New York City's immigrant minorities. Reducing cancer health disparities

Experiences with Childhood Cancer among Latinx Families: Identification of Informational and Support Needs

Latinx children with cancer generally have poorer health outcomes than their non-Latinx White counterparts. The purpose of this study was to examine the experience of Latinx mothers whose children have been diagnosed with cancer at the onset of symptoms, the barriers surrounding the diagnostic process, and the resources families identify are needed post-diagnosis. The researchers conducted two focus groups (one in Spanish, one in English) with Latina mothers of children who have or experienced pediatric cancer in the United States. Two researchers conducted constant comparative analysis of the transcribed focus group audio recordings to identify themes. Themes included a sense of community support at the onset of symptoms, feelings of disbelief, helplessness, overload of information, and a need for advocacy in medical settings. Needs included more palatable and simplified information, financial assistance and resources, increased parental social support, accessible Spanish-speaking providers, and culturally informed care. Latina mothers indicated a range of challenges pertaining to childhood cancer diagnosis and treatment that may impact child and family outcomes. Implications for social work practitioners to reduce disparities and develop intervention programs for Latinx families of children with cancer are discussed.

The financial coping strategies of US cancer patients and survivors

PURPOSE

Coping behaviors may play a mediating role in producing the negative health outcomes observed in financially burdened cancer patients and survivors.

METHODS

Exploratory factor and latent class analysis of survey data.

RESULTS

A total of 510 people completed the survey, ages ranged from 25 to over 75 [over half greater than 55 years old (57.8%)]. Most respondents identified as female (64.7%), white (70.8%), or African American (18.6%). A four-factor model of financial coping was revealed: care-altering, lifestyle-altering, self-advocacy, and financial help-seeking. Respondents grouped into three financial coping classes: low burden/low coping (n = 212), high self-advocacy (n = 143), and high burden/high coping (n = 155). African American respondents were at far greater odds than white respondents of being in the high burden/high coping class (OR = 5.82, 95% CI 3.01-6.64) or the self-advocacy class (OR = 1.99, 95% CI 1.19-2.80) than the low burden/low coping class. Compared to respondents aged 65 years and older, those 35-44 were more likely in the high burden/high coping class (OR = 12.27, 95% CI 7.03-19.87) and the high self-advocacy class (OR = 7.08, 95% CI 5.89-8.28) than the low burden/low coping class.

CONCLUSION

One-third of respondents were in the high burden/high coping class. Age and race/ethnicity were significantly associated with class membership. Some coping strategies may compromise health and well-being. Program and policy interventions that reduce the odds that patients will use strategies that undermine treatment outcomes and increase patient use of protective strategies are needed.

The importance of community and culture for the recruitment, engagement, and retention of Chinese American immigrants in health interventions

Chinese Americans experience cancer health disparities throughout the entire cancer continuum. Yet, they remain underrepresented in health research in part due to barriers in recruitment, engagement, and retention. This paper describes the strategies that we devised, by drawing upon our experiences with conducting two culturally sensitive cancer intervention studies, to help researchers improve their recruitment and retention rates of Chinese Americans in health research and address the gap in knowledge on intervention research with this population. The first study assessed the efficacy, adoption, and impact of an intervention, delivered by community health workers, to improve adherence to recommended stomach cancer prevention guidelines for at-risk Chinese Americans. The second study evaluated the feasibility and preliminary efficacy of a culturally adapted version of the Expressive Helping intervention for Chinese American cancer patients and survivors. Our main recruitment strategies revolved around building community relationships, developing culturally sensitive materials, and establishing good first impressions with participants. Our main engagement and retention strategies focused on attending to cultural sensitivity, fostering relationships, and using technology. Harnessing the community's inherent strengths and prioritizing cultural understanding is crucial for culturally sensitive health research with Chinese Americans.

