Individual, provider, and system risk factors for breast and cervical cancer screening among underserved Black, Latina, and Arab women

Assessment of the Psychosocial Impact of Pancreatic Cancer Surveillance in High-Risk Individuals

OBJECTIVES

Pancreatic cancer (PC) surveillance of high-risk individuals (HRIs) downstages PC and improves survival. However, it remains less clear whether PC surveillance has a positive psychosocial impact on HRIs. Herein, we aimed to define the attitudes and beliefs of HRIs undergoing PC surveillance, and the immediate and sustained psychosocial impact of PC surveillance in HRIs.

METHODS

100 HRIs undergoing PC surveillance by endoscopic ultrasound (EUS) completed three surveys addressing different components of the psychosocial impact of PC surveillance. Logistic regression analyses were performed to identify predictive factors relating to these components.

RESULTS

Most HRIs reported increased perceived benefits of PC surveillance, self-efficacy, and perceived severity of PC. HRIs reported few negative emotions prior to surveillance and frequent positive emotions after surveillance. Compared to prior to surveillance, there was a 53.5% decrease in the level of distress reported by HRIs after surveillance, which was sustained for 4-6 weeks post-surveillance. Family history of PC and lower self-reported mental health were identified as predictors for increased perceived susceptibility to PC (p < 0.01) and greater change in distress pre- to post-surveillance (p < 0.01), respectively.

CONCLUSIONS

Our findings suggest that PC surveillance can lead to sustained psychosocial benefits in HRIs.

Turning the Page on Breast Cancer in Ohio: Lessons learned from implementing a multilevel intervention to reduce breast cancer mortality among Black women

BACKGROUND

Turning the Page on Breast Cancer (TPBC) uses a multilevel approach to reduce breast cancer (BC) mortality among Black women. TPBC intervenes by (1) improving health care facilities' ability to conduct effective BC screening, follow-up, and treatment; (2) involving community-based organizations; and (3) providing education and personal risk information through a culturally relevant website. Ohio has among the worst BC mortality rates in the United States for Black women. TPBC is in its third year of providing targeted interventions in 12 Ohio counties with particularly high BC rates among Black women.

METHODS

TPBC enrolls health care facilities, collects organizational and patient data, and conducts key informant interviews to inform the provision of appropriate evidence-based interventions. TPBC engages Black communities through community-based organizations and social media advertising. The TPBC website offers BC information, connects Black women to community BC resources, and provides access to a risk-assessment tool.

RESULTS

TPBC has provided tailored information packets, evidence-based interventions, and systematic support for improving the tracking and follow-up of breast health care among patients in 10 clinical partnerships. The project has provided education at community events monthly since mid-2021. The TPBC website (http://endbreastcancerohio.org) is promoted through social media (primarily Facebook) and community events to reach Black women aged 25-70 years. To date, 4108 unique users have visited the website, of whom 15.9% completed the risk assessment.

CONCLUSIONS

Novel strategies are needed to address persistent disparities in BC outcomes among Black women. TPBC demonstrates the potential effectiveness of multiple methods of community-based, clinic-based, and web-based engagement.

PLAIN LANGUAGE SUMMARY

Turning the Page on Breast Cancer (TPBC) aims to reduce breast cancer mortality among Black women in Ohio by conducting multilevel, community-engaged interventions in 12 counties. Women are provided risk information and education at virtual and in-person community events and through a community-friendly website that was launched in November 2020. Almost 4000 women have visited the website, which offers community-targeted information, urges screening for individuals at elevated risk, and offers access to patient navigation services; 655 users have used a breast cancer risk-assessment tool on the site. Community-based organizations conduct educational efforts. TPBC partners with health care facilities, which are taught to improve their ability to conduct effective breast cancer screening, follow-up, and treatment. So far, TPBC has provided educational information, evidence-based intervention lists, tailored information packets, and ongoing quarterly support to partners in 10 counties. Evaluation will focus on aggregated data for screening and genetic testing referral at the clinic level.

Breast cancer screening among immigrant Muslim arab women in the United States: Analyzing relationships between beliefs, knowledge, spousal support and mammogram utilization

BACKGROUND

Regular mammogram screenings contribute to a decreased breast cancer (BC) mortality rate. Women from ethnic minorities in the United States, however, often underutilize mammogram screenings; in particular, immigrant Muslim Arab (IMAW) women have low mammogram screening rates.

OBJECTIVE

To explore the associations between mammogram utilization and (a) health and religious beliefs, (b) level of knowledge about mammograms, (c) health care provider (HCP) recommendations, and (d) spousal support.

METHODS

A cross-sectional study employed online data collection. An Arabic or English survey was completed by women who were 45 or older and married, had immigrated from Arab countries, and had no history of breast cancer. Logistic regression was conducted for data analyses.

RESULTS

Of the 184 Immigrant Muslim Arab survey participants, 86.6% reported having had at least one mammogram in their lifetime, and 32.6% adhered to mammograms. Ever having obtained a mammogram and adherence to mammograms were negatively associated with perceived mammogram barriers and positively associated with (a) spousal support, (b) level of mammogram knowledge, and (c) perceived self-confidence. Receiving (HCP) recommendation increased the likelihood of ever having obtained a mammogram. Finally, participants who reported higher levels of perceived mammogram benefits were more likely to have obtained a mammogram within the last 2 years compared to their counterparts.

CONCLUSIONS

IMAW have demonstrated low mammogram adherence rate.

IMPLICATIONS

Nursing clinicians and scholars must play a role in designing and implementing interventions to promote women adherence to mammograms. Involving husbands in these interventions may improve immigrant Muslim Arab women's mammogram adherence rates.

Refugee Family Health Brokers' (FHBs') Experiences with Health Care Providers: A Thematic Analysis

BACKGROUND

The resettlement and post-resettlement quality of life of refugees is often marred by chronic health/mental health conditions. To adequately care for refugees suffering these conditions, a promising strategy is the use of refugee Family Health Brokers (FHBs). FHBs are safe and trusted family members functioning as intermediaries between one's family and health care providers. Although FHBs are known to positively influence health care utilization in their families, little is known about them and this aspect of their family caregiving role and experiences, particularly with health care providers, necessitating further research.

METHODS

Fourteen Bhutanese and three Bosnian refugee FHBs participated in a 2-hr focus group discussing their experiences with health care providers after being surveyed about their FHB role.

RESULTS

Thematic analysis yielded five themes centered around perceptions, knowledge, communication, behavior, and responsibilities reflective of FHBs' experiences, which can be understood as symptoms of existing structural inequalities.

CONCLUSIONS

FHBs primarily conveyed problems, struggles, and dilemmas they experienced more so than rewarding aspects of being an FHB. Suggestions are provided on how to avert these negative experiences from occurring and becoming barriers to developing allyship with FHBs in the context of existing structural inequalities.

A Scoping Literature Review on Evidence-Based Strategies to Increase Cervical Cancer Screening

Previous reviews of strategies to increase cervical cancer screening are more than 10 years old, the U.S. continues to fall short of the Healthy People 2030 cervical cancer screening goal, and guidelines were revised in 2018, therefore an updated review of the existing literature is needed. We conducted a scoping review using electronic databases PubMed, Scopus, and Ovid Medline that included publication dates between 2012 and 2021 to answer the question, "Which strategies implemented in U.S. primary care settings have been most successful in increasing rates of cervical cancer screening since the 2012 US Preventative Services Task Force cervical cancer screening guidelines were published?" We mapped findings to pre-specified implementation strategy categories. After initially identifying 399 articles, we excluded 350 due to duplicates or not meeting review criteria, leaving 49 articles for full review. We excluded 37 of these during full-text review and identified 2 additional articles from the manual search of reference lists for a total of 14 studies for abstraction. Eleven articles reported on strategies resulting in increased cervical cancer screening, and 3 did not. Clinic workflow re-design strategies showed the greatest promise in improving cervical cancer screening rates, education strategies for patients had mixed results, and quality management strategies were not effective. These findings suggest clinical workflow re-structures and patient education strategies can increase cervical cancer screening in primary care settings. Results are particularly important in settings that care for underserved populations, as these settings may need additional implementation strategies to decrease cervical cancer screening disparities.

