Recruitment incentives to reduce disparities among medically underserved men.

Abstract: This study examined two techniques for recruitment by mailed invitation of underserved, low-income men to an educational program about prostate cancer screening. The Ethnic Sensitive technique used special envelopes and letterhead; the $2 Incentive technique used cash to say "thanks" for reading the cover letter. Low-income households were randomized to one of four groups: Controls, Ethnic Sensitive Only, $2 Incentive Only, or the Combination of both approaches. The $2 Incentive technique increased rates of making appointments to attend the educational program (p=0.01), yet many of these men did not keep their appointments. However, the Ethnic Sensitive method doubled actual attendance rates (p = O. 04) and was the most cost-effective method studied.

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Historically, African American and low-in come men have not participated in research studies. Medically underserved men and African American men are less likely to participate in education and screening for prostate cancer (Smedley, Stith, and Nelson, 2003). National legislation to reduce health disparities support research efforts is aimed at improving participation (Haynes & Smedley, 1999; Committee on CA Research Among Minorities, 1999). Still, better recruitment strategies for medically underserved men are needed (Guralnik & Leveille, 1997; Weinrich, Weinrich, Ellison, et al, 2000; Weinrich, Boyd, Greene, et al, 1998).

African-American men have the highest prostate cancer incidence and mortality rates of any ethnic group. Their incidence rate is 206.7 per 100,000, versus 132.7 in Caucasians (Reis, Eisner, Kosary, et al, 2000; Greenlee, Hill-Harmon, Murray, & Thun, 2001). Recent improvements in prostate cancer detection at earlier stages and improved survival rates have not occurred to the same extent in African American as in Caucasian men (Hankey, Feuer, Clegg, et al., 1999).

Poverty is associated with poorer prostate cancer outcomes, and lower-income men are more likely to be diagnosed at an advanced stage (Haynes & Smedley, 1999; Klausner, 1999; Guralnik & Leveille, 1997; Kington & Smith, 1997; Shingawa, 2000; Greenwald, Borgatta, McCorkel, et al, 1996; Roetzheim, Pal, Tennant, et al, 1999; Hebert, Hurley, Olendzki, et al, 1998; Freeman, 1989; Link, Northridge, Phelan, et al, 1998; Hoffman-Goetz, Breen, & Meissner, 1998; Polednak, 1997, Committee on CA Research Among Minorities, 1999; Bennett, Fereira, Davis, et al, 1998, ACS, 1990; Robinson, Ashley, & Haynes, 1996). Although national data bases do not currently gather or report income (P. Wingo, personal correspondence, February 22, 2000), two published studies document the association between prostate cancer and income. Stage at diagnosis of prostate cancer was inversely correlated with income among 117 blacks in North Carolina (Conlisk, Lengerich, Denmark-Wahnfried, et al, 1999). In the South Carolina Prostate Cancer Project (Weinrich, Weinrich, Ellison, et al, 2000), the detection rate for prostate cancer was significantly greater in the lowest income group of men (p < 0.01).

It is not yet known whether the potential benefits of prostate cancer screening outweigh the associated risks. But most experts agree that all men, including the medically underserved, should be involved in prostate cancer screening educational programs, so that they can make an informed decision whether to undergo screening (Brawley, 2001; Weinrich, 2001; Magee & Thompson, 2001).

Recruitment of African American and low income men to educational programs can be difficult, time consuming, and costly. Recruitment strategies reported in the literature include testimonies from sports figures, key community leaders, and political leaders (Paskett, Tatum, D'Agostino, et al, 1999); use of peers (Weinrich, Weinrich, Stromborg, et al, 1993; Weinrich, Boyd, Greene, et al, 1998); health printed materials with reduced literacy levels (Weinrich, 1999, Reflections); and incentives such as a tee-shirts or coupons (Heberlein & Baumgarten 1978).

