Self-reported use of cancer screening tests among Latinos and Anglos in a prepaid health plan

The sound of safety: exploring the determinants of prevention intention in noisy industrial workplaces

Occupational noise exposure is a pervasive issue in many industries, leading to a range of health issues and sleep disturbances among workers. Additionally, there is a strong desire among these workers to prevent industrial accidents. This study, aimed at enhancing worker health and well-being, utilized a survey distributed by the Korean Confederation of Trade Unions to field workers. Data from 1285 workers were collected and analyzed using partial least squares structural equation modeling (PLS-SEM) to identify and understand the factors affecting prevention intention in noisy work environments. Our findings indicate that health problems resulting from occupational noise exposure significantly influence insomnia, perceived severity of potential accidents, perceived benefits of preventive measures, and perceived barriers. Perceived severity was significantly correlated with prevention intention, emphasizing the role of risk perception in motivating preventive behaviors. Perceived benefits were also significantly associated with prevention intention, highlighting the importance of positive outcomes in influencing workers' behaviors. Additionally, perceived barriers showed a significant relationship with prevention intention, suggesting that overcoming these barriers is crucial in promoting preventive behaviors. Demographic factors such as gender displayed a significant association with prevention intention, while age did not. This study provides valuable insights into the multifaceted factors influencing workers' intention to prevent industrial accidents in noisy environments, underlining the importance of comprehensive data collection tools in understanding these dynamics.

Disparities in precision medicine-Examining germline genetic counseling and testing patterns among men with prostate cancer

INTRODUCTION

This study sought to examine whether germline genetic counseling and testing were employed differentially among men with prostate cancer by race and/or ethnicity and other social factors.

METHODS

In this retrospective analysis, all patients with prostate cancer listed as a visit diagnosis during the study period (April 2011 to August 2020) were identified from electronic health records. Patient characteristics were collected along with genetic counselor visits and germline genetic testing results in electronic health records. Multivariable analyses were performed with the primary outcome defined as the receipt of a genetic counseling visit and receipt of genetic testing.

RESULTS

A total of 14,610 patients with a prostate cancer diagnosis code were identified. The majority of patients were White (72%), aged >=65 years (62.7%), English-speaking (95%), married (71.4%), and publicly insured (58.7%). A total of 667 patients completed an appointment with a genetic counselor. A total of 439 patients received germline genetic test result, of whom 403 (91.8%) had also completed an appointment with a genetic counselor. Patients that were 65 years or older (adjusted odds ratio 0.53, 95%CI 0.44-0.65) and non-English proficient (adjusted odds ratio 0.71, 95%CI 0.42-1.21) were less likely to receive genetic counseling. Receiving genetic counseling was the strongest independent predictor of receipt of genetic testing.

CONCLUSIONS

The results of the current study highlight that the role of social factors in contributing to disparities in genetic counseling and testing among men with prostate cancer. These results underscore the importance of developing novel strategies to tackle contributors of observed disparities including language, age, and insurance status.

A Randomized Controlled Trial of a Cervical Cancer Education Intervention for Latinas Delivered Through Interactive, Multimedia Kiosks

US Latina women experience disproportionately high cervical cancer incidence and mortality rates. These health disparities are largely preventable with routine pap tests and human papillomavirus (HPV) screening. This study tested the efficacy of a cervical cancer education intervention to improve risk factor knowledge, attitudes, self-efficacy, and self-reported behavior related to cervical cancer screening among low-income Latinas who had not been screened in the past 2 years, compared to a usual care control group. Low-income Latinas who had not had a pap test in the prior 2 years were recruited from three Federally Qualified Health Centers and randomly assigned to intervention and control groups, with in-person assessment at baseline and 6-month follow-up. Women in the intervention group received a one-time low-literacy cervical cancer education program through an interactive, multimedia kiosk in either English or Spanish based on their language preference. Compared to the control group, the intervention group demonstrated greater knowledge (p < 0.0001) and more favorable attitudes at follow-up; fewer intervention group women never thought of getting a pap test (46 vs. 54 %, p = 0.050) or agreed that it is fate whether a woman gets cervical cancer or not (24 vs. 31 %, p = 0.043). The groups did not differ significantly on the proportion who had obtained or made an appointment for a pap test at follow-up (51 vs. 48 %, p = 0.35). Both groups reported high levels of self-efficacy regarding pap screening at post-intervention. A one-time interactive, multimedia educational intervention improved cervical cancer knowledge and attitudes among low-income Latinas but had no effect on cervical cancer-screening behavior. Exposure of the control group to the pre-test conducted on the multimedia kiosk may have influenced their screening behavior.

Racial Disparities in Colorectal Carcinoma Incidence, Severity and Survival Times Over 10 Years: A Retrospective Single Center Study

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer-related deaths in the United States. Although studies have been performed on malignancy behavior in African Americans and Caucasians, scant data are present on other minority racial groups.

METHODS

A retrospective single center study was performed where 1,860 patient charts with a diagnosis of CRC from January 1, 2004 to December 31, 2014 were reviewed. Data collected on each patient included age, gender, ethnicity, primary site and histological stage at the time of diagnosis. Survival time over the course of 5 years was documented for patients from January 1, 2004 to December 31, 2009. Comparisons were made amongst different racial groups for the above mentioned factors.

RESULTS

Study population consisted of 27.09% African Americans, 65.61% Caucasians, 3.86% Hispanics, 0.54% South Asians, 1.03% Arabs, 0.54% Asians and 0.22% American Indians. Mean age of CRC presentation was found to be significantly different (P < 0.05) between the three largest racial groups: 71 years for Caucasians, 69 years for African Americans, and 61 years for Hispanics. African Americans (27.09%) and Hispanics (28.79%) presented predominantly at stage IV in comparison to other racial groups. Caucasians presented predominantly at stage III (24.84%). The rectum was the most common site of CRC across all racial groups with the exception of Asians, where sigmoid colon was the predominant site (30%). Adenocarcinoma remained the predominant cancer type in all groups. Hispanics had relatively higher incidence rate of carcinoid tumor (12.68%). Survival time analysis showed that Caucasians tend to have better survival probability over 5 years after initial diagnosis as compared to African Americans and Hispanic (P < 0.05).

CONCLUSION

There is lack of studies performed on minority racial groups in North America. Our study highlighted some important clinical differences of CRC presentation in different racial groups which are not well studied and can be used to formulate future multi-center studies to assess disease behavior.

Pathways to Early Cancer Detection for Latinas: En Acción Contra el Cáncer

Latinas have less breast cancer, have more cervical cancer, and obtain fewer screening tests at recommended intervals. This article reviews the epidemiology and use of screening tests for these cancers and cultural factors that affect screening. En Acción Contra el Cáncer was designed to increase use of breast and cervical cancer screening services by distributing free cancer educational materials in Spanish, implementing a media campaign, conducting community outreach, training lay networkers, and assisting clinicians. A survey of 1,601 Latinas, 20 to 74 years old, ascertained screening behavior and knowledge and attitudes about cancer. Comparison of intervention and control cities showed significant differences in proportion insured, married, born in the United States, and less acculturated. There were no significant differences in mammography and Pap smear use, knowledge, and attitudes. Culturally appropriate prevention interventions that target ethnic-specific concerns arc needed.

Printed Health Education Materials for Diverse Communities: Suggestions Learned from the Field

Health education materials designed for the general population may be perceived as unattractive, irrelevant, or unclear by members of certain cultural groups. Given the increasingly multicultural demographics of the United States, planners need to be aware of the specific characteristics of a target audience to address cultural differences and similarities in health messages. The authors describe the use of the subjective culture methodology and social marketing to develop health education materials targeted to multicultural populations, illustrate cultural factors that should be considered when designing printed materials, and outline steps in the design of attractive, stimulating, and culturally appropriate materials. The authors describe the challenges and problems in designing printed materials for multiethnic communities, give suggestions for written educational messages, present a summary of the lessons learned in the development of materials for ethnically diverse populations, and give examples of success stories in multiethnic communities.

