Outcomes of a Dietary Intervention to Reduce Bladder Cancer Recurrence and Progression in Survivors of Non-Muscle-Invasive Bladder Cancer

BACKGROUND

As one of the 10 most common cancers in the United States, bladder cancer is the most expensive cancer to treat. Most bladder cancers (70%-80%) are diagnosed at early stages as non-muscle-invasive bladder cancer (NMIBC), which can be removed. However, 50% to 80% of NMIBC recurs within 5 years, and 15% to 30% progresses with poor survival. Besides life-long surveillance, current treatment is limited. Preclinical and epidemiologic evidence suggest that dietary isothiocyanates (ITCs) in cruciferous vegetables (Cruciferae) could be a noninvasive and cost-effective strategy to improve NMIBC prognosis. Yet, a Cruciferae intervention that increases ITC exposure in NMIBC survivors has not been tested. Thus, the primary aim of this study was to test the effect of a Cruciferae intervention on urinary ITC levels and Cruciferae intake in NMIBC survivors.

PATIENTS AND METHODS

We conducted a 2-arm, double-blinded, randomized controlled trial to test the efficacy of a Cruciferae intervention against a general fruit and vegetable intervention (control) for NMIBC survivors. Both 6-month interventions consisted of mailed educational materials, a live call with staff to review the materials, and 11 interactive voice response calls. We anticipated that our Cruciferae intervention (Power to Redefine Your Health [POW-R Health]) would increase Cruciferae intake to 1 cup/day (secondary outcome), thus raising urinary ITC levels to 10 µM (primary outcome) from baseline to 6-month follow-up.

RESULTS

We randomized 49 patients with NMIBC diagnosed in 2018 through 2019, and retained 42 patients at 6-month follow-up. The treatment group reported 0.94 cups (95% CI, 0.24-1.65; P=.010) higher Cruciferae intake (treatment, 1.37 ± 1.19 cups vs control, 0.56 ± 0.72 cups) and increased urinary ITC levels by 11.1 μmol/g creatinine (treatment, 26.2 ± 20.9 vs control, 7.8 ± 11.5; P=.027) at 6-month follow-up compared with the control group.

CONCLUSIONS

Our dietary intervention is the first to significantly increase Cruciferae intake and urinary ITC levels in NMIBC survivors, demonstrating an increase in ITC to levels that significantly decrease risk of disease-specific survival. A future randomized controlled trial testing POW-R Health on bladder cancer recurrence and progression is warranted. If proven to improve bladder cancer outcomes, our intervention has the potential to be a noninvasive, cost-effective, easily accessible way for NBMIC survivors to improve their bladder cancer prognosis.

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.

"It's Okay With Our Culture but We're in a Different Place and We Have to Show Respect": Marshallese Migrants and Exclusive Breastfeeding Initiation

BACKGROUND

Pacific Islanders in the United States have lower initiation rates and shorter duration of exclusive breastfeeding compared to other racial/ethnic groups.

RESEARCH AIM

To describe infant feeding beliefs and experiences of Marshallese living in the United States.

METHODS

We used a prospective and cross-sectional exploratory, descriptive qualitative design with Marshallese participants (N = 36) residing in the United States between July 2019 and July 2020. Data were collected at 6-8 weeks postpartum. Our qualitative analytic approach integrated inductive and deductive techniques.

RESULTS

Participants' mean age was 27.1 years (SD = 6.1), and 88.9% (n = 32) were born in the Marshall Islands. A majority of participants were single, widowed, or in an unmarried partnership (n = 28, 77.8%). Most participants had a high school education or lower (n = 30, 83.3%). Mean household size was 7.2 (SD = 2.8). Fewer than half of participants had no health insurance (n = 14, 38.9%), and almost all participants (91.7%) did not work at the time of data collection. Two themes emerged: 1) infant feeding initiation and practices; and 2) concerns over breastfeeding in public. The majority of participants' infants received both human milk and formula. Participants described beliefs that breastfeeding in public was against American customs, which influenced their decision about breastfeeding in public.

CONCLUSIONS

Our study was the first to document infant feeding beliefs and experiences of Marshallese living in the United States at 6-8 weeks postpartum. Findings will inform future health education programs.

