CARE Risky Sexual Behavior Index

1. CARE Risky Sexual Behavior Index Paul Reiter, MPH, Electra Paskett, PhD, Mira Katz, PhD, Amy Ferketich, PhD, and Mack Ruffin, MD, MPH

2. Cells to Society: Overcoming Health Disparities

3. CPHHD Transdisciplinary Research Framework:Emerging Cross-Center Themes Community Engagement Neighborhood/Community Context Impact on Patient and Community Biomarker & Animal Model Studies Preclinical and Clinical Studies Genetics, Biological Basis of Disparities, Biomarkers for Risk Assessment and Screening Etiology, Screening, Treatment Dissemination of Research, Quality of Life, Access to Care, Policy

4. Reducing Disparities in Cervical Abnormalities in Appalachia P50-CA105632 The Ohio StateUniversity

5. National Cancer Institute

6. OSU Center For Population Health And Health Disparities Goal To understand why Appalachian Ohio women have high incidence and mortality rates for cervical cancer.

7. Average, Annual, Age-Adjusted Cervical Cancer Incidence and Mortality Rates, Appalachia Ohio, per 100,000 Females, >14y, Whites, 2000-2004

8. Theoretical Framework:Social Determinants of Health Social Structure Education Health Care Delivery Social Environment Social capital Social cohesion Social network Neighborhood disadvantage Material Factors Income Transportation Work Occupation Regulations Psychological Motivation Knowledge/ Risk Early life Health Behavior Cervical screening Tobacco Use Sexual activity Contraception Alcohol use Diet Brain Stress Depression Nicotine dependence Genes Culture Appalachian Norms Pathophysiological Changes HPV CIN Carcinogenesis Morbidity/Mortality Health Status/Outcomes General Health Cervical Health Marmot and Wilkinson, 2001

9. Risky Behaviors Screening - Pap Smear - HPV- Smoking Follow-upOf Abnormalities Cervical Cancer

10. 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

11. 14 Clinics Observational StudyN=571 Multi-level factors associated with tobacco use and Pap testing Project 1N=281 Project 2N=301 RCT testing LHA vs. usual care • Smoking cessation: • Biochemical validation • Pharma-based intervention with behavioral component • Pap smear use: • Risk appropriate guidelines • Barriers counseling Project 3 N=1360 • Case-control study • HPV testing, Pap smear, EBV titers, Cotinine • TGF-alpha receptor

12. Regions 1-4 4 COLUMBIANA 3 CARROLL HOLMES JEFFER 2 SON TUSCARAWAS COSHOCTON HARRISON 8 1 6 5 BELMONT GUERNSEY 7 MUSKINGHAM MONROE NOBLE PERRY MORGAN HOCKING WASHINGTON 9 ROSS ATHENS Clinic locations VINTON 13 HIGHLAND MEIGS CLER Region 1 JACKSON PIKE MONT 12 Region 2 GALLIA ADAMS SCIOTO BROWN 14 10 Region 3 Region 4 LAWRENCE 11

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

14. 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

15. 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

16. 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+ Results n=131 n=134 n=163 Mean = 9.71 Median = 6.00

17. 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

18. Center For Population Health And Health Disparities“Reducing Cervical Cancer In Appalachia” College of Public HealthElectra PaskettMary Ellen WewersStanley LemeshowMira KatzAmy FerketichAnn McAlearney Comprehensive Cancer CenterCathy TatumCecilia DeGraffinreidMelissa HicksDarla Fickle Jill Oliveri Center For BiostatisticsAmy LehmanErinn HadeBryan Ball Dale Rhoda College of NursingKaren AhijevychJudy Harness Pamela Salsberry College of MedicineDavid CohnDouglas Post University of MichiganMack RuffinPaula Lantz Department of EconomicsPatricia Reagan ConsultantsBeti ThompsonElizabeth Unger Department of Pathology Scott Jewell