Developing a culturally targeted video to enhance the use of genetic counseling in Latina women at increased risk for hereditary breast and ovarian cancer.

Disparities for genetic cancer risk assessment (GCRA) for hereditary breast and ovarian cancer (HBOC) persist between Latina and non-Hispanic Whites. There are few tested culturally targeted interventions. We developed a culturally targeted video to enhance GCRA uptake in at-risk Latinas. Interviews with healthcare providers (n = 20) and at-risk Latinas (n = 20) were conducted as formative research to inform the development of the video. Findings from the formative research, health behavior conceptual models, and evidence-based risk communication strategies informed the messages for the script. Then, we conducted a focus group with at-risk Latinas (n = 7) to obtain feedback for final refinement of the script. The final video was piloted for acceptability and potential dissemination in a sample of Latino community health workers (CHWs) (n = 31). Providers and at-risk Latinas suggested using simple language and visual aids to facilitate comprehension. Participants in the focus group identified areas for further clarification (e.g., cost). The result was an 18-min video that illustrates "Rosa's" story. Rosa learns about HBOC risk factors and overcomes barriers to attend genetic counseling. CHWs reported high overall satisfaction with the video (M = 9.61, SD = .88, range 1-10). A culturally targeted video has the potential to reach underserved populations with low literacy and English proficiency.

Take care of your neighborhood.

PURPOSE: Urban women in certain Washington, DC neighborhoods present with advanced breast cancer at high rates despite access to health insurance and health care. METHODS: Through a two-phase intervention, community health workers (CHWs) educated and surveyed individuals regarding healthcare utilization and breast health and cancer awareness. In phase I, CHWs educated and administered a survey to 1092 women, of whom 95.1% had health insurance, in an attempt to explain the high rate of advanced breast cancer despite having health insurance. In phase II, a targeted CHW-administered intervention was designed based on data collected from the phase I survey, and provided to 658 women. Preintervention and postintervention surveys were administered to assess its impact on knowledge and beliefs about breast health and cancer screening. RESULTS: During phase I, respondents most often identified personal factors (28.7%) and fear (27.7%) to explain the high rate of advanced breast cancer despite health insurance status. In phase II, the intervention improved perceptions of the safety and efficacy of mammograms with an absolute 15.4% increase in the respondents who believed that "A mammogram is the safest and most effective test available for finding early breast cancer." Perceived barriers discouraging mammograms were access (17.0%), pain (13.2%), and education (13.1%). CONCLUSIONS: Among an urban population of predominantly insured women with high rates of advanced breast cancer at diagnosis, personal factors and fear were cited as the greatest barriers to breast cancer screening. Educational intervention by CHWs showed a positive impact on respondents' perceptions regarding mammogram safety and efficacy.

Seeking Information on Behalf of Others: An Analysis of Calls to a Spanish-Language Radio Health Program.

OBJECTIVE: Spanish-monolingual Latinos account for 13% of U.S. residents and experience multiple barriers to effective health communication. Information intermediaries/proxies mediate between the linguistically isolated and health care providers. This study characterizes the information needs of surrogate callers and their subjects to a U.S.-based Spanish-language radio health program. METHOD: Content analysis of calls placed (N = 281 calls). RESULTS: Women made 70% of calls; 39.1% of calls were on behalf of children, 11.0% on behalf of parents/older adults, and 18.5% on behalf of spouses/siblings/contemporary adults. Most common topics were disease symptoms/conditions (19.6%), cancer (13.9%), and reproduction/sexuality (12.9%). Calls for children were more likely than those for parents/other adults to pertain to current illness symptoms or conditions; calls for parents were more likely to be about cancer/chronic conditions. Half of all calls sought clarification about a previous medical encounter. CONCLUSION: Information-seeking surrogates may represent a useful strategy for linguistic minorities to overcome structural and individual barriers to health information access. Results suggest that Latinos are willing to seek information on behalf of friends and family and highlight the need for improved, culturally and linguistically appropriate health communication sources. PRACTICE IMPLICATIONS: Leveraging Latinos' natural familial social networks/willingness to share information may improve dissemination of culturally and linguistically appropriate health information. Further implications for patient activation and doctor-patient communication are discussed.

