Effects of health literacy skills, educational attainment, and level of melanoma risk on responses to personalized genomic testing

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.].

Ethical, Legal, and Social Implications of Gene-Environment Interaction Research

Many complex disorders are impacted by the interplay of genetic and environmental factors. In gene-environment interactions (GxE), an individual's genetic and epigenetic makeup impacts the response to environmental exposures. Understanding GxE can impact health at the individual, community, and population levels. The rapid expansion of GxE research in biomedical studies for complex diseases raises many unique ethical, legal, and social implications (ELSIs) that have not been extensively explored and addressed. This review article builds on discussions originating from a workshop held by the National Institute of Environmental Health Sciences (NIEHS) and the National Human Genome Research Institute (NHGRI) in January 2022, entitled: "Ethical, Legal, and Social Implications of Gene-Environment Interaction Research." We expand upon multiple key themes to inform broad recommendations and general guidance for addressing some of the most unique and challenging ELSI in GxE research. Key takeaways include strategies and approaches for establishing sustainable community partnerships, incorporating social determinants of health and environmental justice considerations into GxE research, effectively communicating and translating GxE findings, and addressing privacy and discrimination concerns in all GxE research going forward. Additional guidelines, resources, approaches, training, and capacity building are required to further support innovative GxE research and multidisciplinary GxE research teams.

The Role of Health Literacy in Skin Cancer Preventative Behavior and Implications for Intervention: A Systematic Review

BACKGROUND

Health literacy is essential for individuals to access, understand, and utilize information and services to inform health related decisions and actions. As one of the most diagnosed and preventable forms of cancer, skin cancer disease risk can be reduced through preventative behavior. Currently, there is no focused study looking specifically at health literacy and skin cancer. An understanding of how health literacy affects skin cancer-related preventive behaviors can improve current practices in skin cancer prevention.

OBJECTIVE

To systematically identify, synthesize, and summarize findings on the role of health literacy in skin cancers (including cutaneous squamous cell carcinoma, basal cell carcinoma, and melanoma), with a focus on preventive behaviors using studies that utilized quantifiable health literacy measurements.

METHODS

A literature search was performed by searching PubMed, Embase, PsycINFO, and CINAHL from inception until September 26, 2023 to identify cross-sectional, case-control, cohort, or randomized controlled studies that investigated the association between health literacy and skin cancer prevention and diagnosis.

RESULTS

Health literacy levels varied across geographic regions, specific populations, and ethnicities. Most of the included studies found a positive association between higher health literacy and better skin cancer preventative behaviors. This included sun-protective behaviors such as: wearing sleeved shirts or shirts with collars, using gloves, covering head and face, limiting sun exposure, more sunscreen use, and less sunbathing or indoor tanning. Higher health literacy was associated with increased likelihood to engage in genetic testing and less family influence on health in one study which assessed determinants of interest in skin cancer genetic testing. Another study investigating family communication about skin cancer found that higher health literacy was associated with increased family communication regarding general cancer risk. One sun protection interventional education program was effective at increasing participants' knowledge, awareness of skin cancer risk, willingness to change sun protection, and use of sun protection, but results varied between ethnic groups.

CONCLUSIONS

Skin cancer-related educational interventions can be effective in improving health literacy and potentially lessen the impact of skin cancer through positive behavior modification, early detection, and disease knowledge and awareness. Interventions need to be tailored to its target population to maximize effectiveness due to the varying baseline of health literacy identified across different geographic and ethnic groups. Protocol Registration PROSPERO CRD42022340826.

Melanocortin-1 receptor (MC1R): a review for dermatologists

Melanocortin-1 receptor (MC1R) and its variants have a pivotal role in melanin synthesis. However, MC1R has been associated to non-pigmentary pathways related to DNA-repair activities and inflammation. The aim of this review is to provide an up-to-date overview about the role of MC1R in the skin. Specifically, after summarizing the current knowledge about MC1R structure and polymorphisms, we report data concerning the correlation between MC1R, phenotypic traits, skin aging, other diseases and skin cancers and their risk assessment through genetic testing.

Exploring the role of cancer fatalism and engagement with skin cancer genetic information in diverse primary care patients

OBJECTIVE

To broaden the currently limited reach of genomic innovations, research is needed to understand how psychosocial and cultural factors influence reactions to genetic testing in diverse subgroups. Cancer fatalism is important in cancer prevention and deserves theoretical and empirical attention in the context of genomics and behavior change.