The Impact of IT-Based Healthcare Communication on Mammography Screening Utilization among Women in the United States: National Health Interview Survey (2011-2018)

Effective patient-provider communication improves mammography utilization. Using information technology (IT) promotes health outcomes. However, there are disparities in access to IT that could contribute to disparities in mammography utilization. This study aims to assess the association between IT-based health care communication and mammography utilization and to evaluate if this effect is modified by race/ethnicity and age. To this end, this study was conducted using the National Health Interview Survey from 2011 to 2018. A total of 94,290 women aged 40 years and older were included. Multiple logistic regression models were used, and odds ratios were reported. The study found that all IT-based healthcare communication strategies were significantly associated with mammography utilization in all years from 2011 to 2018. In 2018, women who looked up health information on the internet, scheduled a medical appointment on the internet, and communicated with providers by email had a significantly higher chance to use mammography (p ≤ 0.005 for all strategies across all years). White women and women aged 50 years and older benefited the most from IT-based healthcare communication. In conclusion, facilitating access to IT may help increase mammography utilization, which may contribute to eliminating disparities in breast cancer mortality.

Increased disparities associated with black women and abnormal cervical cancer screening follow-up

•

Timely follow-up and treatment after abnormal cervical cancer screening is lacking in over half of all women.

•

Black women have the lowest rate of follow-up after abnormal screening.

•

One-fourth of Black and Hispanic women have delayed follow-up.

•

Insurance status is also associated with timely follow-up with abnormal cervical cancer screening.

Background

To determine whether race and ethnicity impacts patient adherence to follow-up for colposcopy after abnormal cervical cancer screening.

Methods

This retrospective chart review included women that were randomly selected from patients presenting to our colposcopy clinic from 1/2019 to 12/2019. Inclusion criteria were females age ≥21 years-old and appropriate referral for colposcopy. Patients were grouped into three categories: (1) ADHERENT to follow-up if they came to their first scheduled appointment; (2) DELAYED if they presented more than three months from their original referral (usually missing 1–3 appointments); and (3) NOT ADHERENT if they did not show for their appointment after referral. Analysis was performed using SPSS v.26.

Results

284 women met inclusion criteria for the study. The majority of women were Black (65.2 %) followed by non-Hispanic Whites (20.0 %) and Latinx (14.8 %). Overall, 39.1 % were ADHERENT, 18.6 % were DELAYED, and 42.3 % were NOT ADHERENT. When compared with non-Hispanic White women, there was a significant difference between race/ethnicity and timing of follow-up (p = 0.03). Blacks were more likely to be NOT ADHERENT (45.9 %; p = 0.03), and Latinx and Blacks were the most likely to be DELAYED (35.7 % and 21.1 %; p = 0.03). Private insurance patients were more likely to be ADHERENT for care compared with un-/underinsured patients (78.9 vs 27.8 %, p = 0.0001).

Conclusion

There is inadequate follow-up after abnormal cervical cancer screening across all races/ethnicities; however, lack of adherence is higher in Black patients. Moreover, 25% of Hispanic and Black women present in a delayed fashion. Culturally relevant assessments and interventions are needed to understand and address these gaps.

Organized Breast and Cervical Cancer Screening: Attendance and Determinants in Rural China

To evaluate the attendance and determinants of organized cervical and breast cancer (two-cancer) screening, especially higher-level factors, we conducted a cross-sectional survey in central China from June 2018 to November 2019 among 1949 women (age ≥ 35 years). We examined organizer-level factors, provider-level factors, receiver-lever factors and attendance and participation willingness of screening. The results indicate that the attendance and participation willingness of organized two-cancer screening was 61.19% and 77.15%, respectively. After adjustment for potential confounders, women who received screening notification were more likely to have greater participation willingness and higher attendance than those who received no notification (adjusted odds ratio [aOR] = 1.59, 95% confidence interval [CI]: 1.27-1.99; aOR = 98.03, 95% CI: 51.44-186.82, respectively). Compared with being notified about screening by GPs, being notified by community women's leaders and other community leaders were more likely to lead to greater willingness to participate again (aOR = 2.86, 95% CI: 1.13-7.24; aOR = 3.27, 95% CI: 1.26-8.48, respectively) and recommending screening to others (aOR = 2.18, 95% CI: 1.02-4.65; aOR = 4.14, 95% CI: 1.84-9.30, respectively). The results suggest that notification of women about screening by community leaders is an important organizer-level factor. As a part of public health services, the design and implementation of optimal cancer screening strategies may require public-sector involvement at the organizer level instead of a one-man show by the health sector.

Concordant physician-patient characteristics lose importance for Arab American women and their healthcare- cross-sectional study

Background

Arab American women have preferred women physicians of their own culture in the past. The primary aim of this study is to determine the current influence of religion/culture among MENA women and their preferences for physicians of same sex, culture, and religion on the avoidance and uncomfortableness of routine and women's health exams.

Methods

A cross sectional community survey including religiosity and the importance of physician matched sex, culture, and religion was completed. Outcome measures were avoidance of a routine physical exam, or a women's health exam because of religious/cultural issues; and the uncomfortableness of the women's health exam. Linear regression modeling was used to evaluate the association between outcomes and potential predictors, with significance assessed using a bootstrap method.

Findings

The responses of 97 MENA women 30-65 years old showed that MENA women agreed that they would avoid routine health exams because of religious/cultural issues if their physician was of the same religion or culture as they were (p < 0.001, p < 0.05, respectively) or they had less education (p < 0.05). MENA women also avoided women's health exams due to religious/cultural issues if her physician was of the same religion as she (p < 0.01).

Interpretation

MENA women 30-65 years old may no longer be bound to a female physician of their same religion/culture for their health exams.

Improving physician compliance with mammography screening by implementing a breast cancer screening guideline at a hospital in Bahrain

Background

From a health and safety perspective, it is critical to use adequate, evidence-based breast screening guidelines. The aim of this quality improvement project was to improve physicians’ compliance with breast cancer screening guidelines to enhance the mammography screening rate among eligible women; this was achieved through the implementation of multifaceted changes to the hospital’s processes and the improvement of physicians’ attitudes towards the guidelines.

Methods

The project used the Plan-Do-Study-Act method to implement the changes. This was a pre-post evaluation study. The data were collected from patients’ charts. The primary outcome of interest was the rate of physician compliance with mammography screening guidelines before and after the implementation of the process changes. A literature review was conducted to determine which women should be identified as eligible for mammography screening.

Intervention

The interventions targeted physician knowledge and hospital processes. Improving doctors’ expertise was achieved by implementing the US Preventive Service Task Force recommendation for mammography screening every 2 years for women aged 50–74 years. The process modifications included the establishment of a system that would be effective in identifying at-risk patients and reminding physicians at the point of care.

Results

Over the course of this study, 825 patients met the criteria for breast cancer screening. The rate of physician compliance with the breast cancer screening guideline increased from 2% to 69% after 23 weeks, and the control charts demonstrated a reliable process.

Conclusion

This project examined the relationship between different interventions (identification of the eligible patient, reminder alerts and physician knowledge) and physician compliance with mammography screening guidelines. The results suggest a positive link between the study variables and physicians’ compliance with mammography screening guidelines.

Examination of the Association Between Access to Care and Lung Cancer Screening Among High-Risk Smokers

Objective: The purpose of this study was to examine the influence of access to care on the uptake of low-dose computed tomography (LDCT) lung cancer screening among a diverse sample of screening-eligible patients. Methods: We utilized a cross-sectional study design. Our sample included patients evaluated for lung cancer screening at a large academic medical center (AMC) between 2015 and 2017 who met 2013 USPSTF guidelines for LDCT screening eligibility. The completion of LDCT screening (yes, no) was the primary dependent variable. The independent variable was access to care (insurance type, living within the AMC service area). We utilized binary logistic regression analyses to examine the influence of access to care on screening completion after adjusting for demographic factors (age, sex, race) and smoking history (current smoking status, smoking pack-year history). Results: A total of 1,355 individuals met LDCT eligibility criteria, and of those, 29.8% (n = 404) completed screening. Regression analysis results showed individuals with Medicaid insurance (OR, 1.51; 95% CI, 1.03-2.22), individuals living within the AMC service area (OR, 1.71; 95% CI, 1.21-2.40), and those aged 65-74 years (OR, 1.49; 95% CI, 1.12-1.98) had higher odds of receiving LDCT lung cancer screening. Lower odds of screening were associated with having Medicare insurance (OR, 0.30; 95% CI, 0.22-0.41) and out-of-pocket (OR, 0.27; 95% CI, 0.15-0.47). Conclusion: Access to care was independently associated with lowered screening rates. Study results are consistent with prior research identifying the importance of access factors on uptake of cancer early detection screening behaviors.