Leveraging Population Health Expertise to Enhance Community Benefit

As the Internal Revenue Service strengthens the public health focus of community benefit regulations, and many states do the same with their tax codes, hospitals are being asked to look beyond patients in their delivery system to understand and address the needs of geographic areas. With the opportunities this affords come challenges to be addressed. The regulations' focus on population health is not limited to a defined clinical population—and the resulting emphasis on upstream determinants of health and community engagement is unfamiliar territory for many healthcare systems. At the same time, for many community residents and community-based organizations, large medical institutions can feel complicated to engage with or unwelcoming. And for neighborhoods that have experienced chronic underinvestment in upstream determinants of health—such as social services, housing and education—funds made available by hospitals through their community health improvement activities may seem insufficient and unreliable. Despite these regulatory requirements, many hospitals, focused as they are on managing patients in their delivery system, have not yet invested significantly in community health improvement. Moreover, although there are important exceptions, community health improvement projects have often lacked a strong evidence base, and true health system-community collaborations are relatively uncommon. This article describes how a large academic medical center tapped into the expertise of its population health research faculty to partner with local community-based organizations to oversee the community health needs assessment and to design, implement and evaluate a set of geographically based community-engaged health improvement projects. The resulting program offers a paradigm for health system investment in area-wide population health improvement.

Identifying the barriers to gastric cancer care at safety-net hospitals: A novel comparison of a safety-net hospital to a neighboring quaternary referral academic center in the same healthcare system

BACKGROUND

The three-delays model describes delays in seeking, reaching, and receiving care for vulnerable populations needing treatment. The dominant delay for patients with gastric adenocarcinoma (GAC) is unknown. We aimed to define patients with GAC who reached and received care at our regional safety-net hospital (Grady Memorial Hospital [GMH]) and our neighboring quaternary referral hospital (Emory University Hospital [EUH]).

METHODS

Clinicopathologic data from National Cancer Database (NCDB) participating academic centers were compared with GMH from 2004 to 2014. Outcomes of patients undergoing surgery at GMH were compared to those at EUH.

RESULTS

At presentation, compared to NCDB centers (n = 69 662), GMH patients (n = 154) were more often black (85.1 vs 17.2%; P < 0.001), uninsured (30.5 vs 4.7%; P < 0.001), have stage IV disease (43.5 vs 30.1%; P = 0.017), and received no treatment (40.3 vs 18.4%; P < 0.001). When only comparing patients who underwent curative-intent resection at GMH (n = 23) to EUH (n = 137), median overall survival was similar between both groups (GMH: median not reached; EUH: 59.8 mos; P = 0.785).

CONCLUSION

Although vulnerable patients with GAC within a safety-net hospital present with later stages of the disease, those who received surgery have acceptable outcomes. Thus, efforts should be made to overcome barriers in seeking care.

Awareness of and reactions to mammography controversy among immigrant women

Background

There is substantial expert disagreement about the use of mammography to screen for breast cancer, and this disagreement routinely plays out in the media. Evidence suggests that some women are aware of the controversy over mammography, but less is known about whether immigrant and other underserved women have heard about it and, if so, how they react to it.

Objective

To explore immigrant women's awareness of and reactions to mammography controversy.

Design

Community‐engaged qualitative study: we conducted six focus groups with 53 women aged 35–55 from three immigrant communities (Somali, Latina and Hmong) in a major US metropolitan area. A grounded theory approach was used to identify themes; NVivo 10 was used to enhance analyses.

Results

Several themes emerged: (i) low awareness of mammography controversy across groups, despite self‐reported attention to health information; (ii) high intentions to be screened, even after being told about the controversy; (iii) few reported discussions of mammography's risks and benefits with clinicians; (iv) substantial interest in learning more about mammography and breast cancer, but some low self‐efficacy to obtain such information; and (v) questions about whether health recommendations matter and what qualifies as evidence.

Conclusion

Given on‐going expert disagreement about mammography screening, it is important for clinicians to help women understand mammography's risks and benefits so they can make an informed choice. This is particularly critical for immigrant and other underserved women, who may be less able to access, attend to, process, retain and act on health information (a phenomenon known as communication inequality).

A comparison of human and machine translation of health promotion materials for public health practice: time, costs, and quality

CONTEXT

Most local public health departments serve limited English proficiency groups but lack sufficient resources to translate the health promotion materials that they produce into different languages. Machine translation (MT) with human postediting could fill this gap and work toward decreasing health disparities among non-English speakers.

