Birth Cohort Colorectal Cancer (CRC): Implications for Research and Practice

Colorectal cancer (CRC) epidemiology is changing due to a birth cohort effect, first recognized by increasing incidence of early onset CRC (EOCRC, age <50 years). In this paper, we define "birth cohort CRC" as the observed phenomenon, among individuals born 1960 and later, of increasing CRC risk across successive birth cohorts, rising EOCRC incidence, increasing incidence among individuals aged 50 to 54 years, and flattening of prior decreasing incidence among individuals aged 55 to 74 years. We demonstrate birth cohort CRC is associated with unique features, including increasing rectal cancer (greater than colon) and distant (greater than local) stage CRC diagnosis, and increasing EOCRC across all racial/ethnic groups. We review potential risk factors, etiologies, and mechanisms for birth cohort CRC, using EOCRC as a starting point and describing importance of viewing these through the lens of birth cohort. We also outline implications of birth cohort CRC for epidemiologic and translational research, as well as current clinical practice. We postulate that recognition of birth cohort CRC as an entity-including and extending beyond rising EOCRC-can advance understanding of risk factors, etiologies, and mechanisms, and address the public health consequences of changing CRC epidemiology.

Hard-to-Reach or Hardly Reached? The "Difficulty" of Engaging Cisgender Black Females in Sexual Health Research

Rather than placing the onus on stigmatized and disenfranchised communities as hard-to-reach in sexual health research, we challenge researchers to recognize and provide outreach to populations who are hardly reached, such as cisgender Black women. We posit that the disparate human immunodeficiency virus (HIV) and sexually transmitted infection (STI) rates experienced by Black women in the USA are due in part to social and structural inequities and lack of researcher outreach within these communities. Social inequities give rise to racial and gender discrimination, which often results in structural barriers that researchers may not acknowledge. Structural barriers include medical mistrust and lack of access to preventative sexual health services, health care, education, and other resources. To achieve health equity, researchers must engage with Black women to understand the unique struggles they face and intervene with non-stigmatizing, culturally appropriate interventions. Interventions must utilize gatekeepers, influencers, community organizations, community advisory boards, and peer support. It is critical that sexual health researchers reach out to those who do not fall under the traditional hard-to-reach category but are hardly reached to counteract the current projection that 1 in 32 Black women will be diagnosed with HIV in their lifetime.

Neighborhood factors and survival to old age: The Jackson Heart Study

Few studies have evaluated environmental factors that predict survival to old age. Our study included 913 African American participants in the Jackson Heart Study (JHS) who resided in the tri-county area of the Jackson, MS metropolitan area and were 65-80 years at baseline. Participants were followed from 2000 through 2019 for the outcome of survival to 85 years old. We evaluated each of the following census tract-level measures of the social/physical environment as exposures: socioeconomic status, cohesion, violence, disorder, healthy food stores, residential land use, and walkability. We assessed mediation by physical activity and chronic conditions. As a complementary ecologic analysis, we used census-tract data to examine factors associated with a greater life expectancy. A total of 501 (55%) JHS participants survived to age 85 years or older. Higher social cohesion and greater residential land use were modestly associated with survival to old age (risk difference = 25%, 95% CI: 0-49%; and 4%, 95% CI: 1-7%, respectively). These neighborhood effects were modestly mediated through leisure time physical activity; additionally, social cohesion was mediated through home and yard activity. In our ecologic analysis, a greater percentage of homeowners and a greater proportion of people living in partnered families were associated with higher census-tract level life expectancy. African American older adults living in residential neighborhoods or neighborhoods with high social cohesion were more likely to survive to old age.

Reduction in Racial and Ethnic Disparity in Survival Following Liver Transplant for Hepatocellular Carcinoma in the Direct-acting Antiviral Era

BACKGROUND & AIMS

Black patients with hepatocellular cancer (HCC), often attributed to hepatitis C virus (HCV) infection, have suboptimal survival following liver transplant (LT). We evaluated the impact of direct-acting antiviral (DAA) availability on racial and ethnic disparities in wait list burden post-LT survival for candidates with HCC.

