Community Health Center Population Research Articles

Implementation of patient navigation services to improve colorectal cancer health literacy in a vulnerable community health center population.

e23208 Background: Under-served community populations face social and health inequities which contribute to sub-optimal colorectal cancer (CRC) screening rates and excess mortality risk. Furthermore, these populations may not have the health literacy or food security necessary to mitigate the well-established nutrition-related risk of CRC. This quality improvement study aimed to improve CRC-related health literacy and dietary habits, with the additional goal of improving screening rates in our disadvantaged community health center population. Methods: This single-institutional study utilized the Plan-Do-Study-Act (PDSA) model to implement patient navigation services and administer a cross-sectional survey evaluating nutrition-related CRC risk. Patients eligible for screening were contacted by patient outreach coordinators prior to scheduled primary care appointments, and the survey was administered. During patient visits, outreach coordinators met with them to provide 1:1 education addressing CRC prevention, screening and nutrition. Information on free or low-cost fresh food options was provided to help address barriers such as food insecurity. The outreach coordinators also liaised with physicians to assist with coordination to services. Results: Prior to the intervention 58% of survey respondents (25/43) were not aware of any foods or dietary habits that decreased the risk of colorectal cancer; 51% (22/43) were not aware of foods that increased the risk of colorectal cancer. Most respondents (54%) were in fact not at all worried about possibly developing CRC in their lifetimes (22/41), while 34% (14/41) were a little worried, and the remainder (12%) very or extremely worried. 97% of respondents (33/34) felt more knowledgeable about CRC screening and felt more confident about improving their nutrition to reduce CRC risk after receiving the educational intervention, while 94% of respondents (31/33) stated they would subsequently make dietary changes. Conclusions: Health literacy regarding colorectal cancer was low in this underserved community population. Implementation of a patient navigation intervention led to increased knowledge and confidence in modifying dietary risk factors. However, preliminary data review did not reveal significant change in CRC screening rates during the initial phase of the intervention. One of the initially identified barriers included system-level delays in colonoscopy access. During the Act phase of the PDSA model, patient navigation services will be further optimized by workflow adaptation based on the response of outreach coordinators and patient-reported barriers regarding stool-based testing. [Table: see text]

The Role of Telehealth in Improving Care Connections and Outcomes for Community Health Center Patients with Diabetes.

Does telehealth decrease health disparities by improving connections to care or simply result in new barriers for vulnerable populations who often lack access to technology? This study aims to better understand the role of telehealth and social determinants of health in improving care connections and outcomes for Community Health Center patients with diabetes. This retrospective analysis of Electronic Health Record (EHR) data examined the relationship between telehealth utilization and glycemic control and consistency of connection to the health care team ("connectivity"). EHR data were collected from 20 Community Health Centers from July 1, 2019 through December 31, 2021. Descriptive statistics were calculated, and multivariable linear regression was used to assess the associations between telehealth use and engagement in care and glycemic control. The adjusted analysis found positive, statistically significant associations between telehealth use and each of the 2 primary outcomes. Telehealth use was associated with 0.89 additional months of hemoglobin A1c (HbA1c) control (95% confidence interval [CI], 0.73 to 1.04) and 4.49 additional months of connection to care (95% CI, 4.27 to 4.70). The demonstrated increased engagement in primary care for telehealth users is significant and encouraging as Community Health Center populations are at greater risk of lapses in care and loss to follow up. Telehealth can be a highly effective, patient-centered form of care for people with diabetes. Telehealth can play a critical role in keeping vulnerable patients with diabetes connected to their care team and involved in care and may be an important tool for reducing health disparities.

Uptake of colorectal cancer screening after mailed fecal immunochemical test (FIT) outreach in a newly eligible 45–49-year-old community health center population