OBJECTIVES

(1) To identify the time and costs associated with human translation (HT) of public health documents, (2) determine the time necessary for human postediting of MT, and (3) compare the quality of postedited MT and HT.

DESIGN

A quality comparison of 25 MT and HT documents was performed with public health translators. The public health professionals involved were queried about the workflow, costs, and time for HT of 11 English public health documents over a 20-month period. Three recently translated documents of similar size and topic were then machine translated, the time for human postediting was recorded, and a blind quality analysis was performed.

SETTING

Seattle/King County, Washington.

PARTICIPANTS

Public health professionals.

MAIN OUTCOME MEASURES

(1) Estimated times for various HT tasks; (2) observed postediting times for MT documents; (3) actual costs for HT; and (4) comparison of quality ratings for HT and MT.

RESULTS

Human translation via local health department methods took 17 hours to 6 days. While HT postediting words per minute ranged from 1.58 to 5.88, MT plus human postediting words per minute ranged from 10 to 30. The cost of HT ranged from $130 to $1220; MT required no additional costs. A quality comparison by bilingual public health professionals showed that MT and HT were equivalently preferred.

CONCLUSIONS

MT with human postediting can reduce the time and costs of translating public health materials while maintaining quality similar to HT. In conjunction with postediting, MT could greatly improve the availability of multilingual public health materials.

The Asian Grocery Store-Based Cancer Education Program: Creating New Education Modules

Operating since 1994, the UCSD Moores Cancer Center's Asian Grocery Store-Based Cancer Education Program (the Program) is a proven and sustainable strategy for disseminating cancer and poison control information to Asian and Pacific Islander (API) communities. This paper describes the process taken to identify health topics that can be readily addressed within the Program's infrastructure and reports results of the pilot testing of the educational module that was developed by following that process. The development of each new module is guided by the Health Belief Model and the Tipping Point Model. The process starts with the selection of a health topic demonstrating pressing need and treatment options in the API community. Then, using the Pareto principle, reasonably modifiable risk factors are chosen to be addressed in the module. "Sticky messaging" for the modifiable risk factors is developed to package the health information as memorable and transmissible calls-to-action. Finally, grocery store outreaches were used to pilot test the new module to assess its effectiveness at facilitating health care information to API community members. By adhering to the steps described in this paper, the authors were able to: (1) select liver cancer as a pressing API health issue that could be positively impacted by the Program; (2) identify reasonably modifiable risk factors for the chosen health issue; (3) generate compelling call-to-action messages to decrease risk of exposure; and (4) demonstrate the cultural and linguistic alignment of the liver cancer control module. The development and testing of new health education modules follow a methodical process guided by scientific principles. Understanding and employing the elements of an existing evidence-based and sustainable health education program can increase the likelihood of success in addressing the health needs of the API community.

Cultural Factors Associated with Breast and Cervical Cancer Screening in Korean American Women in the US: An Integrative Literature Review

PURPOSE

This study examined current research theories and methods, cultural factors, and culturally relevant interventions associated with breast and cervical cancer screening in Korean American (KA) women.

METHODS

Based on Ganong's guidelines, the literature on cultural factors associated with breast and cervical cancer screening in KA women was searched using MEDLINE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Sixty-eight articles on breast cancer screening and 66 articles on cervical cancer screening were retrieved from both databases, and a total of 22 articles were included in the literature review based on the selection criteria.

RESULTS

Of the 22 studies reviewed, 14 (63.6%) were descriptive and 8 (36.4%) were interventional. Many studies have used individual focused cognitive theories such as health belief model and different types of operationalization for measures of cultural beliefs. Cultural factors associated with breast and cervical cancer screening in KA women that were identified in descriptive quantitative and qualitative studies included family, embarrassment, preventive health orientation, fatalism, and acculturation. Most culturally relevant interventional studies used education programs, and all education was conducted by bilingual and bicultural health educators at sociocultural sites for KA women.

CONCLUSIONS

Theories focusing on interpersonal relationships and standardized, reliable, and valid instruments to measure cultural concepts are needed to breast and cervical cancer screening research in KA women. Traditional cultural factors associated with cancer screening should be considered for practical implications and future research with KA women.