Pathways to Early Cancer Detection in the Multiethnic Population of the San Francisco Bay Area

The Pathways project studied the relationship of race/ethnicity, socioeconomic status, and culture to breast and cervical cancer screening. A multidisciplinary, multicultural team of investigators assessed the knowledge, attitudes, and practices of women from five race/ethnic groups (N = 4,228) and their barriers to screening utilization. A planning framework guided the development of interventions and analyses of the similarities and differences in screening behaviors across race/ethnic groups. Baseline data for women ages 18 to 74 years showed that levels of screening were higher than national averages for Latina, white, and black women but lower for Chinese and Vietnamese women. Analyses revealed the importance of education and insurance in obtaining recommended screening regardless of race/ethnicity. However, race, ethnicity, and culture are important to the tailoring of effective interventions.

Access and Attitudinal Factors Related to Breast and Cervical Cancer Rescreening: Why are Latinas Still Underscreened?

To identify access, attitudes, and health practices of Latina women undergoing regular mammography and Pap smear screening, 977 Latinas aged 40 to 74, residing in four California cities, answered a telephone interview. Forty-one percent of women had regular mammography, and 73% had regular Pap smear screening. Cancer screening maintenance was associated with having health insurance, a regular place of care, and fewer fatalistic attitudes about cancer. Regular mammography and Pap smear screening were also associated with ever being married, attending church, and having taken hormone replacement therapy. Being older than 50, residing in the United States a long time, and having had a hysterectomy predicted mammography maintenance. Pap smear screening maintenance was negatively associated with poverty, old age, and negative attitudes toward physicians. There are structural and attitudinal barriers to regular cancer screening among Latinas. Interventions that increase access to care and address women's attitudes about cancer are needed.

Using new media to reach Hispanic/Latino cancer survivors

In the USA, cancer is a leading cause of morbidity and premature death among the Hispanic/Latino population. It is estimated that one in two Hispanic men and one in three Hispanic women will be diagnosed with cancer during their lifetime (American Cancer Society 2010). Despite this significant cancer burden, few innovative strategies for communication and outreach to this population currently exist. In 2009, LIVESTRONG launched a national outreach campaign, which utilized social marketing, specifically targeting Hispanics with the goal of increasing awareness and usage of LIVESTRONG's Spanish-language cancer navigation resources. This campaign, one of the first undertaken by a national cancer-related organization, led to increased awareness and utilization of resources, including a 238% increase in traffic over traditional marketing campaigns which focused on radio alone. The success of this campaign highlights the use of social media as a cost-effective method to raise awareness of cancer resources among Hispanics.

Neighborhood changes in concentrated immigration and late stage breast cancer diagnosis

Immigrant women are at greater risk for late stage breast cancer diagnosis. The rapid increase in the US foreign-born population and new immigration patterns lead us to investigate the association between changes in immigrant population and the likelihood of distant metastasis stage at diagnosis of breast cancer among women in Cook County, Illinois. Analyses employed Illinois State Cancer Registry data for 42,714 breast cancer cases diagnosed between 1994 and 2003 in conjunction with 1990 and 2000 Census tract data. We find that concentration of and increases in immigrant populations within neighborhoods contributed to the risk of late stage breast cancer diagnosis. These findings suggest that, although some health indicators for immigrant populations have improved in recent years, important health disparities in breast cancer diagnosis still remain at the neighborhood level. They further suggest that cancer screening and follow-up resources should be directed to areas experiencing rapid increases in immigrant populations.

Recruitment and retention results for a population-based cervical cancer biobehavioral clinical trial

OBJECTIVE

Minority and low-income cancer patients are underrepresented in clinical trials, contributing to diminished access to state-of-the-art care and disparities in cancer outcomes including survivorship issues. In cervical cancer, there is a disproportionate disease burden among minority and underserved women and persistent quality of life disruption. We encountered significant challenges in both recruitment and retention in a randomized biobehavioral clinical trial for cervical cancer survivors, identified through California Cancer Registries, leading to this investigation.

METHODS

To determine differential rates of accrual and retention, data from our trial are analyzed using descriptive statistics, logistic regression and multivariate analysis of variance. Ethnic differences in associations between covariables and attrition rates were tested by interaction factors. Process evaluation and focus group data were obtained to inform improvement strategies.

RESULTS

Of eligible subjects with viable phone numbers, 29% enrolled and 71% actively or passively refused. Enrolled Hispanic women were more likely to have less education (p<0.001), lower income (p=0.003), and more children (p=0.028). The dropout rate was associated with less education (p=0.012), foreign-birth (p=0.061), speaking Spanish in the home (p=0.012). Reported reasons for active refusal were 'too busy' for all women, 'too emotional' for non-Hispanic women, 'too ill' and phlebotomy for Hispanic women. Subsequent focus groups identified specific strategies to improve study materials.

CONCLUSION

Although population-based recruitment of minority and underserved cancer patients continues to be a challenge, specific sociodemographic and disease variables can predict accrual difficulties. The information herein, taken together with disease and culturally relevant strategies, can be useful when recruiting underserved cancer survivors.

Immigration, health care access, and recent cancer tests among Mexican-Americans in California

Immigrants' lower rates of cancer testing may be due to lack of fluency in English and other skills and knowledge about navigating US health care markets, lack of access to health services, or both. We analyzed 9,079 Mexican-American respondents to the 2001 California Health Interview Survey (CHIS) grouped as born in the US, living in the US 10 or more years, or living in the US less than 10 years. The CHIS provides the largest Mexican-American sample in a US survey. Access to care meant having health insurance coverage and a usual source of care. English proficiency meant the respondent took the interview in English. Multivariate logistic regression was used to predict outcomes. Respondents reporting more time in the US were more likely to report access to medical care and to report getting a cancer screening exam. Regardless of time in the US, respondents reporting access had similar test rates. Regression results indicate that time in the US and primary language were not significant relative to use of cancer screening tests, but access to care was. Cancer screening tests that are covered by Every Woman Counts, California's breast and cervical cancer early detection program, had smaller gaps among groups than colorectal cancer screening which is not covered by a program. California is the only state with a survey able to monitor changes in small population groups. Understanding barriers specific to subgroups is key to developing appropriate policy and interventions to increase use of cancer screening exams.

Physicians' approaches to recommending colorectal cancer screening: a qualitative study

Little is known about strategies that physicians use to encourage receipt of colorectal cancer screening (CRCS). This study conducted focus groups with physicians. Twenty-seven physicians participated in four focus groups. Physicians described four categories of approaches: (1) why screening is important, (2) providing test information, (3) motivational strategies, and (4) tailoring strategies. Participants reported tailoring based on their relationship with a patient, as well as to patient gender, education, and language. Tailoring to cultural background or ethnicity was not prominent. Most physicians reported a typical approach to CRCS and reported some tailoring based on gender, education, and language, but not on ethnicity.

