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Article is attached in pdf formReview ethical principles learned this week. When you select your article, consider the possible ethical issues in the research process: sampling, methodology, data collection, etc. The focus should be on the research study, not the health issue.Write a 700- to 1,050-word paper addressing the following:
Summarize the research study.
Identify possible ethical issues within the research study.
Explain how the ethical concerns can influence the research outcomes.
Define validity as it relates to the research study.

Hint: Review previous learning activities for key validity concepts, including internal and external validity and associated threats to validity.

Discuss the importance of research design validity and how research bias can impact validity.

Hint: Research how design validity and instrumentation validity are different concepts.

Discuss how stakeholders can externally influence health care research.

Include possible ethical concerns.

Cite at least 3 peer-reviewed scholarly references.
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J Community Health (2016) 41:650–657
DOI 10.1007/s10900-015-0141-y
ORIGINAL PAPER
Reach of the Montana Cancer Control Program to Women
with Disabilities
Katherine Froehlich-Grobe1 • William C. Shropshire2 • Heather Zimmerman3
Jim Van Brunt3 • Andrea Betts1

Published online: 23 December 2015
Ó Springer Science+Business Media New York 2015
Abstract Women with disabilities have lower screening
rates for breast and cervical cancer with some evidence
suggesting that people with disabilities experience higher
cancer mortality and may receive a different course of
treatment. This study examined whether women with and
without disabilities using Montana Cancer Control Program (MCCP) differ in use of breast (BCS) and cervical
(CCS) screening services, receipt of and follow up for
inconclusive or abnormal results, and compliance with
BCS and CCS US Preventive Services Task Force recommendations. Study participants were women eligible for
MCCP screening services between November 2012 and
October 2014, with eligibility based on insurance status
(underinsured/no insurance), income requirements (200 %
poverty based on income/household size), and age. The data
derive from participant self-report (demographic, disability,
and health history including previous mammogram or
Papanicolaou test) and MCCP records of screening tests
(clinical breast exam, mammogram, or Pap test), results,
and follow up visits. About 11.5 % of MCCP participants
reported having a disability. MCCP recipients with a disability were significantly older, more likely to be non-Hispanic White, and more likely to have poor health profiles.
& Katherine Froehlich-Grobe
kfgrobe@yahoo.com
1
Dallas Regional Campus, Health Promotion/Behavioral
Sciences Department, University of Texas School of Public
Health, Dallas, TX, USA
2

Dallas Regional Campus, Epidemiology, Human Genetics,
and Environmental Sciences Department, University of
Texas School of Public Health, Dallas, TX, USA
3
Chronic Disease Prevention and Health Promotion Bureau,
Public Health and Safety Division, Montana Department of
Public Health and Human Services, Helena, MT, USA
123
Disability status did not affect use of MCCP screening
services, screening outcome, or follow up for inconclusive
or abnormal results. However, women with disability had
significantly lower BCS and CCS compliance (based on US
Preventive Task Force guidelines) than women without
disability, which persisted in adjusted analyses controlling
for other significant factors. The MCCP is reaching un/underinsured Montana women with disabilities. While disability status in this sample was not related to use of MCCP
services or screening outcome, MCCP recipients with disabilities have significantly lower BCS and CCS compliance.
Efforts to increase compliance for un/underinsured Montana
women with a disability are warranted.
Keywords Cancer screening  Women with disability 
Health disparity
Introduction
Nearly 20 % of Americans report living with disability [1],
yet this considerable segment of the population experiences
pervasive health inequalities [2]. Persons with disabilities
experience a disproportionate burden of health risks,
inaccessible health care environments that restrict access to
care, and poor outcomes that are at least partially preventable. One emerging area of concern related to these
inequalities is disparities in cancer screening and outcomes
for women with disabilities.