Weinrich demonstrated that her educational interventions (Client Navigator and Peer Educator), as well as local presentations in medically underserved neighborhoods were useful tools to increase participation in free prostate cancer screening programs (Weinrich, Weinrich, Boyd, et al 1998; Weinrich, 1999, Reflections). In a group of men recruited at their place of work, the cost per man screened varied widely, depending upon the intervention used (Weinrich, Weinrich, Ellison, et al, 1999). Finding simple cost-effective recruitment strategies for low-income and African American men in the general population remains a critical priority. Cost continues to be a major barrier to sharing in the benefits of today's cost-conscious health care system.

The present study tested two intervention techniques using mailed invitations to target low-income and African American men. The goal was to encourage recipients to make an appointment to attend an educational program for prostate cancer screening. The design of the study was inspired by Dillman's total design method (Dillman, 2000). Dillman's book contains suggestions regarding both the type of paper to use for a mail survey and how to include financial incentives for participation.

The two intervention techniques studied here were mailing "ethnic sensitive" letterhead and envelopes (instead of standard University of Louisville stationery) and including $2 to say "thank you" for reading the mailing.

METHODS

SAMPLE

Survey Sampling Inc. provided a roster of 770 household names and addresses constructed by combining US Census and marketing data. Households were chosen for their low median annual household incomes (below $30,000), as well as their proximity to the screening site, their high prostate cancer mortality rates (33.1 to 38.4 per 100,000, versus 24.9 for Kentucky as a whole), and their high likelihood of containing at least one eligible man aged 40 years or greater. About 30% of the households in the target ZIP code areas were African American (Jefferson County, 1995). The demographics of each household were based on aggregated local demographic and economic data.

Before letters were mailed, listed households were randomized to one of the interventions or one of the two control groups. One hundred seventy-one letters were mailed to each group, except for Control Group II (pure controls), which contained 86 addresses. Control Group II received no mailing.

MAILED INTERVENTIONS

Two mailed intervention techniques were tested, both singly and jointly, for recruitment of low-income men: Ethnic Sensitive Only, $2 Incentive Mailing Only, and Combination (using both the Ethnic Sensitive and the $2 Incentive techniques).

This study served only as a pilot study for a larger, subsequent study; no formal field testing was performed. There were two control groups: Control group I, which received a plain letter announcing the free Prostate cancer educational program and the opportunity to obtain free screening, and Control group II (pure community controls) did not receive a letter at all. The two outcomes of interest were responding to the mailed letter by making an appointment to attend, and actually attending the educational program. There was no attempt to follow up non-responding households, by mail or by telephone.

Each mailing included a flyer informing men about the free prostate cancer educational program, which was held at a local hospital. An acceptance form and a stamped return envelope were also included. The cover letter gave eligibility criteria, brief information about prostate cancer screening, and the time, date and location of the program. The letter also emphasized that the prostate cancer screening would be free if they did participate.

The stationery used for the Ethnic Sensitive Intervention technique was an attractive off-the-shelf line of stationery from a local copy center with a design similar to Kente cloth.

The idea of using special paper was taken from Dillman's book (Dillman, 2000); the specific design chosen was based on informal consultation with local African American men. The US Postal Service prostate cancer stamp was also used, and the message "This could save your life" was printed on the front of the envelope. The $2 Incentive Intervention technique added the closing statement, "Thanks for reading this letter" along with two new one-dollar bills. The Combination Intervention combined both approaches. There were two control groups: Control Group 1 received a standard letter asking men to participate in the free prostate cancer educational program; Control Group 2, which was used to detect awareness of the screening program arising by word-of-mouth and local advertisement, received no letter.

PROCEDURES

Men were mailed letters based on their randomization group. All men who kept the appointment signed an informed consent form and completed a questionnaire on site, which obtained basic demographic information and questions measuring knowledge and attitudes towards prostate cancer screening. Attendees then participated in an educational program that focused on the benefits and limitations of prostate cancer screening, and decided whether or not to undergo CaP screening.

Six hundred eighty-four letters were mailed (Figure 1). Twenty-two were undeliverable due to incorrect addresses (3.2%), We therefore estimate that no more than 96.8% (662/684) of the original listings were valid. This estimate was used as part of the procedure to adjust crude response rates.

