Racism and Cancer Screening among Low-Income, African American Women: A Multilevel, Longitudinal Analysis of 2-1-1 Texas Callers

Supporting ColoREctal Equitable Navigation (SCREEN): a protocol for a stepped-wedge cluster randomized trial for patient navigation in primary care

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.

Breast and cervical cancer screenings across gender identity: results from the Behavioral Risk Factor Surveillance System before and during the COVID-19 pandemic

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.

Tools to Measure the Impact of Structural Racism and Discrimination on Gastrointestinal and Hepatology Disease Outcomes: A Scoping Review

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.

Self-reported Racial Discrimination and Healthy Behaviors in Black Adults Residing in Rural Persistent Poverty Areas

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.

Racial Discrimination, Social Disadvantage, and Racial-Ethnic Disparities in COVID-19 Vaccine Uptake

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.

Interventions to reduce cancer screening inequities: the perspective and role of patients, advocacy groups, and empowerment organizations

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.