Work in Progress: Immigrant Health Care from the Vantage of Cancer Testing and Screening.

This letter offers a perspective from cancer testing and screening on the improvements in immigrant insurance coverage and care charted in Bustamante et al.'s April 2019 article in JOIH on "Health Care Access and Utilization Among U.S. Immigrants Before and After the Affordable Care Act." Supportive evidence for their data may be found in complementary literature drawing from both the National Health Interview Survey the authors use and the Medical Expenditure Panel Survey, while post-ACA surveys and state level information suggest disparities remain for lawfully present and undocumented immigrants ineligible for Medicaid and unable to secure insurance to pay medical costs. Existent options for cancer services are discussed. Further relevant reform depends on voter awareness and collaborative efforts between consumer advocates and legislators.

Exploring Genetic Numeracy Skills in a Sample of U.S. University Students.

Misconceptions concerning numerical genetic risk exist even within educated populations. To more fully characterize and understand the extent of these risk misunderstandings, which have large potential impact on clinical care, we analyzed the responses from 2,576 students enrolled at 2 Southwestern universities using the PGRID tool, a 138-item web-based survey comprising measures of understanding of genetics, genetic disease, and genetic risk. The primary purpose of this study was to characterize the intersection of risk perception and knowledge, termed genetic numeracy (GN). Additionally, we identify sociodemographic factors that might shape varying levels of GN skills within the study sample and explore the impact of GN on genetic testing intentions using both the Marascuilo procedure and logistic regression analysis. Despite having some college coursework or at least one college degree, most respondents lacked high-level aptitude in understanding genetic inheritance risk, especially with respect to recessive disorders. Prior education about genetics and biology, as well as exposure to biomedical models of genetics, was associated with higher GN levels; exposure to popular media models of genetics was inversely associated with higher GN levels. Differing GN levels affects genetic testing intentions. GN will become more relevant as genetic testing is increasingly incorporated into general clinical care.

Exploring sexual behaviors and health communication among older women.

Older women around the globe are generally depicted as asexual beings, which may impact patient-provider discussions about sex. We examined data on 703 aging women in the United States to compare factors associated with women perceiving sex as important and women discussing sex with their physicians since turning 50. While 65.1% of participants perceived sex to be important, only 23.8% discussed sex with their providers since turning 50. Factors related to discussing sex included age, education, having a chronic condition, and consuming alcohol. Provider training and tools about sexual health communication could help launch those discussions about sex and increase advocacy for older women's sexual health.

Correlates of CVD and discussing sexual issues with physicians among male military veterans.

PURPOSE: This study aims to identify socio-demographic and health behavior factors associated with cardiovascular disease (CVD) diagnosis and patient-physician communication concerning sexual issues among older Veterans. METHODS: Cross-sectional data were collected from 635 male Veterans over age 55 years as part of the 2010 National Social Life, Health and Aging Project, a nationally-representative, population-based study of community-dwelling older Americans. Two independent logistic regression analyses were performed. RESULTS: Over 33% of Veterans were aged 75 years or older. Over one-half of participants reported having a CVD diagnosis (58%) and sexual intercourse within the previous year (58%); over one-third (37%) reported having one or more sexual dysfunctions and discussing sexual issues with their physician (42%). Veterans diagnosed with CVD were significantly more likely to self-identify as racial/ethnic minorities (OR=1.89, P=0.021), have more chronic disease comorbidities (OR=1.23, P=0.041), and have more sexual dysfunctions (OR=1.19, P=0.028). Veterans diagnosed with CVD were significantly less likely to report having sex within the previous year (OR=0.53, P=0.005). Veterans who reported discussing sexual issues with a physician were significantly more likely to be ≥75 years (OR=1.79, P=0.010), and report more than a high school education (OR=1.62, P=0.016), CVD diagnosis (OR=1.59, P=0.015), sex within the previous year (OR=1.69, P=0.033), and trouble achieving/maintaining an erection (OR=3.39, P<0.001). IMPLICATIONS: These findings suggest older male Veterans, particularly racial/ethnic minorities and those less-educated, may benefit from VA and community-based aging and sexual health/counseling services. These services should promote increased patient-physician communication as well as referrals between physicians and sex health/counseling specialists.