Challenges and possible solutions to colorectal cancer screening for the underserved

Colorectal cancer (CRC) is a leading cause of cancer mortality worldwide. CRC incidence and mortality can be reduced through screening. However, in the United States, screening participation remains suboptimal, particularly among underserved populations such as the uninsured, recent immigrants, and racial/ethnic minority groups. Increasing screening rates among underserved populations will reduce the US burden of CRC. In this commentary focusing on underserved populations, we highlight the public health impact of CRC screening, list key challenges to screening the underserved, and review promising approaches to boost screening rates. We identify four key policy and research priorities to increase screening among underserved populations: 1) actively promote the message, "the best test is the one that gets done"; 2) develop and implement methods to identify unscreened individuals within underserved population groups for screening interventions; 3) develop and implement approaches for organized screening delivery; and 4) fund and enhance programs and policies that provide access to screening, diagnostic follow-up, and CRC treatment for underserved populations. This commentary represents the consensus of a diverse group of experts in cancer control and prevention, epidemiology, gastroenterology, and primary care from across the country who formed the Coalition to Boost Screening among the Underserved in the United States. The group was organized and held its first annual working group meeting in conjunction with the World Endoscopy Organization's annual Colorectal Cancer Screening Committee meeting during Digestive Disease Week 2012 in San Diego, California.

Metrics for the systematic evaluation of community-based outreach

There is an extensive literature on the use of community-based outreach for breast health programs. While authors often report that outreach was conducted, there is rarely information provided on the effort required for outreach. This paper seeks to establish a template for the systematic evaluation of community-based outreach. We describe three types of outreach used by our project, explain our evaluation measures, present data on our outreach efforts, and demonstrate how these metrics can be used to inform a project's decisions about which types of outreach are most effective.

Cancer stage knowledge and desire for information: mismatch in Latino cancer patients?

Having more health knowledge has a crucial and positive impact on cancer outcomes. Patients' cancer knowledge influences their ability to participate actively in decision-making processes for medical care and in treatment choices. The purpose of this study was to determine the demographic and medical correlates of lack of cancer stage knowledge and desire for information among Latino cancer patients. The sample included 271 underserved Latino cancer patients recruited from four cancer clinics in New York City. Participants completed a needs assessment survey in their preferred language, which included sociodemographic and health-related questions. Close to two-thirds of the sample (65%) had no knowledge of their stage, and 38% were unaware of the metastatic state of their tumor. Only 15% of the patients expressed that they would like additional information about their diagnosis and/or treatment. After controlling for sociodemographic characteristics, being an immigrant with limited English proficiency and monolingual in Spanish were predictors of stage unawareness and less desire/need for cancer information. Patients needing interpretation for health care were less likely to know whether their tumor had metastasized and their cancer stage and to desire information about their cancer diagnosis and/or treatment. This study shows considerably low levels of stage awareness among Latinos diagnosed with cancer. This lack of knowledge might adversely impact their treatment decisions and disease management. Future studies should focus on identifying barriers to acquisition of disease information and other disease-specific informational deficits.

"Doctor, what do i have?" Knowledge of cancer diagnosis among immigrant/migrant minorities

This study explores patient knowledge of cancer diagnosis among underserved immigrant/migrant minorities. Patients were recruited at a hospital-based cancer clinic in New York City. Demographic and self-reported diagnosis and treatment information were collected; charts were reviewed to ascertain cancer diagnosis. Four hundred thirty-four patients were included. Eighty-seven percent preferred to speak a language other than English in the health care setting. Sixteen percent had incorrect knowledge of their cancer diagnosis. Multivariate analysis indicated that both preference for a non-English language and diagnosis of a "below the belt" cancer were jointly predictive of incorrect knowledge (LR = 17.01; p = 0.0002). "Below the belt" cancers included bladder, colorectal, gynecological, penile, prostate, and testicular cancers. Among this cohort of immigrant/migrant cancer patients, a considerable proportion was unaware of their correct cancer diagnoses. This may have a significant impact on subsequent cancer education, treatment, and care. Limited-English-proficiency patients may be at particular risk.