Who Seeks Cita Con El Doctor? Twelve Years of Spanish-Language Radio Program Targeting U.S. Latinos.

PURPOSE: Spanish-dominant Latinos make up 13% of the U.S. population, and this group is poorer and faces multiple threats to health compared with the general population. Additionally, Spanish speakers face challenges accessing health information that is often not available in Spanish. This study provides a descriptive epidemiology of a unique, low-cost health information source: the longest-running U.S.-based Spanish-language call-in radio health education program. METHOD: From the universe of all calls 1999 to 2011, stratified random sampling yielded 1,237 analyzed calls, which were manually coded for caller sex, age, proxy status, and health concern. Descriptive statistics were used to examine basic demographics of callers and call topics overall and by sex and proxy caller status. RESULTS: Among all calls, the top three call-generating health topics were specific symptoms/conditions, sexual/reproductive health, and gastrointestinal concerns. The top nine topics were consistent among women, men, and proxy callers; however, relative frequency of topics varied across groups. Nearly one quarter of calls were initiated on behalf of someone, generally a child, spouse or sibling, or parent. Sixty percent of callers were women; women made 70% of proxy calls. CONCLUSION: Understanding the differences in information seeking behaviors, information needs, and source preferences is important for determining where and how to disseminate health information and may help explain disparities in knowledge and health outcomes. The radio talk show format provides a uniquely personal, culturally sensitive channel for meeting health information needs of a vulnerable population while leveraging the cost-effectiveness and wide reach of a mass medium.

Internet access and online cancer information seeking among Latino immigrants from safety net clinics.

Internet use is widespread, but little is known about Internet use for cancer information among Latinos, especially those who rely on safety net clinics. The authors investigated access to and intended use of the Internet for cancer information among low income, immigrant Latinos predominately from Central and South America. A cross-sectional study of 1,273 Latinos 21 years and older attending safety net clinics or health fairs was conducted from June 2007 to November 2008. The authors used logistic regression models to evaluate associations of age, acculturation, psychosocial factors and other covariates with Internet access and intended use of the Internet for cancer information among those with access. Of the sample, 44% reported Internet access. Higher information self-efficacy and greater trust in the Internet were independently associated with Internet access (p = .05 and p < .001, respectively). Among those with access, 53.8% reported they intended to seek cancer help online if they needed information. Those with younger age and higher acculturation, education and self-efficacy had higher odds of intended Internet use for cancer information, considering covariates. In addition, those with high (vs. low) perceived risk of cancer (OR = 1.76; 95% CI [1.14, 2.73]; p = .01) and higher levels of trust in online health information (OR = 1.47 per one-point increase; 95% [CI 1.19, 1.82]; p = .0004) were more likely to intend to seek cancer information online. These findings that Internet access is fairly high in the immigrant Latino population and that the Internet is a trusted source of cancer information suggest that the Internet may be a channel for cancer control interventions.

Patient navigation significantly reduces delays in breast cancer diagnosis in the District of Columbia.