METHODS

Using the United Network for Organ Sharing registry, we identified patients with HCC who were listed and/or underwent LT from 2009 to 2020. Based on date of LT, patients were categorized into 2 era-based cohorts: the pre-DAA era (LT between 2009 and 2011) and DAA era (LT between 2015 and 2017, with follow-up through 2020). Kaplan-Meier and Cox proportional hazards analyses were used to compare post-LT survival, stratified by era and race and ethnicity.

RESULTS

Annual wait list additions for HCV-related HCC decreased significantly in White and Hispanic patients during the DAA era, with no change (P = .14) in Black patients. Black patients had lower 3-year survival than White patients in the pre-DAA era (70.6% vs 80.1%, respectively; P < .001) but comparable survival in the DAA era (82.1% vs 85.5%, respectively; P = .16). 0n multivariable analysis, Black patients in the pre-DAA era had a 53% higher risk (adjusted hazard ratio [HR], 1.53; 95% confidence interval [CI], 1.28-1.84), for mortality than White patients, but mortality was comparable in the DAA era (adjusted HR, 1.23; 95% CI, 0.99-1.52). In a stratified analysis in Black patients, HCV-related HCC carried more than a 2-fold higher risk of mortality in the pre-DAA era (adjusted HR, 2.86; 95% CI, 1.50-5.43), which was reduced in the DAA era (adjusted HR, 1.34; 95% CI, 0.78-2.30).

CONCLUSIONS

With the availability of DAA therapy, racial disparities in post-LT survival have improved.

Multidisciplinary providers' perspectives on engaging young black, gay, bisexual and other men who have sex with men living with HIV in mental health care services

Young Black gay, bisexual, and other men who have sex with men (YB-GBMSM) living with HIV are at high risk for psychological stressors and comorbidities. We sought to gain the perspectives of multidisciplinary providers (including HIV care, mental health care, and social service providers) on their experiences with engaging YB-GBMSM in mental health care within comprehensive HIV primary care centers that included both types of services on-site. We conducted qualitative in-depth interviews with fifteen providers in two clinics, and analyzed the qualitative data using a thematic analysis approach. Our participants described high levels of need for mental health services among YB-GBMSM living with HIV, due to psychological challenges related to living with HIV as well as other frequently occurring life stressors. At the same time, barriers to accessing these services were identified, with mental health stigma, under-recognition of symptoms and confidentiality concerns being the most commonly cited. Strategies to improve mental health service uptake in light of these needs and barriers were discussed, including re-framing of mental health services, addressing logistical barriers, and utilization of a biopsychosocial perspective.

Understanding social capital among young black gay and bisexual men living with HIV: a qualitative exploration

Social capital, defined as the sum of an individual's resource-containing, reciprocal and trustworthy social network connections, has been associated with improved engagement in care among people living with HIV globally. We conducted a qualitative interview study of social capital among 28 young Black gay, bisexual and other men who have sex with men ages 18-29 living with HIV in Atlanta, Georgia. We asked participants about bonding capital (relationships between individuals with similar demographic characteristics), bridging capital (relationships with individuals of different backgrounds), collective efficacy (involvement with community organisations) and satisfaction with their social networks. We found that participants described bonding capital from friends and family in depth, while more gaps were noted in bridging capital and collective efficacy. Bonding capital derived from families was especially critical to participants' satisfaction with their social capital. Findings suggest that interventions targeting young Black gay, bisexual and other men who have sex with men should build upon strong bonds with family and friends, and/or fill gaps in bridging capital and collective efficacy by connecting young men to mentors and organisations.

