Knowledge of the Relationship Between Breastfeeding and Breast Cancer Risk Among Racial and Ethnic Minority Women.

Research indicates breastfeeding can reduce the risk of breast cancer in women. Black and Hispanic women are more likely to die from breast cancer than non-Hispanic white women and are least likely to breastfeed. The current study was designed to evaluate women's knowledge of the link between breastfeeding and decreased breast cancer risk among a racially diverse cohort of pregnant women. Pregnant women 18 and older (N = 89; 48.4% black; 28% Hispanic) were recruited during a prenatal visit to complete a survey. Women indicated limited understanding of the association between breastfeeding and breast cancer risk reduction; less than 40% of black and white women indicated knowledge, while 64.7% of Hispanic women were aware of the association. These findings underscore the need for interventions to educate women about the protective benefits of breastfeeding as a strategy to reduce their breast cancer incidence and mortality.

Examining Social Capital and Its Relation to Breast and Cervical Cancer Screening among Underserved Latinas in the U.S.

Many Latinos in the U.S. experience structural barriers to health care. Social capital and its implications for health and access to health care among this group are not well understood by researchers. This study examined associations between social capital and breast and cervical cancer screening adherence among a sample of 394 predominately Puerto Rican and Dominican women. Data were collected at baseline from Latinas attending screening education programs in Buffalo, New York and New York City in 2011-2012. Social capital was higher among Latinas who were older, better educated, insured, and spoke English. In multivariable logistic regression, a one unit increase in social capital index score was associated with greater adherence to Pap test (OR = 1.61), clinical breast exam (OR = 1.47) and mammography screening (OR = 1.50). Social capital should be further explored as a strategy to facilitate breast and cervical cancer screening among underserved Latinas.

Intrinsic Factors of Non-adherence to Breast and Cervical Cancer Screenings Among Latinas.

Although adhering to regular screenings can improve timely diagnosis and survivorship, Latinas continue to exhibit the lowest breast and cervical cancer screening rates in the country. Initiatives have generally addressed extrinsic factors to combat disparities. However, the answer to increasing screening adherence among Latina women might lie in equally addressing intrinsic factors as well extrinsic factors. Social Cognitive Theory provided the foundation for the design of Esperanza y Vida, a culturally tailored outreach program that educated Latinas on breast and cervical cancer. Non-adherent participants were offered navigation and followed-up to reassess screening behavior. The objective of this manuscript is to outline the salient culture-related intrinsic factors reported by a sample of Latina women from New York and Arkansas in response to open-ended questions asked at 8 months post-educational intervention and navigation services. In turn, the findings are incorporated in an effort to recommend future steps for effective interventions. Content analysis was used to guide the qualitative data analysis. The most salient barriers reported were related to Systems, Organization and Logistics, Time, being Decidedly Unscreened, and Contrary Beliefs or Confusion.

Screening Colonoscopy among Uninsured and Underinsured Urban Minorities.

BACKGROUND/AIMS: Uninsured individuals have lower rates of screening colonoscopy (SC), and little is known regarding the pathology results obtained when they undergo colonoscopies. Since 2004, we have participated in a program that offers SC to uninsured New Yorkers; herein, we report our findings. METHODS: Uninsured, average-risk patients who were at least 50 years of age underwent SC at our institution between April 2004 and June 2011. We analyzed polyp pathology, location, size, incidence of adenomas, and incidence of adenomas with advanced pathology (AAP) with respect to ethnicity, gender, and age. RESULTS: Out of 493 referrals, 222 patients completed the colonoscopies. Polyps were identified in 21.2% of all patients; 14% had adenomas, and 4.5% had AAP. The rates of adenomas among African-Americans, Hispanics, and Whites were 24.3%, 12.1%, and 11.6%, respectively, and the corresponding rates of AAP were 10.8%, 3.5%, and 2.3%. Differences in the polyp type, location, and AAP did not reach statistical significance with respect to ethnicity or gender. Patients aged 60 and older were found to have a higher rate of advanced adenomas compared with younger patients (8.6% vs. 2.6%, p=0.047). CONCLUSIONS: Further efforts to fund screening colonoscopies for uninsured individuals will likely result in the identification of advanced lesions of the colon before they progress to colorectal cancer.