Influence of birthplace on breast cancer diagnosis and treatment for Hispanic women

Research has shown that Hispanic women in the United States are diagnosed with breast cancer at more advanced stages and initiate treatment later than non-Hispanic white women. We investigated whether stage at breast cancer diagnosis and receipt of primary therapy differ by ethnicity and birthplace among US-born Hispanic, foreign-born Hispanic, and white women. We studied 31,012 Hispanic women and 372,313 white women with a first diagnosis of invasive breast cancer during 1988 and 2005 living in a SEER area. We used multinomial logistic regression to assess the association of ethnicity and birthplace with stage at diagnosis and, among women with stage I or II cancers, primary therapy [mastectomy, breast-conserving surgery (BCS) with radiation, BCS without radiation], adjusting for other patient and tumor characteristics. Rates of stage at diagnosis differed significantly by race/ethnicity and birthplace (P < 0.001). Foreign-born Hispanics had lower adjusted rates of stage I breast cancer at diagnosis (35.4%) than US-born Hispanics (40.6%), birthplace-unknown Hispanics (42.3%), and whites (47.4%). Receipt of primary therapy also differed significantly by race/ethnicity and birthplace (P < 0.001). Foreign-born Hispanics and birthplace-unknown Hispanics had lower rates of BCS with radiation (34.9%, 30.7%) than US-born Hispanics (41.5%) and whites (38.8%). Foreign-born Hispanic women in the United States have a lower probability of being diagnosed at earlier stages of breast cancer and, for women with early-stage disease, of receiving radiation following BCS compared to US-born Hispanics and whites. Identifying factors mediating these disparities may help in developing culturally and linguistically appropriate interventions and improving outcomes.

Perspectives of colorectal cancer risk and screening among Dominicans and Puerto Ricans: stigma and misperceptions

Colorectal cancer is the second most common cancer among Latinos, but a lower percentage of Latinos are screened than Whites and Blacks. Along with recognized economic barriers, differences in knowledge and perceptions might impede colorectal screening among Latinos. We conducted 147 individual, qualitative interviews with Dominicans and Puerto Ricans in the northeastern United States to explore their explanatory models for colorectal cancer and screening barriers. Many participants had not previously heard of colorectal cancer. The most commonly mentioned cause of colorectal cancer was anal sex. Also considered risks were "bad food," digestion leading to constipation, and strained bowel movements. Screening barriers included stigma, misperceptions, embarrassment, and machismo. Progress toward increasing colorectal cancer screening requires normalization of this screening among Latinos. Higher patient familiarity, along with improved physician counseling and referral, might contribute to reducing stigma and other barriers, and to enhancing knowledge and Latino community support of colorectal cancer screening.

Acculturation and colorectal cancer screening among older Latino adults: differential associations by national origin

BACKGROUND

Although modest improvements in colorectal cancer (CRC) screening utilization have occurred, rates remain low among Latinos. It is unclear whether acculturation plays a role in the utilization of CRC screening.

OBJECTIVE

This study aimed to examine the relationships between acculturation and CRC screening among older Mexican, Puerto-Rican and Cuban adults.

DESIGN

Cross-sectional observational study.

SUBJECTS

Latinos 50 years and older, never diagnosed with CRC, and who were surveyed in the 2000, 2003 and 2005 National Health Interview Survey (NHIS).

MEASURES

We measured acculturation with US nativity and language of interview, and examined three different CRC screening outcomes: fecal occult blood test (FOBT) in the past year, up-to-date endoscopy and any up-to-date CRC screening. Logistic regression models were adjusted for predisposing, enabling and health-care need factors consistent with the behavioral model of health-care utilization.

MAIN RESULTS

In adjusted analyses, US nativity was positively associated with up-to-date endoscopy among Mexicans (OR: 1.5; 95% CI: 1.1, 2.2), but negatively associated with FOBT in the past year among Puerto Ricans (OR: 0.3; 95% CI: 0.2, 0.7). In contrast to this latter finding among Puerto Ricans, English language interview was positively associated with FOBT in the past year (OR: 2.5; 95% CI: 1.1, 5.4).

CONCLUSION

Results underscore the importance of stratification by national origin in studies of acculturation and cancer screening and of targeting less acculturated adults to promote CRC screening. Clinicians, however, should consider the complexity of acculturation and treat US nativity and language preference as independent dimensions among their Latino patients.

Predisposing and enabling factors associated with mammography use among Hispanic and non-Hispanic white women living in a rural area

CONTEXT

Women who do not receive regular mammograms are more likely than others to have breast cancer diagnosed at an advanced stage.

PURPOSE

To examine predisposing and enabling factors associated with mammography use among Hispanic and non-Hispanic White women.

METHODS

Baseline data were used from a larger study on cancer prevention in rural Washington state. In a sample of 20 communities, 537 women formed the sample for this study. The main outcomes were ever having had a mammogram and having had a mammogram within the past 2 years.

FINDINGS

Reporting ever having had a mammogram was inversely associated with lack of health insurance (OR = 0.37, 95% CI: 0.16-0.84), ages under 50 years (OR = 0.23, 95% CI: 0.12-0.45), high cost of exams (OR = 0.48, 95% CI: 0.27-0.87), and lack of mammography knowledge (OR = 0.16, 95% CI: 0.07-0.37), while increasing education levels were positively associated (OR = 1.72, 95% CI: 1.09-2.70). Reporting mammography use within the past 2 years was inversely associated with ages under 50 years (OR = 0.49, 95% CI: 0.27-0.88) and over 70 years (OR = 0.47, 95% CI: 0.24-0.94), lack of health insurance (OR = 0.23, 95% CI: 0.10-0.50), and high cost of exams (OR = 0.55, 95% CI: 0.35-0.87).

CONCLUSIONS

Continued resources and programs for cancer screening are needed to improve mammography participation among women without health insurance or low levels of education.

Taishotoyama Symposium Barriers to colorectal cancer screening: economics, capacity and adherence

Colorectal cancer is the second leading cause of cancer death in the United States (U.S.). Fecal occult blood testing has been shown in randomized controlled trials to decrease mortality from colorectal cancer. The incidence and mortality associated with colorectal cancer has also been illustrated to be decreased with sigmoidoscopy and colonoscopy through case-control and prospective cohort studies. Current research focuses on determining which screening strategy is optimal, and how we may improve implementation. Primary screening colonoscopy may be most effective; however, this strategy would require up to 2.6 procedures per patient over their lifetime. Based on the U.S. census this equates to 7.5 million procedures annually; the current capacity in the U.S. is insufficient to provide this strategy for all eligible persons. Computed tomographic or magnetic resonance colonography (virtual colonoscopy) may be an attractive alternative, but capacity is also insufficient for implementation. Moreover, since virtual colonoscopy is a diagnostic but not therapeutic test, economic analysis has illustrated that this strategy will not be cost-effective compared to conventional colonoscopy unless it becomes much less expensive or is associated with greater adherence. Fecal DNA testing is a promising technology but current biomarkers are insufficiently sensitive to constitute a viable strategy. Newer tests such as self-propelled, self-guided endoscopes (Aer-O-Scope), 'active' endoscopes that decrease looping (Neoguide) and colon capsule endoscopy require formal evaluation through clinical trials prior to endorsement for colorectal cancer screening. Less than half of all eligible persons in the U.S. adhere to screening recommendations. Factors associated with screening adherence include the patient's level of education, income, access to health care, a family history of colon cancer, male gender and recommendation from the primary care physician. Conversely, non-adherence is associated with concern over the bowel preparation and fear of discomfort and embarrassment with the procedure. Moreover, it appears that the presence of multiple strategies may be the cause of non-adherence in many cases. Patients who are given a choice of several strategies are less likely to adhere to any strategy than patients who are recommended a single strategy. To increase adherence to colorectal cancer screening it is recommended that the patient be instructed to undergo the test to which they are most likely to adhere. Future research should focus on interventions to improve patient adherence to screening, and on developing accurate tests that will achieve high levels of adherence.

Health disparities in receipt of screening mammography in Latinas: a critical review of recent literature

BACKGROUND

Increased use of screening mammography is associated with lower death rates from breast cancer in the United States. Despite recommendations that women over 40 years of age should obtain regular screening mammography at least every 2 years, many women do not adhere to these guidelines. Historically, women from underserved and minority populations have been less likely to receive screening mammography.