Cultural Barriers to Breast Cancer Screening and Medical Mistrust Among Arab American Women

Breast cancer is a common cancer among women in the US and cultural barriers and medical mistrust have been associated with breast cancer screening (BCS) rates among minority populations. A heterogeneous sample of Arab women (N = 196) were recruited from across the Detroit metropolitan area and administered a questionnaire. Multiple regression analyses revealed an association between Arab Cultural Specific Barriers (ACSB) to BCS and Group-Based Medical Mistrust Scale. The environmental ACSB to BCS was associated with the medical mistrust-suspicion of HC providers (β = 0.363, p = 0.01), lack of HC provider support (β = 0.396, p = 0.001), and Arab inequities (β = 0.250, p = 0.05). Findings suggest that ACSB to BCS are predictive of medical mistrust for Arab American women. This study illuminates the need to emphasize strategies that will target the medical care system and the cultural barriers to BCS that Arab American women face in the health care system.

Cervical cancer screening in the United States: Challenges and potential solutions for underscreened groups

Cervical cancer screening rates in the United States are generally high, yet certain groups demonstrate disparities in screening and surveillance. Individuals at greatest risk for cervical cancer are often from marginalized or underserved groups who do not participate in regular screening for a variety of reasons. Using the Population-based Research to Optimize the Screening Process (PROSPR) Trans-Organ Conceptual Model, including concepts of individual-, provider-, facility-, system-, or policy-level factors, we provide a commentary to highlight reasons for low screening participation among subgroups in the U.S. These include racial and ethnic minorities, rural residents, sexual and gender minorities, those with limited English proficiency, those with particular religious beliefs, and various health conditions. We describe barriers and offer potential solutions for each group. In addition, we discuss cross-cutting barriers to screening including difficulty interacting with the healthcare system (limited knowledge and health literacy, lack of provider recommendation/contact), financial (cost, lack of insurance), and logistical barriers (e.g., lack of usual source of care, competing demands, scheduling issues). Solutions to address these barriers are needed to improve screening rates across all underscreened groups. Changes at state and national policy levels are needed to address health insurance coverage. Mobile screening, ensuring that interpreters are available for all visits, and targeted in reach at non-gynecological visits can further overcome barriers. Employing community outreach workers can increase community demand for screening, and patient navigators can improve adherence to both screening and follow-up diagnostic evaluation. HPV self-sampling can address multiple barriers to cervical cancer screening.

Dense Breast Notification Laws' Association With Outcomes in the US Population: A Cross-Sectional Study

OBJECTIVE

Understanding whether states' breast density notifications are associated with desired effects, or disparities, can inform federal policy. We examined self-reported receipt of personal breast density information, breast density discussions with providers, knowledge about density's masking effect, and association with increased breast cancer risk by state legislation status and women's sociodemographic characteristics.

METHODS

Cross-sectional observational population-based telephone survey of women aged >40 years who underwent mammography within prior 2 years, had no history of breast cancer, and had heard the term "breast density."

RESULTS

Among 2,306 women, 57% received personal breast density information. Multivariate regression models adjusted for covariates indicated that women in notification states were 1.5 times more likely to receive density information, and older Black and Asian women of lower income and lower health literacy were less likely. Overall, only 39% of women discussed density with providers; women in notification states were 1.75 times as likely. Older and Asian women were less likely to have spoken with providers; women with high literacy or prior biopsy were more likely. State legislation status was not associated with differences in density knowledge, but Hispanic women and women of lower income or low health literacy had less knowledge regarding density's masking effects; older women were more knowledgeable. Hispanic women and women of lower income or low health literacy were more likely, and middle-aged women less likely, to recognize increased breast cancer risk.

DISCUSSION

Some positive effects were observed, but sociodemographic disparities suggest tailoring of future breast density communications for specific populations of women to ensure equitable understanding.

Differences in cervical cancer screening and follow-up for black and white women in the United States

OBJECTIVE

To study differences in screening adherence and follow-up after an abnormal Pap test in Non-Hispanic Black (Black) and Non-Hispanic White (White) women.

METHODS

An observational cohort study using 2010 National Health Interview Survey cancer module to examine HPV knowledge, screening behavior, and follow-up to abnormal Pap test in Black and White women 18 years of age or older without a hysterectomy. We fit logistic regression models to examine associations between race and primary outcome variables including: HPV awareness, Pap test in the last three years, provider recommended Pap test, received Pap test results, had an abnormal Pap test, recommended follow-up, and adhered to the recommendation for follow-up.

RESULTS

Analyzing data for 7509 women, Black women had lower odds ratios [OR] for: 1) HPV awareness (71% vs 83%; OR = 0.42; 95% CI = 0.36-0.49); 2) reporting Pap screening was recommended (59% vs 64%; OR = 0.76; 95% CI = 0.66-0.88), and 3) acknowledging receipt of Pap results (92% vs 94%; OR = 0.64; 95% CI = 0.49-0.83). Group differences persisted after covariates adjustment. In adjusted models, Black women had higher odds of reporting recent Pap screening (84% vs 77%; OR = 1.7; 95% CI = 1.42-2.03), but reported lower odds of receiving a follow-up recommendation subsequent to abnormal test (78% vs 87%; OR = 0.54; 95% CI = 0.31-0.95).

CONCLUSION

Black women reported higher cervical cancer screening adherence but lower rates of being informed of an abnormal Pap test and contacted for follow-up treatment. We recommend a multilevel approach to deliver culturally appropriate education and communication for patients, physicians, clinicians in training, and clinic level ancillary staff.

Impact of knowledge and attitude on the utilization rate of cervical cancer screening tests among Ethiopian women: A systematic review and meta-analysis

INTRODUCTION

Cervical cancer is a major public health problem, particularly in resource-limited settings. The use of vaccination and screening tests has reduced the burden of cervical cancer in developed countries. However, the situation is quite the reverse in developing countries, including Ethiopia. Hence, this study aimed to estimate the pooled impact of knowledge and attitude on the prevalence of cervical cancer screening service utilization rates among Ethiopian women.

METHODS

Studies that examined cervical cancer screening service utilization among women in Ethiopia were searched from five international databases. Cochran's Q chi-square and the I-squared test statistics were used to check the presence of heterogeneity among the included studies. The funnel plot and Egger's regression tests were also used to assess the presence of publication bias. A weighted DerSimonian and Laird random-effects model was employed. Subgroup analysis was performed by the study population concerning the prevalence of cervical cancer screening service utilization rates. Sensitivity analysis was also conducted to assess the effect of a single study on the pooled estimates. Data analysis was performed using STATA™ Version 14 software.

RESULTS

A total of 44 studies with 28,186 study participants were included. The estimated pooled prevalence of cervical cancer screening service utilization was 8.11% (95% CI: 7.26, 8.97). After adjustment for publication bias with the trim and fill analysis, the estimated prevalence rate appeared to be 5.47% (95% CI: 4.66, 6.28). The prevalence of cervical cancer screening service utilization was higher among HIV-positive women, 16.85%, and in studies conducted among health care workers, 10.24%, than the general population. The pooled effect of knowledge on the utilization of cervical cancer screening tests among Ethiopian women was statistically significant (AOR = 3.20, 95% CI: 1.63, 6.31). Similarly, the pooled estimated odds of utilizing cervical cancer screening tests were 6.1 times higher (AOR = 6.09, 95% CI: 1.09, 34.36) among women who had a favorable attitude towards the screening tests.

CONCLUSION

Knowledge and attitude had a significant impact on the prevalence of cervical cancer screening test utilization rates among women in Ethiopia. However, the prevalence of cervical cancer screening service utilization among Ethiopian women is very low. Hence, large-scale awareness programs and situation-based strategies need to be designed to increase the uptake of cervical cancer screening services in the country.

