The behavioral theory constructs most often used to study mammography utilization-perceived benefit, perceived susceptibility, self-efficacy, intention, and subjective norms-have neither been developed nor sufficiently tested among diverse racial/ethnic subgroups. The authors explored these constructs and their underlying assumptions relating to the social context of Filipina and Latina women. The mixed-methods study included testing construct measures in the multilingual surveys of a concurrent intervention study of 1,463 women from five ethnic groups. social context and individual screening behavior. In-depth interviews were conducted with 11 key informant scholars, 13 community gatekeepers, and 29 lay women, and a supplemental study videotaped and interviewed 9 mother-daughter dyads. Three social context domains emerged: relational culture, social capital, and transculturation and transmigration. The meaning and appropriateness of the five behavioral constructs were analyzed in relation to these domains. In contradistinction to tenets of behavioral theory, the authors found that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs; contextual influences, synthesized from multiple perspectives, can operate at an unconscious level not accessible to the individual; and contextual influences are dynamic, contingent on distal and proximal forces coming together in a given moment and are thus not consistent with an exclusive focus at the individual level. This article describes the study methods, summarizes main findings, and previews the detailed results presented in the other articles in this issue.Keywords behavioral theory; culture; social context; mixed methods; mammographyThe compass is a device whose function is inseparable from its context of origin, the planet Earth. Based on the concept of a magnetic north, a compass would not be useful, for example, on Mars with that planet's multiple magnetic fields. According to one NASA scientist, "If you were a boy scout with a compass on Mars, you would be lost" (J. E. P. Connerney, personal communication, August 22, 2003). Much of health behavior theory, anchored in the realm of individual cognition, has been developed and tested predominantly among university students (Ajzen, 1991) and then applied far more broadly. The bases for the theories are commonalities within groups in factors that influence behavior and the consistency and predictability of relationships among those factors. But these theoretically derived patterns do not operate in the same way for all people. Instead, when used in multicultural settings and among those of diverse socioeconomic backgrounds, this body of work can be likened to "a compass on Mars," a navigational tool that is designed for a set of forces and principles likely to operate differently-or not at all-in another milieu. Yet there is an implied universality in the way health behavior theories and their constructs are used. Despite the current emphasis on dissemin...

This study of mother-adult daughter communication uses qualitative methods to explore the appropriateness of including adult daughters as referents in the measurement of subjective norms (a behavioral theory construct) related to the use of mammography and other health-related tests and services. The methods were chosen to approximate as closely as possible the mother-adult daughter relationship in the context of daily life. This inductive approach contrasts with the deductive origins of the construct. A sample of nine Mexican and Filipina immigrant and U.S.-born mothers and their adult daughters was recruited. Data were collected in two phases: (a) videotaped observations of mother-daughter dyads discussing health-related topics and (b) follow-up interviews designed to obtain an emic (insider) perspective of the videotaped interaction. Results show that adult daughters influence their mothers' ability to navigate the health care system and contribute to health-related decision making and behavior, suggesting that it may be appropriate to include adult daughters in the assessment of subjective norms.Keywords mother-daughter relationship; breast cancer screening; subjective norms Breast cancer is the most commonly diagnosed type of cancer among Mexican and Filipina immigrant and U.S.-born women in California (California Cancer Registry, 2007). Compared to Whites, these women are more likely to be diagnosed at later stages and are more likely to die from this disease (American Cancer Society, 2008; California Cancer Registry, 2007). Latestage diagnosis is attributed in part to lack of participation in early detection behaviors such as mammography screening, access to salient information and education necessary for optimal health choices, and successful navigation of the medical care system (Borrayo & Jenkins, © 2009 by SOPHE Address correspondence to Pamela K. Washington, University of California, San Francisco, 1450 3rd Street, MC 0128, PO Box 589001, San Francisco, phone: (415) 385-6862; pamela.k.washington@gmail.com.. 2001). Health behavior research has developed a body of theory designed to explain and to predict practices such as the use of screening mammography and to inform interventions to increase screening (Rakowski & Breslau, 2004). However, concerns are frequently raised about the lack of attention to culture and social context in these theories and the extent to which the theories are meaningful among diverse communities (Kagawa-Singer, 2000). NIH Public AccessThe current research arose from our study titled Behavioral Constructs and Culture in Cancer Screening (3Cs), a mixed-method (inductive qualitative and deductive quantitative) intensive assessment of the cultural appropriateness of the five behavioral theory constructs most commonly used to explain breast cancer screening and to inform interventions to promote mammography: perceived threat, perceived benefits, intention, self-efficacy, and subjective norms. This analysis explores the specific case of mother-adult daughter comm...

