Breast Cancer Screening Among Women by Nativity, Birthplace, and Length of Time in the United States.

Objective-The U.S. Preventive Services Task Force (USPSTF) recommends biennial mammography screening for women aged 50-74 to reduce mortality from breast cancer. In the United States, foreign-born women have historically had higher breast cancer mortality rates than their U.S.-born peers. This report presents national estimates of mammography screening among women by nativity, birthplace, and percentage of lifetime living in the United States. Methods-Combined data were analyzed from 29,951 women aged 50-74 years who participated in the 2005, 2008, 2010, 2013, and 2015 National Health Interview Survey. The percentage of these women who ever had a mammogram and met the USPSTF recommendations for screening by nativity, birthplace, and percentage of lifetime in the United States was generated. Estimates were adjusted for selected demographic, socioeconomic, and health care access and utilization factors and presented as predictive margins. Results-Overall, foreign-born women were less likely than U.S.-born women to have ever had a mammogram (88.3% compared with 94.1%). Foreign-born women living in the United States for less than 25% of their lifetime were less likely to have ever had a mammogram (76.4%) or meet the USPSTF recommendations (55.0%) compared with U.S.-born women. Foreign-born women living in the United States for 25% or more of their lifetime were also less likely to have ever had a mammogram (90.9%) compared with U.S.-born women. After adjustment for selected sociodemographic characteristics, the percentage of foreign-born women who ever received a mammogram increased but was still lower than that of U.S.-born women. Foreign-born women residing in the United States for less than 25% of their lifetime were as likely as U.S.-born women to have met the USPSTF recommendations (72.1% and 72.4%, respectively), while those residing in the United States for 25% or more of their lifetime (75.1%) were more likely to do so than U.S.-born women. Differences by birthplace were also observed.

Cancer mortality rates among US and foreign-born individuals: United States 2005-2014.

From 1970 to 2010 the foreign-born population in the United States has rapidly increased from 9.6 to 40.0 million individuals. Historically, differences in cancer rates have been observed between US-born and foreign-born individuals. However, comprehensive and up-to-date data on US cancer rates by birth place is lacking. To compare cancer mortality rates among foreign and US-born individuals, population-based cancer mortality data were obtained from the CDC's National Center for Health Statistics. Utilizing data recorded on death certificates, individuals were categorized as US-born or foreign-born. Annual population estimates were obtained from the American Community Survey. Age-adjusted mortality rates and rate ratios (RRs) for all cancer sites were calculated using SEER*Stat. A total of 5,670,535 deaths from malignant cancers were recorded in the US from 2005 to 2014 and 9% of deaths occurred among foreign-born individuals. Overall, foreign-born individuals had a 31% lower cancer mortality rate when compared to US-born individuals (Rate Ratio (RR): 0.69 (95% CI: 0.68-0.69)), and similar results were observed when stratifying by sex, race/ethnicity, age, and geographic region. However, foreign-born individuals did have significantly elevated cancer mortality rates for seven cancers sites, of which five were infection-related, including: nasopharynx (RR: 2.01), Kaposi Sarcoma (RR: 1.94), stomach (RR: 1.82), gallbladder (RR: 1.47), acute lymphocytic leukemia (RR: 1.27), liver and intrahepatic bile duct (RR: 1.24), and thyroid (RR: 1.22) cancers. Many of these deaths could be avoided through improved access to prevention, screening, and treatment services for immigrant populations in the US or in their country of origin.

Cervical Cancer Death Rates Among U.S.- and Foreign-Born Women: U.S., 2005-2014.

