Florida-California Cancer Research, Education and Engagement (CaRE2) Health Equity Center: Structure, Innovations, and Initial Outcomes.

INTRODUCTION: The Florida-California Cancer Research, Education, and Engagement (CaRE2) Health Equity Center is a triad partnership committed to increasing institutional capacity for cancer disparity research, the diversity of the cancer workforce, and community empowerment. This article provides an overview of the structure, process innovations, and initial outcomes from the first 4 years of the CaRE2 triad partnership. METHODS: CaRE2 serves diverse populations in Florida and California using a "molecule to the community and back" model. We prioritize research on the complex intersection of biological, environmental, and social determinants health, working together with scientific and health disparities communities, sharing expertise across institutions, bidirectional training, and community outreach. Partnership progress and outcomes were assessed using mixed methods and four Program Steering Committee meetings. RESULTS: Research capacity was increased through development of a Living Repository of 81 cancer model systems from minority patients for novel cancer drug development. CaRE2 funded 15 scientific projects resulting in 38 publications. Workforce diversity entailed supporting 94 cancer trainees (92 URM) and 34 ESIs (32 URM) who coauthored 313 CaRE2-related publications and received 48 grants. Community empowerment was promoted via outreaching to more than 3000 individuals, training 145 community cancer advocates (including 28 Community Scientist Advocates), and publishing 10 community reports. CaRE2 members and trainees together have published 639 articles, received 61 grants, and 57 awards. CONCLUSION: The CaRE2 partnership has achieved its initial aims. Infrastructure for translational cancer research was expanded at one partner institution, and cancer disparities research was expanded at the two cancer centers.

Association of Preventive Care Attitudes and Beliefs with Colorectal Cancer Screening History among African American Patients of Community Health Centers.

Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer-related death among African Americans in the United States. However, when detected early, CRC is treatable and survival rates are high. CRC health disparities for African Americans compared with other groups may be due in part to lower screening adherence and later stage diagnosis. The objective of this research phase was to test predictors of ever having received CRC screening (i.e., self-report of lifetime receipt of CRC screening) using survey measures in the domains of healthcare communication, trust in doctors, CRC perceived susceptibility, CRC worry, negative cancer beliefs, CRC screening self-efficacy, and cultural constructs for CRC screening in a sample of African American community health center patients. The study recruited 115 African American patients between the ages of 45 to 64 years old from community health centers in north Florida to complete the baseline survey. Our results show significant differences in CRC screening history by age, marital status, level of mistrust of healthcare providers, and level of empowerment toward cancer screening. To increase CRC screening in this population, the study findings suggest development of intervention programs that focus on priority populations of younger, unmarried African Americans, especially given the current trend of early onset CRC. Moreover, survival rates are lower for unmarried and younger African Americans relative to older and married individuals. Such interventions should also aim to increase trust in healthcare providers and increase empowerment for CRC screening decision making to increase screening participation.

Maternal and Perinatal Outcomes Associated With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection During Pregnancy, Florida, 2020-2021: A Retrospective Cohort Study.

BACKGROUND: The objective was to estimate risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy and assess adverse maternal and perinatal outcomes. METHODS: We used a population-based, retrospective cohort of all pregnancies with a live birth or fetal death in Florida from 1 March 2020 to 30 April 2021. Coronavirus disease 2019 (COVID-19) case reports were matched to vital registries. Outcomes assessed were risk of infection in pregnancy, preterm birth, maternal or neonatal admission to an intensive care unit (ICU), perinatal or fetal death, and maternal death. Modified Poisson and multinomial logistic regression models were used to derive relative risk estimates. RESULTS: Of 234 492 women with a live birth or fetal death during the study period, 12 976 (5.5%) were identified with COVID-19 during pregnancy. Risk factors for COVID-19 in pregnancy included Hispanic ethnicity (relative risk [RR] = 1.89), Black race (RR = 1.34), being unmarried (RR = 1.04), and being overweight or obese pre-pregnancy (RR = 1.08-1.32). COVID-19 during pregnancy was associated with preterm birth (RR = 1.31), Cesarean delivery (RR = 1.04), and neonatal (RR = 1.17) and maternal (RR = 3.10) ICU admission; no association was found with increased risk of perinatal (RR = 0.72) or fetal death (RR = 0.86). Women infected during any trimester showed increased risk of preterm birth. Fourteen maternal deaths were identified among COVID-19 cases; of those who died, 12 were obese. The death rate per 10 000 was 22.09 among obese and 1.22 among non-obese gravida with COVID-19 during pregnancy (RR = 18.99, P = .001). CONCLUSIONS: Obesity is a risk factor for SARS-CoV-2 infection in pregnancy and for more severe COVID-19 illness among pregnant women. SARS-CoV-2 infection is associated with preterm birth.

