Racial segregation and genomics-related knowledge, self-efficacy, perceived importance, and communication among medically underserved patients

Social vulnerability and genetic service utilization among unaffected BRIDGE trial patients with inherited cancer susceptibility

BACKGROUND

Research on social determinants of genetic testing uptake is limited, particularly among unaffected patients with inherited cancer susceptibility.

METHODS

We conducted a secondary analysis of the Broadening the Reach, Impact, and Delivery of Genetic Services (BRIDGE) trial at University of Utah Health and NYU Langone Health, involving 2,760 unaffected patients meeting genetic testing criteria for inherited cancer susceptibility and who were initially randomized to either an automated chatbot or an enhanced standard of care (SOC) genetic services delivery model. We used encounters from the electronic health record (EHR) to measure the uptake of genetic counseling and testing, including dichotomous measures of (1) whether participants initiated pre-test cancer genetic services, (2) completed pre-test cancer genetic services, (3) had genetic testing ordered, and (4) completed genetic testing. We merged zip codes from the EHR to construct census tract-weighted social measures of the Social Vulnerability Index. Multilevel models estimated associations between social vulnerability and genetic services utilization. We tested whether intervention condition (i.e., chatbot vs. SOC) moderated the association of social vulnerability with genetic service utilization. Covariates included study arm, study site, age, sex, race/ethnicity, language preference, rural residence, having a recorded primary care provider, and number of algorithm criteria met.

RESULTS

Patients living in areas of medium socioeconomic status (SES) vulnerability had lower odds of initiating pre-test genetic services (adjusted OR [aOR] = 0.81, 95% CI: 0.67, 0.98) compared to patients living in low SES vulnerability areas. Patients in medium household vulnerability areas had a lower likelihood of completing pre-test genetic services (aOR = 0.80, 95% CI: 0.66-0.97) and having genetic testing ordered (aOR = 0.79, 95% CI: 0.63-0.99) relative to patients in low household vulnerability areas. We did not find that social vulnerability associations varied by intervention condition.

CONCLUSIONS

These results underscore the importance of investigating social and structural mechanisms as potential pathways to increasing genetic testing uptake among patients with increased inherited risk of cancer. Census information is publicly available but seldom used to assess social determinants of genetic testing uptake among unaffected populations. Existing and future cohort studies can incorporate census data to derive analytic insights for clinical scientists.

TRIAL REGISTRATION

BRIDGE was registered as NCT03985852 on June 6, 2019 at clinicaltrials.gov.

Structural Determinants of Health Literacy Among Formerly Incarcerated Individuals: Insights From the Survey of Racism and Public Health

BACKGROUND

Formerly incarcerated individuals (FIIs) encounter difficulties with covering the cost of dental and medical care, adhering to medication regimens, and receiving fair treatment from health care providers. Yet, no published research has examined modifiable pathways to increase FIIs' health literacy (HL), which is essential for addressing the health needs of this vulnerable population.

OBJECTIVE

The aim of this article is to examine neighborhood characteristics (neighborhood deprivation, racial and economic polarization, and residential segregation) and public assistance program enrollment as structural determinants of limited health literacy (LHL) among FIIs.

METHODS

Using a socioecological framework, we analyzed a subsample of 578 FIIs from the 2023 Survey of Racism and Public Health, an online cross-sectional survey spanning U.S. Department of Health & Human Services Regions 1, 2, and 3. HL was assessed using the Brief Health Literacy Screen. Logistic regression models estimated unadjusted and adjusted associations of LHL with neighborhood characteristics and public assistance program enrollment. Adjusted models controlled for age, race and ethnicity, gender identity, educational attainment, marital and employment status, number of children, chronic health conditions, and incarceration length.

KEY RESULTS

The 578 FIIs had an average age of 46, with 42% having LHL. We observed a statistically significant association between public assistance program enrollment and LHL (unadjusted odds ratio [OR] = 2.72, 95% confidence interval [CI]: 1.87, 4.01; adjusted OR = 2.50, 95% CI: 1.62, 3.88). We found no statistically significant associations of LHL with neighborhood deprivation, racial and economic polarization, and residential segregation.

CONCLUSIONS

Our findings suggest that there may be an opportunity to develop tailored interventions for increasing HL among FIIs through public assistance programs. Dissemination of HL resources among this marginalized group can improve their self-management of chronic diseases. This is of paramount importance because FIIs must simultaneously navigate other challenges after incarceration (e.g., unstable housing). [HLRP: Health Literacy Research and Practice. 2025;9(1):e8-e18.].

Racial Composition of Social Environments Over the Life Course Using the Pictorial Racial Composition Measure: Development and Validation Study

BACKGROUND

Studies investigating the impact of racial segregation on health have reported mixed findings and tended to focus on the racial composition of neighborhoods. These studies use varying racial composition measures, such as census data or investigator-adapted questions, which are currently limited to assessing one dimension of neighborhood racial composition.

OBJECTIVE

This study aims to develop and validate a novel racial segregation measure, the Pictorial Racial Composition Measure (PRCM).