Testing healthy immigrant effects among late life immigrants in the United States: using multiple indicators

OBJECTIVE

This study tested a healthy immigrant effect (HIE) and postimmigration health status changes among late life immigrants.

METHODS

Using three waves of the Second Longitudinal Study of Aging (1994-2000) and the linked mortality file through 2006, this study compared (a) chronic health conditions, (b) longitudinal trajectories of self-rated health, (c) longitudinal trajectories of functional impairments, and (d) mortality between three groups (age 70+): (i) late life immigrants with less than 15 years in the United States (n = 133), (ii) longer term immigrants (n = 672), and (iii) U.S.-born individuals (n = 8,642). Logistic and Poisson regression, hierarchical generalized linear modeling, and survival analyses were conducted.

RESULTS

Late life immigrants were less likely to suffer from cancer, had lower numbers of chronic conditions at baseline, and displayed lower hazards of mortality during the 12-year follow-up. However, their self-rated health and functional status were worse than those of their counterparts over time.

CONCLUSION

A HIE was only partially supported among older adults.

Contextualizing the survivorship experiences of Haitian immigrant women with breast cancer: opportunities for health promotion

PURPOSE/OBJECTIVES

To examine challenges faced by Haitian immigrant women managing a breast cancer diagnosis.

RESEARCH APPROACH

Trained community health workers conducted focus groups with Haitian women who were breast cancer survivors. A grounded theory approach guided analysis of transcripts.

SETTING

A large community-based organization in Miami, FL.

PARTICIPANTS

18 women took part in three focus groups. Participants were 40 years or older, were ethnically Haitian, and had been diagnosed with breast cancer 6-12 months prior to the study.

METHODOLOGIC APPROACH

Data were collected as part of an ongoing community-based participatory research initiative in Little Haiti, the largest enclave of Haitian settlement in Miami, FL. Community health workers, integral to the initiative, recruited participants through their extensive social networks and community contacts.

MAIN RESEARCH VARIABLES

Screening knowledge, illness beliefs, social and economic consequences of a breast cancer diagnosis, and advice for breast health education.

FINDINGS

Emergent themes suggest that Haitian breast cancer survivors face multiple challenges, including misperceptions about screening guidelines, disease etiology, and risk; a reduced capacity to earn a living because of physical debility; and diminished social support.

CONCLUSIONS

Future research must continue to examine the impact of breast cancer on Haitian immigrant women and identify key strategies, such as community outreach and support programs, to improve their quality of life.

INTERPRETATION

Nurses can play an essential role in such strategies by providing culturally relevant clinical care and partnering with community stakeholders to define the scope and focus of public health intervention.

CBPR with service providers: arguing a case for engaging practitioners in all phases of research

This review synthesizes the literature on CBPR with service providers to identify the benefits to, unique contributions of, and challenges experienced by professional service providers engaged in collaborative research. Service providers benefited by obtaining research-based knowledge to help the communities they serve, gaining research skills, professional relationships, professional development, and new programs. They contributed by informing research aims, designing interventions, conducting recruitment, informing overall study design, and dissemination. Challenges include time, resources, organizational factors, and disconnects between researchers and service providers. Policy and practice implications are explored.

Barriers to cervical cancer screening among Haitian immigrant women in Little Haiti, Miami

Previous research has not examined barriers to Pap test screening among Haitian immigrant women through their own discourse. Community Health Workers conducted in-depth interviews with Haitian women in Little Haiti, Miami. We used a grounded theory approach to analyze data from the in-depth interviews. Emergent themes coalesced into three core categories of screening barriers: structural, psychosocial, and sociocultural. We developed a model of screening barriers to depict the themes within each core category. Screening barriers must be examined and understood from the social contexts in which they are produced in order to create meaningful interventions.

Barriers to breast cancer screening among Haitian immigrant women in Little Haiti, Miami

Previous research has not examined barriers to mammography screening among Haitian immigrant women through their own discourse. Community Health Workers conducted in-depth interviews with Haitian women in Little Haiti, Miami. We used a grounded theory approach to analyze data from the in-depth interviews. Emergent themes coalesced into three core categories of screening barriers: Structural, Psychosocial, and Socio-Cultural. We developed a model of screening barriers to depict the themes within each core category. Screening barriers must be examined and understood from the social contexts in which they are produced in order to create meaningful interventions.