METHODS

The current study employed data from a randomized controlled trial (N = 593) offering skin cancer genetic testing (using the melanocortin-1 receptor [MC1R] gene) in primary care in Albuquerque, New Mexico, USA. We examined interrelations of cancer fatalism with demographics, general health beliefs, perceived risk, perceived control, sun protection and skin screening behaviors and cancer worry in the skin cancer context stratified across Hispanic versus non-Hispanic ethnicity, and examined cancer fatalism as a moderator of intervention effects on study primary outcomes, including 3-month sun protection, cancer worry and perceived risk.

RESULTS

Cancer fatalism was significantly related to the perception of control over skin cancer risk behaviors (ps ≤ 0.01) and demographics (ethnicity, education, health literacy; ps < 0.05), but not consistently related to general health beliefs or risk perception. Cancer fatalism did not moderate intervention effects on primary outcomes, except those with higher cancer fatalism randomized to intervention had higher levels of 3-month cancer worry (p = 0.019).

CONCLUSIONS

These findings will guide future work considering the role of cancer fatalism in use of genomic technologies in the general population. This work anticipates strategies required to address cancer fatalism as translational genomics becomes more commonly available to diverse general population subgroups.

Perceptions and beliefs of community gatekeepers about genomic risk information in African cleft research

BACKGROUND

A fundamental ethical issue in African genomics research is how socio-cultural factors impact perspectives, acceptance, and utility of genomic information, especially in stigmatizing conditions like orofacial clefts (OFCs). Previous research has shown that gatekeepers (e.g., religious, political, family or community leaders) wield considerable influence on the decision-making capabilities of their members, including health issues. Thus, their perspectives can inform the design of engagement strategies and increase exposure to the benefits of genomics testing/research. This is especially important for Africans underrepresented in genomic research. Our study aims to investigate the perspectives of gatekeepers concerning genomic risk information (GRI) in the presence of OFCs in a sub-Saharan African cohort.

METHODS

Twenty-five focus group discussions (FGDs) consisting of 214 gatekeepers (religious, community, ethnic leaders, and traditional birth attendants) in Lagos, Nigeria, explored the opinions of participants on genomic risk information (GRI), OFC experience, and the possibility of involvement in collaborative decision-making in Lagos, Nigeria. Transcripts generated from audio recordings were coded and analyzed in NVivo using thematic analysis.

RESULTS

Three main themes-knowledge, beliefs, and willingness to act-emerged from exploring the perspective of gatekeepers about GRI in this group. We observed mixed opinions regarding the acceptance of GRI. Many participants believed their role is to guide and support members when they receive results; this is based on the level of trust their members have in them. However, participants felt they would need to be trained by medical experts to do this. Also, religious and cultural beliefs were crucial to determining participants' understanding of OFCs and the acceptance and utilization of GRI.

CONCLUSIONS

Incorporating cultural sensitivity into public engagement could help develop appropriate strategies to manage conflicting ideologies surrounding genomic information in African communities. This will allow for more widespread access to the advances in genomics research in underrepresented populations. We also recommend a synergistic relationship between community health specialists/scientists, and community leaders, including spiritual providers to better understand and utilize GRI.

Participant-guided development of bilingual genomic educational infographics for Electronic Medical Records and Genomics Phase IV study

OBJECTIVE

Developing targeted, culturally competent educational materials is critical for participant understanding of engagement in a large genomic study that uses computational pipelines to produce genome-informed risk assessments.

MATERIALS AND METHODS

Guided by the Smerecnik framework that theorizes understanding of multifactorial genetic disease through 3 knowledge types, we developed English and Spanish infographics for individuals enrolled in the Electronic Medical Records and Genomics Network. Infographics were developed to explain concepts in lay language and visualizations. We conducted iterative sessions using a modified "think-aloud" process with 10 participants (6 English, 4 Spanish-speaking) to explore comprehension of and attitudes towards the infographics.

RESULTS

We found that all but one participant had "awareness knowledge" of genetic disease risk factors upon viewing the infographics. Many participants had difficulty with "how-to" knowledge of applying genetic risk factors to specific monogenic and polygenic risks. Participant attitudes towards the iteratively-refined infographics indicated that design saturation was reached.

