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Rivera Rivera JN, AuBuchon KE, Schubel LC, Starling C, Tran J, Locke M, Grady M, Mete M, Blumenthal HJ, Galarraga JE, Arem H. Supporting ColoREctal Equitable Navigation (SCREEN): a protocol for a stepped-wedge cluster randomized trial for patient navigation in primary care. Implement Sci Commun 2024; 5:60. [PMID: 38831365 PMCID: PMC11149321 DOI: 10.1186/s43058-024-00598-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Black individuals in the United States (US) have a higher incidence of and mortality from colorectal cancer (CRC) compared to other racial groups, and CRC is the second leading cause of death among Hispanic/Latino populations in the US. Patient navigation is an evidence-based approach to narrow inequities in cancer screening among Black and Hispanic/Latino patients. Despite this, limited healthcare systems have implemented patient navigation for screening at scale. METHODS We are conducting a stepped-wedge cluster randomized trial of 15 primary care clinics with six steps of six-month duration to scale a patient navigation program to improve screening rates among Black and Hispanic/Latino patients. After six months of baseline data collection with no intervention we will randomize clinics, whereby three clinics will join the intervention arm every six months until all clinics cross over to intervention. During the intervention roll out we will conduct training and education for clinics, change infrastructure in the electronic health record, create stakeholder relationships, assess readiness, and deliver iterative feedback. Framed by the Practical, Robust Implementation Sustainment Model (PRISM) we will focus on effectiveness, reach, provider adoption, and implementation. We will document adaptations to both the patient navigation intervention and to implementation strategies. To address health equity, we will engage multilevel stakeholder voices through interviews and a community advisory board to plan, deliver, adapt, measure, and disseminate study progress. Provider-level feedback will include updates on disparities in screening orders and completions. DISCUSSION Primary care clinics are poised to close disparity gaps in CRC screening completion but may lack an understanding of the magnitude of these gaps and how to address them. We aim to understand how to tailor a patient navigation program for CRC screening to patients and providers across diverse clinics with wide variation in baseline screening rates, payor mix, proximity to specialty care, and patient volume. Findings from this study will inform other primary care practices and health systems on effective and sustainable strategies to deliver patient navigation for CRC screening among racial and ethnic minorities. TRIAL REGISTRATION NCT06401174.
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Affiliation(s)
- Jessica N Rivera Rivera
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
| | - Katarina E AuBuchon
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Laura C Schubel
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
| | - Claire Starling
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA
| | - Jennifer Tran
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Marjorie Locke
- Department of Surgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Melanie Grady
- MedStar Health Institute for Quality and Safety, Washington, DC, USA
| | - Mihriye Mete
- Department of Behavioral Health Research, MedStar Health Research Institute, Washington, DC, USA
- Department of Psychiatry, Georgetown University School of Medicine, Washington, DC, USA
| | - H Joseph Blumenthal
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Washington, DC, USA
| | | | - Hannah Arem
- Healthcare Delivery Research Network, MedStar Health Research Institute, Washington, DC, USA.
- Department of Oncology, Georgetown University, Washington, DC, USA.
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Berzansky I, Reynolds CA, Charlton BM. Breast and cervical cancer screenings across gender identity: results from the Behavioral Risk Factor Surveillance System before and during the COVID-19 pandemic. Cancer Causes Control 2024; 35:865-872. [PMID: 38280155 DOI: 10.1007/s10552-023-01847-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/19/2023] [Indexed: 01/29/2024]
Abstract
PURPOSE Although national medical organizations often neglect to include trans and gender diverse (TGD) people in their breast and cervical cancer screening recommendations, the World Profession Association of Transgender Health recommends that TGD people who are at risk for these cancers follow existing guidelines for cisgender women. Despite WPATH's recommendations, TGD people are less likely to get screened in large part due to discrimination. The COVID-19 pandemic has limited access to cancer screenings among cisgender people, but it is unknown how this has impacted TGD people. METHODS Using national survey data from the Behavioral Risk Factors Surveillance System (BRFSS), we examined differences in cervical and breast cancer screening noncompliance across gender identity at two time points: before and during the COVID-19 pandemic. RESULTS Screening noncompliance increased during the COVID-19 pandemic among cisgender and TGD people (e.g., transgender men, gender non-conforming people). Compared to cisgender women, transgender men and gender non-conforming respondents had higher odds of breast cancer screening noncompliance before and during COVID-19. Transgender men had lower odds of cervical cancer screening noncompliance than cisgender women before COVID-19, but higher odds during the pandemic. Gender non-conforming respondents also had lower odds of cervical cancer screening noncompliance during COVID-19 compared to cisgender women. CONCLUSIONS Screening noncompliance for breast and cervical cancer was more common among TGD people than cisgender women; while these disparities existed before the COVID-19 pandemic, they were exacerbated during the pandemic. Future work should move beyond descriptive statistics and elucidate underlying causes to inform interventions.
