"I'm not ashamed to talk on it!": African-American women's decisions about cervical cancer prevention and control in South Carolina.

BACKGROUND: Cervical cancer disparities persist despite cervical cancer prevention advances and declining mortality rates, particularly among African-American women in the South. The purpose of this qualitative study was to explore behavior, knowledge, and attitudes as influences on health decisions and preferences for cervical cancer prevention and control among African-American women in South Carolina. METHODS: Data were collected from three focus groups conducted with 28 adult women aged 18 to 70 years in South Carolina. Purposive snowball sampling was employed. Data were coded using a content analysis approach in NVivo 10. Fleiss' kappa coefficient, a measure of interrater reliability, was 0.83. FINDINGS: Twenty-seven participants self-identified as African American. The mean age of focus group participants was 45.3 years. Knowledge of human papillomavirus (HPV) and cervical cancer risk was relatively low. Participants positively viewed cervical cancer screening and HPV vaccination. Lack of health insurance and costs were screening barriers. Providers were viewed as trusted health information sources, yet stigma and fear negatively influenced screening. Cultural identity served as a facilitator and barrier for screening. Motivated by strength, identified as a central to African-American womanhood, participants viewed cervical cancer prevention as an important responsibility. However, the "Strong Black Woman" script, which has been associated with self-care and coping strategies, was also a screening barrier owing to competing priorities. CONCLUSIONS: Study findings provide insight into cervical cancer prevention decision making and support tailored interventions. Culturally relevant interventions may better convey evidence-based messages about advances in cervical cancer prevention and control.

Analysis of hospital-based emergency department visits for dental caries in the United States in 2008.

OBJECTIVES: Using nationally representative data, we examined differences in dental care utilization in emergency departments (EDs) among working age adults associated with rural residence and lack of health insurance. METHODS: We used data from the 2008 Nationwide Emergency Department Sample, restricted to working age adults (ages 19-64; 16,928,424 observations). The dependent variable was a principal diagnosis of dental caries. The primary independent variable was patient's area of residence, rural versus urban. The control variables were payer, age, gender, median income, region, and admission timing. Logistic regression analysis was performed to determine the association with residence, payer, and other covariates. Multivariate logistic regression models were estimated. RESULTS: In 2008, there were an estimated 74 million ED visits among working adults ages 19-64 in the United States. Dental caries accounted for between 0.2 percent and 1.0 percent of all visits, depending on patient characteristics. Rural patients were significantly more likely than urban patients to have dental visits. Dental visits were more prevalent among patient with government insurance or self -pay relative to the privately insured. CONCLUSIONS: The Affordable Care Act may reduce the proportion of self-pay visits for dental care. Medicaid expansion may not result in improved dental use among Medicaid patients unless dental services are covered and dental practitioners appropriately engaged.

The role of family history of cancer on cervical cancer screening behavior in a population-based survey of women in the Southeastern United States.

BACKGROUND: Our objective was to determine the association of self-reported family history of cancer (FHC) on cervical cancer screening to inform a potential link with cancer preventive behaviors in a region with persistent cancer disparities. METHODS: Self-reported FHC, Pap test behavior, and access to care were measured in a statewide population-based survey of human papillomavirus and cervical cancer (n = 918). Random-digit dial, computer-assisted telephone interviews were used to contact eligible respondents (adult [ages 18-70] women in South Carolina with landline telephones]. Logistic regression models were estimated using STATA 12. FINDINGS: Although FHC+ was not predictive (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.55-2.51), private health insurance (OR, 2.35; 95% confidence interval [CI], 1.15-4.81) and younger age (18-30 years: OR, 7.76; 95% CI, 1.91, 3.16) were associated with recent Pap test behavior. FHC and cervical cancer screening associations were not detected in the sample. CONCLUSIONS: Findings suggest targeting older women with screening recommendations and providing available screening resources for underserved women.

Receipt of cancer screening services: surprising results for some rural minorities.

BACKGROUND: Evidence suggests that rural minority populations experience disparities in cancer screening, treatment, and outcomes. It is unknown how race/ethnicity and rurality intersect in these disparities. The purpose of this analysis is to examine the cancer screening rates among minorities in rural areas. METHODS: We utilized the 2008 Behavioral Risk Factor Surveillance System (BRFSS) to examine rates of screening for breast, cervical, and colorectal cancer. Bivariate analysis estimated screening rates by rurality and sociodemographics. Multivariate analysis estimated the factors that contributed to the odds of screening. RESULTS: Rural residents were less likely to obtain screenings than urban residents. African Americans were more likely to be screened than whites or Hispanics. Race/ethnicity and rurality interacted, showing that African American women continued to be more likely than whites to be screened for breast or cervical cancer, but the odds decreased with rurality. CONCLUSIONS: This analysis confirmed previous research which found that rural residents were less likely to obtain cancer screenings than other residents. We further found that the pattern of disparity differed according to race/ethnicity, with African Americans having favorable odds of receipt of service regardless of rurality. These results have the potential to create better targeted interventions to those groups that continue to be underserved.