METHODS

A critical review of recent research literature was conducted to evaluate whether Latinas are less likely to receive screening mammography, determine whether disparities in screening mammography persist when controlling for other variables, and examine what other variables are associated with screening mammography. The articles were obtained from a search of the PubMed database.

RESULTS

Fifteen published articles met the inclusion criteria and were critically reviewed. The unadjusted odds ratios (ORs) of the association between Hispanic ethnicity and screening mammography ranged from 0.40 to 0.93. For the most part, the ORs adjusted for other variables in multiple logistic regression analyses increased (range: 0.3 to 1.67). Age, education, income, health insurance, having a usual source of care, and having a recent visit to a physician were consistently related to screening mammography in multiple logistic regression analysis.

CONCLUSIONS

Hispanic ethnicity is a risk factor for lack of adherence to screening mammography. However, other demographic, socioeconomic, and health system variables account for some of the disparity related to Hispanic ethnicity.

Secular changes in colorectal cancer incidence by subsite, stage at diagnosis, and race/ethnicity, 1992-2001

BACKGROUND

Cancers of the colon and rectum are the third most common malignancy among males and females in the United States, although incidence and mortality have declined in recent years. We evaluated recent trends in colorectal cancer incidence in the United States by subsite and stage at diagnosis.

METHODS

Data for this analysis included all cases of colorectal cancer diagnosed between 1992 and 2001 and reported to the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. Incidence rates were stratified by gender, race/ethnicity, anatomic subsite, stage at diagnosis, and SEER registry. Trends in incidence over time were measured using the estimated annual percentage change.

RESULTS

The study population included 95,539 males and 93,329 females with colorectal cancer. For all 12 SEER registries combined, incidence declined between 1992 and 2001 by 1.2% per year among males and 0.7% per year (not statistically significant) among females. Rates for non-Hispanic whites declined by an average of 1.3% per year for males and 0.6% per year for females. Overall rates for black, Asian/Pacific Islander, and Hispanic males and females did not change significantly except for a 0.8% decline among Asian/Pacific Islander males. Declines in rates among males and females were most pronounced for tumors of the sigmoid colon.

CONCLUSIONS

Colorectal cancer rates decreased in the United States during the 1990s. Decreases were most pronounced among males, among non-Hispanic whites, and for tumors of the sigmoid colon. These reductions are probably dueto the increased use of screening.

Demographic, risk factor, and knowledge differences between Latinas and non-Latinas referred to colposcopy

OBJECTIVE

Disparities occur in the incidence and mortality of cervical cancer among minority women in the US. Screening lowers cervical cancer incidence. Screening rates are lower for minority women than for White women in the US. This study sought to identify demographic, risk factor, and perception of the role of Pap smears between Latinas and non-Latinas.

METHODS

A written survey was administered to 150 Latinas and 150 non-Latinas attending a colposcopy unit. Data on demographics, risk factors, screening rates, knowledge about cervical cancer screening, and perceived barriers to participation in screening programs were collected.

RESULTS

A total of 140 Latinas and 146 non-Latinas completed the survey. Marital status and health insurance status were similar in the two groups. 30% of Latinas and 73.3% of non-Latinas reported completing college (p<0.0001). Only 55.7% of Latinas were employed, compared to 82.2% of non-Latinas (p<0.0001). 21% of Latinas and 53.4% of non-Latinas reported an annual income greater than 35,000 dollars (p<0.0001). Among Latinas, women with 1-5 lifetime Pap smears were less likely to have completed college than those with more than 5 lifetime Pap smears (OR=2.11; 95% CI 1.05-4.22) and to have an annual income of less than 35,000 dollars (OR=3.81; 95% CI 1.64-8.87). Latinas were less likely to have > or =6 lifetime sexual partners, use tobacco, and have a history of sexually transmitted infections. Latinas more commonly reported fear of test results (OR, 0.04; 95% CI 0.02-0.09) and inability to communicate with their provider in Spanish (p<0.0001) as barriers to screening than the non-Latina respondents.

CONCLUSIONS

Several of the barriers limiting access to cervical cancer screening programs are also present among screened Latinas undergoing further evaluation for abnormal Pap smears.

Acculturation and mammography screening among Hispanic women living in farmworker communities

The relationship between acculturation and mammography screening practices among Hispanic women is unclear due to inconsistent study findings. The purpose of this research was to further investigate the effect of acculturation on mammography screening practices among Hispanic women and to explore the effect of biculturalism on mammography screening. Hispanic female farmworkers (N = 716) who were 50 years of age and older living in communities in Texas, New Mexico, and California were interviewed at their homes. Data collection was conducted from November 2001 to February 2002. Logistic regression models showed no significant effect for acculturation for the entire sample. Post hoc stratified analysis found that bicultural study participants in California were 3 times more likely to be adherent to screening compared to those with low acculturation. Study findings suggest that distinct differences might exist for Hispanic women living in farmworker communities in California, and perhaps other communities not on the United States-Mexico border. Women in such communities with low levels of acculturation can be targeted for interventions to increase mammography adherence.

Time spent in the united states and breast cancer screening behaviors among ethnically diverse immigrant women: Evidence for acculturation?

The current study was designed to investigate the relations between time spent in the United States and breast cancer screening in a large sample (N=915) of ethnically diverse immigrant women living in New York City. Previous research among Hispanic women has suggested that acculturation positively influences health beliefs and preventive health behaviors. However, research has not yet extended to other growing immigrant groups, including women from Haiti and the English-speaking Caribbean, and has not tested whether time spent in the United States differentially impacts breast screening across groups that are known to vary in their health beliefs. As expected, time spent in the United States was associated with a greater number of mammograms and clinical breast exams. Importantly, these relations held even when controlling for (a) age, income, education, marital status; (b) morbidity, health insurance, physician's recommendation, physical exams; and (c) ethnicity. Moreover, time spent in the United States interacted with being Haitian to predict the number of clinical breast exams. Even though Haitians were less likely to utilize breast cancer screening overall, time spent in the United States had a stronger effect on the number of clinical breast exams for Haitian women. Results are discussed in terms of the ethnic-specificity of health beliefs, how they may change over time and their implications for preventive health behaviors.

Race and ethnic disparities in cervical cancer screening in a safety-net system

OBJECTIVES

The three objectives of this research were: 1) to examine the use of Pap smear tests among low-income women, including minority and immigrant women who were patients in a safety-net healthcare system; 2) to identify policy relevant variables that could lead to changes in use of Pap smear screening services for these women; and 3) to contribute to the literature on use of Pap smear screening, especially among minorities and immigrants. The Behavioral Model for Vulnerable Populations was used as the theoretical framework.

METHODS

Pap smear screening predictors were examined using telephone interviews with a random sample of women aged 18-60, including 465 Non-Hispanic Whites, 285 African Americans, 164 Hispanic Americans, and 256 Hispanic immigrants, enrolled in a safety-net healthcare system in Texas in Fall 2000. Binary logistic regression analysis was used.

RESULTS

The research revealed that Non-Hispanic Whites were most likely to have been screened ever and in the past 3 years, followed by African Americans, Hispanic immigrants, and Hispanic Americans. Among Hispanics, immigrants were most likely to have had Pap smear screening, supporting the "healthy immigrant hypothesis." Older women were most likely to have ever been screened, with younger women, most likely in the past year. Having a usual source of healthcare and a checkup for current pregnancy increased screening, while competing needs (food, clothing, housing) affected screening negatively.

CONCLUSIONS

Culturally competent, community-based care for women is needed to increase Pap smear screening among minority groups, especially Hispanic immigrant and Hispanic American women.