[FIGURE 1 OMITTED]

STATISTICAL PROCEDURES

Data were entered using Microsoft Access and SAS (SAS, 2002). Analyses to compare the relative effectiveness of the interventions were carried out using LogXact (Cytel Software, Cambridge MA) for exact (nonparametric) logistic regression. Analyses were based on die number of men who made appointments (or who attended the program), using the number of letters mailed as the denominator for all response rates.

Many households on the original address list did not contain an eligible respondent. Yet to estimate the true proportion of eligible subjects who made an appointment when they received our letter, it was necessary to estimate the fraction of listed households that contained one. The crude response rates ("responses per address") were therefore divided by the estimated fraction of listed households that contained an eligible respondent ("eligible subjects per address"). This procedure gave adjusted rates (responses per eligible subject). The adjustment occurred only after statistical analyses had been carried out on the original data and had no impact on the statistical significance of the results.

The fraction of households that contained an eligible man was estimated by multiplying the fraction of the 684 letters originally mailed that were not returned due to an invalid address (which we used as a conservative estimate of the proportion of valid addresses) times the proportion of households contacted that contained an eligible subject when we called a random sample of 178 households that had not answered our initial letter. Each of these 178 households was called up to three times, at different times of the day and on different days of the week.

COST AND COST-EFFECTIVENESS ESTIMATES

The cost of preparing each mailed invitation was computed by adding together the cost of each component: stationery, envelope and stamp, reply form for making an appointment, stamped reply envelope, two $1 bills (where applicable), and staff time to prepare each invitation. Costs were compared--per letter mailed, per appointment made, and per actual attendee--for each of the four groups (Controls, Ethnic Sensitive only, $2 Incentive only, and Combination). Fixed costs to present the program were not included in the comparisons.

RESULTS DEMOGRAPHICS OF PARTICIPANTS

Forty-six men made appointments to attend; twenty-seven men actually attended the educational program. One attendee was ineligible for the study (over 70 years old). The mean age of the remaining 26 men was 53 years (SD = 7.9 years). Most of the men were married (69.2%). Twenty percent of the men had an income of less than $833 per month. Detailed demographic data on program attendees is shown in Table 1. No individual demographic data was available for households and men that did not respond. One of the 26 program attendees brought along a friend who had not received a letter, leaving 25 men for the statistical analyses.

The 46 appointments made represent about 7% of the letters mailed (return rate per letter mailed). As explained below in the section on adjusted response rates, the actual response rate among eligible men who received the letters was much higher--over 14% (response rate per eligible household). Similarly, the 26 men who attended represented almost 4% of letters mailed, but over 8% of the eligible men who received letters. These differences reflect the high proportion of invalid addresses on the original list, rather than reluctance by the men to respond to the offer. The effectiveness of the methods studied may be assessed by examining the response rates (per eligible man).

RESULTS FOR EACH INTERVENTION

Control group I, which received only a plain letter, yielded six replies (3.5% of 171) requesting an appointment for screening (note that this is the crude, or unadjusted, rate of responses per household on the mailing list). Four of these six men kept their appointment. The Ethnic Sensitive Only Intervention yielded nine replies (5.3% of 171), eight of whom kept their screening appointment. The Incentive Only Intervention yielded thirteen replies (7.6% of 171), four of whom kept their appointment. Finally, the Combination Intervention yielded eighteen replies (10.5% of 171), nine of whom nine kept their appointment (Table 2). No men from Control Group II (pure controls, who received no letter at all) attended the prostate cancer educational program. Adjusted response rates--described in detail below--were over twice as high as these crude return rates.

In the exact logistic regression models, the interaction between the Ethnic Sensitive and the Incentive Intervention techniques was not statistically significant. Hence, the final models were main-effects models (both for predicting making an appointment and predicting program attendance), under which the effect of each mailing technique did not depend upon whether or not the other technique was used alongside of it.

Although the data in Table 2 suggest that each intervention technique increased the rate of making appointments, only the $2 Incentive mailing technique achieved statistical significance (odds ratio estimate = 2.17, one-sided p=0.01). For the Ethnic Sensitive mailing method, the odds ratio was 1.46 (p=0.14).

