% completed CRC screening. The individual level model included 14 demographic, clinical and encounter based characteristics, had a bootstrap-corrected C-statistic of 0.722 and sufficient calibration. The multilevel model added 9 variables from clinical setting and community characteristics, and the bootstrap-corrected C-statistic remained the same with continued sufficient calibration. The predictive power of the CRC screening model did not improve after adding multilevel data. Our findings suggest that multilevel data added no improvement to the prediction of the likelihood of CRC screening.
• Schneider, J. L., Johnson, C. A., Jenkins, C., Mummadi, R., & Coronado, G. D. (2023). "I was screaming hallelujah": Patient and provider perceptions of blood-based testing for colorectal cancer screening. PloS one, 18(12), e0295685.
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  Blood-based tests for colorectal cancer (CRC) screening can offer many advantages over stool-based tests such as FIT. Yet, we know little about patients' and providers' perceptions of this type of test. We report findings from a qualitative study comparing patient and provider perceptions of blood-based testing for CRC screening.
• Schneider, J. L., Rivelli, J. S., Vaughn, K. A., Thompson, J. H., Petrik, A. F., Escaron, A. L., & Coronado, G. D. (2023). Implementing an enhanced mailed FIT program to improve CRC screening at a federally qualified health center: experiences of patients and staff. Translational behavioral medicine, 13(10), 757-767.
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  Colorectal cancer (CRC) is a leading cause of cancer death in the USA. Screening programs in federally qualified health centers (FQHCs) are essential to reducing CRC-related mortality and morbidity among underserved populations. Centralized, population-based mailed fecal immunochemical test (FIT) programs can improve CRC screening rates, but barriers to implementation remain. We qualitatively explored barriers and facilitators to implementation of a mailed FIT program at a large, urban FQHC that employed advance notification "primers" (live calls and texts) and automated reminders. We interviewed 25 patients and 45 FQHC staff by telephone about their experience with the program. Interviews were transcribed, coded, and content analyzed using NVivo.12. Patients and staff found advance notifications conveyed through live phone calls or text messages to be acceptable and motivational for FIT completion. Live phone primers were helpful in addressing patients' questions and misconceptions about screening, particularly for patients new to screening. Advance notifications sent by text were considered timely and useful in preparing patients for receipt of the FIT. Barriers to implementation included lack of receipt of primers, reminders, or the mailed FIT itself due to inaccurate patient contact information within the FQHC medical record; lack of systems for documenting mailed FIT outreach to coordinate with clinical care; and lack of local caller identification for primers and reminders. Our findings demonstrate that an enhanced mailed FIT program using primers and reminders was acceptable. Our findings can help other FQHCs implement and optimize their mailed FIT programs.
• Schneider, J., Johnson, C., Jenkins, C., Mummadi, R., & Coronado, G. (2023). “I was screaming hallelujah”: Patient and provider perceptions of blood-based testing for colorectal cancer screening. PLoS ONE, 18(12). doi:10.1371/journal.pone.0295685
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  Background Blood-based tests for colorectal cancer (CRC) screening can offer many advantages over stool-based tests such as FIT. Yet, we know little about patients' and providers' perceptions of this type of test. We report findings from a qualitative study comparing patient and provider perceptions of blood-based testing for CRC screening. Methods Patient participants were aged 45-75 years and members of a large, integrated health system. Participants were mailed, but did not complete, a FIT through an organized FIT-screening program and were scheduled for a health-care encounter at any of nine clinical sites. Participants were consented to complete a blood draw. We used purposive sampling to select and recruit patients (who did and did not complete the blood test) and providers/specialists who would be involved in offering the blood test to patients or explaining results. We administered telephone interviews using a semi-structured interview guide and recorded and transcribed all interviews, then coded and analyzed content. Results We interviewed 15 patients (11 completed and 4 did not complete the blood test) and 5 providers (3 primary care providers, one gastroenterologist (GI), and one GI medical assistant). Patients were enthusiastic about completing a blood test, citing the simplicity, ease, convenience, and high perceived accuracy of the test. Providers were also receptive to a blood-based option, if adequate test performance could be achieved and if they have information that informs patients about the pros and cons of blood-based screening versus other screening tests. Conclusions Patients and providers were willing and enthusiastic about blood-based CRC screening tests. Future research focusing on performance and communication is needed.
• Schneider, J., Rivelli, J., Vaughn, K., Thompson, J., Petrik, A., Escaron, A., & Coronado, G. (2023). Implementing an enhanced mailed FIT program to improve CRC screening at a federally qualified health center: experiences of patients and staff. Translational Behavioral Medicine, 13(10). doi:10.1093/tbm/ibad025
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  Colorectal cancer (CRC) is a leading cause of cancer death in the USA. Screening programs in federally qualified health centers (FQHCs) are essential to reducing CRC-related mortality and morbidity among underserved populations. Centralized, population-based mailed fecal immunochemical test (FIT) programs can improve CRC screening rates, but barriers to implementation remain. We qualitatively explored barriers and facilitators to implementation of a mailed FIT program at a large, urban FQHC that employed advance notification "primers"(live calls and texts) and automated reminders. We interviewed 25 patients and 45 FQHC staff by telephone about their experience with the program. Interviews were transcribed, coded, and content analyzed using NVivo.12. Patients and staff found advance notifications conveyed through live phone calls or text messages to be acceptable and motivational for FIT completion. Live phone primers were helpful in addressing patients' questions and misconceptions about screening, particularly for patients new to screening. Advance notifications sent by text were considered timely and useful in preparing patients for receipt of the FIT. Barriers to implementation included lack of receipt of primers, reminders, or the mailed FIT itself due to inaccurate patient contact information within the FQHC medical record; lack of systems for documenting mailed FIT outreach to coordinate with clinical care; and lack of local caller identification for primers and reminders. Our findings demonstrate that an enhanced mailed FIT program using primers and reminders was acceptable. Our findings can help other FQHCs implement and optimize their mailed FIT programs.
• Staman, K., Check, D., Zatzick, D., Mor, V., Fritz, J., Sluka, K., DeBar, L., Jarvik, J., Volandes, A., Coronado, G., Chambers, D., Weinfurt, K., & George, S. (2023). Intervention delivery for embedded pragmatic clinical trials: Development of a tool to measure complexity. Contemporary Clinical Trials, 126. doi:10.1016/j.cct.2023.107105
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  Background: Conducting an embedded pragmatic clinical trial in the workflow of a healthcare system is a complex endeavor. The complexity of the intervention delivery can have implications for study planning, ability to maintain fidelity to the intervention during the trial, and/or ability to detect meaningful differences in outcomes. Methods: We conducted a literature review, developed a tool, and conducted two rounds of phone calls with NIH Pragmatic Trials Collaboratory Demonstration Project principal investigators to develop the Intervention Delivery Complexity Tool. After refining the tool, we piloted it with Collaboratory demonstration projects and developed an online version of the tool using the R Shiny application (https://duke-som.shinyapps.io/ICT-ePCT/). Results: The 6-item tool consists of internal and external factors. Internal factors pertain to the intervention itself and include workflow, training, and the number of intervention components. External factors are related to intervention delivery at the system level including differences in healthcare systems, the dependency on setting for implementation, and the number of steps between the intervention and the outcome. Conclusion: The Intervention Delivery Complexity Tool was developed as a standard way to overcome communication challenges of intervention delivery within an embedded pragmatic trial. This version of the tool is most likely to be useful to the trial team and its health system partners during trial planning and conduct. We expect further evolution of the tool as more pragmatic trials are conducted and feedback is received on its performance outside of the NIH Pragmatic Trials Collaboratory.
• Baldwin, L., Coronado, G., West, I., Schwartz, M., Meenan, R., Vollmer, W., Petrik, A., Shapiro, J., Kulkarni-Sharma, Y., & Green, B. (2022). Health plan-based mailed fecal testing for colorectal cancer screening among dual-eligible Medicaid/Medicare enrollees: Outcomes of 2 program models. Cancer, 128(2). doi:10.1002/cncr.33909
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  Background: Health insurance plans are increasingly offering mailed fecal immunochemical test (FIT) programs for colorectal cancer (CRC) screening, but few studies have compared the outcomes of different program models (eg, invitation strategies). Methods: This study compares the outcomes of 2 health plan–based mailed FIT program models. In the first program (2016), FIT kits were mailed to all eligible enrollees; in the second program (2018), FIT kits were mailed only to enrollees who opted in after an outreach phone call. Participants in this observational study included dual-eligible Medicaid/Medicare enrollees who were aged 50 to 75 years and were due for CRC screening (1799 in 2016 and 1906 in 2018). Six-month FIT completion rates, implementation outcomes (eg, mailed FITs sent and reminders attempted), and program-related health plan costs for each program are described. Results: All 1799 individuals in 2016 were sent an introductory letter and a FIT kit. In 2018, all 1906 were sent an introductory letter, and 1905 received at least 1 opt-in call attempt, with 410 (21.5%) sent a FIT. The FIT completion rate was 16.2% (292 of 1799 [95% CI, 14.5%-17.9%]) in 2016 and 14.6% (278 of 1906 [95% CI, 13.0%-16.2%]) in 2018 (P =.36). The overall implementation costs were higher in 2016 ($40,156) than 2018 ($34,899), with the cost per completed FIT slightly higher in 2016 ($138) than 2018 ($126). Conclusions: An opt-in mailed FIT program achieved FIT completion rates similar to those of a program mailing to all dual-eligible Medicaid/Medicare enrollees. Lay Summary: Health insurance plans can use different program models to successfully mail fecal test kits for colorectal cancer screening to dual-eligible Medicaid/Medicare enrollees, with nearly 1 in 6 enrollees completing fecal testing.
• Coronado, G. (2022). Sustainable infrastructure and risk stratification are needed to appropriately deliver colorectal cancer screening globally. Cancer, 128(6). doi:10.1002/cncr.34059
• Coronado, G., Leo, M., Ramsey, K., Coury, J., Petrik, A., Patzel, M., Kenzie, E., Thompson, J., Brodt, E., Mummadi, R., Elder, N., & Davis, M. (2022). Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial. Implementation Science Communications, 3(1). doi:10.1186/s43058-022-00285-3
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  Background: Screening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer MoonshotSM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees. Methods: Phase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities. Discussion: This study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. Trial registration: Registered at clinicaltrial.gov (NCT04890054) and at the NCI’s Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.
• Coulter, K., Ingram, M., Lohr, A., Figueroa, C., Coronado, G., Espinoza, C., Esparza, M., Monge, S., Velasco, M., Itule-Klasen, L., Bowen, M., Wilkinson-Lee, A., & Carvajal, S. (2022). Adaptation of a Community Clinical Linkages Intervention to the COVID-19 Pandemic: A Community Case Study. Frontiers in Public Health, 10. doi:10.3389/fpubh.2022.877593
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  In this community case study, we describe the process within an academic-community partnership of adapting UNIDOS, a community health worker (CHW)-led community-clinical linkages (CCL) intervention targeting Latinx adults in Arizona, to the evolving landscape of the COVID-19 pandemic. Consistent with community-based participatory research principles, academic and community-based partners made decisions regarding changes to the intervention study protocol, specifically the intervention objectives, participant recruitment methods, CHW trainings, data collection measures and management, and mode of intervention delivery. Insights from this case study demonstrate the importance of community-based participatory research in successfully modifying the intervention to the conditions of the pandemic and also the cultural background of Latinx participants. This case study also illustrates how a CHW-led CCL intervention can address social determinants of health, in which the pandemic further exposed longstanding inequities along racial and ethnic lines in the United States.
• Davis, M., Schneider, J., Petrik, A., Miech, E., Younger, B., Escaron, A., Rivelli, J., Thompson, J., Nyongesa, D., & Coronado, G. (2022). Clinic Factors Associated With Mailed Fecal Immunochemical Test (FIT) Completion: The Difference-Making Role of Support Staff. Annals of Family Medicine, 20(2). doi:10.1370/afm.2772
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  PURPOSE Mailed fecal immunochemical test (FIT) programs can facilitate colorectal cancer (CRC) screening. We sought to identify modifiable, clinic-level factors that distinguish primary care clinics with higher vs lower FIT completion rates in response to a centralized mailed FIT program. METHODS We used baseline observational data from 15 clinics within a single urban federally qualified health center participating in a pragmatic trial to optimize a mailed FIT program. Clinic-level data included interviews with leadership using a guide informed by the Consolidated Framework for Implementation Research (CFIR) and FIT completion rates. We used template analysis to identify explanatory factors and configurational comparative methods to identify specific combinations of clinic-level conditions that uniquely distinguished clinics with higher and lower FIT completion rates. RESULTS We interviewed 39 clinic leaders and identified 58 potential explanatory factors representing clinic workflows and the CFIR inner setting domain. Clinic-level FIT completion rates ranged from 30% to 56%. The configurational model for clinics with higher rates (≥37%) featured any 1 of the following 3 factors related to support staff: (1) adding back-or front-office staff in past 12 months, (2) having staff help patients resolve barriers to CRC screening, and (3) having staff hand out FITs/educate patients. The model for clinics with lower rates involved the combined absence of these same 3 factors. CONCLUSIONS Three factors related to support staff differentiated clinics with higher and lower FIT completion rates. Adding nonphysician support staff and having those staff provide enabling services might help clinics optimize mailed FIT screening programs.
• Escaron, A., Garcia, J., Petrik, A., Ruiz, E., Nyongesa, D., Thompson, J., & Coronado, G. (2022). Colonoscopy Following an Abnormal Fecal Test Result from an Annual Colorectal Cancer Screening Program in a Federally Qualified Health Center. Journal of Primary Care and Community Health, 13. doi:10.1177/21501319221138423
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  Objective: Individuals with an abnormal fecal immunochemical test (FIT) result have an elevated risk of colorectal cancer, and the risk increases if the follow-up colonoscopy is delayed. Of note, rates of follow-up colonoscopy are alarmingly low in federally qualified health centers (FQHCs), US health care settings that serve a majority racial and ethnic minority patient population. We assessed factors associated with colonoscopy after an abnormal FIT result and used chart-abstracted data to assess reasons (including process measures) for lack of follow-up as part of an annual, mailed-FIT outreach program within a large, Latino-serving FQHC. Methods: As part of the National Institutes of Health-funded PROMPT study, we identified patients with an abnormal FIT result and used logistic regression to assess associations between patient demographics and receipt of follow-up colonoscopy, controlling for patients’ preferred language. We report on time (days) to referral and time to colonoscopy. For charts with an abnormal FIT result but no evidence of colonoscopy, we performed a manual abstraction and obtained the reason for the absence of colonoscopy. When there was no evidence of colonoscopy in a patient’s electronic health record (EHR), we performed an automated query of the administrative claims database to identify colonoscopy outcomes. Results: We identified 324 patients with abnormal FIT results from July to October 2018. These patients were mostly publicly insured (Medicaid 53.1%, Medicare 14.5%), 81.8% were aged 50 to 64 years, 55.3% were female, 80.3% were Hispanic/Latino, and 67.3% preferred to speak Spanish. We found that 108/324 (33.3%) patients completed colonoscopy within 12 months, and the median time to colonoscopy was 94 days (IQR: 68-176). Common barriers to colonoscopy completion, obtained from chart-abstracted data, were: no documentation following referral to gastrointestinal (GI) specialist or GI consultation (41.6%), no referral to GI specialist following abnormal fecal test (34.2%), and absence of a valid insurance authorization (6.5%). Conclusions: Multi-level strategies are needed to provide optimal care across the cancer continuum for FQHC patients. In order to reduce the risk of CRC and realize the return on fecal testing investment, concerted system-level efforts are urgently needed to improve rates of follow-up colonoscopy among FQHC patients and redress racial and ethnic disparities in CRC screening outcomes.
• Karlitz, J., Fendrick, A., Bhatt, J., Coronado, G., Jeyakumar, S., Smith, N., Plescia, M., Brooks, D., Limburg, P., & Lieberman, D. (2022). Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population. Population Health Management, 25(3). doi:10.1089/pop.2021.0185
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  Outreach, including patient navigation, has been shown to increase the uptake of colorectal cancer (CRC) screening in underserved populations. This analysis evaluates the cost-effectiveness of triennial multi-target stool DNA (mt-sDNA) versus outreach, with or without a mailed annual fecal immunochemical test (FIT), in a Medicaid population. A microsimulation model estimated the incremental cost-effectiveness ratio using quality-adjusted life years (QALY), direct costs, and clinical outcomes in a cohort of Medicaid beneficiaries aged 50-64 years, over a lifetime time horizon. The base case model explored scenarios of either 100% adherence or real-world reported adherence (51.3% for mt-sDNA, 21.1% for outreach with FIT and 12.3% for outreach without FIT) with or without real-world adherence for follow-up colonoscopy (66.7% for all). Costs and outcomes were discounted at 3.0%. At 100% adherence to both screening tests and follow-up colonoscopy, mt-sDNA costed more and was less effective compared with outreach with or without FIT. When real-world adherence rates were considered for screening strategies (with 100% adherence for follow-up colonoscopy), mt-sDNA resulted in the greatest reduction in incidence and mortality from CRC (41.5% and 45.8%, respectively) compared with outreach with or without FIT; mt-sDNA also was cost-effective versus outreach with and without FIT ($32,150/QALY and $22,707/QALY, respectively). mt-sDNA remained cost-effective versus FIT, with or without outreach, under real-world adherence rates for follow-up colonoscopy. Outreach or navigation interventions, with associated real-world adherence rates to screening tests, should be considered when evaluating the cost-effectiveness of CRC screening strategies in underserved populations.
• Lohr, A., Alves, S., Coulter, K., Redondo-Martinez, F., Coronado, G., David, C., Espinoza, C., Ingram, M., Carvajal, S., & Wilkinson-Lee, A. (2022). Community Health Worker-Led Community Clinical on the U.S. / Mexico Border: Lessons Learned. Progress in Community Health Partnerships: Research, Education, and Action, 16(1). doi:10.1353/cpr.2022.0009
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  Background: Community–clinical linkages (CCLs) connect public health organizations and health care providers to better support patients. Community health workers (CHWs), representatives from priority populations with special connections to their community, can lead CCLs. Objectives: Our objective was to learn about how to conduct a CHW-led CCL from the perspectives of those implementing the intervention. Methods: We conducted focus groups with CHWs and their supervisors and regularly consulted community partners while coding and analyzing data. Results: We learned that CHWs thrive when supported by peers, supervisors, institutions, and researchers. Supervisors— who are new to the CHW role—should consider seeking training in CHW professional development and performance evaluation. Focus group participants agreed that by balancing the strengths and weaknesses of their organization, CHW-led CCLs benefit patients because the collaboration helps them to better manage their health. Conclusions: Future CHW-led CCL practitioners should consider how to best institutionally support CHWs to maximize benefits for patients.
• Rutter, C., May, F., Coronado, G., Pujol, T., Thomas, E., & Cabreros, I. (2022). Racism Is a Modifiable Risk Factor: Relationships Among Race, Ethnicity, and Colorectal Cancer Outcomes. Gastroenterology, 162(4). doi:10.1053/j.gastro.2021.12.251
• Arredondo, E., Dumbauld, J., Milla, M., Madanat, H., Coronado, G., Haughton, J., Garcia-Bigley, F., Ramers, C., Nodora, J., Bharti, B., Lopez, G., Diaz, M., Marquez, J., & Gupta, S. (2021). A Promotor-Led Pilot Study to Increase Colorectal Cancer Screening in Latinos: The Juntos Contra El Cáncer Program. Health Promotion Practice, 22(4). doi:10.1177/1524839920912240
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  Background. Latinos have lower colorectal cancer (CRC) screening rates compared to other racial/ethnic groups in the United States, despite an overall increase in CRC screening over the past 10 years. To address this disparity, we implemented a promotor-led intervention to increase CRC screening test adherence in community-based settings, connecting community members with a partnering federally qualified health center. Purpose. To evaluate the Juntos Contra el Cáncer/Together Against Cancer (JUNTOS) intervention, by assessing pre–post changes in (1) CRC screening test adherence and (2) CRC knowledge and perceived barriers to CRC screening. We also assessed the feasibility and acceptability of program activities. Method. JUNTOS was a group-based intervention, delivered by promotores (community health workers), to promote CRC screening test adherence among Latino adults. The intervention consisted of a culturally tailored 2½-hour interactive workshop followed by an appointment scheduling assistance from a promotor. Workshop participants were Latino adults (males and females) aged 50 to 75 years who were not up-to-date with CRC screening guidelines. We conducted interviews before and 6 to 9 months after the workshop to assess program outcomes. Results. Of the 177 participants included, 118 reported completing the CRC screening test (66.7%) by 6 to 9 months postintervention. We observed baseline to 6- to 9-month increase in CRC knowledge and lower perceived barriers to obtaining CRC screening. Furthermore, the intervention was found to be feasible and acceptable. Conclusion. Results suggest that JUNTOS can be feasibly implemented in partnership with a federally qualified health center. The current study supports group-based CRC interventions in community and clinic settings.
• Coronado, G., Kihn-Stang, A., Slaughter, M., Petrik, A., Thompson, J., Rivelli, J., Jimenez, R., Gibbs, J., Yadav, N., & Mummadi, R. (2021). Follow-up colonoscopy after an abnormal stool-based colorectal cancer screening result: analysis of steps in the colonoscopy completion process. BMC Gastroenterology, 21(1). doi:10.1186/s12876-021-01923-1
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  Background: Delays in receiving follow-up colonoscopy after an abnormal fecal immunochemical test (FIT) result are associated with increased colorectal cancer incidence and mortality. Little is known about patterns of follow-up colonoscopy completion in federally qualified health centers. Methods: We abstracted the medical records of health center patients, aged 50–75 years, who had an abnormal FIT result between August 5, 2017 and August 4, 2018 (N = 711). We assessed one-year rates of colonoscopy referral, pre-procedure visit completion, colonoscopy completion, and time to colonoscopy; associations between these outcomes and patient characteristics; and reasons for non-completion found in the medical record. Results: Of the 711 patients with an abnormal FIT result, 90% were referred to colonoscopy, but only 52% completed a pre-procedure visit, and 43% completed a colonoscopy within 1 year. Median time to colonoscopy was 83 days (interquartile range: 52–131 days). Pre-procedure visit and colonoscopy completion rates were relatively low in patients aged 65–75 (vs. 50–64), who were uninsured (vs. insured) or had no clinic visit in the prior year (vs. ≥ 1 clinic visit). Common reasons listed for non-completion were that the patient declined, or the provider could not reach the patient. Discussion: Efforts to improve follow-up colonoscopy rates in health centers might focus on supporting the care transition from primary to specialty gastroenterology care and emphasize care for older uninsured patients and those having no recent clinic visits. Our findings can inform efforts to improve follow-up colonoscopy uptake, reduce time to colonoscopy receipt, and save lives from colorectal cancer. Trial registration: National Clinical Trial (NCT) Identifier: NCT03925883.
• Coronado, G., Nielson, C., Keast, E., Petrik, A., & Suls, J. (2021). The influence of multi-morbidities on colorectal cancer screening recommendations and completion. Cancer Causes and Control, 32(5). doi:10.1007/s10552-021-01408-2
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  Purpose: Patients’ chronic disease burden can influence the likelihood that providers will recommend cancer screening and that patients will participate in it. Using data from the STOP CRC pragmatic study, we examined associations between chronic disease burden and colorectal cancer screening recommendation and use. Methods: Participating STOP CRC clinics (n = 26) received either usual care or training to implement a mailed fecal immunochemical test (FIT) outreach program. Selected clinic patients (n = 60,187 patients) were aged 50–74 and overdue for colorectal cancer screening. We used logistic regression to examine the associations between FIT recommendations and completion and patients’ chronic disease burden, calculated using the Charlson Comorbidity Index and the Chronic Illness and Disability Payment System. Results: For each index, FIT recommendation odds were 8–9% higher among individuals with minimal chronic disease burden and 13–23% lower among individuals with high chronic disease burden (inverted U-shaped association). Among adults who were ordered a FIT, FIT completion odds were 20% lower for individuals with any, versus no, chronic condition and diminished with increasing disease burden (inverse linear association). Conclusions: Analysis showed an inverted U-shaped association between patients’ chronic disease burden and providers’ recommendation of a FIT and an inverse linear association between patients’ chronic disease burden and FIT completion. ClinicalTrials.gov registration: NCT01742065.
• Coronado, G., Nyongesa, D., Petrik, A., Thompson, J., Escaron, A., Younger, B., Harbison, S., & Leo, M. (2021). Randomized Controlled Trial of Advance Notification Phone Calls vs Text Messages Prior to Mailed Fecal Test Outreach. Clinical Gastroenterology and Hepatology, 19(11). doi:10.1016/j.cgh.2020.07.053
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  Background & Aims: Mailing fecal immunochemical test (FITs) to individuals who are due for screening (mailed FIT outreach) increases colorectal cancer (CRC) screening. Little is known about how phone-based advance notifications (primers) affect the effectiveness of mailed FIT outreach programs. Methods: We performed a prospective study of patients at a large urban health center, 50–75 years old and due for screening, with no record of a prior FIT. Participants were randomly assigned to groups that received a live phone call primer (n = 1203) or a text message primer (n = 1622), from June through December 2018. The participants were then mailed a FIT kit, followed by 2 automated calls, and live reminder calls delivered by the care team. The main outcome was completion of FIT within 3 months of assignment to the live phone call or text message group. Results: Participants had a FIT completion rate of 16.8%, a mean age of 58 years, and 80% were Latino. In adjusted intention to treat analyses (n = 2825), FIT completion rates were higher in the patients assigned to receive a live phone call vs text message primer (percentage point difference, 3.3%; 95% CI, 0.4%–6.2%). Between-group differences increased to 7.3% points (95% CI, 3.6%–11.0%) in the per-protocol analysis of 2144 participants reached by the text message (1320/1622, 81%), live call (438/1203, 36%), or voice message (386/1203, 32%). This rate increased to 14.9% points (95% CI; 9.6%–20.1%) in the per-protocol analysis of 1758 participants reached by the text message or reached by the live call. Conclusions: In a randomized trial, advance notification live phone calls outperformed text messages in prompting health center patients who had not previously completed a FIT to complete a mailed FIT. Clinicaltrials.gov no: NCT03167125
• Coronado, G., Rawlings, A., Petrik, A., Slaughter, M., Johnson, E., Hannon, P., Cole, A., Vu, T., & Mummadi, R. (2021). Precision Patient Navigation to Improve Rates of Follow-up Colonoscopy, An Individual Randomized Effectiveness Trial. Cancer Epidemiology Biomarkers and Prevention, 30(12). doi:10.1158/1055-9965.epi-20-1793
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  Background: Colorectal cancer screening by annual fecal immunochemical test (FIT) with follow-up on abnormal results is a cost-effective strategy to reduce colorectal cancer incidence and mortality. Unfortunately, many patients with abnormal results do not complete a follow-up colonoscopy. We tested whether navigation targeted to patients who are unlikely to complete the procedure may improve adherence and long-term outcomes. Methods: Study participants were patients at a large, integrated health system (Kaiser Permanente Northwest) who were ages 50 to 75 and were due for a follow-up colonoscopy after a recent abnormal FIT result. Probability of adherence to follow-up was estimated at baseline using a predictive risk model. Patients whose probability was 70% or lower were randomized to receive patient navigation or usual care, with randomization stratified by probability category (
• Coury, J., Miech, E., Styer, P., Petrik, A., Coates, K., Green, B., Baldwin, L., Shapiro, J., & Coronado, G. (2021). What’s the “secret sauce”? How implementation variation affects the success of colorectal cancer screening outreach. Implementation Science Communications, 2(1). doi:10.1186/s43058-020-00104-7
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  Background: Mailed fecal immunochemical testing (FIT) programs can improve colorectal cancer (CRC) screening rates, but health systems vary how they implement (i.e., adapt) these programs for their organizations. A health insurance plan implemented a mailed FIT program (named BeneFIT), and participating health systems could adapt the program. This multi-method study explored which program adaptations might have resulted in higher screening rates. Methods: First, we conducted a descriptive analysis of CRC screening rates by key health system characteristics and program adaptations. Second, we generated an overall model by fitting a weighted regression line to our data. Third, we applied Configurational Comparative Methods (CCMs) to determine how combinations of conditions were linked to higher screening rates. The main outcome measure was CRC screening rates. Results: Seventeen health systems took part in at least 1 year of BeneFIT. The overall screening completion rate was 20% (4–28%) in year 1 and 25% (12–35%) in year 2 of the program. Health systems that used two or more adaptations had higher screening rates, and no single adaptation clearly led to higher screening rates. In year 1, small systems, with just one clinic, that used phone reminders (n = 2) met the implementation success threshold (≥ 19% screening rate) while systems with > 1 clinic were successful when offering a patient incentive (n = 4), scrubbing mailing lists (n = 4), or allowing mailed FIT returns with no other adaptations (n = 1). In year 2, larger systems with 2–4 clinics were successful with a phone reminder (n = 4) or a patient incentive (n = 3). Of the 10 systems that implemented BeneFIT in both years, seven improved their CRC screening rates in year 2. Conclusions: Health systems can choose among many adaptations and successfully implement a health plan’s mailed FIT program. Different combinations of adaptations led to success with health system size emerging as an important contextual factor.
• Davis, M., Schneider, J., Gunn, R., Rivelli, J., Vaughn, K., & Coronado, G. (2021). A qualitative study of patient preferences for prompts and reminders for a direct-mail fecal testing program. Translational Behavioral Medicine, 11(2). doi:10.1093/tbm/ibaa010
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  Programs that directly mail fecal immunochemical tests (FIT) to patients can increase colorectal cancer (CRC) screening, especially in low-income and Latino populations. Few studies have explored patient reactions to prompts or reminders that accompany such programs. As part of the Participatory Research to Advance Colon Cancer Prevention pilot study, which tested prompts and reminders to a direct-mail FIT program in a large, urban health center, we conducted telephone interviews among English-and Spanish-speaking participants who were assigned to receive a series of text message prompts, automated phone call reminders, and/or live phone call reminders. We analyzed interviews using a qualitative content analysis approach. We interviewed 41 participants, including 25 responders (61%) and 16 nonresponders (39%) to the direct-mail program. Participants appreciated program ease and convenience. Few participants recalled receiving prompts or automated/live reminders; nevertheless, the vast majority (95%, n = 39) thought reminders were acceptable and helpful and suggested that 2-3 reminders delivered starting 1 week after the mailed FIT would optimally encourage completion. Prompts and reminders used with mailed-FIT programs are accepted by patients, and my help boost response rates.