METHODS

The PRCM is a 10-item questionnaire of pictures representing social environments across adolescence and adulthood: neighborhoods and blocks (adolescent and current), schools and classrooms (junior high and high school), workplace, and place of worship. Cognitive interviews (n=13) and surveys (N=549) were administered to medically underserved patients at a primary care clinic at the Barnes-Jewish Hospital. Development of the PRCM occurred across pilot and main phases. For each social environment and survey phase (pilot and main), we computed positive versus negative pairwise comparisons: mostly Black versus all other categories, half Black versus all other categories, and mostly White versus all other categories. We calculated the following validity metrics for each pairwise comparison: sensitivity, specificity, correct classification rate, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, false positive rate, and false negative rate.

RESULTS

For each social environment, the mostly Black and mostly White dichotomizations generated better validity metrics relative to the half Black dichotomization. Across all 10 social environments in the pilot and main phases, mostly Black and mostly White dichotomizations exhibited a moderate-to-high sensitivity, specificity, correct classification rate, positive predictive value, and negative predictive value. The positive likelihood ratio values were >1, and the negative likelihood ratio values were close to 0. The false positive and negative rates were low to moderate.

CONCLUSIONS

These findings support that using either the mostly Black versus other categories or the mostly White versus other categories dichotomizations may provide accurate and reliable measures of racial composition across the 10 social environments. The PRCM can serve as a uniform measure across disciplines, capture multiple social environments over the life course, and be administered during one study visit. The PRCM also provides an added window into understanding how structural racism has impacted minoritized communities and may inform equitable intervention and prevention efforts to improve lives.

Racial Composition of Past and Current Social Environments and Health Literacy

BACKGROUND

Research is needed to understand the impact of social determinants of health on health literacy throughout the life course. This study examined how racial composition of multiple past and current social environments was related to adults' health literacy.

METHODS

In this study, 546 adult patients at a primary care clinic in St. Louis, Missouri, completed a self-administered written questionnaire that assessed demographic characteristics and a verbally administered component that assessed health literacy with the Rapid Estimate of Adult Literacy in Medicine - Revised (REALM-R) and Newest Vital Sign (NVS), and self-reported racial composition of six past and four current social environments. Multilevel logistic regression models were built to examine the relationships between racial composition of past and current social environments and health literacy.

RESULTS

Most participants identified as Black or multiracial (61%), had a high school diploma or less (54%), and household income <$20,000 (72%). About 56% had adequate health literacy based on REALM-R and 38% based on NVS. In regression models, participants with multiple past white environments (e.g., locations/conditions in which most of the people who live, go to school, work, and have leisure time are White) and (vs. 0 or 1) were more likely to have adequate health literacy based on REALM-R (adjusted odds ratio [aOR] = 1.79; 95% confidence interval [CI]: 1.04-3.07). Similarly, participants who had multiple past white social environments were more likely (aOR = 1.94, 95% CI: 1.15-3.27) to have adequate health literacy based on NVS than those who had not. The racial composition of current social environments was not significantly associated with health literacy in either model.

CONCLUSIONS

Racial composition of past, but not current, educational and residential social environments was significantly associated with adult health literacy. The results highlight the importance of examining the impact of social determinants over the life course on health literacy. The findings suggest that policies ensuring equitable access to educational resources in school and community contexts is critical to improving equitable health literacy. [HLRP: Health Literacy Research and Practice. 2024;8(3):e130-e139.].

Determinants of Breast Cancer Screening Adherence During the COVID-19 Pandemic in a Cohort at Increased Inherited Cancer Risk in the United States

BACKGROUND

We examined neighborhood characteristics concerning breast cancer screening annual adherence during the COVID-19 pandemic.

METHODS

We analyzed 6673 female patients aged 40 or older at increased inherited cancer risk in 2 large health care systems (NYU Langone Health [NYULH] and the University of Utah Health [UHealth]). Multinomial models were used to identify predictors of mammogram screening groups (non-adherent, pre-pandemic adherent, pandemic period adherent) in comparison to adherent females. Potential determinants included sociodemographic characteristics and neighborhood factors.

RESULTS

Comparing each cancer group in reference to the adherent group, a reduced likelihood of being non-adherent was associated with older age (OR: 0.97, 95% CI: 0.95, 0.99), a greater number of relatives with cancer (OR: 0.80, 95% CI: 0.75, 0.86), and being seen at NYULH study site (OR: 0.42, 95% CI: 0.29, 0.60). More relatives with cancer were correlated with a lesser likelihood of being pandemic period adherent (OR: 0.89, 95% CI: 0.81, 0.97). A lower likelihood of being pre-pandemic adherent was seen in areas with less education (OR: 0.77, 95% CI: 0.62, 0.96) and NYULH study site (OR: 0.35, 95% CI: 0.22, 0.55). Finally, greater neighborhood deprivation (OR: 1.47, 95% CI: 1.08, 2.01) was associated with being non-adherent.

CONCLUSION

Breast screening during the COVID-19 pandemic was associated with being older, having more relatives with cancer, residing in areas with less educational attainment, and being seen at NYULH; non-adherence was linked with greater neighborhood deprivation. These findings may mitigate risk of clinically important screening delays at times of disruptions in a population at greater risk for breast cancer.