DISCUSSION

There were several elements that contributed to the participants' comprehension (or misunderstanding) of the infographics. Visualization and iconography techniques best resonated with those who could draw on prior experiences or knowledge and were absent in those without. Limited graphicacy interfered with the understanding of absolute and relative risks when presented in graph format. Notably, narrative and storytelling theory that informed the creation of a vignette infographic was most accessible to all participants.

CONCLUSION

Engagement with the intended audience who can identify strengths and points for improvement of the intervention is necessary to the development of effective infographics.

Assessment of skin cancer precision prevention materials among Hispanics in Florida and Puerto Rico

OBJECTIVE

To assess Hispanic participants' ratings of intervention materials and examine differences by language preference.

METHODS

Participants on a skin cancer prevention trial were randomized to receive generic (n = 457) or precision prevention materials conveying average (n = 195) or higher genetic risk (n = 268) based on MC1R genotype. Three months after receiving either English or Spanish language prevention materials, participants reported amount read, believability and clarity of materials, and intention to change preventive behavior.

RESULTS

Participants reported high levels on all four outcomes, but the precision prevention groups noted lower clarity than the generic group (p = 3.2 ×10-6). Participants preferring Spanish provided consistently higher scores than those preferring English. Among English-preferring participants, those in the precision prevention groups scored lower on all measures than those in the generic group.

CONCLUSIONS

Skin cancer prevention materials were well-received by Hispanic participants. Higher scores among participants preferring Spanish may indicate acquiescence bias, or that translated prevention materials met their linguistic needs. Participants in the precision prevention groups with English language preference may have challenges in the uptake of genetic risk results.

PRACTICE IMPLICATIONS

Availability of Spanish materials may have facilitated higher scores. Additional strategies should be explored to optimize participants' believability and clarity of precision prevention materials.

Communicating Personal Melanoma Polygenic Risk Information: Participants’ Experiences of Genetic Counseling in a Community-Based Study

Personalized polygenic risk information may be used to guide risk-based melanoma prevention and early detection at a population scale, but research on communicating this information is limited. This mixed-methods study aimed to assess the acceptability of a genetic counselor (GC) phone call in communicating polygenic risk information in the Melanoma Genomics Managing Your Risk randomized controlled trial. Participants (n = 509) received personalized melanoma polygenic risk information, an educational booklet on melanoma prevention, and a GC phone call, which was audio-recorded. Participants completed the Genetic Counseling Satisfaction Survey 1-month after receiving their risk information (n = 346). A subgroup took part in a qualitative interview post-study completion (n = 20). Survey data were analyzed descriptively using SPSS, and thematic analysis of the qualitative data was conducted using NVivo 12.0 software. The survey showed a high level of acceptability for the GC phone call (mean satisfaction score overall: 4.3 out of 5, standard deviation (SD): 0.6) with differences according to gender (mean score for women: 4.4, SD: 0.6 vs. men: 4.2, SD: 0.7; p = 0.005), health literacy (lower literacy: 4.1, SD: 0.8; average: 4.3, SD: 0.6; higher: 4.4, SD: 0.6: p = 0.02) and polygenic risk group (low risk: 4.5, SD: 0.5, SD: average: 4.3, SD: 0.7, high: 4.3, SD: 0.7; p = 0.03). During the GC phone calls, the discussion predominately related to the impact of past sun exposure on personal melanoma risk. Together our findings point to the importance of further exploring educational and support needs and preferences for communicating personalized melanoma risk among population subgroups, including diverse literacy levels.

Interest and Utility of MC1R Testing for Melanoma Risk in Dermatology Patients with a History of Nonmelanoma Skin Cancer