• Kepka, D., Christini, K., McGough, E., Wagner, A., Del Fiol, G., Gibson, B., Ayres, S., Brandt, H., Mann, S., Petrik, A., & Coronado, G. (2021). Successful Multi-Level HPV Vaccination Intervention at a Rural Healthcare Center in the Era of COVID-19. Frontiers in Digital Health, 3. doi:10.3389/fdgth.2021.719138
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  Objectives: To develop and test a human papillomavirus (HPV) vaccination intervention that includes healthcare team training activities and patient reminders to reduce missed opportunities and improves the rate of appointment scheduling for HPV vaccination in a rural medical clinic in the United States. Methods: The multi-level and multi-component intervention included healthcare team training activities and the distribution of patient education materials along with technology-based patient HPV vaccination reminders for parents/caregivers and young adult patients. Missed vaccination opportunities were assessed pre- and post-intervention (n = 402 and n = 99, respectively) by retrospective chart review and compared using Pearson χ2. The patient parent/caregiver and young adult patient population (n = 80) was surveyed following the reminder messages and penalized logistic regression quantified unadjusted odds of scheduling a visit. Results: Missed opportunities for HPV vaccination declined significantly from the pre-intervention to the post-intervention period (21.6 vs. 8.1%, respectively, p = 0.002). Participants who recalled receipt of a vaccination reminder had 7.0 (95% CI 2.4–22.8) times higher unadjusted odds of scheduling a visit compared with those who did not recall receiving a reminder. The unadjusted odds of confirming that they had scheduled or were intending to schedule a follow-up appointment to receive the HPV vaccine was 4.9 (95% CI 1.51–20.59) times greater among those who had not received the vaccine for themselves or for their child. Conclusions: Results from this intervention are promising and suggest that vaccination interventions consisting of provider and support staff education and parent/caregiver and patient education materials, and reminders can reduce missed opportunities for vaccinations in rural settings.
• Meenan, R., Baldwin, L., Coronado, G., Schwartz, M., Coury, J., Petrik, A., West, I., & Green, B. (2021). Costs of Two Health Insurance Plan Programs to Mail Fecal Immunochemical Tests to Medicare and Medicaid Plan Members. Population Health Management, 24(2). doi:10.1089/pop.2020.0041
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  BeneFIT is a 4-year observational study of a mailed fecal immunochemical test (FIT) program in 2 Medicaid/Medicare health plans in Oregon and Washington. In Health Plan Oregon's (HPO) collaborative model, HPO mails FITs that enrollees return to their clinics for processing. In Health Plan Washington's (HPW) centralized model, FITs are mailed directly to enrollees who return them to a centralized laboratory. This paper examines model-specific Year 1 development and implementation costs and estimates costs per screened enrollee. Staff completed activity-based costing spreadsheets. Non-labor costs were from study and external data. Data matched each plan's 2016 development and implementation dates. HPO development costs were $23.0K, primarily administration (eg, clinic recruitment). HPW development costs were $37.3K, 38.8% for FIT selection and mailing/tracking protocols. Year 1 implementation costs were $51.6K for HPO and $139.7K for HPW, reflecting HPW's greater outreach. Labor was 50.4% ($26.0K) of HPO's implementation costs, primarily enrollee eligibility and processing returned FITs, and was shared by HPO ($17.0K) and 6 participating clinics ($9.0K). Labor was 10.5% of HPW's implementation costs, primarily administration and enrollee eligibility. HPO's implementation costs per enrollee were 12.3% higher ($18.36) than for HPW ($16.34). Similar proportions of completed FITs among screening-eligibles produced a 15% lower cost per completed FIT in HPW ($89.75) vs. HPO ($105.79). Implementation costs for HPO only (without clinic costs) were $15.16/mailed introductory letter, $16.09/mailed FIT, and $87.35/completed FIT, comparable to HPW. Results highlight cost implications of different approaches to implementing a mailed FIT program in 2 Medicaid/Medicare health plans.
• Mojica, C., Lind, B., Gu, Y., Coronado, G., & Davis, M. (2021). Predictors of Colorectal Cancer Screening Modality Among Newly Age-Eligible Medicaid Enrollees. American Journal of Preventive Medicine, 60(1). doi:10.1016/j.amepre.2020.08.003
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  Introduction: This study examines individual- and practice-level predictors of screening modality among 1,484 Medicaid enrollees who initiated colorectal cancer screening (fecal immunochemical test/fecal occult blood tests or colonoscopy) within a year of turning age 50 years. Understanding screening modality patterns for patients and health systems can help optimize colorectal cancer screening initiatives that will lead to high screening completion rates. Methods: Multivariable logistic regression was conducted in 2019 to analyze Medicaid claims data (January 2013–June 2015) to explore predictors of colonoscopy screening (versus fecal testing). Results: Overall, 64% of enrollees received a colonoscopy and 36% received a fecal immunochemical test/fecal occult blood test. Male (OR=1.21, 95% CI=1.08, 1.37) compared with female enrollees and those with 4–6 (OR=1.57, 95% CI=1.15, 2.15), 7–10 (OR=2.23, 95% CI=1.64, 3.03), and ≥11 (OR=1.79, 95% CI=1.22, 2.65) primary care visits compared with 0–3 visits had higher odds of colonoscopy screening. Non-White, non-Hispanic enrollees (OR=0.71, 95% CI=0.58, 0.87) compared with White, non-Hispanics Whites had lower odds of colonoscopy screening. Practices with an endoscopy facility within their ZIP code (OR=1.50, 95% CI=1.08, 2.08) compared with practices without a nearby endoscopy facility had higher odds of colonoscopy screening. Conclusions: Among newly age-eligible Medicaid enrollees who received colorectal cancer screening, non-White, non-Hispanic individuals were less likely and male enrollees and those with ≥4 primary care visits were more likely to undergo colonoscopy versus fecal immunochemical test/fecal occult blood test. Colonoscopy also was the more common modality among adults whose primary care clinic had an endoscopy facility in the same ZIP code. Future research is needed to fully understand patient, provider, and practice preferences regarding screening modality.
• Tuzzio, L., Meyers, C., Dember, L., Grudzen, C., Melnick, E., Staman, K., Huang, S., Richards, J., DeBar, L., Vazquez, M., Green, B., Coronado, G., Jarvik, J., Braciszewski, J., Ho, P., Wells, B., James, K., Toto, R., D'Onofrio, G., , Volandes, A., et al. (2021). Accounting for quality improvement during the conduct of embedded pragmatic clinical trials within healthcare systems: NIH Collaboratory case studies. Healthcare, 8. doi:10.1016/j.hjdsi.2020.100432
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  Embedded pragmatic clinical trials (ePCTs) and quality improvement (QI) activities often occur simultaneously within healthcare systems (HCSs). Embedded PCTs within HCSs are conducted to test interventions and provide evidence that may impact public health, health system operations, and quality of care. They are larger and more broadly generalizable than QI initiatives, and may generate what is considered high-quality evidence for potential use in care and clinical practice guidelines. QI initiatives often co-occur with ePCTs and address the same high-impact health questions, and this co-occurrence may dilute or confound the ability to detect change as a result of the ePCT intervention. During the design, pilot, and conduct phases of the large-scale NIH Collaboratory Demonstration ePCTs, many QI initiatives occurred at the same time within the HCSs. Although the challenges varied across the projects, some common, generalizable strategies and solutions emerged, and we share these as case studies. Key lessons: Study teams often need to monitor, adapt, and respond to QI during design and the course of the trial. Routine collaboration between ePCT researchers and health systems stakeholders throughout the trial can help ensure research and QI are optimally aligned to support high-quality patient-centered care.
• Baldwin, L., Schneider, J., Schwartz, M., Rivelli, J., Green, B., Petrik, A., & Coronado, G. (2020). First-year implementation of mailed FIT colorectal cancer screening programs in two Medicaid/Medicare health insurance plans: Qualitative learnings from health plan quality improvement staff and leaders. BMC Health Services Research, 20(1). doi:10.1186/s12913-019-4868-5
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  Background: Colorectal cancer screening rates remain low, especially among certain racial and ethnic groups and the uninsured and Medicaid insured. Clinics and health care systems have adopted population-based mailed fecal immunochemical testing (FIT) programs to increase screening, and now health insurance plans are beginning to implement mailed FIT programs. We report on challenges to and successes of mailed FIT programs during their first year of implementation in two health plans serving Medicaid and dual eligible Medicaid/Medicare enrollees. Methods: This qualitative descriptive study gathered data through in-depth interviews with staff and leaders at each health plan (n = 10). The Consolidated Framework for Implementation Research, field notes from program planning meetings between the research team and the health plans, and internal research team debriefs informed interview guide development. Qualitative research staff used Atlas.ti to code the health plan interviews and develop summary themes through an iterative content analysis approach. Results: We identified first-year implementation challenges in five thematic areas: 1) program design, 2) vendor experience, 3) engagement/communication, 4) reaction/satisfaction of stakeholders, and 5) processing/returning of mailed kits. Commonly experienced challenges by both health plans related to the time-consuming nature of the programs to set up, and complexities and delays in working with vendors. We found implementation successes in the same five thematic areas as well as four additional areas of: 1) leadership support, 2) compatibility with the health plan, 3) broader impacts, and 4) collaboration with researchers. Commonly experienced successes included the ability to adapt the mailed FIT program to the individual health plan culture and needs, and the synchronicity between the programs and their organizational missions and goals. Conclusions: Both health plans successfully adapted mailed FIT programs to their own culture and resources and used their strong quality management resources to maximize success in overcoming the time demands of setting up the program and working with their vendors. Mailed FIT programs administered by health plans, especially those serving Medicaid- and dual eligible Medicaid/Medicare-insured populations, may be an important resource to support closing gaps in colorectal cancer screening among traditionally underserved populations.
• Coronado, G. (2020). Who is reached with clinic in-reach and outreach strategies to promote colorectal cancer screening?. American Journal of Public Health, 110(4). doi:10.2105/ajph.2020.305593
• Coronado, G., Green, B., West, I., Schwartz, M., Coury, J., Vollmer, W., Shapiro, J., Petrik, A., & Baldwin, L. (2020). Direct-to-member mailed colorectal cancer screening outreach for Medicaid and Medicare enrollees: Implementation and effectiveness outcomes from the BeneFIT study. Cancer, 126(3). doi:10.1002/cncr.32567
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  Background: Colorectal cancer screening uptake is low, particularly among individuals enrolled in Medicaid. To the authors' knowledge, little is known regarding the effectiveness of direct-to-member outreach by Medicaid health insurance plans to raise colorectal cancer screening use, nor how best to deliver such outreach. Methods: BeneFIT is a hybrid implementation-effectiveness study of 2 program models that health plans developed for a mailed fecal immunochemical test (FIT) intervention. The programs differed with regard to whether they used a centralized approach (Health Plan Washington) or collaborated with health centers (Health Plan Oregon). The primary implementation outcome of the current study was the percentage of eligible enrollees to whom the plans delivered each intervention component. The primary effectiveness outcome was the rate of FIT completion within 6 months of mailing of the introductory letter. Results: The health plans identified 12,000 eligible enrollees (8551 in Health Plan Washington and 3449 in Health Plan Oregon). Health Plan Washington mailed an introductory letter and FIT kit to 8551 enrollees (100%) and delivered a reminder call to 839 (10.3% of the 8132 attempted). Health Plan Oregon mailed an introductory letter, and a letter and FIT kit plus a reminder postcard to 2812 enrollees (81.5%) and 2650 enrollees (76.8%), respectively. FIT completion rates were 18.2% (1557 of 8551 enrollees) in Health Plan Washington. In Health Plan Oregon, completion rates were 17.4% (488 of 2812 enrollees) among enrollees who were mailed an introductory letter and 18.3% (484 of 2650 enrollees) among enrollees who also were mailed a FIT kit plus reminder postcard. Conclusions: The implementation of mailed FIT outreach by health plans may be effective and could reach many individuals at risk of developing colorectal cancer.
• Coronado, G., Johnson, E., Leo, M., Schneider, J., Smith, D., Mummadi, R., Petrik, A., Thompson, J., & Jimenez, R. (2020). Patient randomized trial of a targeted navigation program to improve rates of follow-up colonoscopy in community health centers. Contemporary Clinical Trials, 89. doi:10.1016/j.cct.2019.105920
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  Background: Colorectal cancer (CRC) screening by annual fecal immunochemical test (FIT) is an accessible and cost-effective strategy to lower CRC incidence and mortality. However, this mode of screening depends on follow-up colonoscopy after a positive FIT result. Unfortunately, nearly one-half of FIT-positive patients fail to complete this essential screening component. Patient navigation may improve follow-up colonoscopy adherence. To deliver patient navigation cost-effectively, health centers could target navigation to patients who are unlikely to complete the procedure on their own. Objectives: The Predicting and Addressing Colonoscopy Non-adherence in Community Settings (PRECISE) clinical trial will validate a risk model of follow-up colonoscopy adherence and test whether patient navigation raises rates of colonoscopy adherence overall and among patients in each probability stratum (low, moderate, and high probability of adherence without intervention). Methods: PRECISE is a collaboration with a large community health center whose patient population is 37% Latino. Eligible patients will be aged 50–75, have an abnormal FIT result in the past month, and be due for a follow-up colonoscopy. Patients will be randomized to patient navigation or usual care. Primary outcomes will be colonoscopy completion within one year of a positive FIT result, cost, and cost-effectiveness. Secondary outcomes will include time to colonoscopy receipt, adequacy of bowel prep, and communication of results to primary care providers. Primary and secondary outcomes will be reported overall and by probability stratum. Discussion: This innovative clinical trial will test the effectiveness and financial feasibility of using a precision health intervention to improve CRC screening completion in community health centers. Trial Registration: National Clinical Trial (NCT) Identifier: NCT03925883.
• Coronado, G., Schneider, J., Green, B., Coury, J., Schwartz, M., Kulkarni-Sharma, Y., & Baldwin, L. (2020). Health plan adaptations to a mailed outreach program for colorectal cancer screening among Medicaid and Medicare enrollees: The BeneFIT study. Implementation Science, 15(1). doi:10.1186/s13012-020-01037-4
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  Background: Promoting uptake of evidence-based innovations in healthcare systems requires attention to how innovations are adapted to enhance their fit with a given setting. Little is known about real-world variation in how programs are delivered over time and across multiple populations and contexts, and what motivates adaptations. Methods: As part of the BeneFIT study of mailed fecal immunochemical tests (FIT) to increase colorectal cancer screening, we interviewed 9 leaders from two participating Medicaid/Medicare health insurance plans to examine adaptations to their health plan-initiated mailed FIT outreach programs in the second year of implementation. We applied an adaptation and modification model developed by Stirman and colleagues to document content and context modifications made to the two programs. Results: Both health plans made substantial changes to their programs in the second year; adaptations differed substantially across health plans. In Health Plan Oregon, adaptations generally targeted health centers and member populations, most content adaptations involved tailoring program components, and the program was expanded to four additional health centers. In contrast, Health Plan Washington's second-year content adaptations were primarily at the level of members, and generally involved adding program components. Moreover, Health Plan Washington undertook large-scale context adaptations to the setting where the program was led (local vs. national), the personnel who administered the program (vendor and staffing), and the population selected for outreach (limiting outreach to dual-eligible members). Conclusions: Both programs implemented a variety of adaptations that reflected the values and incentives of the broader health plan contexts. Financial incentives for screening allowed Health Plan Oregon to expand but led Health Plan Washington to offer more targeted outreach to a subset of eligible enrollees. The breadth of changes made by each health system reflects the necessity of evaluating programs in context and adjusting to specific challenges as they are identified. Further research is needed to understand the effects of these types of adaptations on program efficiency and enrollee and health system outcomes.
• Green, B., Baldwin, L., West, I., Schwartz, M., & Coronado, G. (2020). Low Rates of Colonoscopy Follow-up After a Positive Fecal Immunochemical Test in a Medicaid Health Plan Delivered Mailed Colorectal Cancer Screening Program. Journal of Primary Care and Community Health, 11. doi:10.1177/2150132720958525
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  Background: Follow-up colonoscopy after a positive fecal immunochemical test (FIT) is necessary for colorectal cancer (CRC) screening to be effective. We report colonoscopy follow-up rates after a positive FIT overall and by population characteristics in the BeneFIT demonstration pilot, a Medicaid health insurance plan-delivered mailed FIT outreach program. Methods: In 2016, 2 health insurance plans in Oregon and in Washington state mailed FIT kits to Medicaid patients who, based on claims data, were overdue for CRC screening. We report follow-up colonoscopy completion rates after positive FIT, and differences in completion rates by age, sex, race, ethnicity, preferred language, and number of primary care visits in the prior year. This research was human subjects approved with a waiver of consent for data collection. Results: The FIT positivity rates in Health Plan Oregon and Health Plan Washington were 7.9% (39/488) and 14.6% (125/857), respectively. Colonoscopy completion rates within 12 months of the positive test were 35.9% (14/41) in Health Plan Oregon and 32.8% (41/125) in Health Plan Washington. Colonoscopy completion rates were higher among individuals who preferred a language other than English (Non-English speakers 70.0%, English speakers 31.3%, P =.04). Conclusion: In a health plan-delivered mailed FIT outreach program, follow-up colonoscopy rates after a positive test were low. Additional interventions are needed to assure colonoscopy after a positive FIT test and to reap the benefits of screening.
• Green, B., West, I., Baldwin, L., Schwartz, M., Coury, J., & Coronado, G. (2020). Challenges in Reaching Medicaid and Medicare Enrollees in a Mailed Fecal Immunochemical Test Program. Journal of Community Health, 45(5). doi:10.1007/s10900-020-00809-9
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  BeneFIT was a demonstration project that worked with a Medicaid/Medicare health plan to implement a mailed fecal immunochemical test (FIT) program. The goal was to reach age-eligible enrollees who were due for colorectal cancer (CRC) screening and prompt them to complete a FIT. One health insurance plan collaborated with six federally qualified health centers (FQHCs) in Oregon. Reach was defined as the percent of eligible individuals overdue for CRC screening who were mailed a FIT in 2016. We examined patient-level factors associated with reach, using multivariable log binomial regression and FIT completion rates at 6 months. The health plan identified 3386 age-eligible members overdue for CRC screening. Of these, 2615 (77.2%) were reached (mailed FIT kits) and 771 (22.8%) were not; 478 (14.1%) because they were not considered to be clinic patients and 290 (8.6%) because of mailing issues. Patient-level factors associated with not being reached were: being male, being Medicaid-insured (vs. Medicare), and having no primary care visits (vs. 4+ visits) in the last year. Among all enrollees identified as overdue for CRC screening, FIT completion rates at 6 months were 14.8% overall and 18.5% in the subgroup reached. In a mailed FIT program, a health insurance plan attempted to reach as many enrollees overdue for CRC screening as possible, however 22.8% were not mailed a FIT. Additional efforts are needed to ensure that the hardest to reach enrollees can participate in CRC screening.
• Gupta, S., Coronado, G., Argenbright, K., Brenner, A., Dominitz, J., Green, B., Issaka, R., Levin, T., Reuland, D., Richardson, L., Robertson, D., Singal, A., Pignone, M., & Castañeda, S. (2020). Mailed fecal immunochemical test outreach for colorectal cancer screening: Summary of a Centers for Disease Control and Prevention–sponsored Summit. CA Cancer Journal for Clinicians, 70(4). doi:10.3322/caac.21615
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  Uptake of colorectal cancer screening remains suboptimal. Mailed fecal immunochemical testing (FIT) offers promise for increasing screening rates, but optimal strategies for implementation have not been well synthesized. In June 2019, the Centers for Disease Control and Prevention convened a meeting of subject matter experts and stakeholders to answer key questions regarding mailed FIT implementation in the United States. Points of agreement included: 1) primers, such as texts, telephone calls, and printed mailings before mailed FIT, appear to contribute to effectiveness; 2) invitation letters should be brief and easy to read, and the signatory should be tailored based on setting; 3) instructions for FIT completion should be simple and address challenges that may lead to failed laboratory processing, such as notation of collection date; 4) reminders delivered to initial noncompleters should be used to increase the FIT return rate; 5) data infrastructure should identify eligible patients and track each step in the outreach process, from primer delivery through abnormal FIT follow-up; 6) protocols and procedures such as navigation should be in place to promote colonoscopy after abnormal FIT; 7) a high-quality, 1-sample FIT should be used; 8) sustainability requires a program champion and organizational support for the work, including sufficient funding and external policies (such as quality reporting requirements) to drive commitment to program investment; and 9) the cost effectiveness of mailed FIT has been established. Participants concluded that mailed FIT is an effective and efficient strategy with great potential for increasing colorectal cancer screening in diverse health care settings if more widely implemented.
• Mojica, C., Bradley, S., Lind, B., Gu, Y., Coronado, G., & Davis, M. (2020). Initiation of Colorectal Cancer Screening Among Medicaid Enrollees. American Journal of Preventive Medicine, 58(2). doi:10.1016/j.amepre.2019.09.015
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  Introduction: Few studies have explored how individual- and practice-level factors influence colorectal cancer screening initiation among Medicaid enrollees newly age eligible for colorectal cancer screening (i.e., turning 50 years). This study explored colorectal cancer screening initiation among newly age-eligible Medicaid enrollees in Oregon. Methods: Medicaid claims data (January 2013 to June 2015) were used to conduct multivariable logistic regression (in 2018 and 2019) to explore individual- and practice-level factors associated with colorectal cancer screening initiation among 9,032 Medicaid enrollees. Results: A total of 17% of Medicaid enrollees initiated colorectal cancer screening; of these, 64% received a colonoscopy (versus fecal testing). Colorectal cancer screening initiation was positively associated with turning 50 years in 2014 (versus 2013; OR=1.21), being Hispanic (versus non-Hispanic white; OR=1.41), urban residence (versus rural; OR=1.23), and having 4 to 7 (OR=1.90) and 8 or more (OR=2.64) primary care visits compared with 1 to 3 visits in the year after turning 50 years. Having 3 or more comorbidities was inversely associated with initiation (OR=0.75). The odds of screening initiation were also higher for practices with 3 to 4 (OR=1.26) and 8 or more (OR=1.34) providers compared with 1 to 2 providers, and negatively associated with percentage of Medicaid panel age eligible for colorectal cancer screening (OR=0.92). Conclusions: Both individual- and practice-level factors are associated with disparities in colorectal cancer screening initiation among Oregon Medicaid enrollees. Future work promoting colorectal cancer screening might focus on additional barriers to the timely initiation of colorectal cancer screening and explore the effect of practice in-reach and population outreach strategies.
• Nielson, C., Petrik, A., Green, B., Coronado, G., & O’Connor, E. (2020). Prospective Cohort study of Predictors of Follow-Up Diagnostic Colonoscopy from a Pragmatic Trial of FIT Screening. Scientific Reports, 10(1). doi:10.1038/s41598-020-59032-0
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  The goal of this study was to explore diagnostic colonoscopy completion in adults with abnormal screening fecal immunochemical test (FIT) results. This was a secondary analysis of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (Stop CRC) study, a cluster-randomized pragmatic trial to increase uptake of CRC screening in federally qualified community health clinics. Diagnostic colonoscopy completion and reasons for non-completion were ascertained through a manual review of electronic health records, and completion was compared across a wide range of individual patient health and sociodemographic characteristics. Among 2,018 adults with an abnormal FIT result, 1066 (52.8%) completed a follow-up colonoscopy within 12 months. Completion was generally similar across a wide range of participant subpopulations; however, completion was higher for participants who were younger, Hispanic, Spanish-speaking, and had zero or one of the Charlson medical comorbidities, compared to their counterparts. Neighborhood-level predictors were not associated with diagnostic colonoscopy completion. Thus, completion of a diagnostic colonoscopy was relatively low in a large sample of community health clinic adults who had an abnormal screening FIT result. While completion was generally similar across a wide range of characteristics, younger, healthier, Hispanic participants tended to have a higher likelihood of completion.
• O'Connor, E., Vollmer, W., Petrik, A., Green, B., & Coronado, G. (2020). Moderators of the effectiveness of an intervention to increase colorectal cancer screening through mailed fecal immunochemical test kits: Results from a pragmatic randomized trial. Trials, 21(1). doi:10.1186/s13063-019-4027-7
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  Background: Colorectal cancer (CRC) screening rates remain suboptimal, particularly in low-income and underserved populations. Mailed fecal immunochemical testing (FIT) may overcome common barriers to screening; however, the effect of mailed FIT kits may differ across important subpopulations. The goal of the current study was to examine sociodemographic and health-related factors that moderate the effect of an intervention of automated direct mail of FIT kits at health clinics serving low-income populations. Methods: This study is a secondary analysis of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) study, a cluster-randomized pragmatic trial to increase uptake of CRC screening in patients seen at federally qualified health centers. The intervention involved tools embedded in the electronic medical records to enable participating clinics to mail FIT kits and related materials to eligible participants. We examined the rate of FIT completion by potential moderating characteristics using electronic health record data supplemented by the American Community Survey and the Centers for Medicare & Medicaid Services Geographic Variation datasets, linked via geocoding to patients' addresses. All patients aged 50-75 seen in participating health clinics who were eligible for CRC screening were included. Results: Although not always statistically significant, we saw a consistent pattern of increased FIT return rates among intervention participants compared to control participants across all subgroups studied, with incidence rate ratios (IRRs) generally ranging from 1.25 to 1.50. FIT completion in the intervention group ranged from 15 and 20% across subpopulations, typically three to six percentage points higher than the control group participants. The only moderator with a statistically significant interaction was race: persons of Asian descent showed a twofold response to the intervention (adjusted incidence rate ratio [aIRR] = 2.06, 95% confidence interval 1.41 to 3.00). Conclusions: Response to a mailed FIT intervention was generally consistent across a wide range of individual and neighborhood-level patient characteristics, including typically underserved patients and those in low-resource communities. Trial registration: ClinicalTrials.gov, NCT01742065. Registered on 5 December 2012.
• Petrik, A., Green, B., Schneider, J., Miech, E., Coury, J., Retecki, S., & Coronado, G. (2020). Factors Influencing Implementation of a Colorectal Cancer Screening Improvement Program in Community Health Centers: an Applied Use of Configurational Comparative Methods. Journal of General Internal Medicine, 35. doi:10.1007/s11606-020-06186-2
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  Background: Evidence-based programs such as mailed fecal immunochemical test (FIT) outreach can only affect health outcomes if they can be successfully implemented. However, attempts to implement programs are often limited by organizational-level factors. Objectives: As part of the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) pragmatic trial, we evaluated how organizational factors impacted the extent to which health centers implemented a mailed FIT outreach program. Design: Eight health centers participated in STOP CRC. The intervention consisted of customized electronic health record tools and clinical staff training to facilitate mailing of an introduction letter, FIT kit, and reminder letter. Health centers had flexibility in how they delivered the program. Main Measures: We categorized the health centers’ level of implementation based on the proportion of eligible patients who were mailed a FIT kit, and applied configurational comparative methods to identify combinations of relevant organizational-level and program-level factors that distinguished among high, medium, and low implementing health centers. The factors were categorized according to the Consolidated Framework for Implementation Research model. Key Results: FIT tests were mailed to 21.0–81.7% of eligible participants at each health center. We identified a two-factor solution that distinguished among levels of implementation with 100% consistency and 100% coverage. The factors were having a centralized implementation team (inner setting) and mailing the introduction letter in advance of the FIT kit (intervention characteristics). Health centers with high levels of implementation had the joint presence of both factors. In health centers with medium levels of implementation, only one factor was present. Health centers with low levels of implementation had neither factor present. Conclusions: Full implementation of the STOP CRC intervention relied on a centralized implementation team with dedicated staffing time, and the advance mailing of an introduction letter. Trial Registration: ClinicalTrials.gov Identifier: NCT01742065 Registered 05 December 2012–Prospectively registered.
• Petrik, A., Keast, E., Johnson, E., Smith, D., & Coronado, G. (2020). Development of a multivariable prediction model to identify patients unlikely to complete a colonoscopy following an abnormal FIT test in community clinics. BMC Health Services Research, 20(1). doi:10.1186/s12913-020-05883-2
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  Background: Colorectal cancer (CRC) is the 3rd leading cancer killer among men and women in the US. The Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project aimed to increase CRC screening among patients in Federally Qualified Health Centers (FQHCs) through a mailed fecal immunochemical test (FIT) outreach program. However, rates of completion of the follow-up colonoscopy following an abnormal FIT remain low. We developed a multivariable prediction model using data available in the electronic health record to assess the probability of patients obtaining a colonoscopy following an abnormal FIT test. Methods: To assess the probability of obtaining a colonoscopy, we used Cox regression to develop a risk prediction model among a retrospective cohort of patients with an abnormal FIT result. Results: Of 1596 patients with an abnormal FIT result, 556 (34.8%) had a recorded colonoscopy within 6 months. The model shows an adequate separation of patients across risk levels for non-adherence to follow-up colonoscopy (bootstrap-corrected C-statistic > 0.63). The refined model included 8 variables: age, race, insurance, GINI income inequality, long-term anticoagulant use, receipt of a flu vaccine in the past year, frequency of missed clinic appointments, and clinic site. The probability of obtaining a follow-up colonoscopy within 6 months varied across quintiles; patients in the lowest quintile had an estimated 18% chance, whereas patients in the top quintile had a greater than 55% chance of obtaining a follow-up colonoscopy. Conclusions: Knowing who is unlikely to follow-up on an abnormal FIT test could help identify patients who need an early intervention aimed at completing a follow-up colonoscopy. Trial registration: This trial was registered at ClinicalTrials.gov (NCT01742065) on December 5, 2012. The protocol is available.
• Schneider, J., Rivelli, J., Gruss, I., Petrik, A., Nielson, C., Green, B., & Coronado, G. (2020). Barriers and Facilitators to Timely Colonoscopy Completion for Safety Net Clinic Patients. American Journal of Health Behavior, 44(4). doi:10.5993/ajhb.44.4.8
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  Objectives: In this study, we conducted telephone interviews with patients in community clinics who had abnormal fecal immunochemical test (FIT) results to identify follow-up colonoscopy challenges. The FIT is an effective colorectal cancer screening method, but its value is contingent on follow-up diagnostic colonoscopy. Methods: We explored barriers at 3 timepoints: (1) abnormal FIT-result communication, (2) scheduling/completion of colonoscopy, and (3) receipt of results. We sought to understand variation in experience by both Spanish and English language patients. Results: We interviewed 32 patients (16 English; 16 Spanish), 66% of whom were women. There were 13 early completers (≤ 2 months after FIT result), 14 later completers (> 2 months after FIT result), and 5 non-completers of the colonoscopy. The greatest challenge was fear of the procedure, expressed more often by Spanish language (SL) participants and later completers. SL participants also cited cost and lack of clear communication about the need for a colonoscopy. English language (EL) participants experienced lack of reliable transportation. Conclusions: Barriers to timely colonoscopy completion following an abnormal FIT can occur at different transitions in care and vary by patient characteristics. Our findings may inform the design of programs to improve colonoscopy completion in safety net clinics.