Immigration reform and the health of Latino immigrants in California

This paper examines Latino immigrant health within the context of the current debate over immigration reform and the resulting cultural construction of public health in California. A review of epidemiologic and ethnographic data indicates that the subordinate socioeconomic status of Latino immigrants plays a major role in both disease etiology and access to health services. However, this status does not explain why certain patterns of health services utilization and disease morbidity and mortality persist although political and economic circumstances have changed. These patterns include the reluctance to utilize certain health services despite access to health insurance and the presence of an epidemiologic paradox in which Latinos have health status indicators comparable to or better than that of other ethnic groups despite high poverty, low education, and lack of access to care. An "economy of culture" model is used to explain these inconsistencies in the political economy model of Latino immigrant health.

Annual report to the nation on the status of cancer, 1975–2003, featuring cancer among U.S. Hispanic/Latino populations

BACKGROUND

The American Cancer Society, Centers for Disease Control and Prevention, National Cancer Institute, and North American Association of Central Cancer Registries collaborate annually to provide U.S. cancer information, this year featuring the first comprehensive compilation of cancer information for U.S. Latinos.

METHODS

Cancer incidence was obtained from 90% of the Hispanic/Latino and 82% of the U.S. populations. Cancer deaths were obtained for the entire U.S. population. Cancer screening, risk factor, incidence, and mortality data were compiled for Latino and non-Latino adults and children (incidence only). Long-term (1975-2003) and fixed-interval (1995-2003) trends and comparative analyses by disease stage, urbanicity, and area poverty were evaluated.

RESULTS

The long-term trend in overall cancer death rates, declining since the early 1990s, continued through 2003 for all races and both sexes combined. However, female lung cancer incidence rates increased from 1975 to 2003, decelerating since 1991 and breast cancer incidence rates stabilized from 2001 to 2003. Latinos had lower incidence rates in 1999-2003 for most cancers, but higher rates for stomach, liver, cervix, and myeloma (females) than did non-Latino white populations. Latino children have higher incidence of leukemia, retinoblastoma, osteosarcoma, and germ-cell tumors than do non-Latino white children. For several common cancers, Latinos were less likely than non-Latinos to be diagnosed at localized stages.

CONCLUSIONS

The lower cancer rates observed in Latino immigrants could be sustained by maintenance of healthy behaviors. Some infection-related cancers in Latinos could be controlled by evidence-based interventions. Affordable, culturally sensitive, linguistically appropriate, and timely access to cancer information, prevention, screening, and treatment are important in Latino outreach and community networks.

Cancer screening among jail inmates: frequency, knowledge, and willingness

OBJECTIVES

We determined jail inmates' knowledge of cancer screening tests, their frequency of screening, and their willingness to undergo screening in jail in order to assess preventive health services for jail inmates.

METHODS

We performed a cross-sectional interview survey of random samples of county jail inmates (n=133).

RESULTS

Approximately half (53%) the participants were African American, 17% were White, 11% were Latino, and 9% reported multiple ethnicities. Among women aged 18 years and older, 90% had had a Papanicolaou (Pap) test within 3 years, and 94% were willing to be screened in jail. Having ever had a Pap test while incarcerated was significantly associated with being up to date on cervical cancer screening. For women aged 40 years and older, 41% reported having had a mammogram within 2 years, and 88% were willing to have one. Among men (n=51) and women (n=4) aged 50 years and older, 25% had knowledge of colon cancer screening, 31% were up to date, and 69% were willing to be screened. Increased knowledge about colon cancer screening was significantly associated with being White and having insurance. Jail inmates, particularly African Americans, had significantly lower frequency of sigmoidoscopy and colonoscopy than the general population.

CONCLUSIONS

Jail could be an appropriate venue in which to provide cancer screening for a high-risk population. Inmates were receptive to jail-based screening.

Acculturation and cancer screening among Latinas: results from the National Health Interview Survey

BACKGROUND

Although early detection of breast and cervical cancer is one of the most effective means of assuring timely treatment and survival, the cultural hypothesis proposes that traditional norms, values, and beliefs deter Latinas from being screened.

PURPOSE

We assessed whether acculturation is associated with Latinas' receipt of a recent mammogram, clinical breast examination (CBE), and Papanicolaou (Pap) test, and the contribution of acculturation to screening after adjusting for sociodemographic variables.

METHODS

We used data from the Health Promotion and Disease Prevention Supplement of the 1991 National Health Interview Survey. The sample for analyses of Pap test utilization included 1,370 Latinas age 18 and over, and for mammography and CBE, 525 Latina women age 40 and over.

RESULTS

Acculturation was associated with a higher likelihood of having had a recent mammogram, but this effect was not significant when controlling for sociodemographic factors. In both adjusted and unadjusted analyses, acculturation did not predict recent Pap smears. Acculturation was associated with greater likelihood of recent CBE, controlling for sociodemographic factors.

CONCLUSIONS

The association between acculturation and cancer screening is inconsistent. Theoretical models are needed to explain the mechanisms involved in the association (or lack thereof) between acculturation and screening.

Poor patient comprehension of abnormal mammography results

BACKGROUND

Screening mammography for women 50 to 69 years of age may lead to 50% having an abnormal study. We set out to determine the proportion of women who understand their abnormal mammogram results and the factors that predict understanding.

METHODS

We surveyed 970 women age 40 to 80 years identified with abnormal mammograms from 4 clinical sites. We collected information on demographic factors, language of interview, consultation with a primary care physician, receipt of follow-up tests, and method of notification of index mammogram result. This study examines the following outcomes: the participant's report of understanding of her physician's explanation of results of the index mammogram, and a comparison of the radiology report to the participant's report of her index mammogram result. Multivariate models controlled for age, education, income, insurance status, and clinical site.

RESULTS

The majority (70%) reported a "full understanding" of their physician's explanation of their abnormal mammogram, but a significant minority (30%) reported less than a full understanding (somewhat, not at all, did not explain). Among women of Asian ethnicity, only 63% reported full understanding. Asian ethnicity was a negative predictor (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.3 to 0.7), and consultation with a primary care physician was a positive predictor (OR, 2.3; 95% CI, 1.7 to 3.3) of reported full understanding. Of the 304 women with a suspicious abnormality, only 51% understood their result to be abnormal. Women notified in person or by telephone were more likely than women notified in writing to understand their result to be abnormal (OR, 2.3; 95% CI, 1.2 to 4.8).

CONCLUSION

Almost half of women with the most suspicious mammograms did not understand that their result was abnormal. Our data suggest that direct communication with a clinician in person or by phone improves comprehension.

Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas

PURPOSE

Although rates of cancer screening for Latinas are lower than for non-Latina whites, little is known about how insurance status, ethnicity, and nativity interact to influence these disparities. Using a large statewide database, our study examined the relationship between breast and cervical cancer screening rates and socioeconomic and health insurance status among foreign-born Latinas, US-born Latinas, and non-Latina whites in California.

METHODS

Data from the1998 California Women's Health Survey (CWHS) were analyzed (n = 3,340) using multiple logistic regression models. Utilization rates of mammography, clinical breast examinations, and Papanicolaou (Pap) smear screening among foreign-born Latinas, US-born Latinas, and non-Latina whites were the outcome measures.

RESULTS

Foreign-born Latinas had the highest rates of never receiving mammography, clinical breast examinations, and Pap smears (21%, 24%, 9%, respectively) compared with US-born Latinas (12%, 11%, 7%, respectively) and non-Latina whites (9%, 5%, 2%, respectively). After controlling for socioeconomic factors, foreign-born Latinas were more likely to report mammography use in the previous 2 years and Pap smear in the previous 3 years than non-Latina whites. Lack of health insurance coverage was the strongest independent predictor of low utilization rates for mammography (odds ratio [OR] = 2.05; 95% confidence interval [CI], 1.53-2.76), clinical breast examinations (OR = 2.29; 95% CI, 1.80-2.90) and Pap smears (OR = 2.89; 95% CI, 2.17-3.85.)