For actual attendance at the CaP screening educational program, the logistic regression model showed no evidence whatsoever that the $2 Incentive technique increased participation. But the Ethnic Sensitive technique led to substantial increases in attendance. The odds ratios associated with program attendance for the Ethnic Sensitive and $2 Incentive mailing techniques were equal to 2.18 (one-sided p<0.04) and 1.09 (p=0.50), respectively.

ADJUSTED RESPONSE RATES

As explained in the Methods section, response rates were adjusted by dividing each by the estimated fraction of households on the original list that contained an eligible male subject. Of the 684 letters mailed, 22 were returned by the Postal Service "due to invalid address." Assuming that the remaining 662 addresses were all valid, the proportion of addresses that represented valid households was 662/684, or 96.78%. Of the 178 nonresponding households mentioned earlier that were selected at random for telephone calls to ascertain eligibility, 48.5% of the ones that were reached contained a man who met the study inclusion criteria (see Figure 1 for details). The product of these two ratios is 96.78% x 48.39% = 46.83%. Each crude response rate (per household listed) was divided by 0.4683 to obtain the estimated true response rate per eligible man. This correction for ineligible addresses on the original list more than doubled the estimated response rates. Results are graphed below in Figure 2.

[FIGURE 2 OMITTED]

Response to the program was quite favorable. Every man who attended the educational program chose to have the prostate cancer screening.

COST OF THE MAILING

The Control Mailing letters each cost $1.43--twenty-five cents for letterhead and envelope, $0.17 for reply form and envelope, $0.68 for two postage stamps, and $0.33 for labor to prepare and seal the envelope. The Ethnic Sensitive technique added $0.10 to the cost for stationery and envelope, and the $2 Incentive technique added two dollars. Costs per invitation for the Ethnic Sensitive only, $2 Incentive only, and Combination invitations were therefore $1.53, $3.43, and $3.53, respectively. Dividing each of the costs by the corresponding crude or adjusted response rate for making an appointment or attending the educational program yielded costs per appointment or attendee, which are shown below in Table 3.

Costs per appointment made ranged from $13.61 (Ethnic Sensitive only) to $21.13 ($2 Incentive only). Costs per program attendee ranged from $15.32 (Ethnic Sensitive only) to $68.67 ($2 Incentive only). The cost per appointment made and the cost per program attendee were each lowest by far for the Ethnic Sensitive only method. This resulted from the modest additional cost of the Ethnic Sensitive stationery and from the substantial increase in response rates.

The results can also be shown in terms of the expected number of men who will make an appointment or who will attend the educational program for each $100 in recruitment cost. Each estimate is just $100 divided by the cost per appointment or attendee. Results derived from the adjusted response rates are shown in Figure 3. The superiority of the Ethnic Sensitive Only method is clearly apparent; for program attendance, it is almost twice as effective as the next best choice.

[FIGURE 3 OMITTED]

DISCUSSION

Compared to the recruitment techniques described in the Introduction, neither technique was expensive. This approach worked at least as well as the strategies discussed earlier, which used Peer Educators or Client Navigators for subjects recruited from their work sites.

The large discrepancy in the rate at which men kept their appointments was of particular interest. Did men who received the $2 Incentive feel under an obligation to make an appointment? If so, why did they so often fail to attend the educational program? Why was the Ethnic Sensitive/mailing so successful? Did it have particular appeal to African American men? Or was it simply that, as more than one respondent remarked, "I knew it wasn't a bill as soon as I saw it?" These questions need to he addressed in subsequent studies, to help refine future recruitment methods for this group of subjects.

LIMITATIONS OF THIS STUDY

Several considerations should be taken into account before attempting to generalize our results:

* The response rates are low, even after adjusting for ineligible household addresses, making it difficult to generalize the findings. This population is difficult to study; few if any studies achieve high response rates without large investment of time and money.

* No attempt was made to follow up non-responding households. More thorough follow-up, either by mail or by telephone, could have increased response rates substantially.