Sociodemographic and Clinical Characteristics Associated With Worst Pain Intensity Among Cancer Patients.

AIMS: Patients with cancer have pain due to their cancer, the cancer treatment and other causes, and the pain intensity varies considerably between individuals. Additional research is needed to understand the factors associated with worst pain intensity. Our study aim was to determine the association between worst pain intensity and sociodemographics and cancerspecific factors among patients with cancer. DESIGN: A total of 1,280 patients with cancer recruited from multiple cancer centers over 25 years in the United States were asked to complete a questionnaire that collected respondents' demographic, chronic pain, and cancer-specific information. SETTINGS: Worst, least, and current pain intensities were captured using a modified McGill Pain Questionnaire (pain intensity measured on 0-10 scale). A generalized linear regression analysis was utilized to assess the associations between significant bivariate predictors and worst pain intensity scores.Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (ß = 0.6859), previous toothache pain (ß = 0.0960), headache pain (ß = 0.0549), and stomachache pain (ß = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. CONCLUSIONS: Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (ß = 0.6859), previous toothache pain (ß = 0.0960), headache pain (ß = 0.0549), and stomachache pain (ß = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. Findings identified being Hispanic and having previous severe toothache, stomachache, and headache pain as significant predictors of worst pain intensity among patients with cancer. After controlling for selected covariates, we did not note statistical differences in worst pain during a 25-year period. Therefore,studies focused on improving the management of pain among patients with cancer should target interventions for those with Hispanic heritage and those with past history of severe common pain.

Assessing the effectiveness of a community health advisor plus screen to save educational intervention on stool-based testing adherence in an African American safety net clinic population: study protocol for a randomized pragmatic trial.

BACKGROUND: Colorectal cancer (CRC) is the second most deadly cancer affecting US adults and is also one of the most treatable cancers when detected at an earlier clinical stage of disease through screening. CRC health disparities experienced by African Americans are due in part to the later stage of diagnosis, suggesting the importance of improving African Americans' CRC screening participation. The national Screen to Save (S2S) initiative employs a community health educator to deliver CRC screening education which can be tailored for specific populations, and such approaches have increased CRC screening rates in disadvantaged and racial/ethnic minority populations. METHODS/DESIGN: In this trial emphasizing stool-based CRC screening, focus groups informed the development of an adapted S2S video and brochure tailored for African Americans and identified preferred motivational text messages for a multicomponent community health advisor (CHA) intervention. A CHA hired from the community was trained to deliver a 6-week CRC educational intervention consisting of an initial face-to-face meeting followed by 5 weeks of calls and texts. Interested eligible persons are enrolled primarily through recruitment by two partnering community health centers (CHCs) and secondarily through various outreach channels and, after consenting and completing a baseline survey, are randomly assigned to one of two study arms. The CHCs are blinded to study arm assignment. Intervention arm participants receive the brochure and CHA intervention while participants assigned to the control group receive only the brochure. All participants receive a stool-based CRC screening test from their health center, and the primary outcome is the completion of the screening test at 12 months. Secondary objectives are to estimate the effect of the intervention on mediating factors, explore the effect of moderating factors, and perform a cost-effectiveness analysis of the CHA intervention. DISCUSSION: The TUNE-UP study will enhance understanding about CRC screening in African Americans obtaining primary health care through CHCs and is one of the very few studies to examine a CHA intervention in this context. A better understanding of the mechanisms by which the intervention affects patient beliefs and behaviors will help focus future research while the exploratory cost-effectiveness analysis will inform CHCs' decision-making about implementing a CHA program to increase screening and reduce cancer health disparities. TRIAL REGISTRATION: ClinicalTrials.gov NCT04304001 . Registered on March 11, 2020.

Image-based documentation of vulvodynia pain location.

Aims: Better documentation of vulvar pain is needed. We examined pain locations marked on general body and genital specific outlines among women with vulvodynia. Methods: 62 women (mean age 32.1 ± 9.5 years) with vulvodynia marked their pain on a digital genital specific outline (22 segments) and 59 of those women also marked their pain on a digital general body outline (48 segments). We used ImageJ software to determine body surface area (BSA) for each outline. Results: On the general body outline, 24/48 segments were marked; 22/22 segments were marked on the genital specific outline. There was a moderate correlation (r = 0.43; p = 0.001) between the BSA marked on the general body outline and the BSA marked on the genital area outline. Conclusions: Findings support concurrent validity of the BSA as a measure of pain location using either outline.