• Coronado, G., Thompson, J., Petrik, A., Nyongesa, D., Leo, M., Castillo, M., Younger, B., Escaron, A., & Chen, A. (2019). Patient-refined messaging for a mailed colorectal cancer screening program: Findings from the PROMPT study. Journal of the American Board of Family Medicine, 32(3). doi:10.3122/jabfm.2019.03.180275
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  BackgroUnd: Improving uptake of colorectal cancer screening has the potential of saving thousands of lives. We compared the effectiveness of automated and live prompts and reminders as part of a mailed fecal immunochemical test (FIT) outreach program. Design and Methods: Participants were 1767 adults aged 50 to 75 eyars who were not up-to-date with colorectal cancer screening recommendations at a participating community health center clinic. In addition to a mailed FIT kit, participants were randomized to receive (1) a text message prompt and 2 automated phone call reminders (automated condition); (2) up to 3 live call reminders (live condition); or (3) a text message prompt, 2 automated call reminders, and up to 3 live reminders (combined automated plus live condition). We assessed FIT completion rates in each group 6 months following randomization. Key Results: Nearly one-third of participants completed an FIT within 6 months. Compared with adults allocated to the automated condition, FIT completion rates were higher in adults allocated to the live condition (32.3% vs 26.0%; adjusted difference, 6.3 percentage points; 95% CI, 1.1–11.4) and in adults allocated to the combined automated plus live condition (35.7% vs 26.0%; adjusted difference, 9.7 percentage points; 95% CI, 4.4 –14.9). The number of kits needed to mail to achieve a completed FIT ranged from 2.8 in the combined automated plus live condition to 3.8 in the automated condition. Conclusions: Among unscreened individuals in this population, live phone call reminders either alone or in combination with automated prompts and reminders outperformed automated approaches alone.
• Curtis, L., Dember, L., Vazquez, M., Murray, D., DeBar, L., Staman, K., Septimus, E., Mor, V., Volandes, A., Wells, B., Huang, S., Green, B., Coronado, G., Meyers, C., Tuzzio, L., Hernandez, A., & Sugarman, J. (2019). Addressing guideline and policy changes during pragmatic clinical trials. Clinical Trials, 16(4). doi:10.1177/1740774519845682
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  While conducting a set of large-scale multi-site pragmatic clinical trials involving high-impact public health issues such as end-stage renal disease, opioid use, and colorectal cancer, there were substantial changes to both policies and guidelines relevant to the trials. These external changes gave rise to unexpected challenges for the trials, including decisions regarding how to respond to new clinical practice guidelines, increased difficulty in implementing trial interventions, achieving separation between treatment groups, and differential responses across sites. In this article, we describe these challenges and the approaches used to address them. When deliberating appropriate action in the face of external changes during a pragmatic clinical trial, we recommend considering the well-being of the participants, clinical equipoise, and the strength and quality of the evidence associated with the change; involving those charged with data and safety monitoring; and where possible, planning for potential external changes as the trial is being designed. Any solution must balance the primary obligation to protect the well-being of participants with the secondary obligation to protect the integrity of the trial in order to gain meaningful answers to important public health questions.
• Davis, M., Gunn, R., Pham, R., Wiser, A., Lich, K., Wheeler, S., & Coronado, G. (2019). Key collaborative factors when medicaid accountable care organizations work with primary care clinics to improve colorectal cancer screening: Relationships, data, and quality improvement infrastructure. Preventing Chronic Disease, 16(8). doi:10.5888/pcd16.180395
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  Purpose Accountable Care Organizations (ACOs) are implementing interventions to achieve triple-aim objectives of improved quality and experience of care while maintaining costs. Partnering across organizational boundaries is perceived as critical to ACO success. Methods We conducted a comparative case study of 14 Medicaid ACOs in Oregon and their contracted primary care clinics using public performance data, key informant interviews, and consultation field notes. We focused on how ACOs work with clinics to improve colorectal cancer (CRC) screening - one incentivized performance metric. Results ACOs implemented a broad spectrum of multi-component interventions designed to increase CRC screening. The most common interventions focused on reducing structural barriers (n = 12 ACOs), delivering provider assessment and feedback (n = 11), and providing patient reminders (n = 7). ACOs developed their processes and infrastructure for working with clinics over time. Facilitators of successful collaboration included a history of and commitment to collaboration (partnership); the ability to provide accurate data to prioritize action and monitor improvement (performance data), and supporting clinics' reflective learning through facilitation, learning collaboratives; and support of ACO as well as clinic-based staffing (quality improvement infrastructure). Two unintended consequences of ACO-clinic partnership emerged: potential exclusion of smaller clinics and metric focus and fatigue. Conclusion Our findings identified partnership, performance data, and quality improvement infrastructure as critical dimensions when Medicaid ACOs work with primary care to improve CRC screening. Findings may extend to other metric targets.
• Davis, M., Shafer, P., Renfro, S., Hassmiller Lich, K., Shannon, J., Coronado, G., McConnell, K., & Wheeler, S. (2019). Does a transition to accountable care in Medicaid shift the modality of colorectal cancer testing?. BMC Health Services Research, 19(1). doi:10.1186/s12913-018-3864-5
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  Background: Health care reform is changing preventive services delivery. This study explored trajectories in colorectal cancer (CRC) testing over a 5-year period that included implementation of 16 Medicaid Accountable Care Organizations (ACOs, 2012) and Medicaid expansion (2014) - two provisions of the Affordable Care Act (ACA) - within the state of Oregon, USA. Methods: Retrospective analysis of Oregon's Medicaid claims for enrollee's eligible for CRC screening (50-64 years) spanning January 2010 through December 2014. Our analysis was conducted and refined April 2016 through June 2018. The analysis assessed the annual probability of patients receiving CRC testing and the modality used (e.g., colonoscopy, fecal testing) relative to a baseline year (2010). We hypothesized that CRC testing would increase following Medicaid ACO formation - called Coordinated Care Organizations (CCOs). Results: A total of 132,424 unique Medicaid enrollees (representing 255,192 person-years) met inclusion criteria over the 5-year study. Controlling for demographic and regional factors, the predicted probability of CRC testing was significantly higher in 2014 (+ 1.4 percentage points, p < 0.001) compared to the 2010 baseline but not in 2012 or 2013. Increased fecal testing using Fecal Occult Blood Tests (FOBT) or Fecal Immunochemical Tests (FIT) played a prominent role in 2014. The uptick in statewide fecal testing appears driven primarily by a subset of CCOs. Conclusions: Observed CRC testing did not immediately increase following the transition to CCOs in 2012. However increased testing in 2014, may reflect a delay in implementation of interventions to increase CRC screening and/or a strong desire by newly insured Medicaid CCO members to receive preventive care.
• Green, B., Coronado, G., Schwartz, M., Coury, J., & Baldwin, L. (2019). Using a continuum of hybrid effectiveness-implementation studies to put research-tested colorectal screening interventions into practice. Implementation Science, 14(1). doi:10.1186/s13012-019-0903-5
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  Background: Few previous studies have applied the hybrid effectiveness-implementation design framework to illustrate the way in which an intervention was progressively implemented and evaluated across multiple studies in diverse settings. Methods: We describe the design components and methodologies of three studies that sought to improve rates of colorectal cancer (CRC) screening using mailed outreach, and apply domains put forth by Curran et al.: research aims, research questions, comparison conditions, sample, evaluation methods, measures, and potential challenges. The Hybrid 1 study (emphasis on effectiveness) was a patient-level randomized trial of a mailed fecal test and stepped phone-outreach intervention program delivered in an integrated healthcare system (21 clinics, 4673 patients). The primary outcome was effectiveness (CRC screening uptake). Implementation outcomes included cost-effectiveness and acceptability. The Hybrid 2 study (shared emphasis on effectiveness and implementation) was a pragmatic cluster-randomized trial of mailed fecal immunochemical test (FIT) outreach implemented at safety net clinics (26 clinics, 41,000 patients). The intervention used electronic health record tools (adapted from Hybrid 1) and clinic personnel to deliver the intervention. Outcomes included effectiveness (FIT completion) and implementation (FIT kits delivered, clinic barriers and facilitators, cost-effectiveness). Hybrid 3 study (emphasis on implementation) is a demonstration project being conducted by two Medicaid/Medicare insurance plans (2 states, 12,000 patients) comparing two strategies for implementing mailed FIT programs that addressed Hybrid 2 implementation barriers. Outcomes include implementation (activities delivered, barriers) and effectiveness (FIT completion). Results: The effectiveness-implementation typology successfully identified a number of distinguishing features between the three studies. Two additional features, program design and program delivery, varied across our studies, and we propose adding them to the current typology. Program design and program delivery reflect the process by which and by whom a program is designed and delivered (e.g., research staff vs. clinic/health plan staff). Conclusions: We describe three studies that demonstrate the hybrid effectiveness to implementation continuum and make recommendations for expanding the hybrid typology to include new descriptive features. Additional comparisons of Hybrid 1, 2, and 3 studies may help confirm whether our hybrid typology refinements are generalizable markers of the pipeline from research to practice.
• Green, B., Vollmer, W., Keast, E., Petrik, A., & Coronado, G. (2019). Challenges in assessing population reach in a pragmatic trial. Preventive Medicine Reports, 15. doi:10.1016/j.pmedr.2019.100910
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  Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) was a pragmatic cluster-randomized trial conducted at federally qualified health centers and designed to “Reach” as many unscreened patients as possible by directly mailing them fecal screening tests. STOP CRC used an electronic health record registry to identify individuals' needing CRC screening and mail interventions to them. The registry was updated daily removing individuals completing CRC screening or those who no longer were clinic patients. Reach, a component RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance), is defined as the absolute number, percent, and representativeness of individuals “willing to participate in” or “exposed to” an initiative. We describe the complexities of measuring Reach in a pragmatic trial. Overall 21,134 patients were on the registry list for at least one day, with 18,226 remaining after removing patients completing screening before any mailings. Observed Reached (the percent of individuals exposed to the intervention) using each denominator was 30.7% and 35.6% respectively. Reach improved only modestly after accounting for factors that made it impossible for clinics to send mailings. Few differences were observed in demographic and health care utilization factors among individuals Reached versus not Reached, suggesting that health center Implementation was more influential than patients' willingness or ability to participate. A pragmatic definition of Reach that accounted for dynamic changes the absolute number eligible and the proportion exposed was more useful than traditional definitions of Reach. Actual Reach was dependent on Implementation and not patient level characteristics. Clinical Trials Registration Number: ClincalTrials.gov (NCT01742065).
• Griffith, W., Vigoren, E., Smith, M., Workman, T., Thompson, B., Coronado, G., & Faustman, E. (2019). Application of improved approach to evaluate a community intervention to reduce exposure of young children living in farmworker households to organophosphate pesticides. Journal of Exposure Science and Environmental Epidemiology, 29(3). doi:10.1038/s41370-018-0028-y
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  The take-home pathway is a significant source of organophosphate pesticide exposure for young children (3–5 years old) living with an adult farmworker. This avoidable exposure pathway is an important target for intervention. We selected 24 agricultural communities in the Yakima Valley of Washington State and randomly assigned them to receive an educational intervention (n = 12) to reduce children’s pesticide exposure or usual care (n = 12). We assessed exposure to pesticides in nearly 200 adults and children during the pre and post-intervention periods by measuring metabolites in urine. We compared pre- and post-intervention exposures by expressing the child’s pesticide metabolite concentration as a fraction of the adult’s concentration living in the same household, because the amount of pesticides applied during the collection periods varied. Exposures in our community were consistently higher, sometimes above the 95 th percentile of the exposures reported by the National Health and Nutrition Examination Survey (NHANES). While intervention and control communities demonstrated a reduction in the ratio of child to adult exposure, this reduction was more pronounced in intervention communities (2.7-fold, p < 0.001 compared to 1.7-fold, p = 0.052 for intervention and control, respectively). By examining the child/adult biomarker ratio, we demonstrated that our community-based intervention was effective in reducing pesticide exposure to children in agricultural communities.
• Meenan, R., Coronado, G., Petrik, A., & Green, B. (2019). A cost-effectiveness analysis of a colorectal cancer screening program in safety net clinics. Preventive Medicine, 120. doi:10.1016/j.ypmed.2019.01.014
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  STOP CRC is a cluster-randomized pragmatic study of a colorectal cancer (CRC) screening program within eight federally-qualified health centers (FQHCs) in Oregon and California promoting fecal immunochemical testing (FIT) with appropriate colonoscopy follow-up. Results are presented of a cost-effectiveness analysis of STOP CRC. Organization staff completed activity-based costing spreadsheets, assigning labor hours by intervention activity and job-specific wage rates. Non-labor costs were from study data. Data were collected over February 2014–February 2016; analyses were performed in 2016–2017. Incremental cost-effectiveness ratios (ICERs) using completed FITs adjusted for number of screening-eligible patients (SEPs), as the effectiveness measure were calculated overall and by organization. Intervention delivery costs totaled $305 K across eight organizations (range: $10.2 K–$110 K). Overall delivery cost per SEP was $14.43 (range: $10.37–$19.10). The largest cost category across organizations was implementation, specifically mailing preparation. The overall ICER was $483 per SEP-adjusted completed FIT (range: $96–$1021 among organizations with positive effectiveness). Lagged data accounting for implementation delay produced comparable results. The costs of colonoscopies following abnormal FITs decreased the overall ICER to S409 because usual care clinics generated more such colonoscopies than intervention clinics. Using lagged data, follow-up colonoscopies increase the ICER by 4.3% to $460. Results indicate the complex implications for cost-effectiveness of implementing standard CRC screening within a pragmatic setting involving FQHCs with varied patient populations, clinical structures, and resources. Performance variation across organizations emphasizes the need for future evaluations that inform the introduction of efficient CRC screening to underserved populations.
• Molina, Y., Henderson, V., Ornelas, I., Scheel, J., Bishop, S., Doty, S., Patrick, D., Beresford, S., & Coronado, G. (2019). Understanding Complex Roles of Family for Latina Health: Evaluating Family Obligation Stress. Family and Community Health, 42(4). doi:10.1097/fch.0000000000000232
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  We developed a measure of family obligation stress and compared its relationship to health and unmet health care needs relative to social support among a sample of US-based Latinas. Data come from a randomized controlled trial within 4 clinics to increase mammography among Latinas (n = 539). The 1-factor measure had acceptable reliability and construct validity. Family obligation stress was associated with worse health and greater unmet health care needs. Family obligation stress varied by years in the United States and country of origin. Our measure of family obligation stress contributes new venues to family research among Latino populations.
• Nielson, C., Vollmer, W., Petrik, A., Keast, E., Green, B., & Coronado, G. (2019). Factors Affecting Adherence in a Pragmatic Trial of Annual Fecal Immunochemical Testing for Colorectal Cancer. Journal of General Internal Medicine, 34(6). doi:10.1007/s11606-018-4820-0
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  Background: Colorectal cancer screening by fecal immunochemical test (FIT) reduces the burden of colorectal cancer. However, effectiveness relies on annual adherence, which presents challenges for clinic staff and patients. Objective: Describe FIT return rates and identify factors associated with FIT adherence over 2 years in a mailed FIT outreach program in federally qualified health centers. Design: Observational study nested in the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) trial. Five thousand one hundred ninety-five patients had an initial FIT order and were followed for ≥ 2 years (3574 also had a FIT order in the second year). Main Measures: FIT return percent in each year and patient- and neighborhood-level characteristics associated with FIT adherence. Key Results: Overall, the proportion of FIT orders that were completed was 46% in the patients’ first year and 41% in the patients’ second year. Of the 5195 patients with a FIT order in year 1, 3574 (69%) also had a FIT order in year 2 (71% of year 1 adherers and 67% of year 1 non-adherers, p = 0.009). Among those with a FIT order in the second year, the FIT return rate was about twice as high among those who were adherent in the first year (952/1674, or 57%) as among those who were not (531/1900, or 28%, p < 0.0001). Patient-level characteristics associated with higher odds of FIT return were a history of FIT screening at baseline, age over 65 (vs 50–65), no current tobacco use, recent receipt of a mammogram or flu vaccine, Asian ancestry (compared to non-Hispanic white), and non-English preference. The only neighborhood factor associated with lower FIT return rate was patient’s larger residential city size. Conclusion: Our findings can inform the customization of programs to promote FIT return among patients who receive care at federally qualified health centers. Trial Registration: http://www.clinicaltrials.gov.
• O'Leary, M., Lich, K., Gu, Y., Wheeler, S., Coronado, G., Bartelmann, S., Lind, B., Mayorga, M., & Davis, M. (2019). Colorectal cancer screening in newly insured Medicaid members: A review of concurrent federal and state policies. BMC Health Services Research, 19(1). doi:10.1186/s12913-019-4113-2
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  Background: Colorectal cancer (CRC) screening is underutilized by Medicaid enrollees and the uninsured. Multiple national and state policies were enacted from 2010 to 2014 to increase access to Medicaid and to promote CRC screening among Medicaid enrollees. We aimed to determine the impact of these policies on screening initiation among newly enrolled Oregon Medicaid beneficiaries age-eligible for CRC screening. Methods: We identified national and state policies affecting Medicaid coverage and preventive services in Oregon during 2010-2014. We used Oregon Medicaid claims data from 2010 to 2015 to conduct a cohort analysis of enrollees who turned 50 and became age-eligible for CRC screening (a prevention milestone, and an age at which guideline-concordant screening can be assessed within a single year) during each year from 2010 to 2014. We calculated risk ratios to assess whether first year of Medicaid enrollment and/or year turned 50 was associated with CRC screening initiation. Results: We identified 14,576 Oregon Medicaid enrollees who turned 50 during 2010-2014; 2429 (17%) completed CRC screening within 12 months after turning 50. Individuals newly enrolled in Medicaid in 2013 or 2014 were 1.58 and 1.31 times more likely, respectively, to initiate CRC screening than those enrolled by 2010. A primary care visit in the calendar year, having one or more chronic conditions, and being Hispanic was also associated with CRC screening initiation. Discussion: The increased uptake of CRC screening in 2013 and 2014 is associated with the timing of policies such as Medicaid expansion, enhanced federal matching for preventive services offered to Medicaid enrollees without cost sharing, and formation of Medicaid accountable care organizations, which included CRC screening as an incentivized quality metric.
• Thompson, J., Davis, M., Michaels, L., Rivelli, J., Castillo, M., Younger, B., Castro, M., Reich, S., & Coronado, G. (2019). Developing patient-refined messaging for a mailed colorectal cancer screening program in a Latino-based community health center. Journal of the American Board of Family Medicine, 32(3). doi:10.3122/jabfm.2019.03.180026
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  Introduction: Colon cancer is the second leading cause of cancer death in the United States, and screening rates are disproportionately low among Latinos. One factor thought to contribute to the low screening rate is the difficulty Latinos encounter in understanding health information, and therefore in taking appropriate health action. Therefore, we used Boot Camp Translation (BCT), a patient engagement approach, to engage Latino stakeholders (ie, patients, clinic staff) in refining the messages and format of colon cancer screening reminders for a clinic-based direct mail fecal immunochemical testing (FIT) program. Methods: Patient participants were Latino, ages 50 to 75 years, able to speak English or Spanish, and willing to participate in the in-person kickoff meeting and follow-up phone calls over a 3-month period. We held separate BCT sessions for English- and Spanish-speaking participants. As part of the in-person meetings, a bilingual colon cancer expert presented on colon health and screening messages and BCT facilitators led interactive sessions where participants reviewed materials and reminder messages in various modalities (eg, letter, text). Participants considered what information about colon cancer screening was important, the best methods to share these messages, and the timing and frequency with which these messages should be delivered to patients to encourage FIT completion. We used follow-up phone calls to iteratively refine materials developed based on key learnings from the in-person meeting. Results: Twenty-five adults participated in the in-person sessions (English [n 12]; Spanish [n 13]). Patient participants were primarily enrolled in Medicaid/uninsured (76%) and had annual household incomes less than $20,000 (67%). Key themes distilled from the sessions included increasing awareness that screening can prevent colon cancer, stressing the urgency of screening, emphasizing the motivating influence of family, and using personalized messages from the practice such as 'I' or 'we' statements in letters or automated phone call reminders delivered by humans. Participants in both sessions noted the importance of receiving an automated or live alert before a FIT kit is mailed and a reminder within 2 weeks of FIT kit mailing. Discussion: Using BCT, we successfully incorporated participant feedback to adapt culturally relevant health messages to promote FIT testing among Latino patients served by community clinics. Materials will be tested in the larger Participatory Research to Advance Colon Cancer Prevention (PROMPT) trial.
• Thompson, J., Schneider, J., Rivelli, J., Petrik, A., Vollmer, W., Fuoco, M., & Coronado, G. (2019). A Survey of Provider Attitudes, Beliefs, and Perceived Barriers Regarding a Centralized Direct-Mail Colorectal Cancer Screening Approach at Community Health Centers. Journal of Primary Care and Community Health, 10. doi:10.1177/2150132719890950
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  Background: Colorectal cancer screening (CRC) rates are low, particularly among individuals with low socioeconomic status. Organized CRC screening programs have demonstrated success in increasing screening rates. Little is known about provider attitudes, beliefs, and practices related to CRC screening or how they are influenced by an organized CRC screening program. Methods: In 2014 and 2016, providers from 26 safety net clinics in Oregon and Northern California were invited to complete baseline and follow-up online surveys for the Strategies and Opportunities to Stop Colon Cancer in Priority Populations (STOP CRC) study. The provider survey link was sent electronically to primary care providers serving adult patients. Providers were sent reminders every 2 weeks via email to complete the survey, up to 3 reminders total. In this article, we describe learnings about provider attitudes, beliefs, and practices related to CRC screening after implementation of the STOP CRC program. Results: A total of 166 unique providers completed baseline and/or follow-up surveys, representing 228 responses. Main themes included (1) favorable shifts in attitude toward fecal immunochemical test (FIT) and direct-mail cancer screening programs, (2) changes in provider perception of key barriers, and (3) growing interest in centralized automated systems for identifying patients due for CRC screening and eligible for population-based outreach. Discussion: Providers are interested in improved information systems for identifying patients due for CRC screening and delivering population-based outreach (ie, to distribute FIT kits outside of the clinic visit) to help reduce health system- and patient-level barriers to screening. Trial Registration: National Clinical Trial (NCT) Identifier NCT01742065.
• Coronado, G., Petrik, A., Vollmer, W., Taplin, S., Keast, E., Fields, S., & Green, B. (2018). Effectiveness of a mailed colorectal cancer screening outreach program in community health clinics the STOP CRC cluster randomized clinical trial. JAMA Internal Medicine, 178(9). doi:10.1001/jamainternmed.2018.3629
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  IMPORTANCE Approximately 24 million US individuals receive care at federally qualified health centers, which historically have low rates of colorectal cancer screening. The US Preventive Services Task Force recommends routine colorectal cancer screening for individuals aged 50 to 75 years. OBJECTIVE To determine the effectiveness of an electronic health record (EHR)-embedded mailed fecal immunochemical test (FIT) outreach program implemented in health centers as part of standard care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized pragmatic clinical trial was conducted in 26 federally qualified health center clinics, representing 8 health centers in Oregon and California, randomized to intervention (n = 13) or usual care (n = 13). All participants were overdue for colorectal cancer screening during the accrual interval (February 4, 2014 to February 3, 2015). INTERVENTIONS Electronic health record-embedded tools to identify eligible adults and to facilitate implementation of a stepwise mailed intervention involving (1) an introductory letter, (2) a mailed FIT, and (3) a reminder letter; training, collaborative learning, and facilitation through a practice improvement process. MAIN OUTCOMES AND MEASURES Effectiveness was measured as clinic-level proportions of adults who completed a FIT, and secondarily, any colorectal cancer screening within 12 months of accrual or by August 3, 2015. Implementation was measured as clinic-level proportions of adults who were mailed an introductory letter and ordered a FIT. RESULTS Twenty-six clinics with 41 193 adults (mean [SD] age, 58.5 [6.3] years; 22 994 women) were randomized to receive the direct mail colorectal screening intervention (13 clinics; 21 134 patients) or usual care (13 clinics; 20 059 patients). Compared with usual care clinics, intervention clinics had significantly higher adjusted clinic-level proportion of participants who completed a FIT (13.9% vs 10.4%; difference, 3.4 percentage points; 95% CI, 0.1%-6.8%) and any colorectal cancer screening (18.3% vs 14.5%; difference, 3.8 percentage points; 95% CI, 0.6%-7.0%). We observed large variation across health centers in effectiveness (FIT completion differences range, −7.4 percentage points to 17.6 percentage points) and implementation (proportion who were mailed a FIT range, 6.5% to 68.2%). The number needed to mail to achieve a completed FIT was 4.8 overall, and 4.0 in clinics that mailed a FIT reminder. CONCLUSIONS AND RELEVANCE An EHR-embedded mailed FIT outreach intervention significantly improved rates of FIT completion and rates of any colorectal cancer screening. Higher rates of colorectal cancer screening occurred in clinics that successfully implemented the mailed outreach program.
• Coronado, G., Rivelli, J., Fuoco, M., Vollmer, W., Petrik, A., Keast, E., Barker, S., Topalanchik, E., & Jimenez, R. (2018). Effect of Reminding Patients to Complete Fecal Immunochemical Testing: A Comparative Effectiveness Study of Automated and Live Approaches. Journal of General Internal Medicine, 33(1). doi:10.1007/s11606-017-4184-x
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  Background: The Community Preventive Services Task Force recommends multi-component interventions, including patient reminders, to improve uptake of colorectal cancer screening. Objective: We sought to compare the effectiveness of different forms of reminders for a direct-mail fecal immunochemical test (FIT) program. Design: Patient-randomized controlled trial. Participants: 2772 adults aged 50–75, not up to date with colorectal cancer screening recommendations, with a clinic visit in the previous year at any of four participating health center clinics. Intervention: Participants were mailed an introductory letter and FIT. Those who did not complete their FIT within 3 weeks were randomized to receive (1) a reminder letter, (2) two automated phone calls, (3) two text messages, (4) a live phone call, (5) a reminder letter and a live phone call, (6) two automated phone calls and a live phone call, or (7) two text messages and a live phone call. Patients with a patient portal account were sent two email reminders, but were not randomized. Main Measures: FIT return rates for each group, 6 months following randomization. Key Results: A total of 255 (10%) participants returned their FIT within 3 weeks of the mailing. Among randomized participants (n = 2010), an additional 25.5% returned their FITs after reminders were delivered (estimated overall return rate = 32.7%). In intention-to-treat analysis, compared to the group allocated to receive a reminder letter, return rates were higher for the group assigned to receive the live phone call (OR = 1.51 [1.03–2.21]) and lower for the group assigned to receive text messages (OR = 0.66 [0.43–0.99]). Reminder effectiveness differed by language preference. Conclusions: Our data suggest that FIT reminders that included a live call were more effective than reminders that relied solely on written communication (a text message or letter). Trial Registration: ClinicalTrials.gov/ctc2/show/NCT01742065.
• Coury, J., Schneider, J., Green, B., Baldwin, L., Petrik, A., Rivelli, J., Schwartz, M., & Coronado, G. (2018). Two Medicaid health plans' models and motivations for improving colorectal cancer screening rates. Translational Behavioral Medicine, 10(1). doi:10.1093/tbm/iby094
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  Screening rates for colorectal cancer (CRC) remain low, especially among certain populations. Mailed fecal immunochemical testing (FIT) outreach initiated by U.S. health plans could reach underserved individuals, while solving CRC screening data and implementation challenges faced by health clinics. We report the models and motivations of two health insurance plans implementing a mailed FIT program for age-eligible U.S. Medicaid and Medicare populations. One health plan operates in a single state with ~220,000 enrollees; the other operates in multiple states with ~2 million enrollees. We conducted in-depth qualitative interviews with key stakeholders and observed leadership and clinic staff planning during program development and implementation. Interviews were transcribed and coded using a content analysis approach; coded interview reports and meeting minutes were iteratively reviewed and summarized for themes. Between June and September 2016, nine participants were identified, and all agreed to the interview. Interviews revealed that organizational context was important to both organizations and helped shape program design. Both organizations were hoping this program would address barriers to their prior CRC screening improvement efforts and saw CRC screening as a priority. Despite similar motivations to participate in a mailed FIT intervention, contextual features of the health plans led them to develop distinct implementation models: a collaborative model using some health clinic staffing versus a centralized model operationalizing outreach primarily at the health plan. Data are not yet available on the models' effectiveness. Our findings might help inform the design of programs to deliver mailed FIT outreach.
• Davis, M., Freeman, M., Shannon, J., Coronado, G., Stange, K., Guise, J., Wheeler, S., & Buckley, D. (2018). A systematic review of clinic and community intervention to increase fecal testing for colorectal cancer in rural and low-income populations in the united states – How, what and when?. BMC Cancer, 18(1). doi:10.1186/s12885-017-3813-4
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  Background: Interventions to improve fecal testing for colorectal cancer (CRC) exist, but are not yet routine practice. We conducted this systematic review to determine how implementation strategies and contextual factors influenced the uptake of interventions to increase Fecal Immunochemical Tests (FIT) and Fecal Occult Blood Testing (FOBT) for CRC in rural and low-income populations in the United States. Methods: We searched Medline and the Cochrane Library from January 1998 through July 2016, and Scopus and clinicaltrials.gov through March 2015, for original articles of interventions to increase fecal testing for CRC. Two reviewers independently screened abstracts, reviewed full-text articles, extracted data and performed quality assessments. A qualitative synthesis described the relationship between changes in fecal testing rates for CRC, intervention components, implementation strategies, and contextual factors. A technical expert panel of primary care professionals, health system leaders, and academicians guided this work. Results: Of 4218 citations initially identified, 27 unique studies reported in 29 publications met inclusion criteria. Studies were conducted in primary care (n = 20, 74.1%), community (n = 5, 18.5%), or both (n = 2, 7.4%) settings. All studies (n = 27, 100.0%) described multicomponent interventions. In clinic based studies, components that occurred most frequently among the highly effective/effective study arms were provision of kits by direct mail, use of a pre-addressed stamped envelope, client reminders, and provider ordered in-clinic distribution. Interventions were delivered by clinic staff/community members (n = 10, 37.0%), research staff (n = 6, 22.2%), both (n = 10, 37.0%), or it was unclear (n = 1, 3.7%). Over half of the studies lacked information on training or monitoring intervention fidelity (n = 15, 55.6%). Conclusions: Studies to improve FIT/FOBT in rural and low-income populations utilized multicomponent interventions. The provision of kits through the mail, use of pre-addressed stamped envelopes, client reminders and in-clinic distribution appeared most frequently in the highly effective/effective clinic-based study arms. Few studies described contextual factors or implementation strategies. More robust application of guidelines to support reporting on methods to select, adapt and implement interventions can help end users determine not just which interventions work to improve CRC screening, but which interventions would work best in their setting given specific patient populations, clinical settings, and community characteristics. Trial registration: In accordance with PRISMA guidelines, our systematic review protocol was registered with PROSPERO, the international prospective register of systematic reviews, on April 16, 2015 (registration number CRD42015019557).