PurposeWe assessed fecal immunochemical test (FIT) uptake following a mailed FIT intervention among 45–49-year-olds newly eligible for colorectal cancer (CRC) screening based on 2021 United States Preventive Services Task Force screening recommendations. We also tested the effect of an enhanced versus plain mailing envelope on FIT uptake.MethodsIn February 2022 we mailed FITs to eligible 45–49-year-olds at one Federally Qualified Health Center (FQHC) clinic. We determined the proportion who completed FITs within 60 days. We also conducted a nested randomized trial comparing uptake using an enhanced envelope (padded with tracking label and colored messaging sticker) versus plain envelope. Finally, we determined the change in CRC screening by any modality (e.g., FIT, colonoscopy) among all clinic patients in this age group (i.e., clinic-level screening) between baseline and 6 months post-intervention.ResultsWe mailed FITs to 316 patients. Sample characteristics: 57% female, 58% non-Hispanic Black, and 50% commercially insured. Overall, 54/316 (17.1%) returned a FIT within 60 days, including 34/158 (21.5%) patients in the enhanced envelope arm versus 20/158 (12.7%) in the plain envelope arm (difference 8.9 percentage points, 95% CI: 0.6–17.2). Clinic-level screening among all 45–49-year-olds increased 16.6 percentage points (95% CI: 10.9–22.3), from 26.7% at baseline to 43.3% at 6 months.ConclusionCRC screening appeared to increase following a mailed FIT intervention among diverse FQHC patients aged 45–49. Larger studies are needed to assess acceptability and completion of CRC screening in this younger population. Visually appealing mailers may improve uptake when implementing mailed interventions.Trial registration The trial was registered on May 28, 2020 at ClinicalTrials.gov (identifier NCT04406714).

Adherence to Daily Oral TDF/FTC for PrEP in Community Health Center Populations: The Sustainable Health Center Implementation PrEP Pilot (SHIPP) Study.

The prevention effectiveness of oral preexposure prophylaxis (PrEP) is highly dependent on medication adherence but no validated longer term PrEP adherence measures are readily available for use by primary care clinicians caring for diverse populations. We compared two self-report measures (number of doses missed in past 7days and day-by-day past week pill taking) to results of tenofovir concentrations in dried blood spot (DBS) samples at quarterly visits over the first 12months of PrEP use. 1420 men and women in five US community health centers enrolled in a medication adherence substudy. For 3, 6, 9 and 12months, the respective percentages of persons with self-report vs DBS levels consistent having taken all 7 doses in the week prior were 71% (51%), 70% (47%), 71% (46%) and 69% (44%). Conversely, the percentage of participants reporting taking 0-1 doses in the week prior by self-report vs DBS drug levels at 3, 6, 9 and 12months consistent with this level of nonadherence of 6% (9%), 5% (10%), 8% (9%), and 9% (15%). The estimated risk of low adherence (estimated 0-1 doses in the week prior) was higher for participants of Black (RR 1.60, CI 1.09-2.34) or "Other" race (RR 1.62, CI 0.99-2.65) compared with participants of White race; being a transgender female (RR 2.31, CI 1.33-4.02) compared to men who have sex with men; or enrollment at a study site with less experience in the provision of PrEP. The estimated risk of low adherence by DBS was lower for participants with a higher number of sex partners in the past 3months and those having a bachelor's degree or higher. More work is needed to provide clinicians with measures to assess medication adherence in diverse US populations being prescribed PrEP to support its effective use in reducing HIV acquisition in individuals and at the community level.

Non-English Language Availability of Community Health Center Websites.

For limited English-proficient (LEP) patients, the digital divide has narrowed, creating a new population of Internet users. However, language-appropriate health information is difficult to find. Community health center (CHC) websites are health information resources and their homepages are critical access points for patients. CHCs supported by Health Resources and Services Administration (HRSA) care for many LEP patients. We sought to determine the number of HRSA-supported CHC websites providing translated homepage content. In February 2017, we performed a cross-sectional analysis of the language availability of CHC homepages. The primary outcome was availability of translated content on CHC homepages. Secondary outcomes were method of translation and associations between homepage translation and CHC demographics, including percent LEP population and socioeconomic and Internet access characteristics. Of the 1400 CHC homepages, 480 (34.3%) provided translated information with half using Google Translate. We found higher odds of having a translated homepage as the LEP population by county increased [odds ratio (OR): 1.26, confidence interval (CI): 1.07-1.49, P=0.005], Internet subscription at the state level increased (OR: 1.19, CI: 1.02-1.38, P=0.026), and if health centers were in metropolitan areas (OR: 1.81, CI: 1.31-2.51, P<0.001). There was also higher likelihood of having a homepage translated to Spanish in counties with higher Spanish LEP populations (OR: 1.39, CI: 1.19-1.63, P<0.001), but this did not extend to non-Spanish languages (OR: 0.85, CI: 0.71-1.04, P=0.131). Despite increased Internet use among LEP patients and linguistic diversity of the CHC populations, there is a lack of language-appropriate content on CHC website homepages.