Factors related to hepatitis B screening among Africans in New York City.

OBJECTIVE: To understand factors that US Africans identify as barriers and facilitators for accessing hepatitis B (HBV) screening. METHODS: In-depth interviews were conducted and guided by the PEN-3 model to elicit culturally driven information in minority communities. RESULTS: Interviews were conducted with 22 US Africans. Salient themes that emerged were HBV knowledge, complexity of the US medical system, unaccustomed to preventive care, language and health literacy, availability and accessibility of screening, fear of disclosure, reliance on faith community, stigma of HBV, primacy towards a higher power on illnesses, and social systems influences. CONCLUSIONS: Findings were consistent with other at-risk populations, however, emphasis on privacy and fear of disclosure are distinct to Africans. This reinforces the need for a culturally targeted intervention for this at-risk population.

Colorectal neoplasia detection among black and Latino individuals undergoing screening colonoscopy: a prospective cohort study.

BACKGROUND: Most prospective studies of screening colonoscopy (SC) in average-risk, asymptomatic individuals have included few minority individuals. Little is known about the prevalence and distribution of adenomas found at screening colonoscopy among black and Latino individuals. OBJECTIVE: To determine the prevalence and distribution of histologically confirmed adenomas among black and Latino participants enrolled in a prospective SC study. DESIGN: Cross-sectional analysis of consecutive patients undergoing SC between 2008 and 2011. SETTING: Urban academic medical center. PATIENTS: Average risk, asymptomatic black and Latino patients aged ≥50 years undergoing SC. INTERVENTION SC MAIN OUTCOME MEASUREMENTS: Adenoma prevalence and distribution by ethnic group. RESULTS: A total of 584 patients (270 black, 314 Latino) completed SC. Overall, 26.4% had adenomas, and 20% had proximal adenomas. Advanced adenomas occurred in 11.5% (12.2% black vs 10.8% Latino; P = .21) and proximal advanced adenomas in 7.5% (5.9% black vs 8.9% Latino; P = .17). These rates were at least as high as those of other studies that enrolled mainly white participants. LIMITATIONS: Lack of comparison group of white patients. CONCLUSION: The prevalence of adenomas, advanced adenomas, and proximal adenomas was high in both black and Latino participants. The high prevalence of clinically significant proximal lesions has implications for the choice of colon cancer screening test and colonoscopic surveillance intervals.

Culturally targeted patient navigation for increasing african americans' adherence to screening colonoscopy: a randomized clinical trial.

BACKGROUND: Patient navigation has been an effective intervention to increase cancer screening rates. This study focuses on predicting outcomes of screening colonoscopy for colorectal cancer among African Americans using different patient navigation formats. METHODS: In a randomized clinical trial, patients more than 50 years of age without significant comorbidities were randomized into three navigation groups: peer-patient navigation (n = 181), pro-patient navigation (n = 123), and standard (n = 46). Pro-patient navigations were health care professionals who conducted culturally targeted navigation, whereas peer-patient navigations were community members trained in patient navigation who also discussed their personal experiences with screening colonoscopy. Two assessments gathered sociodemographic, medical, and intrapersonal information. RESULTS: Screening colonoscopy completion rate was 75.7% across all groups with no significant differences in completion between the three study arms. Annual income more than $10,000 was an independent predictor of screening colonoscopy adherence. Unexpectedly, low social influence also predicted screening colonoscopy completion. CONCLUSIONS: In an urban African American population, patient navigation was effective in increasing screening colonoscopy rates to 15% above the national average, regardless of patient navigation type or content. IMPACT: Because patient navigation successfully increases colonoscopy adherence, cultural targeting may not be necessary in some populations.

Implementation of culturally targeted patient navigation system for screening colonoscopy in a direct referral system.