* A more accurate listing of eligible households would have saved substantial effort and expense. But our subjects move frequently, which makes it extremely difficult to obtain and maintain accurate address lists.

* The low rate at which men who received the $2 Incentive kept their appointments deserves study, particularly to ascertain whether more intensive follow-up, perhaps including a telephone reminder, might increase their rate of participation.

Regardless of the recruitment method used, health care providers must recognize that recruiting low-income men is requires a large commitment of time and resources. Even with the best recruitment methods, the response rate for medically underserved men will remain significantly lower than for men who have more experience in accessing the health care system, and greater personal resources to cover the cost of care.

The adjusted response rates, which reflect the true probability that an eligible recipient responds to the mailing, were at the lower end of the response rates--20% to 80%--that are commonly reported in the mail survey literature (Dillman, 2000). The authors emphasize that this is a credible response rate for the medically underserved men from low-income households studied here. Most mail surveys target the general population or even middle or upper-income households (for marketing purposes).

These results could be useful in any urban setting where recruitment using mailed letters is desired. Generalizing the specific results obtained in this study uncritically to other settings is not advisable, since the specific demographic characteristics of each study population will influence overall participation. Yet the Ethnic Sensitive technique may well prove useful in other contexts. Future research could test the intervention in other ethnic groups as well as measure the impact of the Ethnic Sensitive stationery on men from Caucasian, Latino, and other ethnic groups. Health care providers desiring to recruit medically underserved men for health programs or health research may also find our results useful for their work.

Table 1. Demographic Description of Men Who Attended the Educational
Program.

Demographics                              Number   (percent)

Age (mean = 53 years; s.d. = 7.9 years)
  40-49 years                                9       (35%)
  50-59 years                               13       (50%)
  60-74 years                                4       (15%)

Rain
  African American                          21       (81%)
  Caucasian                                  5       (19%)

Income * (categories in questionnaire)
  <=$5,000 per year                          2        (8%)
  5,001-$9,999                               3       (12%)
  $10,000-$24,999                            5       (19%)
  $25,000-$49,999                           11       (42%)
  $50,000 or more                            4       (15%)
  Missing                                    1        (4%)

Education
  Less than High School Graduate             4       (15%)
  High School Graduate                       9       (35%)
  Some College or More                      13       (50%)

Marital Status
  Married                                   18       (69%)
  Not Married                                8       (31%)

Ever had Prostate Exam
  Previous DRE                              17       (65%)
  Previous PSA assay                        12       (46%)

Table 2. Responses to Invitations to Attend CaP Screening Educational
Program
                                               Made an
                                             appointment
                                  Letters     to attend     Attended
                                  mailed       program      Program

Type of Mailing                      N       N   Percent   N   Percent

Control Group II (plain letter)     171      6    (3.5%)   4    (2.3%)
Ethnic Sensitive technique only     171      9    (5.3%)   8    (4.7%)
$2 Incentive technique only         171     13    (7.6%)   4    (2.3%)
Combination (both techniques        171     18   (10.5%)   9    (5.3%)
  jointly)

Table 3. Summary of Qualitative Data of Self-Reported Life Changes
among College Students since the September 11 Attacks.

Life changes experienced                                Frequency

More anxious and emotional                                  44
  Fear of densely populated area, feeling scared and
    worried
  Apprehensive about deployment of self or loved ones
  Being more precautions at school and on job
  More concerned about safety of loved ones
  Reluctant to go out, considering moving to another
    country
  Emotional trauma due to loss of someone close
  Antagonistic to Arabs, disappointed with humanity
  As an Arab, being afraid of Americans

More appreciative of life, family, and friends              22
  Realizing life is precious, not taking life for
    granted
  Not getting angry over little things in life
  More apt to do everything I want to do
  Taking care of family members and loved ones more
  More frequent contacts with family members

Changes in means of transportation                          20
  More reluctant to fly, more worried about plane
    travel
  Fewer use of air travel, stop using air travel
  Not taking train, greater alertness in traveling

Increased concern about society and politics                12
  Watching news more frequently
  More concerned about what's going on in the world
  More aware ofworld peace

Financial loss                                               8
  Losing a job, having hard time getting a job,
    decreased work hours
  Postponement of wedding

More patriotic                                               7
  Plan to join the army or ROTC, feeling more
    patriotic

Being more spiritual                                         7
  Praying more, more trust and faith in God

Note. Total respondents who answered to the open-ended question were
120. Some respondents listed multiple life changes.

