Adherence of low-income women to cancer screening recommendations

Tumors, Treatments, and Trust: Cancer Characteristics, Outcomes, and Screening Uptake in Transgender and Gender-Diverse Patients

BACKGROUND

More than 2.5 million adults in the United States identify as transgender or gender-diverse (TGD), but little data exist on cancer screening and care for this population. We examined cancer characteristics, screening adherence, genetic testing, and provider inclusive language for TGD patients with cancer.

METHODS

This single institution retrospective cohort study identified TGD patients with cancer between 2000 and 2022. Demographic, clinicopathological, treatment, and screening data were collected, as well as data on gender-affirming care (GAC) and use of patients' personal pronouns in medical records. Descriptive statistics and regression analyses were used to report outcomes.

RESULTS

Sixty unique patients with 69 cancer diagnoses were included: 63.3% were transgender women, 21.7% transgender men, 6.7% nonbinary, and 8.3% were genderqueer. Sixty-five percent had a family history of cancer. Only 46.2% of those who met genetic testing criteria were referred. On review of recommended cancer screening, colorectal screening had the greatest uptake (62%), followed by breast (48.3%), lung (35.7%), cervical (33.3%), and prostate (32%); 8.5% of cancers were diagnosed on screening. Individuals with Medicare had reduced odds of screening uptake (OR 0.07, 95% CI 0.01-0.58) versus private insurance. With respect to GAC, 73.3% used gender-affirming hormone therapy and 41% had gender-affirming surgery. After initiating GAC and asserting personal pronouns, 75% were referred to by incorrect name/pronouns in provider documentation.

CONCLUSIONS

Our TGD cancer patient cohort had low rates of disease-specific cancer screening and inadequate genetic referrals. Many providers did not use appropriate patient names/pronouns. Provider and patient interventions are needed to ensure inclusive preventative and oncologic care for this marginalized population.

The Impact of COVID-19 on Breast Cancer Care: A Qualitative Analysis of Surgeons' Perspectives

INTRODUCTION

While studies have documented delays in breast cancer (BC) care during the COVID-19 pandemic due to healthcare restrictions, there have been no studies on the experiences, and, particularly, the challenges with providing care faced by breast surgeons during this unprecedented time. This paper aims to understand the perspectives of breast surgeons regarding the impact of the COVID-19 pandemic on BC care.

METHODS

We used purposeful and snowball sampling to identify breast surgeons in Ontario, Canada. One-on-one qualitative semi-structured interviews were conducted exploring the impact of the pandemic on BC treatment, psychosocial well-being of patients and providers, and the future state of BC care. Audio-recorded interviews were transcribed verbatim and analyzed using Thematic Analysis.

RESULTS

A total of 10 breast surgeons (5 community and 5 academic) were interviewed. Breast surgeons reported that the pandemic led to increased multidisciplinary collaboration and innovations in delivery of BC surgery (e.g., increased use of regional anesthesia). Multiple surgeons identified that the pandemic created disparities in BC care based geographic location and that existing disparities in care based on ethnicity or marginalization were exacerbated. Last, surgeons identified that virtual care improved, but also created some challenges to how BC care was delivered, with many hoping for this to be continued after the pandemic was over.

CONCLUSIONS

In this study, breast surgeons identified unique challenges and solutions to BC care delivery during the pandemic. Concerns regarding disparities in care based on geographic location and marginalized patients require further study to improve future BC care.

Effect of Clinician Posture on Patient Perceptions of Communication in the Inpatient Setting: A Systematic Review

BACKGROUND

Nonverbal communication plays a pivotal role in the provision of effective patient care and has been associated with important patient health outcomes. Clinician posture, a nonverbal form of communication, may influence the patient experience and satisfaction. The relationship between clinician posture (i.e., standing or at the patient's eye level) and patient perceptions of clinician communication in the hospital-a setting with heightened power dynamics between patient and clinician-is currently unknown.

METHODS

We conducted searches of Ovid MEDLINE, EBSCO CINAHL Complete, EBSCO PsycInfo, Elsevier Embase/Embase Classic, Elsevier Scopus, and Web of Science Core Collection up to May 2023. English language studies were included if they compared clinician posture (eye-level or standing) during adult inpatient (including emergency department) interactions. Two authors independently abstracted data from included studies and assessed risk of bias or quality of evidence. A third author arbitrated any disagreements. Studies reported adherence to the posture intervention and/or patient perception outcomes. The latter included encounter duration, preferences for posture type, perceptions of interaction quality and clinician communication and compassion, and standardized assessments of patient satisfaction.

RESULTS

Fourteen studies (six randomized controlled trials, four quasi-experimental studies, four observational studies) assessed clinician posture at the bedside. Ten noted at least one favorable outcome for clinicians who communicated at the patient's eye level, three revealed no differences in patient perceptions between standing and sitting, and one noted higher patient ratings for standing clinicians. Findings were limited by variation in interventions and outcomes, generally high risk of bias, and relatively low adherence to assigned posture groups.

DISCUSSION

Compared to standing, eye-level communication by clinicians appears beneficial. The magnitude and types of benefits clinicians and patients may gain from this behavior remain unclear given heterogeneity and generally high risk of bias in available studies. With its relatively easy implementation and potential for benefit, clinicians should consider communicating with their hospitalized patients at eye level.

REGISTRATION

PROSPERO, CRD42020199817.

Patient Perspectives Regarding Healthcare Professional Attire

Introduction Physician attire has been shown to influence patients' impression of their healthcare provider. Scrubs and formal office attire are interchangeably worn by physicians. This study aimed to determine differences in scrubs and formal office attire on patient perceptions of professionalism, friendliness, aptitude, and empathy. Methods A single-center questionnaire study was conducted and a total of 150 patients were included. Patients were recruited from the inpatient and outpatient settings. Patients completed a questionnaire in which they rated 22 photographs. The photographs comprised a series of randomly arranged vignettes, with each participating physician appearing twice - once in formal office attire, once in scrubs. The physicians served as their own controls. Patients were asked to rate the depicted physicians based on the following four criteria - professionalism, friendliness, aptitude, and empathy. Each criterion was rated on an 11-point scale (0-10). Comprehensive demographic information, including age, gender, and race, was collected. Results A total of 150 responses were collected (50 inpatient and 50 orthopaedic surgery outpatient, 50 general medicine outpatient). Scrubs were rated significantly higher than formal office attire in all domains: professionalism [mean 7.52 (SD 1.95) vs. 6.69 (SD 2.38), p< 0.001], friendliness [mean 7.54 (SD 1.86) vs. 6.87 (SD 2.23), p< 0.001], aptitude [mean 7.44 (SD 1.99) vs. 6.72 (SD 2.36), p < 0.001] and empathy [mean 7.36 (SD 2.01) vs. 6.71 (SD 2.36), p < 0.001]. The perceived age of the physician did not affect any of the domain scores. Female physicians scored poorer in professionalism [mean 6.95 (SD 2.30) vs. 7.20 (SD 2.16), p < 0.05] compared to male physicians, but this difference resolved when analyzing only physicians wearing Scrubs.  Conclusion Patients view physicians in scrubs as having higher professionalism, friendliness, aptitude, and empathy as compared to physicians in formal office attire. Physicians should don standardized colored scrubs with a prominent name tag to improve patient perceptions.

Disparity in Breast Cancer Care: Current State of Access to Screening, Genetic Testing, Oncofertility, and Reconstruction

Breast cancer is the most common cancer diagnosed in women, accounting for an estimated 30% of all new cancer diagnoses in women in 2022. Advances in breast cancer treatment have reduced the mortality rate over the past 25 years by up to 34% but not all groups have benefitted equally from these improvements. These disparities span the continuum of care from screening to the receipt of guideline-concordant therapy and survivorship. At the 2022 American College of Surgeons Clinical Congress, a panel session was dedicated to educating and discussing methods of addressing these disparities in a coordinated manner. While there are multilevel solutions to address these disparities, this article focuses on screening, genetic testing, reconstruction, and oncofertility.

Prevalence, correlates, and sources of women's health information-seeking behaviors in the United States

OBJECTIVE

To investigate the prevalence, correlates, and sources of women's health information-seeking behaviors in the United States using the Andersen Behavioral Model.

METHODS

The 2012-2019 Health Information National Trends Survey data were used to analyze how and where women seek health theoretically. Weighted prevalence, descriptive analysis, and separate multivariable logistic regression models were computed to test the argument.