National data have established that women with disabilities are less likely to receive breast and cervical cancer
screening at recommended intervals [3–6]. Furthermore
persons with disabilities experience higher cancer mortality
and may receive a different course of treatment than persons without disabilities [7]. A study conducted by
J Community Health (2016) 41:650–657
McCarthy et al. [8] reported that women with disabilities
who receive Medicare and are diagnosed with stage I to
IIIA breast cancer: (1) experience higher breast-cancer
mortality and all-cause mortality; (2) are less likely to
receive breast-conserving surgery; and (3) are less likely to
receive standard treatments after breast-conserving surgery
[8]. Examining the same outcomes using Surveillance,
Epidemiology, and End Results (SEER) data from the
National Cancer Institute, Roetzheim et al. [9] found
women with disabilities who had a fee for service Medicare
plan had worse outcomes than those with a managed care
plan. Thus, early detection may be of particular importance
for women with disabilities who are underinsured.
Healthy People 2020 includes explicit objectives to
reduce barriers to health care among persons with disabilities (see http://www.healthypeople.gov/2020/topicsobjectives/topic/disability-and-health). Reported barriers to
screening among women with disabilities include cost,
transportation, lack of accessible facilities, and lack of
doctor recommendation [10–12]. Furthermore, emerging
research suggests that predominantly rural geographic
settings may present greater disparities in screening utilization than more densely populated ones [13–15]. However, most published evidence demonstrating disabilityrelated disparities in clinical preventive service use,
including cancer screening, is drawn from large national
surveys, such as the Behavioral Risk Factor Surveillance
System and Medical Expenditure Panel Survey [6].
Given the emerging evidence regarding inequalities in
cancer screening and care for women with disabilities, this
study evaluates reach to women with disabilities by a statebased cancer screening program that targets providing cancer screening to underinsured women in a rural state. The
specific objectives of this paper were to examine whether
Montana Cancer Control Program (MCCP) clients with and
without disabilities differed in their (1) use of cancer
screening services, (2) compliance with national breast and
cervical cancer screening recommendations, and (3) receipt
of and follow up for inconclusive or abnormal screening
results. In addition, the study examined what demographic or
health history factors were associated with compliance with
US Preventive Services Task Force (USPSTF) recommendations the relationship between disability status and compliance in unadjusted and adjusted models.
Methods
Data Source
Primary data collection occurred within the Montana
Department of Public Health and Human Services
(DPHHS). Since 1996 the MCCP has provided colorectal
651
cancer, breast cancer, and cervical cancer screening to
uninsured or underinsured Montanans who meet both age
and income requirements. The MCCP provides cancer
screening services by providing direct payment to service
providers who conduct the service. Only data from breast
and cervical cancer screening participants were used for
this analysis. The MCCP collected self-reported and
screening result data for all screening program participants.
Sample
The sample includes women eligible for the MCCP from
November 1st, 2012 through October 31st, 2014. The
MCCP’s eligibility requirements for breast cancer screening (BCS) were women 50–64 years of age, plus 65 and
older if not enrolled in Medicare B (coverage for medically
necessary services), who were uninsured or underinsured,
and earned below 200 % of the federal poverty level based
on number of residents in household and total household
income. Women eligible for cervical cancer screening
(CCS) included those between the ages of 21–64 years of
age, plus those 65 and older if at high risk for cervical
cancer and not enrolled in Medicare B with the same
insurance and income threshold requirements as for breast
cancer screening. Eligibility exceptions for age, income,
and insurance guidelines were made based on additional
factors such as cancer risk and/or previous history. Medicare B beneficiaries are excluded as Medicare B covers two
types of services: (1) preventive services to prevent illness
or detect a disease or (2) medically necessary services or
supplies for diagnosis or treatment of a medical condition.
Data
Self-reported data included basic demographic information
(e.g. age, race, ethnicity, residence, health insurance status), plus recipient’s self-reported health history and health
behavior information [e.g., previous mammogram and
Papanicolaou (i.e. ‘‘Pap’’) test, history of breast problems
and hysterectomy (the nature of the problems or procedure
were not further specified), and tobacco use].
Items to determine disability status for this study were
based upon the six disability types measured in the
American Community Survey (ACS): (1) hearing difficulty; (2) vision difficulty; (3) cognitive difficulty; (4)
ambulatory difficulty; (5) self-care difficulty; and (6)
independent living difficulty (see https://www.census.gov/
people/disability/methodology/acs.html).