Implementation and Utilization of a "Pink Card" Walk-In Screening Mammography Program Integrated With Physician Visits

PURPOSE

The aim of this study was to evaluate the implementation and utilization of the Pink Card program, which links a physician-delivered reminder that a woman is due for screening mammography (SM) during an office visit with the opportunity to undergo walk-in screening.

METHODS

In 2016, the authors' community-based breast imaging center provided physicians from three primary care and obstetrics and gynecology practices located in the same outpatient facility business card-sized Pink Cards to offer women due for SM during office visits. The card includes a reminder that screening is due and can be used to obtain SM on a walk-in basis. The primary outcome measure was the proportion of women who used Pink Cards among all screened women over 2 years. Independent predictors of Pink Card utilization were evaluated using multivariate logistic regression analyses.

RESULTS

Among 3,688 women who underwent SM, Pink Cards were used by 19.9% (733 of 3,688). Compared with women with prescheduled screening visits, Pink Card users were more likely to be Asian (odds ratio [OR], 1.37; P =.032), Black (OR, 2.05; P = .002), and Medicaid insured (OR, 1.71; P = .013) and less likely to use English as their primary language (OR, 2.75; P = .003). Additionally, Pink Card users were less likely to be up to date for biennial SM compared with women with prescheduled visits (31.9% [234 of 733] versus 66.6% [1,968 of 2,955], P < .001).

CONCLUSIONS

The Pink Card walk-in SM program can improve screening access, particularly for racial/ethnic minorities and Medicaid-insured patients. Expansion of this program may help reduce disparities and increase engagement in breast cancer screening.

Racial/Ethnic Disparities in the Burden of HIV/Cervical Cancer Comorbidity and Related In-hospital Mortality in the USA

OBJECTIVE

The purpose of this study was to determine whether cervical cancer is a risk factor for early mortality among women with HIV and whether racial/ethnic disparity predicted in-hospital death among women living with HIV and diagnosed with cervical cancer.

METHODS

We conducted a population-based study using the National Inpatient Sample (NIS) database comprising hospitalized HIV-positive women with or without cervical cancer diagnosis, from 2003 through 2015. We compared trends in the rates of cervical cancer, in-hospital death, and years of potential life lost (YPLL) by race/ethnicity.

RESULTS

We identified 2,613,696 women with HIV, and among them, 5398 had cervical cancer. The prevalence of cervical cancer (per 10,000) was 9.3 for NH-Whites, 30.9 among NH-Blacks, and 30.2 for Hispanics. Rates of cervical cancer over time diminished significantly only among NH-Whites (average annual percent change (AAPC), - 5.8 (- 9.7, - 1.8)), and YPLL in women with cervical cancer decreased significantly only in NH-Whites (AAPC, - 6.2 (- 10.1, - 2.0)). Cervical cancer was associated with increased odds of in-hospital death overall (OR 2.24 (1.59-3.15)) and among NH-Blacks (OR 2.03 (1.30-3.18)) only.

CONCLUSIONS

NH-Blacks and Hispanics with HIV remain at increased risk for concurrent diagnosis of cervical cancer compared with NH-Whites. Moreover, NH-Black women with HIV and cervical cancer are at greatest risk for in-hospital death. The findings emphasize the need for a more robust prevention strategy among minority women to reduce the high burden of HIV/cervical cancer and related mortality.

Using Community-Based Participatory Research to Explore Health Care Perceptions of a Select Group of Arab Americans

Introduction: As the Arab American population grows in the United States, relatively little has been published about the health status of this population. The purpose of the research was to (1) discover health care perceptions of Arab Americans and (2) identify strategies to ensure the provision of culturally congruent health care. Method: Community-based participatory research methodology was used for this descriptive study. Interviews and focus groups were conducted with Arab Americans residing in northeast Pennsylvania. Results: Three themes were identified: (1) perceptions of health resulting in delays in seeking health care, (2) cultural values and practices resulting in need for culturally congruent provision of care, and (3) mistrust of the U.S. health care system resulting in underutilization of services. Discussion: Results indicate the need for nurses to implement culturally congruent community-based strategies and interventions for meeting health care needs of Arab Americans. By understanding the community’s perceptions and attitudes, nurses will be better positioned to ultimately move toward the goal of reducing health disparities in this underserved population.

Prevalence, Perceived Benefits, and Perceived Barriers Regarding Breast Cancer Screening Among Three Arab American Women Subgroups

Introduction: Mammography screening (MS) has been identified as a valuable tool to decrease mortality rates from breast cancer (BC). Arab American women (AAW) have been recognized as an ethnic group that needs further research to promote their participation in BC screening. This study aims to explore MS rates, and investigate differences in attitudes and beliefs about BC screening in AAW. Method: This comparative, cross-sectional study investigated 316 American Muslim and Christian women from three Arab countries. The Arab Culture-Specific Barriers instrument was employed. Results: The results revealed lower MS rates in AAW compared with national screening rates. Cultural and religious benefits and barriers were identified. Discussion: This study was able to provide a better understanding of AAW beliefs, attitudes, and behaviors regarding BC screening based on their unique ethnic identity and religion. Implications of such findings include increasing efforts to improve MS rates and providing cultural training for health care professionals.

Differential Impact of Education Level, Occupation and Marital Status on Performance of the Papanicolaou Test among Women from Various Regions in Brazil

Background:

In Brazil, little is known regarding the underlying causes of differences among populations regarding socio-economic variables that affect women’s cervical cancer screening behavior. The present study focused on socio-economic variables that affect women’s performance of the Papanicolaou test, comparing two distinct Brazilian populations.

Methods:

We collected data regarding performance of the Papanicolaou test and socio-economic variables from 559 women in Mato Grosso do Sul (MS), in the Central East region, and 338 women in Paraíba (PB), in the Northeast region of Brazil. Nominal logistic regression modeling was performed to identify independent variables for both groups of data.

Results:

Of the women interviewed from MS and PB, 116 out of 599 (19.37%) and 94 out of 338 (27.81%), respectively, had not performed the Papanicolaou test within the last three years (p = 0.025). Low educational level characterized 570 (95.16%) and 203 (60.06%) of women from MS and PB, respectively (p = 0.000). Women in PB who had a low educational level and were unemployed had a 2.96-fold (OR = 0.338; 95% CI: 0.121 - 0.939) and 2.40-fold (OR = 0.416; 95% CI: 0.199 - 0.869) lower chance, respectively, to have performed the Papanicolaou test ≥ three times, or once within the last three years (p = 0.029; p = 0.014). The chance of women in MS who did not live in a stable relationship to have performed the test ≥ three times was 1.79-fold (OR = 0.560; 95% CI: 0.348 – 0.901) lower compared to women who reported a stable relationship (p = 0.039).

Conclusions:

High educational level, employment, and having a stable interpersonal relationship positively associated with performance of the Papanicolaou test among women in PB and MS. Despite having predominantly a low educational level, women in MS performed the Papanicolaou test more frequently than those in PB.

An Investigation of Unmet Socio-Economic Needs Among Arab American Breast Cancer Patients Compared with Other Immigrant and Migrant Patients

Although Arabs are a growing population in the United States, they are a hidden minority when compared to larger, more studied groups like Latinos and Caribbean immigrants of African descent (CIAD). There is limited research pertaining to patients' unmet socioeconomic and supportive care needs when undergoing breast cancer treatment, particularly among immigrants and migrants. This is a comparative study of a nested cohort of 36 Arabs, 145 Latinos and 128 CIAD breast cancer patients participating in the Integrated Cancer Care Access Network and their areas of needed assistance. The patients were recruited from eleven community cancer clinics in New York City and through community based organizations. Patients most commonly reported needing financial, transportation, and food assistance. Arabs were more likely than their CIAD and Latino counterparts to have health insurance and legal aid needs. Arabs also has the highest proportion of patients unaware of their own cancer stage, at odds with their report of lower information needs than the other groups. Additional culturally tailored Arabic language interventions are needed to educate Arabic speaking breast cancer patients to help facilitate access to available services.