RESULTS

The overall prevalence of seeking health information from any source was (83%, 95% CI: 0.82-0.84). Between 2012 and 2019, the analysis revealed a downward trend in health information seeking from any source (85.2-82.4%), health care provider (19.0-14.8%), family/friends (10.4-6.6%), and traditional channels (5.4-4.8%). Interestingly, there was an increase in Internet usage from 65.4% to 73.8%.

CONCLUSIONS

We found statistically significant relationships between the predisposing, enabling, and need factors of the Andersen Behavioral Model. Specifically, age, race/ethnicity, income levels, educational status, perceived health status, having a regular provider, and smoking status predicted women's health information-seeking behaviors.

PRACTICE IMPLICATIONS

Our study concludes that several factors influence health information-seeking behaviors, and disparities exist in the channels through which women seek care. The implications for health communication strategies, practitioners, and policymakers are also discussed.

Colorectal cancer screening completion by patients due or overdue for screening after reminders: a retrospective study

BACKGROUND

Patient and clinician reminders were implemented as part of an adherence improvement project at University of Florida (UF) Internal Medicine Clinics. We sought to assess colorectal cancer (CRC) screening completion rates among patients not up-to-date with screening following distribution of reminders and to identify characteristics correlated with screening outcomes.

METHODS

Retrospective chart review was performed for patients not up-to-date with CRC screening for whom at least one reminder (patient and/or clinician) was issued in June 2018. The primary endpoint, the completion of a CRC screening test, is characterized as the ratio of completed screening tests to the number of patients not up-to-date with screening. All analyses were performed using R 4.0 software.

RESULTS

Of the 926 patients included, 403 (44%; 95% CI, 0.40-0.47) completed a CRC screening test within 24 months following a reminder. Family history of CRC (relative risk (RR) 1.33; P = 0.007), flu immunization within two years of the reminder (RR 1.23; P = 0.019), and receiving a patient reminder either alone (RR 1.62; P < 0.001) or in combination with a clinician reminder (RR 1.55; P = 0.006) were positively associated with CRC screening completion. Reporting being divorced, separated, or widowed was negatively associated with screening completion (RR 0.70; P = 0.004).

CONCLUSION

Reminders, in particular patient reminders, seem to be an effective method to enhance screening among patients not up-to-date with CRC screening. This study suggests that reminder efforts should be focused at the level of the patients and provides insight on target populations for practical interventions to further increase CRC screening adherence.

Damaged Masculinity: How Honor Endorsement Can Influence Prostate Cancer Screening Decision-Making and Prostate Cancer Mortality Rates

Prior research has established factors that contribute to the likelihood that men seek out prostate cancer screenings. The current study addresses how endorsing the ideology found in cultures of honor may serve as a barrier to prostate cancer screenings. Two studies were conducted which analyzed the impact of stigma on men's decisions to seek out prostate cancer screenings (Study 1) as well as how prostate cancer deaths may be higher in the culture of honor regions due to men's reticence to seek out screenings (Study 2). Results suggest that older, honor-endorsing men are less likely to have ever sought out a prostate cancer screening due to screening stigma and that an honor-oriented region (southern and western United States) displays higher rates of prostate cancer death than a non-honor-oriented region (northern United States). These findings suggest that honor may be a cultural framework to consider when practitioners address patients' screening-related concerns.

The Puerto Rico Community Cancer Control Outreach Program: Developing Capacity-Building Activities on Cancer Screening Guidelines and HPV Vaccination Recommendations for Health Care Professionals

OBJECTIVE

This study evaluated physicians' knowledge of cancer screening guidelines and human papillomavirus (HPV) recommendations.

METHODS

The Puerto Rico Community Cancer Control Outreach Program in collaboration with the Comprehensive Cancer Control Program and the Breast and Cervical Cancer Early Detection Program developed an educational activity for physicians who attended a professional annual meeting. This activity consisted of 2 sessions: one about cancer screening guidelines and the other about HPV and HPV vaccination. A survey measuring the attendees' knowledge of the session topics was administered before and after each session. Changes in knowledge were assesed using McNemar's test with a significance level of 0.05.

RESULTS

A total of 43 physicians responded to the survey about cancer screening, and 67 responded to the survey about HPV. A significant increase in the mean score of the pre-test (3.3 ± 1.42) and post-test (6.7 ± 1.38) of the cancer screening guidelines was observed as well as in that of the pre-test (7.82 ± 1.44) and post-test (9.66 ± 0.53) of HPV. The results showed that there were improvements regarding the most recent cervical cancer screening and colonoscopy guidelines as well as in the knowledge of HPV serotypes.

CONCLUSION

This mid-day educational activity significantly improved knowledge among primary care physicians. Given its feasibility, future efforts should discuss the most recent cancer guidelines and emerging socio behavioral factors that impact vaccination.

International patient preferences for physician attire: results from cross-sectional studies in four countries across three continents

OBJECTIVE

The patient-physician relationship impacts patients' experiences and health outcomes. Physician attire is a form of nonverbal communication that influences this relationship. Prior studies examining attire preferences suffered from heterogeneous measurement and limited context. We thus performed a multicentre, cross-sectional study using a standardised survey instrument to compare patient preferences for physician dress in international settings.

SETTING

20 hospitals and healthcare practices in Italy, Japan, Switzerland and the USA.

PARTICIPANTS

Convenience sample of 9171 adult patients receiving care in academic hospitals, general medicine clinics, specialty clinics and ophthalmology practices.

PRIMARY AND SECONDARY OUTCOME MEASURES

The survey was randomised and included photographs of a male or female physician dressed in assorted forms of attire. The primary outcome measure was attire preference, comprised of composite ratings across five domains: how knowledgeable, trustworthy, caring and approachable the physician appeared, and how comfortable the respondent felt. Secondary outcome measures included variation in preferences by country, physician type and respondent characteristics.

RESULTS

The highest rated forms of attire differed by country, although each most preferred attire with white coat. Low ratings were conferred on attire extremes (casual and business suit). Preferences were more uniform for certain physician types. For example, among all respondents, scrubs garnered the highest rating for emergency department physicians (44.2%) and surgeons (42.4%). However, attire preferences diverged for primary care and hospital physicians. All types of formal attire were more strongly preferred in the USA than elsewhere. Respondent age influenced preferences in Japan and the USA only.

CONCLUSIONS

Patients across a myriad of geographies, settings and demographics harbour specific preferences for physician attire. Some preferences are nearly universal, whereas others vary substantially. As a one-size-fits-all dress policy is unlikely to reflect patient desires and expectations, a tailored approach should be sought that attempts to match attire to clinical context.

Comprehensiveness of care for women with depression: Association between primary care use and cervical cancer screening

OBJECTIVE

To explore comprehensiveness of care in patients with depression by examining associations between a diagnosis of depression, frequency of primary care visits, and Papanicolaou test completion.

DESIGN

Cross-sectional retrospective survey using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network.

SETTING

Primary care practices in Ontario.

PARTICIPANTS

Women aged 21 to 69 eligible to receive Pap tests in 2015.

MAIN OUTCOME MEASURES

Associations between 2 predictors (depression and number of primary care visits in 2015) and Pap test completion were measured.

RESULTS

Overall, 125,258 women were included: 20.5% completed a Pap test and 16.4% had a diagnosis of depression. Having a diagnosis of depression was associated with lower likelihood of Pap test completion (adjusted odds ratio [AOR]=0.92, 95% CI 0.88 to 0.95). A greater number of primary care visits was associated with a higher likelihood of Pap test completion; this association was stronger in women with a diagnosis of depression (AOR=4.9, 95% CI 4.16 to 5.69) than in those without (AOR=3.4, 95% CI 3.25 to 3.60).

CONCLUSION

While depression was associated with fewer completed Pap tests, women with depression who saw their family doctors more often were more likely to be screened for cervical cancer. More primary care visits for depression treatment may be associated with an improved likelihood of screening for cervical cancer.