BACKGROUND: Patient Navigation (PN) originated in Harlem as an intervention to help poor women overcome access barriers to timely breast cancer treatment. Despite rapid, nationally widespread adoption of PN, empirical evidence on its effectiveness is lacking. In 2005, National Cancer Institute initiated a multicenter PN Research Program (PNRP) to measure PN effectiveness for several cancers. The George Washington Cancer Institute, a project participant, established District of Columbia (DC)-PNRP to determine PN's ability to reduce breast cancer diagnostic time (number of days from abnormal screening to definitive diagnosis). METHODS: A total of 2,601 women (1,047 navigated; 1,554 concurrent records-based nonnavigated) were examined for breast cancer from 2006 to 2010 at 9 hospitals/clinics in DC. Analyses included only women who reached complete diagnostic resolution. Differences in diagnostic time between navigation groups were tested with ANOVA models including categorical demographic and treatment variables. Log transformations normalized diagnostic time. Geometric means were estimated and compared using Tukey-Kramer P value adjustments. RESULTS: Average-geometric mean [95% confidence interval (CI)]-diagnostic time (days) was significantly shorter for navigated, 25.1 (21.7, 29.0), than nonnavigated women, 42.1 (35.8, 49.6). Subanalyses revealed significantly shorter average diagnostic time for biopsied navigated women, 26.6 (21.8, 32.5) than biopsied nonnavigated women, 57.5 (46.3, 71.5). Among nonbiopsied women, diagnostic time was shorter for navigated, 27.2 (22.8, 32.4), than nonnavigated women, 34.9 (29.2, 41.7), but not statistically significant. CONCLUSIONS: Navigated women, especially those requiring biopsy, reached their diagnostic resolution significantly faster than nonnavigated women. IMPACT: Results support previous findings of PN's positive influence on health care. PN should be a reimbursable expense to assure continuation of PN programs.

Information channels associated with awareness of human papillomavirus infections and vaccination among Latino immigrants from safety net clinics.

We report on information channels associated with awareness about human papillomavirus (HPV) among immigrant Central and South American Latinos. We conducted a survey of 1,334 Latino ≥ 21 years attending safety-net clinics in 2007-2008. Logistic regression analyses evaluated associations with HPV awareness. Forty-eight percent were aware of HPV infection and 40% were aware of the vaccine. Spanish television (38%) and providers (23%) were the primary HPV information sources. Infection awareness was associated with internet use (OR 1.47; 95% CI 1.10-1.96) and self-efficacy to find health information (OR 1.19; 95% CI 1.08-1.30). Vaccine awareness was associated with media use for health information (OR 1.27; 95% CI 1.09-1.49) and internet use (OR 1.59; 95% CI 1.18-2.13). Although Spanish television has reached this low HPV awareness group, there may be missed opportunities for education by providers. Television and the internet may also be effective channels for future interventions.

Patient and provider factors associated with colorectal cancer screening in safety net clinics serving low-income, urban immigrant Latinos.

BACKGROUND: Latinos have lower colorectal cancer screening rates than Whites. METHODS: We reviewed a random sample of charts between July 2009 and February 2010 of safety-net clinic of 840 immigrants (50 years and older) from Central and South America receiving care. Logistic regression evaluated associations of ever vs. never screening, patient and physician factors. RESULTS: Ever screening rates were 24.5%, and only 17% of charts noted a physician screening recommendation. However, the odds of screening were 9.89 times higher (95% CI: 6.25-15.64, p<.001) among patients with a physician recommendation vs. those without, considering covariates. The odds of screening were 0.61 times lower (95% CI: 0.40-0.92, p=.02) in patients with a body mass index ≥ 30 vs. <30. CONCLUSIONS: While rates were low, determinants of screening were similar in this Latino subgroup to those reported in other Latino and non-Latino populations. Low rates of documented physician screening recommendations may indicate a potential missed opportunity for cancer control in safety-net clinics.

Cancer prevention in the 21st century: the Preventorium concept.

The Cancer Preventorium model described here has proven successful in targeting the Hispanic population of a large metropolitan area in the United States to change the point of contact within the health care system from patients with advanced conditions seeking treatment to those screened while presumably healthy to detect disease early.

'The worst thing about hospice is that they talk about death': contrasting hospice decisions and experience among immigrant Central and South American Latinos with US-born White, non-Latino cancer caregivers.