A clinico-epidemiological study of trachoma in urban and rural population of Sagar District Madhya Pradesh, India

Background and Objectives: Trachoma is the most common cause of infectious blindness worldwide and despite various control programs, it persists, leads to significant ocular morbidity. In this article, we aim to determine the burden of trachoma and its related risk factors amongst the urban and rural populations of Sagar, Madhya Pradesh. Materials and Methods: Rapid assessment for trachoma was conducted in urban and rural Community Health Center (CHC) of Bundelkhand Medical College, Sagar according to standard World Health Organization guidelines. An average of 60 children in rural CHC and 50 children in urban CHC aged 1-10 years was assessed clinically for signs of active trachoma with status of hygiene. Additionally, all adults above 15 years of age in these centers community were examined for evidence of trachomatous trichiasis (TT) and corneal opacity. Environmental risk factors contributing to trachoma like limited access to potable water and functional latrine, presence of animal pen, hand wash and garbage within the urban and rural CHCs populations. Results: Overall, 18 of 110 children (16.36%; confidence interval [CI]: 9.5-23.2) had evidence of follicular stage of trachoma and 12 children (10.91%; CI: 5.2-16.6) had evidence of intense trachomatous inflammation intense and scarring stages trachomatous scarring of trachoma. Nearly 19 (17.27%; CI: 10.3-24.2) children were noted to have unclean faces and 17 (15.45%; CI: 8.8-22.1) children were found with unclean hands in both the centers. TTs & TO was noted in 19 adults (1.05%; CI: 0.8-1.2). The environmental sanitation was not found to be satisfactory in the study centers mainly due to the co-habitance of people with domestic animals like pigs, hens, goats, dogs, etc., in most (66.67%) of the person households. Conclusion: Active trachoma and trachomatous trichiasis were observed actively in both urban and rural populations wherein trachoma surveillance and control measures are needed.

Food insecurity, food assistance and health status in the U.S. community health center population.

This study explored the relationship between food insecurity, food assistance, and self-reported health status among community health center (CHC) clients. Using data from the 2009 Community Health Center Patient Survey (n = 4,562), representing Federally Qualified Health Center clients, we conducted logistic regression analyses to identify the association between food insecurity and fair/poor health status, controlling for food assistance and sociodemographic factors. Approximately 1/3 of the sample (31.9%) reported fair/poor health status, 10.9% reported food insecurity, and 52.6% reported public food assistance. Multivariate analyses revealed that, among women, those with food insecurity had significantly higher odds of reporting fair/poor health status (AOR = 2.14, 95% CI 1.20-3.82). Expansion of financial access to health care via the Patient Protection and Affordable Care Act coupled with recent funding cuts to the Supplemental Nutrition Assistance Program means that CHCs play an increasingly important role in addressing food insecurity.

Rates of Hepatitis C Screening after USPSTF Birth Cohort Screening Recommendation Within a Large Community Health Center Population

Introduction: Approximately 3 million people are infected with Hepatitis C (HCV) in the U.S. Most (75%) are unaware of their viral status, causing significant morbidity and mortality due to delayed treatment. Previously, screening for HCV was recommended based on at-risk identifiers. In 2013, USPSTF released birth cohort screening recommendations for adults born between 1945-1965. Community health centers (CHCs) serve as the primary care safety-net for more than 22 million patients, most of whom are low-income and at risk of health inequities. The purpose of our study was 1) understand current screening prevalence; 2) quantify the screening gap by demographic characteristics; and 3) identify opportunities and barriers to improving screening rates across CHCs. Methods: Electronic charts for all eligible patients with an office visit between January 1, 2010 and December 31, 2013 were reviewed for a HCV screen. Demographic variables included age, race, gender, and ethnicity. Results: Among 60,949 eligible patients, 3.4% had a HCV screen. Males were more likely than females to be screened (4.6% vs. 2.7%; p≤.01); Non-Hispanics were more likely to be screened than Hispanics (6.7% vs. 2.4%; p≤.01). By race, Native Americans had the highest screening rates (8.9%), followed by blacks (3.8%), and whites (3.4%) (p≤.01). Conclusion: To our knowledge, this is the first large-scale study assessing the gap in screening based on the new HCV screening recommendations amongst CHCs. Reasons for low screening include limited awareness of guidelines, communication barriers, prioritization of HCV screening, and limited treatment options for low-income patients. Opportunities include integrating HCV screening into national clinical quality measure initiatives (e.g. meaningful use; medical home), subsidized medications, and professional/patient education. This study highlights that focused strategies are desperately needed to improve screening and treatment gaps among patients at-risk for HCV health inequities.Table 1

