CARE Risky Sexual Behavior Index

Paul Reiter, MPH, Electra Paskett, PhD, Mira Katz, PhD, Amy Ferketich, PhD,

and Mack Ruffin, MD, MPH

Cells to Society: Overcoming Health Disparities

Neighborhood/Community Context

Community Engagement

Preclinical and Clinical

Studies

Impact on Patient and Community

Biomarker & Animal Model

Studies

CPHHD Transdisciplinary Research Framework:

Emerging Cross-Center Themes

Genetics, Biological Basis of

Disparities, Biomarkers for

Risk Assessment and Screening

Etiology, Screening, Treatment

Dissemination of Research, Quality of Life, Access to

Care, Policy

Reducing Disparities in Cervical Abnormalities in

Appalachia

P50-CA105632 The Ohio State University

National Cancer Institute

Goal To understand why Appalachian

Ohio women have high incidence and mortality rates

for cervical cancer.

OSU Center For Population Health

And Health Disparities

Average, Annual, Age-Adjusted Cervical Cancer Incidence and Mortality Rates,

Appalachia Ohio, per 100,000 Females, >14y, Whites, 2000-2004

Region Incidence Rates

Mortality Rates

United States 11.2 2.3

Ohio 10.9 2.7

Non-Appalachia Ohio

10.3 2.5

Appalachia Ohio 14.5 3.8

Theoretical Framework:Social Determinants of Health

CultureAppalachian Norms

PsychologicalMotivationKnowledge/ Risk

WorkOccupationRegulations

Brain

StressDepressionNicotine dependence

Morbidity/MortalityHealth Status/OutcomesGeneral HealthCervical Health

Pathophysiological ChangesHPVCINCarcinogenesis

Health BehaviorCervical screening

Tobacco Use

Sexual activity

Contraception

Alcohol use

Diet

Social EnvironmentSocial capitalSocial cohesionSocial networkNeighborhood disadvantage

Early life

Social Structure

EducationHealth Care Delivery

Genes

Material FactorsIncomeTransportation

Marmot and Wilkinson, 2001

ScreeningRisky Behaviors

Follow-upOf Abnormalities

- HPV- Smoking

- Pap Smear

Cervical Cancer

Rationale Certain behaviors put women at increased risk for

cervical abnormalities and HPV infection

Cervical cancer “risk” from sexual behaviors has not been quantified in a manner like other types of “risk”, e.g. breast cancer

An easy to use tool could be used to identify and target high risk women for education, surveillance, screening, and interventions

The CARE study provides an opportunity to develop and validate such a tool for cervical cancer in a high risk population

14 Clinics

Observational Study N=571

Multi-level factors associated with tobacco use and Pap testing

Project 1 N=281

Pap smear use:

•Risk appropriate guidelines

•Barriers counseling

Project 2 N=301

Smoking cessation:

•Biochemical validation

•Pharma-based intervention with

behavioral component

RCT testing LHA vs. usual care

Project 3 N=1360

Case-control study

•HPV testing, Pap smear, EBV titers, Cotinine

•TGF-alpha receptor

ADAMS

ATHENS

BROWNGALLIA

HIGHLAND

HOCKING

JACKSON

LAWRENCE

MEIGS

MONROE

MORGAN

NOBLEPERRY

PIKE

ROSS

SCIOTO

VINTON

WASHINGTON

CLER

MONT

SON

CARROLL

COLUMBIANA

BELMONT

COSHOCTON

GUERNSEY

HARRISON

HOLMESJEFFER

Region 1

Region 2

Region 3Region 4

Regions 1-4

MUSKINGHAM

12

2

3

4

5

6

7

8

9

10

11

1

13

14

TUSCARAWAS

Clinic locations

Eligibility Criteria

Age 18 and older No history of cervical cancer English speaking Not pregnant Randomly selected from clinic population Agree to participate

Baseline Survey

Face-to-Face Interview Home interview administered using CAPI

system with an audio portion to collect sensitive data

Conducted with research interviewer present

and averaged 1.5 hours to complete

Self-Administered Survey Given/mailed to participant to complete Completed surveys given to interviewer

or mailed to OSU

Methods

Creation (n=300): Association of 8 individual risky sexual behaviors with history of abnormal Pap smear was used to determine weights Overall scores calculated using weighting scheme

and history of each behavior

Validation (n=128): Goodness-of-fit in model containing overall index scores and history of abnormal Pap smear

Lowess curve examined (n=428) to determine cutoff points for high, medium, low group

Results Weighting Scheme:

Past STI=20 Age at 1st sexual

intercourse and number of lifetime sexual partners=5

Condom use, sex for money, partners with IV drug use, male partners sex with other men, partners past STI=1

Validation Sample: Hosmer-Lemshow test

did not indicate lack of fit (p=0.2999)

Cutoff Points: Low=5 or less Medium=6 – 10 High=11+

Risky Sexual Behahavior I ndex

Classification (n=428)

0

10

20

30

40

50

60

Low Med HighP

erc

en

t (%

)

Overall Level Abnormal Pap

n=134 n=131 n=163

Mean = 9.71 Median = 6.00

Future Use

Predict who is more likely to develop cervical abnormalities/compare by population group

Target women with higher scores for more frequent Pap tests and HPV vaccination

Direct interventions to high risk women to reduce risk

Educate women about their risk for cervical abnormalities

Comprehensive Cancer CenterCathy TatumCecilia DeGraffinreidMelissa HicksDarla Fickle Jill Oliveri

University of MichiganMack RuffinPaula Lantz

College of NursingKaren AhijevychJudy HarnessPamela Salsberry

Center For Population Health And Health Disparities“Reducing Cervical Cancer In Appalachia”

College of MedicineDavid CohnDouglas Post

ConsultantsBeti ThompsonElizabeth Unger

Department of EconomicsPatricia Reagan

College of Public HealthElectra PaskettMary Ellen WewersStanley LemeshowMira KatzAmy FerketichAnn McAlearney

Department of Pathology Scott Jewell

Center For BiostatisticsAmy LehmanErinn HadeBryan BallDale Rhoda