An evaluation of an Extension for Community Healthcare Outcomes (ECHO) intervention in cancer prevention and survivorship care

To improve cancer care in Indiana, a telementoring program using the Extension for Community Healthcare Outcomes (ECHO) model was introduced in September 2019 to promote best-practice cancer prevention, screening, and survivorship care by primary care providers (PCPs). The aim of this study was to evaluate the program’s educational outcomes in its pilot year, using Moore’s Evaluation Framework for Continuing Medical Education and focusing on the program’s impact on participants’ knowledge, confidence, and professional practice. We collected data in 22 semi-structured interviews (13 PCPs and 9 non-PCPs) and 30 anonymous one-time surveys (14 PCPs and 16 non-PCPs) from the program participants (hub and spoke site members), as well as from members of the target audience who did not participate. In the first year, average attendance at each session was 2.5 PCPs and 12 non-PCP professionals. In spite of a relatively low PCP participation, the program received very positive satisfaction scores, and participants reported improvements in knowledge, confidence, and practice. Both program participants and target audience respondents particularly valued three features of the program: its conversational format, the real-life experiences gained, and the support received from a professional interdisciplinary community. PCPs reported preferring case discussions over didactics. Our results suggest that the Cancer ECHO program has benefits over other PCP-targetted cancer control interventions and could be an effective educational means of improving cancer control capacity among PCPs and others. Further study is warranted to explain the discrepancies among study participants’ perceptions of the program’s strengths and the relatively low PCP participation before undertaking a full-scale effectiveness study.

The effect of blister packaging Iron and Folate on adherence to medication and hemoglobin levels among pregnant women at National Referral Hospital antenatal clinics in a low to middle income country: a Randomised Controlled Trial (The IFAd Trial)

Introduction

Anemia in pregnancy is an important global public health problem. It is estimated that 38% of pregnant women worldwide are anemic. In Africa, literature from observational studies show 20% of maternal deaths are attributed to anemia. In Uganda, 50% of pregnant women have iron deficiency anaemia. The proportion of pregnant women receiving Iron-Folic acid (IFA) supplementation has improved. However, the number of IFA pills consumed is still low. We carried out a randomized controlled trial to determine the effect of dispensing blister and loose packaged IFA pills on adherence measured by count on next return visit and hemoglobin levels among pregnant women at two National Referral Hospitals in Kampala, Uganda.

Methods

This trial was conducted between April and October 2016. Nine hundred fifty pregnant women at ≤28 weeks were randomized to either the blister (intervention arm) or loose (control arm) packaged IFA. The participants completed the baseline measurements and received 30 pills of IFA at enrolment to swallow one pill per day. We assessed adherence by pill count and measured hemoglobin at four and 8 weeks. The results were presented using both intention-to-treat and per-protocol analysis.

Results

There were 474 participants in the control and 478 in the intervention arms. Adherence to IFA intake was similar in the two groups at 4th week (40.6 and 39.0%, p = 0.624) and 8th week (51.9 and 46.8%, p = 0.119). The mean hemoglobin level at 4 weeks was higher in the blister than in the loose packaging arms (11.9 + 1.1 g/dl and 11.8 + 1.3 g/dl, respectively; p = 0.02), however, similar at week 8 (12.1 + 1.2 and 12.0 + 1.3, respectively; p = 0.23). However, over the 8-week period blister packaging arm had a higher change in hemoglobin level compared to loose package (blister package 0.6 ± 1.0; loose packaging 0.2 ± 1.1; difference: 0.4 g/dL (95% CI: 0.24–0.51 g/dL); p = 0.001. There were no serious adverse events.

Conclusions

Our results showed no effect of blister packaging on IFA adherence among pregnant women. However, our findings showed that blister packaged group had a higher hemoglobin increase compared to loose iron group.

Trial registration

No. PACTR201707002436264 (20 /07/ 2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04507-3.

Determinants of mammography screening in Iranian women: A systematic review and meta-analysis

BACKGROUND

Mammography is the most effective method for early detection of breast cancer (BC), however, it has performed in low-level. The aim of this study was to investigate the determinants of mammography in Iran.

METHODS

This study was a systematic review which was performed based on articles published in both Persian and English languages among Iranian patients in the period of 2000 to 2020 by using keywords of "Iran and mammography". Papers were selected from national databases including (SID, Magiran) and international database including (Scopus, PubMed and web of science), finally related articles to mammography were reviewed.

RESULTS

Findings indicated that 35-50% of breast cancer can be detected in the early stages by mammography, however, it is in low rate of performance among Iranian women. Age, age of menarche, occupation, family history, marital status, family support, number of pregnancies, physician recommendations, perceived sensibility and severity, self-efficacy and perceived benefits are the most important predictors of performing mammography in Iran.

CONCLUSION

Due to the growing trend of breast cancer cases in the country and low mammography rates in Iranian population, high risk groups such as women with BC family history, low income level, low education level, older age and people with history of breast complications were more emphasized for performing mammography through health centers. Therefore, appropriate planning to reduce the barriers of mammography could be helpful.

Exploring Barriers and Facilitators of Adherence to Artemisinin-Based Combination Therapies for the Treatment of Uncomplicated Malaria in Children in Freetown, Sierra Leone

Medication adherence is an essential step in the malaria treatment cascade. We conducted a qualitative study embedded within a randomized controlled trial comparing the adherence to the recommended dosing of two artemisinin-based combination therapies (ACT) to treat uncomplicated malaria in Freetown, Sierra Leone. This study explored the circumstances and factors that influenced caregiver adherence to the ACT prescribed for their child in the trial. In-depth interviews were conducted with 49 caregivers; all interviews were recorded, transcribed, and translated. Transcripts were coded and aggregated into themes, applying a thematic content approach. We identified four key factors that influenced optimal treatment adherence: (1) health system influences, (2) health services, (3) caregivers' experiences with malaria illness and treatment, and (4) medication characteristics. Specifically, caregivers reported confidence in the health system as facilities were well maintained and care was free. They also felt that health workers provided quality care, leading them to trust the health workers and believe the test results. Ease of medication administration and perceived risk of side effects coupled with caregivers' prior experience treating malaria influenced how medications were administered. To ensure ACTs achieve maximum effectiveness, consideration of these contextual factors and further development of child-friendly antimalarials are needed.

Colorectal Cancer Screening Prevalence and Adherence for the Cancer Prevention Project of Philadelphia (CAP3) Participants Who Self-Identify as Black

INTRODUCTION

Colorectal cancer is the third leading cause of cancer-related deaths among Black men and women. While colorectal cancer screening (CRCS) reduces mortality, research assessing within race CRCS differences is lacking. This study assessed CRCS prevalence and adherence to national screening recommendations and the association of region of birth with CRCS adherence, within a diverse Black population.

METHODS

Data from age-eligible adults, 50-75 years, (N = 357) participating in an ongoing, cross-sectional study, was used to measure CRCS prevalence and adherence and region of birth (e.g., Caribbean-, African-, US-born). Prevalence and adherence were based on contemporaneous US Preventive Services Task Force guidelines. Descriptive statistics were calculated and adjusted prevalence and adherence proportions were calculated by region of birth. Adjusted logistic regression models were performed to assess the association between region of birth and overall CRCS and modality-specific adherence.

RESULTS

Respondents were 69.5% female, 43.3% married/living with partner, and 38.4% had <$25,000 annual income. Overall, 78.2% reported past CRCS; however, stool test had the lowest prevalence overall (34.6%). Caribbean (95.0%) and African immigrants (90.2%) had higher prevalence of overall CRCS compared to US-born Blacks (59.2%) (p-value <0.001). African immigrants were five times more likely to be adherent to overall CRCS compared to US-born Blacks (OR = 5.25, 95% CI 1.34-20.6). Immigrants had higher odds of being adherent to colonoscopy (Caribbean OR = 6.84, 95% CI 1.49-31.5; African OR = 7.14, 95% CI 1.27-40.3) compared to US-born Blacks.

CONCLUSIONS

While Caribbean and African immigrants have higher prevalence and adherence of CRCS when compared US-born Blacks, CRCS is still sub-optimal in the Black population. Efforts to increase CRCS, specifically stool testing, within the Black population are warranted, with targeted interventions geared towards US-born Blacks.