Distribution of cervical and breast cancer risk factors in women and their screening behaviours

Breast cancer and cervical cancer are important causes of cancer-related mortality in women all over the world. The present study was conducted in order to investigate the distribution of cervical and breast cancer risk factors in women and their knowledge and behaviours about cancer screening methods. The study is cross-sectional in nature. It was conducted with the participation of 1,886 women in Turkey. Data were collected through a questionnaire. The knowledge and behaviours of women aged 40 and over about breast cancer or cervical cancer screening methods were investigated according to the education level; results showed that the rates of those who knew and did breast self-examination were significantly lower in illiterate women. Besides, the rates of women who did breast self-examination were significantly lower in those who were aged 40 and over, and the rates of those who had clinical breast examination and Pap smear test were significantly lower in women aged 39 and below (p < 0.01). This study identified the most notable breast and cervical cancer risk factors as low education levels, high number of deliveries, short breastfeeding period, obesity and low socio-economic level. For this reason, public health policies should be developed to minimise these risk factors.

Increasing Breast and Cervical Cancer Screening in Rural and Border Texas with Friend to Friend Plus Patient Navigation

The Friend to Friend plus Patient Navigation Program (FTF+PN) aims to build an effective, sustainable infrastructure to increase breast and cervical screening rates for underserved women in rural Texas. The objective of this paper is to identify factors that (1) distinguish participants who chose patient navigation (PN) services from those who did not (non-PN) and (2) were associated with receiving a mammogram or Papanicolaou (Pap) test. This prospective study analyzed data collected from 2689 FTF+PN participants aged 18-99 years from March 1, 2012 to February 28, 2015 who self-identified as African American (AA), Latina, and non-Hispanic white (NHW). Women who were younger, AA or Latina, had less than some college education, attended a FTF+PN event because of the cost of screening or were told they needed a screening, and who reported a barrier to screening had higher odds of being a PN participant. Women who were PN participants and had more contacts with program staff had greater odds of receiving a mammogram and a Pap compared with their reference groups. Latina English-speaking women had lower odds of receiving a mammogram and a Pap compared with NHW women and Latina Spanish-speaking women had higher odds of receiving a Pap test compared with NHW women. Women with greater need chose PN services, and PN participants had higher odds of getting a screening compared with women who did not choose PN services. These results demonstrate the success of PN in screening women in rural Texas but also that racial/ethnic disparities in screening remain.

Prevalence and determinants in cytology testing for cervical cancer screening in Spain (2006-14)

Background

Cervical cancer has decreased in developed countries thanks to cytology screening programmes. The aims of this study were To analyse the frequency and evolution of performing cytology tests and to determine the variables that influence their use.

Methods

Cross-sectional study of non-institutionalized women who participated in the national health survey (2006, 2011/12) and the European Health Survey in Spain (2009, 2014). Study variables: cytology-testing, time since last cytology-test, reason for performing the test, age, nationality, marital status, social status, education level and place of residence.

Results

The study evaluated 53 628 women in Spain over 15 years old, with a mean age of 52.68 (SD ± 19.12). About 94.1% were Spanish, 49.2% were married and 77.2% lived with a partner. In 2014, 72% had a cytology test, a number that increased significantly. Women aged 25-65 were 5.13 times more likely to undergo a cytology test than those aged 15-24 years old (odds ratio (OR): 5.13; P < 0.001); women with university educations were 9.23 times more likely to undergo a cytology test than those without university educations (P > 0.001); those of social classes I and II (high) were 1.2 more likely to undergo a cytology test than those of low social class (P = 0.026); and Spanish women were 1.74 times more likely to undergo a cytology test than foreigners living in Spain (P < 0.001).

Conclusion

Frequency of cytology testing has increased in the last few years. Screening for cervical cancer is associated with higher social status, education level, age, and not being foreign.

Screening Mammography Utilization and Medicare Beneficiaries' Perceptions of Their Primary Care Physicians

RATIONALE AND OBJECTIVES

To assess associations between screening mammography utilization and Medicare beneficiaries' relationships with, and impressions of, their primary care physicians.

MATERIALS AND METHODS

Using the Medicare Current Beneficiary Survey Access to Care Public Use File, we retrospectively studied responses from a national random cross section of Medicare beneficiaries surveyed in 2013 regarding perceptions of their primary care physicians and their screening mammography utilization. Statistical analysis accounted for subject weighting factors to estimate national screening utilization.

RESULTS

Among 7492 female Medicare beneficiaries, 62.0% (95% confidence interval 59.8%-64.2%) underwent screening mammography. Utilization was higher for beneficiaries having (vs. not) a regular medical practice or clinic (63.2% vs. 34.6%) and a usual physician (63.8% vs. 50.3%). Utilization was higher for beneficiaries very satisfied (vs. very dissatisfied) with the overall quality of care they received (66.0% vs. 35.8%), their ease of getting to a doctor (67.7% vs. 43.2%), and their physician's concerns for their health (65.7% vs. 53.4%), as well as for beneficiaries strongly agreeing (vs. strongly disagreeing) that their physician is competent (66.0% vs. 54.1%), understands what is wrong (66.3% vs. 47.1%), answers all questions (67.0% vs. 46.7%), and fosters confidence (66.0% vs. 50.6%). Independent predictors of screening mammography utilization (P < .05) were satisfaction with quality of care, having a regular practice or clinic, and satisfaction with ease of getting to their physician.

CONCLUSIONS

Screening mammography utilization is higher among Medicare beneficiaries with established primary physician relationships, particularly when those relationships are favorable. To optimize screening mammography utilization, breast imagers are encouraged to support initiatives to enhance high-quality primary care relationships.

Role of Race/Ethnicity, Language, and Insurance in Use of Cervical Cancer Prevention Services Among Low-Income Hispanic Women, 2009-2013

Introduction

Hispanic women in the United States have an elevated risk of cervical cancer, but the existing literature does not reveal why this disparity persists.

Methods

We performed a retrospective cohort analysis of 17,828 low-income women aged 21 to 64 years seeking care at Oregon community health centers served by a hosted, linked electronic health record during 2009 through 2013. We assessed the odds of having had Papanicolaou (Pap) tests and receiving human papillomavirus (HPV) vaccine, by race/ethnicity, insurance status, and language.

Results

Hispanic women, regardless of pregnancy status or insurance, had greater odds of having had Pap tests than non-Hispanic white women during the study period. English-preferring Hispanic women had higher odds of having had Pap tests than Spanish-preferring Hispanic women (OR, 2.08; 95% confidence interval [CI], 1.63–2.66) but lower odds of having received HPV vaccination (OR, 0.21; 95% CI, 0.12–0.38). Uninsured patients, regardless of race/ethnicity, had lower odds of HPV vaccine initiation than insured patients did. Once a single dose was received, there were no significant racial/ethnic differences in vaccine series completion.

Conclusion

In this sample of low-income women seeking care at Oregon community health centers, we found minimal racial/ethnic disparities in the receipt of cervical cancer prevention services. Inequities by insurance status, especially in the receipt of HPV vaccine, persist. Community health center–based care may be a useful model to address racial/ethnic disparities in prevention, but this model would need further population-wide study.

Decisional balance and self-efficacy mediate the association among provider advice, health literacy and cervical cancer screening

PURPOSE

Health literacy has emerged as a potential determinant of cancer screening, yet limited literature has investigated the pathways which health literacy influences Pap tests among immigrant women who experience a higher incidence of cervical cancer. This study aimed to test a health literacy-focused sociocognitive model which proposes motivational (knowledge, decisional balance) and volitional (self-efficacy) factors mediating the association between health literacy and triennial Pap tests.

METHODS

Using structural equation modeling, we conducted a secondary analysis of baseline data obtained from a randomized controlled trial to promote breast and cervical cancer screenings among 560 Korean American women 21-65 years of age. They were interviewed on demographics such as education and English proficiency, provider advice, health literacy, knowledge of cervical cancer, decisional balance for Pap tests, self-efficacy, and Pap test use.

RESULTS

Higher health literacy predicted high level of knowledge and high decisional balance score, and greater self-efficacy and then only decisional balance and self-efficacy affected Pap tests. High level of knowledge predicted Pap tests through its impact on the decisional balance score. Receiving provider advice both directly and indirectly predicted Pap tests through high level of health literacy, high level of decisional balance and greater self-efficacy.