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Affiliation(s)
- Isa Berzansky
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Colleen A Reynolds
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Brittany M Charlton
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
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Liu JJ, DeCuir N, Kia L, Peterson J, Miller C, Issaka RB. Tools to Measure the Impact of Structural Racism and Discrimination on Gastrointestinal and Hepatology Disease Outcomes: A Scoping Review. Clin Gastroenterol Hepatol 2023; 21:2759-2788.e6. [PMID: 36549469 PMCID: PMC10279803 DOI: 10.1016/j.cgh.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/23/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Structural racism and discrimination (SRD) are important upstream determinants of health perpetuated by discriminatory laws and policies. Therefore, measuring SRD and its impact on health is critical to developing interventions that address resultant health disparities. We aimed to identify gastrointestinal (GI) or liver studies that report measures of SRD or interventions to achieve health equity in these domains by addressing upstream determinants of health. METHODS We conducted a scoping review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping reviews guidelines. Studies that used an SRD measure or examined an upstream intervention in GI or liver disease were included. Studies that described health disparities in GI or liver conditions without mentioning SRD were excluded. Study characteristics, findings, and limitations were extracted. RESULTS Forty-six articles (19 studies using SRD measures and 27 studies of upstream interventions) were identified. Measures of residential racial segregation were reported most frequently. SRD was associated with poorer health outcomes for racial and ethnic minority populations. Although upstream intervention studies focused primarily on policies related to colon cancer screening and organ graft allocation, racial and ethnic disparities often persisted post-intervention. CONCLUSIONS To achieve health equity in GI and liver conditions, there is an urgent need for research that goes beyond describing health disparities to incorporating measures of SRD and implementing interventions that address this understudied determinant of health.
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Affiliation(s)
- Joy J Liu
- Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Nicole DeCuir
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Leila Kia
- Division of Gastroenterology, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Jonna Peterson
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Corinne Miller
- Galter Health Sciences Library & Learning Center, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Rachel B Issaka
- Division of Gastroenterology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Center, Seattle, Washington; Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Center, Seattle, Washington.
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Yeary KHK, Willis DE, Yu H, Johnson B, McElfish PA. Self-reported Racial Discrimination and Healthy Behaviors in Black Adults Residing in Rural Persistent Poverty Areas. J Racial Ethn Health Disparities 2023:10.1007/s40615-023-01738-8. [PMID: 37555914 PMCID: PMC11331421 DOI: 10.1007/s40615-023-01738-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 07/25/2023] [Accepted: 07/27/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Racism is a social determinant of health inequities and associated with poorer health and health behaviors. As a domain of racism, self-reported racial discrimination affects health through unhealthy behaviors (e.g., smoking) but the understudied impact of self-reported racial discrimination's relationship with healthy behaviors (e.g., cancer screening) precludes a comprehensive understanding of racism's impact on health inequities. Understanding how self-reported racial discrimination impacts healthy behaviors is even more important for those living in rural persistent poverty areas (poverty rates of 20% or more of a population since 1980), who have a higher disease burden due to poverty's interaction with racism. The distinct sociocultural context of rural persistent poverty areas may result in differential responses to self-reported racial discrimination compared to those in non-persistent poverty areas. METHODS A community-engaged process was used to administer a survey to a convenience sample of 251 Black adults residing in 11 rural persistent poverty counties in the state of Arkansas. Self-reported racial discrimination, fruit and vegetable intake, colorectal cancer screening, cervical cancer screening, and screening mammography were assessed. Stress and religion/spirituality were also assessed as potential mediators or moderators in the relationship between self-reported racial discrimination and healthy behaviors. RESULTS In adjusted models, those reporting more self-reported racial discrimination had a higher probability of having had a test to check for cervical cancer (situation discrimination: OR = 1.23, 95% CI: 1.04-1.5; frequency discrimination: OR = 1.06, 95% CI: 1.02-1.12). Stress and religion/spirituality were not significant mediators/moderators. DISCUSSION Greater self-reported racial discrimination was associated with a higher odds of cervical cancer screening. Black adults residing in rural persistent poverty areas may have greater self-reported racial discrimination-specific coping and racial identity attitudes.
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Affiliation(s)
| | - Don E Willis
- University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Han Yu
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, 14263, USA
| | - Beverly Johnson
- University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
| | - Pearl A McElfish
- University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA
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Haro-Ramos AY, Bacong AM, Rodriguez HP. Racial Discrimination, Social Disadvantage, and Racial-Ethnic Disparities in COVID-19 Vaccine Uptake. AJPM FOCUS 2023; 2:100072. [PMID: 36744154 PMCID: PMC9889250 DOI: 10.1016/j.focus.2023.100072] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Introduction Racial-ethnic disparities in COVID-19 vaccination are well documented. The extent to which racism, manifested at the individual and ZIP code levels, explains disparities in early vaccination uptake remains unclear. Methods Data from a statewide poll of California registered voters (N=10,256), conducted between April 29 and May 5, 2021, linked to area-level resource data, were analyzed. Weighted multivariable logistic regression models examined racial disparities in COVID-19 vaccination. Decomposition analyses quantified how much of the observed racial disparities in vaccination were explained by racial discrimination and social disadvantage (i.e., educational attainment, 2019 household income, and ZIP code social vulnerability). Results Latinx (64.6%) and Black (66.7%) adults were less likely to have at least 1 COVID-19 vaccine dose by April or May 2021 than White adults (74.7%). In adjusted analyses, Latinx (AOR=0.69, 95% CI=0.57, 0.84) and Black (AOR=0.51, 95% CI=0.37, 0.70) adults had a lower likelihood of being vaccinated than Whites. Social disadvantage accounted for 77.4% (p<0.05) and 35.8% (p<0.05) of the explainable variation in Latinx-White and Black-White disparities, respectively. Self-reported racial discrimination was not associated with COVID-19 vaccination in adjusted analyses. Conclusions Social disadvantage but not self-reported racial discrimination explained racial-ethnic disparities in COVID-19 vaccination in California. Removing resource-related barriers may help to increase the relatively low COVID-19 vaccination rates among Black and Latinx populations.