Low-income minorities often face system-based and personal barriers to screening colonoscopy (SC). Culturally targeted patient navigation (CTPN) programs employing professional navigators (Pro-PNs) or community-based peer navigators (Peer-PNs) can help overcome barriers but are not widely implemented. In East Harlem, NY, USA, where approximately half the residents participate in SC, 315 African American patients referred for SC at a primary care clinic with a Direct Endoscopic Referral System were recruited between May 2008 and May 2010. After medical clearance, 240 were randomized to receive CTPN delivered by a Pro-PN (n = 106) or Peer-PN (n = 134). Successful navigation was measured by SC adherence rate, patient satisfaction and navigator trust. Study enrollment was 91.4% with no significant differences in SC adherence rates between Pro-PN (80.0%) and Peer-PN (71.3%) (P = 0.178). Participants in both groups reported high levels of satisfaction and trust. These findings suggest that CTPN Pro-PN and Peer-PN programs are effective in this urban primary care setting. We detail how we recruited and trained navigators, how CTPN was implemented and provide a preliminary answer to our questions of the study aims: can peer navigators be as effective as professionals and what is the potential impact of patient navigation on screening adherence?

Fistula awareness among sisters of women with fistula.

OBJECTIVE: To determine whether sisters of women with obstetric fistula (OF) were aware of their sisters' condition, in order to inform the development of survey questions that adapt the sister-based method to fistula rate estimation. METHODS: Twelve women with OF and 20 of their sisters were interviewed using semi-structured questionnaires in rural Uganda in 2007. Topics included fistula awareness and perceptions of causality. RESULTS: Eleven women had vesicovaginal fistula and 1 had rectovaginal fistula. Three were primiparous at time of fistula occurrence; 6 had a parity of 6 or more. Nineteen sisters were aware their sister had OF; 12 became aware at the time of occurrence. The majority of participants (fistula patients and their sisters) associated OF with mistakes made by hospital personnel or problems during procedures. CONCLUSION: Sisters were generally aware of OF within their family. Larger studies are needed to assess the validity and reliability of the sister-based method in capturing fistula through household surveys. In the present study, there was a widespread perception among fistula patients and their sisters that fistula is caused by medical procedures. More research is needed to understand this perception, and program development efforts are required to improve patient perceptions of hospital care.

Cost analysis of a patient navigation system to increase screening colonoscopy adherence among urban minorities.

BACKGROUND: Patient navigation (PN) is being used increasingly to help patients complete screening colonoscopy (SC) to prevent colorectal cancer. At their large, urban academic medical center with an open-access endoscopy system, the authors previously demonstrated that PN programs produced a colonoscopy completion rate of 78.5% in a cohort of 503 patients (predominantly African Americans and Latinos with public health insurance). Very little is known about the direct costs of implementing PN programs. The objective of the current study was to perform a detailed cost analysis of PN programs at the authors' institution from an institutional perspective. METHODS: In 2 randomized controlled trials, average-risk patients who were referred for SC by primary care providers were recruited for PN between May 2008 and May 2010. Patients were randomized to 1 of 4 PN groups. The cost of PN and net income to the institution were determined in a cost analysis. RESULTS: Among 395 patients who completed colonoscopy, 53.4% underwent SC alone, 30.1% underwent colonoscopy with biopsy, and 16.5% underwent snare polypectomy. Accounting for the average contribution margins of each procedure type, the total revenue was $95,266.00. The total cost of PN was $14,027.30. Net income was $81,238.70. In a model sample of 1000 patients, net incomes for the institutional completion rate (approximately 80%), the historic PN program (approximately 65%), and the national average (approximately 50%) were compared. The current PN program generated additional net incomes of $35,035.50 and $44,956.00, respectively. CONCLUSIONS: PN among minority patients with mostly public health insurance generated additional income to the institution, mainly because of increased colonoscopy completion rates.

Effect of comorbid conditions on adherence to colorectal cancer screening.