Higher risk of death in rural blacks and whites than urbanites is related to lower incomes, education, and health coverage.

Health outcomes among rural minority populations are seldom examined. Our research studied mortality among urban and rural white, black, and Hispanic adults ages 45-64, comparing outcomes for each group. We found the mortality risk to be higher among both rural white and rural minority populations compared to urban whites; rural blacks were at higher risk of death than urban blacks. When personal characteristics and circumstances of these populations-such as level of education, presence of health insurance, and income above or below the poverty line-were held statistically equal, disparities were reduced or eliminated. Our study suggests that policies directed toward reducing differences related to education, poverty, and health insurance would go a long way toward eliminating the disparities in health status between urban and rural populations.

Cancer screening delivery in persistent poverty rural counties.

BACKGROUND: Rural populations are diagnosed with cancer at different rate and stages than nonrural populations, and race/ethnicity as well as the area-level income exacerbates the differences. The purpose of this analysis was to explore cancer screening rates across persistent poverty rural counties, with emphasis on nonwhite populations. METHODS: The 2008 Behavioral Risk Factor Surveillance System was used, combined with data from the Area Resource File (analytic n = 309 937 unweighted, 196 344 347 weighted). Unadjusted analysis estimated screening rates for breast, cervical, and colorectal cancer. Multivariate analysis estimated the odds of screening, controlling for individual and county-level effects. RESULTS: Rural residents, particularly those in persistent poverty counties, were less likely to be screened than urban residents. More African Americans in persistent poverty rural counties reported not having mammography screening (18.3%) compared to 15.9% of urban African Americans. Hispanics had low screening rates across all service types. Multivariate analysis continued to find disparities in screening rates, after controlling for individual and county-level factors. African Americans in persistent poverty rural counties were more likely to be screened for both breast cancer (odds ratio, 1.44; 95% confidence interval, 1.12-1.85) and cervical cancer (1.46; 1.07-1.99) when compared with urban whites. CONCLUSIONS: Disparities in cancer screening rates exist across not only race/ethnicity but also county type. These disparities cannot be fully explained by either individual or county-level effects. Programs have been successful in improving screening rates for African American women and should be expanded to target other vulnerable women as well as other services such as colorectal cancer screening.

Receipt of influenza and pneumonia vaccinations: the dual disparity of rural minorities.

OBJECTIVES: To examine the receipt of age-appropriate influenza and pneumococcal polysaccharide vaccinations (PPV), with particular attention to rural minority persons. DESIGN: Data were drawn from the 2005 Behavioral Risk Factor Surveillance System. The dependent variables were self-reported receipt of annual influenza immunizations in adults aged 50 and older (n=177,417) or lifetime pneumococcal immunizations in adults aged 65 and older (n=81,762). The main independent variables were residence and race. MEASUREMENTS: All data are self-reported. Multivariate analysis controlled for selected personal and county-level characteristics. Analyses were conducted in 2009/10. RESULTS: Forty-two percent of adults aged 50 and older reported an influenza vaccination; 31.1% of rural African Americans reported an influenza vaccination, and 64.6% reported a PPV. White and African-American rural residents reported lower vaccination rates. Adjusted analysis indicated an interaction between race and rurality. White rural residents were more likely to be vaccinated than other whites, whereas rural African Americans were less likely to be vaccinated than urban African Americans. CONCLUSION: This study confirms previous findings while finding an interactive effect between rurality and race. The results indicated the importance of provider availability to delivery. Alternative delivery methods may be an effective solution to improve delivery rates.

Specialty care use in US patients with chronic diseases.

Despite efforts to eliminate health disparities, racial, ethnic, and geographic groups continue lag behind their counterparts in health outcomes in the United States. The purpose of this study is to determine variation in specialty care utilization by chronic disease status. Data were extracted from the Commonwealth Fund 2006 Health Care Quality Survey (n = 2475). A stratified minority sample design was employed to ensure a representative sample. Logistic regression was used in analyses to predict specialty care utilization in the sample. Poor perceived health, minority status, and lack of insurance was associated with reduced specialty care use and chronic disease diagnosis.