INTRODUCTION: Historically, foreign-born women in the U.S. are less likely to be screened and are more likely to die from cervical cancer when compared with their U.S.-born counterparts. In order to inform prevention efforts and reduce this health disparity, mortality data were obtained from the National Center for Health Statistics to describe cervical cancer mortality among U.S.- and foreign-born women. METHODS: Annual population estimates were obtained from the U.S. Census Bureau's American Community Survey from 2005 to 2014. From 2017 to 2018, age-adjusted mortality rates and rate ratios were calculated by nativity status, race/ethnicity, age, geographic region, and country of birth. RESULTS: From 2005 to 2014, a total of 5,924 deaths from cervical cancer were recorded among the foreign-born population, compared with 33,893 deaths among U.S.-born women. Overall, foreign-born women had a lower cervical cancer mortality rate when compared with the U.S.-born women (rate ratio=0.95, 95% CI=0.92, 0.97). However, older foreign-born women had significantly higher mortality rates compared with U.S.-born women: aged 65-79 years (rate ratio=1.15, 95% CI=1.09, 1.22) and ≥80 years (rate ratio=1.43, 95% CI=1.32, 1.55). Women born in Mexico had significantly elevated rates of cervical cancer mortality (rate ratio=1.35, 95% CI=1.27, 1.42) when compared with U.S.-born women. CONCLUSIONS: Efforts that work to increase cervical cancer screening access and guideline compliance might further reduce the cervical cancer deaths in the U.S., and the excess burden observed among older foreign-born women.

Gastric cancer mortality rates among US and foreign-born persons: United States 2005-2014.

BACKGROUND: Historically, foreign-born individuals in the US have had an elevated risk of dying from gastric cancer when compared to US-born individuals. This is primarily due to factors that occur prior to their immigration to the US, including diet and underlying risk of H. pylori infection. METHODS: National mortality data from 2005 to 2014 were obtained from the CDC's National Center for Health Statistics. Annual population estimates were obtained from the US Census Bureau's American Community Survey for foreign-born and US-born persons. Age-adjusted gastric cancer mortality rates and rate ratios (RR) were calculated stratified by birth place, age, race/ethnicity, and geographic location. RESULTS: From 2005 to 2014, 111,718 deaths from malignant gastric cancer occurred in the US, of which 24,583 (22%) occurred among foreign-born individuals. Overall, foreign-born individuals had higher mortality rates compared with US-born individuals (RR 1.82; 95% CI 1.80, 1.85) and this difference remained after stratifying by sex, age, and geographic location. However, this finding was primarily driven by the low rate of gastric cancer mortality among US-born whites, with similar mortality rates observed among all other foreign-born and US-born groups. Gastric cancer mortality rates significantly decreased during the study period overall (AAPC - 2.50; 95% CI - 3.21, - 1.79) with significant declines observed among US-born (AAPC - 2.81; 95% CI - 3.55, - 2.07) and the foreign-born (AAPC - 2.53; 95% CI - 3.20, - 1.86) population. CONCLUSIONS: Efforts directed at reducing the prevalence of gastric cancer risk factors could help reduce the elevated burden observed among foreign-born individuals and US-born minority groups.

Trends in liver cancer mortality in the United States: Dual burden among foreign- and US-born persons.

BACKGROUND: Since the mid-1980s, the burden of liver cancer in the United States has doubled, with 31,411 new cases and 24,698 deaths occurring in 2014. Foreign-born individuals may be more likely to die of liver cancer than individuals in the general US-born population because of higher rates of hepatitis B infection, a low socioeconomic position, and language barriers that limit the receipt of early cancer detection and effective treatment. METHODS: To determine whether liver cancer mortality rates were higher among foreign-born individuals versus US-born individuals in the United States, population-based cancer mortality data were obtained from the National Center for Health Statistics of the Centers for Disease Control and Prevention. Annual population estimates were obtained from the US Census Bureau's American Community Survey. Age-adjusted mortality rates and rate ratios (RRs) for liver cancer stratified by birth place were calculated, and the average annual percent change (AAPC) was used to evaluate trends. RESULTS: A total of 198,557 deaths from liver and intrahepatic bile duct cancer were recorded during 2005-2014, and 16% occurred among foreign-born individuals. Overall, foreign-born individuals had a 24% higher risk of liver cancer mortality than US-born individuals (RR, 1.24; 95% confidence interval [CI], 1.22-1.25). Foreign-born individuals did not have any significant changes in liver cancer mortality rates overall, but among US-born individuals, liver cancer mortality rates significantly increased (AAPC, 2.7; 95% CI, 2.1-3.3). CONCLUSIONS: Efforts that address the major risk factors for liver cancer are needed to help to alleviate the health disparities observed among foreign-born individuals and reverse the increasing trend observed in the US-born population.

Challenges in Recruiting African-Born, US-Based Participants for HIV and Tuberculosis Research.