• Heintzman, J., Hatch, B., Coronado, G., Ezekiel, D., Cowburn, S., Escamilla-Sanchez, O., & Marino, M. (2018). Role of race/ethnicity, language, and insurance in use of cervical cancer prevention services among low-income Hispanic Women, 2009-2013. Preventing Chronic Disease, 15(2). doi:10.5888/pcd15.170267
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  Introduction Hispanic women in the United States have an elevated risk of cervical cancer, but the existing literature does not reveal why this disparity persists. Methods We performed a retrospective cohort analysis of 17,828 low-income women aged 21 to 64 years seeking care at Oregon community health centers served by a hosted, linked electronic health record during 2009 through 2013. We assessed the odds of having had Papanicolaou (Pap) tests and receiving human papillomavirus (HPV) vaccine, by race/ethnicity, insurance status, and language. Results Hispanic women, regardless of pregnancy status or insurance, had greater odds of having had Pap tests than non-Hispanic white women during the study period. English-preferring Hispanic women had higher odds of having had Pap tests than Spanish-preferring Hispanic women (OR, 2.08; 95% confidence interval [CI], 1.63-2.66) but lower odds of having received HPV vaccination (OR, 0.21; 95% CI, 0.12-0.38). Uninsured patients, regardless of race/ethnicity, had lower odds of HPV vaccine initiation than insured patients did. Once a single dose was received, there were no significant racial/ethnic differences in vaccine series completion. Conclusion In this sample of low-income women seeking care at Oregon community health centers, we found minimal racial/ethnic disparities in the receipt of cervical cancer prevention services. Inequities by insurance status, especially in the receipt of HPV vaccine, persist. Community health center-based care may be a useful model to address racial/ethnic disparities in prevention, but this model would need further population-wide study.
• Nielson, C., Petrik, A., Jacob, L., Vollmer, W., Keast, E., Schneider, J., Rivelli, J., Kapka, T., Meenan, R., Mummadi, R., Green, B., & Coronado, G. (2018). Positive predictive values of fecal immunochemical tests used in the STOP CRC pragmatic trial. Cancer Medicine, 7(9). doi:10.1002/cam4.1727
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  Annual fecal immunochemical testing (FIT) is cost-effective for colorectal cancer (CRC) screening. However, FIT positivity rates and positive predictive value (PPV) can vary substantially, with false-positive (FP) results adding to colonoscopy burden without improving cancer detection. Our objective was to describe FIT PPV and the factors associated with FP results among patients undergoing CRC screening. In an ongoing pragmatic clinical trial of mailed-FIT outreach, clinics delivered one of three FIT brands (InSure, OC-Micro, and Hemosure). Patients who had a positive FIT result and a follow-up colonoscopy were included in this analysis (N = 1130). Patients’ demographic and medical histories were abstracted from electronic health records (EHR). Associations with a FP result (ie, a positive FIT result with no evidence of advanced neoplasia during follow-up colonoscopy) were evaluated for FIT brand and patient factors using mixed-effects multivariable logistic regression. The mean proportion of FIT-positive results ranged from 8% in centers using the OC-Micro test to 21% for Hemosure. PPVs for advanced neoplasia were 0.30 to 0.17, respectively (P for χ2 = 0.08). In multivariable-adjusted models, use of Hemosure was associated with greater odds of a FP result than OC-Micro (OR = 2.00, 95% CI: 0.47-8.56) or InSure (OR = 1.72, 95% CI: 0.44-6.68). However, only female sex (OR = 1.58, 95% CI: 1.19-2.10) and history of a colorectal condition (OR = 2.17, 95% CI: 1.13-4.15) were significantly associated with FP. In conclusion, FIT positivity varied by brand, and FP results differed by patient factors available through the EHR. These results can be used to minimize the frequency of FP results, reducing patient distress and colonoscopy burden.
• Nielson, C., Rivelli, J., Fuoco, M., Gawlik, V., Jimenez, R., Petrik, A., & Coronado, G. (2018). Effectiveness of automated and live phone reminders after mailed-FIT outreach in a pilot randomized trial. Preventive Medicine Reports, 12. doi:10.1016/j.pmedr.2018.10.012
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  The effectiveness of annual mailed fecal immunochemical testing (FIT) outreach is highest when return rates are optimized, which is aided by patient reminders. In a pilot patient-randomized controlled trial in two western Washington clinics of the Sea Mar Community Health Centers, we compared the effectiveness of two phone-based approaches to mailed FIT outreach reminders. In fall 2016, patients ages 50–75, due for colorectal cancer screening, and with a visit in the previous year at either of two clinics, were mailed an introductory letter and FIT. Those who did not return the FIT within 3 weeks (N = 427) were randomized to receive either: a) a series of up to 6 automated phone reminders; or b) the combination of automated and live phone reminders (up to 6 in total). The sole outcome was FIT return within 6 months after the FIT mailing. FIT completion rates were similar in the groups assigned to receive automated calls vs automated plus live calls (40% vs 39%; p = 0.89). The effectiveness of FIT reminder mode differed by language preference (p for interaction = 0.03): among Spanish-preferring patients (n = 106), FIT return rates were higher in the automated-only group than to the auto- plus live-call group (62% vs 39%, p = 0.02). Among English-preferring patients, no difference in modes was observed (n = 279, 32% vs 34%, p = 0.74). We observed no added benefit of live reminder calls in a mailed FIT plus automated call reminder program; our findings may inform efforts to efficiently optimize mailed-FIT outreach programs. ClinicalTrials.gov identifier NCT01742065
• Petrik, A., Le, T., Keast, E., Rivelli, J., Bigler, K., Green, B., Vollmer, W., & Coronado, G. (2018). Predictors of Colorectal Cancer Screening Prior to Implementation of a Large Pragmatic Trial in Federally Qualified Health Centers. Journal of Community Health, 43(1). doi:10.1007/s10900-017-0395-7
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  Colorectal cancer screening can prevent cancer deaths. Federally qualified health centers serve a unique patient population that often is not screened. Knowing who in this environment is getting screened via fecal testing and via colonoscopy can assist in tailoring intervention to raise rates of colorectal cancer screening. We examined patient-level and neighborhood-level characteristics associated with being up to date with colorectal cancer screening guidelines. We also examined associations between these factors and being screened with a fecal test. We observed an increase in colorectal cancer screening rates from 2010 to 2015. Adjusted analyses revealed that the following factors were significantly associated with colorectal cancer screening: aged 65 or older, having any type of insurance, previous outpatient visits, and current or other preventive screenings. Among adults aged 50–75 who were up to date with colorectal cancer screening, factors associated with use of fecal testing, as opposed to colonoscopy, were: being younger, speaking a non-English language, being uninsured, having prior office visits, and having had a flu shot in past year. Our findings may inform clinic-based effort to raise rates of colorectal cancer screening, especially in the community clinic setting. Trial Registration: ClinicalTrials.gov, NCT01742065.
• Scheel, J., Tillack, A., Mercer, L., Coronado, G., Beresford, S., Molina, Y., & Thompson, B. (2018). Mobile Versus Fixed Facility: Latinas’ Attitudes and Preferences for Obtaining a Mammogram. Journal of the American College of Radiology, 15(1). doi:10.1016/j.jacr.2017.08.030
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  Purpose Mobile mammographic services have been proposed as a way to reduce Latinas’ disproportionate late-stage presentation compared with white women by increasing their access to mammography. The aims of this study were to assess why Latinas may not use mobile mammographic services and to explore their preferences after using these services. Methods Using a mixed-methods approach, a secondary analysis was conducted of baseline survey data (n = 538) from a randomized controlled trial to improve screening mammography rates among Latinas in Washington. Descriptive statistics and bivariate regression were used to characterize mammography location preferences and to test for associations with sociodemographic indices, health care access, and perceived breast cancer risk and beliefs. On the basis of these findings, a qualitative study (n = 18) was used to explore changes in perceptions after using mobile mammographic services. Results More Latinas preferred obtaining a mammogram at a fixed facility (52.3% [n = 276]) compared with having no preference (46.3% [n = 249]) and preferring mobile mammographic services (1.7% [n = 9]). Concerns about privacy and comfort (15.6% [n = 84]) and about general quality (10.6% [n = 57]) were common reasons for preferring a fixed facility. Those with no history of mammography preferred a fixed facility (P
• Thompson, J., Davis, M., Leo, M., Schneider, J., Smith, D., Petrik, A., Castillo, M., Younger, B., & Coronado, G. (2018). Participatory Research to Advance Colon Cancer Prevention (PROMPT): Study protocol for a pragmatic trial. Contemporary Clinical Trials, 67. doi:10.1016/j.cct.2018.02.001
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  Background: Colon cancer is the second leading cause of cancer deaths in the United States. The Participatory Research to Advance Colon Cancer Prevention (PROMPT) study is a collaboration between two research institutions and a federally qualified health center (FQHC). The study seeks to raise colon cancer screening rates using a direct-mail fecal immunochemical testing (FIT) and reminder program in an FQHC serving a predominantly Latino population in California. Methods: PROMPT is a pragmatic trial enrolling 16 clinics. The study will test automated and live prompts (i.e., alerts, reminders) to a direct-mail FIT program in two phases. In Phase I, we tailored and defined intervention components for the pilot using a community-based participatory research approach called boot camp translation. We then plan to conduct a three-arm patient-randomized comparative effectiveness trial in two pilot clinics to compare 1) automated prompts, 2) live prompts, and 3) a combination of automated plus live prompts to alert and remind patients to complete screening. In Phase II, the adapted best practice intervention will be spread to additional clinics within the FQHC (estimated population 27,000) and assessed for effectiveness. Patient and staff interviews will be conducted to explore receptivity to the program and identify barriers to implementation. Discussion: This pragmatic trial applies innovative approaches to engage diverse stakeholders and will test the effectiveness and spread of a direct-mail plus reminder program. If successful, the program will provide a model for a cost-effective method to raise colon cancer screening rates among Latino patients receiving care in FQHCs. Trial registration: National Clinical Trial (NCT) Identifier NCT03167125.
• Coronado, G., Schneider, J., Petrik, A., Rivelli, J., Taplin, S., & Green, B. (2017). Implementation successes and challenges in participating in a pragmatic study to improve colon cancer screening: perspectives of health center leaders. Translational Behavioral Medicine, 7(3). doi:10.1007/s13142-016-0461-1
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  Little is known about the challenges faced by community clinics who must address clinical priorities first when participating in pragmatic studies. We report on implementation challenges faced by the eight community health centers that participated in Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), a large comparative effectiveness cluster-randomized trial to evaluate a direct-mail program to increase the rate of colorectal cancer (CRC) screening. We conducted interviews, at the onset of implementation and 1 year later, with center leaders to identify challenges with implementing and sustaining an electronic medical record (EMR)-driven mailed program to increase CRC screening rates. We used the Consolidated Framework for Implementation Research to thematically analyze the content of meeting discussions and identify anticipated and experienced challenges. Common early concerns were patients’ access to colonoscopy, patients’ low awareness of CRC screening, time burden on clinic staff to carry out the STOP CRC program, inability to accurately identify eligible patients, and incompatibility of the program’s approach with the patient population or organizational culture. Once the program was rolled out, time burden remained a primary concern and new organizational capacity and EMR issues were raised (e.g., EMR staffing resources and turnover in key leadership positions). Cited program successes were improved CRC screening processes and rates, more patients reached, reduced costs, and improved patient awareness, engagement, or satisfaction. These findings may inform any clinic considering mailed fecal testing programs and future pragmatic research efforts in community health centers.
• Coury, J., Schneider, J., Rivelli, J., Petrik, A., Seibel, E., D'Agostini, B., Taplin, S., Green, B., & Coronado, G. (2017). Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics. BMC Health Services Research, 17(1). doi:10.1186/s12913-017-2364-3
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  Background: The Plan-Do-Study-Act (PDSA) cycle is a commonly used improvement process in health care settings, although its documented use in pragmatic clinical research is rare. A recent pragmatic clinical research study, called the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), used this process to optimize the research implementation of an automated colon cancer screening outreach program in intervention clinics. We describe the process of using this PDSA approach, the selection of PDSA topics by clinic leaders, and project leaders' reactions to using PDSA in pragmatic research. Methods: STOP CRC is a cluster-randomized pragmatic study that aims to test the effectiveness of a direct-mail fecal immunochemical testing (FIT) program involving eight Federally Qualified Health Centers in Oregon and California. We and a practice improvement specialist trained in the PDSA process delivered structured presentations to leaders of these centers; the presentations addressed how to apply the PDSA process to improve implementation of a mailed outreach program offering colorectal cancer screening through FIT tests. Center leaders submitted PDSA plans and delivered reports via webinar at quarterly meetings of the project's advisory board. Project staff conducted one-on-one, 45-min interviews with project leads from each health center to assess the reaction to and value of the PDSA process in supporting the implementation of STOP CRC. Results: Clinic-selected PDSA activities included refining the intervention staffing model, improving outreach materials, and changing workflow steps. Common benefits of using PDSA cycles in pragmatic research were that it provided a structure for staff to focus on improving the program and it allowed staff to test the change they wanted to see. A commonly reported challenge was measuring the success of the PDSA process with the available electronic medical record tools. Conclusion: Understanding how the PDSA process can be applied to pragmatic trials and the reaction of clinic staff to their use may help clinics integrate evidence-based interventions into their everyday care processes. Trial registration: Clinicaltrials.gov NCT01742065. Registered October 31, 2013.
• Davis, M., Renfro, S., Pham, R., Hassmiller Lich, K., Shannon, J., Coronado, G., & Wheeler, S. (2017). Geographic and population-level disparities in colorectal cancer testing: A multilevel analysis of Medicaid and commercial claims data. Preventive Medicine, 101. doi:10.1016/j.ypmed.2017.05.001
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  Morbidity and mortality from colorectal cancer (CRC) can be attenuated through guideline concordant screening and intervention. This study used Medicaid and commercial claims data to examine individual and geographic factors associated with CRC testing rates in one state (Oregon). A total of 64,711 beneficiaries (4516 Medicaid; 60,195 Commercial) became newly age-eligible for CRC screening and met inclusion criteria (e.g., continuously enrolled, no prior history) during the study period (January 2010–December 2013). We estimated multilevel models to examine predictors for CRC testing, including individual (e.g., gender, insurance, rurality, access to care, distance to endoscopy facility) and geographic factors at the county level (e.g., poverty, uninsurance). Despite insurance coverage, only two out of five (42%) beneficiaries had evidence of CRC testing during the four year study window. CRC testing varied from 22.4% to 46.8% across Oregon's 36 counties; counties with higher levels of socioeconomic deprivation had lower levels of testing. After controlling for age, beneficiaries had greater odds of receiving CRC testing if they were female (OR 1.04, 95% CI 1.01–1.08), commercially insured, or urban residents (OR 1.14, 95% CI 1.07–1.21). Accessing primary care (OR 2.47, 95% CI 2.37–2.57), but not distance to endoscopy (OR 0.98, 95% CI 0.92–1.03) was associated with testing. CRC testing in newly age-eligible Medicaid and commercial members remains markedly low. Disparities exist by gender, geographic residence, insurance coverage, and access to primary care. Work remains to increase CRC testing to acceptable levels, and to select and implement interventions targeting the counties and populations in greatest need.
• Liles, E., Coronado, G., Perrin, N., Harte, A., Nungesser, R., Quigley, N., Potter, N., Weiss, G., Koenig, T., & deVos, T. (2017). Uptake of a colorectal cancer screening blood test is higher than of a fecal test offered in clinic: A randomized trial. Cancer Treatment and Research Communications, 10. doi:10.1016/j.ctarc.2016.12.004
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  Introduction Colorectal cancer screening programs seek to maintain patient adherence to repeated tests over the duration of patients’ screening eligibility. This study compares uptake of an experimental blood test with that of a FIT for colorectal cancer screening in an office setting. Methods This small two-site randomized controlled trial (ClinicalTrials.gov, ID NCT02251782) assigned 413 average-risk adults overdue for screening in an integrated health system to one of two arms: Offer of a FIT versus offer of a blood test for colorectal cancer screening. The primary outcome was completion of the offered test within six weeks. Secondary outcomes were the proportion of participants with positive test results, and the proportion of participants with positive results who completed colonoscopy within 3 months of referral. Results 99.5% (CI95: 97.3%-100%) of participants in the blood test arm and 88.1% (CI95: 83.0% − 91.8%) of participants in the FIT arm completed the offered test, a difference of 11.4% (CI95: 6.9% − 15.9%, p
• Scheel, J., Molina, Y., Coronado, G., Bishop, S., Doty, S., Jimenez, R., Thompson, B., Lehman, C., & Beresford, S. (2017). Healthcare factors for obtaining a mammogram in latinas with a variable mammography history. Oncology Nursing Forum, 44(1). doi:10.1188/17.onf.66-76
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  Purpose/Objectives: To understand the relationship between mammography history and current thoughts about obtaining a mammogram among Latinas and examine the mediation effects of several healthcare factors. Design: Cross-sectional survey. Setting: Federally qualified health centers (Sea Mar Community Health Centers) in western Washington. Sample: 641 Latinas nonadherent and adherent with screening mammography. Methods: Baseline survey data from Latinas with a mammography history of never, not recent (more than two years), or recent (less than two years) were analyzed. Preacher and Hayes methods were used to estimate the mediation effect of healthcare factors. Main Research Variables: The survey assessed mammography history, sociodemographic and healthcare factors, and current thoughts about obtaining a mammogram. Findings: Latinas' thoughts about obtaining a mammogram were associated with mammography history. Having had a clinical breast examination mediated 70% of differences between Latinas with a never and recent mammography history. Receipt of a provider recommendation mediated 54% of differences between Latinas with and without a recent mammography history. Conclusions: These findings emphasize the importance of the patient-provider relationship during a clinic visit and help inform how nurses may be incorporated into subsequent screening mammography interventions tailored to Latinas. Implications for Nursing: As providers, health educators, and researchers, nurses have critical roles in encouraging adherence to screening mammography guidelines among Latinas.
• Simon, G., Coronado, G., Debar, L., Dember, L., Green, B., Huang, S., Jarvik, J., Mor, V., Ramsberg, J., Septimus, E., Staman, K., Vazquez, M., Vollmer, W., Zatzick, D., Hernandez, A., & Platt, R. (2017). Data sharing and embedded research. Annals of Internal Medicine, 167(9). doi:10.7326/m17-0863
• Weinfurt, K., Hernandez, A., Coronado, G., DeBar, L., Dember, L., Green, B., Heagerty, P., Huang, S., James, K., Jarvik, J., Larson, E., Mor, V., Platt, R., Rosenthal, G., Septimus, E., Simon, G., Staman, K., Sugarman, J., Vazquez, M., , Zatzick, D., et al. (2017). Pragmatic clinical trials embedded in healthcare systems: Generalizable lessons from the NIH Collaboratory. BMC Medical Research Methodology, 17(1). doi:10.1186/s12874-017-0420-7
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  Background: The clinical research enterprise is not producing the evidence decision makers arguably need in a timely and cost effective manner; research currently involves the use of labor-intensive parallel systems that are separate from clinical care. The emergence of pragmatic clinical trials (PCTs) poses a possible solution: these large-scale trials are embedded within routine clinical care and often involve cluster randomization of hospitals, clinics, primary care providers, etc. Interventions can be implemented by health system personnel through usual communication channels and quality improvement infrastructure, and data collected as part of routine clinical care. However, experience with these trials is nascent and best practices regarding design operational, analytic, and reporting methodologies are undeveloped. Methods: To strengthen the national capacity to implement cost-effective, large-scale PCTs, the Common Fund of the National Institutes of Health created the Health Care Systems Research Collaboratory (Collaboratory) to support the design, execution, and dissemination of a series of demonstration projects using a pragmatic research design. Results: In this article, we will describe the Collaboratory, highlight some of the challenges encountered and solutions developed thus far, and discuss remaining barriers and opportunities for large-scale evidence generation using PCTs. Conclusion: A planning phase is critical, and even with careful planning, new challenges arise during execution; comparisons between arms can be complicated by unanticipated changes. Early and ongoing engagement with both health care system leaders and front-line clinicians is critical for success. There is also marked uncertainty when applying existing ethical and regulatory frameworks to PCTS, and using existing electronic health records for data capture adds complexity.
• Coronado, G., Beresford, S., McLerran, D., Jimenez, R., Patrick, D., Ornelas, I., Bishop, S., Scheel, J., & Thompson, B. (2016). Multilevel intervention raises latina participation in mammography screening: Findings from ¡fortaleza Latina!. Cancer Epidemiology Biomarkers and Prevention, 25(4). doi:10.1158/1055-9965.epi-15-1246
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  Background: Breast cancer is the most commonly diagnosed cancer in women in the United States, and Latinas have relatively low rates of screening participation. The Multilevel Intervention to Increase Latina Participation inMammography Screening study (¡Fortaleza Latina!) sought to assess the efficacy of a clinic-and patient-level program to increase breast cancer screening among Latinas in Western Washington who seek care at a safety net health center. Methods:The study enrolled536 Latinas ages 42to74who hada primary care clinic visit in the previous 5 years andhadnotobtained a mammogram in the previous 2 years. Participants were blockrandomized within clinic to either (i) a control arm (usual care) or (ii) a promotora-led, motivational interviewing intervention that included a home visit and telephone follow-up. At the clinic level, two of four participating clinics were provided additional mammography services delivered by a mobile mammography unit. Results: Rates of screening mammography 1 year postrandomization were 19.6% in the intervention group and 11.0% in the usual care group (P < 0.01), based on medical record data. No significant differences in participants' mammography screening were observed in clinics randomized to additional mammography services versus usual care (15.8% vs. 14.4%; P = 0.68). Conclusion: This multilevel intervention of promotora-delivered motivational interviewing and free mammography services modestly raised rates of participation in breast cancer screening among Latinas. Impact: Our findings can inform future efforts to boost mammography participation in safety net practices.
• Coronado, G., Retecki, S., Schneider, J., Taplin, S., Burdick, T., & Green, B. (2016). Recruiting community health centers into pragmatic research: Findings from STOP CRC. Clinical Trials, 13(2). doi:10.1177/1740774515608122
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  Background: Challenges of recruiting participants into pragmatic trials, particularly at the level of the health system, remain largely unexplored. As part of Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), we recruited eight separate community health centers (consisting of 26 individual safety net clinics) into a large comparative effectiveness pragmatic study to evaluate methods of raising the rates of colorectal cancer screening. Methods: In partnership with STOP CRC's advisory board, we defined criteria to identify eligible health centers and applied these criteria to a list of health centers in Washington, Oregon, and California affiliated with Oregon Community Health Information Network, a 16-state practice-based research network of federally sponsored health centers. Project staff contacted centers that met eligibility criteria and arranged in-person meetings of key study investigators with health center leadership teams. We used the Consolidated Framework for Implementation Research to thematically analyze the content of discussions during these meetings to identify major facilitators of and barriers to health center participation. Results: From an initial list of 41 health centers, 11 met the initial inclusion criteria. Of these, leaders at three centers declined and at eight centers (26 clinic sites) agreed to participate (73%). Participating and nonparticipating health centers were similar with respect to clinic size, percent Hispanic patients, and percent uninsured patients. Participating health centers had higher proportions of Medicaid patients and higher baseline colorectal cancer screening rates. Common facilitators of participation were perception by center leadership that the project was an opportunity to increase colorectal cancer screening rates and to use electronic health record tools for population management. Barriers to participation were concerns of center leaders about ability to provide fecal testing to and assure follow-up of uninsured patients, limited clinic capacity to prepare mailings required by the study protocol, discomfort with randomization, and concerns about delaying program implementation at some clinics due to the research requirements. Conclusion: Our findings address an important research gap and may inform future efforts to recruit community health centers into pragmatic research.
• Johnson, K., Neta, G., Dember, L., Coronado, G., Suls, J., Chambers, D., Rundell, S., Smith, D., Liu, B., Taplin, S., Stoney, C., Farrell, M., & Glasgow, R. (2016). Use of PRECIS ratings in the National Institutes of Health (NIH) Health Care Systems Research Collaboratory. Trials, 17(1). doi:10.1186/s13063-016-1158-y
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  Background: The National Institutes of Health (NIH) Health Care Systems Research Collaboratory (NIH Collaboratory) seeks to produce generalizable knowledge about the conduct of pragmatic research in health systems. This analysis applied the PRECIS-2 pragmatic trial criteria to five NIH Collaboratory pragmatic trials to better understand 1) the pragmatic aspects of the design and implementation of treatments delivered in real world settings and 2) the usability of the PRECIS-2 criteria for assessing pragmatic features across studies and across time. Methods/Design: Using the PRECIS-2 criteria, five pragmatic trials were each rated by eight raters. For each trial, we reviewed the original grant application and a required progress report written at the end of a 1-year planning period that included changes to the protocol or implementation approach. We calculated median scores and interrater reliability for each PRECIS domain and for the overall trial at both time points, as well as the differences in scores between the two time points. We also reviewed the rater comments associated with the scores. Results: All five trials were rated to be more pragmatic than explanatory, with comments indicating that raters generally perceived them to closely mirror routine clinical care across multiple domains. The PRECIS-2 domains for which the trials were, on average, rated as most pragmatic on the 1 to 5 scale at the conclusion of the planning period included primary analysis (mean=4.7 (range=4.5 to 4.9)), recruitment (4.3 (3.6 to 4.8)), eligibility (4.1 (3.4 to 4.8)), setting (4.1 (4.0 to 4.4)), follow-up (4.1 (3.4 to 4.9)), and primary outcome (4.1 (3.5 to 4.9)). On average, the less pragmatic domains were organization (3.3 (2.6 to 4.4)), flexibility of intervention delivery (3.5 (2.1-4.5)), and flexibility of intervention adherence (3.8 (2.8-4.5)). Interrater agreement was modest but statistically significant for four trials (Gwet's AC1 statistic range 0.23 to 0.40) and the intraclass correlation coefficient ranged from 0.05 to 0.31. Rating challenges included assigning a single score for domains that may relate to both patients and care settings (that is, eligibility or recruitment) and determining to what extent aspects of complex research interventions differ from usual care. Conclusions: These five trials in diverse healthcare settings were rated as highly pragmatic using the PRECIS-2 criteria. Applying the tool generated insightful discussion about real-world design decisions but also highlighted challenges using the tool. PRECIS-2 raters would benefit from additional guidance about how to rate the interwoven patient and practice-level considerations that arise in pragmatic trials. Trial registrations: Clinicaltrials.gov trial registrations: NCT02019225 , NCT01742065 , NCT02015455 , NCT02113592 , NCT02063867.
• Knerr, S., Hohl, S., Molina, Y., Neuhouser, M., Li, C., Coronado, G., Fullerton, S., & Thompson, B. (2016). Engaging study participants in research dissemination at a center for population health and health disparities. Progress in Community Health Partnerships: Research, Education, and Action, 10(4). doi:10.1353/cpr.2016.0065
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  Background: Research dissemination is a priority for The Partnership for Understanding and Eliminating Disparate Outcomes (PUEDO) for Latinas, a Center for Population Health and Health Disparities located at the Fred Hutchinson Cancer Research Center (FHCRC). Objectives: We aimed to identify types of PUEDO research findings our participants wanted and why, dissemination audiences beyond PUEDO participants, and strategies to communicate diverse findings about breast cancer and breast cancer disparities. Methods: Five focus groups with PUEDO study participants (N = 25) were transcribed for qualitative content analysis (average participants per focus group, 5; range, 2–11). Results: Participants reported wanting to learn aggregate and personal results and were influenced by their life experiences, their experiences as study participants, and the relevance they believed specific results would have for their lives. Women advocated for broad dissemination and inclusive communication using a simple paper-based strategy that would be accessible to diverse audiences (e.g., study participants, policymakers, recent immigrants). Conclusions: Focus groups informed PUEDO’s dissemination strategy, which concentrates on study participants and the regional Latino community. This approach to dissemination should maximize information uptake and community benefit.
• Larson, E., Tachibana, C., Thompson, E., Coronado, G., DeBar, L., Dember, L., Honda, S., Huang, S., Jarvik, J., Nelson, C., Septimus, E., Simon, G., & Johnson, K. (2016). Trials without tribulations: Minimizing the burden of pragmatic research on healthcare systems. Healthcare, 4(3). doi:10.1016/j.hjdsi.2015.07.005
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  Pragmatic clinical trials are increasingly common because they have the potential to yield findings that are directly translatable to real-world healthcare settings. Pragmatic clinical trials need to integrate research into clinical workflow without placing an undue burden on the delivery system. This requires a research partnership between investigators and healthcare system representatives. This paper, organized as a series of case studies drawn from our experience in the NIH Health Care Systems Research Collaboratory, presents guidance from informational interviews of physician–scientists, health services researchers, and delivery system leaders who recently launched pragmatic clinical trials.