Exploring the Reality of Using Patient Experience Data to Provide Resident Feedback: A Qualitative Study of Attending Physician Perspectives.

INTRODUCTION: Little is known about the attitudes of faculty and residents toward the use of patient experience data as a tool for providing resident feedback. The purpose of this study was to explore the attitudes of teaching faculty surrounding patient experience data and how those attitudes may influence the feedback given to trainees. METHODS: From July 2013 to August 2013, we conducted in-depth, face-to-face, semistructured interviews with 9 attending physicians who precept residents in internal medicine at 2 continuity clinics (75% of eligible attendings). Interviews were coded using conventional content analysis. RESULTS: Content analysis identified six potential barriers in using patient experience survey data to provide feedback to residents: 1) perceived inability of residents to learn or to incorporate feedback, 2) punitive nature of feedback, 3) lack of training in the delivery of actionable feedback, 4) lack of timeliness in the delivery of feedback, 5) unclear benefit of patient experience survey data as a tool for providing resident feedback, and 6) lack of individualized feedback. CONCLUSION: Programs may want to conduct an internal review on how patient experience data is incorporated into the resident feedback process and how, if at all, their faculty are trained to provide such feedback.

Explanatory Models of Genetics and Genetic Risk among a Selected Group of Students.

This exploratory qualitative study focuses on how college students conceptualize genetics and genetic risk, concepts essential for genetic literacy (GL) and genetic numeracy (GN), components of overall health literacy (HL). HL is dependent on both the background knowledge and culture of a patient, and lower HL is linked to increased morbidity and mortality for a number of chronic health conditions (e.g., diabetes and cancer). A purposive sample of 86 students from three Southwestern universities participated in eight focus groups. The sample ranged in age from 18 to 54 years, and comprised primarily of female (67.4%), single (74.4%), and non-White (57%) participants, none of whom were genetics/biology majors. A holistic-content approach revealed broad categories concerning participants' explanatory models (EMs) of genetics and genetic risk. Participants' EMs were grounded in highly contextualized narratives that only partially overlapped with biomedical models. While higher education levels should be associated with predominately knowledge-based EM of genetic risk, this study shows that even in well-educated populations cultural factors can dominate. Study findings reveal gaps in how this sample of young adults obtains, processes, and understands genetic/genomic concepts. Future studies should assess how individuals with low GL and GN obtain and process genetics and genetic risk information and incorporate this information into health decision making. Future work should also address the interaction of communication between health educators, providers, and genetic counselors, to increase patient understanding of genetic risk.

Examining sexual dysfunction in non-muscle-invasive bladder cancer: results of cross-sectional mixed-methods research.