Research is critical for developing HIV and tuberculosis (TB) programming for U.S. African-born communities, and depends on successful recruitment of African-born people. From January 2014 to June 2016, we recruited African-born people for HIV and TB research in King County, Washington. We compared the characteristics of study participants and the underlying populations of interest, and assessed recruitment strategies. Target enrollment for the HIV study was 167 participants; 51 participants (31%) were enrolled. Target enrollment for the TB study was 218 participants; 38 (17%) were successfully recruited. Of 249 prior TB patients we attempted to contact by phone, we reached 72 (33%). Multiple recruitment strategies were employed with variable impact. Study participants differed from the underlying populations in terms of gender, country of origin and language. Inequities in research participation and in meaningful opportunities for such participation may exacerbate existing health disparities.

Enacted HIV-related stigma and breast-health beliefs and practices among African American women living with HIV: The mediating roles of internalized HIV-related stigma and depressive symptoms.

Reducing HIV-related stigma among African American women living with HIV is a priority to improve HIV-specific health outcomes, but may also impact other health beliefs and practices. Testing this hypothesis is important because African American women experience worse health outcomes, including for breast cancer. This study examines the relationship between enacted HIV-related stigma and breast health beliefs and practices and the mediating effects of depressive symptoms and internalized HIV-related stigma. We use baseline data from a stigma reduction intervention trial for adult African American women living with HIV in Chicago, IL and Birmingham, AL (n = 237). Data were collected using computer-assisted self-interviewing software. After adjusting for covariates, enacted HIV-related stigma was associated with greater perceived threat of breast cancer, specifically in terms of breast cancer fear (p <0.0001), but not regular breast healthcare engagement (p = .17). Internalized HIV-related stigma and depressive symptoms were associated with enacted HIV-related stigma, perceived threat of breast cancer, and regular breast healthcare engagement (all p <.05). Internalized HIV-related stigma mediated the relationship between enacted HIV-related stigma and perceived threat of breast cancer (p = .001); depressive symptoms did not (p = .84). We provide evidence concerning broader influences of internalized HIV-related stigma for the health of African American women living with HIV. Future studies should consider the impact of HIV stigma on other health beliefs and behaviors.

Cervical Cancer Screening Among Women by Birthplace and Percent of Lifetime Living in the United States.

OBJECTIVE: The aim of the study was to provide national estimates of Pap test receipt, by birthplace, and percent of lifetime in the United States (US). MATERIALS AND METHODS: Pooled nationally representative data (2005, 2008, 2013, 2015) from the National Health Interview Survey were used to examine differences in Pap test receipt among adult US women by birthplace and percent of lifetime in the US. Descriptive estimates were age-adjusted. Regression models were adjusted for selected sociodemographic and healthcare access and utilization factors and presented as predicted margins. RESULTS: Foreign-born women 18 years and older were more than twice as likely to have never received a Pap test compared with US-born women (18.6% vs 6.8%). Regression models showed that foreign-born women from Mexico (9.8%), South America (12.6%), Caribbean (14.6%), Southeast Asia (13.7%), Central Asia (20.4%), South Asia (22.9%), Middle East (25.0%), Africa (27.8%), Europe (16.4%), and Former Soviet Union (28.2%) were more likely to be unscreened compared with US-born women (7.6%). Foreign-born women who spent less than 25% of their life in the US had higher prevalence of never having a Pap test (20%) compared with foreign-born who spent more than 25% of their life in the US (12.7%). CONCLUSIONS: Using national survey, we found that where a woman is born and the percent of her lifetime spent residing in the US do impact whether she gets screened at least once in her lifetime. IMPACT: These findings may inform cervical cancer screening efforts targeting foreign-born women.

CDC Activities to Enhance Training in Cancer Prevention and Control in Field Epidemiology Training Programs in Low- and Middle-Income Countries.