CONCLUSIONS

Findings from this study suggest possible pathways through which provider advice and health literacy affect Pap tests. Interventions targeting immigrant women with limited English proficiency should consider skill-based approaches such as health literacy training, promoting patient-provider communications and emphasizing decisional balance and self-efficacy as potentially sustainable ways of promoting Pap tests.

Correlates of Cervical Cancer Screening Among Adult Latino Women: A 5-Year Follow-Up

BACKGROUND

Latinas have the highest incidence rates of cervical cancer in the United States, and Latinas in the United States are less likely to utilize cervical cancer screening.

METHOD

We used secondary data analysis of a non-clinical convenience sample (n=316 women at baseline; n=285 at five-year follow-up) to examine correlates of cervical cancer screening among adult Latina women. Univariate and multiple logistic regression models using Generalized Estimated Equations (GEE) algorithm were utilized to assess the influence of the independent variables.

RESULTS

Women who reported their main healthcare source as community health clinics, women who were sexually active, and women who reported that a healthcare provider discussed HIV prevention with them were more likely to report having a cervical cancer screening (aOR=2.06; CI=1.20, 3.52).

CONCLUSION

The results suggest a need for continued efforts to ensure that medically underserved women (e.g., Latina women) receive counseling and education about the importance of preventive cancer screening.

Health system barriers and enablers to early access to breast cancer screening, detection, and diagnosis: a global analysis applied to the MENA region

OBJECTIVES

To identify barriers and enablers that impact access to early screening, detection, and diagnosis of breast cancer both globally and more specifically in the Middle East and North Africa (MENA) region (with a specific focus on Egypt, Jordan, Oman, Saudi Arabia, United Arab Emirates [UAE], and Kuwait) with a specific focus on the health system.

STUDY DESIGN

A systematic review of literature.

METHODS

We conducted a systematic reviewing using the PRISMA methodology. We searched PubMed, Global Index Medicus, and EMBASE for studies on 'breast cancer', 'breast neoplasm,' or 'screening, early detection, and early diagnosis' as well as key words related to the following barriers: religion, culture, health literacy, lack of knowledge/awareness/understanding, attitudes, fatalism/fear, shame/embarrassment, and physician gender from January 1, 2000 until September 1, 2016. Two independent reviewers screened both titles and abstracts. The application of inclusion and exclusion criteria yielded a final list of articles. A conceptual framework was used to guide the thematic analysis and examine health system barriers and enablers to breast cancer screening at the broader macro health system level, at the health provider level, and the individual level. The analysis was conducted globally and in the MENA region.

RESULTS

A total of 11,936 references were identified through the initial search strategy, of which 55 were included in the final thematic analysis. The results found the following barriers and enablers to access to breast cancer screening at the health system level, the health provider level, and the individual level: health system structures such as health insurance and care coordination systems, costs, time concerns, provider characteristics including gender of the provider, quality of care issues, medical concerns, and fear. In addition, the following seven barriers and enablers were identified at the health system or provider level as significantly impacting screening for breast cancer: (1) access to insurance, (2) physician recommendation, (3) physician gender, (4) provider characteristics, (5) having a regular provider, (6) fear of the system or procedure, and (7) knowledge of the health system. More specifically, the largest increased odds for having a mammogram was from having insurance, having a physician recommendation, type of provider (mainly gynecologist), and having regular contact with a physician. Clinical breast examinations were increased by having insurance and having regular contact with a physician. The eight studies identified from the MENA region identified barriers to breast cancer screening related to service quality, fear of pain and of cancer itself, female versus male provider, having a physician recommend the screen, cost issues as well as time and convenience of the services.

CONCLUSIONS

There are a number of system changes that can be made to remove barriers to breast cancer screening. Some of these system changes apply directly to MENA countries. A larger health system assessment of a country is warranted to determine which health system changes should be made to most efficiently and effectively improve access to breast cancer screening.

Recent trends in racial and regional disparities in cervical cancer incidence and mortality in United States

BACKGROUND

Although black women experienced greater cervical cancer incidence and mortality rate reduction in recent years, they continue to have higher incidence rates than whites. Great variations also exist among geographic regions of the US, with the South having both the highest incidence and mortality rates compared to other regions. The present study explores the question of whether living in the South is associated with greater racial disparity in cervical cancer incidence and mortality by examining race- and region-specific rates and the trend between 2000 and 2012.

METHODS

The Surveillance, Epidemiology, and End Results (SEER) 18 Program data was used. Cervical cancer incidence and mortality rates, annual percent changes, and disparity ratios were calculated using SEER*Stat software and Joinpoint regression for four groups: US14-Non-Hispanic White (NHW), US14-Non-Hispanic Black (NHB), South-NHW, and South-NHB, where South included 4 registries from Georgia and Louisiana and US14 were 14 US registries except the four South registries.

RESULTS

The average age-adjusted cervical cancer incidence rate was the highest among South-NHBs (11.1) and mortality rate was the highest among US14-NHBs (5.4). In 2012, the degree of racial disparities between South-NHBs and South-NHWs was greater in terms of mortality rates (NHB:NHW = 1.80:1.35) than incidence rates (NHB:NHW = 1.45:1.15). While mortality disparity ratios decreased from 2000-2012 for US14-NHB (APC: -1.9(-2.3,-1.4), mortality disparity ratios for South-NHWs (although lower than NHBs) increased compared to US14-NHW. Incidence rates for NHBs continued to increase with increasing age, whereas rates for NHWs decreased after age 40. Mortality rates for NHBs dramatically increased at age 65 compared to a relatively stable trend for NHWs. The increasing racial disparity with increasing age in terms of cervical cancer incidence rates became more pronounced when corrected for hysterectomy prevalence.

CONCLUSIONS

Black race and South region were associated with higher cervical cancer incidence and mortality. Cervical cancer rates uncorrected for hysterectomy may underestimate regional and racial disparities. Increasing incidence rates for older NHBs compared to NHWs warrant further research to determine whether screening should continue for NHBs over age 65.

Multilevel Intervention Raises Latina Participation in Mammography Screening: Findings from ¡Fortaleza Latina!

BACKGROUND

Breast cancer is the most commonly diagnosed cancer in women in the United States, and Latinas have relatively low rates of screening participation. The Multilevel Intervention to Increase Latina Participation in Mammography Screening study (¡Fortaleza Latina!) sought to assess the efficacy of a clinic- and patient-level program to increase breast cancer screening among Latinas in Western Washington who seek care at a safety net health center.

METHODS

The study enrolled 536 Latinas ages 42 to 74 who had a primary care clinic visit in the previous 5 years and had not obtained a mammogram in the previous 2 years. Participants were block-randomized within clinic to either (i) a control arm (usual care) or (ii) a promotora-led, motivational interviewing intervention that included a home visit and telephone follow-up. At the clinic level, two of four participating clinics were provided additional mammography services delivered by a mobile mammography unit.

RESULTS

Rates of screening mammography 1 year post-randomization were 19.6% in the intervention group and 11.0% in the usual care group (P < 0.01), based on medical record data. No significant differences in participants' mammography screening were observed in clinics randomized to additional mammography services versus usual care (15.8% vs. 14.4%; P = 0.68).

CONCLUSION

This multilevel intervention of promotora-delivered motivational interviewing and free mammography services modestly raised rates of participation in breast cancer screening among Latinas.

IMPACT

Our findings can inform future efforts to boost mammography participation in safety net practices. Cancer Epidemiol Biomarkers Prev; 25(4); 584-92. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".

Cervical Cancer Screening Among Arab Women in the United States: An Integrative Review

PROBLEM IDENTIFICATION

Arab American women are an ethnic minority and immigrant population in the United States with unique and nuanced sociocultural factors that influence preventive health behaviors. The aims of this article are to evaluate and synthesize the existing evidence on cervical cancer screening behaviors, as well as determine factors that influence these behaviors, among Arab American women.
.

LITERATURE SEARCH

Extensive literature searches were performed using PubMed, CINAHL®, Scopus, Embase, and Cochrane databases; articles published through October 2015 were sought. 
.

DATA EVALUATION

Of 17 articles, 14 explicitly identified Arab and/or Muslim women and cervical cancer screening in either the title or the abstract; the remaining three focused on cancer attitudes and behaviors in Arab Americans in general but measured cervical cancer screening. Eleven articles reported different aspects of one intervention. Because of methodologic heterogeneity, the current authors synthesized results narratively.
.

