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-CA 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, RegionIncidence Rates Mortality Rates United States Ohio Non-Appalachia Ohio Appalachia Ohio

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

ScreeningRisky Behaviors Follow-up Of 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 BROWN GALLIA HIGHLAND HOCKING JACKSON LAWRENCE MEIGS MONROE MORGAN NOBLE PERRY PIKE ROSS SCIOTO VINTON WASHINGTON CLER MONT SON CARROLL COLUMBIANA BELMONT COSHOCTON GUERNSEY HARRISON HOLMES JEFFER Region 1 Region 2 Region 3 Region 4 Regions 1-4 MUSKINGHAM 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+ 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 Center Cathy Tatum Cecilia DeGraffinreid Melissa Hicks Darla Fickle Jill Oliveri University of Michigan Mack Ruffin Paula Lantz College of Nursing Karen Ahijevych Judy Harness Pamela Salsberry Center For Population Health And Health Disparities “Reducing Cervical Cancer In Appalachia” College of Medicine David Cohn Douglas Post Consultants Beti Thompson Elizabeth Unger Department of Economics Patricia Reagan College of Public Health Electra Paskett Mary Ellen Wewers Stanley Lemeshow Mira Katz Amy Ferketich Ann McAlearney Department of Pathology Scott Jewell Center For Biostatistics Amy Lehman Erinn Hade Bryan Ball Dale Rhoda