Women with genital pain need to be able to show their healthcare provider where they have pain, and providers need to document where women have pain. In total, 62 women with vulvodynia used a computer tablet to mark their pain on a general body outline and a genital specific outline. We used computer software to document the location of women's pain looking at percent body surface area. Women marked half of the segments on the general body outline and all the segments on the genital specific outline. Because women marked almost the same percent of body surface area on the general body outline as they did on the genital specific outline, percent body surface may be used to measure pain location.

Engaging the Community on Colorectal Cancer Screening Education: Focus Group Discussions Among African Americans.

Colorectal cancer (CRC) is the third most diagnosed cancer in the USA, and African Americans experience disproportionate CRC diagnosis and mortality. Early detection could reduce CRC incidence and mortality, and reduce CRC health disparities, which may be due in part to lower screening adherence and later stage diagnosis among African Americans compared to whites. Culturally tailored interventions to increase access to and uptake of CRC stool-based tests are one effective strategy to increase benefits of screening among African Americans. The objectives of this study were to obtain feedback from African Americans on CRC educational materials being developed for a subsequent behavioral clinical trial and explore participants' knowledge, attitudes, and beliefs about CRC and CRC screening. Seven focus groups were conducted between February and November 2020. Participants were African Americans recruited through community contacts. Four focus groups were held in-person and three were conducted virtually due to Covid-19 restrictions. Participants ranked CRC educational text messages and provided feedback on a culturally tailored educational brochure. A focus group guide with scripted probes was used to elicit discussion and transcripts were analyzed using traditional content analysis. Forty-two African Americans participated. Four themes were identified from focus group discussions: (1) knowledge, attitudes, and beliefs on CRC and CRC screening; (2) reliable sources of cancer education information; (3) cultural factors affecting perspectives on health; and (4) community insights into cancer education. Participant input on the brochure was incorporated in content creation. Engaging African American community members to qualitatively examine cancer prevention has value in improving implementation strategy and planning for behavioral clinical trials.

Physician Training Related to Environmental Hazards near Ash Superfund Sites.

Physicians do not receive formal environmental health training in medical schools. The objectives of this study were to provide health care providers with basic environmental medicine training to better advise, treat or refer patients in the community and to observe any differences in the environmental medicine learning gains pre/post- test assessment. To rectify the problem of the lack of physicians' training related to environmental hazards, we conducted an environmental health workshop which targeted physicians living near Health Zone 1, Superfund ash sites. Fifty health care providers from both St. Vincent Family Medicine and Department of Health, Duval County Health Department (DOH-Duval) participated in a pre-test survey before the training and a post-test survey following the training. We used a non-parametric Wilcoxon Signed-Rank test to compare pre- and post- knowledge of training participants. At the 10% level of significance, the number of incorrect answers significantly declined in the post-training survey compared to the pre-training survey for all participants from both facilities combined (p=0.083). Site-specific analysis show, while a significant difference was found for participants from the St. Vincent's site (p=0.084), the difference for participants from the DOH-Duval site was not significant (p = 0.102), although the number of incorrect answers declined. The training resulted in learning gains for the 50 participants and the evaluations were very positive with 100% of physicians recommending this training to other health care providers. Additionally, training participants gave a high mark for the environmental medicine pocket guide. In 2019, the ash sites are 90% remediated and cleanup is expected to be completed in 2022. There is still a need for additional training for physicians due to other active sites (i.e., Kerr-McGee) in the community. This study highlights the importance of providing environmental hazards training to physicians and the approach by which it could be delivered effectively.

Utilizing Genomics through Family Health History with the Theory of Planned Behavior: Prediction of Type 2 Diabetes Risk Factors and Preventive Behavior in an African American Population in Florida.