Cultural beliefs and attitudes toward health and health care among Asian-born women in the United States

OBJECTIVE

To describe Asian-born women's cultural beliefs and attitudes towards health, illness, and health care practices.

DATA SOURCES

Online databases PubMed and CINAHL.

STUDY SELECTION

Twenty-four studies published between January 2000 and May 2009 were retrieved based on the inclusion criteria.

DATA EXTRACTION

Data on publication year, authors, study sample, sample size (only Asian women in the United States were included), design, and related key findings were extracted.

DATA SYNTHESES

Data were organized under three categories: Asian cultural beliefs about health and illness, health promotion and illness prevention, and health care practices. Common beliefs across groups and unique beliefs within specific Asian ethnic groups were synthesized. The results indicated that different Asian ethnic groups share some health beliefs, but each group also has unique health beliefs. Existing literature on cultural health beliefs of Asian-born women is limited.

CONCLUSION

Health care providers can use the findings of this review to improve health care utilization among Asian-born women.

Exploring disparities and variability in perceptions and self-reported colorectal cancer screening among three ethnic subgroups of U. S. Blacks

PURPOSE/OBJECTIVES

To explore perceptions of colorectal cancer (CRC) and self-reported CRC screening behaviors among ethnic subgroups of U. S. blacks.

DESIGN

Descriptive, cross-sectional, exploratory, developmental pilot.

SETTING

Medically underserved areas in Hillsborough County, FL.

SAMPLE

62 men and women aged 50 years or older. Ethnic subgroup distribution included 22 African American, 20 English-speaking Caribbean-born, and 20 Haitian-born respondents.

METHODS

Community-based participatory research methods were used to conduct face-to-face individual interviews in the community.

MAIN RESEARCH VARIABLES

Ethnic subgroup, health access, perceptions of CRC (e.g., awareness of screening tests, perceived risk, perceived barriers to screening), healthcare provider recommendation, and self-reported CRC screening.

FINDINGS

Awareness of CRC screening tests, risk perception, healthcare provider recommendation, and self-reported use of screening were low across all subgroups. However, only 55% of Haitian-born participants had heard about the fecal occult blood test compared to 84% for English-speaking Caribbean-born participants and 91% for African Americans. Similarly, only 15% of Haitian-born respondents had had a colonoscopy compared to 50% for the English-speaking Caribbean and African American subgroups.

CONCLUSIONS

This exploratory, developmental pilot study identified lack of awareness, low risk perception, and distinct barriers to screening. The findings support the need for a larger community-based study to elucidate and address disparities among subgroups.

IMPLICATIONS FOR NURSING

Nurses play a major role in reducing cancer health disparities through research, education, and quality care. Recognition of the cultural diversity of the U. S. black population can help nurses address health disparities and contribute to the health of the community.

Preventing cervical cancer in the Latina population

Cervical cancer causes great morbidity and mortality worldwide and in the United States. Infection with oncogenic human papillomavirus (HPV), the etiological agent of almost all cervical cancer cases, is common among sexually active women in the United States. Over the past 5 decades, the implementation of Papanicolaou screening programs in the United States has led to a significant decrease in cervical cancer cases. However, notable disparities in the incidence and mortality of cervical cancer and cervical screening rates among Hispanics in the United States remain. If current disparities persist without intervention, the Latina population in the United States may remain at a higher risk of developing and dying from cervical cancer. We discuss disparities in cervical cancer screening, incidence, and mortality among the Latina population, as well as the barriers that may propagate these disparities. We also address how these barriers can be overcome through the coordination of outreach programs and widespread prophylactic HPV vaccination to reduce cervical cancer disparities in Latinas.

The development of a community-based family asthma management intervention for Puerto Rican children

BACKGROUND

Puerto Rican children maintain disproportionately high asthma prevalence rates and effective asthma management interventions are needed.

OBJECTIVES

This article describes how community-based participatory research (CBPR) was implemented in the development of a culturally tailored family asthma management intervention for Puerto Rican children: CALMA (a Spanish acronym for Take Control, Empower Yourself, and Achieve Asthma Management).