CONCLUSIONS

Breast and cervical cancer screening rates vary by ethnicity and nativity, with foreign-born Latinas experiencing the highest rates of never being screened. After accounting for socioeconomic factors, differences by ethnicity and nativity are reversed or eliminated. Lack of health insurance coverage remains the strongest predictor of cancer screening underutilization.

Impact of U.S. citizenship status on cancer screening among immigrant women

OBJECTIVES

We evaluated the relationship between U.S. citizenship status and the receipt of Pap smears and mammograms among immigrant women in California.

DESIGN

Cross-sectional study using data from the 2001 California Health Interview Survey.

PATIENTS/PARTICIPANTS

Noninstitutionalized, civilian women, aged 18 years and older living in California.

MEASUREMENTS AND MAIN RESULTS

We analyzed data from the 2001 California Health Interview Survey and used logistic regression models to adjust for sociodemographic factors and for access and utilization of health services. After adjusting we found that U.S. citizen immigrants were significantly more likely to report receiving a Pap smear ever (adjusted prevalence ratio [aPR], 1.05; 95% confidence interval [CI], 1.01 to 1.08), a recent Pap smear (aPR, 1.07; 95% CI, 1.03 to 1.11), a mammogram ever (aPR, 1.17; 95% CI, 1.12 to 1.21), and a recent mammogram (aPR, 1.38; 95% CI, 1.26 to 1.49) as compared to immigrants who are not U.S. citizens. Also associated with receiving cancer screening were income, having a usual source of care, and having health insurance. Hispanic women were more likely to receive Pap smears as compared to whites and Asians.

CONCLUSIONS

Not being a U.S. citizen is a barrier to receiving cervical and breast cancer screening. Additional research is needed to explore causal factors for differences in cancer screening rates between citizens and noncitizens.

Results of mujeres felices por ser saludables: a dietary/breast heafth randomized chnicail trial for latino women

BACKGROUND

Data are limited on the efficacy of health-focused interventions for young, low-acculturated Latino women. Because breast cancer is the most commonly diagnosed cancer and the most common cause of cancer mortality in this population, combined interventions that address both early detection and dietary patterns could help reduce both morbidity and mortality associated with breast cancer in this underserved population.

PURPOSE

Mujeres Felices por ser Saludables was randomized intervention study designed to assess the efficacy of an 8-month combined dietary and breast health intervention to reduce fat and increase fiber intake as well as to increase the frequency and proficiency of breast self-examination (BSE) and reduce anxiety related to BSE among Latinas.

METHODS

Blocked randomization in blocks of 6 was used to randomize 256 20- to 40-year-old Latinas to the intervention (n = 127) or control group (n = 129). The intervention group attended an 8-month multicomponent education program designed specifically for low-acculturated Latinas. The control group received mailed health education material on a schedule comparable to the intervention. A total of 195 women (76.2%) completed both the baseline and 8-month follow-up interviews.

RESULTS

The intervention and control groups were similar on baseline sociodemographic characteristics. At the 8-month follow up, the intervention group reported lower dietary fat (P < .001) and higher fiber intake (p = .06); a higher proportion reported practicing BSE at the recommended interval (p < .001) and showed improved BSE proficiency (p < .001) compared to the control group. BSE-related anxiety was low for both groups at baseline, and no difference in reduction was observed.

CONCLUSIONS

This project provides a successful model for achieving dietary change and improving breast health behavior in young, low-acculturated Latinas.

Factors associated with colorectal cancer screening among the US urban Japanese population

OBJECTIVES

The author examined the prevalence and predictors of colorectal cancer screening among the urban Japanese population of the United States.

METHODS

A sample of Japanese residents of major US metropolitan areas completed a self-administered mailed survey.

RESULTS

Physician recommendation, acculturation, and perceived psychological costs were consistent predictors of screening for colorectal cancer. Gender and marital status were related to screening via fecal occult blood testing; age, susceptibility, and health insurance were related to sigmoidoscopy/colonoscopy screening.

CONCLUSIONS

Colorectal cancer screening among the urban Japanese population could be increased with interventions seeking to promote physician recommendations for screening, alleviate perceived psychological costs among patients, and improve physician-patient communication.

Barriers to colorectal cancer screening in Latino and Vietnamese Americans. Compared with non-Latino white Americans

OBJECTIVE

To identify current colorectal cancer (CRC) screening practices and barriers to screening in the Latino, Vietnamese, and non-Latino white populations.

METHODS

We conducted a telephone survey of Latino, non-Latino white, and Vietnamese individuals living in San Jose, California. We asked about demographics, CRC screening practices, intentions to be screened, and barriers and facilitators to screening.

RESULTS

Seven hundred and seventy-five individuals (40% white, 29.2% Latino, and 30.8% Vietnamese) completed the survey (Response Rate 50%). Overall, 23% of respondents reported receipt of fecal occult blood test (FOBT) in the past year, 28% reported sigmoidoscopy (SIG) in the past 5 years, and 27% reported colonoscopy (COL) in the past 10 years. Screening rates were generally lower in Latinos and Vietnamese. Vietnamese were less likely than whites to have had SIG in the past 5 years (odds ratio [OR], 0.26; 95% confidence interval [CI], 0.09 to 0.72), but ethnicity was not an independent predictor of FOBT or COL. Only 22% of Vietnamese would find endoscopic tests uncomfortable compared with 79% of whites (P <.05). While 21% of Latinos would find performing an FOBT embarrassing, only 8% of whites and 3% of Vietnamese felt this way (P <.05). Vietnamese were more likely than whites to plan to have SIG in the next 5 years (OR, 2.24; 95% CI, 1.15 to 4.38), but ethnicity was not associated with planning to have FOBT or COL.

CONCLUSIONS

Rates of CRC screening are lower in ethnic minority populations than in whites. Differences in attitudes and perceived barriers suggest that culturally tailored interventions to increase CRC screening will be useful in these populations

Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care

CONTEXT

Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace.

OBJECTIVE

To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening.

DESIGN, SETTING, AND SUBJECTS

Cross-sectional study using 1998 data from the National Health Interview Survey.

MAIN OUTCOME MEASURES

Completion of cervical, breast, or colorectal cancer screening.

RESULTS

Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents.

CONCLUSION

Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born.

Prevenção do câncer de colo do útero: um modelo teórico para analisar o acesso e a utilização do teste de Papanicolaou

Vários estudos têm apontado que a permanência das altas taxas de incidência e mortalidade por câncer cérvico-uterino deve-se à baixa qualidade e cobertura do teste de Papanicolaou, principalmente em países em desenvolvimento. Pretende-se neste artigo analizar alguns pontos relacionados às medidas de prevenção e controle do câncer cervical quanto à efetividade do teste de Papanicolaou, a lógica operacional e científica por detrás das políticas públicas de prevenção ao câncer cervical e a cobertura do teste em países norte-americanos, europeus e na América Latina. Consideram-se, ainda, os modelos explicativos que estão sendo propostos para avaliar o acesso e a utilização deste serviço, a partir da análise dos fatores associados à realização do teste de Papanicolaou descritos pela literatura. Propõe-se uma nova abordagem na investigação destes fatores, buscando a integração e interlocução de outros aspectos de cunho social, cultural e organizacional na análise do acesso e da utilização deste exame, visando um planejamento mais coerente das ações de prevenção e promoção à saúde com as necessidades e direitos das mulheres.