AIM: African Americans are disproportionately affected by type 2 diabetes. The purpose of this study was to assess to what extent African Americans' knowledge and awareness of family health history and related risk factors for developing type 2 diabetes influence their likelihood of adopting a preventive behavior. METHODS: This study employed an anonymous pencil-and-paper, self-administered survey consisting of two sections. Section 1 was a modified version of the US Surgeon General's Family Health History Initiative and the American Diabetes Association Diabetes Risk Factor Survey. Section 2 of the survey was based on the constructs of the theory of planned behavior. Over 394 African American participants completed the survey. RESULTS: 'Perceived behavioral control' was the strongest predictor of 'likelihood of adopting preventive behavior'. Participants were aware of their family history as a risk factor for type 2 diabetes, but it was not a significant predictor of behavior modifications based on that knowledge. CONCLUSION: The lack of perceived risk in this population shows the importance of not only knowing one's risk factors but translating those risk factors to a more personalized form that fits into the current lifestyle of the individual in a meaningful way.

Polyisoprenylated methylated protein methyl esterase as a putative drug target for androgen-insensitive prostate cancer.

Prostate cancer (CaP) is the most frequently diagnosed cancer in US men, with an estimated 236,590 new cases and 29,720 deaths in 2013. There exists the need to identify biomarkers/therapeutic targets for the early/companion diagnosis and development of novel therapies against the recalcitrant disease. Mutation and overexpression-induced abnormal activities of polyisoprenylated proteins have been implicated in CaP. Polyisoprenylated methylated protein methyl esterase (PMPMEase) catalyses the only reversible and terminal reaction of the polyisoprenylation pathway and may promote the effects of G proteins on cell viability. In this review, the potential role of PMPMEase to serve as a new drug target for androgen-insensitive CaP was determined. Specific PMPMEase activities were found to be 3.5- and 4.5-fold higher in androgen-sensitive 22Rv1 and androgen-dependent LNCaP and 1.5- and 9.8-fold higher in castration-resistant DU 145 and PC-3 CaP cells compared to normal WPE1-NA22 prostate cells. The PMPMEase inhibitor, L-28, induced apoptosis with EC50 values ranging from 1.8 to 4.6 µM. The PMPMEase activity in the cells following treatment with L-28 followed a similar profile, with IC50 ranging from 2.3 to 130 µM. L-28 disrupted F-actin filament organisation at 5 µM and inhibited cell migration 4-fold at 2 µM. Analysis of a CaP tissue microarray for PMPMEase expression revealed intermediate, strong, and very strong staining in 94.5% of the 92 adenocarcinoma cases compared to trace and weak staining in the normal and normal-adjacent tissue controls. The data are an indication that effective targeting of PMPMEase through the development of more potent agents may lead to the successful treatment of metastatic CaP.

Health insurance and breast-conserving surgery with radiation treatment.

OBJECTIVES: To examine the impact of health insurance type on treatment of early-stage breast cancer using breast-conserving surgery (BCS) with radiation therapy (RT) among women in Florida and identify factors that contribute to the variations in receiving the treatment in women with the same health insurance type. STUDY DESIGN AND METHODS: Breast cancer cases diagnosed during 1997 to 2002 were obtained from the Florida Cancer Data System. Women 40 years and older diagnosed with localized breast cancer were included. Demographic, insurance, and treatment information were extracted and linked with 2000 census data. χ² and multilevel logistic regression analyses were used. RESULTS: A total of 33,706 women were diagnosed with localized breast cancer in Florida during 1997 to 2002. The average age of the women was 66 years, 58.62% had BCS while 38.61% had mastectomy, and only 2.77% had no surgical treatment. Type of health insurance plays a significant role in receiving BCS with RT. Furthermore, we found significant variations in the use of BCS with RT among women who have the same type health insurance by marital status, age, tumor size, year of diagnosis, level of education, and poverty level. CONCLUSIONS: Although clinical practice guidelines recommend BCS with RT to treat women with localized breast cancer, significant differences in receiving the recommended treatment is found between and within types of health insurance. Identifying cultural barriers and educating the public about available treatment options are the major policy implications of this study. These observed differences require further study.

Polyisoprenylated methylated protein methyl esterase overexpression and hyperactivity promotes lung cancer progression.