METHOD

CALMA was developed according to CBPR principles and contemporary asthma guidelines through the collaboration of diverse members of the local, professional, and medical communities, academia, and local government. All group members contributed unique perspectives, making CALMA's development a collaborative effort.

LESSONS LEARNED

The CALMA community dealt with challenges in both incorporating and managing a diverse group of stakeholders and maintaining equity in decision making power. However, the community maintained strengths, such as incorporating culturally accepted remedies and addressing culturally specific myths in the intervention, as well as having the medical community directly involved in overseeing the accuracy of the intervention.

CONCLUSION

A CBPR approach enhanced the cultural sensitivity of the intervention as well as its potential for sustainability.

Cancer outcomes research in a rural area: a multi-institution partnership model

Whereas, most cancer research data come from high-profile academic centers, little is known about the outcomes of cancer care in rural communities. We summarize the experience of building a multi-institution partnership to develop a cancer outcomes research infrastructure in Southwest Georgia (SWGA), a primarily rural 33-county area with over 700,000 residents. The partnership includes eight institutions: the Emory University in Atlanta, the Centers for Disease Control and Prevention (CDC), the Georgia Comprehensive Center Registry (the Registry), the Southwest Georgia Cancer Coalition (the Coalition), and the four community cancer centers located within the SWGA region. The practical application of the partnership model, its organizational structure, and lessons learned are presented using two specific examples: a study evaluating treatment decisions and quality of life among prostate cancer patients, and a study of treatment discontinuation among prostate, breast, lung, and colorectal cancer patients. Our partnership model allowed us to (1) use the Coalition as a link between Atlanta-based researchers and local community; (2) collaborate with the area cancer centers on day-to-day study activities; (3) involve the Registry personnel and resources to identify eligible cancer cases and to perform data collection; and (4) raise community awareness and sense of study ownership through media announcements organized by the Coalition. All of the above activities were performed in consultation with the funding institution (CDC) and its project directors who oversee several other studies addressing similar research questions throughout the country. Our partnership model may provide a useful framework for cancer outcomes research projects in rural communities.

A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial

BACKGROUND

Minority racial/ethnic groups have low colorectal cancer (CRC) screening rates.

OBJECTIVE

To evaluate a culturally tailored intervention to increase CRC screening, primarily using colonoscopy, among low income and non-English speaking patients.

DESIGN

Randomized controlled trial conducted from January to October of 2007.

SETTING

Single, urban community health center serving a low-income, ethnically diverse population.

PATIENTS

A total of 1,223 patients 52-79 years of age overdue for CRC screening, randomized to intervention (n = 409) vs. usual care control (n = 814) groups.

INTERVENTION

Intervention patients received an introductory letter with educational material followed by phone or in-person contact by a language-concordant "navigator." Navigators (n = 5) were community health workers trained to identify and address patient-reported barriers to CRC screening. Individually tailored interventions included patient education, procedure scheduling, translation and explanation of bowel preparation, and help with transportation and insurance coverage. Rates of colorectal cancer screening were assessed for intervention and usual care control patients.

RESULTS

Over a 9-month period, intervention patients were more likely to undergo CRC screening than control patients (27% vs. 12% for any CRC screening, p < 0.001; 21% vs. 10% for colonoscopy completion, p < 0.001). The higher screening rate resulted in the identification of 10.5 polyps per 100 patients in the intervention group vs. 6.8 in the control group (p = 0.04).

LIMITATIONS

Patients were from one health center. Some patients may have obtained CRC screening outside our system.

CONCLUSIONS

A culturally tailored, language-concordant navigator program designed to identify and overcome barriers to colorectal cancer screening can significantly improve colonoscopy rates for low income, ethnically and linguistically diverse patients. ClinicalTrials.gov registration number: NCT00476970.

Ethnicity and gestational diabetes in New York City, 1995-2003

OBJECTIVE

To characterise the patterns of occurrence of gestational diabetes among a wide range of ethnic groups that reside in New York City.

DESIGN

Birth records and hospital discharge data were linked to more accurately assess the risk of gestational diabetes by ethnicity, compare risk in US-born to foreign-born women, and assess time trends.