REFERENCES

American Cancer Society (1990). Report to the Nation: Cancer in the poor. CA Cancer J Clin, 39, 263-265. Bennett, C.L., Fereira, M.R., Davis, T.C., Kaplan, J., Weinberger, M., Kuzel, T., Seday, M.A., Sartor, O. (1998). Relation between literacy, race, and stage of presentation among low-income patients with prostate cancer. Clin Oncology, 16, 3101-3104.

Brawley, O. (2001). Prostate Cancer Screening: A note of caution. In I.M Thompson, M.I. Resnick, & E.A. Klein (Eds.), Prostate cancer screening (pp. 175 - 185). New Jersey: Humana Press.

Committee on Cancer Research Among Minorities and Medically Underserved: The Unequal Burden of Cancer (1999). Washington D.C.: National Academy Press.

Conlisk, E.A., Lengerich, E.J., Demark-Wahnfried, W, Schildkraut, J.M., Aldrich, T. (1999). Prostate cancer: demographic and behavioral correlates of stage at diagnosis among blacks and whites in North Carolina. Urology, 53, 1194-1199.

Dillman, D.A. (2000). Mail and Internet Surveys: The Tailored Design Method. New York: J. Wiley, 2nd ed.

Freeman, H.P (1989). Cancer in the socioeconomically disadvantaged. CA Cancer J Clin, 39, 263-265.

Greenlee, R.T., Hill-Harmon, M.B., Murray, T., et al (2001). Cancer statistics, 2001. CA Cancer J Clin, 51, 15-36.

Greenwald, H.P., Borgatta, E.F., McCorkel, R., et al (1996). Explaining reduced cancer survival among the disadvantaged. Milbank Q, 74, 215-238.

Guralnik, J.M., Leveille, S.G.(1997). Annotation: Race, Ethnicity, and Health outcomes- Untraveling the Mediating Role of Socioeconomic Stares. American Journal of Public Health, 87, 728-730.

Hankey, B.F., Feuer, E.J., Clegg, L., et al (1999). Cancer surveillance series: interpreting trends in prostate cancer--part I: Evidence of the effects of screening in recent prostate cancer incidence, mortality, and survival rates. Journal of the National Cancer Institute, 91, 1017-1024.

Haynes, M. A., & Smedley, B. D. (Eds.). (1999). The unequal burden of cancer: An assessment of NIH research and programs far ethnic minorities and the medically underserved Washington, D.C.: National Academy Press.

Heberlein, T.A., Baumgarten, R. (1978) Factors affecting response rates to mailed questionnaires: A quantitative analysis of the published literature. American Sociological Review, 43, 447-462.

Hebert, J.R., Hurley, T.G., Olendzki, B.C., et al (1998). Nutritional and socioeconomic factors in relation to prostate cancer mortality: A cross-national study. Journal of the National Cancer Institute, 90, 1637-1647.

Hoffman-Goetz, L., Breen, N.L., Meissner, H.(1998) The impact of social class on the use of cancer screening within three racial/ethnic groups in the United States. Ethnic Disparities, 8, 43-51.

Jefferson County Health Department, Office of Community Health Planning, Kentucky Annual Vital Statistics Report. (1995). Louisville, KY: Kentucky Department for Public Health, Health Data Board.

Kington, R.S., Smith, J.O. (1997). Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health, 87, 805-810.

Klausner, R.D. (1999). The Unequal Burden of Cancer: NCI Response to a Report by the Institute of Medicine. Statement before U.S. Senate Appropriations Subcommittee on Labor, Health and Human Services, Education and Related Agencies, January 21, 1999.