This article reviews evidence on hospitals' and health systems' impacts on community health improvement. We begin with an overview of the history of community benefit and then discuss the lack of a widely accepted definition and measurement of community benefit activities as well as the expectations and accountability of tax-exempt not-for-profit hospitals and health systems in community initiatives. We highlight the approaches of two systems and identify strategic, cultural, technical, and structural challenges associated with increasing community benefit and health-improvement activities. We conclude by offering recommendations for policy and practice.

77 Background: Beginning in 2015, the National Accreditation Program for Breast Centers (NAPBC) requires accredited facilities to provide Survivorship Care Plans (SCP) to breast cancer patients treated with curative intent. Here we describe lessons learned with the use of telemedicine in the delivery of SCPs at Kaiser Permanente East Bay. Methods: SCP implementation followed a two-step process: patients who are diagnosed and complete treatment in 2016 are given a SCP at their last surgical or medical oncology appointment (YTD, n=8); 2) patients diagnosed in 2015 who completed treatment in 2015-2016 were contacted by a physician assistant and offered an appointment by telephone or in-person to deliver the care plan (n=152). Both clinic and telemedicine appointments consist of a detailed review of treatment received, post-treatment follow-up care, discussion of health education resources, and provision of referrals as appropriate. Patients also have the opportunity to ask questions about treatment and follow-up care. Results: Among patients diagnosed in 2015 who were offered a TAV or in-person visit, 44.0% preferred a telephone appointment. Actual appointment duration ranged from 10 to 30 minutes. Lack of co-payment and fees associated with transportation as well as loss of income due to taking time off work were the primary factors cited choosing telemedicine over in-person clinic appointments. Interestingly, no differences in member satisfaction scores for in-person vs. telephone visits were observed. Conclusions: Findings suggest telemedicine may be effective in the delivery of SCPs. Similar to rural settings, use of telemedicine in urban settings has a unique capacity to increase service to breast cancer patients.

231 Background: An electronic surveillance database was created to monitor patients for five years following curative treatment for colorectal cancer. The database serves as an alert system and data repository for imaging, serology, and colonoscopy surveillance tests preloaded for each patient in accordance with NCCN guidelines based upon TNM cancer staging. Methods: The chiefs of Surgery and Oncology defined end-user specifications for the Filemaker Pro database. Key features include preloaded tests based upon NCCN guidelines, expected date of completion, and exam results. The database also tracks tests overdue or ordered but not yet obtained. A new workflow consisting of a monthly report of new colorectal cases from Pathology and a meeting of surgical and oncology physicians and physician assistants to review the report, update the database with new patients, and identify patients due for follow-up was established. Results: 250 cases are currently being monitored. By 2019, the database is poised to be the largest in Kaiser Permanente (KP) dedicated to active surveillance following colorectal cancer treatment. Conclusions: In addition to ensuring that individual patients obtain surveillance tests at the intervals based upon national guidelines for each TNM classification, the database can also be used to assess surveillance results and recurrence rates. The database format has also proven invaluable for other services. The Thoracic service recently created a database modeled after colorectal surveillance to begin tracking lung cancer patients. Beginning in 2016, the colorectal database became a Regional KP initiative and will be incorporated into HealthConnect (electronic medical record).