Barriers to breast cancer screening for low-income Mexican and Dominican women in New York City

The proportion of Mexican and Dominican women has increased rapidly in New York City and in other urban areas, and breast cancer screening rates continue to be lower for Latina women as a whole, but particularly for some nationality subgroups. The current analysis explored the reasons why Mexican and Dominican women from medically underserved communities in New York City do not seek breast cancer screening. Data were collected through interviews with 298 Mexican and Dominican women aged 40-88 years; the interviews included an open-ended question on the barriers women face in seeking screening. The three most commonly cited barriers were not taking care of oneself (descuido) (52.3%), lack of information (49.3%), and fear (44.6%). Women who had been screened cited fear, pain, or other personal barriers more often, but women who had never had a mammogram cited cost or other logistical barriers. Responses from Dominican and Mexican women were significantly different, with Mexican women more often citing shame or embarrassment and Dominican women more often citing fear. The dependent variable, barriers to screening, was grouped into major categories. When sociodemographic factors were controlled for, the effect of ethnicity disappeared. Multivariate logistic regression revealed that women with a source of health care were less likely to cite any logistical barriers, but significantly more likely to report only personal barriers (such as fear or descuido). The analysis indicated that personal barriers were very prevalent in the communities studied. It may not be sufficient merely to increase access to breast cancer screening services for low-income Latinas: even when women have a source of health care, personal barriers may prevent many women from seeking screening. Outreach programs need to be tailored to the target communities as there are significant differences among groups of Latinas. Targeted outreach programs must work in tandem with programs to increase access to ensure that both personal and logistical barriers to screening are addressed.

The individual and beyond: a socio-rational choice model of service participation among homeless adults with substance abuse problems

While substance user service programs can help homeless adults solve their substance use and housing problems, relatively few needy individuals use and complete these programs. The lack of participation is poorly explained by typical empirical studies, most of which consider the role in service participation of various personal traits and client problems. The current article instead seeks to explain service participation through the application of an alternative, "socio-rational choice" model. This model has three premises: Clients weigh the costs and benefits of participating in services against alternative uses of their time and resources. The clients' weighing procedures reflect their personal situations and perceptions of the treatment environment. The perceptions of their personal situations and perceptions of the treatment environment are affected by the manner in which clients react to representatives of service systems, members of their social network including both housed and homeless persons, and other individuals. Secondary evidence supports many of the model's hypotheses and generally suggests that homeless clients may be heavily affected by their experiences with individuals and systems with which they come into contact.

Receipt of preventive services among privately insured minorities in managed care versus fee-for-service insurance plans

OBJECTIVE

We compare preventive services utilization among privately insured African Americans and Hispanics in managed care organizations (MCOs) versus fee-for-service (FFS) plans. We also examine racial/ethnic disparities in the receipt of preventive services among enrollees in FFS or MCO plans.

DESIGN

Analysis of the nationally representative 1996 Medical Expenditure Panel Survey.

PARTICIPANTS

Participants included 1,120 Hispanic, 929 African-American, and 6,383 non-Hispanic white (NHW) adults age 18 to 64 years with private health insurance.

MEASUREMENTS AND MAIN RESULTS

We examined self-reported receipt of physical examination, blood pressure measurement, cholesterol assessment, Papanicolau testing, screening mammography, and breast and prostate examinations. Multivariate modeling was used to adjust for age, gender, education, household income, and health status. Hispanics in MCOs were more likely than their FFS counterparts to report having preventive services, with adjusted differences ranging from 5 to 19 percentage points (P <.05 for physical examination, blood pressure measurement, breast examination and Pap smear). Among African Americans, such patterns were of a smaller magnitude. In both MCOs and FFS plans the proportion of African Americans reporting preventive services was equal to or greater than NHWs. In contrast, among Hispanic women in FFS, a non-statistically significant trend of fewer cancer screening tests than NHW's was observed (Pap smears 75% vs 80%; mammograms 66% vs 74%, respectively). In both MCO and FFS plans, Hispanics were less likely than NHWs to report having blood pressure and cholesterol measurement (P <.05).

CONCLUSIONS

With the demise of traditional MCOs, reform efforts should incorporate those aspects of MCOs that were associated with greater preventive service utilization, particularly among Hispanics. Existing ethnic disparities warrant further attention.

Recruitment strategies for cervical cancer prevention study

OBJECTIVE

The aim of this study was to describe recruitment strategies for a single-visit cervical cancer prevention study.

METHODS

From January through December 1999, low-income, predominantly Latino women were recruited to participate in a single-visit cervical cancer prevention study. For the first 6 months, all women who had ever visited one of two community-based study clinics were invited to participate (clinic registry recruitment). For the remainder of the year, recruitment was modified to be primarily inclusive of advertisements in English- and Spanish-language community newspapers and fliers left in local businesses and organizations (media campaign recruitment). Eligible volunteers were randomized to one of two study arms, usual-care program or single-visit program. All study subjects completed demographic and medical questionnaires delivered by bilingual staff. Women who declined to participate in this study were asked to provide reasons for this preference. Statistical analyses included the use of chi-square, logistic regression, and Student's t test.

RESULTS

The proportion of women who agreed to participate was higher in the media recruitment group than in the clinic registry group [51% (535/1041) compared to 26% (405/1542), P < 0.001]. The no-show rate among participants solicited from the media strategy was significantly less than that from the clinic registry. There were no significant differences in the median age, number of months since the last Papanicolaou smear, incidence of abnormal Papanicolaou smear, education, or income of the subjects based on the recruitment strategy.

CONCLUSION

A media-based recruitment strategy was effective for this single-visit cervical prevention study. This approach may be effective for recruitment of other low-income groups to clinical trials.

Predictors of digital rectal examination in U.S. Latinos

BACKGROUND

Little is known about prostate and colorectal cancer knowledge, attitudes, and screening practices among U.S. Latino men. Even less is known about the population's subgroup variations. This study assessed predictors of having obtained digital rectal examinations (DREs) among four Latino subgroups.

METHODS

Findings in this report are based on a cross-sectional telephone survey conducted between October 1993 and June 1994 as part of a multisite demonstration project for cancer prevention and control. The survey was conducted in eight U.S. cities identified via census data as having relatively high concentrations of targeted Latino subgroups. The analysis included 1499 Latino men aged > or = 40 who self-identified as Central American, Cuban American, Mexican American, or Puerto Rican.

RESULTS

Overall, 53% of the sample reported ever having had a DRE and 68% reported ever having heard of the procedure. For all subgroups, the only significant predictor for obtaining a DRE was "ever heard of DRE." "Having your doctor discuss DRE" was a significant factor for Mexican Americans and Puerto Ricans.

CONCLUSIONS

The lack of a universal DRE cancer-screening model among Latino groups highlights the need to address barriers in the context of the population's diversity. Ecologic approaches and clinician communication with Latinos need to be tailored to accommodate subgroup differences in knowledge, attitude, and practices related to DRE.

Factors related to cancer screening in Hispanics: a comparison of the perceptions of Hispanic community members, health care providers, and representatives of organizations that serve Hispanics

Hispanics have lower rates of screening for cervical, breast, and colon cancer than non-Hispanics. Activities to increase cancer screening in this population may not be informed by Hispanics, which may have implications for success rates of interventions. In this study, the perceptions about cancer screening behaviors in Hispanics are compared among three groups: a random sample of respondents (75% Hispanic) to a population-based survey, health care providers (primarily non-Hispanic), and representatives of organizations that serve Hispanics (36% Hispanic). While there was agreement that socioeconomic factors were important for cancer screening, differing views were expressed regarding the importance of cultural factors for cancer screening among Hispanics. Interventions developed by those who serve the Hispanic population may be based on inaccurate perceptions about the beliefs and practices of the population served. For effective interventions, it will be necessary to understand the factors important to Hispanics for cancer screening.