• Oluloro, A., Petrik, A., Turner, A., Kapka, T., Rivelli, J., Carney, P., Saha, S., & Coronado, G. (2016). Timeliness of Colonoscopy After Abnormal Fecal Test Results in a Safety Net Practice. Journal of Community Health, 41(4). doi:10.1007/s10900-016-0165-y
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  Fecal testing can only reduce colorectal cancer mortality if patients with an abnormal test result receive a follow-up colonoscopy. As part of the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) project, we examined factors associated with adherence to follow-up colonoscopy among patients with abnormal fecal test results. As part of STOP CRC outreach, Virginia Garcia Memorial Health Center staff distributed 1753 fecal immunochemical tests (FIT), of which 677 (39 %) were completed, and 56 had an abnormal result (8 %). Project staff used logistic regression analyses to examine factors associated with colonoscopy referral and completion. Of the 56 patients with abnormal FIT results; 45 (80 %) had evidence of a referral for colonoscopy, 32 (57 %) had evidence of a completed colonoscopy within 18 months, and 14 (25 %) within 60 days of an abnormal fecal test result. In adjusted analysis, Hispanics had lower odds of completing follow-up colonoscopy within 60 days than non-Hispanic whites (adjusted OR 0.20; 95 % CI 0.04, 0.92). Colonoscopy within 60 days trended lower for women than for men (adjusted OR 0.25; 95 % CI 0.06–1.04). Among the 24 patients lacking medical record evidence of a colonoscopy, 19 (79 %) had a documented reason, including clinician did not pursue, patient refused, and colonoscopy not indicated. No reason was found for 21 %. Improvements are needed to increase rates of follow-up colonoscopy completion, especially among female and Hispanic patients.
• Petrik, A., Green, B., Vollmer, W., Le, T., Bachman, B., Keast, E., Rivelli, J., & Coronado, G. (2016). The validation of electronic health records in accurately identifying patients eligible for colorectal cancer screening in safety net clinics. Family Practice, 33(6). doi:10.1093/fampra/cmw065
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  Background. While electronic health records (EHRs) play a key role in increasing colorectal cancer (CRC) screening by identifying individuals who are overdue, important shortfalls remain. Objectives. As part of the Strategies and Opportunities to STOP Colon Cancer (STOP CRC) study, we assessed the accuracy of EHR codes in identifying patients eligible for CRC screening. Methods. We selected a stratified random sample of 800 study participants from 26 participating clinics, in the Pacific Northwest region of the USA. We compared data obtained through codes in the EHR to conduct a manual chart audit. A trained chart abstractor completed the abstraction of eligible and ineligible patients. Results. Of 520 individuals in need of CRC screening, identified via the EHR, 459 were confirmed through chart review (positive predictive value = 88%). Of 280 individuals flagged as up-to-date in their screening per EHR data, 269 were confirmed through chart review (negative predictive value = 96%). Among the 61 patients incorrectly classified as eligible, 83.6% of disagreements were due to evidence of a prior colonoscopy or referral that was not captured in recognizable fields in the EHR. Conclusions. Our findings highlight importance of better capture of past screening events in the EHR. While the need for better population-based data is not unique to CRC screening, it provides an important example of the use of population-based data not only for tracking care, but also for delivering interventions.
• Coronado, G., Petrik, A., Spofford, M., Talbot, J., Do, H., & Taylor, V. (2015). Clinical Perspectives on Colorectal Cancer Screening at Latino-Serving Federally Qualified Health Centers. Health Education and Behavior, 42(1). doi:10.1177/1090198114537061
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  Purpose. Colorectal cancer is the second most common cause of cancer death in the United States, and rates of screening for colorectal cancer are low. We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (operating 17 clinics) about barriers to utilization of screening services for colorectal cancer. Method. We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving Federally Qualified Health Center networks in Oregon. All interviews were recorded, transcribed, and coded, and themes were grouped by influences at three levels: the patient, the organization, and the external environment. Results. Estimated proportions of eligible patients who are underscreened for colorectal cancer ranged from 20% to 70%. Underscreening was thought to occur among low-income, underinsured, and undocumented patients and patients having multiple health concerns. Limited funding to pay for follow-up testing in patients with positive screens was cited as the key factor contributing to underscreening. Conclusions. We identified health care provider perceptions about the underutilization of screening services for colorectal cancer; our findings may inform future efforts to promote guideline-appropriate cancer screening.
• Coronado, G., Schneider, J., Sanchez, J., Petrik, A., & Green, B. (2015). Reasons for non-response to a direct-mailed FIT kit program: lessons learned from a pragmatic colorectal-cancer screening study in a federally sponsored health center. Translational Behavioral Medicine, 5(1). doi:10.1007/s13142-014-0276-x
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  Colorectal cancer screening rates are below optimal. As part of a pilot clinic-based pragmatic study aiming to raise rates of colorectal-cancer screening, we explored patients’ reasons for not responding to a direct-mailed screening invitation. We conducted telephone interviews with patients who were mailed a fecal immunochemical test (FIT) but who did not return it to the lab. Interviews were audio-recorded, transcribed, and coded for thematic analysis. We met our goal of 20 interviews (10 in English and 10 Spanish; 75 % female). Reasons for not completing tests were fear of results or cost of follow-up colonoscopy (n = 9); not having received the test in the mail (n = 7); concerns about mailing fecal matter or that test results could be mixed up (n = 6); and being busy or forgetful (n = 4). Efforts to improve uptake of colorectal cancer screening in a direct-mailed program ought to address concerns identified in our study.
• Coronado, G., Gutierrez, J., Jhingan, E., Angulo, A., & Jimenez, R. (2014). Patient and clinical perspectives on changes to mammography screening guidelines. Breast Journal, 20(1). doi:10.1111/tbj.12219
• Coronado, G., Jimenez, R., Martinez-Gutierrez, J., McLerran, D., Ornelas, I., Patrick, D., Gutierrez, R., Bishop, S., & Beresford, S. (2014). Multi-level Intervention to increase participation in mammography screening: ¡Fortaleza Latina! study design. Contemporary Clinical Trials, 38(2). doi:10.1016/j.cct.2014.06.008
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  Background: Breast cancer is the most common cancer and the leading cause of death among Latinas in the United States. The Multi-level Intervention to Increase Participation in Mammography Screening study (¡Fortaleza Latina!) is a partnership among research institutions, a Latino-serving community-based primary care clinic organization, and a cancer treatment center. The study will assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington. Methods/design: The intervention is a multi-level breast cancer screening program in four participating primary care clinics. The study is a parallel randomized controlled trial of 600 Latino women aged 42-74 who are non-compliant with breast cancer screening guidelines. Participants will be randomized within clinic using block randomization to: (1) a control arm (usual care); and (2) a theory-based counseling program consisting of a 'promotora' or community health worker-led home-based intervention to encourage breast cancer screening. At the clinic-level, two clinics will offer additional mammography services provided by a mobile mammography unit operated by the Seattle Cancer Care Alliance. The primary endpoint is the rate of mammography uptake over the 1-year follow-up period. Discussion: This multi-level intervention aims to raise rates of participation in breast cancer screening among Latino women. If effective, the program may improve rates of early detection of breast cancer in Latino women.Clinicaltrials.gov Registration Number: NCT02010008. © 2014.
• Coronado, G., Sanchez, J., Petrik, A., Kapka, T., Devoe, J., & Green, B. (2014). Advantages of wordless instructions on how to complete a fecal immunochemical test: Lessons from patient advisory council members of a federally qualified health center. Journal of Cancer Education, 29(1). doi:10.1007/s13187-013-0551-4
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  Some patients face difficulty understanding instructions for completing the fecal immunochemical test (FIT), a self-administered test to screen for colorectal cancer. We sought to develop and test low-literacy instructions for completing the FIT. Working in partnership with a Latino-serving Federally Qualified Health Center (FQHC) in the Portland Metro area, we developed and tested low-literacy instructions for completing the FIT; the instructions contained seven words (mail within 3 days; Devolver dentro de 3 dias). We conducted focus groups of Spanish-speaking patients on the advisory council of our partnering FQHC organization, and we gathered feedback from the project's advisory board members and clinic staff. We mailed a FIT kit to each patient, along with either (a) instructions written in English and Spanish, consisting of 415 words; or (b) low-literacy "wordless" instructions. We asked patients to complete the test before providing feedback. Our qualitative assessment showed that the wordless instructions were preferred over instructions consisting of words. Wordless instructions might aid efforts to raise the rates of colorectal cancer screening among low-literacy and non-English-speaking populations. © 2013 Springer Science+Business Media New York.
• Coronado, G., Vollmer, W., Petrik, A., Aguirre, J., Kapka, T., DeVoe, J., Puro, J., Miers, T., Lembach, J., Turner, A., Sanchez, J., Retecki, S., Nelson, C., & Green, B. (2014). Strategies and opportunities to STOP colon cancer in priority populations: Pragmatic pilot study design and outcomes. BMC Cancer, 14(1). doi:10.1186/1471-2407-14-55
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  Background: Colorectal-cancer is a leading cause of cancer death in the United States, and Latinos have particularly low rates of screening. Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC) is a partnership among two research institutions and a network of safety net clinics to promote colorectal cancer screening among populations served by these clinics. This paper reports on results of a pilot study conducted in a safety net organization that serves primarily Latinos.Methods: The study assessed two clinic-based approaches to raise rates of colorectal-cancer screening among selected age-eligible patients not up-to-date with colorectal-cancer screening guidelines. One clinic each was assigned to: (1) an automated data-driven Electronic Health Record (EHR)-embedded program for mailing Fecal Immunochemical Test (FIT) kits (Auto Intervention); or (2) a higher-intensity program consisting of a mailed FIT kit plus linguistically and culturally tailored interventions delivered at the clinic level (Auto Plus Intervention). A third clinic within the safety-net organization was selected to serve as a passive control (Usual Care). Two simple measurements of feasibility were: 1) ability to use real-time EHR data to identify patients eligible for each intervention step, and 2) ability to offer affordable testing and follow-up care for uninsured patients.Results: The study was successful at both measurements of feasibility. A total of 112 patients in the Auto clinic and 101 in the Auto Plus clinic met study inclusion criteria and were mailed an introductory letter. Reach was high for the mailed component (92.5% of kits were successfully mailed), and moderate for the telephone component (53% of calls were successful completed). After exclusions for invalid address and other factors, 206 (109 in the Auto clinic and 97 in the Auto Plus clinic) were mailed a FIT kit. At 6 months, fecal test completion rates were higher in the Auto (39.3%) and Auto Plus (36.6%) clinics compared to the usual-care clinic (1.1%).Conclusions: Findings showed that the trial interventions delivered in a safety-net setting were both feasible and raised rates of colorectal-cancer screening, compared to usual care. Findings from this pilot will inform a larger pragmatic study involving multiple clinics.Trial registration: ClinicalTrial.gov: NCT01742065. © 2014 Coronado et al.; licensee BioMed Central Ltd.
• Coronado, G., Vollmer, W., Petrik, A., Taplin, S., Burdick, T., Meenan, R., & Green, B. (2014). Strategies and Opportunities to STOP Colon Cancer in Priority Populations: Design of a cluster-randomized pragmatic trial. Contemporary Clinical Trials, 38(2). doi:10.1016/j.cct.2014.06.006
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  Background: Colorectal cancer is the second-leading cause of cancer deaths in the United States. The Strategies and Opportunities to Stop Colorectal Cancer (STOP CRC) in Priority Populations study is a pragmatic trial and a collaboration between two research institutions and a network of more than 200 safety net clinics. The study will assess the effectiveness of a system-based intervention designed to improve the rates of colorectal-cancer screening using fecal immunochemical testing (FIT) in federally qualified health centers in Oregon and Northern California. Material and methods: STOP CRC is a cluster-randomized comparative-effectiveness pragmatic trial enrolling 26 clinics. Clinics will be randomized to one of two arms. Clinics in the intervention arm (1) will use an automated, data-driven, electronic health record-embedded program to identify patients due for colorectal screening and mail FIT kits (with pictographic instructions) to them; (2) will conduct an improvement process (e.g. Plan-Do-Study-Act) to enhance the adoption, reach, and effectiveness of the program. Clinics in the control arm will provide opportunistic colorectal-cancer screening to patients at clinic visits. The primary outcomes are: proportion of age- and screening-eligible patients completing a FIT within 12. months; and cost, cost-effectiveness, and return on investment of the intervention. Conclusions: This large-scale pragmatic trial will leverage electronic health record information and existing clinic staff to enroll a broad range of patients, including many with historically low colorectal-cancer screening rates. If successful, the program will provide a model for a cost-effective and scalable method to raise colorectal-cancer screening rates. © 2014 Elsevier Inc.
• Green, B., & Coronado, G. (2014). BeneFITs to increase colorectal cancer screening in priority populations. JAMA Internal Medicine, 174(8). doi:10.1001/jamainternmed.2014.730
• Green, B., Coronado, G., Devoe, J., & Allison, J. (2014). Navigating the murky waters of colorectal cancer screening and health reform. American Journal of Public Health, 104(6). doi:10.2105/ajph.2014.301877
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  The Affordable Care Act (ACA) mandates that both Medicaid and insurance plans cover life-saving preventive services recommended by the US Preventive Services Task Force, including colorectal cancer (CRC) screening and choice between colonoscopy, flexible sigmoidoscopy, and fecal occult blood testing (FOBT). People who choose FOBT or sigmoidoscopy as their initial test could face high, unexpected, out-of-pocket costs because the mandate does not cover needed follow-up colonoscopies after positive tests. Some people will have no coverage for any CRC screening because of lack of state participation in the ACA or because they do not qualify (e.g., immigrant workers). Existing disparities in CRC screening and mortality will worsen if policies are not corrected to fully cover both initial and follow-up testing.
• Johnson, K., Tachibana, C., Coronado, G., Dember, L., Glasgow, R., Huang, S., Martin, P., Richards, J., Rosenthalprofessor, G., Septimus, E., Simon, G., Solberg, L., Suls, J., Thompson, E., & Larson, E. (2014). A guide to research partnerships for pragmatic clinical trials. BMJ (Online), 349. doi:10.1136/bmj.g6826
• Molina, Y., Ornelas, I., Doty, S., Bishop, S., Beresford, S., & Coronado, G. (2014). Family/friend recommendations and mammography intentions: The roles of perceived mammography norms and support. Health Education Research, 30(5). doi:10.1093/her/cyv040
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  Identifying factors that increase mammography use among Latinas is an important public health priority. Latinas are more likely to report mammography intentions and use, if a family member or friend recommends that they get a mammogram. Little is known about the mechanisms underlying the relationship between social interactions and mammography intentions. Theory suggests that family/friend recommendations increase perceived mammography norms (others believe a woman should obtain a mammogram) and support (others will help her obtain a mammogram), which in turn increase mammography intentions and use. We tested these hypotheses with data from the ¡Fortaleza Latina! study, a randomized controlled trial including 539 Latinas in Washington State. Women whose family/friend recommended they get a mammogram within the last year were more likely to report mammography intentions, norms and support. Perceived mammography norms mediated the relationship between family/friend recommendations and intentions, Mediated Effect = 0.38, 95%CI [0.20, 0.61], but not support, Mediated Effect = 0.002, 95%CI [-0.07, 0.07]. Our findings suggest perceived mammography norms are a potential mechanism underlying the effect of family/friend recommendations on mammography use among Latinas. Our findings make an important contribution to theory about the associations of social interactions, perceptions and health behaviors.
• Byrd, T., Wilson, K., Smith, J., Coronado, G., Vernon, S., Fernandez, M., Thompson, B., Ortiz, M., Lairson, D., & Fernandez-Esquer, M. (2013). AMIGAS: A multicity, multicomponent cervical cancer prevention trial among Mexican American women. Cancer, 119(7). doi:10.1002/cncr.27926
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  BACKGROUND: Considerable efforts have been undertaken in the United States to reduce cervical cancer incidence and mortality by increasing screening; however, disparities in screening rates continue to exist among certain racial and ethnic minority groups. The objective of the current study was to determine the effectiveness of a lay health worker-delivered intervention-AMIGAS (Ayudando a las Mujeres con Informacion, Guia, y Amor para su Salud [helping women with information, guidance, and love for their health])-to increase Papanicolaou (Pap) test screening among 3 populations of women of Mexican origin. METHODS: Six hundred thirteen women of Mexican origin in 3 treatment sites were randomized among 4 study arms: the full AMIGAS program with a video and a flip chart (n = 151), the AMIGAS program without the video (n = 154), the AMIGAS program without the flip chart (n = 155), and a usual care control group (n = 153). Six months after enrollment, women were surveyed and reported whether or not they had been screened. RESULTS: Women in any of the intervention arms were statistically significantly more likely to report being screened than those in the usual care group in both an intent-to-treat analysis and a per-protocol analysis. In the intent-to-treat analysis, 25% of women in the control group and 52% in the full AMIGAS program group reported having had Pap tests (P
• Coronado, G., Petrik, A., Spofford, M., Talbot, J., Do, H., Sanchez, J., Kapka, T., & Taylor, V. (2013). Perceptions of under and overutilization of cervical cancer screening services at latino-serving community health centers. Journal of Community Health, 38(5). doi:10.1007/s10900-013-9701-1
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  We sought to gather the perceptions of clinic personnel at Latino-serving Federally Qualified Health Centers (FQHCs) about patients' utilization of screening services for cervical cancer. We conducted one-on-one interviews among 17 clinic personnel at four Latino-serving FQHCs in Oregon. The clinic personnel we interviewed observed both under and overutilization of cervical cancer screening services. Clinic personnel estimated that 20-60 % of eligible patients were underscreened for cervical cancer, with 30 % the most commonly cited percentage. Underscreening was thought to occur among low-income, underinsured, and undocumented patients. Overscreening for cervical cancer was estimated to occur in 10-50 % of eligible patients, with 10 % the most frequently cited proportion. Overscreening was thought to occur among women younger than age 21 and women with a recent pregnancy. Our findings may inform future efforts to promote guideline-appropriate cancer screening and coordinated follow-up care. © 2013 Springer Science+Business Media New York.
• Livaudais, J., LaCroix, A., Chlebowski, R., Li, C., Habel, L., Simon, M., Thompson, B., Erwin, D., Hubbell, F., & Coronado, G. (2013). Racial/ethnic differences in use and duration of adjuvant hormonal therapy for breast cancer in the women's health initiative. Cancer Epidemiology Biomarkers and Prevention, 22(3). doi:10.1158/1055-9965.epi-12-1225
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  Background: Five-year breast cancer survival rates are lower among Hispanic and African-American women than among Non-Hispanic White women. Differences in breast cancer treatment likely play a role. Adjuvant hormonal therapies increase overall survival among women with hormone receptor-positive breast cancer. Methods: We examined racial/ethnic differences in use and duration of adjuvant hormonal therapy among 3,588 postmenopausal women enrolled in the Women's Health Initiative (WHI) Extension Study. Women diagnosed with hormone receptor-positive localized or regional stage breast cancer after study enrollment were surveyed between September 2009 and August 2010 and asked to recall prior use and duration of adjuvant hormonal breast cancer therapy. ORs comparing self-reported use and duration with race/ethnicity (Hispanic, African-American, Asian/Pacific Islander vs. Non-Hispanic White) were estimated using multivariableadjusted logistic regression. Results: Of the 3,588 women diagnosed from 1994 to 2009; 3,039 (85%) reported any use of adjuvant hormonal therapy, and 67% of women reporting ever-use who were diagnosed before 2005 reported using adjuvant hormonal therapy for the optimal duration of 5 years or more. In adjusted analysis, no statistically significant differences in use or duration by race/ethnicity were observed. Conclusions: This study did not find significant differences in use or duration of use of adjuvant hormonal therapy by race/ethnicity. Impact: Findings should be confirmed in other population-based samples, and potential reasons for discontinuation of therapy across all racial/ethnic groups should be explored. © 2013 American Association for Cancer Research.
• Martinez-Gutierrez, J., Jhingan, E., Angulo, A., Jimenez, R., Thompson, B., & Coronado, G. (2013). Cancer screening at a federally qualified health center: A qualitative study on organizational challenges in the era of the patient-centered medical home. Journal of Immigrant and Minority Health, 15(5). doi:10.1007/s10903-012-9701-8
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  Federally Qualified Health Centers (FQHCs) serve uninsured and minority populations, who have low cancer screening rates. The patient-centered medical home (PCMH) model aims to provide comprehensive preventive services, including cancer screening, to these populations. Little is known about organizational factors influencing the delivery of cancer screening in this context. We conducted 18 semi-structured interviews with clinic personnel at four FQHC clinics in Washington State. All interviews were recorded and transcribed verbatim and analyzed by two bilingual coders to identify salient themes. We found that screening on-site, scheduling separate visits for preventive care, and having non-provider staff recommend and schedule screening services facilitated the delivery of cancer screening. We found work overload to be a barrier to screening. To successfully implement screening strategies within the PCMH model, FQHCs must enhance facilitators and address organizational gaps in their cancer screening processes. © 2012 Springer Science+Business Media, LLC.
• Ulrich, A., Thompson, B., Livaudais, J., Espinoza, N., Cordova, A., & Coronado, G. (2013). Issues in biomedical research: What do hispanics think?. American Journal of Health Behavior, 37(1). doi:10.5993/ajhb.37.1.9
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  Objective: To examine barriers and facilitators of biomedical research participation among Hispanics in a rural community in Washington State. Methods: Questionnaires addressed socio-demographics, health care access, and barriers and facilitators of participation in biomedical studies. This is a descriptive analysis of the findings. Results: Barriers include the need to care for family members (82%), fear of having to pay for research treatments (74%), cultural beliefs (65%), lack of time (75%) and trust (71%), and the degree of hassle (73%). Facilitators include having a friend/relative with the disease being researched (80%) and monetary compensation (73%). Conclusion: Researchers should be mindful of these facilitators and barriers when recruiting for biomedical research studies. Copyright (c) PNG Publications. All rights reserved.
• Coronado, G., Holte, S., Vigoren, E., Griffith, W., Barr, D., Faustman, E., & Thompson, B. (2012). Do workplace and home protective practices protect farm workers? findings from the "For Healthy Kids" study. Journal of Occupational and Environmental Medicine, 54(9). doi:10.1097/JOM.0b013e31825902f5
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  OBJECTIVE:: To assess associations of protective workplace and home practices with pesticide exposure levels. METHODS:: Using data from orchard workers in the Yakima Valley, Washington, we examined associations of workplace and home protective practices with (1) urinary metabolite concentrations of dimethylthiophosphate (DMTP) in adults and children aged 2 to 6 years and (2) azinphos-methyl levels in house and vehicle dust. RESULTS:: Data were collected from 95 orchard workers and 94 children. Contrary to expectation, adult farm workers who wore boots or washed hands using hand sanitizer had higher concentrations of DMTP than those who did not. Children who attended daycare had higher DMTP concentrations than children who did not. CONCLUSIONS:: Few workplace or home practices were associated with pesticide exposure levels; workers who used hand sanitizer had higher concentrations of DMTP, as did children who attended daycare. Copyright © 2012 by American College of Occupational and Environmental Medicine.
• Coronado, G., Ondelacy, S., Schwarz, Y., Duggan, C., Lampe, J., & Neuhouser, M. (2012). Recruiting underrepresented groups into the carbohydrates and related biomarkers (CARB) cancer prevention feeding study. Contemporary Clinical Trials, 33(4). doi:10.1016/j.cct.2012.03.017
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  Using data from a randomized, controlled feeding study, which aimed to recruit 88 participants (including 22 Hispanics and 22 African Americans), we examined strategies for recruiting individuals from underrepresented groups into research trials. Study eligibility criteria included participants who 1) were 18-45. years old; 2) had a body mass index (BMI) > 18 < 24.9 or BMI > 28.0 < 40.0; 3); had no preexisting health conditions; 4) were non-smoking; 5) had normal fasting blood glucose level (< 100. mg/dL); and 6) spoke English. Participants were recruited using two overarching methods: media-based strategies (flyers and posters, email announcements, announcements in local and campus newspapers, and the Internet) and in-person strategies (presentations in university classes and community events). Participants were enrolled March 2006-March 2009. We present the numbers of individuals requesting study information, completing pre-enrollment screening questionnaires, and enrolling in the study. A total of 1036 individuals requested study information, and 396 completed a pre-enrollment screening questionnaire; 90 enrolled in the study (22 Hispanics and 18 African Americans). Among enrolled participants, in-person recruitment strategies were reported by 39% of African Americans, 73% of Hispanics, and 30% of non-Hispanic Whites (P< 0.001). In-person recruitment strategies were successful among Hispanics. Mass media recruitment strategies were successful among non-Hispanic Whites but enlisted relatively few Hispanic participants. Both strategies recruited nearly equal percentages of African Americans. These data suggest that different strategies are needed to effectively recruit racial/ethnic population subgroups into intervention studies. © 2012 Elsevier Inc.
• Duggan, C., Coronado, G., Martinez, J., Byrd, T., Carosso, E., Lopez, C., Benavides, M., & Thompson, B. (2012). Cervical cancer screening and adherence to follow-up among Hispanic women study protocol: A randomized controlled trial to increase the uptake of cervical cancer screening in Hispanic women. BMC Cancer, 12. doi:10.1186/1471-2407-12-170
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  Background: In the US, Hispanic women have a higher incidence of, and mortality from, cervical cancer than non-Hispanic white women. The reason for this disparity may be attributable to both low rates of screening and poor adherence to recommended diagnostic follow-up after an abnormal Pap test. The 'Cervical Cancer Screening and Adherence to Follow-up Among Hispanic Women' study is a collaboration between a research institution and community partners made up of members from community based organizations, the Yakima Valley Farm Workers Clinic and the Breast, Cervical, and Colon Health Program of the Yakima District The study will assess the efficacy of two culturally-appropriate, tailored educational programs designed to increase cervical cancer screening among Hispanic women, based in the Yakima Valley, Washington, US.Methods/design: A parallel randomized-controlled trial of 600 Hispanic women aged 21-64, who are non-compliant with Papanicolau (Pap) test screening guidelines. Participants will be randomized using block randomization to (1) a control arm (usual care); (2) a low-intensity information program, consisting of a Spanish-language video that educates women on the importance of cervical cancer screening; or (3) a high-intensity program consisting of the video plus a 'promotora' or lay-community health educator-led, home based intervention to encourage cervical cancer screening. Participants who attend cervical cancer screening, and receive a diagnosis of an abnormal Pap test will be assigned to a patient navigator who will provide support and information to promote adherence to follow-up tests, and any necessary surgery or treatment. Primary endpoint: Participants will be tracked via medical record review at community-based clinics, to identify women who have had a Pap test within 7 months of baseline assessment. Medical record reviewers will be blinded to randomization arm. Secondary endpoint: An evaluation of the patient navigator program as a method to improve adherence and reduce time to follow-up among participants who receive an abnormal Pap test result. An additional secondary endpoint is the cost-effectiveness of the two different intensity intervention programs.Discussion: This culturally sensitive intervention aims to increase compliance and adherence to cervical screening in a Hispanic population. If effective, such interventions may reduce incidence of cervical cancer.Trial registration: NCT01525433. © 2012 Duggan et al.; licensee BioMed Central Ltd.
• Kepka, D., Coronado, G., Rodriguez, H., & Thompson, B. (2012). Development of a radionovela to promote HPV vaccine awareness and knowledge among latino parents. Public Health Reports, 127(1). doi:10.1177/003335491212700118
• Kepka, D., Ulrich, A., & Coronado, G. (2012). Low knowledge of the three-dose HPV vaccine series among mothers of rural hispanic adolescents. Journal of Health Care for the Poor and Underserved, 23(2). doi:10.1353/hpu.2012.0040
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  Background. Few previous investigations on correlates of HPV vaccine uptake have included Hispanics, a group known to have a disproportionately high risk of cervical cancer. Methods. Rural Hispanic mothers of daughters aged 9-17 (n578) were recruited at local community events to participate in a standardized Spanish-language survey that examined factors related to vaccine uptake. Results. Approximately 35% of the mothers reported that their daughter had received at least one dose of the vaccine. Mothers who had heard of the HPV vaccine were more likely to have a vaccinated daughter (p,.01). Mothers who thought their daughter's father would approve were more likely to have a vaccinated daughter (p5.004). Contrary to expectation, parents who believed that only one injection is necessary were more likely to have a vaccinated daughter (p5.009). Conclusions. HPV vaccine education programs that target both parents are needed to ensure that Hispanic parents receive the complete HPV vaccine regimen. © Meharry Medical College.
• Livaudais, J., Hershman, D., Habel, L., Kushi, L., Gomez, S., Li, C., Neugut, A., Fehrenbacher, L., Thompson, B., & Coronado, G. (2012). Racial/ethnic differences in initiation of adjuvant hormonal therapy among women with hormone receptor-positive breast cancer. Breast Cancer Research and Treatment, 131(2). doi:10.1007/s10549-011-1762-1
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  Mortality after breast cancer diagnosis is known to vary by race/ethnicity even after adjustment for differences in tumor characteristics. As adjuvant hormonal therapy decreases risk of recurrence and increases overall survival among women with hormone receptor-positive tumors, treatment disparities may play a role. We explored racial/ethnic differences in initiation of adjuvant hormonal therapy, defined as two or more prescriptions for tamoxifen or aromatase inhibitor filled within the first year after diagnosis of hormone receptor-positive localized or regional-stage breast cancer. The sample included women diagnosed with breast cancer enrolled in Kaiser Permanente Northern California (KPNC). Odds ratios [OR] and 95% confidence intervals [CI] compared initiation by race/ethnicity (Hispanic, African American, Chinese, Japanese, Filipino, and South Asian vs. non-Hispanic White [NHW]) using logistic regression. Covariates included age and year of diagnosis, area-level socioeconomic status, co-morbidities, tumor stage, histology, grade, breast cancer surgery, radiation and chemotherapy use. Our sample included 13,753 women aged 20-79 years, diagnosed between 1996 and 2007, and 70% initiated adjuvant hormonal therapy. In multivariable analysis, Hispanic and Chinese women were less likely than NHW women to initiate adjuvant hormonal therapy ([OR] = 0.82; [CI] 0.71-0.96 and [OR] = 0.78; [CI] 0.63-0.98, respectively). Within an equal access, insured population, lower levels of initiation of adjuvant hormonal therapy were found for Hispanic and Chinese women. Findings need to be confirmed in other insured populations and the reasons for under-initiation among these groups need to be explored. © 2011 Springer Science+Business Media, LLC.