INTRODUCTION: More than 70,000 new cases of bladder cancer are diagnosed in the United States annually; with 75% being non-muscle-invasive (NMIBC). Research examining sexual dysfunction in bladder cancer survivors is limited, and previous studies have focused on cystectomy patients. AIMS: To evaluate the impact of sexual dysfunction on NMIBC survivors. METHODS: Mixed-methods data collection integrated a quantitative survey (Study 1; n = 117) and semi-structured qualitative interviews (Study 2; n = 26) from a non-overlapping sample of NMIBC survivors. We performed descriptive and classification and regression tree (CART) analyses of survey data and qualitative analysis of interviews. MAIN OUTCOME MEASURES: Self-reported sexual activity, interest in sex, and physiologic symptoms (e.g., male erectile/ejaculatory difficulties, female vaginal dryness) over the previous 4 weeks; partner communication about sexuality; contamination concerns; illness intrusiveness. RESULTS: Participants in these studies averaged 65 years of age (mean and median) and were male (77%), white (91%), and married (75%). Survey (Study 1) results linked NMIBC treatment to sexual symptoms and relationship issues. Many participants reported sexual inactivity (38.8%). Sexually active participants reported erectile difficulties (60.0%), vaginal dryness (62.5%), and worry about contaminating partner with treatment agents (23.2%). While almost one-half reported the usefulness of talking with partners about sexual function, only one-fifth of participants reported sharing all concerns with their partners. CART analysis supported the importance of communication. One-half of interviewees (Study 2) reported sexual dysfunction. Two-thirds reported negative impacts on their relationships, including perceived loss of intimacy and divorce; over one-third were sexually inactive for fear of contaminating their partner or spreading NMIBC. CONCLUSIONS: Survivors' sexual symptoms may result from NMIBC, comorbidities, or both. These results inform literature and practice by raising awareness about the frequency of symptoms and the impact on NMIBC survivors' intimate relationships. Further work is needed to design symptom management education programs to dispel misinformation about contamination post-treatment and improve quality of life. Kowalkowski MA, Chandrashekar A, Amiel GE, Lerner SP, Wittmann DA, Latini DM, and Goltz HH. Examining sexual dysfunction in non-muscle-invasive bladder cancer: Results of cross-sectional mixed-methods research. Sex Med 2014;2:141-151.

Forming and developing your professional identity: easy as PI.

Health education and promotion specialists and professional organizations have worked hard to successfully establish and maintain the status of health education/promotion (HE/P) as a unique and essential profession and to solidify practitioners' sense of professional identity. A professional identity is critical to a person's sense of self: It is about connecting with roles, responsibilities, values, and ethical standards unique to a specific profession. Professional identity is a complex issue in the HE/P profession; the distinction between personal and professional identities has been debated repeatedly over the years (e.g., should HE/P professionals be role models for clients?). The purpose of this Tool is to explain the concept of professional identity; provide new, emerging, and experienced HE/P with a greater understanding of what it means to have a professional identity; present processes and benchmarks of professional identity development; and offer specific tips and strategies for developing and enhancing an HE/P professional identity.

Educational opportunities in bladder cancer: increasing cystoscopic adherence and the availability of smoking-cessation programs.

Cancer survivors who continue to smoke following diagnosis are at increased risk for recurrence. Yet, smoking prevalence among survivors is similar to the general population. Adherence to cystoscopic surveillance is an important disease-management strategy for non-muscle-invasive bladder cancer (NMIBC) survivors, but data from Surveillance, Epidemiology, and End Results program (SEER) suggest current adherence levels are insufficient to identify recurrences at critically early stages. This study was conducted to identify actionable targets for educational intervention to increase adherence to cystoscopic monitoring for disease recurrence or progression. NMIBC survivors (n = 109) completed telephone-based surveys. Adherence was determined by measuring time from diagnosis to interview date; cystoscopies received were then compared to American Urological Association (AUA) guidelines. Data were analyzed using non-parametric tests for univariate and logistic regression for multivariable analyses. Participants averaged 65 years (SD = 9.3) and were primarily white (95 %), male (75 %), married (75 %), and non-smokers (84 %). Eighty-three percent reported either Ta- or T1-stage bladder tumors. Forty-five percent met AUA guidelines for adherence. Compared to non-smokers, current smokers reported increased fear of recurrence and psychological distress (p < 0.05). In regression analyses, non-adherence was associated with smoking (OR = 33.91, p < 0.01), providing a behavioral marker to describe a survivor group with unmet needs that may contribute to low cystoscopic adherence. Research assessing survivorship needs and designing and evaluating educational programs for NMIBC survivors should be a high priority. Identifying unmet needs among NMIBC survivors and developing programs to address these needs may increase compliance with cystoscopic monitoring, improve outcomes, and enhance quality of life.

Transforming practices: a primer on action research.