This
study
defined a woman as having a disability if she indicated at
any time during her use of screening services experiencing
one or more of these limitations. Women also had the
option to decline to answer these questions.
123
652
Compliance for BCS and CCS was based on the most
current guidelines (as of July 2015) published by the
USPSTF [16, 17] The USPSTF recommends that women
between the ages of 50–74 receive a mammogram biennially and that women 21–65 years old receive a Papanicolaou (Pap test) at least once every 3 years or once every
5 years if a human papillomavirus (HPV) test is included in
conjunction with the Pap test. This study determined
screening compliance based on women’s age at their initial
visit (those 50–74), report of having a previous mammogram/Pap test history in the last 2 (mammogram) or 3 years
(Pap smear), and/or receipt of a mammogram and/or Pap
test at the MCCP. We excluded women that were not
within the recommended age range as well as cases in
which we suspected information bias or systematic error
may be present (e.g. inconsistent reporting of previous
mammogram and/or Pap test). Additional analyses examined differences based on disability status for (1) the proportion of women received an abnormal or inconclusive
result and (2) those who did not follow up within 90 days
after receiving an abnormal result.
Statistical Analysis
Primary statistical analysis was performed on IBM
SPSS.21 and 95 % confidence intervals for binomial proportions were calculated using STATA 13.0. Basic
descriptive statistics were calculated (i.e. mean, frequency)
for demographic and health behavior/history data. An
independent sample t test examined differences in age by
disability status and cancer screening compliance. Chi
square tests measured differences by disability and cancer
screening compliance for categorical variables (i.e. race/
ethnicity, tobacco use, breast problems, hysterectomy). The
coefficient Cramer’s V was used to measure effect size for
analyzing two nominal variables. Both unadjusted and
adjusted logistic regressions were conducted to examine
whether disability status was significantly related to compliance for BCS and CCS. Covariates identified in the
multinomial logistic regression included age at first visit,
race/ethnicity, health insurance status, tobacco use, breast
problem status (for BCS compliance), and hysterectomy
status (for CCS compliance).
Results
The dataset included 7521 women who enrolled in MCCP
services during this 2 years time period (Table 1). MCCP
participants tended to be middle-aged (mean = 51.2 ±
8.8 years), non-Hispanic White (71.8 %) and non-Hispanic
Native American (19.5 %) women. Most were uninsured
(98.6 %). In terms of their history of health problems and
123
J Community Health (2016) 41:650–657
behaviors, 8.8 % reported having breast problems, 16.2 %
reported having had a previous hysterectomy, and 16.6 %
reported using tobacco. Eight-hundred sixty four of the
7521 women (11.5 %) reported one or more disabilities,
distributed as follows: 145 women reported a hearing difficulty (1.9 %), 62 a vision difficulty (0.8 %), 424 a cognitive difficulty (5.6 %), 465 an ambulatory difficulty
(6.2 %), 122 a self-care difficulty (1.6 %), and 237 an
independent living difficulty (3.2 %).
Table 1 also presents these data by disability status.
Women with disabilities were significantly older (52.5 ±
8.2 years) than women without disabilities (51.0 ± 8.8
years; p 0.001). Women with disabilities also had different distributions based on race/ethnicity than women
without disabilities (v2 = 11.69; p 0.001). Women with
disabilities were also significantly more likely than those
without disabilities to report using tobacco (29.7 vs.
14.9 %; p 0.001) with a Cramer’s V of 0.128, indicating
a moderate effect size, and to report having health
problems.
No significant differences were detected between
women with and without disabilities in their use of MCCP
screening services for having a clinical breast examination
(CBEs), a mammogram, or a Pap test (Table 1). Most
(92.5 %) MCCP users received either a CBE or mammogram with the MCCP, over three-quarters (78.7 %) had
a mammogram, and about half (51.9 %) had a Pap test.
There were also not significant differences between
women with and without disability for receipt of an
abnormal or inconclusive result for BCS or CCS that
required follow up (19.0 vs. 17.9 % and 21.2 vs. 19.6 %
respectively) or for rates of failing to follow-up within
90 days (3.2 vs. 1.9 % vs. 0.6 % vs. 0.5 %). While not
significant, there was a trend for women with disabilities
to have slightly higher rates of BCS and CCS results that
require follow up.