Hospice care is promoted as a model for improving end of life care and decreasing burden on caregivers. However, hospice use is low in Latinos and little is known about how Latinos make hospice decisions and experience hospice once enrolled. Qualitative methods were used in this study to conduct in-depth interviews and focus groups with 15 Latino bereaved hospice family caregivers and 15 White non-Latino bereaved hospice family caregivers to describe hospice experiences and evaluate whether cultural factors affected the experience. Differences in decision-making and caregiving experience were identified that were influenced by culture. For example, cultural values of denial, secrecy about prognosis and a collective, family-centered system influenced hospice decisions and experience in Latinos but not non-Latinos. This study identifies a significant dilemma: that is, how to discuss hospice with a patient and family who prefer not to discuss a terminal prognosis. Future research is needed to extend these preliminary results; such results may be useful for designing interventions to improve end of life care and caregiving in Latinos.

Are health-care relationships important for mammography adherence in Latinas?

BACKGROUND: Latinas are the fastest growing racial ethnic group in the United States and have an incidence of breast cancer that is rising three times faster than that of non-Latino white women, yet their mammography use is lower than that of non-Latino women. OBJECTIVES: We explored factors that predict satisfaction with health-care relationships and examined the effect of satisfaction with health-care relationships on mammography adherence in Latinas. DESIGN AND SETTING: We conducted a cross-sectional survey of 166 Latinas who were >or=40 years old. Women were recruited from Latino-serving clinics and a Latino health radio program. MEASUREMENTS: Mammography adherence was based on self-reported receipt of a mammogram within the past 2 years. The main independent variable was overall satisfaction with one's health-care relationship. Other variables included: self report of patient-provider communication, level of trust in providers, primary language, country of origin, discrimination experiences, and perceptions of racism. RESULTS: Forty-three percent of women reported very high satisfaction in their health-care relationships. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships compared to women with lower trust and who experienced discrimination (p < .01). Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence (OR: 3.34, 95% CI: 1.47-7.58), controlling for other factors. CONCLUSIONS: Understanding the factors that impact Latinas' mammography adherence may inform intervention strategies. Efforts to improve Latina's satisfaction with physicians by building trust may lead to increased use of necessary mammography.

Perceived risk of breast cancer among Latinas attending community clinics: risk comprehension and relationship with mammography adherence.

OBJECTIVE: To describe breast cancer risk perceptions, determine risk comprehension, and evaluate mammography adherence among Latinas. METHODS: Latina women age >or=35, primarily from Central and South America, were recruited from community-based clinics to complete in-person interviews (n = 450). Risk comprehension was calculated as the difference between numeric perceived risk and Gail risk score. Based on recommended guidelines from the year data were collected (2002), mammography adherence was defined as having a mammogram every one to two years for women >or=40 years of age. RESULTS: Breast cancer risk comprehension was low, as 81% of women overestimated their risk and only 6.9% of women were high risk based on Gail risk scores. Greater cancer worry and younger age were significantly associated with greater perceived risk and risk overestimation. Of women age eligible for mammography (n = 328), 29.0% were non-adherent to screening guidelines. Adherence was associated with older age, (OR = 2.99, 95% CI = 1.76-5.09), having insurance (OR = 1.81, 95% CI = 1.03-3.17), greater acculturation (OR = 1.18, 95% CI = 1.02-1.36), and higher breast cancer knowledge (OR = 2.03, 95% CI = 1.21-3.40). CONCLUSIONS: While most Latinas over-estimated their breast cancer risk, older age, having insurance, being more acculturated, and having greater knowledge were associated with greater screening adherence in this Latino population. Perceived risk, risk comprehension, and cancer worry were not associated with adherence. In Latinas, screening interventions should emphasize knowledge and target education efforts at younger, uninsured, and less acculturated mammography-eligible women.

Latin American Cancer Research Coalition. Community primary care/academic partnership model for cancer control.