Influence of Hispanic ethnicity on outcome after resection of carcinoma of the head of the pancreas

BACKGROUND

Poor outcomes in Hispanic patients have been reported for tumors at a number of sites. The authors sought to determine whether a similar phenomenon occurs in Hispanics after the resection of solid epithelial tumors of the head of the pancreas.

METHODS

Between 1983-1995, 273 patients with noncystic epithelial carcinoma of the head of the pancreas were evaluated. Resection was accomplished in 104 patients (38%); these patients were the focus of the current retrospective review. Of the patients who underwent resection, 26 (25%) were Hispanic and 78 (75%) were non-Hispanic.

RESULTS

Although Hispanic patients tended to present at a significantly younger age and their serum bilirubin level was significantly higher, no other differences in clinical characteristics were observed. After resection, Hispanic patients had a median survival of only 11.4 months, whereas the non-Hispanic group had a median survival of 21.7 months (P = 0.009). Hispanic ethnicity, as well as age > 74 years and jaundice at the time of presentation also were found to be significant prognostic factors on multivariate analysis. Hispanic patients did not present with more advanced disease and no delays in assessment by a physician or in proceeding to surgery were observed. Furthermore, the rate of resection was the same in Hispanic patients and non-Hispanic patients. Long-term survival after palliative bypass was similarly worse in the Hispanic subgroup.

CONCLUSIONS

Hispanic patients treated at the study center appeared to have a diminished survival after resection of a tumor of the head of the pancreas. No treatment-related factors were identified that could explain this discrepancy in outcome.

Hispanic women's perceptions regarding cervical cancer screening

OBJECTIVE

To examine factors affecting cervical cancer screening behaviors.

DESIGN

Qualitative, descriptive.

SETTING

Interviews were conducted in participants' homes.

PARTICIPANTS

Purposive sample of 20 Hispanic women 18 to 65 years of age.

RESULTS

Participants accessed the health care system primarily during times of illness or in association with impending marriage, obtaining birth control, or childbearing. Barriers to screening participation included personal/cultural and provider/ system factors. Motivators included personal experience with others having cervical cancer, perceived importance of the Pap smear in maintaining health, reduction of financial barriers, and access to culturally appropriate health care.

CONCLUSIONS

Factors affecting cervical cancer screening behavior among Hispanic women are identifiable and describable. Knowledge of barriers and motivators can be utilized to design effective nursing interventions and community-based programs.

Receipt of cancer screening procedures among Hispanic and non-Hispanic health maintenance organization members

BACKGROUND

Hispanic Americans have been shown to receive fewer cancer screening procedures than nonminority populations. Although lack of insurance or a regular source of care appear to be important determinants, cultural factors also have been suggested. This study examines whether Hispanic patients receive cancer screening at the same rate as the non-Hispanic population when both groups have equivalent insurance and a regular source of care.

METHODS

Receipt of five cancer screening procedures (mammography, Pap test, fecal occult blood testing, breast examination, and rectal examination) was determined for adult health maintenance organization (HMO) members who met appropriate age and gender criteria. Rates of receipt were compared for 2 cohorts over a 2-year period: Hispanic members identified by surname and a comparison group, a 10% random sample of the non-Spanish surnamed members. Only members with at least one HMO contact over the study period were included. Logistic regression was used to test whether being in the Hispanic group was associated with decreased likelihood of receiving the procedure at least once over the 2 years, adjusting for potential confounders.

RESULTS

Among the comparison group, a high proportion received each recommended procedure at least once (0.70-0.86). The proportions were very similar for the Hispanic group (0.67-0.84). None of the rates differed statistically for the two groups.

CONCLUSIONS

Hispanic HMO members received cancer screening at the same high rate as non-Hispanics, suggesting that insurance coverage and continuity of care are more important than cultural factors in determining rates of cancer screening receipt.

Hispanic women's breast and cervical cancer knowledge, attitudes, and screening behaviors

PURPOSE

This study examined breast and cervical cancer knowledge, attitudes, and screening behaviors among different Hispanic populations in the United States.

DESIGN

Data were collected from a random digit dial telephone survey of 8903 Hispanic adults from eight U.S. sites. Across sites, the average response rate was 83%.

SETTING

Data were collected as part of the baseline assessment in a national Hispanic cancer control and prevention intervention study.

SUBJECTS

Analysis was restricted to 2239 Hispanic women age 40 and older who were self-identified as either Central American (n = 174), Cuban (n = 279), Mexican American (n = 1550), or Puerto Rican (n = 236).

MEASURES

A bilingual survey instrument was used to solicit information on age, education, income, health insurance coverage, language use, U.S.-born status, knowledge of screening guidelines, attitudes toward cancer, and screening participation. Differences in knowledge and attitudes across Hispanic groups were assessed by either chi-square tests or analysis of variance. Logistic regression models assessed the influence of knowledge and attitudes on screening participation.

RESULTS

The level of knowledge of guidelines ranged from 58.3% (Mexican Americans) to 71.8% (Cubans) for mammography, and from 41.1% (Puerto Ricans) to 55.6% (Cubans) for Pap smear among the different Hispanic populations. Attitudes also varied, with Mexican Americans and Puerto Ricans having more negative or fatalistic views of cancer than Cuban or Central Americans. Knowledge was significantly related to age, education, income, language preference, and recent screening history. Overall, attitudes were not predictive of mammography and Pap smear behavior.

CONCLUSIONS

Factors related to mammography and Pap smear screening vary among the different Hispanic populations. Limitations include the cross-sectional nature of the study, self-reported measures of screening, and the limited assessment of attitudes. The data and diversity of Hispanic groups reinforce the position that ethno-regional characteristics should be clarified and addressed in cancer screening promotion efforts. The practical relationships among knowledge, attitudes, and cancer screening are not altogether clear and require further research.

Health care reform in Oregon: the impact of the Oregon Health Plan on utilization of mammography

BACKGROUND

In 1994, Oregon implemented the Oregon Health Plan (OHP), extending health care coverage under a system of capitated managed care to uninsured citizens living below the Federal Poverty Level (FPL). We conducted a study to measure receipt of clinical preventive services among women newly enrolled in the OHP.

METHODS

Six hundred and sixty six women aged 52-64, and living below the FPL in Oregon were randomly selected from OHP enrollment rosters and interviewed by telephone. A follow-up survey was conducted 1 year later. The main outcome of interest was receipt of a screening mammogram during the first year in the OHP.

RESULTS

At enrollment 17% (65/383) of participants had never had health care coverage. Sixty-six percent of the women (220/333) were overdue for a mammogram. Fifty-five percent (121/220) reported cost as the main reason they had not had this procedure. Mammography rates doubled under the OHP (21% to 52%, 95% CI = 0.25-0.38, p < 0.001). Among women who were overdue for a mammogram at the time they enrolled, an expressed plan to get a mammogram (OR3.0, 95% CI = 1.1-8.7, p = 0.04), citing cost as the main reason for being overdue (OR3.0, 95% CI = 1.3-7.2, p = 0.014), receipt of a routine checkup (OR9.5, 95%CI = 3.7-24.9, p < 0.001), and health care provider's (HCP's) recommendation for mammography (OR8.1,95% CI = 2.9-23.0, p < 0.001) were independently associated with receipt of a mammogram.

CONCLUSION

The OHP enrolled and successfully delivered clinical preventive services to a medically under served population. Even after removing the financial barrier, obstacles to mammography remain. These may be overcome by health systems changes to insure receipt of routine checkups and appropriate provider recommendations.