Exploring influences on methamphetamine use among Black gay, bisexual and other men who have sex with men in Atlanta: A focus group study

BACKGROUND

Methamphetamine use is a contributor to HIV risk and poor health outcomes among gay, bisexual and other men who have sex with men (GBMSM). There is a paucity of research examining methamphetamine use and its social context specifically among Black GBMSM. We therefore sought to: (1) describe trends in methamphetamine use among Black GBMSM in Atlanta, Georgia, and (2) examine the risk environment (micro-, meso‑ and macro-level factors operating in the political, social, physical, economic, and healthcare environments) that might elevate risk for methamphetamine use in this population.

METHODS

We conducted a qualitative study consisting of eight focus groups with 54 key informants between December 2019 and March 2020. Participants represented community-based and healthcare organizations that work closely with Black GBMSM. Our thematic analysis included an iterative, team coding approach combining deductive and inductive elements.

RESULTS

Participants unanimously agreed that methamphetamine use was increasingly prevalent among Black GBMSM in Atlanta, with many describing a historical arc in which methamphetamine use - previously associated with predominantly white, affluent GBMSM - was now common among younger, lower socioeconomic status Black GBMSM. At the micro-level, participants described contributors to increasing methamphetamine use including use as a sex drug, and the interrelated burdens of stress and mental illness, housing instability, geographic mobility and poverty. At the meso‑level, participants described virtual and physical sex scenes including use of geosocial networking apps that facilitated the spread of methamphetamine use in the Black GBMSM community. At the macro-level, participants described how policies prioritizing other concerns (e.g., HIV, opioids) seemed to limit resources available for methamphetamine prevention and treatment programming.

CONCLUSION

Multi-level environmental influences are working together to elevate risk for methamphetamine use among Black GBMSM in Atlanta, with potential to adversely impact health and well-being and undermine HIV prevention and treatment efforts.

Deterrents and motivators of HIV testing among young Black men who have sex with men in North Carolina

In the United States (US), young, Black men who have sex with men (YBMSM) are disproportionately affected by HIV. Delayed and infrequent HIV testing has been associated with the increased likelihood of YBMSM to be infected, yet unaware. Despite increased efforts to provide HIV testing to YBMSM in the US, HIV testing remains underutilized by YBMSM in the South. To develop strategies to increase HIV testing, this study sought to understand the factors that affect HIV testing utilization among YBMSM. Twenty-two HIV-positive and HIV-negative YBMSM aged 22-33 in North Carolina participated in semistructured interviews. Qualitative thematic analysis revealed that deterrents and motivators to HIV testing spanned individual, social, and structural levels. Deterrents included a low perceived risk of HIV, fear of receiving an HIV-positive test result, lack of HIV testing locations, healthcare provider mistreatment and privacy concerns due to intersectional stigma. Motivators of HIV testing included health maintenance, social support, and increased access to HIV testing. The findings from this study contribute to ongoing research that aims to address inconsistent HIV testing and late HIV diagnosis among YBMSM. Interventions to address intersectional stigma in community and healthcare settings can enhance utilization of HIV prevention services .

Associations Between Neighborhood Problems and Sexual Behaviors Among Black Men Who Have Sex with Men in the Deep South: The MARI Study