Cruciferous Vegetable Intervention to Prevent Cancer Recurrence in Non-Muscle Invasive Bladder Cancer Survivors: Development using a Systematic Process (Preprint)

Background

Bladder cancer is one of the top 10 most common cancers in the United States. Most bladder cancers (70%-80%) are diagnosed at early stages as non–muscle-invasive bladder cancer (NMIBC), which can be removed surgically. However, 50% to 80% of NMIBC cases recur within 5 years, and 15% to 30% progress with poor survival. Current treatments are limited and expensive. A wealth of preclinical and epidemiological evidence suggests that dietary isothiocyanates in cruciferous vegetables (Cruciferae) could be a novel, noninvasive, and cost-effective strategy to control NMIBC recurrence and progression.

Objective

The aim of this study is to develop a scalable dietary intervention that increases isothiocyanate exposure through Cruciferae intake in NMIBC survivors.

Methods

We worked with a community advisory board (N=8) to identify relevant factors, evidence-based behavior change techniques, and behavioral theory constructs used to increase Cruciferae intake in NMIBC survivors; use the PEN-3 Model focused on incorporating cultural factors salient to the group’s shared experiences to review the intervention components (eg, the saliency of behavioral messages); administer the revised intervention to community partners for their feedback; and refine the intervention.

Results

We developed a multicomponent intervention for NMIBC survivors consisting of a magazine, tracking book, live telephone call script, and interactive voice messages. Entitled POW-R Health: Power to Redefine Your Health, the intervention incorporated findings from our adaptation process to ensure saliency to NMIBC survivors.

Conclusions

This is the first evidence-based, theoretically grounded dietary intervention developed to reduce bladder cancer recurrence in NMIBC survivors using a systematic process for community adaptation. This study provides a model for others who aim to develop behavioral, community-relevant interventions for cancer prevention and control with the overall goal of wide-scale implementation and dissemination.

Inequities in Access to Medical Care Among Adults Diagnosed with Diabetes: Comparisons Between the US Population and a Sample of US-Residing Marshallese Islanders

OBJECTIVE

We examined barriers to accessing medical care for migrant US-residing Marshallese Islanders.

METHODS

Cross-sectional analyses were conducted to identify potential inequities. Surveys from largely migrant diabetic Marshallese Islanders (n = 255) were compared with nationally representative data. Two major outcomes were assessed including 1-whether or not one reported having forgone medical care in the past year because of cost-and 2-whether or not one reported not having a usual source of care.

RESULTS

Overall, 74% and 77% of Marshallese Islanders reported forgone care and no usual source of care, respectively, versus 15% and 7% of the US diabetic population. In multivariable analyses, being younger; uninsured; unemployed; male; of lower education; Native American or Hispanic (versus White); and residing in the South were associated with forgone care nationwide, whereas only lacking insurance was associated with forgone care among Marshallese Islanders. Nationwide being younger; uninsured; unmarried; female; of lower education; Native American or Hispanic (versus White); and residing in the South were associated with not having a usual source of care, whereas only being younger and uninsured were associated with not having a usual source of care among Marshallese Islanders.

CONCLUSION

The largest group of diabetic Marshallese Islanders in the continental US faces severe healthcare access inequities necessitating policies that increase access to health insurance options and associated resources.

Implementation costs of a community health worker delivered weight loss intervention in black churches serving underserved communities

Black adults bear a disproportionate burden of the obesity epidemic but are underrepresented in weight loss research and lose less weight than their white counterparts in weight loss interventions. Comprehensive behavioral weight loss interventions cause weight loss, but their high cost have stymied their implementation in black and other underserved communities. Recent translations of evidence-based weight loss interventions for black communities have been designed to increase intervention reach. However, the costs of implementing such interventions have seldom been reported in the context of a randomized controlled trial. Thus, the costs of implementing a community-health worker delivered Diabetes Prevention Program (DPP) adaptated for rural black adults of faith (The WORD) are reported. Data from a randomized controlled effectiveness trial conducted in 31 churches (n = 440) were used to calculate implementation costs. All participants received the 16-session core weight loss intervention and weight loss data was collected at baseline and 6 months. Participants lost an average of 2.53 kg at 6 months. Total implementation costs were $340.95 per participant. Thus, the implementation cost was $138 per kg. This is one of the few comprehensive examinations of costs for a DPP translation for black adults of faith and provide initial data from which practitioners and policy makers can use to determine the engagement of churches to disseminate the DPP through churches. Future studies are needed to confirm the extent churches are a cost-effective strategy to cause weight loss in black communities.