SYNTHESIS

Key factors influencing cervical cancer screening were identified as the following.

CONCLUSIONS

Cervical cancer screening rates among Arab American women are comparable to other ethnic minorities and lower than non-Hispanic White women. Findings are inconsistent regarding factors influencing cervical cancer screening behaviors in this underrepresented group. 
.

IMPLICATIONS FOR RESEARCH

Significant need exists for more research to better understand cervical cancer prevention behaviors in this group to inform culturally relevant interventions. Healthcare providers play a crucial role in increasing cervical cancer screening awareness and recommendations for Arab American women.

Racial and ethnic disparities in universal cervical length screening with transvaginal ultrasound

OBJECTIVE

Determine if race or ethnicity is associated with missed or late transvaginal cervical length screening in a universal screening program.

METHODS

Retrospective cohort study of nulliparous women with singleton gestations and a fetal anatomical ultrasound from 16-24 weeks' gestation from January 2012 to November 2013. We classified women into mutually exclusive racial and ethnic groups: non-Hispanic black (black), Hispanic, Asian, non-Hispanic white (white), and other or unknown race. We used log-binomial regression to calculate the risk ratio (RR) and 95% confidence interval (CI) of missed or late (≥20 weeks' gestation) screening versus optimally timed screening between the different racial and ethnic groups.

RESULTS

Among the 2967 women in our study population, 971 (32.7%) had either missed or late cervical length screening. Compared to white women, black (RR: 1.3; 95% CI: 1.1-1.5) and Hispanic (RR:1.2; 95% CI: 1.01-1.5) women were more likely to have missed or late screening. Among women screened, black (versus white) women were more likely to be screened late (RR: 2.2; 95% CI: 1.6-3.1).

CONCLUSIONS

Black and Hispanic women may be more likely to have missed or late cervical length screenings.

Impact of provider-patient communication on cancer screening adherence: A systematic review

Cancer screening is critical for early detection and a lack of screening is associated with late-stage diagnosis and lower survival rates. The goal of this review was to analyze studies that focused on the role of provider-patient communication in screening behavior for cervical, breast, and colorectal cancer. A comprehensive search was conducted in four online databases between 1992 and 2016. Studies were included when the provider being studied was a primary care provider and the communication was face-to-face. The search resulted in 3252 records for review and 35 articles were included in the review. Studies were divided into three categories: studies comparing recommendation status to screening compliance; studies examining the relationship between communication quality and screening behavior; and intervention studies that used provider communication to improve screening behavior. There is overwhelming evidence that provider recommendation significantly improves screening rates. Studies examining quality of communication are heterogeneous in method, operationalization and results, but suggest giving information and shared decision making had a significant relationship with screening behavior. Intervention studies were similarly heterogeneous and showed positive results of communication interventions on screening behavior. Overall, results suggest that provider recommendation is necessary but not sufficient for optimal adherence to cancer screening guidelines. Quality studies suggest that provider-patient communication is more nuanced than just a simple recommendation. Discussions surrounding the recommendation may have an important bearing on a person's decision to get screened. Research needs to move beyond studies examining recommendations and adherence and focus more on the relationship between communication quality and screening adherence.

Development and Validation of the Spanish Numeracy Understanding in Medicine Instrument

BACKGROUND

The Spanish-speaking population in the U.S. is large and growing and is known to have lower health literacy than the English-speaking population. Less is known about the health numeracy of this population due to a lack of health numeracy measures in Spanish.

OBJECTIVE

we aimed to develop and validate a short and easy to use measure of health numeracy for Spanish-speaking adults: the Spanish Numeracy Understanding in Medicine Instrument (Spanish-NUMi).

DESIGN

Items were generated based on qualitative studies in English- and Spanish-speaking adults and translated into Spanish using a group translation and consensus process. Candidate items for the Spanish NUMi were selected from an eight-item validated English Short NUMi. Differential Item Functioning (DIF) was conducted to evaluate equivalence between English and Spanish items. Cronbach's alpha was computed as a measure of reliability and a Pearson's correlation was used to evaluate the association between test scores and the Spanish Test of Functional Health Literacy (S-TOFHLA) and education level.

PARTICIPANTS

Two-hundred and thirty-two Spanish-speaking Chicago residents were included in the study.

KEY RESULTS

The study population was diverse in age, gender, and level of education and 70 % reported Mexico as their country of origin. Two items of the English eight-item Short NUMi demonstrated DIF and were dropped. The resulting six-item test had a Cronbach's alpha of 0.72, a range of difficulty using classical test statistics (percent correct: 0.48 to 0.86), and adequate discrimination (item-total score correlation: 0.34-0.49). Scores were positively correlated with print literacy as measured by the S- TOFHLA (r = 0.67; p < 0.001) and varied as predicted across grade level; mean scores for up to eighth grade, ninth through twelfth grade, and some college experience or more, respectively, were 2.48 (SD ± 1.64), 4.15 (SD ± 1.45), and 4.82 (SD ± 0.37).

CONCLUSIONS

The Spanish NUMi is a reliable and valid measure of important numerical concepts used in communicating health information.

Racial/Ethnic Differences Affecting Adherence to Cancer Screening Guidelines Among Women

BACKGROUND

Race/ethnicity has been shown to modify the effects between obesity and cancer screening among women. The purpose of this article is to update the literature with recent data to examine how the association between different characteristics, including body mass index (BMI), and cancer screening compliance varies by race/ethnicity in a national sample of women.

MATERIALS AND METHODS

Three cycles of the Health Information National Trends Survey (HINTS) were combined for this cross-sectional study. Weighted descriptive statistics were evaluated using chi-square tests. Multivariable logistic regression evaluated associations between women with underweight or normal (<25), overweight (25-29.9), and obese (>30) BMIs and cancer screening concordant with guidelines (Papanicolaou [Pap] testing ≤3 years, ages 21+ years; mammography ≤2 years, ages 40+ years) in analyses stratified by race/ethnicity. We also assessed variance between racial/ethnic groups in how age, income, and insurance status were associated with cancer screening compliance.

RESULTS

This study included 4992 women who were evaluated for Pap testing and 3773 for mammography. In analyses stratified by race/ethnicity, whites with a higher household income were more likely to report having a Pap test (adjusted prevalence ratio [aPR] 2.16, 95% confidence interval [95% CI] 1.38-3.40) and a mammogram (aPR 1.63, 95% CI 1.04-2.55) compared to lower income white women. Black women with BMIs between 25 and 30 were less likely to receive a Pap test (aPR 0.38, 95% CI 0.19-0.76) than black women with BMIs <25, while no association was observed among the other groups. Insurance was associated with increased likelihood of Pap testing among white and black women. Insurance coverage was positively associated with mammography only among white and Hispanic women.

CONCLUSIONS

We found variations in adherence to cancer screening guidelines by age, insurance coverage, and income between racial/ethnic groups. Little evidence was observed for variations in screening by BMI.

A Randomized Trial of Human Papillomavirus Self-Sampling as an Intervention to Promote Cervical Cancer Screening Among Women With HIV

OBJECTIVE

Women living with HIV experience higher risk of cervical cancer, but screening rates in the United States are lower than recommended. The purpose of this study was to examine whether an intervention using self-sampling of cervicovaginal cells for human papillomavirus (HPV) with results counseling would increase cervical cytology ("Pap") testing among women with HIV.

MATERIALS AND METHODS

This was a randomized controlled trial to test the effectiveness of an intervention of self-sampling for HPV and results counseling. Participants were 94 women older than 18 years, with HIV infection, attending an HIV clinic for a primary care visit, whose last cervical cancer screening was 18 months or more before baseline. Women were assigned to the intervention or information-only group. The primary outcome was completion of cervical cytology testing within 6 months of baseline. The secondary outcome was the women's perceived threat of developing cervical cancer.

RESULTS

A total of 94 women were enrolled and analyzed in the study. The cytology completion rate overall was 35% by 6 months from baseline. There were no differences in comparing HPV-positive with HPV-negative women nor comparing them with the information-only group. In the intervention group, a positive HPV test increased perceived threat of cervical cancer.