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Affiliation(s)
- Alein Y Haro-Ramos
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, California
| | - Adrian M Bacong
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Hector P Rodriguez
- Division of Health Policy and Management, School of Public Health, University of California, Berkeley, Berkeley, California
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Richardson-Parry A, Baas C, Donde S, Ferraiolo B, Karmo M, Maravic Z, Münter L, Ricci-Cabello I, Silva M, Tinianov S, Valderas JM, Woodruff S, van Vugt J. Interventions to reduce cancer screening inequities: the perspective and role of patients, advocacy groups, and empowerment organizations. Int J Equity Health 2023; 22:19. [PMID: 36707816 PMCID: PMC9880917 DOI: 10.1186/s12939-023-01841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/21/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Health inequities lead to low rates of cancer screening in certain populations, such as low-income and ethnic minority groups. Different interventions to address this have been developed with mixed results. However, interventions are not always developed in collaboration with the people they target. The aim of our article is to present the viewpoint of patients, survivors, advocates, and lay persons on interventions to increase cancer screening from a health inequity perspective. METHODS We prepared talking points to guide discussions between coauthors, who included representatives from nine patient and survivor advocacy groups, organizations working for citizen/patient empowerment, and health equity experts. Perspectives and opinions were first collected through video conferencing meetings and a first draft of the paper was prepared. All authors, read through, revised, and discussed the contents to reach an agreement on the final perspectives to be presented. RESULTS Several themes were identified: it is important to not view screening as a discrete event; barriers underlying an individual's access and willingness to undergo screening span across a continuum; individually tailored interventions are likely to be more effective than a one-size fits-all approach because they may better accommodate the person's personal beliefs, knowledge, behaviors, and preferences; targeting people who are unknown to medical services and largely unreachable is a major challenge; including professional patient advocacy groups and relevant lay persons in the cocreation of interventions at all stages of design, implementation, and evaluation is essential along with relevant stakeholders (healthcare professionals, researchers, local government and community organizations etc). CONCLUSIONS Interventions to address cancer screening inequity currently do not adequately solve the issue, especially from the viewpoint of patients, survivors, and lay persons. Several core pathways should be focused on when designing and implementing interventions: advancing individually tailored interventions; digital tools and social media; peer-based approaches; empowerment; addressing policy and system barriers; better design of interventions; and collaboration, including the involvement of patients and patient advocacy organizations.
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Affiliation(s)
- Afua Richardson-Parry
- Viatris Global Healthcare UK, Building 4, Trident Place, Mosquito Way, Hatfield, London, AL10 9UL UK
| | - Carole Baas
- grid.470316.7Alamo Breast Cancer Foundation, 909 Midland Creek Drive, Southlake, TX 76092 USA
| | - Shaantanu Donde
- Viatris Global Healthcare, Building 4, Trident Place, Mosquito Way, Hatfield, London, AL10 9UL UK
| | - Bianca Ferraiolo
- Cittadinanzattiva - Active Citizenship Network, Rue Philippe Le Bon 46, 1000 Brussels, Belgium
| | - Maimah Karmo
- grid.430731.2Tigerlily Foundation, 42020 Village Center Plaza, #120-156, Stone Ridge, 20105 USA
| | - Zorana Maravic
- Digestive Cancers Europe, Rue de la Loi 235/27, 1040 Brussels, Belgium
| | - Lars Münter
- Danish Committee for Health Education, Classensgade 71, 5, 2100 Copenhagen, Denmark
| | - Ignacio Ricci-Cabello
- grid.507085.fBalearic Islands Health Research Institute (IdISBa) and CIBER de Epidemiología y Salud Pública (CIBERESP), C/ Escola Graduada 3, 07002 Palma, Balearic Islands Spain
| | - Mitchell Silva
- Esperity, Clos Chapelle-aux-Champs 30, 1200 Brussels, Belgium
| | - Stacey Tinianov
- Advocates for Collaborative Education, 824 Windsor Street, Santa Cruz, CA 95062 USA
| | - Jose M. Valderas
- grid.4280.e0000 0001 2180 6431National University of Singapore, 1E Kent Ridge Road, NUHS Tower Block, Singapore, 119228 Singapore
| | | | - Joris van Vugt
- Viatris, Aalsterweg 172, 5644 RH Eindhoven, The Netherlands
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