Perceptions of a reproductive health self-assessment tool (RH-SAT) in an urban community health center

ObjectivePhysicians face barriers to incorporating recommended contraceptive and preconception health services, including reproductive life plans (RLPs), into primary care. With promising findings from early studies of RLPs, we examined the impact of a novel reproductive health self-assessment tool (RH-SAT) on reproductive health counseling. MethodsWe created the RH-SAT for an urban community health center population and trained providers on preconception and contraceptive guidelines. Semi-structured interviews were conducted to assess perceptions of the tool with 22 patients and with all 15 providers at the clinic. Transcripts were thematically analyzed using a grounded theoretical approach. ResultsPatients and providers reported the RH-SAT presented new and thought-provoking material that promoted patient participation and facilitated counseling. ConclusionThis RH-SAT is acceptable and useful to patients and providers in an underserved urban health center. In accordance with Medical Communication Alignment Theory (MCAT), increased patient participation in reproductive health discussions may alert providers to patient interest in these topics. Practice implicationsThis study provides preliminary evidence that the RH-SAT can help overcome barriers to reproductive health counseling in primary care. Providers may wish to incorporate tools into their practice to improve communication with patients about their reproductive health goals.

Mortality by Race Among Low-Income Adults With Early-Onset Insulin-Treated Diabetes

OBJECTIVETo determine if long-term mortality rates in early-onset insulin-treated diabetes differ by race among adults of similar socioeconomic status.RESEARCH DESIGN AND METHODSA total of 391 (299 African Americans, 92 whites) mostly low-income adults 40–79 years of age with insulin-treated diabetes diagnosed before 30 years of age were recruited from community health centers in the southeast U.S. Cox models were used to estimate hazard ratios (HRs) of all-cause mortality among African Americans compared with whites. Additionally, standardized mortality ratios (SMRs) were used to compare the mortality experience of the individuals with diabetes with both national and general community health center sex- and race-specific population norms.RESULTSMean age at diabetes diagnosis and cohort entry, respectively, was 21 and 50 years in African Americans and 19 and 51 years in whites. During an average of 6.7 years of follow-up, 29% of African Americans and 35% of whites died. In multivariable analysis, no significant mortality difference was observed among African Americans compared with whites (HR 0.83 [95% CI 0.53–1.30]; P = 0.51). Compared with the race-specific U.S. general population, SMRs for those with diabetes were 5.7 in African Americans and 11.7 in whites. However, when compared with the same source population (i.e., the community health center population), SMRs were 3.5 and 3.7 in African Americans and whites, respectively.CONCLUSIONSElevated mortality persists in men and women with long duration of early-onset insulin-treated diabetes, but given survival to 40 years of age and similarly low economic status and access to health care, our data do not suggest a racial disparity in mortality.

Predictors of Diabetic Retinopathy in a Community Health Center Population

Abstract Objective. To determine the predictors of diabetic retinopathy (DR) in a Federally Qualified Health Center population of patients. Research design and methods. We retrospectively evaluated 526 patients who were screened for DR in the first year of a newly implemented telemedicine program (July 2009 to June 2010). Through this program, a total of 139 patients were diagnosed with DR, whereas 387 patients were not and then served as the comparator group. Multivariate logistic regression was used to determine the predictors of DR in this cohort of patients. Results. After multivariate analysis, four positive predictors of DR were found: insulin use (adjusted odds ratio [AOR] 1.94 [1.17–3.22]), years with diabetes (AOR 1.22 [1.16–1.28]), A1C (AOR 1.15 [1.02–1.29]), and kidney disease (AOR 5.11 [2.33–11.20]). No variables were found to decrease the odds of DR. Conclusion. Among patients with diabetes, use of insulin therapy, longer duration of diabetes, presence of kidney disease, and higher A1C values increase the odds of DR. These preliminary data may suggest patients who are at higher risk of DR to further prioritize screening for DR with a newly implemented telemedicine program.