CONCLUSIONS

The intervention did not improve cytology test attendance, although education about HPV and cervical cancer risk as part of study procedures was associated with testing for 35% of this group of women whose previous cytology occurred an average of 3.6 years before the baseline appointment. Self-sampling for HPV testing was feasible.

Effect of Patient Navigation on Breast Cancer Screening Among African American Medicare Beneficiaries: A Randomized Controlled Trial

BACKGROUND

There is growing evidence that patient navigation improves breast cancer screening rates; however, there are limited efficacy studies of its effect among African American older adult women.

OBJECTIVE

To evaluate the effect of patient navigation on screening mammography among African American female Medicare beneficiaries in Baltimore, MD.

DESIGN

The Cancer Prevention and Treatment Demonstration (CPTD), a multi-site study, was a randomized controlled trial conducted from April 2006 through December 2010.

SETTING

Community-based and clinical setting.

PARTICIPANTS

The CPTD Screening Trial enrolled 1905 community-dwelling African American female Medicare beneficiaries who were ≥65 years of age and resided in Baltimore, MD. Participants were recruited from health clinics, community centers, health fairs, mailings using Medicare rosters, and phone calls.

INTERVENTIONS

Participants were randomized to either: printed educational materials on cancer screening (control group) or printed educational materials + patient navigation services designed to help participants overcome barriers to cancer screening (intervention group).

MAIN MEASURE

Self-reported receipt of mammography screening within 2 years of the end of the study.

KEY RESULTS

The median follow-up period for participants in this analysis was 17.8 months. In weighted multivariable logistic regression analyses, women in the intervention group had significantly higher odds of being up to date on mammography screening at the end of the follow-up period compared to women in the control group (odds ratio [OR] 2.26, 95 % confidence interval [CI]1.59-3.22). The effect of the intervention was stronger among women who were not up to date with mammography screening at enrollment (OR 3.63, 95 % CI 2.09-6.38).

CONCLUSION

Patient navigation among urban African American Medicare beneficiaries increased self-reported mammography utilization. The results suggest that patient navigation for mammography screening should focus on women who are not up to date on their screening.

Variation in Women's Understanding of Prenatal Testing

OBJECTIVE

To investigate women's understanding of prenatal testing options and of their own experience with screening, diagnostic genetic testing, or both.

METHODS

This was a secondary analysis of data from a randomized controlled trial of enhanced information and values clarification regarding prenatal genetic testing in the absence of financial barriers to testing. Women in the third trimester of pregnancy were asked whether they had discussed prenatal genetic testing with their health care providers, whether they understood this testing was optional, and whether they had undergone testing during their pregnancy. Multivariable logistic regression models were fit to determine independent predictors of these outcomes.

RESULTS

Data were available from 710 study participants. Discussions about screening tests were reported by 654 participants (92%); only 412 (58%) reported discussing diagnostic testing. That screening and diagnostic testing were optional was evident to approximately two thirds of women (n=470 and 455, respectively). Recall of actual tests undergone was correct for 626 (88%) for screening and for 700 (99%) for diagnostic testing. Racial, ethnic and socioeconomic variation existed in the understanding of whether screening and diagnostic tests were optional and in the correct recall of whether screening had been undertaken in the current pregnancy. In the usual care group, women receiving care in low-income settings were less likely to recall being offered diagnostic testing (adjusted odds ratio 0.23 [0.14-0.39]).

CONCLUSION

Disparities exist in women's recall of prenatal genetic testing discussions and their understanding of their own experience. Interventions that explain testing options to women and help clarify their preferences may help to eliminate these differences.

What women want: patient recommendations for improving access to breast and cervical cancer screening and follow-up

BACKGROUND

The patient voice remains underrepresented in clinical and public health interventions. To inform interventions that strive to improve access to breast and cervical cancer screening and follow-up among low-income populations, we explored recommendations from low-income women pursuing health care in the safety net.

METHODS

Semi-structured interviews were conducted among women receiving follow-up care for an abnormal breast or cervical cancer screening result or a positive cancer diagnosis in federally qualified health centers, free clinics, or an academic cancer center in the Chicago metropolitan area.

FINDINGS

Of the 138 women interviewed in the parent study, 52 women provided recommendations for improving access to screening and follow-up care. Most were between 41 and 65 years old (62%) and African American (60%) or White (25%). Recommendations included strengthening community-based health education with more urgent messaging, strategic partnerships, and active learning experiences to increase patient engagement, which women regarded as a key driver of access. Women also suggested increasing access by way of changes to health care delivery systems and policy, including more direct patient-provider and patient-clinic communications, addressing delays caused by high patient volume, combining preventive services, expanding insurance coverage, and adjusting screening guidelines.

CONCLUSIONS

This exploratory study demonstrates important insights from the patient lens that may help to increase the acceptability and efficacy of community and clinical interventions aimed at improving access to breast and cervical cancer screening and follow-up. Further research is needed to identify appropriate integration of patient input into interventions, practice, and policy change.

Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context

IMPORTANCE

The patient-centered medical home (PCMH) model of primary care is being implemented in a wide variety of socioeconomic contexts, yet there has been little research on whether its effects differ by context. Clinical preventive service use, including cancer screening, is an important outcome to assess the effectiveness of the PCMH within and across socioeconomic contexts.

OBJECTIVE

To determine whether the relationship between the PCMH and cancer screening is conditional on the socioeconomic context in which a primary care physician practice operates.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal study spanning July 1, 2009, through June 30, 2012, using data from the Blue Cross Blue Shield of Michigan Physician Group Incentive Program was conducted. Michigan nonpediatric primary care physician practices that participated in the Physician Group Incentive Program (5452 practice-years) were included. Sample size and outlier exclusion criteria were applied to each outcome. We examined the interaction between practices' PCMH implementation scores and their socioeconomic context. The implementation of a PCMH was self-reported by the practice's affiliated physician organizations and was measured as a continuous score ranging from 0 to 1. Socioeconomic context was calculated using a market-based approach based on zip code characteristics of the practice's patients and by combining multiple measures using principal components analysis.

MAIN OUTCOMES AND MEASURES

Breast, cervical, and colorectal cancer screening rates for practices' Blue Cross Blue Shield of Michigan patients.

RESULTS

The implementation of a PCMH was associated with higher breast, cervical, and colorectal cancer screening rates across most market socioeconomic contexts. In multivariable models, the PCMH was associated with a higher rate of screening for breast cancer (5.4%; 95% CI, 1.5% to 9.3%), cervical cancer (4.2%; 95% CI, 1.4% to 6.9%), and colorectal cancer (7.0%; 95% CI, 3.6% to 10.5%) in the lowest socioeconomic group but nonsignificant differences in screening for breast cancer (2.6%; 95% CI, -0.1% to 5.3%) and cervical cancer (-0.5%; 95% CI, -2.7% to 1.7%) and a higher rate of colorectal cancer (4.5%; 95% CI, 1.8% to 7.3%) screening in the highest socioeconomic group. Because PCMH implementation was associated with larger increases in screening in lower socioeconomic practice settings, models suggest reduced disparities in screening rates across these contexts. For example, the model-predicted disparity in breast cancer screening rates between the highest and lowest socioeconomic contexts was 6% (77.9% vs 72.2%) among practices with no PCMH implementation and 3% (80.3% vs. 77.0%) among practices with full PCMH implementation.

CONCLUSIONS AND RELEVANCE

In our study, the PCMH model was associated with improved cancer screening rates across contexts but may be especially relevant for practices in lower socioeconomic areas.

Physician and Family Recommendations to Obtain a Mammogram and Mammography Intentions: The Moderating Effects of Perceived Seriousness and Risk of Breast Cancer

A growing body of literature has demonstrated psychosocial factors enable mammography intentions and usage among Latinas. Although these factors (e.g., family recommendations, breast cancer perceptions) likely influence one another, little research has examined interactive effects. The current study assessed the moderating effect of perceived breast cancer seriousness and risk on associations between recommendations to obtain mammography and mammography intentions. This sample included 97 Latinas in rural Eastern Washington State. After adjusting for age, two significant interactions emerged: perceived seriousness × physician recommendation and perceived risk × family recommendation. This exploratory study provides important directions for future communication research and planning to improve screening disparities.