Kindness Media Rapidly Inspires Viewers and Increases Happiness, Calm, Gratitude, and Generosity in a Healthcare Setting

Background and Objectives: Stress is a ubiquitous aspect of modern life that affects both mental and physical health. Clinical care settings can be particularly stressful for both patients and providers. Kindness and compassion are buffers for the negative effects of stress, likely through strengthening positive interpersonal connection. In previous laboratory-based studies, simply watching kindness media uplifts (elevates) viewers, increases altruism, and promotes connection to others. The objective of the present study is to examine whether kindness media can affect viewers in a real-world, pediatric healthcare setting. Methods: Parents and staff in a pediatric dental clinic were studied. Study days were randomized for viewers to watch either original kindness media or the standard televised children's programming that the clinic shows. Participants scored self-rated pre-media emotions in a survey, watched either media type for 8 min, and then completed the survey. All participants were informed that they would receive a gift card for their participation. After completion of the survey, participants were asked if they wanted to keep the card or donate it to a family in need. Results: Fifty (50) participants completed the study; 28 were parents and 22 were staff. In comparison to viewers of children's programming, participants who watched kindness media had significant increases in feeling happy, calmer, more grateful, and less irritated (p < 0.05), with trends observed in feeling more optimistic and less anxious. Kindness media caused marked increases in viewers' reports of feeling inspired, moved, or touched (p < 0.001). No change was observed in self-reported compassion, although baseline levels were self-rated as very high. People who watched kindness media were also more generous, with 85% donating their honoraria compared to 54% of Standard viewers (p = 0.03). Conclusions: Kindness media can increase positive emotions and promote generosity in a healthcare setting.

Temporal trends and regional disparities in cancer screening utilization: an observational Swiss claims-based study

Background

We examined colorectal, breast, and prostate cancer screening utilization in eligible populations within three data cross-sections, and identified factors potentially modifying cancer screening utilization in Swiss adults.

Methods

The study is based on health insurance claims data of the Helsana Group. The Helsana Group is one of the largest health insurers in Switzerland, insuring approximately 15% of the entire Swiss population across all regions and age groups. We assessed proportions of the eligible populations receiving colonoscopy/fecal occult blood testing (FOBT), mammography, or prostate-specific antigen (PSA) testing in the years 2014, 2016, and 2018, and calculated average marginal effects of individual, temporal, regional, insurance-, supply-, and system-related variables on testing utilization using logistic regression.

Results

Overall, 8.3% of the eligible population received colonoscopy/FOBT in 2014, 8.9% in 2016, and 9.2% in 2018. In these years, 20.9, 21.2, and 20.4% of the eligible female population received mammography, and 30.5, 31.1, and 31.8% of the eligible male population had PSA testing. Adjusted testing utilization varied little between 2014 and 2018; there was an increasing trend of 0.8% (0.6–1.0%) for colonoscopy/FOBT and of 0.5% (0.2–0.8%) for PSA testing, while mammography use decreased by 1.5% (1.2–1.7%). Generally, testing utilization was higher in French-speaking and Italian-speaking compared to German-speaking region for all screening types. Cantonal programs for breast cancer screening were associated with an increase of 7.1% in mammography utilization. In contrast, a high density of relevant specialist physicians showed null or even negative associations with screening utilization.

Conclusions

Variation in cancer screening utilization was modest over time, but considerable between regions. Regional variation was highest for mammography use where recommendations are debated most controversially, and the implementation of programs differed the most.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10079-8.

Using Intervention Mapping to Develop Health Education and Health Policy Components to Increase Breast Cancer Screening and Chemotherapy Adherence Among Syrian and Iraqi Refugee Women in Beirut, Lebanon

Introduction: Despite the continuous increase in the incidence of metastatic breast cancer among Syrian and Iraqi refugee women residing in camp settings in Lebanon, mammography and chemotherapy adherence rates remain low due to multiple social, economic, and environmental interfering factors. This in turn led to an alarming increase in breast cancer morbidity and mortality rates among the disadvantaged population. Methods: Intervention mapping, a systematic approach which guides researchers and public health experts in the development of comprehensive evidence-based interventions (EBIs) was used to plan a health education and health policy intervention to increase breast cancer screening and chemotherapy adherence among Iraqi and Syrian refugee women aged 30 and older who are residing in refugee camps within the Beirut district of Lebanon. Results: The generation of the logic model during the needs assessment phase was guided by an extensive review of the literature and reports published in peer-reviewed journals or by international/local organizations in the country to determine breast cancer incidence and mortality rates among refugee women of Syrian and Iraqi nationalities. The underlying behavioral and environmental determinants of the disease were identified from qualitative and quantitative studies carried out among the target population and also aided in assessing the sub-behaviors related to the determinants of breast cancer screening and chemotherapy completion as well as factors affecting policy execution to formulate performance objectives. We then developed matrices of change objectives and their respective methods and practical applications for behavior change at the intrapersonal, interpersonal, organizational, and societal levels. Both educational components (brochures, flyers) and technological methods (videos disseminated via Whats app and Facebook) will be adopted to apply the different methods selected (modeling, self-reevaluation, consciousness raising, persuasion, and tailoring). We also described the development of the educational and technological tools, in addition to providing future implementers with methods for pre-testing and pilot-testing of individual and environmental prototype components. Conclusion: The use of intervention mapping in the planning and implementation of holistic health promotion interventions based on information collected from published literature, case reports, and theory can integrate the multiple disciplines of public health to attain the desired behavioral change.

Patient Preferences for Physician Attire: A Multicenter Study in Japan

BACKGROUND

Previous studies have shown that patients have specific expectations regarding physician dress. Japan has a cultural background that is in many ways distinct from western countries. Thus, physician attire may have a different impact in Japan.

METHODS

We conducted a multicenter, cross-sectional study to examine patients' preferences for and perceptions of physician attire in Japan. The questionnaire was developed using photographs of either a male or female physician dressed in seven different forms of attire, and it was randomly distributed to inpatients and outpatients. Respondents were asked to rate the provider pictured; they were also asked to provide preferences for different forms of attire in varied clinical settings. Preference was evaluated for five domains (knowledgeable, trustworthy, caring, approachable, and comfortable). We also assessed variation in preferences for attire by respondent characteristics.

RESULTS

A total of 1,233 (61%) patients indicated that physician dress was important, and 950 (47%) patients agreed that it influenced their satisfaction with care. Compared with all forms, casual attire with a white coat was the most preferred dress. Older patients more often preferred formal attire with a white coat in primary care and hospital settings. In addition, physician attire had a greater impact on older respondents' satisfaction and experience.

CONCLUSION

The majority of Japanese patients indicated that physician attire is important and influenced their satisfaction with care. Geography, settings of care, and patient age appear to play a role in patient preferences.

The roles of clinical audit and test sets in promoting the quality of breast screening: a scoping review

Breast screening programmes enhance the probability of early breast cancer detection in many countries worldwide; however, the success of these efforts is highly dependent on the ability of breast screen readers to detect abnormalities in the screened population, which has low prevalence. Therefore, this task can be challenging. Clinical audit is a key quality assurance measure that aims to keep the screen reading performance within acceptable standards. Auditing, nonetheless, is a lengthy process, and its accuracy is dependent on available clinical data, which often can be limited. Mammographic standardised test sets are a different screen reading evaluation approach that provides participants with instant feedback based on a simulated environment. Although a test set provides unique evaluative qualities, its ability to represent clinical performance is debated. This article describes the distinctive roles of clinical audit and test sets in measuring and improving the quality of breast screening and highlights the relationship between test sets and clinical performance.

Is Adherence to a Gluten-Free Diet by Adult Patients With Celiac Disease Influenced by Their Knowledge of the Gluten Content of Foods?

The aim of this study was to investigate adherence to a gluten-free diet and potentially associated factors, focusing on the relationship between adherence and knowledge of the gluten content of foods and of celiac disease in general. A questionnaire was completed by adult patients diagnosed with celiac disease including demographics, dietary practices, sources of information, and attitude to the disease. Their knowledge of disease and gluten-free diet was assessed using a newly developed scale comprising 31 statements on celiac disease in general and foods appropriate in a gluten-free diet. A validated questionnaire was used to measure adherence to diet. One hundred four patients with celiac disease took part in the study, 65% of them reported strictly adhering to a gluten-free diet. Factors associated with adherence were membership of the Italian Celiac Association and receiving support from this association, Internet, and social media. Patients' knowledge regarding celiac disease and gluten-free diet was generally poor: one patient answered all questions correctly. Knowledge of celiac disease and gluten-free diet was strongly and significantly associated with adherence to a gluten-free diet. The association between knowledge of celiac disease and gluten-free diet in patients with celiac disease and their adherence to the diet suggests the promotion of education and behavioral programs.