• Livaudais, J., Li, C., John, E., Terry, M., Daly, M., Buys, S., Habel, L., Thompson, B., Yanez, N., & Coronado, G. (2012). Racial and ethnic differences in adjuvant hormonal therapy use. Journal of Women's Health, 21(9). doi:10.1089/jwh.2011.3254
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  Background: In the United States, 5-year breast cancer survival is highest among Asian American women, followed by non-Hispanic white, Hispanic, and African American women. Breast cancer treatment disparities may play a role. We examined racial/ethnic differences in adjuvant hormonal therapy use among women aged 18-64 years, diagnosed with hormone receptor-positive breast cancer, using data collected by the Northern California Breast Cancer Family Registry (NC-BCFR), and explored changes in use over time. Methods: Odds ratios (OR) comparing self-reported ever-use by race/ethnicity (African American, Hispanic, non-Hispanic white vs. Asian American) were estimated using multivariable adjusted logistic regression. Analyses were stratified by recruitment phase (phase I, diagnosed January 1995-September 1998, phase II, diagnosed October 1998-April 2003) and genetic susceptibility, as cases with increased genetic susceptibility were oversampled. Results: Among 1385 women (731 phase I, 654 phase II), no significant racial/ethnic differences in use were observed among phase I or phase II cases. However, among phase I cases with no susceptibility indicators, African American and non-Hispanic white women were less likely than Asian American women to use hormonal therapy (OR 0.20, 95% confidence interval [CI]0.06-0.60; OR 0.40, CI 0.17-0.94, respectively). No racial/ethnic differences in use were observed among women with 1+ susceptibility indicators from either recruitment phase. Conclusions: Racial/ethnic differences in adjuvant hormonal therapy use were limited to earlier diagnosis years (phase I) and were attenuated over time. Findings should be confirmed in other populations but indicate that in this population, treatment disparities between African American and Asian American women narrowed over time as adjuvant hormonal treatments became more commonly prescribed. © Copyright 2012, Mary Ann Liebert, Inc. 2012.
• Neuhouser, M., Schwarz, Y., Wang, C., Breymeyer, K., Coronado, G., Wang, C., Noar, K., Song, X., & Lampe, J. (2012). A low-glycemic load diet reduces serum C-reactive protein and modestly increases adiponectin in overweight and obese adults. Journal of Nutrition, 142(2). doi:10.3945/jn.111.149807
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  Low-glycemic load (GL) diets improve insulin resistance and glucose homeostasis in individuals with diabetes. Less is known about whether low-GL diets, independent of weight loss, improve the health profile for persons without diabetes or other preexisting conditions. We conducted a randomized, cross-over feeding study testing low- compared to High-GL diets on biomarkers of inflammation and adiposity in healthy adults. Eighty participants (n = 40 with BMI 18.5-24.9 kg/m 2; n = 40 with BMI 28.0-40.0 kg/m 2) completed two 28-d feeding periods in random order where one period was a high-GL diet (mean GL/d = 250) and the other a low-GL diet (mean GL/d = 125). Diets were isocaloric with identical macronutrient content (as percent energy). All food was provided and participants maintained weight and usual physical activity. Height, weight, and DXA were measured at study entry and weight assessed again thrice per week. Blood was drawn from fasting participants at the beginning and end of each feeding period and serum concentrations of high-sensitivity CRP, serum amyloid A, IL-6, leptin, and adiponectin were measured. Linear mixed models tested the intervention effect on the biomarkers; models were adjusted for baseline biomarker concentrations, diet sequence, feeding period, age, sex, and body fat mass. Among participants with high-body fat mass (>32.0% for males and >25.0% for females), the low-GL diet reduced CRP (P = 0.02) and marginally increased adiponectin (P = 0.06). In conclusion, carbohydrate quality, independent of energy, is important. Dietary patterns emphasizing low-GL foods may improve the inflammatory and adipokine profiles of overweight and obese individuals. © 2012 American Society for Nutrition.
• Nonnenmann, M., Coronado, G., Thompson, B., Griffith, W., Hanson, J., Vesper, S., & Faustman, E. (2012). Utilizing pyrosequencing and quantitative PCR to characterize fungal populations among house dust samples. Journal of Environmental Monitoring, 14(8). doi:10.1039/c2em30229b
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  Molecular techniques are an alternative to culturing and counting methods in quantifying indoor fungal contamination. Pyrosequencing offers the possibility of identifying unexpected indoor fungi. In this study, 50 house dust samples were collected from homes in the Yakima Valley, WA. Each sample was analyzed by quantitative PCR (QPCR) for 36 common fungi and by fungal tag-encoded flexible (FLX) amplicon pyrosequencing (fTEFAP) for these and additional fungi. Only 24 of the samples yielded amplified results using fTEFAP but QPCR successfully amplified all 50 samples. Over 450 fungal species were detected by fTEFAP but most were rare. Twenty-two fungi were found by fTEFAP to occur with at least an average of ≥0.5% relative occurrence. Many of these fungi seem to be associated with plants, soil or human skin. Combining fTEFAP and QPCR can enhance studies of fungal contamination in homes. © 2012 The Royal Society of Chemistry.
• Richman, A., Coronado, G., Arnold, L., Fernandez, M., Glenn, B., Allen, J., Wilson, K., & Brewer, N. (2012). Cognitive testing of human papillomavirus vaccine survey items for parents of adolescent girls. Journal of Lower Genital Tract Disease, 16(1). doi:10.1097/lgt.0b013e3182293a49
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  OBJECTIVE: Many studies have been conducted to understand what factors are associated with human papillomavirus (HPV) vaccine acceptability and completion of the 3-dose vaccination series, but few have examined whether people understand the survey items used to assess these relationships. Through a multisite collaborative effort, we developed and cognitively tested survey items that represent constructs known to affect vaccine acceptability and completion. MATERIALS AND METHODS: Investigators from 7 research centers in the United States used cognitive interviewing techniques and in-person and telephone interviews to test 21 items. Four rounds of testing, revising, and retesting were conducted among racially and ethnically diverse parents (n = 62) of girls between the ages of 9 and 17 years. RESULTS: The final survey contained 20 items on attitudes and beliefs relevant to HPV vaccine. Some parents misinterpreted statements about hypothetical vaccine harms as statements of fact. Others were unwilling to answer items about perceived disease likelihood and perceived vaccine effectiveness, because they said the items seemed to have a "right" answer that they did not know. On the basis of these and other findings from cognitive testing, we revised the wording of 14 questions to improve clarity and comprehension. We also revised instructions, response options, and item order. CONCLUSIONS: Cognitive testing of HPV vaccine survey items revealed important differences between intended and ascribed item meaning by participants. Use of the tested survey questions presented here may increase measurement validity and researchers' ability to compare findings across studies and populations. Additional testing using quantitative methods can help to further validate these items. © 2012 The American Society for Colposcopy and Cervical Pathology.
• Runchey, S., Pollak, M., Valsta, L., Coronado, G., Schwarz, Y., Breymeyer, K., Wang, C., Lampe, J., & Neuhouser, M. (2012). Glycemic load effect on fasting and post-prandial serum glucose, insulin, IGF-1 and IGFBP-3 in a randomized, controlled feeding study. European Journal of Clinical Nutrition, 66(10). doi:10.1038/ejcn.2012.107
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  Background/objectives: The effect of a low glycemic load (GL) diet on insulin-like growth factor-1 (IGF-1) concentration is still unknown but may contribute to lower chronic disease risk. We aimed to assess the impact of GL on concentrations of IGF-1 and IGF-binding protein-3 (IGFBP-3).Subjects/methods: We conducted a randomized, controlled crossover feeding trial in 84 overweight obese and normal weight healthy individuals using two 28-day weight-maintaining high- and low-GL diets. Measures were fasting and post-prandial concentrations of insulin, glucose, IGF-1 and IGFBP-3. In all 80 participants completed the study and 20 participants completed post-prandial testing by consuming a test breakfast at the end of each feeding period. We used paired t-tests for diet component and linear mixed models for biomarker analyses.Results: The 28-day low-GL diet led to 4% lower fasting concentrations of IGF-1 (10.6 ng/ml, P0.04) and a 4% lower ratio of IGF-1/IGFBP-3 (0.24, P0.01) compared with the high-GL diet. The low-GL test breakfast led to 43% and 27% lower mean post-prandial glucose and insulin responses, respectively; mean incremental areas under the curve for glucose and insulin, respectively, were 64.3±21.8 (mmol/l/240 min; P0.01) and 2253±539 (μU/ml/240 min; P0.01) lower following the low- compared with the high-GL test meal. There was no effect of GL on mean homeostasis model assessment for insulin resistance or on mean integrated post-prandial concentrations of glucose-adjusted insulin, IGF-1 or IGFBP-3. We did not observe modification of the dietary effect by adiposity.Conclusions: Low-GL diets resulted in 43% and 27% lower post-prandial responses of glucose and insulin, respectively, and modestly lower fasting IGF-1 concentrations. Further intervention studies are needed to weigh the impact of dietary GL on risk for chronic disease. © 2012 Macmillan Publishers Limited All rights reserved.
• Taylor, V., Liu, Q., Yasui, Y., Talbot, J., Sos, C., Ornelas, I., Coronado, G., & Bastani, R. (2012). Physical activity among Cambodian Americans: An exploratory study. Journal of Community Health, 37(5). doi:10.1007/s10900-011-9528-6
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  Available data indicate that Asian Americans as a group have lower levels of physical activity than non-Latino whites. However, few studies have focused on physical activity among Asian American sub-groups. Our objectives were to describe levels of physical activity, as well as individual and environmental correlates of physical activity among Cambodian Americans. We conducted a telephone survey of Cambodians living in three geographic areas (Central California, Northern California, and the Pacific Northwest) during 2010. Physical activity levels were assessed using the International Physical Activity Questionnaire (IPAQ) short version. Survey items addressed demographic characteristics, knowledge about the health benefits of physical activity, social norms and supports with respect to physical activity, the availability of neighbourhood recreational facilities, and neighbourhood characteristics. Our study group included 222 individuals. Only 12% of the study group reported low levels of physical activity, 40% reported moderate levels, and 48% reported high levels. Physical activity was strongly associated with the availability of neighborhood recreational facilities such as parks, but not with neighborhood characteristics such as heavy traffic. Our results suggest that a majority of Cambodian Americans are adherent to current physical activity guidelines. Neighborhood recreational facilities that provide opportunities for leisure-time physical activity are associated with higher levels of physical activity in Cambodian communities. Future research should assess the reliability and validity of the IPAQ in a Cambodian American study group. © Springer Science+Business Media, LLC 2012.
• Coronado, G., Beasley, J., & Livaudais, J. (2011). Alcohol consumption and the risk of breast cancer. Salud Publica de Mexico, 53(5).
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  Epidemiologic studies addressing the association of alcohol consumption with breast cancer consistently suggest a modest association and a dose-response relationship. The epidemiologic evidence does not point to a single mechanism to explain the association, and several mechanisms have been proposed. Alcohol consumption is shown to increase levels of endogenous estrogens, known risk factors for breast cancer. This hypothesis is further supported by data showing that the alcohol-breast cancer association is limited to women with estrogen-receptor positive tumors. Products of alcohol metabolism are known to be toxic and are hypothesized to cause DNA modifications that lead to cancer. Recent research has focused on genes that influence the rate of alcohol metabolism, with genes that raise blood concentrations of acetaldehyde hypothesized to heighten breast cancer risk. Mounting evidence suggests that antioxidant intake (e.g. folate) may reduce alcohol-associated breast cancer risk, because it neutralizes reactive oxygen species, a second-stage product of alcohol metabolism. Diets lacking sufficient antioxidant intake, as a result, may further elevate the risk of breast cancer among alcohol consumers. Given that alcohol consumption is increasing worldwide and especially among women in countries of rapid economic growth, a greater understanding of the mechanisms underlying the known alcohol-breast cancer association is warranted. Avoiding overconsumption of alcohol is recommended, especially for women with known risk factors for breast cancer.
• Coronado, G., Golovaty, I., Longton, G., Levy, L., & Jimenez, R. (2011). Effectiveness of a clinic-based colorectal cancer screening promotion program for underserved Hispanics. Cancer, 117(8). doi:10.1002/cncr.25730
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  Background: Hispanics in the United States are less likely than other groups to receive screening services for colorectal cancer. Methods: The authors conducted a clinic-based individual randomized trial that enrolled Hispanic patients ages 50 to 79 years who had been seen in the Seattle-based community clinic in the past 5 years. A total of 501 patients met the eligibility criteria and were randomized to 1 of 3 conditions: 1) usual care; 2) mailed fecal occult blood test (FOBT) card and instructions on how to complete the test (mailed FOBT only); and 3) mailed FOBT card and instructions on how to complete the test, telephone reminders, and home visits (mailed FOBT and outreach). The authors assessed postintervention differences in rates of FOBT screening in intervention and usual care groups using computerized medical records reviewed from June 2007 to March 2008. Results: Data analysis occurred between November 2008 and September 2009. Nine-month postintervention screening rates were 26% among patients who received the mailed packet only intervention (P
• Coronado, G., Holte, S., Vigoren, E., Griffith, W., Barr, D., Faustman, E., & Thompson, B. (2011). Organophosphate pesticide exposure and residential proximity to nearby fields: Evidence for the drift pathway. Journal of Occupational and Environmental Medicine, 53(8). doi:10.1097/JOM.0b013e318222f03a
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  Objectives: Residential proximity to pesticide-treated farmland is an important pesticide exposure pathway. Methods: In-person interviews and biological samples were collected from 100 farmworker and 100 non-farmworker adults and children living in Eastern Washington State. We examined the relationship of residential proximity to farmland to urinary metabolite concentrations of dimethylphosphate (DMTP) and levels of pesticide residues in house dust. Results: DMTP concentrations were higher in farmworkers than non-farmworkers (71 μg/L vs 6 μg/L) and in farmworker children than non-farmworker children (17 μg/L vs 8 μg/L). Compared to non-farmworker households, farmworker households had higher levels of azinphos-methyl (643 ng/g vs 121 ng/g) and phosmet (153 ng/g vs 50 ng/g). Overall, a 20% reduction in DMTP concentration was observed per mile increase in distance from farmland. Conclusions: Lower OP metabolite concentrations correlated with increasing distance from farmland. Copyright © 2011 by American College of Occupational and Environmental Medicine.
• Coronado, G., Sos, C., Talbot, J., Do, H., & Taylor, V. (2011). To be healthy and to live long, we have to exercise: Psychosocial factors related to physical activity among cambodian Americans. Journal of Community Health, 36(3). doi:10.1007/s10900-010-9319-5
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  Regular physical activity produces various health benefits; however, relatively few adults in the United States (US) get enough physical activity. Little is known about physical activity behaviors, and barriers and facilitators to physical activity among Cambodian-Americans. Cambodian Americans were recruited from community venues to participate in one-on-one interviews and focus groups. A total of 20 adults (10 women and 10 men) participated in one-on-one interviews and 37 adults (23 women and 14 men) participated in one of four focus groups. Fifteen of the 20 interviews and all the focus groups were conducted in Khmer. Participants were generally born in Cambodia and over two-thirds had a high school education or less. About one-half of the participants met or exceeded the 2008 US Department of Health and Human Services physical activity guidelines. Commonly reported types of physical activity were walking, running, and working out at the gym. Barriers to physical activity included lack of time, inconvenient work hours, and family responsibilities. Perceived benefits of physical activity included improved health, improved appearance, and reductions in stress. Sweating caused by physical activity was thought to produce a variety of health benefits. Data from this qualitative study could be used to inform the development of culturally-relevant physical activity survey measures and culturally-relevant physical activity interventions for Cambodian Americans. © 2010 Springer Science+Business Media, LLC.
• Kepka, D., Coronado, G., Rodriguez, H., & Thompson, B. (2011). Evaluation of a Radionovela to promote HPV vaccine awareness and knowledge among hispanic parents. Journal of Community Health, 36(6). doi:10.1007/s10900-011-9395-1
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  Hispanic women have more than a 1.5-fold increased cervical cancer incidence and mortality compared to non-Hispanic white women in the United States. The Centers for Disease Control recommends the HPV vaccine for females at ages 11 and 12 years, though it is approved for females aged 9-26 to protect against the primary types of high-risk HPV (HPV-16 and HPV-18) that cause approximately 70% of cervical cancer cases. Few culturally-tailored Spanish HPV vaccine awareness programs have been developed. This study evaluates the efficacy of a Spanish radionovela as an educational tool. Rural Hispanic parents of daughters aged 9-17 (n = 88; 78 mothers and 10 fathers) were randomized to listen to the HPV vaccine radionovela or to another public service announcement. Participants completed a 30 min pretest posttest questionnaire. Parents who listened to the HPV radionovela (intervention group) scored higher on six knowledge and belief items. They were more likely to confirm that HPV is a common infection (70% vs. 48%, P = .002), to deny that women are able to detect HPV (53% vs. 31%, P = .003), to know vaccine age recommendations (87% vs. 68%, P = .003), and to confirm multiple doses (48% vs. 26%, P = .03) than control group parents. The HPV vaccine radionovela improved HPV and HPV vaccine knowledge and attitudes. Radionovela health education may be an efficacious strategy to increase HPV vaccine awareness among Hispanic parents. © 2011 Springer Science+Business Media, LLC.
• Beasley, J., Coronado, G., Livaudais, J., Angeles-Llerenas, A., Ortega-Olvera, C., Romieu, I., Lazcano-Ponce, E., & Torres-Mejía, G. (2010). Alcohol and risk of breast cancer in mexican women. Cancer Causes and Control, 21(6). doi:10.1007/s10552-010-9513-x
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  Background Little is known about the relationship between alcohol intake and breast cancer risk among Mexican women. This association may be modified by folate and Vitamin B12. Methods A population-based case-control study conducted in Mexico recruited 1,000 incident breast cancer cases aged 35-69 and 1,074 controls matched on age, region, and health care system. In-person interviews were conducted to assess breast cancer risk factors and recent diet using a food frequency questionnaire. Conditional logistic regression models estimated adjusted odds ratios and 95% confidence intervals. Results Over one-half (57%) of cases and less than onehalf of controls (45%) reported any lifetime alcohol consumption. Compared with never drinkers, women reporting ever drinking (Adjusted OR = 1.25, 95% CI = 0.99-1.58) had a greater odds of breast cancer. There was evidence for interaction in the association between ever consuming any alcohol and breast cancer by folate (p for interaction = 0.04) suggesting women with lower folate intake had a higher odds of breast cancer (Adjusted OR = 1.99, 95% CI = 1.26-3.16) compared to women with higher folate intake (OR = 1.12, 95% CI = 0.69-1.83). Conclusions Our findings support evidence that any alcohol intake increases risk of breast cancer. Insufficient intake of folate may further elevate risk for developing breast cancer among women who consume alcohol. © Springer Science+Business Media B.V. 2010.
• Ceballos, R., Coronado, G., Thompson, B., Ceballos, R., Coronado, G., & Thompson, B. (2010). Having a diagnosis of diabetes is not associated with general diabetes knowledge in rural hispanics. Journal of Rural Health, 26(4). doi:10.1111/j.1748-0361.2010.00299.x
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  Purpose: The prevalence of diabetes among Hispanics in Washington State is 30% greater than it is for non-Hispanic whites. Hispanics also have higher rates of diabetes-related complications and mortality due to the disease. Although interventions have been developed for the Hispanic community, studies in rural settings are limited. To address this we conducted a study to identify factors associated with general diabetes knowledge in a rural Hispanic population.Methods: This study was conducted as part of a larger project in partnership with a local community hospital in Washington State's Lower Yakima Valley. Diabetes knowledge was assessed as part of a screening survey using 5 statements selected from the Diabetes Knowledge Questionnaire. Men and women (N = 1,297) between the ages of 18 and 92 attending community-oriented events took part in the survey. Gender, education, age, birthplace, diabetic status, and family history of diabetes were tested as predictors of diabetes knowledge.Findings: Overall, general knowledge was high with 71%-84% of participants responding correctly to 4 of 5 statements, while only 17% of participants responded correctly to a fifth statement. Although no variable was associated with all statements, family history, gender, and education were most frequently associated with knowledge. Diabetic status, age, and birthplace were less often or not associated with the knowledge statements.Conclusion: Contrary to expectations, having a diagnosis of diabetes was not among the factors most frequently associated with diabetes knowledge. Future research should investigate the roles of family history, gender, and diabetic status as conduits of diabetes education among rural Hispanics. © 2010 National Rural Health Association.
• Coronado, G., Griffith, W., Vigoren, E., Faustman, E., & Thompson, B. (2010). Where's the dust? Characterizing locations of azinphos-methyl residues in house and vehicle dust among farmworkers with young children. Journal of Occupational and Environmental Hygiene, 7(12). doi:10.1080/15459624.2010.521028
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  Organophosphate pesticides are commonly used in the United States, and farmworkers are at risk for chronic exposure. Using data from a community randomized trial to interrupt the take-home pathway of pesticide exposure, we examined the association between floor surface type (smooth floor, thin carpet, and thick carpet) and rooms in which dust samples were collected (living room vs. non-living room) and concentrations of azinphos-methyl residues in home environments. We also examined the association between vehicle type (truck, auto, or other) and footwell floor surfaces (carpeted, smooth surface, or no mat) and concentrations of azinphos-methyl in vehicle dust samples. Dust samples were collected from 203 and 179 households and vehicles, respectively. All households had at least one child aged 2-6. Vehicle dust samples were collected from footwells of the vehicle used for commuting to and from work. A total of 183 samples were collected from living rooms, and 20 were collected from other rooms in the home. Forty-two samples were collected from thick carpets, 130 from thin carpets, and 27 from smooth floor surfaces. Thick and thin carpets had a significantly greater dust mass than smooth floor surfaces (6.0 g/m2 for thick carpets, 7.8 g/m2 for thin carpets, and 1.5 g/m2 for smooth surfaces). Of the 179 vehicle samples, 113 were from cars, 34 from trucks, and 32 from other vehicles. Vehicles with no mats had a significantly higher mass of dust (21.3 g) than those with hard mats (9.3 g) but did not differ from vehicles with plush mats (12.0 g). Further research is needed to characterize the environment in which children may be exposed to pesticides. Copyright © 2010 JOEH, LLC.
• Coronado, G., O'Connell, M., Anderson, J., Ogaz, D., Thompson, B., & Löest, H. (2010). Undergraduate cancer training program for underrepresented students: Findings from a minority institution/cancer center partnership. Journal of Cancer Education, 25(1). doi:10.1007/s13187-009-0006-0
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  Students from racially/ethnically diverse backgrounds are underrepresented in graduate programs in biomedical disciplines. One goal of the Minority Institution/Cancer Center partnership between New Mexico State University (NMSU) and the Fred Hutchinson Cancer Research Center (FHCRC) is to expand the number of underrepresented students who are trained in cancer research. As part of the collaboration, a summer internship program has been organized at the FHCRC. The program runs for 9 weeks and involves mentored research, research seminars, coffee breaks, social activities, and a final poster session. This study examined the graduate school attendance rates of past interns, explored interns' perceptions of the training program, and identified ways to improve the program. Thirty undergraduate students enrolled at NMSU participated in the internship program from 2002 to 2007 and telephone interviews were conducted on 22 (73%) of them. One-third of the students were currently in graduate school (32%); the remaining were either working (36%), still in undergraduate school (27%), or unemployed and not in school (5%). Students rated highly the following aspects of the program: mentored research, informal time spent with mentors, and research seminars. Students also reported the following activities would further enhance the program: instruction on writing a personal statement for graduate school and tips in choosing an advisor. Students also desired instruction on taking the GRE/MCAT, receiving advice on selecting a graduate or professional school, and receiving advice on where to apply. These findings can inform the design of internship programs aimed at increasing rates of graduate school attendance among underrepresented students. © 2009 Springer.
• Coronado, G., Soto, G., Gonzalez, K., Martinez, J., Holte, S., Thompson, B., & Püschel, K. (2010). Strategies for increasing mammography screening in primary care in Chile: Results of a randomized clinical trial. Cancer Epidemiology Biomarkers and Prevention, 19(9). doi:10.1158/1055-9965.epi-10-0313
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  Background: Breast cancer is the cancer with the highest incidence among women in Chile and in many Latin American countries. Breast cancer screening has very low compliance among Chilean women. Methods: We compared the effects on mammography screening rates of standard care, of a low-intensity intervention based on mail contact, and of a high-intensity intervention based on mail plus telephone or personal contact. A random sample of 500 women with the age of 50 to 70 years registered at a community clinic in Santiago who had not had a mammogram in the past 2 years were randomly assigned to one of the three intervention groups. Six months after randomization, participants were re-evaluated for their compliance with mammography screening. The outcome was measured by self-report and by electronic clinical records. An intention to treat model was used to analyze the results. Results: Between 92% and 93% of participants completed the study. Based on electronic records, mammography screening rates increased significantly from 6% in the control group to 51.8% in the low-intensity group and 70.1% in the high-intensity group. About 14% of participants in each group received opportunistic advice, 100% of participants in the low- and high-intensity groups received the mail contact, and 50% in the high-intensity group received a telephone or personal contact. Conclusion: A primary care intervention based on mail or brief personal contact could significantly improve mammogram screening rates. Impact: A relatively simple intervention could have a strong impact in breast cancer prevention in underserved communities. ©2010 AACR.
• Kepka, D., Coronado, G., Rodriguez, H., & Thompson, B. (2010). Acculturation and HPV infection among Latinas in the United States. Preventive Medicine, 51(2). doi:10.1016/j.ypmed.2010.06.002
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  Objective: To describe the relationship between acculturation and human papillomavirus (HPV) infection among diverse US Latinas, a group at high risk for cervical cancer. Methods: Using survey and medical testing data from the 2003-2004 National Health and Nutrition Examination Survey (NHANES), we examined the relationship between acculturation level and HPV infection among diverse Latinas (n=503) and Mexican American women (n=442). Multivariable logistic regression was performed using infection with any type of HPV and with high-risk oncogenic genotypes as outcome variables. Results: More acculturated Mexican American women were more likely to be infected with high-risk HPV than less acculturated women. In multivariate analyses, Mexican Americans with higher levels of self-rated English language ability (2.48 OR, 95% CI: 1.42-4.33); with birth in the US (2.07 OR, 95% CI: 1.03-4.16); and with US born parents (2.98 OR, 95% CI: 1.45-3.72) were more likely to be infected with high-risk HPV genotypes. Mexican American women with higher levels of acculturation were more likely to test positive for other sexually transmitted infections. Conclusion: Higher acculturation levels related to more frequent infection with high-risk HPV genotypes and other STIs among US Mexican American women. This association may in part be due to engagement in sexual behaviors. © 2010 Elsevier Inc.
• Livaudais, J., Coronado, G., Espinoza, N., Islas, I., Ibarra, G., & Thompson, B. (2010). Educating hispanic women about breast cancer prevention: Evaluation of a home-based promotora-led intervention. Journal of Women's Health, 19(11). doi:10.1089/jwh.2009.1733
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  Objectives: Trained community health promoters (i.e., promotoras) conducted home-based group educational interventions (home health parties) to educate Hispanic women from the Lower Yakima Valley of Washington state about breast cancer and mammography screening. Methods: Women aged 40-79 participating in the parties completed baseline and follow-up surveys 6 months postintervention (n=70). Changes in general cancer knowledge, breast cancer screening practices, and intentions to be screened among participants from baseline to follow-up were measured using McNemar's test for marginal homogeneity to evaluate the effectiveness of the parties. Results: The average age of the sample was 50.0 years (standard deviation [SD] 10.0), 84% reported less than an eighth grade education, and 54% were covered by the state's Basic Health Care Plan. Significant changes between baseline and follow-up were observed with respect to (1) believing that risk of cancer could not be reduced (41% vs. 15%, respectively, p=0.001), (2) ever having a mammogram (83% vs. 91%, p=0.014), (3) discussing a mammogram with a doctor (37% vs. 67%, p
• Livaudais, J., Thompson, B., Godina, R., Islas, I., Ibarra, G., & Coronado, G. (2010). A qualitative investigation of cancer survivorship experiences among rural hispanics. Journal of Psychosocial Oncology, 28(4). doi:10.1080/07347332.2010.488146
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  Cancer survivorship experiences were explored among Hispanic men and women with cancer and family members of cancer survivors, recruited from two rural Washington communities in the Lower Yakima Valley. Five focus groups were conducted from February 2006 to October 2007 with 31 women and 10 men. Disbelief, fear, sadness, strength, courage, faith, and hope were common reactions to diagnosis. Concerns about family/children, losing medical coupons, and feelings of depression/isolation were identified as challenges faced after diagnosis. Participants identified smoking and environmental exposures as causes of cancer, but many believed operating on tumors caused cancer to spread. Participants used conventional treatments but identified herbal/natural remedies as cures. Most participants reported negative experiences with physicians and believed their community would benefit from language-appropriate information regarding prevention and treatment. The importance of linking survivors through support groups was emphasized and information elicited from sessions has been used to organize survivor support groups in these two communities. Copyright © Taylor & Francis Group, LLC.
• Thompson, B., McLerran, D., Livaudais, J., & Coronado, G. (2010). A group-randomized tobacco trial among 30 Pacific Northwest colleges: Results from the campus health action on tobacco study. Nicotine and Tobacco Research, 12(6). doi:10.1093/ntr/ntq064
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  Introduction: We conducted a group-randomized trial to increase smoking cessation and decrease smoking onset and prevalence in 30 colleges and universities in the Pacific Northwest. Methods: Random samples of students, oversampling for freshmen, were drawn from the participating colleges; students completed a questionnaire that included seven major areas of tobacco policies and behavior. Following this baseline, the colleges were randomized to intervention or control. Three interventionists developed Campus Advisory Boards in the 15 intervention colleges and facilitated intervention activities. The freshmen cohort was resurveyed 1 and 2 years after the baseline. Two-years postrandomization, new cross-sectional samples were drawn, and students were surveyed. Results: At follow-up, we found no significant overall differences between intervention and control schools when examining smoking cessation, prevalence, or onset. There was a significant decrease in prevalence in private independent colleges, a significant increase in cessation among rural schools, and a decrease in smoking onset in urban schools. Discussion: Intervention in this college population had mixed results. More work is needed to determine how best to reach this population of smokers. © The Author 2010. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved.
• Thompson, B., Ondelacy, S., Godina, R., & Coronado, G. (2010). A small grants program to involve communities in research. Journal of Community Health, 35(3). doi:10.1007/s10900-010-9235-8
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  A key tenet of community-based participatory research is that communities be involved in all facets of research, from defining the problem to identifying solutions, to assisting in the research, and to participating in the publication of results. In this study, we instituted a small grants program for community participation. A Request for Applications (RFA) was developed and circulated widely throughout the Valley. The RFA sought proposals to address health disparities in cancer education, prevention, and treatment among Hispanics living in the Valley. Funds available were $2,500.00-3,500.00 for 1 year's worth of work. To help evaluate the progress of the RFA community projects according to the perspectives of the Community Advisory Board (CAB), an open-ended, semi-structured interview was created and administered by a former staff member to CAB members. In 4 years, ten small grants proposed by community members were funded. Funds allocated totaled approximately $25,000. Interviews with CAB members indicated that the RFA program was perceived positively, but there were concerns about sustainability. Our community grants program resulted in the implementation of several novel cancer prevention programs conducted by a variety of community organizations in the Lower Yakima Valley. © 2010 Springer Science+Business Media, LLC.