Public access to genetic information is increasing, and community dermatologists may progressively encounter patients interested in genetic testing for melanoma risk. Clarifying potential utility will help plan for this inevitability. We determined interest and uptake of genetic risk feedback based on melanocortin receptor gene (MC1R) variants, immediate (two weeks) responses to risk feedback, and test utility at three months in patients (age ≥ 18, with a history of nonmelanoma skin cancer). Participants (N = 50) completed a baseline survey and were invited to consider MC1R testing via the study website. Testing interest and uptake were assessed through registration of test decision, request of a saliva test kit, and kit return (all yes/no). Immediate responses to risk feedback included feedback-relevant thoughts, emotions, communication, and information seeking after result receipt; test utility outcomes included family and physician communication and information seeking. Results indicated good retention at both time points (76%; 74%). Half (48%) logged onto the study website, and of these, most (92%) chose testing and (95%) returned a saliva sample. After two weeks, most (94%) had read all the risk feedback information and distress was low (M = 8.81, 7–28, SD = 2.23). Many (69%) had talked with their family about the results. By three months, most had spoken with family (92%) and physicians (80%) about skin cancer risk. Physician communication was higher (70%) in those tested versus those not tested (40%, p = 0.02). The substantial interest and promising outcomes associated with MC1R genetic testing in dermatology patients inform intervention strategies to enhance benefits and minimize risks of skin cancer genetic testing.

Assessment of melanoma precision prevention materials incorporating MC1R genetic risk information

Few studies have examined cognitive responses to mailed precision prevention materials. MC1R is a robust, well-described melanoma susceptibility marker. The purpose was to assess cognitive responses to generic or precision prevention materials incorporating MC1R genetic risk. Non-Hispanic White participants (n = 1134) enrolled in a randomized controlled trial received either precision prevention materials incorporating MC1R genetic risk (higher/average) or generic prevention (standard) materials. Six months after baseline, 808 (71.3%) participants reported on the amount of prevention materials read (5-point scale); believability and clarity of materials; intention to change preventive behaviors (7-point Likert scale); and recall of their MC1R genetic risk. Comparisons were conducted using Kruskal-Wallis and chi-squared tests. Overall, participants read most to all (Mdn = 4, IQR = 2) of the prevention materials, reported high believability (Mdn = 7, IQR = 1) and clarity (Mdn = 7, IQR = 1), and moderate intention to change preventive behaviors (Mdn = 5, IQR = 2). Higher-risk participants reported slightly less clarity (Mdn = 6, IQR = 2) than either average-risk (Mdn = 6, IQR = 1, p = 2.50 × 10-3) or standard participants (Mdn = 7, IQR = 1, p = 2.30 × 10-5); and slightly less believability (Mdn = 6, IQR = 1) than standard participants (Mdn = 7, IQR = 1, p = .005). Higher-risk participants were 2.21 times as likely (95% CI = 1.43-3.43) to misremember or forget their risk compared to average-risk participants; misremembering was observed only among higher-risk participants (14%). Mailed precision prevention information were mostly read, highly believable and clear, and resulted in moderate levels of intention to change sun protection behaviors, bolstering the feasibility of population-level precision prevention. Defensive reactions may explain lower clarity, believability, and higher incorrect risk recall among higher-risk participants.

Effect of Superstitious Beliefs and Risk Intuitions on Genetic Test Decisions

INTRODUCTION

Moving beyond numeric representations of risk perceptions, we examine cognitive causation, or superstitious thinking, and negative affect in risk as predictors of MC1R (i.e., moderate v. high risk) skin cancer genetic testing and responses to this testing.

METHODS

Participants (N = 496) completed baseline assessments using validated measures of cognitive causation (beliefs that thinking about cancer risk increases cancer likelihood) and negative affect in risk (negative feelings generated during risk perception) and subsequently received a test offer. Participants could access a website to learn about and request genetic testing. Those who tested (n = 167) completed assessments of cognitive and affective reactions 2 wk after testing, including the Impact of Events-Revised Intrusive thoughts subscale.

RESULTS

Those with higher negative affect in risk were less likely to return a saliva sample for testing (odds ratio = 0.98, 95% confidence interval = 0.96-0.99). Those with higher cognitive causation reported more fear (b = 0.28-0.31; P's < 0.05). Higher negative affect in risk was associated with more emotion-laden test responses, particularly in those receiving higher-risk as compared with average-risk results.

CONCLUSION

Negative affect in risk did not hamper test information seeking, although it did inhibit the uptake of genetic testing. Those with higher cognitive causation showed more fear regarding their test result, as indicated by higher distress in those who received average-risk results and lower believability in those who received higher-risk results.