The WORD: Outcomes of a Behavioral Weight Loss Maintenance Effectiveness Trial in Rural Black Adults of Faith

OBJECTIVE

Rural black communities bear a disproportionate burden of obesity. To increase reach among underserved groups, community-based weight loss and maintenance interventions are crucial.

METHODS

The Diabetes Prevention Program (DPP) was adapted for rural black adults of faith to create The Wholeness, Oneness, Righteousness, Deliverance (WORD) trial, a group-based, community health worker-delivered weight loss intervention. A Weight Loss Only arm (16 sessions) was compared with a Weight Loss + Maintenance arm (16 + 12 sessions) in a cluster randomized controlled trial of 31 churches (n = 440). Weight and related behaviors were assessed at 0, 6, 12, and 18 months.

RESULTS

The WORD produced weight loss from baseline to 6 months (percentage body weight change -2.47 [-3.13 to -1.80]). Among those who lost 5% of their baseline weight, there was a statistical trend of lower weight regain in the Weight Loss + Maintenance arm compared with control. Maintenance arm participants reported higher activity at 12 months. There were no between-arm differences at 18 months.

CONCLUSIONS

The WORD produced weight loss from baseline to 6 months on par with that produced by other DPP adaptations for black communities, including adaptations using health professionals. Weight regain was also consistent with that reported in prior literature. Continuing sessions as part of the church's mission may foster adoption of DPP-based weight loss programs.

Health Research Funding Agencies' Policies, Recommendations, and Tools for Dissemination

THE PROBLEM

Dissemination is a key component of translational research. However, research participants rarely receive findings from the studies in which they have participated. Funding agencies have a significant amount of influence to promote research dissemination through requirements, recommendations, and tools. However, it is not clear to what extent current funding agencies promote dissemination to study participants.Purpose of Article: A review of major health research funders was conducted to ascertain the current policies, recommendations, and tools related to 1) academic dissemination, 2) lay community dissemination, and 3) returning results to research participants.

KEY POINTS

Several agencies have policies, recommendations, and tools for academic dissemination; however, few have the same policies, recommendations, and tools for dissemination to research participants and the lay communities they are recruited from.

CONCLUSIONS

Funding agencies have a unique opportunity to encourage the dissemination of research results to research participants and lay community audiences by developing policies to increase dissemination of grantees' research findings.

Strategies to Facilitate Equitable Resource Sharing in Community-Engaged Research

BACKGROUND

Community subcontracts are an essential component of community-engaged research, particularly community-based participatory research (CBPR). However, several barriers have limited community-based organizations' (CBOs) ability to serve as subcontractors on research grants. This article describes the barriers and strategies to implementing community subcontracts through a case study of the implementation of one federal grant.

LESSONS LEARNED

Specific lessons learned at the CBO level, budget-creation level, and university-level are described to overcome barriers in executing community subcontracts in community-engaged research.

CONCLUSIONS

We call for institutional changes to facilitate equitable resource sharing in community-engaged research.

Overweight and Obesity Among School Bus Drivers in Rural Arkansas

Introduction

Obesity is a major public health concern. Compared with other occupational groups, transportation workers, such as school bus drivers, have higher rates of obesity. However, little is known about the body weight and related health behaviors of these drivers, and opportunities for intervention are undetermined.

Methods

We collected multilevel data from school bus drivers working from 4 school bus garages in Little Rock, Arkansas, and their work environment from January through July of 2017. Data on weight, height, sociodemographic characteristics, work factors, weight-related behaviors, and psychosocial variables were collected from 45 drivers. Analyses explored associations between body mass index (BMI; weight in kg/ height in m²) and sociodemographic characteristics, work factors, weight-related behaviors, and psychosocial variables. Two focus groups with a total of 20 drivers explored drivers’ perspectives about healthy weight. Observational data at the bus and garage levels were collected through 2 “ride-alongs” and an environmental scan.

Results

Drivers in our sample were predominately overweight or obese (91.1%), and most did not meet dietary or physical activity guidelines. Drivers who were currently dieting had higher BMIs (36.4; standard deviation [SD], 8.2) than drivers who were not dieting (28.5; SD, 7.7); drivers who reported eating less to lose weight had higher BMIs (38.1; SD, 8.5) than those who did not report eating less (29.5; SD, 6.0). Drivers who did not meet physical activity recommendations had higher BMIs (36.5; SD, 9.8) than those who met recommendations (30.9; SD, 4.8). Structural barriers and work stress were significant barriers to achieving a healthy weight. Resources for healthful eating and physical activity were limited in the garage.