Public's perception and satisfaction on the role and services provided by family physicians in Saudi Arabia: A cross-sectional study

Background

Few studies have addressed the awareness of the family physicians' (FPs) role and its impact on the quality of primary healthcare. This study aims to explore public's perception and satisfaction on the role and services provided by FPs in the Kingdom of Saudi Arabia (KSA).

Materials and Methods

An online survey was conducted using a convenience sample of 830 participants age 18 years and above from Jazan region, KSA. Statistical analysis was done using SPSS including descriptive studies and Chi-square or Fisher's exact test.

Results

A total of 830 valid responses were analyzed, of which 55.1% were females. The median age of respondents was 32.5 years (range 18-75 years). Most of the respondents (90.2%) did not have a regular FP. A considerable proportion of the participants were aware of the principles (81.2%) and essential role of family medicine (73.3%), health conditions that FPs can treat (59.9%), and conditions they do not treat (n = 622, 74.9%). The majority agreed on the value of involving FPs in their care (76.7%), the priority of FPs in the action of health-seeking (58.9%), and the sufficiency of FPs' expertise (55.5%). However, only 28.3% had a positive experience with FPs. In addition, 59.8% preferred to first seek healthcare from specialists from other specialties.

Conclusion

In general, participants in this study had good perception of the role of FPs as important components in the healthcare system. However, there may be some gaps in the physician-patient communication which may contribute to the dissatisfaction reported by most of the present sample.

Predictors of Cervical Cancer Screening Among Infrequently Screened Women Completing Human Papillomavirus Self-Collection: My Body My Test-1

Background: Approximately one-half of cervical cancer cases in the United States occur in underscreened or never-screened women. We examined predictors to completing Papanicolaou (Pap) testing and whether a positive human papillomavirus (HPV) self-collection result affects Pap testing adherence among underscreened women. Materials and Methods: Low-income women aged 30-65 years who reported no Pap testing in ≥4 years were recruited in North Carolina. Knowledge, attitudes, and barriers regarding cervical cancer and Pap testing were assessed by telephone questionnaires. We mailed self-collection kits for HPV testing and provided information regarding where to obtain affordable Pap testing. Participants received $45 for completing all activities. We used multivariable logistic regression to assess the predictors of longer reported time since last Pap (≥10 vs. 4-9 years) and of completion of Pap testing following study enrollment (follow-up Pap). Results: Participants (n = 230) were primarily black (55%), uninsured (64%), and with ≤high school education (59%). Cost and finding an affordable clinic were the most commonly reported barriers to screening. White women and those with ≤high school education reported longer intervals since last Pap test. Half of the participants reported completing a follow-up Pap test (55%). Women with a positive HPV self-collection were five times more likely to report completing a follow-up Pap test than those with negative self-collection (odds ratio = 5.1, 95% confidence interval 1.4-25.7). Conclusions: Improving awareness of resources for affordable screening could increase cervical cancer screening in underserved women. Home-based HPV self-collection represents an opportunity to re-engage infrequently screened women into preventive screening services.

Understanding patient preference for physician attire in ambulatory clinics: a cross-sectional observational study

OBJECTIVES

We explored patient perceptions regarding physician attire in different clinical contexts and resultant effects on the physician-patient relationship.

SETTING

The 900-bed University Hospital Zurich, Switzerland.

PARTICIPANTS

A convenience sample of patients receiving care in dermatology, infectious diseases and neurology ambulatory clinics of the University Hospital Zurich participated in a paper-based survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

The survey instrument was randomised and showed photographs of male or female physicians wearing various forms of attire. On the basis of the respondents' ratings of how the physician's attire affected perceptions across five domains (knowledgeable, trustworthy, caring, approachable and comfort with the physician), a composite preference score for attire was calculated as the primary outcome. Secondary outcomes included variation in preferences by respondent characteristics and context in which care was provided.

RESULTS

Of 834 patient respondents (140 in dermatology, 422 in infectious diseases and 272 in neurology), 298 (36%) agreed that physician attire was important. When compared with all available choices, the combination of white scrubs with white coat was rated highest while a business suit ranked lowest. Variation in preferences and opinions for attire were noted relative to respondent demographics and the clinical setting in which the survey was administered. For example, compared with younger patients, respondents ≥65 years of age more often reported that physician dress was both important to them and influenced how happy they were with their care (p=0.047 and p=0.001, respectively).

CONCLUSIONS

Outpatients at a large Swiss University hospital prefer their physicians to be dressed in white scrubs with white coat. Substantial variation among respondents based on demographics, type of physician and clinical setting were observed. Healthcare systems should consider context of care when defining policies related to dress code.

Patient Uncertainty as a Predictor of 30-day Return Emergency Department Visits: An Observational Study

OBJECTIVE

The objective was to examine the relationship between patient uncertainty at the time of emergency department (ED) discharge as measured by the "Uncertainty Scale" (U-Scale) and 30-day return ED visits. We hypothesized that a higher score on the U-Scale predicts a higher likelihood of a 30-day return ED visit.

METHODS

This was a cross-sectional single-site pilot study performed with adult patients discharged from an urban academic ED to assess the relationship of U-Scale total and subscale scores with 30-day return ED visits. We collected demographic and U-Scale scores at the time of ED discharge and subsequent 30-day ED utilization data by follow-up telephone call.

RESULTS

No association was found between the total U-Scale score and subsequent ED utilization. Patients with higher uncertainty on the Treatment Quality subscale of the U-Scale had higher odds of a 30-day return ED visit (adjusted odds ratio [AOR] = 1.16), while patients with lower uncertainty on the Decision to Seek Care subscale had higher odds of a 30-day return ED visit (AOR = 0.68).

CONCLUSION

Patient uncertainty as measured by the U-Scale total score was not predictive of subsequent ED utilization. However, uncertainty related to treatment quality and the decision to seek care as measured by the U-Scale subscales may be important in predicting repeat ED utilization. Unlike individual patient factors such as age and race that have been associated with frequent ED visits in prior studies, these domains of uncertainty are potentially modifiable. Providers and health systems may successfully prevent recurrent acute care encounters through implementation of interventions designed to address patient uncertainty. Further work is needed to refine the U-Scale and test its predictive utility among a larger patient cohort.

Health and Racial Disparity in Breast Cancer

Breast cancer is the most common noncutaneous malignancy and the second most lethal form of cancer among women in the United States. It currently affects more than one in ten women worldwide. The chance for a female to be diagnosed with breast cancer during her lifetime has significantly increased from 1 in 11 women in 1975 to 1 in 8 women (Altekruse, SEER Cancer Statistics Review, 1975-2007. National Cancer Institute, Bethesda, 2010). This chance for a female of being diagnosed with cancer generally increases with age (Howlader et al, SEER Cancer Statistics Review, 1975-2010. National Cancer Institute, Bethesda, 2013). Fortunately, the mortality rate from breast cancer has decreased in recent years due to increased emphasis on early detection and more effective treatments in the White population. Although the mortality rates have declined in some ethnic populations, the overall cancer incidence among African American and Hispanic population has continued to grow. The goal of the work presented in this book chapter is to highlight similarities and differences in breast cancer morbidity and mortality rates among non-Hispanic white and non-Hispanic black populations. This book chapter also provides an overview of breast cancer, racial/ethnic disparities in breast cancer, breast cancer incidence and mortality rate linked to hereditary, major risk factors of breast cancer among minority population, breast cancer treatment, and health disparity. A considerable amount of breast cancer treatment research have been conducted, but with limited success for African Americans compared to other ethnic groups. Therefore, new strategies and approaches are needed to promote breast cancer prevention, improve survival rates, reduce breast cancer mortality, and ultimately improve the health outcomes of racial/ethnic minorities. In addition, it is vital that leaders and medical professionals from minority population groups be represented in decision-making in research so that racial disparity in breast cancer can be well-studied, fully addressed, and ultimately eliminated in breast cancer.