Action research (AR) is a powerful tool for health education and promotion practitioners who want to focus on improving the quality of their programs and services. In this Tool, we describe the characteristics and controversial aspects of AR, differentiate between traditional and action research, present the benefits of applying AR methods/techniques for investigating problems related to professional practice, and offer a four-phase methodological framework for conducting AR studies. Unlike traditional research, AR is a methodology that links theory, research, and practice; advances new knowledge and understandings via iterative action cycles; employs frontline health practitioners as researchers; and promotes collaborative practitioner-community partnerships. Egalitarian in its approach, AR offers an "insider's perspective" centered on context-specific problems and issues related to health promotion. AR falls into two categories: large-scale community-based research and small-scale practice-based research. Each cycle of the AR framework includes four phases: (a) preplanning/needs assessment, (b) planning/study organization, (c) action and observation/study implementation, and (d) reflection and planning/data analysis and interpretation. Using the AR primer in this Tool has the potential to empower health education/promotion practitioners, encourage collaborative partnerships, enhance practitioners' knowledge base, and promote social change.

Using growth curve analysis to examine challenges in instrumentation in longitudinal measurement in home visiting.

Home visitation programs aim to decrease child maltreatment, yet limited longitudinal data exists concerning their screening and assessment instruments. "At risk" families (N = 2,054) were screened using the Family Stress Checklist and referred to Healthy Families Indiana. The Home Observation Measurement of the Environment Scale (HOME) and Community Life Skills Scale (CLS) were administered at multiple intervals. Growth curve analyses indicate families with lower HOME and CLS scores received more home visits and visits between assessments. However, these instruments may have "ceiling effects" and may be unsuitable for longitudinal assessment and program evaluation. Programmatic changes were made based on evaluation results.

Symptom management strategies for men with early-stage prostate cancer: results from the Prostate Cancer Patient Education Program (PC PEP).

While the literature on prostate cancer health-related quality of life has grown extensively, little is known about symptom management strategies used by men to manage treatment-related side effects and the effectiveness of those strategies. We collected 628 symptom management reports from 98 men treated for localized prostate cancer. Participants were recruited from email lists and a prostate cancer clinic in Northern California. Data were collected using the Critical Incident Technique. Symptom management reports were assigned to categories of urinary, sexual, bowel, mental health, systemic, or "other." We calculated descriptive statistics by symptom type and management strategy effectiveness. The most common symptoms were urinary (26 %) and sexual (23 %). Participants' symptom management strategies varied widely, from medical and surgical interventions (20 %) to behavioral strategies (11 %) to diet and lifestyle interventions (12 %). The effectiveness of symptom management strategies varied, with sexual symptoms being managed effectively only 47 % of the time to mental health symptom management strategies considered effective 89 % of the time. Doing nothing was a commonly reported (15 %) response to symptoms and was effective only 14 % of the time. Men report the least effectiveness in symptom management for sexual dysfunction after prostate cancer treatment. Including men's experience with managing treatment side effects may be an important way to improve survivorship programs and make them more acceptable to men. More work is needed to find out why men frequently do nothing in response to symptoms when effective solutions exist and how providers can successfully engage such men.

Racial differences in sexual dysfunction among postdeployed Iraq and Afghanistan veterans.

This study examined the racial/ethnic differences in prevalence and risk factors of sexual dysfunction among postdeployed Iraqi/Afghanistan veterans. A total of 3,962 recently deployed veterans were recruited from Houston Veterans Affairs medical center. The authors examined sociodemographic, medical, mental-health, and lifestyle-related variables. Sexual dysfunction was diagnosed by ICD9-CM code and/or medicines prescribed for sexual dysfunction. Analyses included chi-square, analysis of variance, and multivariate logistic regression. Sexual dysfunction was observed 4.7% in Whites, 7.9% in African Americans, and 6.3% in Hispanics. Age, marital status, smoking, and hypertension were risk factors for Whites, whereas age, marital status, posttraumatic stress disorder and hypertension were significant for African Americans. For Hispanics, only age and posttraumatic stress disorder were significant. This study identified that risk factors of sexual dysfunction varied by race/ethnicity. All postdeployed veterans should be screened; and psychosocial support and educational materials should address race/ethnicity-specific risk factors.