Comprehension of skin cancer genetic risk feedback in primary care patients

Few studies have examined comprehension and miscomprehension of genetic risk feedback for moderate-risk genes in the general population. We examined the prevalence and nature of accurate and inaccurate genetic risk feedback comprehension among those who received genetic testing for melanocortin-1-receptor (MC1R) gene variants that confer moderate melanoma risk. Participants (N = 145 Albuquerque, NM) were tested as part of a randomized controlled trial. Two weeks after receiving MC1R genetic risk feedback, participants answered open-ended questions regarding their reactions to the MC1R feedback report. Participants' comprehension of their feedback (average-risk or higher-risk for melanoma) was evaluated through qualitative analysis of open-ended responses. Most participants demonstrated comprehension of their feedback results (i.e., 63% of average-risk participants [ARPs]; 51% of higher-risk participants [HRPs]). Miscomprehension was evident in fewer participants (i.e., 16% of ARPs, 11% of HRPs). A few ARPs misunderstood the purpose of testing, whereas a few HRPs reported confusion about the meaning of their risk feedback. Some participants' responses to the open-ended questions were too ambiguous to ascertain comprehension or miscomprehension (i.e., 21% of ARPs, 38% of HRPs). Taken together, these findings suggest that genetic testing feedback for MC1R risk variants is largely comprehensible to general population participants. This study adds to the work examining comprehension and usage of common, moderate risk genetic information in public health contexts. However, to maximize the utility of genetic risk information in the general population, further research is needed to investigate and address areas where common genetic risk feedback misunderstandings occur.

Behavioral and Psychological Outcomes Associated with Skin Cancer Genetic Testing in Albuquerque Primary Care

Simple Summary

Genetic information is publicly available but research examining the best use of such information has not engaged diverse members of the public. We examined public reactions to melanoma genetic testing (using the melanocortin-1 receptor [MC1R] gene) in a study randomizing (like the flip of a coin) 600 diverse primary care patients to a MC1R test offer or usual care. We found that testing did not improve sun protection and skin cancer screening, nor did it lead worry to increase. However, groups less aware of their skin cancer risk, including those who thought their risk was “unlikely” at the start of the study, showed significant improvements in sun protection at three months. In conclusion, testing might be very helpful for certain people who have the most to learn about their risk, who may become motivated to protect themselves from the damaging effects of the sun as a result of skin cancer genetic testing.

Abstract

Public availability of genetic information is increasing; thus, efforts to improve diversity in basic and translational research in genomics is a top priority. Given the increasing U.S. incidence and mortality of melanoma, and the prevalence of common melanocortin-1 receptor (MC1R) gene melanoma risk variants in the general population, we examined genomic testing of MC1R for skin cancer risk in a randomized controlled trial in Albuquerque, New Mexico primary care. Participants were 48% Hispanic and were randomized 5:1 to a MC1R test invitation or usual care. We assessed 3 month sun protection, skin cancer screening, and skin cancer worry outcomes associated with testing, and key effect moderators (e.g., cancer risk perceptions, and skin cancer risk factors). Our findings indicate that the primary outcomes were unchanged by the MC1R test offer, test acceptance, and level of risk feedback. Moderator analyses showed that those with lower risk perception, and those with skin that readily tans, significantly increased their sun protection in response to higher than average risk feedback. Risk feedback did not prompt cancer worry, and average risk feedback did not erode existing sun protection. This study paves the way for the development of tailored strategies to address low skin cancer risk awareness in this understudied context of public health genomics.

Behind the Scene: Exploiting MC1R in Skin Cancer Risk and Prevention

Melanoma and non-melanoma skin cancers (NMSCs) are the most frequent cancers of the skin in white populations. An increased risk in the development of skin cancers has been associated with the combination of several environmental factors (i.e., ultraviolet exposure) and genetic background, including melanocortin-1 receptor (MC1R) status. In the last few years, advances in the diagnosis of skin cancers provided a great impact on clinical practice. Despite these advances, NMSCs are still the most common malignancy in humans and melanoma still shows a rising incidence and a poor prognosis when diagnosed at an advanced stage. Efforts are required to underlie the genetic and clinical heterogeneity of melanoma and NMSCs, leading to an optimization of the management of affected patients. The clinical implications of the impact of germline MC1R variants in melanoma and NMSCs' risk, together with the additional risk conferred by somatic mutations in other peculiar genes, as well as the role of MC1R screening in skin cancers' prevention will be addressed in the current review.