Multilevel Predictors of Continued Adherence to Breast Cancer Screening Among Women Ages 50-74 Years in a Screening Population

Background: U.S. women of ages 50-74 years are recommended to receive screening mammography at least biennially. Our objective was to evaluate multilevel predictors of nonadherence among screened women, as these are not well known. Materials and Methods: A cohort study was conducted among women of ages 50-74 years with a screening mammogram in 2011 with a negative finding (Breast Imaging-Reporting and Data System 1 or 2) within Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium research centers. We evaluated the association between woman-level factors, radiology facility, and PROSPR research center, and nonadherence to breast cancer screening guidelines, defined as not receiving breast imaging within 27 months of an index screening mammogram. Multilevel mixed-effects logistic regression was used to calculate odds ratios and 95% confidence intervals. Results: Nonadherence to guideline-recommended screening interval was 15.5% among 51,241 women with a screening mammogram. Non-Hispanic Asian/Pacific Islander women, women of other races, heavier women, and women of ages 50-59 years had a greater odds of nonadherence. There was no association with ZIP code median income. Nonadherence varied by research center and radiology facility (variance = 0.10, standard error = 0.03). Adjusted radiology facility nonadherence rates ranged from 10.0% to 26.5%. One research center evaluated radiology facility communication practices for screening reminders and scheduling, but these were not associated with nonadherence. Conclusions: Breast cancer screening interval nonadherence rates in screened women varied across radiology facilities even after adjustment for woman-level characteristics and research center. Future studies should investigate other characteristics of facilities, practices, and health systems to determine factors integral to increasing continued adherence to breast cancer screening.

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

Identifying the Social Determinants of Breast Health Behavior: a Qualitative Content Analysis

Background: Prevention, early diagnosis and reduction of mortality caused by breast cancer are the priorities of the world health systems. The aim of this study was to identify the social factors that affect the women’s breast health behavior based on the social determinants model of the World Health Organization (WHO). Materials and Method: This qualitative study was conducted and analyzed using content analysis approach. The data were collected from 32 participants by semi-structured interviews and focused group discussion. The participants comprised of breast surgeons, radiologists, health care providers and women over 35 years of age in Tehran who were selected through purposeful sampling. The interviews continued until data saturation was reached. Results: Based on the experiences of the participants, three themes were obtained from the data that shaped the women’s breast health behavior, including 1) the context of health policy, 2) socioeconomic status, and 3) cultural, psychological, and behavioral factors. Conclusion: A better understanding of social determinants related to breast health behavior can be effective in designing and applying of appropriate theories and models of education and intervention, so that, by early diagnosis of breast cancer and timely treatment of patients, the disease complications and mortality would be reduced.

Understanding patient preference for physician attire: a cross-sectional observational study of 10 academic medical centres in the USA

OBJECTIVE

Several large studies have shown that improving the patient experience is associated with higher reported patient satisfaction, increased adherence to treatment and clinical outcomes. Whether physician attire can affect the patient experience-and how this influences satisfaction-is unknown. Therefore, we performed a national, cross-sectional study to examine patient perceptions, expectations and preferences regarding physicians dress.

SETTING

10 academic hospitals in the USA.

PARTICIPANTS

Convenience sample of 4062 patients recruited from 1 June 2015 to 31 October 2016.

PRIMARY AND SECONDARY OUTCOMES MEASURES

We conducted a questionnaire-based study of patients across 10 academic hospitals in the USA. The questionnaire included photographs of a male and female physician dressed in seven different forms of attire. Patients were asked to rate the provider pictured in various clinical settings. Preference for attire was calculated as the composite of responses across five domains (knowledgeable, trustworthy, caring, approachable and comfortable) via a standardised instrument. Secondary outcome measures included variation in preferences by respondent characteristics (eg, gender), context of care (eg, inpatient vs outpatient) and geographical region.

RESULTS

Of 4062 patient responses, 53% indicated that physician attire was important to them during care. Over one-third agreed that it influenced their satisfaction with care. Compared with all other forms of attire, formal attire with a white coat was most highly rated (p=0.001 vs scrubs with white coat; p<0.001 all other comparisons). Important differences in preferences for attire by clinical context and respondent characteristics were noted. For example, respondents≥65 years preferred formal attire with white coats (p<0.001) while scrubs were most preferred for surgeons.

CONCLUSIONS

Patients have important expectations and perceptions for physician dress that vary by context and region. Nuanced policies addressing physician dress code to improve patient satisfaction appear important.

Development and Application of the Lincoln Adherence Instrument Record for Assessing Client Adherence to Advice in Dog Behavior Consultations and Success

Adherence to the advice of medical practitioners is critical to successful treatment outcomes and has been much researched in human health, but is less well studied in the veterinary and clinical animal behavior fields. Given that the management of behavior problems often requires substantial change in established client behavior, it is likely that adherence is a substantive issue affecting success. However, little is known about the relationships between relevant factors, and there is no established way of assessing these. Therefore, the aim of this study was to develop an instrument for coding factors likely to impinge on pet owner adherence to behavior advice and validate its utility through the identification of the factors appearing to relate most closely to a successful treatment outcome in a sample population from our clinic. Potential factors affecting adherence were identified from human health and animal behavior studies, and a survey instrument developed with items matched to these factors. Forty-two dog owners who had attended the University of Lincoln Animal Behavior Clinic over a 2-year period provided data used in the analysis. The assessment of treatment outcome success by clients and clinicians was correlated, but clinicians tended to overestimate success by half a point on a 5-point scale. Eleven items relating to adherence were found to correlate with client ratings of treatment success in a univariate analysis, with three of these remaining in an ordinal logistic regression model. These three related to trust in the advice given by the clinician, concern over distress caused to the pet in the longer term and the perceived recommendation of treatment measures that had failed. By further examining the relationship between all of these factors in a hierarchical cluster analysis, we were able to postulate ways in which we might be able to improve client adherence and thus treatment success. This provides a model for the application of the instrument in any veterinary behavior practice wishing to use client feedback to rationalize areas of the consultation which might be improved.

Compliance of the recurrent renal stone former with current best practice guidelines

INTRODUCTION

Patient compliance to best practice guidelines is a significant factor in preventing renal stone recurrence. While patient compliance has been historically poor, there remains a paucity of data in the renal stone setting. We evaluated compliance of the recurrent renal stone former with current Canadian Urological Association (CUA) best practice guidelines.

METHODS

A prospective, cross-sectional study design was used to evaluate patient compliance. Recurrent renal stone former patients were consecutively recruited from McMaster's Institute of Urology and completed a one-time questionnaire developed in accordance with CUA best practice guidelines. Questionnaire sections included: 1) demographics; 2) interaction(s) and satisfaction with their healthcare provider; and 3) knowledge, attitudes, and compliance with best practices.

RESULTS

A total of 300 patients were enrolled in the study; 55.3% were men, 69.5% had a history of stone surgery, while 23.7% had a positive family history. Participants perceived satisfactory education from their urologist and primary care physician 82.7% and 59.7% of the time, respectively (p<0.05). Nearly a quarter of patients (22.8%) perceived their stone disease to be severe and 67.1% of patients believed in the efficacy of preventative stone measures. Overall, 45.8% of patients were compliant with CUA best practice guidelines. The majority of patients (72.6%) complied with high fluid intake, the most critical stone preventative practice.

CONCLUSIONS

Consistent with previous studies, compliance to dietary recommendations in this evaluation of recurrent stone formers was low. Study findings may be attributed to insufficient knowledge translation, lack of perceived disease severity, and/or patient uncertainty in the importance of preventative stone practices.

Perceptions of Cervical Cancer Screening, Screening Behavior, and Post-Migration Living Difficulties Among Bhutanese-Nepali Refugee Women in the United States

Bhutanese-Nepali refugees are one of the largest refugee groups to be resettled in the U.S. in the past decade. Cervical cancer is a leading cause of cancer disparity in this population, yet screening rates are suboptimal. Nepali-speaking interviewers administered a community health needs questionnaire to a convenience sample of Bhutanese-Nepali refugees in a Midwestern city between July to October of 2015. Descriptive statistics were used to describe socio-demographic characteristics, Pap smear beliefs, post-migration living difficulties, and screening status. Differences in Pap test uptake between groups were tested using t test and Chi square statistics. Of the 97 female participants, 44.3% reported ever having had a Pap smear. Screening rates were lowest among women who did not know English at all. Most women had positive perceptions of Pap smears (80%) and 44.4% had received a Pap test recommendation from their healthcare provider, family, or friends. Pap testing was significantly higher among those who had positive perceptions (58.3 vs. 11.1% for women of negative perception, p = 0.01) and those who had received a recommendation (87.5 vs. 18.6% for women who had no recommendations, p < 0.001). Significant predictors of having a Pap smear were having a healthcare provider/family/friends recommendation (OR 65.3, 95% CI 11.4-373.3) and greater number of post-migration living difficulties (OR 1.18, 95% CI 1.02-1.37). The results of this study have important implications for the development of cervical cancer prevention programs targeting Bhutanese-Nepali refugees. Providing cancer prevention interventions early in the resettlement process could impact Pap test uptake in this population.