SETTING

New York City.

POPULATION

All singleton live births occurring between 1995 and 2003.

METHODS

Multivariable binomial regression analysis of ethnicity and gestational diabetes, yielding adjusted risk ratios with non-Hispanic white women as the referent.

MAIN OUTCOME MEASURE

Diagnosis of gestational diabetes on birth certificate or in hospital discharge.

RESULTS

Adjusted relative risks (aRRs) were modestly elevated for African-Americans and sub-Saharan Africans and somewhat higher (<2.0) for non-Hispanic Caribbeans, Hispanic Caribbeans, Central Americans, and South Americans. The aRR was 4.7 (95% CI = 4.6-4.9) for South Central Asians (with an absolute gestational diabetes risk of 14.3%), 2.8 (95% CI = 2.7-3.0) among South-East Asian and Pacific Islanders, and 2.3 (95% CI = 2.2-2.4) among East Asians. Among South Central Asians, the greatest risks were found for women from Bangladesh (aRR = 7.1, 95% CI = 6.8-7.3). Foreign-born women consistently had higher risk than US-born women. Risk for gestational diabetes increased over time among South Central Asians, some Hispanic groups, and African-Americans.

CONCLUSIONS

Risk of gestational diabetes appears to vary markedly among ethnic groups, subject to potential artefacts associated with screening and diagnosis. These differences would have direct implications for health care and may suggest aetiologic hypotheses.

Health emigration: a challenge in paediatric oncology

For the past 10 years European states have experienced an increasing flow of emigrating families from developing countries seeking better medical care for their sick children. For Italian paediatricians this has become a new challenge, considering the cultural differences in customs regarding the illness. The onset of a life-threatening disease has a strong impact on the family. The natural bond between the patient and the family must be preserved and strengthened; parents should be encouraged to entertain their child during hospitalization. The inclusion of art therapy may facilitate communication, especially for children of a different language and culture. This approach can help medical staff to understand better both the child's and the parents' anxieties and feelings. This article discusses facets of the now well-known phenomenon of ;health emigration', that is, when a family searches abroad in the hope of finding the most advanced medical treatment possible for their sick child.

Crossing borders, crossing cultures: barriers to communication about cancer prevention and treatment along the U.S./Mexico border

OBJECTIVE

To describe cultural barriers to cancer prevention and treatment efforts among Latinos living along the U.S./Mexico border.

METHODS

In-depth interviews with 8 Mexican immigrants who are residents of a Texas colonia were conducted to understand the roles of culture and poverty in their experiences with cancer. Questions were asked about participants' cancer experiences, religiosity, medical establishment barriers, and cultural identity. Narrative and thematic analysis was used to highlight dialectical tensions inherent in the stories.

RESULTS

The participants' narratives illustrate how poverty and Latino cultural beliefs create barriers to effective cancer prevention and treatment based on: (1) metaphysical beliefs about how they developed cancer and religious beliefs about how it was cured; (2) gender identity and treatment in the U.S. medical system and; (3) national/cultural identity and treatment in the U.S. medical system.

CONCLUSION

Structural and cultural barriers interact in complex ways as low-income Latino/a patients and their families attempt to receive cancer care on the U.S./Mexico border. The manner in which these patients negotiate the tensions may reinforce barriers and inability to access health care and should be specifically addressed.

PRACTICE IMPLICATIONS

Immigrant populations worldwide are especially vulnerable to health care disparities. Effective cancer prevention and treatment messages must be constructed to help patients and families reconcile cultural and economic tensions in ways that allow them maintain their identities but still receive the necessary health care.

Oral health disparities in the United States

Oral health disparities refers to the existence of differences in the incidence, prevalence, mortality, and burden of oral diseases and other adverse health conditions, as well as the use of health care services, among specific population groups in the United States. Existence of disparities in oral health status, accessing and using the oral health care delivery system, and receiving treatment depending on gender, race or ethnicity, education, income, disability, geographic location, and sexual orientation have been documented. Different states have initiated a series of steps as tools to document, assess, develop strategies, and monitor progress in efforts to eliminate or reduce oral health disparities in the United States.