The Latin American Cancer Research Coalition (LACRC) was funded by NCI as a Special Populations Network to 1) provide training to clinic staff in cancer control and foster development of Latino faculty training, 2) conduct a needs assessment with the community clinics, 3) enhance the ability of the clinics to promote healthy lifestyles, 4) collaborate on research projects to improve use of early detection, and 5) explore partnerships to increase access to culturally competent cancer care. The LACRC developed a model for cancer control focused on community-based clinics as the focal point for in-reach and community outreach targeted to Latinos to reduce cancer disparities. This framework was designed to link the community to local hospitals and academic centers, build capacity, and promote diffusion of innovations directly into delivery systems. Eight research projects submitted by junior investigator/clinic teams have been funded by NCI. These research projects range from recruiting for clinical trials to prevention to survivorship. The LACRC has trained 6 cancer control coordinators from partner sites and educated 59 undergraduate minority student interns in aspects of cancer control research. Central to LACRC's success to date has been the creation and maintenance of an infrastructure of trusting relationships, especially those developed between clinician/investigators and individuals within the greater Latino community. Community clinics can be effective agents for cancer control among Latinos. Latinos are likely to participate in research conducted by culturally representative teams of researchers using culturally appropriate recruiting strategies. Cancer 2006. (c) 2006 American Cancer Society.

Brief report: if you build it, they will come: methods for recruiting Latinos into cancer research.

BACKGROUND: Latinos have low representation in cancer prevention trials and intervention studies. Culturally appropriate recruitment strategies are needed to address this issue. OBJECTIVE: To describe and summarize the effectiveness of recruitment strategies used by the Latin American Cancer Research Coalition (LACRC). DESIGN: Descriptive report of recruitment methods. PARTICIPANTS: Uninsured Latino immigrants (N=1,170; 77% female, 23% male) from Central and South America recruited to 7 cancer control studies. APPROACH: The LACRC recruitment model involved inclusion of Latino researchers and providers, and use of culturally acceptable materials released through culturally appropriate outlets such as Latino radio stations. RESULTS: The overall participation rate was high-96% of patients identified as eligible agreed to participate. Women were excellent referrals for recruiting men to research studies. Additionally, a local Latino radio program was used to efficiently recruit eligible study participants. CONCLUSIONS: Latinos are interested and willing to participate in cancer control studies when culturally relevant approaches are used. Research teams that partner with Latino researchers and with Latino service providers are important in educating Latinos about cancer control and encouraging participation in research.

Breast cancer prevention in community clinics: will low-income Latina patients participate in clinical trials?

BACKGROUND: Latinas have low rates of participation in breast cancer prevention trials. We evaluated the feasibility and effectiveness of a randomized trial of brief counseling and print materials compared to print materials alone to increase intent to participate in a breast cancer prevention trial. METHODS: We enrolled 450 women Spanish-speaking women from three urban community primary care clinics. The outcome was intent, defined as might, probably, or definitely would enroll in the trial. We also examined results using a more stringent definition restricted to probably and definitely intend to participate. RESULTS: The trial was feasible within these busy clinics, and 96% of women agreed to participate. The level of breast cancer knowledge was fairly high (66% correct answers), but understanding about clinical trials was lower (40.5% correct answers). Using the less stringent criteria for intent, 72% of women stated that they intended to enroll in the STAR trial if eligible, but rates of intent decreased to 52% with framing that included medication side effects and 45% if uterine cancer was mentioned (P < 0.01 for trend). Using the more stringent definition, slightly fewer than half of the women indicated an interest in participating, with the same trend towards decreasing intent with increasing presentation of side effects. The intervention was only effective using the less stringent definition and if no side effects were mentioned (77% intent vs. 67% in the intervention and control groups, respectively, P = 0.03). Intention was independently associated with greater worry about breast cancer and younger age, but not acculturation or knowledge. CONCLUSIONS: Latina women are interested in participating in clinical trials to prevent breast cancer, although interest declines with increasing discussion of side effects. Unfortunately, brief education only increased rates of intention using the least stringent definition and when no side effects were presented in framing the question. Future work should focus on qualitative research to understand the theoretical foundations of preventive health behaviors in this population.