The involvement of hyperactive polyisoprenylated proteins in cancers has stimulated the search for drugs to target and suppress their excessive activities. Polyisoprenylated methylated protein methyl esterase (PMPMEase) inhibition has been shown to modulate polyisoprenylated protein function. For PMPMEase inhibition to be effective against cancers, polyisoprenylated proteins, the signaling pathways they mediate and/or PMPMEase must be overexpressed, hyperactive and be involved in at least some cases of cancer. PMPMEase activity in lung cancer cells and its expression in lung cancer cells and cancer tissues were investigated. PMPMEase was found to be overexpressed and significantly more active in lung cancer A549 and H460 cells than in normal lung fibroblasts. In a tissue microarray study, PMPMEase immunoreactivity was found to be significantly higher in lung cancer tissues compared to the normal controls (p < 0.0001). The mean scores ± SEM were 118.8 ± 7.7 (normal), 232.1 ± 25.1 (small-cell lung carcinomas), 352.1 ± 9.4 (squamous cell carcinomas), 311.7 ± 9.8 (adenocarcinomas), 350.0 ± 24.2 (papillary adenocarcinomas), 334.7 ± 30.1 (adenosquamous carcinomas), 321.9 ± 39.7 (bronchioloalveolar carcinomas), and 331.3 ± 85.0 (large-cell carcinomas). Treatment of lung cancer cells with L-28, a specific PMPMEase inhibitor, resulted in concentration-dependent cell death (EC50 of 8.5 µM for A549 and 2.8 µM for H460 cells). PMPMEase inhibition disrupted actin filament assembly, significantly inhibited cell migration and altered the transcription of cancer-related genes. These results indicate that elevated PMPMEase activity spur cell growth and migration, implying the possible use of PMPMEase as a protein biomarker and drug target for lung cancer.

The association of alcohol consumption with tobacco use in Black and White college students.

This study explored the association of alcohol and tobacco use among college students. A survey was administered in 2004 to 2,189 Black and White students from the southeastern United States. The prevalence of alcohol and tobacco use, tobacco use characteristics according to level of alcohol consumed, and percentage of students using tobacco according to type of alcoholic beverages consumed were evaluated. The interaction of race and gender with alcohol and tobacco use was explored. Our findings extend prior investigations that have found alcohol use associated with smoking and suggest attention be paid to the relation of alcohol to other forms of tobacco. Racial and gender differences are highlighted. This study was funded by Mayo Clinic. The study's limitations were noted.

Barriers to the use of genetic testing: a study of racial and ethnic disparities.

PURPOSE: Racial and ethnic disparities in health are evident among a range of diseases and health care services. New genetic technologies are likely to increase these disparities as access to expensive genetic tests further widens the gap. METHODS: Our analysis used data from a national representative sample collected in 2000. The total sample size for our analysis was 1724 men and women (consisting of 946 non-Hispanic whites, 392 Latinos, and 386 blacks) aged 18 to 91 years. Ordered logistic regression and binary logistic regression analysis were applied to investigate differences by race/ethnicity. RESULTS: Results showed significant differences by racial/ethnic groups in knowledge and concerns about the potential misuse of genetic testing. A significant difference was also found between the types of health insurance coverage by race/ethnicity as well as significantly higher levels of mistrust in a physician and the medical system. CONCLUSION: Our findings raise concern about several barriers among minorities and calls for a development of educational and communication strategies that facilitate in narrowing the gap between racial and ethnic groups.

A spatial evaluation of socio demographics surrounding National Priorities List sites in Florida using a distance-based approach.

BACKGROUND: Over the last two decades, various spatial techniques have been demonstrated using geographical information systems (GIS) to adequately estimate and characterize inequities of minority populations living near environmentally hazardous facilities. However, these methods have produced mixed results. In this study, we use recently developed variations of the "distance based" approach to spatially evaluate and compare demographic and socioeconomic disparities surrounding the worst hazardous waste sites in Florida. METHODS: We used data from the 2000 US Census Bureau and the Florida Department of Environmental Protection to identify selected socio and economic variables within one (1) mile of 71 National Priorities List (NPL) or Superfund sites in Florida. ArcMap (ESRI, v. 9.2) was used to map the centroid locations of each of the NPL sites as well as identify and estimate the number of host and non-host tracts. The unit of analysis in this study was at the census tract level. Logistic regression (SAS v9.1.3) was used to determine if race/ethnicity and socioeconomic indicators are significant predictors of the location of NPL sites. RESULTS: There were significant differences in race/ethnicity composition and socio-economic factors between NPL host census tracts and non-host census tracts in Florida. The percentages of Blacks (OR = 5.7, p < 0.001), the percentage of Hispanic/Latino (OR = 5.84, p < 0.001), and percent employed in blue collar occupations (OR = 2.7, p < 0.01) were significant predictors of location of NPL facilities. CONCLUSION: The recently developed distance-based method supports previous studies and suggests that race and ethnicity play substantial roles in where hazardous facilities are located in Florida. Recommendations include using distance-based methods to evaluate socio and demographic characteristics surrounding other less known environmental hazardous facilities, such as landfills, or Toxic Release Inventory (TRI) sites.