Link, B.G., Northridge, M.E., Phelan, J.K., et al (1998). Social epidemiology and the fundamental cause concept: on the structuring of effective cancer screens by socioeconomic status. Milbank Q, 76, 375-402.

Magee, C., Thompson, I. (2000). Evidence of the effectiveness of Prostate Cancer Screening. In I. Thompson, M. Resnick, & E. Klein, (Eds.), Prostate Cancer Screening (pp. 157-174). Totowa, N .J.: Humana Press.

Paskett ED, Tatum cm, D'Agostino, R. Jr., et al (1999). Community-based interventions to improve breast and cervical cancer screening: results of the Forsyth County Cancer Screening (FoCaS) Project. Cancer Epidemiolical Biomarkers Prevention, 8, 453-459.

Polednak, A.P. (1997). Stage at diagnosis of prostate cancer in Connecticut by poverty and race. Ethn Dis, 7, 215-220.

Reis, L. A., Eisner, M. P., Kosary, C. L., et al. (2000). Cancer statistics review, 1973-1997. Bethesda, MD: National Cancer Institute.

Robinson, S., Ashley, M., Haynes, M. (1996). Prostate cancer treatment in black and white men: the need to consider both stage at diagnosis and socioeconomic status. Journal of Community Health, 21, 77-87.

Roetzheim, R.G., Pal, N., Tennant, C., et al (1996). Effects of health insurance and race on early detection of cancer. Journal of the National Cancer Institute, 91, 1409-1415.

SAS Institute (2001). Statistical Analysis System, v.8.02. Cary, N.C.: SAS Institute.

Shingawa, S.M. (2000). The excess burden of breast carcinoma in minority and medically underserved communities. Cancer (supplement), 88, 1217-1223.

Smedley, B.D., Stith, A.Y., & Nelson, A.R. (Eds.). (2003). Unequal treatment confronting racial and ethnic disparities in healthcare. Washington, D.C.: National Academies Press.

Weinrich, S.P., Weinrich, M., Atwood, J., et al (1999). Cost for prostate cancer educational programs by race and educational method. American Journal of Health Behavior, 23, 144-156.

Weinrich, S.P., Boyd, M.D., Greene, F., et al (1998). Community Sites for Recruitment of African-American Men into Prostate Cancer Screening. Cancer Practice, 6, 23-30.

Weinrich, S.P., Weinrich, M.C., Boyd, M.D., et al (1998). Increasing Prostate Cancer Screening in African American Men with Peer Educator and Client Navigator Educational Interventions. Journal of Cancer Education, 13, 213-219.

Weinrich, S.P., Weinrich, M., Ellison, G., et al (2000). Contrasting Cost of a Prostate Cancer Educational Program by Income. American Journal of Health Behavior, 24, 422-433.

Weinrich, S. P (2001). The debate about prostate cancer screening: What nurses need to know. Seminars in Oncology Nursing, 17, 78-84.

Weinrich, S.P., Weinrich, M.C., Stromborg, M., et al (1993). Using Elderly Educators to increase colorectal cancer screening. The Gerontologist, 33, 401-406.

Weinrich, S. (1999). The high risk of low literacy. Reflections (Fourth Quarter), 22-24.

HEALTH EDUCATION RESPONSIBILITY AND COMPETENCY ADDRESSED

Responsibility II--Planning Effective Health Education Programs

Competency A--Recruit community organizations, resource people, and potential participants for support assistance in program planning

Sub-competency 4--Incorporate feasible ideas and recommendations into the planning process

Martin Weinrich, Ph.D. is with the School of Public Health and Health Information Sciences, Sally Weinrich, Ph.D. and Rachelle Seger, B.A. are with the School of Nursing, Inka Weissbecker, M.S. is a Doctoral Student in Clinical Psychology, Department of Psychology and Brain Sciences, and Kathy Mayberry Brent, B.A. is with the Office of Grants Management at the University of Louisville, Louisville, KY. Address all correspondence to Martin C. Weinrich, Ph.D., School of Public Health and Health Information Sciences, University of Louisville, Louisville, KY 40292; PHONE: [phone]; E-MAIL: [e-mail].