Cancer is one of the leading causes of morbidity and mortality worldwide. In 2012, there were > 14 million new cancer cases and > 8 million cancer deaths, with 70% of these deaths occurring in low- and middle-income countries (LMICs). Part of the success of cancer prevention and control efforts requires the development and strengthening of the public health workforce, particularly in LMICs where the cancer burden is the greatest. The US Centers for Disease Control and Prevention (CDC) supports workforce capacity development globally through Field Epidemiology Training Programs (FETPs) established in ministries of health in > 70 countries. To enhance training in cancer prevention and control in FETPs, the CDC has developed an open-access curriculum in applied cancer epidemiology and supports FETP trainees who conduct cancer-related planned projects. The curriculum contains modules on cancer registration, screening, and comprehensive cancer control that are particularly relevant to current cancer control efforts in many LMICs. Pilot testing of the curriculum showed an increase in trainees' cancer knowledge and covered content trainees found to be relevant to their field epidemiology training and projects and future work in cancer prevention and control. Since 2013, the CDC has supported 13 trainees with cancer-related projects; two have published articles, two have presented their results at international conferences, and others are writing manuscripts on their project outcomes. Through the development of an open-access applied cancer epidemiology curriculum and by supporting cancer-related projects for FETP trainees, the CDC provided technical assistance for LMICs to build capacity for cancer prevention and control efforts.

"You are always hiding. It's the worst way to live." Exploring Stigma in African Immigrants Living With HIV in a Large Northwest U.S. Metropolitan Area.

African immigrants living in the United States are disproportionately and uniquely affected by HIV. Evidence shows that stigma may contribute to this inequity. Applying a biopsychosocial model of health, our qualitative study explored HIV-related stigma and its impact on African immigrants living with HIV in a large northwestern U.S. metropolitan area. We conducted in-depth, semi-structured interviews with 20 African immigrants living with HIV. In the biological health realm, HIV-related stigma contributed to adverse health care environments, disruptions in care, and poor physical health. In the psychological health realm, it was associated with emotional vulnerability, depressive symptoms, and negative coping. In the social health realm, stigma lead to disclosure challenges, isolation, and poor social support. HIV-related stigma was an extensive and pervasive burden for this population. The biopsychosocial model was a helpful lens through which to explore HIV-related stigma and identify opportunities for future research and intervention.

Involving religious leaders in HIV care and treatment at a university-affiliated hospital in Ethiopia: Application of formative inquiry.

In sub-Saharan Africa, religious views strongly influence how people relate to illness, health, and healing. Belief in the curative power of religion, including for HIV, persists in many communities. As such, many funding agencies and organisations working in the field of HIV have incorporated religious institutions into their programmes in various capacities. Yet, debate continues regarding the benefits and drawbacks of including sectarian organisations in the fight against HIV. In the current study, we sought to explore whether patients with HIV would be amenable to receiving HIV-related psychosocial support from religious leaders. We interviewed 48 Ethiopian Orthodox Church followers who presented for routine HIV care at Gondar University Hospital ART (antiretroviral treatment) clinic. Although almost half (46%) of participants self-identified as 'very religious', the majority of them (73%) had not disclosed their HIV status to a religious leader. Study participants highlighted multiple factors that could potentially affect their willingness to involve religious leaders in their HIV care. We discuss these findings in relation to religion and HIV in the African context. Our findings support the use of formative qualitative work prior to developing and implementing programmes that integrate faith and medical communities.

Stigma in Ethiopia: association with depressive symptoms in people with HIV.

Rates of depression among people living with HIV can be as high as 50%. In many settings, HIV-related stigma has been associated with depressive symptoms which may lead to poor engagement in care and ultimately, poorer health outcomes. Stigma is a major issue in Ethiopia but data examining the relationship between stigma and depression in Ethiopia are lacking. We performed a mixed-methods cross-sectional study to examine the relationship between stigma of HIV/AIDS and depressive symptoms in Gondar, Ethiopia. We interviewed patients who presented for routine HIV care at Gondar University Hospital during the study period, examining depressive symptoms and HIV/AIDS-related stigma using standardized measures. Multiple-regression was used to assess the relationship between depressive symptoms, stigma, and gender. Of 55 patients included in this analysis, 63.6% were female and most participants had limited formal education (69%, less than 12th grade education). The majority reported experiencing both stigma (78%) and depressive symptoms (60%) ranging in severity from mild to moderately severe. Higher levels of HIV-related stigma were significantly associated with higher levels of depressive symptoms (ß = 0.464, p ≤ 0.001). Although gender was associated with stigma, it was not associated with depressive symptoms (ß = -0.027, p > 0.05). Results suggest the importance of psychosocial issues in the lives of people with HIV in Ethiopia.