Primary care cancer control interventions including Latinos: a review.

BACKGROUND: Even though 86% of adult Latinos have a usual source of care, there is a paucity of literature on primary care-based interventions to promote cancer prevention and control in this population. This systematic review examines published primary care-based cancer control interventions that included Latinos. METHODS: MEDLINE, the Cochrane Registry, and EMBASE were searched from January 1985 to January 2003. Any primary care-based intervention using a controlled trial, quasi-experimental, or pre-post design that targeted breast, cervical, or colorectal cancer was included if at least 5% of the sample was Latino. RESULTS: A total of 14 intervention studies met inclusion criteria. Seven of the 14 studies described patient or provider reminder interventions. Other interventions incorporated into the primary care setting one of the following: community health educators, culturally sensitive videos, audit with feedback, materials from the "Put Prevention Into Practice" campaign, and vouchers for free screenings. The heterogeneity of designs and outcome variables and the low number of Latinos presented obstacles to combining data to estimate the overall effectiveness of primary care interventions for this population. Qualitatively, patient and physician reminders and management systems strategies including audit with feedback for providers appear to result in improved screening utilization. CONCLUSIONS: There is a paucity of data on the effectiveness of primary care cancer control interventions directed at Latinos. Primary care-based interventions that have been effective in non-Latinos could incorporate culturally appropriate elements and lessons from community-based research and could be applied to Latinos so that their effectiveness can be assessed in this group.

Patient and provider priorities for cancer prevention and control: a qualitative study in Mid-Atlantic Latinos.

OBJECTIVE: This study examines the cancer prevention and control priorities of uninsured Latin Americans and their primary care providers in metropolitan Washington, D.C. Patient and provider priorities are compared to identify common ground for future interventions in resource constrained primary care settings. METHODS: Ten focus groups were conducted among 88 Latin-American patients from 5 primary care clinics. Key informant interviews and a priority setting exercise were conducted among the clinicians and medical directors at these same clinics. Prompted by semi-structured open-ended questions, the key informant interviews and focus groups elicited patient and provider concerns and priorities for cancer prevention and control. All focus group sessions and key informant interviews were audiotaped, transcribed verbatim, and coded independently by 2 reviewers. Interrater reliability for the overall coding of distinct units of text into one of 4 major content areas was excellent, (Kappa = 0.95; 95% CI 0.94, 0.98). RESULTS: All comments from the patient focus groups and provider key informant interviews fell into one of 4 content areas: cancer knowledge, attitudes and beliefs, patient socioeconomic concerns, and clinic capabilities to provide services. The most frequently mentioned theme among patients was their own lack of knowledge about cancer screening, particularly about colorectal cancer screening. Other leading patient priorities were the perceived costs of screening tests and the resource constraints of the primary care clinics serving the uninsured. Leading attitudinal concerns about screening were fatalism, embarrassment about the screening test, and non-concordant clinician gender. The leading priorities among clinicians were increasing patient knowledge about screening tests, time limitations of the clinical encounter, and primary care clinic resource constraints. The areas of greatest overlap in priorities between patients and providers were the themes of low patient knowledge about cancer screening and prevention, and recognition of the resource constraints under which these "safety net" clinics operate. CONCLUSIONS: Patient knowledge level about screening, particularly colorectal cancer screening, and the impact of clinical resource constraints on the delivery of cancer screening are common priorities of uninsured Latino patients and their primary care clinicians. Stepping up efforts to improve cancer screening and prevention for Latinos requires an initial investment in developing the basic clinical infrastructure (ie, clinic capacity) of sites serving this special population. Common priorities identified from patient and provider data should be used to design evidence-based cancer prevention and control interventions within the resource limitations of the primary care settings serving the uninsured.