202 Background: The Commission on Cancer (CoC) requires accredited facilities to evaluate cancer patients for distress a minimum of one time at a pivotal visit during their cancer journey. Here we describe lessons learned with the implementation of distress testing at the Kaiser Permanente Oakland Medical Center. Methods: The implementation timeframe was April to December 2015. Testing guidelines were created including a definition of pivotal visit. Use of the validated NCCN Distress Thermometer was approved by the East Bay Comprehensive Cancer Committee. A workflow was developed whereby a paper copy of the tool was given to patients at their first cycle of chemotherapy. A RN Case Manager or Social Worker then triaged completed forms. Referrals were made by the case manager, social worker, or attending physician based on patients’ self-reported disposition and level of distress. This information was subsequently entered into patients’ electronic medical record. Completed forms were then entered into an Excel database to facilitate data analysis. Results: Overall, patients were receptive to testing. 232 tests were completed. 55.7% (n = 125) self-reported a score between 0 to 3 (low distress). Worry, fatigue, problems with sleep, financial issues, and problems with transportation were the most common stressors. 42.7% patients received a referral. Referrals to a MSW or RN Case Manager were most common. Interestingly, there were no referrals to psychiatric services. Conclusions: Careful consideration to workflow processes be must factored into implementing distress testing. Findings from our 2015 pilot informed the expansion of testing in all outpatient cancer clinics in 2016.

177 Background: There is strong evidence that physical activity mitigates negative psychosocial effects and sequelae associated with adjuvant chemotherapy among cancer survivors. Given the many benefits of physical activity in this population, it is important to understand the factors that influence continued participation post diagnosis. One possible determinant that has received little attention to date is the influence of social support. This study is unique in that it is the first to explore the role of social support for physical activity among young survivors of breast cancer through the use of mixed methods. Methods: Survey data (n = 273) were used to determine actual levels of moderate and vigorous physical activity. These data were subsequently used to identify women of interest to participate in face-to-face qualitative interviews. Semi-structured interviews (n = 31) were conducted with a subset of women from the quantitative sample. Participants were Bay Area women who were age 55 or less and premenopausal at the time of diagnosis and who also received adjuvant chemotherapy. Following qualitative analyses, hypotheses were developed to test the association between social support and obtaining recommended levels of physical activity through the use of logistic regression analyses using a sample of 273 women. Results: Qualitative analyses indicated that women who have a partner with whom they engage in physical activity are more likely to adopt and maintain physical activity behaviors over time. Regression analyses provide evidence that women who have support specifically for physical activity are more likely to meet recommended activity guidelines (b = .030, OR = 1.030 per unit of scale, p = .003, C.I. = 1.01 – 1.05). Conclusions: When considering correlates of physical activity, social support specific to physical activity may be important or even pivotal in assisting survivors to adopt and/or maintain participation in a given activity at recommended levels.

75 Background: Beginning in 2015, the Commission on Cancer (CoC) requires accredited facilities to provide eligible patients with a Survivorship Care Plan (SCP). While the benefits of SCPs in the quality and continuity of care are well documented in the literature, there is a dearth of information regarding best practices for implementation. Here we describe lessons learned in the development of a SCP at the Kaiser Permanente Oakland Medical Center (OMC). Methods: Adult patients with a diagnosis of stage 1-3 cancer who received curative treatment were identified by the Northern California Kaiser Permanente Cancer Registrar. Consistent with CoC guidelines for 2015, 10% of all eligible patients (n = 1160) are required to receive a SCP 3-6 months following active treatment. Thus, a total of 116 patients with a diagnosis of breast, colon, lung/bronchus, prostate, or melanoma of the skin at OMC were given a SCP. The implementation timeframe was July to December 2015. Use of a modified ASCO template was recommended for its rigor across the required domains. Following template approval by the Comprehensive Cancer Committee (CCC), a workflow consisting of identifying patients’ last treatment and manual data entry by a Physician Assistant (PA) as well as automated data population in the Kaiser Permanente electronic medical record system was developed. Completed SCPs were then provided to patients during a clinic visit. The workflow process was refined as appropriate based on feedback from staff & physicians. Results: Depending on the scope of treatment, mean preparation time is 10 minutes per plan using specific diagnosis codes via an electronic medical record system. Further, it takes 30 minutes for a PA or other Ancillary personnel to discuss the plan with a patient. Patient response was generally positive upon receipt of the plan. Conclusions: Successful SCP implementation is contingent upon engagement from multiple stakeholders. Per standard CoC 3.3, the implementation rate will increase annually from 10% in 2015 to 100% by 2019. Careful consideration to workflow processes and resources planning be must factored into achieving 100% compliance across all disease sites by 2019.