Compliance rates with the USPSTF guidelines (Table 1)
among the full sample were low, with about half (51.9 %)
of MCCP enrollees compliant with BCS and less than half
(43.5 %) CCS compliant. However, compliance rates for
both BCS and CCS were significantly lower among women
with disabilities. Women with disabilities were less likely
to be BCS compliant (45.0 %; 95 % CI 40.9, 49.1 %) than
women without disabilities (52.9 %; 95 % CI 51.3,
54.4 %) (v2 = 12.735; p 0.001). For CCS compliance,
women with disabilities were significantly less compliant
(37.2 %; 95 % CI 33.9, 40.5 %) than women without disabilities (44.3 %; 95 % CI 43.1, 45.5 %) (v2 = 15.688;
p 0.001). Table 2 presents results from analyses that
examined whether demographic and health history factors
were related to screening compliance. Women compliant
with both the BCS and CCS guidelines were significantly
younger (BCS: compliant 55.7 ± 4.8 years; non-compliant
J Community Health (2016) 41:650–657
653
Table 1 Demographic, health behavior, health history, and screening compliance by disability status of women in MT Cancer Control
Prevention (MCCP) program: November 2012–October 2014
Variables
Total
n = 7521
Disability
n = 864
No disability
n = 6657
Significance
Age at first visit (mean, SD)
51.2 ± 8.8
52.5 ± 8.2
51.0 ± 8.8
p 0.001b
Cramer’s Va
v2 = 11.69**
Race/ethnicity (%)
White, non-Hispanic
5374 (71.8)
635 (74.2)
4739 (71.4)
Native American, non-Hispanic
1457 (19.5)
139 (16.2)
1318 (19.9)
Hispanic, any race (including multiracial)
248 (3.3)
22 (2.6)
226 (3.4)
Any race (including multiracial), nonHispanic
410 (5.5)
60 (7.0)
350 (5.3)
106 (1.4)
7 (0.8)
99 (1.5)
NSc
Tobacco use
1247 (16.6)
257 (29.7)
990 (14.9)
v2 = 122.321***
0.128
Breast problems
663 (8.8)
111 (12.8)
552 (8.3)
v2 = 19.741***
0.051
Hysterectomy
1219 (16.2)
168 (19.4)
1051 (15.8)
v2 = 7.529**
0.032
BCS (CBEb and/or mammogram)
6959 (92.5)
796 (92.1)
6163 (92.6)
NSc
BCS (mammogram only)
5918 (78.7)
691 (78.7)
5227 (78.5)
NSc
CCS (Pap test only)
3906 (51.9)
457 (52.9)
3449 (51.8)
NSc
BCS and CCS (CBE and/or Mam ? Pap
test)
3403 (45.2)
393 (45.5)
3010 (45.2)
NSc
1279 (18.0)
154 (19.0)
1125 (17.9)
NSc
26 (2.0)
5 (3.2)
21 (1.9)
NSc
Result requires follow-up
1442 (19.6)
179 (21.2)
1263 (19.6)
NSc
Failed to follow-up
7 (0.5)
1 (0.6)
6 (0.5)
NSc
Health insurance (%)
Health behavior/history (%)
Received MCCP screening (C1 visit) (%)
BCS results (N = 7103; %)
Result requires follow-up
Failed to follow-up
d
CCS results (n = 7341; %)
BCS compliance (%; 95 % CI)
Screening compliance
Mammogram, every 2 years, women
50–74 yearse
CCS Compliance (%; 95 % CI)
Total n = 4634
Disability n = 589
No disability
n = 4045
Significance
Cramer’s V
2403 (51.9; 50.4,
53.3)
265 (45.0; 40.9,
49.1)
2138 (52.9; 51.3,
54.4)
v2 = 12.735***
0.052
Significance
Cramer’s V
Screening compliance
Total n = 7416
Pap test, every 3 years, women
21–65 years olde
a
3227 (43.5; 42.4, 44.7)
Disability n = 850
316 (37.2; 33.9, 40.5)
No disability n = 6566
2911 (44.3; 43.1, 45.5)
2
v = 15.688***
0.046
Cramer V interpretations: only can be used to determine relative differences in association
b
Independent sample T test
c
Non significant
d
Analysis conducted on 1287
e
Based on most recent USPSTF recommendations
Pearson Chi Square: * p .05; ** p .01; *** p .001
58.0 ± 3.9 years; p 0.001 | CCS: compliant 50.1 ± 8.9
years; non-compliant 51.9 ± 8.3 years; p 0.001) and
significantly more likely to have insurance (BCS:
v2 = 8.964; p 0.01 | CCS: v2 = 17.97; p 0.001).