Potential barriers to colorectal cancer (CRC) screening include preexisting medical conditions (comorbidities), physician recommendation, psychosocial factors, and screening preparedness. This study's purpose was to investigate the impact of comorbid conditions on CRC screening among African Americans. A stage-matched randomized clinical trial was performed. Asymptomatic African Americans over age 50, with a primary care physician, and eligible for CRC screening were recruited at The Mount Sinai Hospital from 2005 to 2008. One hundred sixty-one patients were assessed for referral for, and completion of, CRC screening, comorbid conditions, "readiness to change," and number of physician visits within the observation period. Data was compared to a pretrial index to predict the likely effect of comorbid conditions on CRC screening. One hundred fifty-nine patients completed the study; 108 (68.9%) were referred for and 34 (21.2%) completed CRC screening. No demographic characteristics were associated with CRC screening completion. CRC screening referrals were similar for all patients, regardless of comorbidities or clinical visits. Comorbidities rated as having extreme influence on CRC screening showed a trend toward lower screening rates. There was a significant increase in screening rates among participants in advanced stages of readiness at enrollment. These data suggest that while comorbidities did not predict colonoscopy completion, they may play a role in concert with other factors. This is the only study to assess the effect of screening colonoscopy in an African American primary care setting. We must continue to explore interventions to narrow the disparate gap in screening and mortality rates.

Reported benefits of participation in a research study.

Racial and ethnic minorities are significantly underrepresented in clinical research trials. Several socio-cultural and systemic barriers, ranging from discrimination by the health care system, medical mistrust, to low physician referral rates and lack of knowledge of research studies have been identified as impacting participation. One hundred and fifteen participants were culturally matched and were interviewed followed by up to an additional four interviews over a 12 month period. Responses were analyzed to understand the perceived benefits to participating in a prospective, randomized, longitudinal clinical research trial about screening colonoscopy. Over two-thirds (64.4%) of participants reported "knowledge, awareness, and/or information about colonoscopy and general health" as being the greatest benefit they received. Desire to undergo the screening and the pride of completing the study was ranked second and third, respectively. Understanding the reasons that participants choose to participate in research studies will ultimately assist researchers close the gap in minority representation, allowing for greater generalizability of research findings.

Cervical cancer screening among immigrant Hispanics: an analysis by country of origin.

As the largest and most diverse ethnic minority population in the U.S., it is important to examine differences in and correlates of Pap test adherence among Hispanics by country of origin. The data for these analyses are baseline responses from a Randomized Controlled Trial. Bivariate and multivariable logistic regression models were conducted among Hispanic immigrant women who identified as Mexican, Puerto Rican, Dominican, or Central/South American (n = 1,305). There were significant differences in Pap test adherence: Dominicans (81.6%), Mexicans (77.5%), Central/South Americans (71.2%), and Puerto Ricans (69.3%). In multivariable analyses, there were different correlates of Pap test adherence for each country of origin. For example, marriage status (P = .0001) and younger age (P = .006) were positively associated with adherence among Mexican women. This research provides insight into the variability that exists among Hispanics and can help improve understanding of important determinants that may influence Pap test screening among diverse Hispanics.

Sociocultural determinants of breast and cervical cancer screening adherence: an examination of variation among immigrant Latinas by country of origin.

This paper seeks to examine differences in sociodemographic characteristics and culturally-relevant psychosocial and interpersonal factors across four sub-groups of immigrant Latinas, and how these factors are associated with adherence to age-specific breast and cervical cancer screening. Data come from a baseline survey using an electronic audience response system from a randomized controlled trial to test the effectiveness of a cancer screening program in New York and Arkansas (n=1,548). Mexican women were least likely to be adherent to cancer screening tests (clinical breast exam, mammogram, or Pap test). Mexican women also differed from the other sub-groups in terms of sociodemographics, barriers, and interactions within the health care system. Correlates of screening adherence differed by country of origin, with the exception of spouse/partner attendance at the program, which was negatively associated with adherence across several sub-groups. Findings provide important information about Latina sub-group variability that can help inform the development of breast and cervical cancer screening interventions.

Esperanza y Vida: a culturally and linguistically customized breast and cervical education program for diverse Latinas at three different United States sites.