• Coronado, G., Thompson, B., & Chen, L. (2009). Sociodemographic correlates of cancer screening services among hispanics and non-hispanic whites in a rural setting. American Journal of Health Behavior, 33(2). doi:10.5993/ajhb.33.2.7
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  Objectives: To examine the relationship between age, race, ethnicity, education, insurance coverage, and income and use of cancer screening services. Methods: We used a population-based sample (N=1863) from a community randomized intervention study that took place in eastern Washington State. Results: Pap testing was directly associated with having public health insurance (vs private coverage), and having a high income (>$35,000 vs ≤$15,000). Having Medicare coverage was predictive of having had a mammogram or sigmoidoscopy / colonoscopy screening, but not an FOBT. Conclusions: Our findings may reflect age-dependent factors that influence access to health care.
• Coronado, G., Vigoren, E., Griffith, W., Faustman, E., & Thompson, B. (2009). Organophosphate pesticide exposure among pome and non-pome farmworkers: A subgroup analysis of a community randomized trial. Journal of Occupational and Environmental Medicine, 51(4). doi:10.1097/jom.0b013e31819b9ce8
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  OBJECTIVE: We examined the effectiveness of a community randomized intervention among farmworkers who did and did not work in pome fruit (apples and pears). METHODS: Urine samples were collected from two cross-sectional groups of farmworkers and analyzed for the presence of dimethylthiophosphate. RESULTS: There was no significant time by crop interaction for changes in urinary metabolite concentrations among adult farmworkers (P = 0.79 pome fruit workers; P = 0.83 non-pome fruit workers) or their children (P = 0.25 children of pome fruit workers; P = 0.91 children of non-pome fruit workers). We found greater urinary metabolite concentrations of dimethylthiophosphate among pome fruit workers (compared with non-pome fruit workers) and among workers at final data collection (compared with baseline). CONCLUSION: Further research is needed to identify effective interventions to reduce pesticide exposure in farmworkers and their children. © 2009 The American College of Occupational and Environmental Medicine.
• Do, H., Seng, P., Talbot, J., Acorda, E., Coronado, G., & Taylor, V. (2009). HPV vaccine knowledge and beliefs among Cambodian American parents and community leaders. Asian Pacific Journal of Cancer Prevention, 10(3).
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  Background: The cervical cancer incidence rate among Cambodian American women is 15.0 per 100,000, compared to 7.7 per 100,000 among non-Latina white women. HPV infection has been identified as a universal risk factor for cervical cancer. The HPV vaccine was recently approved in the United States for females aged 9- 26 years. There is little information about HPV vaccination knowledge and beliefs in Southeast Asian communities. Methods: We conducted 13 key informant interviews with Cambodian community leaders, as well as four focus groups with Cambodian parents (37 participants). Two of the focus groups included fathers and two of the focus groups included mothers. Interview and focus group questions addressed HPV vaccine barriers and facilitators. Results: Participants had limited knowledge about HPV infection and the HPV vaccine. Barriers to HPV vaccination included a lack of information about the vaccine, as well as concerns about vaccine safety, effectiveness, and financial costs. The most important facilitators were a health care provider recommendation for vaccination and believing in the importance of disease prevention. Discussion: Future cervical cancer control educational programs for Cambodians should promote use of the HPV vaccine for age-eligible individuals. Health care providers who serve Cambodian communities should be encouraged to recommend HPV vaccination.
• Livaudais, J., Thompson, B., Islas, I., Ibarra, G., Anderson, J., & Coronado, G. (2009). Workplace exposures and protective practices of hispanic warehouse workers. Journal of Immigrant and Minority Health, 11(2). doi:10.1007/s10903-008-9156-0
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  Background: This study was undertaken to assess workplace hazards and protective practices among Hispanic men and women working post-harvest in asparagus, apple and pear packaging warehouses. Methods: Three focus groups were conducted in July 2003 with 25 workers (20 women, 5 men) recruited from communities in the Yakima Valley, Washington. Focus group content informed the design of an in-person structured interview administered to 50 additional warehouse workers from August to November 2006. Results: Focus group participants reported difficult working conditions, exposure to chemicals, adverse health effects and use of work and home protective practices to minimize exposures for themselves and their families. Structured interview participants reported few workplace exposures to chemicals although many reported engaging in workplace and home protective practices. Discussion: Findings from this research can direct initial efforts to determine if and how interventions for warehouse workers may be designed to protect against hazardous workplace exposures. © Springer Science+Business Media, LLC 2008.
• Locke, E., Coronado, G., Thompson, B., & Kuniyuki, A. (2009). Seasonal Variation in Fruit and Vegetable Consumption in a Rural Agricultural Community. Journal of the American Dietetic Association, 109(1). doi:10.1016/j.jada.2008.10.007
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  Background: Seasonal variation in fruit and vegetable consumption has been documented in a limited number of previous investigations and is important for the design of epidemiologic investigations and in the evaluation of intervention programs. Objective: This study investigates fruit and vegetable consumption behaviors among Hispanic farmworkers and non-farmworkers in a rural agricultural community. Design: A larger study recruited 101 farmworker families and 100 non-farmworker families from the Yakima Valley in Washington State between December 2004 and October 2005. All families were Hispanic. An in-person administered questionnaire collected information on consumption of locally grown fruits and vegetables and sources of obtaining fruits and vegetables. Data on dietary intake asked whether or not the respondent had consumed a given fruit or vegetable in the past month. Data were collected longitudinally, coinciding with three agricultural seasons: thinning (summer), harvest (fall), and nonspray (winter). Statistical analyses performed: Generalized estimating equations were used to test for statistical significance between proportions of the population who consumed a given fruit or vegetable across agricultural seasons. Multivariable logistic regression was performed and corresponding odds ratios and 95% confidence intervals are reported. Results: The proportion of respondents who ate apples, pears, plums, peaches, apricots, peppers, corn, and cucumbers was highest in the fall harvest season, whereas the proportions of those who ate cherries and asparagus were highest in the summer thinning season. Compared to non-farmworkers, a higher proportion of farmworkers reported having eaten peaches, apricots, cherries, green beans, carrots, peppers, corn, pumpkin, squash, and onions, in the past month. Conclusions: Epidemiologic investigations and public health interventions that examine the consumption of fruits and vegetables should consider seasonal variation in consumption patterns, especially in agricultural communities. © 2009 American Dietetic Association.
• Strong, L., Thompson, B., Koepsell, T., Meischke, H., & Coronado, G. (2009). Reducing the take-home pathway of pesticide exposure: Behavioral outcomes from the Para Niños Saludables study. Journal of Occupational and Environmental Medicine, 51(8). doi:10.1097/jom.0b013e3181ad4995
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  OBJECTIVE: To evaluate the effectiveness of a community intervention in promoting adoption of behaviors to reduce the take-home pathway of pesticide exposure in farmworker households. METHODS: Using two cross-sectional samples of farmworker households in 11 intervention and 12 comparison communities in Washington State, we examined whether differences over time in reported pesticide safety practices varied by community intervention status. RESULTS: Pesticide safety practices increased in both intervention and comparison communities over time. Changes were significantly greater in intervention communities for removing work shoes before entering the home (P = 0.003) and marginally significantly greater for changing out of work clothes within 1 hour of arriving home (P = 0.05). CONCLUSIONS: The intervention was associated with modest effects in certain behaviors among farmworkers. Further research is needed to identify successful strategies for reducing the take-home pathway of pesticide exposure. © 2009 The American College of Occupational and Environmental Medicine.
• Taylor, V., The, C., Lam, W., Acorda, E., Li, L., Coronado, G., Yasui, Y., Bajdik, C., & Hislop, G. (2009). Evaluation of a hepatitis B educational ESL curriculum for Chinese immigrants. Canadian Journal of Public Health, 100(6). doi:10.1007/bf03404345
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  Objectives: According to recent census data, 1,216,600 Canadians are of Chinese descent, and over 80% of Chinese Canadians are foreign born. Approximately 10% of Chinese immigrants are chronic carriers of hepatitis B, compared with less than 0.5% of the general population. English as a second language (ESL) classes provide ready access for individuals with limited English proficiency who are not reached by English language health education materials and media campaigns. We conducted a group-randomized trial to evaluate the effectiveness of a hepatitis B ESL educational curriculum for Chinese immigrants. Methods: Five community-based organizations that provide ESL education in the greater Vancouver area participated in the study. Forty-one ESL classes (which included 325 Chinese students) were randomly assigned to experimental or control status. A follow-up survey, conducted six months after randomization, assessed knowledge about hepatitis B. Generalized estimating equations were used to analyze the data. Results: Follow-up surveys were completed by 298 (92%) of the students. At follow-up, experimental group students were significantly (p
• Tejeda, S., Thompson, B., Coronado, G., & Martin, D. (2009). Barriers and facilitators related to mammography use among lower educated Mexican women in the USA. Social Science and Medicine, 68(5). doi:10.1016/j.socscimed.2008.12.023
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  This study explores barriers to and facilitators of breast cancer screening and how people in a woman's social network influence these screening behaviors. A total of 40 semi-structured qualitative interviews were conducted in rural Washington State (USA) among Mexican women aged 50 and over. Eligible women reported either having had a mammogram within the last two years, over two years ago, or never. We found that lack of health insurance, the perception that the mammogram is painful, and fear of finding cancer were cited as barriers to participation in mammography screening. Women who had lived in the US for a shorter period were more likely to report never having had a mammogram than women who had lived in the US for a longer period. Women often cited daughters and female friends as those from whom they received advice or encouragement to receive a mammogram. Few differences were found related to network size and mammography use among the groups. These findings may be useful in designing interventions to promote mammography use. Including daughters in intervention activities may help facilitate mammography use among Mexican women. © 2009 Elsevier Ltd. All rights reserved.
• Tejeda, S., Thompson, B., Coronado, G., Heagerty, P., & Martin, D. (2009). Celebremos la Salud: A community-based intervention for hispanic and non-hispanic white women living in a rural area. Journal of Community Health, 34(1). doi:10.1007/s10900-008-9127-3
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  The evaluation for Celebremos La Salud, a community randomized trial of Hispanic cancer prevention found no differences in mammography screening rates between intervention and control communities. The goal of the present study was to determine reasons for the intervention's lack of effectiveness. In the first aim, we assessed reach of the intervention. In the second, we assessed which intervention activities were associated with mammography use. In the third, we examined whether factors related to health care access, education level, or age modified the effect of the intervention. Data were used from a post-intervention survey of 20 rural communities in Washington State. Hispanic (N = 202) and non-Hispanic White (N = 389) women, over age 40 formed the sample. Reporting having awareness of or having participated in intervention activities was positively associated with Hispanic ethnicity and intervention group and negatively associated with lack of health insurance and having a lower education level. Only one intervention activity was associated with screening use. Having participated in presentations at organizations was positively associated with having had a mammogram in the previous 2 years for Hispanic women. No individual level modifiers influenced the intervention's effectiveness. Heavily targeting the intervention to Hispanic women and not reaching as many White women may have contributed to the lack of intervention effect. Increasing mammography screening rates among women living in a rural area may require improved access to health care and reaching women with lower education levels and lack of health insurance. © 2008 Springer Science+Business Media, LLC.
• Tejeda, S., Thompson, B., Coronado, G., Martin, D., & Heagerty, P. (2009). Predisposing and enabling factors associated with mammography use among hispanic and non-hispanic white women living in a rural area. Journal of Rural Health, 25(1). doi:10.1111/j.1748-0361.2009.00203.x
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  Context: Women who do not receive regular mammograms are more likely than others to have breast cancer diagnosed at an advanced stage. Purpose: To examine predisposing and enabling factors associated with mammography use among Hispanic and non-Hispanic White women. Methods: Baseline data were used from a larger study on cancer prevention in rural Washington state. In a sample of 20 communities, 537 women formed the sample for this study. The main outcomes were ever having had a mammogram and having had a mammogram within the past 2 years. Findings: Reporting ever having had a mammogram was inversely associated with lack of health insurance (OR = 0.37, 95% CI: 0.16-0.84), ages under 50 years (OR = 0.23, 95% CI: 0.12-0.45), high cost of exams (OR = 0.48, 95% CI: 0.27-0.87), and lack of mammography knowledge (OR = 0.16, 95% CI: 0.07-0.37), while increasing education levels were positively associated (OR = 1.72, 95% CI: 1.09-2.70). Reporting mammography use within the past 2 years was inversely associated with ages under 50 years (OR = 0.49, 95% CI: 0.27-0.88) and over 70 years (OR = 0.47, 95% CI: 0.24-0.94), lack of health insurance (OR = 0.23, 95% CI: 0.10-0.50), and high cost of exams (OR = 0.55, 95% CI: 0.35-0.87). Conclusions: Continued resources and programs for cancer screening are needed to improve mammography participation among women without health insurance or low levels of education. © 2009 National Rural Health Association.
• Thompson, B., Coronado, G., Gonzalez, K., Rain, C., Rivera, S., & Püschel, K. (2009). 'If I feel something wrong, then I will get a mammogram': Understanding barriers and facilitators for mammography screening among Chilean women. Family Practice, 27(1). doi:10.1093/fampra/cmp080
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  Background. Breast cancer is the leading cause of cancer among women in Chile and in many Latin American countries. Breast cancer screening is an effective strategy to reduce mortality, but it has a very low compliance among Chilean women. Objective. To understand barriers and facilitators for breast cancer screening in a group of Chilean women aged 50-70. Methods. Following the Predisposing, Enabling and Reinforcing (PRECEDE) framework, seven focus groups (N = 48 women) were conducted with women that have had diverse experiences with breast cancer and screening practices. Information was collected using field notes and audio and video recording. Following the grounded theory model, a sequential process of open, axial and selective coding was used for the information analysis. Atlas ti 5.5 software was used for coding and segmenting the data obtained from the interviews. Results. The presence of symptoms and/or the finding of lumps through breast self-examination (BSE) were the main predisposing factors for getting a mammogram. Secrecy, embarrassment and fatalism about breast cancer were significant cultural factors that influenced the decision to seek mammogramscreening. Confidence in medical staff and dignity in the treatment at the clinic were important enabling factors. The main reinforcing factors for getting the test were a sense of fulfilment by doing something good for themselves and getting timely information about the results. Conclusions. Primary health care providers should use culturally appropriate strategies to better inform women about the importance of mammography screening and the limitations of BSE for preventing advanced breast cancer. © The Author 2009. Published by Oxford University Press.
• Coronado, G., Taylor, V., Hislop, T., Teh, C., Acorda, E., Do, H., Chen, H., & Thompson, B. (2008). Opinions from ESL instructors and students about curricula on hepatitis B for use in immigrant communities. Journal of Cancer Education, 23(3). doi:10.1080/08858190802039151
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  Background. Chinese immigrants in Canada have a disproportionately high risk for hepatitis B compared with non-Hispanic Whites. Hepatitis B is the leading cause of hepatocellular carcinoma among Asian immigrants to North America. English-as-a-second-language (ESL) classes are an effective way of reaching newly immigrated individuals and are a potential channel for delivering health messages. Methods. Using data from 6 focus groups among ESL instructors and students, we characterized perceptions about activities that are successfully used in ESL classrooms and strategies for delivering hepatitis B information. Results. Instructors and students generally reported that activities that focused on speaking and listening skills and that addressed content relevant to students' daily lives were successful in the classroom. Instructors generally avoided material that was irrelevant or too difficult to understand. Focus group participants offered strategies for delivering hepatitis B information in ESL classrooms; these strategies included addressing symptoms and prevention and not singling out a specific population subgroup to avoid stigmatization. Conclusions. These findings might assist efforts to develop ESL curricula that target immigrant populations. Copyright © AACE and EACE.
• Coronado, G., Woodall, E., Do, H., Li, L., Yasui, Y., & Taylor, V. (2008). Heart disease prevention practices among immigrant Vietnamese women. Journal of Women's Health, 17(8). doi:10.1089/jwh.2007.0751
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  Background: Cardiovascular disease is a leading cause of death in the United States as well as in many countries around the world, including Vietnam. Methods: Using data from a household survey of Vietnamese American women aged 20-79 years in Seattle, Washington, collected in 2006 and 2007, we examined heart disease prevention practices. Multivariable analyses were conducted to examine the relationship between demographic factors and preventive behaviors. Results: A total of 1523 immigrant women completed interviews. The average daily consumption of fruits and vegetables was 3.5 servings, and 31% of our sample reported being physically active (engaging in at least 30 minutes of physical activity 5 or more days per week). Few respondents reported being current smokers (1.5%). Over three quarters of women had received a recent blood pressure check and a recent cholesterol check. Age and length of time in the United States were strongly associated with several cardiovascular prevention behaviors. Conclusions: Our findings confirm the need for continued efforts to develop and implement targeted educational campaigns to reduce the risk of cardiovascular disease among Vietnamese American women. © 2008 Mary Ann Liebert, Inc.
• Puschel, K., Thompson, B., Coronado, G., Huang, Y., Gonzalez, L., & Rivera, S. (2008). Effectiveness of a brief intervention based on the '5A' model for smoking cessation at the primary care level in Santiago, Chile. Health Promotion International, 23(3). doi:10.1093/heapro/dan010
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  Chilean women have the highest smoking rates in Latin America. Prevalence in this population is about 40%. There are no national programs for smoking cessation at the primary care level. This study explores the feasibility and effectiveness of a brief counseling intervention targeted to women smokers of childbearing age who seek primary care in Santiago, Chile. A quasi-experimental design was used to compare the effect of an intervention based on the '5A' model developed by the National Cancer Institute in the United States and the standard care provided in two control clinics. Women smokers seeking care at the three primary care clinics were contacted during a 2 months period and offer to participate in the study. Sampling was stratified according to the age groups to ensure comparability between cohorts. Quotas were calculated for each age group. Participants were asked about their willingness to quit, self-efficacy, smoking behavior, addiction level as well as support received for smoking cessation. After 18 months of intervention all women were re-evaluated. A total of 773 women were recruited for the study; 76% of them completed the trial. Women smokers are characterized by a large percentage of light smokers with a low self-efficacy for quitting and with very low information on where and how to get assistance to quit. At study end, 15.2% of women reported quitting smoking at least for 1 month in the intervention clinic versus 7.8% in one of the control clinics (p < 0.05) and 14.6% in the second control clinic (p = NS). Over 70% of women in the intervention clinic were asked, assessed and received advice for quitting in comparison with
• Taylor, V., Coronado, G., Acorda, E., Teh, C., Tu, S., Yasui, Y., Bastani, R., & Hislop, T. (2008). Development of an ESL curriculum to educate Chinese immigrants about hepatitis B. Journal of Community Health, 33(4). doi:10.1007/s10900-008-9084-x
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  Chinese immigrants to North America have substantially higher rates of chronic hepatitis B infection than the general population. One area for strategic development in the field of health education is the design and evaluation of English-as-a-Second language (ESL) curricula. The theoretical perspective of the Health Behavior Framework, results from a community-based survey of Chinese Canadian immigrants with limited English proficiency, and findings from focus groups of ESL instructors as well as Chinese ESL students were used to develop a hepatitis B ESL educational module. This research was conducted in Vancouver, BC. Survey data showed that less than three-fifths of the respondents had been tested for hepatitis B, and documented some important hepatitis B knowledge deficits. Further, only about one-quarter had ever received a physician recommendation for hepatitis B serologic testing. The ESL curriculum aims to both promote hepatitis B testing and improve knowledge, and includes seven different ESL exercises: Warm-up, vocabulary cards, information-gap, video, jigsaw, guided discussion, and problem/advice cards. Our quantitative and qualitative methods for curriculum development could be replicated for other health education topics and in other limited English speaking populations. © 2008 Springer Science+Business Media, LLC.
• Taylor, V., Cripe, S., Acorda, E., Teh, C., Coronado, G., Do, H., Woodall, E., & Hislop, T. (2008). Development of an ESL Curriculum to Educate Chinese Immigrants about Physical Activity. Journal of Immigrant and Minority Health, 10(4). doi:10.1007/s10903-007-9085-3
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  Regular physical activity reduces the risk of many chronic conditions. Multiple studies have shown that Asians in North America engage in less physical activity than the general population. One area for strategic development in the area of health education is the design and evaluation of English as a second language (ESL) curricula. The PRECEDE model and findings from focus groups were used to develop a physical activity ESL curriculum for Chinese immigrants. In general, focus group participants recognized that physical activity contributes to physical and mental wellbeing. However, the benefits of physical activity were most commonly described in terms of improved blood circulation, immune responses, digestion, and reflexes. The importance of peer pressure and the encouragement of friends in adhering to regular physical activity regimens were mentioned frequently. Reported barriers to regular physical activity included lack of time, weather conditions, and financial costs. The ESL curriculum aims to both promote physical activity and improve knowledge, and includes seven different ESL exercises. Our curriculum development methods could be replicated for other health education topics and in other limited English-speaking populations. © Springer Science+Business Media, LLC 2007.
• Thompson, B., Coronado, G., Vigoran, E., Griffith, W., Fenska, R., Kissel, J., Shirai, J., & Faustman, E. (2008). Para niños saludables: A community intervention trial to reduce organophosphate pesticide exposure in children of farmworkers. Environmental Health Perspectives, 116(5). doi:10.1289/ehp.10882
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  Background: Exposure to organophosphate (OP) pesticides is an occupational hazard for farmworkers and affects their children through the take-home pathway. Objectives: We examined the effectiveness of a randomized community intervention to reduce pesticide exposure among farmworkers and their children. Methods: We conducted a baseline survey of a cross-sectional sample of farmworkers (year 1) in 24 participating communities. Communities were randomized to intervention or control. After 2 years of intervention, a new cross-sectional survey of farmworkers was conducted (year 4). Farmworkers with a Chad 2-6 years of age were asked to participate in a substudy in which urine was collected from the farmworker and child, and dust was collected from the home and the vehicle driven to work. Results: The median concentration of urinary metabolites was higher in year 4 than in year 1 for dimethylthiophosphate (DMTP) and dimethydithiophosphate in adults and for DMTP for children. There were significant increases within both the intervention and control communities between year 1 and year 4 (p < 0.005); however, the differences were not significant between study communities after adjusting for year (p = 0.21). The dust residue data showed azinphos-methyl having the highest percentage of detects in vehicles (86% and 84% in years 1 and 4, respectively) and in house dust (85% and 83% in years 1 and 4, respectively). There were no significant differences between intervention and control communities after adjusting for year (p = 0.49). Conclusions: We found no significant decreases in urinary pesticide metabolite concentrations or in pesticide residue concentrations in house and vehicle dust from intervention community households compared with control community households after adjusting for baseline, Then negative findings may have implications for future community-wide interventions.
• Coronado, G., Taylor, V., Tu, S., Yasui, Y., Acorda, E., Woodall, E., Yip, M., Li, L., & Hislop, T. (2007). Correlates of hepatitis B testing among Chinese Americans. Journal of Community Health, 32(6). doi:10.1007/s10900-007-9060-x
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  Chinese Americans are 10 times more likely to be diagnosed with hepatocellular carcinoma (HCC) than their white counterparts. About 80% of HCC's among Asian immigrants are associated with hepatitis B virus (HBV) infection. We used data from in-person interviews of Chinese residents in Seattle to examine factors associated with HBV testing. The survey was completed by 206 men and 236 women (cooperation rate: 58%). Less than one-half (48%) of respondents had been tested for HBV. Factors associated (p < 0.01) with ever having tested in bivariate comparisons included knowing that Chinese are more likely to be infected with HBV than Whites; individuals can be infected with HBV for life; HBV infection can cause liver cancer; not believing that HBV can be prevented by having a positive attitude; having a family member, friend, or medical doctor recommend testing; asking for testing from a medical doctor; and not needing interpreter services. In multiple regression analyses, the following factors were independently associated with testing: believing that Chinese were more likely than Whites to get HBV (p = 0.004), having a doctor recommend testing (p ≤ 0.001), asking a doctor for the test (p < 0.001) and not needing an interpreter for doctors visits (p = 0.002). Intervention programs to improve HBV testing rates in Chinese Americans should include strategies to improve knowledge about the risk of HBV and encourage effective communication with health care providers about HBV testing. © 2007 Springer Science+Business Media, LLC.
• Coronado, G., Thompson, B., Tejeda, S., Godina, R., & Chen, L. (2007). Sociodemographic factors and self-management practices related to type 2 diabetes among Hispanics and non-Hispanic whites in a rural setting. Journal of Rural Health, 23(1). doi:10.1111/j.1748-0361.2006.00067.x
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  Context: Hispanics in the United States have a higher prevalence of non-insulin-dependent diabetes mellitus (type 2 diabetes) and experience more complications for the disease than non-Hispanic whites. Differences in medical management or self-management practices may, in part, explain the relative high risk for diabetes complications among Hispanics. Purpose: Using data from a community-randomized intervention study on cancer prevention, we examined the medical management and self-management practices of Hispanics and non-Hispanic whites who have diabetes. Methods: Locally hired bilingual personnel conducted in-person interviews of a random selection of 1,863 adults in 20 communities in the Yakima Valley of eastern Washington State. Findings: A total of 70 Hispanics (11% age-adjusted prevalence) and 87 non-Hispanic whites (7.3% age-adjusted prevalence) reported having type 2 diabetes. Hispanics with a high level of acculturation were slightly more likely to have diabetes, compared to those with a low level of acculturation, though the association was nonsignificant. Hispanics were significantly less likely than non-Hispanic whites to treat their diabetes with diet and exercise (36% vs 61.3%; P ≤.001). Annual eye examinations were less commonly reported among Hispanics (48.9%) than among non-Hispanic whites (72.7%). Conclusions: Our data indicate that Hispanics engage less frequently in self-management practices to control diabetes than non-Hispanic whites. © 2007 National Rural Health Association.
• Hislop, T., Teh, C., Low, A., Tu, S., Yasui, Y., Coronado, G., Li, L., & Taylor, V. (2007). Predisposing, reinforcing and enabling factors associated with hepatitis b testing in chinese canadians in british columbia. Asian Pacific Journal of Cancer Prevention, 8(1).
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  Background: Liver cancer, a significant health problem in Chinese, can be controlled through HBV blood testing, vaccination, and community education about HBV. The PRECEDE framework has been very helpful in identifying factors associated with health practices. Objectives: The objective was to identify factors associated with HBV testing in Chinese Canadians, using the PRECEDE framework. Methods: Five hundred and thirtythree randomly selected Chinese Canadian adults were interviewed about HBV blood testing practices. Factors were grouped as predisposing, reinforcing and enabling. Results: Fifty-five percent had received HBV blood testing. Several predisposing factors, all reinforcing factors and one enabling factor were associated with HBV testing in bivariate analysis. A physician's recommendation for testing was the strongest factor associated with testing in multiple logistic regression analysis (OR=4.4, p
• Neuhouser, M., Thompson, B., Coronado, G., Martinez, T., & Qu, P. (2007). A Household Food Inventory Is Not a Good Measure of Fruit and Vegetable Intake among Ethnically Diverse Rural Women. Journal of the American Dietetic Association, 107(4). doi:10.1016/j.jada.2007.01.013
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  Environmental measures of food availability are surrogates of consumption. Such measures may be useful among populations for whom standard dietary assessment is difficult. The objective of this cross-sectional study was to test whether a measure of the household dietary environment would perform as well as or better than a standard fruit and vegetable assessment among ethnically diverse rural women. Participants were 154 non-Hispanic white, 157 Hispanic, and 102 Native American adult women residing in rural Washington state. Participants completed an interviewer-administered household inventory of fruits and vegetables and a standard measure of fruit and vegetable intake used in the 5 A Day for Better Health Program. Pearson correlation coefficients assessed the validity of the measures against biomarkers of fruit and vegetable consumption (serum carotenoids). Pearson correlations were poor to modest between the household inventory and serum carotenoids (r=0.06 to 0.22) and between the 5 A Day responses and serum carotenoids (r=-0.08 to 0.17). There were no differences by ethnic group; both short tools performed poorly compared with the biomarkers across Hispanic, non-Hispanic white, and Native-American participants. In conclusion, both the household inventory and the popular 5 A Day measure were poor indicators of fruit and vegetable intake in this sample of ethnically diverse rural women. © 2007 American Dietetic Association.
• Thompson, B., Coronado, G., Chen, L., Thompson, L., Halperin, A., Jaffe, R., McAfee, T., & Zbikowski, S. (2007). Prevalence and characteristics of smokers at 30 Pacific Northwest colleges and universities. Nicotine and Tobacco Research, 9(3). doi:10.1080/14622200701188844
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  College is an important transition period during which young adults explore tobacco use. Few large-scale studies have been conducted among college students regarding tobacco use. We initiated a study examining tobacco use in 30 colleges and universities in the Pacific Northwest. We conducted a baseline survey among students. Sample size varied by the school size; for the 14 largest schools, we drew a random sample of all students, oversampling freshmen (n ≈ 750) so that we could recruit and follow a cohort to assess smoking onset during the college years. Of the remaining students, we sampled equivalent numbers of sophomores, juniors, and seniors (n = 200 each). For the 16 schools with fewer than 1,350 students, we surveyed all students. We found overall smoking rates of 17.2%. Males (18.6%) were more likely to smoke than females (16.6%; p =.03), and public college students were more likely to smoke (20.5%) than those who attended private independent schools (18.9%; p =.61), whose rates were higher than those of private religious schools (11.6%; p =.001). Overall, college students are light smokers who do not smoke every day of the month. Further, they tend not to be highly dependent on tobacco, do not consider themselves regular smokers, and plan to quit before they graduate (56.8%). School type should be considered when estimating smoking rates among 4-year college students. Data indicate that college smokers wish and plan to quit before graduation, suggesting that efforts to assist smokers in quitting during the college years may be fruitful.
• Bird, Y., Moraros, J., Olsen, L., Coronado, G., & Thompson, B. (2006). Adolescents' smoking behaviors, beliefs on the risks of smoking, and exposure to ETS in Juárez, Mexico. American Journal of Health Behavior, 30(4). doi:10.5993/ajhb.30.4.9
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  Objective: To assess the smoking behaviors, beliefs about the risks of smoking, and exposure to ETS among adolescents in Juárez, Mexico. Methods: A cross-sectional study was conducted with sixth-grade students (N = 506), aged 11-13 years old, attending 6 randomly selected schools. Schools were classified by school setting and SES. Results: Students attending a low SES school setting were more likely to have smoked (P
• Coronado, G., Farias, A., Thompson, B., Godina, R., & Oderkirk, W. (2006). Attitudes and beliefs about colorectal cancer among Mexican Americans in communities along the US-Mexico border. Ethnicity and Disease, 16(2).