The impact of improving access to primary care

OBJECTIVES

To measure the size and timing of changes in utilization and costs for employees and dependents who had major access barriers to primary care removed, across an 8-year period (2007 to 2014).

STUDY DESIGN AND METHODS

Retrospective observational study examining patterns of utilization and costs before and after the implementation of a worksite medical office in 2010. The worksite office offered convenient primary care services with no travel from work, essentially guaranteed same day access, and no co-pay. Trends in visit rates and costs were compared for an intervention fixed cohort group (employees and dependents) at the employer (n = 1211) with a control fixed cohort group (n = 542 162) for 6 types of visits (primary, urgent, emergency, inpatient, specialty, and other outpatient). Difference-in-differences methods assessed the significance of between-group changes in utilization and costs.

RESULTS

The worksite medical office intervention group had an increase in primary care visits relative to the control group (+43% vs +4%, P < 0.001). This was accompanied by a reduction in urgent care visits by the intervention group compared with the control group (-43% vs -5%, P < 0.001). There were no differences in the other types of visits, and the total visit costs for the intervention group increased 5.7% versus 2.7% for the control group (P = 0.008). A sub-group analysis of the intervention group (comparing dependents to employees) found that that the dependents achieved a reduction in costs of 2.7% (P < 0.001) across the study period.

CONCLUSIONS

The potential for long-term reduction in utilization and costs with better access to primary care is significant, but not easily nor automatically achieved.

Factors related to longitudinal adherence in colorectal cancer screening: qualitative research findings

BACKGROUND

The effectiveness of screening in colorectal cancer prevention depends on sustained participation rates. The objective of this study was to explore factors related to the longitudinal adherence of screening behavior in the context of a biennial population-based cancer screening program.

METHODS

Eight focus groups were conducted with individuals who were invited two or three consecutive times to a population-based colorectal cancer screening program using a fecal occult blood test and who agreed to participate in the program at least once (n = 45). The criteria used to select the study members included adherence to fecal occult blood test maintenance, factors regarding their initial participation in the colorectal cancer screening, sex, and contextual educational level.

RESULTS

The participants expressed a high level of satisfaction with the program; however, they showed a low level of understanding with respect to cancer screening. Consulting a general practitioner was cited by all participants as an important factor that mediated their final decision or influenced their behavior as a whole with regard to the program. Fear played a different role in the screening behavior for regular and irregular adherent participants. In the adherent participants, fear facilitated their continued participation in the screening program, whereas for the irregular participants, fear led them to avoid or refuse further screening. Having a close person diagnosed with colorectal cancer was a facilitator for the regular adherent participants. The irregular adherent participants showed some relaxation with respect to screening after a negative result and considered that further screening was no longer necessary.

CONCLUSION

Considering the importance of primary healthcare professionals in the decision regarding sustained participation, it is important to better engage them with cancer screening programs, as well as improve the communication channels to provide accurate and balanced information for both health professionals and individuals.

Knowledge Gained and Retained from a Video-Centered, Community-Based Intervention for Ebola Prevention, Congo

There are few effective communication interventions to respond to Ebola Virus Disease (EVD) outbreaks, and their development is a continuing challenge. The largest outbreak of EVD was first recognized in 2014 and once again highlighted the need for health education communication campaigns. EVD emergence and transmission are associated with behaviors that increase exposure to infected individuals and infected wildlife. In 2008-2009, an educational video-centered intervention consisting of a film followed by a structured discussion was developed to improve EVD knowledge, attitudes, and behaviors (KABs) for prevention of EVD and care of infected people. The film was produced for a Congolese audience in local languages and features doctors and residents from the region. The objective of the study was to assess the effectiveness of this intervention to change KABs related to EVD. The intervention was conducted over 12 months and reached >60,000 people; 220 individuals were sampled before and immediately after the intervention, and a subsample of 53 who had received the intervention 1 year earlier were interviewed to assess changes in KABs related to EVD. Statistically significant improvements in EVD recognition, transmission, and mitigation of risk after the intervention were observed. This study also demonstrates significant retention of knowledge one year after the intervention. Overall, the intervention was effective in improving KABs among a limited literacy population and knowledge was retained for more than one year. The materials and approaches developed were used in 2014 as part of a social mobilization strategy in response to an Ebola outbreak in the Congo Basin.

Association of Insurance and Community-Level Socioeconomic Status With Treatment and Outcome of Squamous Cell Carcinoma of the Pharynx

Importance

Community-level socioeconomic status, particularly insurance status, is increasingly becoming important as a possible determinant in patient outcomes.

Objective

To determine the association of insurance and community-level socioeconomic status with outcome for patients with pharyngeal squamous cell carcinoma (SCC).

Design, Setting, and Participants

This study extracted data from more than 1500 Commission on Cancer-accredited facilities collected in the National Cancer Database. A total of 35 559 patients diagnosed with SCC of the pharynx from 2004 through 2013 were identified. The χ2 test, Kaplan-Meier method, and Cox regression models were used to analyze data from April 1, 2016, through April 16, 2017.

Main Outcomes and Measures

Overall survival was defined as time to death from the date of diagnosis.

Results

Among the 35 559 patients identified (75.6% men and 24.4% women; median age, 61 years [range, 18-90 years]), 15 146 (42.6%) had Medicare coverage; 13 061 (36.7%), private insurance; 4881 (13.7%), Medicaid coverage; and 2471 (6.9%), no insurance. Uninsured patients and Medicaid recipients were more likely to be younger, black, or Hispanic; to have lower median household income and lower educational attainment; to present with higher TNM stages of disease; and to start primary treatment at a later time from diagnosis. Those with private insurance (reference group) had significantly better overall survival than uninsured patients (hazard ratio [HR], 1.72; 95% CI, 1.59-1.87), Medicaid recipients (HR, 1.99; 95% CI, 1.88-2.12), or Medicare recipients (HR, 2.07; 95% CI, 1.99-2.16), as did those with median household income of at least $63 000 (reference) vs $48 000 to $62 999 (HR, 1.19; 95% CI, 1.13-1.26), $38 000 to $47 999 (HR, 1.31; 95% CI, 1.24-1.38), and less than $38 000 (HR, 1.51; 95% CI, 1.43-1.59). On multivariable analysis, insurance status and median household income remained independent prognostic factors for overall survival even after accounting for educational attainment, race, Charlson/Deyo comorbidity score, disease site, and TNM stage of disease.

Conclusions and Relevance

Insurance status and household income level are associated with outcome in patients with SCC of the pharynx. Those without insurance and with lower household income may significantly benefit from improving access to adequate, timely medical care. Additional investigations are necessary to develop targeted interventions to optimize access to standard medical treatments, adherence to physician management recommendations, and subsequently, prognosis in these patients at risk.

Influence of insurance status and income in anaplastic astrocytoma: an analysis of 4325 patients

To determine the impact of insurance status and income for anaplastic astrocytoma (AA). Data were extracted from the National Cancer Data Base. Chi square test, Kaplan-Meier method, and Cox regression models were employed in SPSS 22.0 (Armonk, NY: IBM Corp.) for data analyses. 4325 patients with AA diagnosed from 2004 to 2013 were identified. 2781 (64.3%) had private insurance, 925 (21.4%) Medicare, 396 (9.2%) Medicaid, and 223 (5.2%) were uninsured. Those uninsured were more likely to be Black or Hispanic versus White or Asian (p < 0.001), have lower median income (p < 0.001), less educated (p < 0.001), and not receive adjuvant chemoradiation (p < 0.001). 1651 (38.2%) had income ≥$63,000, 1204 (27.8%) $48,000-$62,999, 889 (20.5%) $38,000-$47,999, and 581 (13.4%) had income <$38,000. Those with lower income were more likely to be Black or Hispanic versus White or Asian (p < 0.001), uninsured (p < 0.001), reside in a rural area (p < 0.001), less educated (p < 0.001), and not receive adjuvant chemoradiation (p < 0.001). Those with private insurance had significantly higher overall survival (OS) than those uninsured, on Medicaid, or on Medicare (p < 0.001). Those with income ≥$63,000 had significantly higher OS than those with lower income (p < 0.001). On multivariate analysis, age, insurance status, income, and adjuvant therapy were independent prognostic factors for OS. Being uninsured and having income <$38,000 were independent prognostic factors for worse OS in AA. Further investigations are warranted to help determine ways to ensure adequate medical care for those who may be socially disadvantaged so that outcome can be maximized for all patients regardless of socioeconomic status.