A pilot study to gauge nutritional behavior regarding eye health in an urban community health center population

Purpose The purpose of this pilot study was to assess the knowledge base of an urban community health center population on the link between nutrition and eye health to determine current habits and then utilize this information for an educational intervention. Methods A survey was given to 150 patients of an ethnically mixed, lower socioeconomic cohort. The data served as a guide for a focus group. An exit survey and a 1-month follow-up call were used to assess the success of the group. Results Approximately 83% of respondents were aware of a link between healthy food and healthy eyes. Fewer knew of the ocular benefits of specific nutrients such as omega-3 (42.7%) or vitamin C, vitamin E, lutein, and zeaxanthin (32.7%). Only 60% knew smoking could negatively affect eyesight. The largest age group was older than 55 years (26%), and the largest racial group was black (31.3%). The majority (64.7%) ate fish 1 to 2 days a week, and 40% ate green leafy vegetables 3 to 4 days a week. In the cohort, 73.3% reported they would take supplements or change eating habits to improve ocular health. Only 8% who participated in the survey attended the focus group. At the 1-month follow-up, 75% said they had changed their eating habits based on the information presented. Conclusions Although educating a community health center population about nutrition and ocular health can have a positive effect on patient behaviors, it is difficult, even with incentives, to engage this cohort in participating in focus groups aimed at changing behavior.

Reducing Visual Health Disparities in At-Risk Community Health Center Populations

Community health centers (CHCs) have an impressive record of addressing health disparities through consistently delivering high-quality and affordable care in a culturally competent manner, while also producing cost savings to the nation's healthcare system. Thus CHCs are optimally positioned to reduce visual health disparities and improve visual health outcomes by being included in the primary care services that they deliver. An estimated three million health center patients have risk factors for vision disorders and eye disease, yet a recent policy briefing survey conducted by The George Washington University reported that about 20 percent of centers provide on-site eye and vision care.

Characteristics of Frequent Attenders At a Community Health Center

As high utilizers of health care resources, frequent attenders to medical practices pose a significant issue for primary health care. Studies documenting content of visits and characteristics of frequent attenders have paid limited attention to community health center populations. This study profiles these high utilizers comparing them to non-frequent attenders. Through medical record abstraction, retrospective and longitudinal patient data were obtained for a 30-month time period for 382 established patients. Older patients 45 to 64 years (OR = 1.85; 95% CI: 0.92, 3.70) and Medicaid recipients (OR = 3.22; 95% CI: 1.54, 6.72) were more likely to be frequent attenders. Patients residing furthest away from the CHC were also the most frequent of attenders (OR = 3.68; 95% CI: 1.22, 11.13), as were those with a diagnosis of diabetes (OR = 5.03; 95% CI: 2.17, 11.70) or depression (OR = 1.85; 95% CI: 0.96, 3.56). Patients who used the Emergency Department more (OR = 1.54; 95% CI: 1.23,1.91) had the highest number of visits, although those patients who missed more appointments as a proportion of the number of scheduled appointments were less likely to be frequent attenders (OR = 0.49; 95% CI: 0.36, 0.66). Through developing interventions such as customized social report cards and applying elements of the Chronic Care Model, these results can help administrators and policy makers ensure that frequent attenders are cared for adequately and that safety net providers' resources are appropriate to the tasks demanded of them.

Colorectal cancer screening among a sample of community health center attendees.

To determine the rate of colorectal cancer screening in patients attending a sample of community health centers, medical records of 1,176 patients from eight community health centers were abstracted. Among the patients studied, 43.8% of patients had undergone at least one of the three colorectal screening tests (fecal occult blood test, colonoscopy, or flexible sigmoidoscopy) in the recommended interval. Colorectal screening in this community health center population was predicted by male gender, being African American, older age, having a greater number of chronic illnesses, a family history of colorectal cancer, and by having engaged in other preventive cancer screenings in the previous year. Although screening rates certainly were not optimal, they compare favorably to rates reported in national surveys for the general population. Our results add to a growing body of evidence that community health centers, despite serving disadvantaged populations, are able to deliver preventive care at rates comparable to health facilities used by the general population.