Breast cancer is the most common cause of cancer and the leading cause of cancer death among Latinas in the United States. In addition, Latinas experience a disproportionate burden of cervical cancer incidence, morbidity, and mortality compared with non-Hispanic White women. Lower use of breast and cervical cancer screening services may contribute to these disparities. To address the underutilization of breast and cervical cancer screening among diverse subgroups of Latinas, a peer-led education program called Esperanza y Vida ("Hope and Life") was developed and administered at 3 sites (2 in New York and 1 in Arkansas). Immigrant Latina women and their partners were educated about the importance of breast and cervical cancer screening, with the goals of increasing their knowledge about these cancers and their screening behavior. An analysis of the intervention's findings at baseline among female participants demonstrated significant sociodemographic, interpersonal, cultural, health care system, and program variability in 3 distinct geographic regions in the United States. These data indicate the need for and feasibility of customizing cancer outreach and educational programs for diverse Latina subgroups living in various U.S. regions, with implications for informing the expansion and replication of the program in other regions of the country.

Descriptive characteristics of a colon disease family registry at an urban hospital.

BACKGROUND: Hospital registries are an important component of cancer screening efforts of individuals and communities. This paper describes the structure and goals of a Colon Disease Family Registry at a metropolitan hospital. Patient characteristics, differences between gastrointestinal diseases among probands, subjective distress in relation to perception of colorectal cancer, and quality of life were examined. METHODS: Participants were patients with colorectal cancer (CRC), familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal carcinoma (HNPCC) and inflammatory bowel disease ulcerative colitis (UC) and Crohn's disease representing a range of colonic diseases. A total of 630 probands were recruited into the registry and administered a questionnaire. RESULTS: Of the 630 probands, 198 (31.4%) were diagnosed with CRC, 36 (5.3%) with FAP or HNPCC and 272 (43.2%) with UC or Crohn's. The majority of all three groups had some level of college education, was white, and reported a household income greater then $70,000. The Impact of Event Scale score was found to be of notable significance when categorized by relation to proband (p<0.01) and proband diagnoses (p ≤ 0.000). On the quality of life item, the largest difference was between FAP or HNPCC and UC or Crohn's without CRC. CONCLUSION: Subjective distress scores were higher for CRC probands in comparison to probands with other colorectal diseases. Quality of life was relatively high for all probands. Psychological distress should be explored in more depth and more frequently to screen for any concomitant psychiatric disorders like post-traumatic symptoms that have been linked to a cancer diagnosis.

Esperanza y Vida: training lay health advisors and cancer survivors to promote breast and cervical cancer screening in Latinas.

The use of lay health advisors (LHAs) to promote community-based health education programs is well documented and is considered an effective way to reach underserved communities. Esperanza y Vida (Hope & Life) is an educational outreach program to increase breast and cervical cancer screening for diverse Latinas. It incorporates Latino LHAs (men and women) and cancer survivor role models, sobrevivientes, in the program delivery. An interactive training program, conducted by bilingual staff across three sites (Little Rock, Arkansas; Buffalo, New York and New York City) included 74 sobrevivientes and LHAs who were recruited and trained. All training attendees completed an initial application assessing socio-demographics, experience and availability as well as, true/false surveys at the beginning (pre-) and end of the training (post-) measuring knowledge levels of breast and cervical cancer health. Data analysis indicated a significant increase of both breast and cervical cancer knowledge for attendees trained as LHAs (pre = 60%; post = 80%; p = 0.000), whereas sobrevivientes had a higher baseline knowledge of breast health (74%), and therefore did not show a significant increase following training (79%). However, sobrevivientes did display a significant increase in cervical cancer knowledge (p = 0.003). These findings demonstrate the impact of training and how LHAs may be recruited at different levels of knowledge and experience and be successfully trained in key program elements. Moreover, results indicate that sobrevivientes may be impacted differently, or require variations in training approaches. This information can be useful in developing and customizing curriculum for future lay health training programs.

Understanding the barriers and facilitators of colorectal cancer screening among low income immigrant hispanics.