There is a disproportionately high HIV incidence among Black men who have sex with men (MSM) despite equal or lower levels of HIV risk behaviors compared to White MSM. Due to high levels of racial segregation in the U.S., Black MSM have an elevated likelihood of living in neighborhoods that contain psychosocial stressors, which, in turn, may increase behaviors promoting HIV infection. We examined associations between perceived neighborhood problems and sexual behaviors among Black MSM in the Deep South, a population at highest risk of HIV. Data came from the MARI Study, which included Black MSM ages 18-66 years recruited from the Jackson, MS, and Atlanta, GA, metropolitan areas (n = 377). Participants completed questions about neighborhood problems (e.g., excessive noise, heavy traffic/speeding cars and trash/litter) and sexual behaviors (e.g., condomless sex and drug use before or during sex). We used Poisson's regression model with robust standard errors to estimate the adjusted prevalence ratio (aPR; 95% confidence intervals [CI]) of neighborhood problems (coded as tertiles [tertile 1 = low neighborhood problems, tertile 2 = medium neighborhood problems, tertile 3 = high neighborhood problems] as well as continuously) with sexual behaviors, after adjustment for sociodemographic characteristics and other variables. About one-fourth of the sample reported at least one neighborhood problem, with the most common (31.6%) being no/poorly maintained sidewalks, which indicates an infrastructural problem. In multivariable models, compared to those in the lowest tertile, those reporting more neighborhood problems (tertile 2: aPR = 1.49, 95% CI = 1.04, 2.14 and tertile 3: aPR = 1.53, 95% CI = 1.05, 2.24) reported more drug use before or during sex (p for trend = .027). Neighborhood problems may promote behaviors (e.g., drug use before or during sex) conducive to HIV infection. Structural interventions could improve community infrastructure to reduce neighborhood problems (e.g., no/poorly maintained sidewalks and litter). These interventions may help to reduce HIV incidence among Black MSM in the Deep South.

"My Sexuality…It Creates a Stress": HIV-Related Communication Among Bisexual Black and Latino Men, New York City

Men who have sex with men and women (including bisexual men) comprise 35% of all men who have sex with men (MSM) in the U.S. It is estimated that 121,800 men who have been bisexually active within the past year are living with HIV in the U.S. Communication about HIV may result in risk-reduction behaviors. However, little is known about the nature or context for HIV prevention communication among bisexual men, particularly for blacks and Hispanic/Latinos who are disproportionately at greater HIV risk. Therefore, we explored patterns and contexts of HIV-related communications occurring within personal social networks among bisexual black and Hispanic/Latino men. Using respondent-driven sampling methods, we conducted semi-structured interviews from 2011 to 2012 among 36 participants living in New York City. We examined interview responses from participants for main themes using computer-assisted thematic analyses. The three main themes identified were: (1) communication strategies (e.g., "You can tell a lot from how a person responds just by the tone of their voice"), (2) barriers (e.g., "My sexuality…it creates a stress"), and (3) motivations for these communications (e.g., "I know that's a(n) issue in the black community…if I could help another brother, I will do it"). Our findings can inform HIV prevention efforts such as social messaging campaigns and other risk-reduction interventions designed for bisexual men.

Life after Stroke in an Urban Minority Population: A Photovoice Project

Stroke is a leading cause of disability in the United States and disproportionately affects minority populations. We sought to explore the quality of life in urban, minority stroke survivors through their own photos and narratives. Using the Photovoice method, seventeen stroke survivors were instructed to take pictures reflecting their experience living with and recovering from stroke. Key photographs were discussed in detail; participants brainstormed ways to improve their lives and presented their work in clinical and community sites. Group discussions were recorded, transcribed, and coded transcripts were reviewed with written narratives to identify themes. Participants conveyed recovery from stroke in three stages: learning to navigate the initial physical and emotional impact of the stroke; coping with newfound physical and emotional barriers; and long-term adaptation to physical impairment and/or chronic disease. Participants navigated this stage-based model to varying degrees of success and identified barriers and facilitators to this process. Barriers included limited access for disabled and limited healthy food choices unique to the urban setting; facilitators included presence of social support and community engagement. Using Photovoice, diverse stroke survivors were able to identify common challenges in adapting to life after stroke and important factors for recovery of quality of life.

Are Non-intellectually Disabled Black Youth with ASD Less Impaired on Parent Report than Their White Peers?

There is a lack of research examining differences in functioning in autism spectrum disorder (ASD) across ethnicity, particularly among those without intellectual disability (ID). This study investigated ethnic differences in parent-reported impairment in executive function, adaptive behavior, and social-emotional functioning. White and Black youth (n = 64; ages 6-17) with ASD without ID were compared on each of these domains. Black youth had significantly lower levels of impairment on all three domains. Findings may reflect better daily functioning among Black youth with ASD and/or cultural differences in parent response to questionnaires. Regardless, these findings raise concern about the sensitivity of commonly used measures for Black children with ASD and the impact of culture on daily functioning and symptom manifestation.