Integrated Cancer Screening Performance Indicators: A Systematic Review

Cancer screening guidelines recommend that women over 50 years regularly be screened for breast, cervical and colorectal cancers. Population-based screening programs use performance indicators to monitor uptake for each type of cancer screening, but integrated measures of adherence across multiple screenings are rarely reported. Integrated measures of adherence that combine the three cancers cannot be inferred from measures of screening uptake of each cancer alone; nevertheless, they can help discern the proportion of women who, having received one or two types of screening, may be more amenable to receiving one additional screen, compared to those who haven't had any screening and may experience barriers to access screening such as distance, language, and so on. The focus of our search was to identify indicators of participation in the three cancers, therefore our search strategy included synonyms of integrated screening, cervical, breast and colorectal cancer screening. Additionally, we limited our search to studies published between 2000 and 2015, written in English, and pertaining to females over 50 years of age. The following databases were searched: MEDLINE, EMBASE, EBM Reviews, PubMed, PubMed Central, CINAHL, and Nursing Reference Center, as well as grey literature resources. Of the 78 initially retrieved articles, only 7 reported summary measures of screening across the three cancers. Overall, adherence to cervical, breast and colorectal cancer screening ranged from around 8% to 43%. Our review confirms that reports of screening adherence across breast, cervical and colorectal cancers are rare. This is surprising, as integrated cancer screening measures can provide additional insight into the needs of the target population that can help craft strategies to improve adherence to all three screenings.

Colorectal Cancer in African Americans: An Update

This review is an update to the American College of Gastroenterology (ACG) Committee on Minority Affairs and Cultural Diversity's paper on colorectal cancer (CRC) in African Americans published in 2005. Over the past 10 years, the incidence and mortality rates of CRC in the United States has steadily declined. However, reductions have been strikingly much slower among African Americans who continue to have the highest rate of mortality and lowest survival when compared with all other racial groups. The reasons for the health disparities are multifactorial and encompass physician and patient barriers. Patient factors that contribute to disparities include poor knowledge of benefits of CRC screening, limited access to health care, insurance status along with fear and anxiety. Physician factors include lack of knowledge of screening guidelines along with disparate recommendations for screening. Earlier screening has been recommended as an effective strategy to decrease observed disparities; currently the ACG and American Society of Gastrointestinal Endoscopists recommend CRC screening in African Americans to begin at age 45. Despite the decline in CRC deaths in all racial and ethnic groups, there still exists a significant burden of CRC in African Americans, thus other strategies including educational outreach for health care providers and patients and the utilization of patient navigation systems emphasizing the importance of screening are necessary. These strategies have been piloted in both local communities and Statewide resulting in notable significant decreases in observed disparities.

Joint breast and colorectal cancer screenings in medically underserved women

BACKGROUND

Breast and colon cancer screening in rural community clinics is underused.

OBJECTIVE

To evaluate the effectiveness and cost-effectiveness of alternative interventions designed to promote simultaneous screening for breast and colon cancer in community clinics.

METHODS

A 3-arm, quasi-experimental evaluation was conducted during May 2008-August 2011 in 8 federally qualified health clinics in predominately rural Louisiana. Baseline screening rates reported by the clinics was <10% for breast cancer (using mammography) and 1%-2% for colon cancer (using the fecal occult blood test [FOBT]). 744 women aged 50 years or older who were eligible for routine mammography and an FOBT were recruited. The combined screening efforts included: enhanced care; health literacy-informed education (education alone), or health literacy-informed education with nurse support (nurse support).

RESULTS

Postintervention screening rates for completing both tests were 28.1% with enhanced care, 23.7% with education alone, and 38.7% with nurse support. After adjusting for age, race, and literacy, patients who received nurse support were 2.21 times more likely to complete both screenings than were those who received the education alone (95% confidence interval [CI], 1.12-4.38; P = .023). The incremental cost per additional woman completing both screenings was $3,987 for education with nurse support over education alone, and $5,987 over enhanced care.

LIMITATIONS

There were differences between the 3 arms in sociodemographic characteristics, literacy, and previous screening history. Not all variables that were significantly different between arms were adjusted for, therefore adjustments for key variables (age, race, literacy) were made in statistical analyses. Other limitations related generalizability of results.

CONCLUSIONS

Although joint breast and colon cancer screening rates were increased substantially over existing baseline rates in all 3 arms, the completion rate for both tests was modest. Nurse support and telephone follow-up were most effective. However, it is not likely to be cost effective or affordable in clinics with limited resources.

Third Annual Fecal Occult Blood Testing in Community Health Clinics

OBJECTIVES

Our objective was to determine the effectiveness of 3 approaches to encourage completion of fecal occult blood testing (FOBT) in the third year of the intervention.

METHODS

Between 2008 and 2011, a quasi-experimental intervention was conducted in 8 predominantly rural Federally Qualified Health Centers. Clinics were randomly assigned to enhanced care (screening recommendation and FOBT kit mailed annually), education (patients additionally received a health literacy appropriate pamphlet and simplified FOBT instructions), or nurse support (same as education but with nurse follow-up). Participants included 206 patients with negative FOBTs in years 1 and 2; ages 50-85, 80% female, 70% African American, and 52% had limited health literacy. The main outcome measure was completion of a third annual FOBT.

RESULTS

Third-year FOBT rates were 48% overall, 34.2% enhanced care, 59.6% education, and 47.4% nurse support (p = .21), even after adjustment for sex, marital status, and health literacy.

CONCLUSION

All mailed interventions were similarly effective in sustaining rates of FOBT screening. Post hoc analyses of the results analyzed by health literacy skills found that patients with both limited and adequate health literacy skills were more likely to complete FOBTs when mailed simplified instructions.

Determinants of breast cancer screening uptake in Kurdish women of Iran

Background: Recently, a national breast cancer screening program has been introduced in Iran.The aim of this study was to examine the determinants of breast cancer screening uptake among Kurdish women, in order to identify those characteristics that may be potentially associated with the screening uptake.

Methods: Through a cross sectional study, in 2014, a random sample of 561 women aged 40 years and older without the history of breast cancer and identified with Kurdish background in Baneh county, Iran, were recruited and interviewed by two trained interviewers. Data were collected using a valid and reliable researcher made questionnaire. Univariate and multivariate logistic regression models with self-reported screening history as the dependent variable were used to estimate the odds ratios (ORs) with 95% of CI.

Results: The mean age of women was 43.64 (SD = 5.17). The participation rate in the mammography program was 16.8% (95% CI: 13.7-19.8%). The lowest level of participation was found among women aged 60 and older (OR = 0.30, 95% CI: 0.14-0.69), illiterate (OR = 0.63,95% CI: 0.40-0.99) and post-menopausal (OR = 0.56, 95% CI: 0.35-0.91) women.

Conclusion: It was found that the level of breast screening uptake was low among Kurdish women compared to those reported in the previous studies. Designing participation enhancing interventions with a specific focus on older, illiterate and post-menopausal women are recommended.

Health Information Seeking and Cancer Screening Adherence Rates

Effective screening tools are available for many of the top cancer killers in the USA. Searching for health information has previously been found to be associated with adhering to cancer screening guidelines, but Internet information seeking has not been examined separately. The current study examines the relationship between health and cancer Internet information seeking and adherence to cancer screening guidelines for breast, cervical, and colorectal cancer in a large nationally representative dataset. The current study was conducted using data from the Health Information National Trends Survey from 2003 and 2007. The study examined age-stratified models which correlated health and cancer information seeking with getting breast, cervical, and colorectal cancer screening on schedule, while controlling for several key variables. Internet health and cancer information seeking was positively associated with getting Pap screening on schedule, while information seeking from any sources was positively associated with getting colorectal screening on schedule. People who look for health or cancer information are more likely to get screened on schedule. Some groups of people, however, do not exhibit this relationship and, thus, may be more vulnerable to under-screening. These groups may benefit more from targeted interventions that attempt to engage people in their health care more actively.