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  Purpose: The purpose of this study was to examine Mexican American knowledge, attitudes, and beliefs about colorectal cancer and barriers to receiving colorectal cancer screening exams. Design: We developed an open-topic focus group schedule that addressed knowledge, attitudes, and beliefs about screening for colorectal cancer and identified cultural issues to be considered when developing educational interventions to increase screening participation. Focus groups were used to elicit participant responses. Setting: Two small communities (colonias) along the US-Mexico border. Subjects: Mexican Americans ages ≥50 years. Results: A total of 43 individuals (20 men and 23 women) participated in the focus groups, each of which lasted ≈90 minutes. Few focus group participants had ever heard of colorectal cancer or specific screening exams to detect early forms of cancer. Participants identified cost of medical care and embarrassment about receiving colorectal exams as barriers to screening participation. Respondents commonly expressed fatalistic attitudes about their chances of recovering from cancer, some preferred not to know if they had cancer or believed that they would refuse treatment if diagnosed with cancer. Nevertheless, many participants noted that strong support from family and friends or a strong will would allow one to survive cancer. Conclusion: Interventions to improve participation in screening services for colorectal cancer should focus on reducing the influences of cost and embarrassment and improving levels of knowledge about colorectal cancer and the need for screening.
• Coronado, G., Vigoren, E., Thompson, B., Griffith, W., & Faustman, E. (2006). Organophosphate pesticide exposure and work in pome fruit: Evidence for the take-home pesticide pathway. Environmental Health Perspectives, 114(7). doi:10.1289/ehp.8620
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  Organophosphate (OP) pesticides are commonly used in the United States, and farmworkers are at risk for chronic exposure. Using a sample of 218 farmworkers in 24 communities and labor camps in eastern Washington State, we examined the association between agricultural crop and OP pesticide metabolite concentrations in urine samples of adult farmworkers and their children and OP pesticide residues in house and vehicle dust samples. Commonly reported crops were apples (71.6%), cherries (59.6%), pears (37.2%), grapes (27.1%), hops (22.9%), and peaches (12.4%). Crops were grouped into two main categories: pome fruits (apples and pears) and non-pome fruits. Farmworkers who worked in the pome fruits had significantly higher concentrations of dimethyl pesticide metabolites in their urine and elevated azinphos-methyl concentrations in their homes and vehicles than workers who did not work in these crops. Among pome-fruit workers, those who worked in both apples and pears had higher urinary metabolites concentrations and pesticide residue concentrations in dust than did those who worked in a single pome fruit. Children living in households with pome-fruit workers were found to have higher concentrations of urinary dimethyl metabolites than did children of non-pome-fruit workers. Adult urinary concentrations showed significant correlations with both the vehicle and house-dust azinphos-methyl concentrations, and child urinary concentrations were correlated significantly with adult urinary concentrations and with the house-dust azinphos-methyl concentration. The results provide support for the take-home pathway of pesticide exposure and show an association between measures of pesticide exposure and the number of pome-fruit crops worked by farmworkers.
• Ebel, B., Coronado, G., Thompson, B., Martinez, T., Fitzgerald, K., Vaca, F., & Rivara, F. (2006). Child passenger safety behaviors in Latino communities. Journal of Health Care for the Poor and Underserved, 17(2). doi:10.1353/hpu.2006.0058
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  Booster seats protect child occupants between 4 and 8 years of age. The objective of this study was to determine barriers and facilitators for booster seat use among Latino families. We conducted one-to-one elicitation interviews with 56 mothers and 35 fathers of booster-eligible Latino children in an urban county and a rural county in Washington State. Half of the parents did not consistently use booster seats. Interviews were recorded, transcribed, translated, and coded. Statements expressed by at least one-third of respondents were entered into explanatory models. Motivators for booster use were child safety and concern about getting a ticket. Facilitators for booster use included affordability, ease of use, and children liking the seat. Barriers were the belief that the child was too big/old, perceived child resistance, and cost. Rural parents preferred radio to television messages. Campaign messages highlighting the risks to child safety and the risk of a citation are likely to motivate booster seat use among Latino families.
• Puschel I, K., Thompson, B., Coronado, G., Rivera M, S., Valencia C, G., Montero L, J., Díaz V, D., González V, L., & Iñiguez C, S. (2006). Smoking interventions in Primary Health Care. Smoking profile of women and beliefs and attitudes of local health care teams. Revista Medica de Chile, 134(6).
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  Background: Chile has one of the highest prevalence rate of smoking in the world. Brief counseling interventions for smoking cessation at the primary health care level are effective. Compliance with counseling intervention is strongly associated with beliefs and attitudes of the primary health care team that deliver it. The effectiveness of these interventions improve if they are applied to smoking populations with higher motivation of change and high self-efficacy for quitting. Aim: To study the smoking profile of a group of smoking women in Santiago and to identify beliefs and attitudes of the primary health care team members to implement smoking cessation interventions. Material and Methods: A cross-sectional design that included 306 women smokers attending two primary health care clinics in Santiago. Perceptions, beliefs and attitudes of 34 primary care team members from three clinics in Santiago were explored using a qualitative methodology. Results: The study identified a subgroup of 18% of women highly motivated to quit (decisional stage of change) and a 58% with a high self-efficacy. Beliefs and attitudes of staff at the clinics were characterized by invisibility, ambivalence and fatalism regarding the effectiveness of smoking cessation interventions. Conclusions: There is a subgroup of smoking women with a high probability of quitting if they receive an appropriate counseling. Developing a systematic approach for smoking cessation intervention at the primary care setting in Chile should consider the invisibility, ambivalence and fatalism of primary health care team members towards this topic.
• Tejeda, S., Thompson, B., Coronado, G., & Rees, J. (2006). A cervical cancer curriculum for hispanic adolescents in rural high schools: A pilot study. Journal of Health Care for the Poor and Underserved, 17(4). doi:10.1353/hpu.2006.0136
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  We assessed the effectiveness of a one-hour curriculum about cervical cancer for high school students. The curriculum was developed and delivered to 142 female students in the 9th to 12th grade at two high schools in rural Eastern Washington State. Self-administered questionnaires assessed changes in knowledge, beliefs, and attitudes related to cervical cancer and Pap smears. Baseline results from a predominantly Hispanic adolescent sample (73%) indicated low pre-test knowledge and negative beliefs and attitudes. Post-test results indicated that there was a significant change in the intervention group for knowledge questions when compared with the control group. Only some changes to more positive beliefs and attitudes about cervical cancer and screening were significant in the post-test. The findings suggest that a culturally appropriate high school curriculum may inform young Hispanic women about important cervical cancer screening practices.
• Thompson, B., Coronado, G., Chen, L., & Islas, I. (2006). Celebremos La Salud! A community randomized trial of cancer prevention (United States). Cancer Causes and Control, 17(5). doi:10.1007/s10552-006-0006-x
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  Background: Compared to non-Hispanic whites, Hispanics in the United States are at higher risk for certain types of cancer. Methods: In a randomized controlled trial of 20 communities, we examined whether a comprehensive intervention influenced cancer screening behaviors and lifestyle practices in rural communities in Eastern Washington State. Cross-sectional surveys at baseline and post-intervention included interviews with a random sample of approximately 100 households per community. The interview included questions on ever use and recent use of Pap test, mammogram, and fecal occult blood test (FOBT) and sigmoidoscopy/colonoscopy, fruit and vegetable consumption and smoking practices. Results: We found few significant changes in use of screening services for cervical (Pap test), breast (mammogram) or colorectal cancer (fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy) between intervention and control communities. We found no significant differences in fruit and vegetable consumption nor in smoking prevalence between the two groups. We found more awareness of and participation in intervention activities in the treatment communities than the control communities. Conclusions: Our null findings might be attributable to the low dose of the intervention, a cohort effect, or contamination of the effect in non-intervention communities. Further research to identify effective strategies to improve cancer prevention lifestyle behaviors and screening practices are needed. © Springer 2006.
• Thompson, B., Coronado, G., Chen, L., Thompson, L., Hymer, J., & Peterson, A. (2006). Preferred smoking policies at 30 pacific Northwest colleges. Public Health Reports, 121(5). doi:10.1177/003335490612100514
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  Objective. Research shows that restrictive smoking policies on college campuses could discourage smoking onset or help facilitate cessation efforts among students. However, many colleges and universities are reluctant to establish restrictive smoking policies for fear of student objections. Our study examined preferred smoking policies among college students in the Pacific Northwest. Methods. We conducted a baseline cross-sectional descriptive study of a grouped randomized controlled trial at 30 four-year colleges and universities in Idaho, Oregon, and Washington. Results. Of the 14,237 students who responded to the survey, 17.3% were smokers. All respondents were knowledgeable about indoor smoking policies; however, there was incongruence regarding outside policies. Some 88% of never smokers wanted a completely smoke-free indoor policy, while a substantial percentage (58%) of smokers concurred (odds ratio [OR]50.19, p
• Bonhauser, M., Fernandez, G., Montero, J., Thompson, B., Coronado, G., Püschel, K., & Yañez, F. (2005). Improving physical fitness and emotional well-being in adolescents of low socioeconomic status in Chile: Results of a school-based controlled trial. Health Promotion International, 20(2). doi:10.1093/heapro/dah603
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  Regular physical activity is associated with a reduced risk of all-cause mortality, and mortality due to cardiovascular disease and cancer. Among adolescents, physical activity is associated with benefits in the prevention and control of emotional distress, and improvement of self-esteem. Countries in transitional epidemiological scenarios, such as Chile, need to develop effective strategies to improve physical activity as a way to face the epidemic of chronic diseases. The objective of this study was to evaluate the effects of a school-based physical activity program on physical fitness and mental health status of adolescents living in a low socioeconomic status area in Santiago, Chile. A quasi-experimental design was used to evaluate the effects of the program over one academic year. The study included 198 students aged 15 years old. Two ninth grade classes were randomly selected as the intervention group, with two classes of the same grade as controls. A social planning approach was used to develop the intervention. The program was designed and implemented based on student preferences, teachers' expertise and local resources. Changes in physiological and mental health status were assessed. After the intervention, maximum oxygen capacity achieved a significant increase of 8.5% in the intervention versus 1.8% in the control group (p < 0.0001). Speed and jump performance scores improved significantly more in the intervention versus the control group (p > 0.01). Anxiety score decreased 13.7% in the intervention group versus 2.8% in the control group (p < 0.01), and self-esteem score increased 2.3% in the intervention group and decreased 0.1% in the control group after the end of the program (p < 0.0001). No significant change was observed in the depressive score. Student participation and compliance with the program was >80%. To conclude, a school-based program to improve physical activity in adolescents of low socioeconomic status, obtained a high level of participation and achieved significant benefits in terms of physical fitness and mental health status. © The Author 2005. Published by Oxford University Press. All rights reserved.
• Coronado, G., Thompson, B., McLerran, D., Schwartz, S., & Koepsell, T. (2005). A short acculturation scale for Mexican-American populations. Ethnicity and Disease, 15(1).
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  Acculturation is important to examine variables that differentiate members of ethnic groups so that interventions can be appropriately targeted. By using a population-based sample of Mexican-origin adults, we sought to validate an acculturation scale for Mexican-American populations. The acculturation instrument included eight items adapted from the Acculturation Rating Scale for Mexican Americans (ARSMA). By using principal component analysis, we calculated eigenvalues for the eight items. The first principal component accounted for 66% of the variance. Language spoken most of the time, by itself, explained 62.4% of the variance of the full model, whereas birthplace, by itself, accounted for 74%. Slight increases in correlation values were observed beyond a four-item model that included language spoken most of the time, language thought, ethnic identity, and birthplace. Future studies should compare this scale with other multidimensional scales.
• Coronado, G., Thompson, B., McLerran, D., Schwartz, S., & Koepsell, T. (2005). For the patient. Scale to measure how Mexican-American populations fit into U.S. culture.. Ethnicity & disease, 15(1).
• Israel, B., Parker, E., Rowe, Z., Salvatore, A., Minkler, M., Butz, A., Mosley, A., Coates, L., Lambert, G., Potito, P., Brenner, B., Rivera, M., Romero, H., Thompson, B., Coronado, G., Halstead, S., & López, J. (2005). Community-based participatory research: Lessons learned from the Centers for Children's Environmental Health and Disease Prevention Research. Environmental Health Perspectives, 113(10). doi:10.1289/ehp.7675
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  Over the past several decades there has been growing evidence of the increase in incidence rates, morbidity, and mortality for a number of health problems experienced by children. The causation and aggravation of these problems are complex and multifactorial. The burden of these health problems and environmental exposures is borne disproportionately by children from low-income communities and communities of color. Researchers and funding institutions have called for increased attention to the complex issues that affect the health of children living in marginalized communities - and communities more broadly - and have suggested greater community involvement in processes that shape research and intervention approaches, for example, through community-based participatory research (CBPR) partnerships among academic, health services, public health, and community-based organizations. Centers for Children's Environmental Health and Disease Prevention Research (Children's Centers) funded by the National Institute of Environmental Health Sciences and U.S. Environmental Protection Agency were required to include a CBPR project. The purpose of this article is to provide a definition and set of CBPR principles, to describe the rationale for and major benefits of using this approach, to draw on the experiences of six of the Children's Centers in using CBPR, and to provide lessons learned and recommendations for how to successfully establish and maintain CBPR partnerships aimed at enhancing our understanding and addressing the multiple determinants of children's health.
• Thompson, B., Coronado, G., Neuhouser, M., & Chen, L. (2005). Colorectal carcinoma screening among Hispanics and non-Hispanic whites in a rural setting. Cancer, 103(12). doi:10.1002/cncr.21124
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  BACKGROUND. Colorectal carcinoma ranks as the second most common cancer and the second leading cause of cancer death in the United States. Hispanics are less likely than their non-Hispanic white counterparts to have ever received a fecal occult blood test (FOBT) or sigmoidoscopy/colonoscopy. Little is known about the barriers to screening in the Hispanic population. METHODS. The authors used baseline data from a community randomized trial of cancer prevention to compare screening prevalence and the associations between reported barriers and screening participation between Hispanics (n = 137) and non-Hispanic whites (n = 491) age > 50 years. RESULTS. Hispanics were less likely than non-Hispanic whites to have ever received an FOBT (P = 0.003) or sigmoidoscopy/colonoscopy (P = 0.001). No significant difference across ethnic groups was observed in the prevalence of recent screening using FOBT (29.8% for Hispanics vs. 34.5% for non-Hispanic whites; P = 0.41), but recent use of sigmoidoscopy/colonoscopy was lower for Hispanics (24.1% for Hispanics vs. 33.7% for non-Hispanic whites; P 0.06). Lacking health care coverage or having few years of education were directly associated with failure to ever receive an FOBT or sigmoidoscopy/ colonoscopy. CONCLUSIONS. Interventions to improve adherence to colorectal carcinoma screening recommendations among Hispanics should target initial screening examinations, particularly among those lacking health care coverage or having low levels of education. © 2005 American Cancer Society.
• Coronado, G., Thompson, B., Koepsell, T., Schwartz, S., & McLerran, D. (2004). Use of Pap test among Hispanics and non-Hispanic whites in a rural setting. Preventive Medicine, 38(6). doi:10.1016/j.ypmed.2004.01.009
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  Background. Hispanic women in the United States have a higher incidence of invasive cervical cancer than non-Hispanic whites. A key factor related to the relatively high incidence is the underutilization of cancer-screening services. Several previous investigations have reported that Hispanic women are less likely to comply with screening recommendations for Pap testing; some have identified factors that are associated with non-compliance with screening recommendations. Methods. Using baseline personal interview data from a randomized community trial on cancer prevention in a rural area, we assessed the association between health barriers and non-compliance with cervical screening recommendations. Results. Among Hispanic women (n = 382), those with a lower level of acculturation were more likely than highly acculturated Hispanic and non-Hispanic white women (n = 385) to report personal barriers as reasons for not getting an initial or subsequent screening exam. Such barriers include fear of finding cancer, fear of finding diseases other than cancer, and embarrassment about receiving a physical exam. Certain structural barriers, such as cost of care, no time off work, and lack of transportation, were reported to be associated with non-compliance with routine cervical cancer screening, especially among non-Hispanic white women. Conclusions. Future research should examine barriers related to initial and subsequent screening among Hispanics with varying levels of acculturation. © 2004 Institute For Cancer Prevention and Elsevier Inc. All rights reserved.
• Coronado, G., Thompson, B., Strong, L., Griffith, W., & Islas, I. (2004). Agricultural task and exposure to organophosphate pesticides among farmworkers. Environmental Health Perspectives, 112(2). doi:10.1289/ehp.6412
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  Little is known about pesticide exposure among farmworkers, and even less is known about the exposure associated with performing specific farm tasks. Using a random sample of 213 farmworkers in 24 communities and labor camps in eastern Washington State, we examined the association between occupational task and organophosphate (OP) pesticide residues in dust and OP metabolite concentrations in urine samples of adult farmworkers and their children. The data are from a larger study that sought to test a culturally appropriate intervention to break the takehome pathway of pesticide exposure. Commonly reported farm tasks were harvesting or picking (79.2%), thinning (64.2%), loading plants or produce (42.2%), planting or transplanting (37.6%), and pruning (37.2%). Mixing, loading, or applying pesticide formulations was reported by 20% of our sample. Workers who thinned were more likely than those who did not to have detectable levels of azinphos-methyl in their house dust (92.1% vs. 72.7%; p = 0.001) and vehicle dust (92.6% vs. 76.5%; p = 0.002). Thinning was associated with higher urinary pesticide metabolite concentrations in children (91.9% detectable vs. 81.3%; p = 0.02) but not in adults. Contrary to expectation, workers who reported mixing, loading, or applying pesticide formulations had lower detectable levels of pesticide residues in their house or vehicle dust, compared with those who did not perform these job tasks, though the differences were not significant. Future research should evaluate workplace protective practices of fieldworkers and the adequacy of reentry intervals for pesticides used during thinning.
• Coronado, G., Thompson, B., Tejeda, S., & Godina, R. (2004). Attitudes and beliefs among Mexican Americans about type 2 diabetes. Journal of Health Care for the Poor and Underserved, 15(4). doi:10.1353/hpu.2004.0057
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  Hispanics in the United States have a disproportionately high risk for non-insulin-dependent diabetes mellitus (type 2 diabetes) compared with non-Hispanic whites. Little is known of the attitudes and beliefs about diabetes in this group. Using data from six focus groups of 42 Mexican Americans (14 men and 28 women), we characterized perceptions about the causes of and treatments for type 2 diabetes. Many participants believed diabetes is caused by having a family history of the disease, eating a diet high in fat or sugar, and engaging in minimal exercise. Experiencing strong emotions such as fright (susto), intense anger (coraje), or sadness and depression (tristeza) was also thought to precipitate diabetes. Nearly all participants expressed the belief that it is important to follow doctors' recommendations for diet and exercise, oral medication or insulin; many also cited herbal therapies, such as prickly pear cactus (nopal) and aloe vera (savila) as effective treatments. These findings may be useful in designing interventions to reduce the burden of diabetes in Hispanic populations.
• Fenske, R., Kissel, J., Shirai, J., Curl, C., Galvin, K., Coronado, G., Thompson, B., & Griffith, W. (2004). Agricultural task not predictive of children's exposure to OP pesticides (multiple letters) [5]. Environmental Health Perspectives, 112(15).
• Krieger, R., Zhang, X., Coronado, G., Thompson, B., Strong, L., Griffith, W., & Islas, I. (2004). Activities and organophosphate exposures: Need for the numbers (multiple letters) [2]. Environmental Health Perspectives, 112(13).
• Neuhouser, M., Thompson, B., Coronado, G., & Solomon, C. (2004). Higher fat intake and lower fruit and vegetables intakes are associated with greater acculturation among mexicans living in Washington State. Journal of the American Dietetic Association, 104(1). doi:10.1016/j.jada.2003.10.015
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  Objective: To examine associations of diet with acculturation among Hispanic immigrants from Mexico to Washington state and to compare dietary patterns of Hispanic with non-Hispanic white residents. Design: Data are part of the baseline assessment for a community-randomized cancer prevention trial. The Fat-Related Diet Habits questionnaire and the National 5-A-Day for Better Health program dietary assessment instruments were used to collect data on fat and fruit and vegetable intake, respectively. Data were also collected on demographic characteristics and acculturation status. Subjects/Setting: A total of 1,689 adult Hispanic and non-Hispanic white residents of 20 communities in the Yakima Valley, WA, completed in-person interviews. Statistical Analyses Performed: Mixed model regression analyses tested associations of acculturation with diet. These models compared the fat and the fruit and vegetable intake of Hispanics vs non-Hispanic white residents. Additional analyses compared the diets of highly acculturated Hispanics with low-acculturated Hispanics. All models included age, sex, income, and education and were also adjusted for the random effect of community. Results: Dietary patterns varied by ethnicity and acculturation status. On average, compared with non-Hispanic white residents, Hispanics consumed one more serving of fruits and vegetables per day (P
• Strong, L., Thompson, B., Coronado, G., Griffith, W., Vigoren, E., & Islas, I. (2004). Health symptoms and exposure to organophosphate pesticides in farmworkers. American Journal of Industrial Medicine, 46(6). doi:10.1002/ajim.20095
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  Background: Few studies have examined the relationship between reported health symptoms and exposure to organophosphate (OP) pesticides. Methods: Fisher's exact test was used to assess the relationship between self-reported health symptoms and indicators of exposure to OP pesticides in 211 farmworkers in Eastern Washington. Results: The health symptoms most commonly reported included headaches (50%), burning eyes (39%), pain in muscles, joints, or bones (35%), a rash or itchy skin (25%), and blurred vision (23%). Exposure to pesticides was prevalent. The proportion of detectable samples of various pesticide residues in house and vehicle dust was weakly associated with reporting certain health symptoms, particularly burning eyes and shortness of breath. No significant associations were found between reporting health symptoms and the proportion of detectable urinary pesticide metabolites. Conclusions: Certain self-reported health symptoms in farmworkers may be associated with indicators of exposure to pesticides. Longitudinal studies with more precise health symptom data are needed to explore this relationship further. © 2004 Wiley-Liss, Inc.
• Thompson, B., Coronado, G., Grossman, J., Puschel, K., Solomon, C., Islas, I., Curl, C., Shirai, J., Kissel, J., & Fenske, R. (2003). Pesticide take-home pathway among children of agricultural workers: Study design, methods, and baseline findings. Journal of Occupational and Environmental Medicine, 45(1). doi:10.1097/00043764-200301000-00012
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  Farmworkers are exposed to pesticides and may take home pesticide residues to their families. In this paper, self-reported pesticide exposure and home practices to reduce the amount of pesticide residues taken home were examined among 571 farmworkers. Urine samples from a subsample of farmworkers and children and dust samples from households and vehicles also assessed pesticide exposure. Overall, 96% of respondents reported exposure to pesticides at work. Many employers did not provide resources for hand washing. Farmworkers' protective practices to keep pesticide residues out of the home were at a low level. In a subset of respondents, pesticide levels above the limit of quantitation were seen in the urine of children and adults and in house and vehicle dust. The results support the take-home pathway of pesticide exposure. Ways must be found to reduce this pesticide exposure among children of farmworkers.
• Curl, C., Fenske, R., Kissel, J., Shirai, J., Moate, T., Griffith, W., Coronado, G., & Thompson, B. (2002). Evaluation of take-home organophosphorus pesticide exposure among agricultural workers and their children. Environmental Health Perspectives, 110(12). doi:10.1289/ehp.021100787
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  We analyzed organophosphorus pesticide exposure in 218 farm worker households in agricultural communities in Washington State to investigate the take-home pathway of pesticide exposure and to establish baseline exposure levels for a community intervention project. House dust samples (n = 156) were collected from within the homes, and vehicle dust samples (n = 190) were collected from the vehicles used by the farm workers to commute to and from work. Urine samples were obtained from a farm worker (n = 213) and a young child (n = 211) in each household. Dust samples were analyzed for six pesticides, and urine samples were analyzed for five dilkylphosphate (DAP) metabolites. Azinphosmethyl was detected in higher concentrations (p < 0.0001) than the other pesticides: geometric mean concentrations of azinphosmethyl were 0.53 μ/g in house dust and 0.75 μg/g in vehicle dust. Dimethyl DAP metabolite concentrations were higher than diethyl DAP metabolite concentrations in both child and adult urine (p < 0.0001). Geometric mean dimethyl DAP concentrations were 0.13 μmol/L in adult urine and 0.09 μmol/L in child urine. Creatinine-adjusted geometric mean dimethyl DAP concentrations were 0.09 μmol/g in adult urine and 0.14 μmol/g in child urine. Azinphosmethyl concentrations in house dust and vehicle dust from the same household were significantly associated (r2=0.41, p < 0.0001). Dimethyl DAP levels in child and adult urine from the same household were also significantly associated (r2 = 0.18, p < 0.0001), and this association remained when the values were creatinine adjusted. The results of this work support the hypothesis that the take-home exposure pathway contributes to residential pesticide contamination in agricultural homes where young children are present.
• Thompson, B., Coronado, G., Solomon, C., McClerran, D., Neuhouser, M., & Feng, Z. (2002). Cancer prevention behaviors and socioeconomic status among Hispanics and non-Hispanic Whites in a rural population in the United States. Cancer Causes and Control, 13(8). doi:10.1023/a:1020280427712
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  Objectives: Socioeconomic status is explored as a predictor of differences between Hispanics and non-Hispanic Whites in cancer prevention behavior. Methods: In a cross-sectional study, in-person interviews (n = 1795) were conducted in a population-based random sample of adults in 20 communities with a high proportion of Hispanics. Results: Hispanics were significantly less likely than non-Hispanic Whites to ever have had cervical (p < 0.001), breast (p = 0.007), or colorectal cancer (FOBT p = 0.008; sigmoidoscopy/colonoscopy p < 0.002) screening. After adjusting for socioeconomic status (education and having health insurance), only differences in cervical cancer remained significant (p = 0.024). After adjusting for socioeconomic status, Hispanics had a significantly higher intake of fruits and vegetables per day (4.84 servings) than non-Hispanic Whites (3.84 servings) (p < 0.001); and fat behavior score was marginally significant after adjustment for socioeconomic status (p = 0.053). Significantly fewer Hispanics were current smokers than non-Hispanic Whites (p < 0.001). Conclusions: There is only limited support for the hypothesis that socioeconomic status is a major determinant of some cancer-related behaviors; specifically, socioeconomic status is related to mammography and colorectal screening, but not cervical cancer, dietary behavior, or smoking.
• Thompson, B., Coronado, G., Puschel, K., & Allen, E. (2001). Identifying constituents to participate in a project to control pesticide exposure in children of farmworkers. Environmental Health Perspectives, 109(3). doi:10.1289/ehp.01109s3443
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  Farmers in Washington State use pesticides to control harmful pests that might interfere with the quality of their products. Farmworkers, who are primarily responsible for thinning, harvesting, and other agricultural work, are often exposed to these pesticides and take home pesticide residues on their clothing, shoes, and skin, potentially exposing children in the household to pesticides. We designed a project to reduce children's exposure by using a community organization model. To better understand the community views regarding pesticide exposure, we conducted a qualitative community analysis. Two methods of data gathering were used to collect information. Individual interviews were conducted with some respondents, and small group discussions were held with others. Analysis indicated wide disparity among involved groups in their views on pesticides; however, a number of themes common to the majority of the constituents were identified and discussed with a community planning group. Because of the contention around pesticides, the group recommended every constituent participate in decision making. The group noted it was important to emphasize that the research project could provide scientific information on pesticide exposure to everyone in the Lower Yakima Valley. Our study demonstrates both the widely varying views of different constituents around the issue of pesticide exposure and common themes that can form the basis for collaboration and consensus on approaching the issue.
• Coronado, G., & Thompson, B. (2000). Rural Mexican American men's attitudes and beliefs about cancer screening. Journal of Cancer Education, 15(1).
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  Introduction. Mexican American men are thought to receive fewer cancer screening services for prostate and colon cancer than the general male population; however, little is known about this group. Methods. A population- based cross-sectional study was conducted to examine the knowledge, beliefs, attitudes, and use of cancer screening services among a sample of high- acculturated Mexican American, low-acculturated Mexican American, and non- Mexican American white men in Washington State. A total of 158 men (127 Mexican American; 31 non-Mexican American white) completed an in-person interview. Results. The Mexican American men were more likely to report employment in agriculture and had completed fewer years of formal education compared with the non-Mexican American men, and were more likely than their non-Mexican American counterparts to have little knowledge about the causes of cancer and the need for cancer prevention practices. Further, the Mexican American men were more likely to report avoidant and fatalistic attitudes about cancer. Conclusion. Future research should address variables that are related to the low level of cancer screening among Mexican American men.
• Coronado, G., Marshall, L., & Schwartz, S. (2000). Complications in pregnancy, labor, and delivery with uterine leiomyomas: A population-based study. Obstetrics and Gynecology, 95(5). doi:10.1016/s0029-7844(99)00605-5
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  Objective: To determine the extent to which uterine leiomyomas are associated with characteristics of pregnancy, labor, and neonatal outcome recorded on birth certificates. Methods: In a population-based series of women who delivered singleton live infants in Washington state from 1987-1993, we linked computerized birth certificates and hospital discharge records to investigate the relationship between uterine leiomyomas and complications in pregnancy and delivery. Subjects were 2065 women with uterine leiomyomas noted on computerized hospital discharge records. From the remaining records, a comparison group of women without uterine leiomyomas diagnoses were selected at random and frequency-matched by birth year to women with leiomyomas. We used unconditional logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of pregnancy or delivery complications in relation to uterine leiomyomas after multivariate adjustment. Results: Women with leiomyomas were more likely than controls to be over age 35 at delivery, nulliparous, or black. We observed independent associations between uterine leiomyomas and abruptio placentae (OR 3.87, 95% CI 1.63, 9.17), first trimester bleeding (OR 1.82, 95% CI 1.05, 3.20), dysfunctional labor (OR 1.85, 95% CI 1.26, 2.72), and breech presentation (OR 3.98, 95% CI 3.07, 5.16). The risk of cesarean was also higher among women with uterine leiomyomas (OR 6.39, 95% CI 5.46, 7.50), but a portion of the excess risk might have been due to biased detection of leiomyomas at cesarean delivery. Conclusion: Leiomyomas appear to increase likelihood of complications during pregnancy, labor, and delivery. Copyright (C) 2000 The American College of Obstetricians and Gynecologists.