Compliance status also differed significantly by race/ethnicity distribution (BCS: v2 = 11.170; p 0.05 | CCS:
123
654
J Community Health (2016) 41:650–657
Table 2 Demographics and health behaviors/history by cancer screening compliance of women in MT Cancer Control Prevention (MCCP)
Program: November 2012–October 2014
BCS Compliance n = 4634a
Variables
Age at first visit
(mean ± SD)
CCS Compliance n = 7416b
Yes
No
Significance
55.7 ± 4.8
58.0 ± 3.9
p 0.001c
Cramer’s
Vg
Yes
No
Significance
50.1 ± 8.9
51.9 ± 8.3
p 0.001c
v2 = 10.570*
Race/ethnicity (%)
Cramer’s
Vg
v2 = 47.429***
White, non-Hispanic
1809
(75.7)
1598
(72.0)
2444
(76.0)
2879
(69.1)
Native American, nonHispanic
409 (17.1)
456 (20.6)
508 (15.8)
905 (21.7)
Hispanic, any race
including multiracial
69 (2.9)
56 (2.5)
101 (3.1)
143 (3.4)
Non-Hispanic, any race
including multir
104 (4.3)
108 (4.9)
163 (5.1)
241 (5.8)
42 (1.7)
17 (0.8)
v2 = 8.945**
66 (2.0)
37 (0.9)
v2 = 17.970***
382 (15.9)
332 (14.9)
NSd
519 (16.1)
713 (17.0)
NSd
293 (9.1)
356 (8.5)
NSd
273 (8.5)
922 (22.0)
v2 = 247.594***
Health insurance (%)
0.044
0.049
Health behavior/history (%)
Tobacco use
Breast problems
216 (9.0)
Hysterectomy
523 (21.8)
145 (6.5)
449 (20.1)
v = 9.981**
NS
0.046
d
2
No limitation
2138
(89.0)
v = 15.988***
1907
(85.5)
2911
(90.2)
165 (6.9)
181 (8.1)
179 (5.5)
313 (7.5)
2? Limitations
100 (4.2)
143 (6.4)
137 (4.2)
221 (5.3)
B
Standard
error
Wald
statistic
Sig
OR
95 %
CIf
B
Standard
error
Wald
Statistic
Sig
OR
95 %
CIf
-0.315
0.089
12.665
.001
0.73
0.613,
0.868
-0.297
0.075
15.61
.001
0.74
0.641,
0.861
B
Standard
error
Wald
statistic
Sig
AORe
95 %
CIf
B
Standard
error
Wald
statistic
Sig
AORe
95 %
CIf
-0.238
0.096
6.125
0.013
0.79
0.653,
0.952
-0.258
0.081
10.1
0.001
0.77
0.659,
0.906
Disability status
unadjusted for
covariates
11 cases exlcuded of 4656 elligible women due to info bias or systematic error
b
42 cases exluded of 7458 elligible women due to info bias or systematic error
c
Independent sample T Test
d
Non significant
e
Adjusted odds ratio
95 % confidence interval
f
g
3655
(87.3)
1 Limitation
Disability status
adjusted for covariate
Cramer V interpretations: only can be used to determine relative differences in association
Pearson Chi Square: * p .05; ** p .01; *** p .001
123
0.183
2
v = 15.178;
p = 0.001
Disability status (%)
a
2
J Community Health (2016) 41:650–657
v2 = 48.525; p 0.001). While tobacco use was not
related to compliance for either BCS or CCS, women with
a history of breast problems were more likely to be compliant for BCS (v2 = 9.981; …
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