Sexual dysfunction among male veterans returning from Iraq and Afghanistan: prevalence and correlates.

INTRODUCTION: Sexual dysfunction (SD) is not well described in the Iraq/Afghanistan veteran population despite high prevalence of multiple risk factors for this issue. AIM: To estimate the prevalence and examine the association of various sociodemographic, mental health, comorbid conditions and life style factors with sexual dysfunction in Iraq/Afghanistan veterans. METHODS: This exploratory cross-sectional study was conducted using data from the VA administrative database. A total of 4,755 Iraq/Afghanistan veterans were identified who sought treatment from the Michael E. DeBakey Veterans Affairs Medical Center inpatient and outpatient clinic between September 2007 and August 2009. MAIN OUTCOME MEASURES: Sexual dysfunction was determined by ICD9-CM codes related to sexual health issues and/or by specific medications, primarily phosphodiesterase-5 inhibitors (PDE5i), prescribed for erectile dysfunction. RESULTS: The overall prevalence of sexual dysfunction was 5.5% (N = 265). By age category, it was 3.6% (N = 145) for Iraq/Afghanistan veterans aged 18-40 years and 15.7% (N = 120) for Iraq/Afghanistan veterans aged > 40 years, respectively. A multivariate logistic-regression model revealed that annual income, marital status, post-traumatic stress disorder, and hypertension were significant risk factors of SD (all P < 0.05) among younger Iraq/Afghanistan veterans, whereas among the older Iraq/Afghanistan veterans, being African American and having PTSD and hypertension were significant risk factors of SD (all P < 0.05). There was marked discrepancy between documented erectile dysfunction and prescription of a PDE5i. CONCLUSIONS: These data demonstrate that a significant proportion of Iraq/Afghanistan veterans have SD and that the risk factors differ between younger and older veterans. Our findings also suggest that SD is likely under-coded. To better identify the scope of the problem, systematic screening for sexual dysfunction may be appropriate perhaps as part of an initial post-deployment health evaluation.

A pilot study of HIV/STI risk among men having sex with men using erectile dysfunction medications: challenges and opportunities for sexual medicine physicians.

INTRODUCTION: A growing literature suggests relationships between erectile dysfunction medications (EDM) and riskier sexual behavior among men who have sex with men (MSM). Questions remain concerning EDM use and related HIV/sexually transmitted infections (STI) risk among older MSM, particularly those 40 years and over, for whom EDM may be medically warranted. AIM: This exploratory pilot study explores the relationship between EDM and risky sexual behavior in a convenience sample of MSM using EDM and attending historic sex-on-premises venues. METHODS: We examined anonymous surveys from 139 MSM. Bivariate relationships were examined. We then fit a multiple logistic regression model to determine predictors of engaging in unprotected anal intercourse (UAI) at last EDM, using variables identified as being significantly related to UAI in the bivariate analyses. Potential predictors entered the model in a stepwise fashion. MAIN OUTCOME MEASURES: The primary outcome measure was engaging in UAI at last EDM use. RESULTS: MSM participating in the study ranged from 27 to 77 years and averaged 52.0 years (standard deviation = 10.73 years). These participants were primarily older MSM; fewer were younger MSM (12.12%), under age 40. Participants reporting UAI at last EDM use (N = 41) were significantly younger (P < 0.01). Men visiting bars within the last 6 months reported less UAI (P < 0.01). Both variables were independent predictors of UAI in the logistic regression model (P < 0.01). CONCLUSIONS: Similar to reports from younger MSM, our findings suggest older MSM using EDM and reporting UAI are also recreational drug users. We include recommendations for urologists and other sexual medicine physicians treating MSM who may be at elevated risk for HIV/STI infection because of joint EDM and club drug use.