Colorectal cancer (CRC) screening rates are low among Hispanics; thus understanding screening barriers and facilitators is essential. A survey, based on blended health promotion theories, was conducted with low income, mostly immigrant, Hispanics at community based organizations and health clinics in New York City. Correlates of undergoing colonoscopy screening were examined. Four hundred men (28%) and women were interviewed. Older age, longer US residence, having a regular health care provider and provider recommendation predicted colonoscopy receipt (P values <0.01). Greater fear and worry concerning colonoscopy and fewer perceived screening benefits were associated with reduced screening likelihood (P values <0.05). In a multivariate model, colonoscopy receipt was negatively associated with Medicaid and positively associated with English preference, physician recommendation for and encouragement of screening and less fear. Interventions that educate physicians and patients regarding colonoscopy screening guidelines, increase physicians' screening referrals, and reduce patients' fear are needed.

Sociodemographic correlates of stage of adoption for colorectal cancer screening in African Americans.

OBJECTIVES: African Americans have the highest incidence and mortality rates from colorectal cancer in the United States. Endoscopic screening, while effective in reducing both, is greatly underutilized. This research sought to understand sociodemographic factors related to stage of readiness for endoscopic screening. DESIGN: One hundred fifty nine African American women (76.1%) and men (mean age = 57.0 years) who were non-adherent to endoscopic screening guidelines were recruited and asked to complete semi-structured interviews. SETTING: Participants were all being seen for a non-acute primary care medical visit at one of two urban hospitals. The theoretical framework that informed this study was the Trans-theoretical Model (TTM) and the emphasis on Stage of Change or intention for undergoing endoscopic screening. MAIN OUTCOME AND MEASURES: Based on their stage of readiness to undergo screening, 67 (42%) were categorized as precontemplative (Has no plans to have a colonoscopy) while 92 were categoriezed as being in a contemplative or preparation stage. Using chi-square and Student t-tests, differences were examined between the two groups. RESULTS: No sociodemographic variables distinguished the two groups. However, people in the contemplative/preparation group were more likely to: have a regularly seen healthcare professional (63.7% vs 36.3%; P = .005), have had a previous recommendation for screening (65.7% vs 34.3%; P = .003); had heard of a colonoscopy (63.6% vs 36.4%; P = .000) and have been told by a healthcare professional that they needed a colonoscopy (73.1% vs 26.9%; P = .000). CONCLUSIONS: This study helps us to better understand the relevance of sociodemographic characteristics that may be associated with completing endoscopic colorectal cancer screening. In addition, we confirm that physician recommendation and individual awareness of the procedure are significant factors in readiness to get screened.

Demographic, medical, and psychosocial correlates to CAM use among survivors of colorectal cancer.

GOALS OF WORK: Complementary and alternative medicines (CAM) use among cancer patients is becoming more prevalent; however, our understanding of factors contributing to patients' decisions to participate in CAM is limited. This study examined correlates of CAM use among colorectal cancer (CRC) survivors, an understudied population that experiences many physical and psychological difficulties. MATERIALS AND METHODS: The sample was 191, predominantly white, CRC survivors (mean age = 59.9 +/- 12.6) who were members of a colon disease registry at a NYC metropolitan hospital. Participants completed assessments of sociodemographic characteristics, psychosocial factors [e.g., psychological functioning, cancer specific distress, social support (SS), quality of life (QOL)], and past CAM use (e.g., chiropractic care, acupuncture, relaxation, hypnosis, and homeopathy). MAIN RESULTS: Seventy-five percent of participants reported using at least one type of CAM; most frequently reported was home remedies (37%). Younger (p < 0.01) or female patients (p < 0.01) were more likely to participate in CAM than their older male counterparts. Among psychosocial factors, poorer perceived SS (p = 0.00), more intrusive thoughts (p < 0.05), and poorer overall perceived QOL (p < 0.05) were associated to CAM use. In a linear regression model (including age, gender, SS, intrusive thoughts, and perceived QOL), only age remained a significant predictor of CAM use. CONCLUSION: These findings demonstrate that CAM use is prevalent among CRC survivors and should be assessed routinely by providers. CAMs may serve as a relevant adjunct to treatment among CRC patients as well as an indication of need for additional SS, especially among younger patients.