The impact of tailored interventions on a community health center population

We conducted a 4-year randomized study in a community health center that serves primarily low income Blacks in Durham, North Carolina. Patients (1318 at baseline) were assigned randomly to one of three study groups: provider prompting intervention alone, provider prompting and tailored print materials or the previous group and tailored telephone counseling. The purpose of the study was to determine whether increasingly intensive, tailored print and telephone interventions also were increasingly effective in promoting adherence to mammograms, Pap tests and overall cancer screening compliance. Thus, the combination of tailored print interventions (print and telephone) should have been more effective than the provider prompting intervention alone, or the print intervention and prompting combination. This is one of the few studies to examine a measure of overall cancer screening compliance and to assess the benefit of combinations of tailored interventions in promoting adherence to cancer screening. Patients gave extremely high ratings to the interventions. At the bivariate level, we found a significant effect of the most intensive group (provider prompting intervention, tailored print communications and tailored telephone counseling) on Pap test compliance ( P=0.05) and borderline significance at the multivariate level ( P=0.06) as well on overall screening compliance ( P=0.06). There was not a significant effect on mammography, probably because a majority of the patients were receiving regular mammograms. We also found some important subgroup differences. For example, a larger proportion of women reported Pap tests in the tailored print and counseling group when they believed the materials were `meant for me.' These results show that a combination of tailored interventions may have potential for reaching the women who have too often been labeled the `hard to reach.'

Readiness to change smoking behavior in a community health center population.

This study examines predictors of readiness to change smoking behavior in a sample of smokers who receive care at a community health center that serves a predominantly low income African American population. Prior to initiating interventions we conducted a telephone survey with a random sample of 1318 adult users who had visited the center in the last 18 months; 379 (28.8%) were current smokers (40.3% of males, 23.9% of females, 42.7% of Whites, and 25.3%, of African Americans). Multiple logistic regression analysis showed nine factors significantly associated with readiness to change smoking behavior: male gender; a previous quit attempt; a perception of risk of lung cancer from smoking; greater desire to quit smoking; a perception that smoking bothers others; doctor advice to stop smoking at last health visit; records kept for scheduling doctor appointments; thinking that losing a pleasure would not be a problem if quit smoking; and poorer self-reported health status. These findings provide direction for developing interventions for similar low income, high risk populations. The results indicate that it may be useful to heighten awareness of the risks of smoking and to assure that smokers receive clear quit smoking messages from their providers. Women need special attention since they are less ready to quit than men.

Cancer Screening Practices Among Women in a Community Health Center Population

Cancer takes a disproportionate toll on disadvantaged Americans. Poverty and low education are risk factors for underuse of cancer screening. In this report, we discuss predictors of adherence to cancer screening (mammography, clinical breast exam [CBE], and Pap tests) among 926 women who receive care at a community health center that serves a predominantly low-income and minority population. We examine predictors for each of the tests and for a composite measure of overall cancer screening test compliance. In studying multiple screening behaviors we not only investigate factors associated with each individual behavior, but we also identify consistently effective factors across several behaviors. The analysis indicates consistent effects of age, education, and insurance status on cancer screening. In addition, decisional balance, a measure of a person's beliefs about the pros and cons of complying with the screening test, is associated strongly with adherence. We have extended earlier findings about the positive relationship between decisional balance and mammography to include decisional balance and Pap tests, as well. This finding suggests that behavioral interventions that target decisional balance can effectively promote adherence to cancer screening tests.

Feasibility Study of a Head and Neck (Upper Aero-Digestive Tract) Cancer Examination&lt;xref ref-type="fn" rid="FN2"&gt;2&lt;/xref&gt;

Nearly all of the requirements for a cancer screening program can be met for head and neck--upper aero-digestive tract (UADT)--cancers. These UADT squamous cancers have a clearly definable high-risk group (smokers, greater than or equal to 40 yr), known etiology (tobacco and alcohol), identifiable premalignant lesions, a high prevalence rate worldwide, and high curability with "early" diagnosis. However, a need exists for an efficient detection examination suitable for physicians and dentists alike. Such an examination was designed and field tested as a feasibility study. The examination consisted of a six-step, dentist-oriented, site-targeted, 10-minute procedure, including the use of a fiberoptic pharyngoscope. Two practicing dentists were instructed in the procedure and used it on a randomly selected, high-risk Health America, Inc.--Park DuValle Community Health Center population, who were voluntary responders to a questionnaire and a phone call. Analysis of results showed easy and reproducible teachability, a high degree of acceptance by dentists and examinees, accuracy, and low cost. Associated findings were the following: Of 6,206 respondents, ages 40 and over, 27% were current smokers; 29% were ex-smokers; and 33% never smoked. Of invited current and ex-smokers, ages 40 and over, 51% appeared for a single examination. Compliance emerged as the major problem. The feasibility demonstrated in this study appears to justify a larger, controlled investigation.

Compliance in a community health center population.

Compliance in a community health center population.