Factors Influencing Black Churches' Readiness to Address HIV

This study employed a community-based participatory research approach to understand factors that influence church readiness to engage in HIV prevention and treatment activities. A convenience sample of twenty-six Black faith leaders participated in four focus groups. Data analysis was done through qualitative content analysis. Three themes emerged. First, the pastor's blessing and authority as the church's decision-maker determines readiness to engage in HIV prevention. Second, the church's purview of sexual health as part of a holistic ministry facilitates faith leader's readiness. Lastly, securing financial and human resources makes it feasible for faith leaders to implement activities. Findings suggest HIV-related stigma alone does not explain readiness to address HIV. Participants also discussed activities their churches are equipped to handle, including HIV testing events and health fairs.

Black breast cancer survivors experience greater upper extremity disability

Over one-third of breast cancer survivors experience upper extremity disability. Black women present with factors associated with greater upper extremity disability, including: increased body mass index (BMI), more advanced disease stage at diagnosis, and varying treatment type compared with Whites. No prior research has evaluated the relationship between race and upper extremity disability using validated tools and controlling for these factors. Data were drawn from a survey study among 610 women with stage I-III hormone receptor positive breast cancer. The disabilities of the arm, shoulder and hand (QuickDASH) is an 11-item self-administered questionnaire that has been validated for breast cancer survivors to assess global upper extremity function over the past 7 days. Linear regression and mediation analysis estimated the relationships between race, BMI and QuickDASH score, adjusting for demographics and treatment types. Black women (n = 98) had 7.3 points higher average QuickDASH scores than White (n = 512) women (p < 0.001). After adjusting for BMI, age, education, cancer treatment, months since diagnosis, and aromatase inhibitor status, Black women had an average 4-point (95 % confidence interval 0.18-8.01) higher QuickDASH score (p = 0.04) than White women. Mediation analysis suggested that BMI attenuated the association between race and disability by 40 %. Even several years post-treatment, Black breast cancer survivors had greater upper extremity disability, which was partially mediated by higher BMIs. Close monitoring of high BMI Black women may be an important step in reducing disparities in cancer survivorship. More research is needed on the relationship between race, BMI, and upper extremity disability.

Impact of parent-child communication interventions on sex behaviors and cognitive outcomes for black/African-American and Hispanic/Latino youth: a systematic review, 1988-2012

PURPOSE

We reviewed human immunodeficiency virus (HIV) and sexually transmitted infection (STI)- behavioral interventions implemented with disproportionately affected black/African-American and Hispanic/Latino youth and designed to improve parent-child communications about sex. We compared their effectiveness in improving sex-related behavior or cognitive outcomes.

METHODS

A search of electronic databases identified peer-reviewed studies published between 1988 and 2012. Eligible studies were U.S.-based parent-child communication interventions with active parent components, experimental and quasiexperimental designs, measurement of youth sexual health outcomes, and enrollment of ≥ 50% black/African-American or Hispanic/Latino youth. We conducted systematic, primary reviews of eligible papers to abstract data on study characteristics and youth outcomes.

RESULTS

Fifteen studies evaluating 14 interventions were eligible. Although youth outcome measures and follow-up times varied, 13 of 15 studies (87%) showed at least one significantly improved youth sexual health outcome compared with controls (p < .05). Common components of effective interventions included joint parent and child session attendance, promotion of parent/family involvement, sexuality education for parents, developmental and/or cultural tailoring, and opportunities for parents to practice new communication skills with their youth.

CONCLUSIONS

Parent-child communication interventions that include parents of youth disproportionately affected by HIV/STIs can effectively reduce sexual risk for youth. These interventions may help reduce HIV/STI-related health disparities and improve sexual health outcomes.