Disparities in the receipt of cardiac revascularization procedures between blacks and whites: an analysis of secular trends.

INTRODUCTION: Mortality rates for coronary heart disease (CHD) have declined markedly since the early 1970s. However, CHD remains the number one cause of death in the United States. The decline in mortality has been attributed to declines in CHD risk factors (tobacco use, hypertension) and the increase in protective behaviors (exercise, weight control). Medical interventions may have also contributed to the decline in mortality. Despite these declines in mortality, racial disparities persist between Blacks and Whites. The purpose of this study was to examine the differences in receipt of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft. METHODS: Data from the National Hospital Discharge Survey were used for the analysis. Patients who were Black or White and > or = 40 years of age were included. Independent variables included age at discharge, sex, race, and insurance coverage. Multivariate logistic regression was used to derive odds ratios for the receipt of the three procedures by age group, sex, insurance type, and race. RESULTS: Significant differences (P < .05) in the odds of receipt of all of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft were found by age group, insurance type, sex, and race. While the disparities persisted from 1979 to 2004, the magnitude of the differences decreased during this time period. CONCLUSION: Disparities by race, sex, and insurance type existed in the receipt of three cardiac procedures. Although differences are narrowing over time, further in-depth studies are needed to elucidate the patient, physician, and healthcare system factors associated with the disparity in receipt of these beneficial procedures.

Differences among Black and White young adults on prior attempts and motivation to help a smoker quit.

This study assessed differences between Black and White young adults on prior attempts and motivation to help a smoker quit. A total of 1,621 undergraduates (912 Black, 709 White; 63% female) ages 18-24 years completed a cross-sectional survey. Overall, 54% reported they had previously tried to help someone else stop smoking (52% among Blacks vs. 58% among Whites, p=0.016). Among nonsmokers who indicated they were close to a smoker whom they thought should quit, Blacks were most often concerned about a family member whereas Whites endorsed concern most often for a friend (p<0.001). Blacks were more likely than Whites to indicate interest in learning ways to help this smoker to quit (p<0.001) but there was no significant differences on motivation level (46% of Blacks and 42% of Whites reported they were "very" or "extremely" motivated to help this person quit). After adjusting for gender, the results remained unchanged. Tobacco control efforts could focus on optimizing these supportive behaviors as well as expressed motivation and interest in helping a smoker to quit among young adult nonsmokers.

Analysis of prostate cancer incidence using geographic information system and multilevel modeling.

This study investigated racial differences in prostate cancer incidence, stage and grade in Florida using individual, community and environmental data from three data sets. Prostate cancer data were obtained from the Florida Department of Health. Census-tract-level characteristics were extracted from census data. County-level environmental data were obtained from the Department of Environmental Protection. Geographic Information Systems (GIS) was used to show racial and geographic disparities. Multilevel modeling was applied to examine the relationship of prostate cancer stage and grade to factors at the aforementioned levels. The results indicated that at the individual patient level, advanced/late cancer stage was significantly associated with older age, being black, being unmarried, tobacco use and being diagnosed in early years. At the census-tract level, late cancer stage was related to low median income and low percentage of people with some college education. No significant association was found for environmental factors. Similar results were found for tumor grade. These findings are consistent with national data demonstrating striking racial/ethnic disparities, improved stage and grade over time, and the importance of socioeconomic status. The GIS results also add local community perspectives important for planning community education and outreach to reduce racial disparities in low-income neighborhoods and low-literacy populations.

Migration, community context, and child immunization in Ethiopia.

This paper examines the relationship between parental migration status and child immunization in Southern Ethiopia, a region characterized by high mortality and morbidity. Using the 1997 Community and Family Survey and a multilevel modeling approach, we find that children born to rural-rural migrant mothers have significantly less chance of receiving full immunization coverage than children born to non-migrant mothers. The social mechanism that explains this huge disparity is that rural-rural migrant women have limited social networks in the host community. In addition, significant variation in receiving complete immunization is found by age of child (a likely period effect), mother's education, and distance to nearest health center. Marked child immunization differentials are also observed by ethnicity. The results from the multilevel analysis confirm the persistence of substantial community effects, even after controlling for a standard array of personal and household characteristics. Given the low levels of vaccination among children born to migrant women, health policy interventions and information campaigns might be effectively augmented to reach such migrant women and their children. Community and ethnic group effects suggest that further targeting of health activities could be efficient and effective.