Conclusion

Our study provides preliminary data on the prevalence, risk factors, and perceptions of overweight and obesity among school bus drivers. Study data on drivers’ body weight, health-related behaviors, and psychosocial characteristics could serve as a basis for worksite interventions to improve drivers’ health.

Reach and Adoption of a Randomized Weight Loss Maintenance Trial in Rural African Americans of Faith: The WORD (Wholeness, Oneness, Righteousness, Deliverance)

PURPOSE

There is minimal information regarding the Reach and Adoption of evidence-based weight loss maintenance interventions for African Americans of faith.

DESIGN

The WORD (Wholeness, Oneness, Righteousness, Deliverance) was an 18-month, cluster randomized trial designed to reduce and maintain weight loss in African American adults of faith. Participants received the Diabetes Prevention Program adapted core weight loss program for 6 months, and churches were subsequently randomized to 12-month maintenance treatment or control. All participants underwent body weight and associated behavioral and psychosocial assessments at baseline, 6, 12, and 18 months. The current article focuses on assessing Reach and Adoption at baseline and 6 months using the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

SETTING

Lower Mississippi Delta.

PARTICIPANTS

Thirty churches, 61 WORD Leaders (WLs), and 426 participants.

INTERVENTION

Group delivered by trained community members (WLs).

MEASURES

Body mass index and percentage weight lost from baseline to 6-month follow-up were measured. Reach was assessed at participant, WL, and church levels through calculating participation rates and sociodemographics of each level. Adoption was assessed at church and WL levels.

ANALYSIS

Descriptive statistics summarized baseline characteristics of each level. Continuous and categorical end point comparisons were made.

RESULTS

Participants' participation rate was 0.84 (n = 437 agreed to participate, n = 519 eligible invited to participate); they were predominantly female, employed, and had a mean age of 49.8. Dropouts by 6 months were younger, had differential marital status, and religious attendance compared with retained participants. Church participation rate was 0.63 (n = 30 enrolled, n = 48 eligible approached) and the majority reported ≤100 active members. The WL participation rate was 0.61 (n = 61 implemented intervention, n = 100 eligible approached); they were primarily female and aged 53.9 (mean).

CONCLUSION

Recruitment, engagement, and delivery strategies employed by the WORD show promise of sustained engagement and adoption in other faith-based behavioral weight management programs for African Americans.

Engagement practices that join scientific methods with community wisdom: designing a patient-centered, randomized control trial with a Pacific Islander community

This article illustrates how a collaborative research process can successfully engage an underserved minority community to address health disparities. Pacific Islanders, including the Marshallese, are one of the fastest growing US populations. They face significant health disparities, including extremely high rates of type 2 diabetes. This article describes the engagement process of designing patient-centered outcomes research with Marshallese stakeholders, highlighting the specific influences of their input on a randomized control trial to address diabetes. Over 18 months, an interdisciplinary research team used community-based participatory principles to conduct patient-engaged outcomes research that involved 31 stakeholders in all aspects of research design, from defining the research question to making decisions about budgets and staffing. This required academic researcher flexibility, but yielded a design linking scientific methodology with community wisdom.

Analyzing factors associated with women's attitudes and behaviors toward screening mammography using design-based logistic regression

We examined the factors associated with screening mammography adherence behaviors and influencing factors on women's attitudes toward mammography in non-adherent women. Design-based logistic regression models were developed to characterize the influencing factors, including socio-demographic, health related, behavioral characteristics, and knowledge of breast cancer/mammography, on women's compliance with and attitudes toward mammography using the 2003 Health Information National Trends Survey data. Findings indicate significant associations among adherence to mammography and marital status, income, health coverage, being advised by a doctor to have a mammogram, having had Pap smear before, perception of chance of getting breast cancer, and knowledge of mammography (frequency of doing mammogram) in both women younger than 65 and women aged 65 and older. However, number of visits to a healthcare provider per year and lifetime number of smoked cigarettes are only significant for women younger than 65. Factors significantly associated with attitudes toward mammography in non-adherent women are age, being advised by a doctor to have a mammogram, and seeking cancer information. To enhance adherence to mammography programs, physicians need to continue to advise their patients to obtain mammograms. In addition, increasing women's knowledge about the frequency and starting age for screening mammography may improve women's adherence. Financially related factors such as income and insurance are also shown to be significant factors. Hence, healthcare policies aimed at providing breast cancer screening services to underserved women will likely enhance mammography participation.