Colorectal cancer information avoidance is associated with screening adherence

Colorectal cancer (CRC) is the fourth most common cancer among U.S. men and women and the second deadliest. Effective screening modalities can either prevent CRC or find it earlier, but fewer than two thirds of U.S. adults are adherent to CRC screening guidelines. We tested whether people who defensively avoid CRC information have lower adherence to CRC screening recommendations and weaker intentions for being screened and whether CRC information avoidance adds predictive ability beyond known determinants of screening. Participants, aged 45-75 years, completed a survey about known structural determinants of CRC screening (healthcare coverage, healthcare use, provider recommendation), CRC information avoidance tendencies, and screening behavior (n = 887) and intentions (n = 425). Models were tested with multivariable regression and structural equation modeling (SEM). To the extent that participants avoided CRC information, they had lower odds of being adherent to CRC screening guidelines (OR = 0.55) and if non-adherent, less likely to intend to be screened (b=-0.50). In the SEM model, avoidance was negatively associated with each known structural determinant of screening and with lower screening adherence (ps < 0.01). Fit was significantly worse for nested SEM models when avoidance was not included, (i.e., the paths to avoidance were fixed to zero). Information avoidance was associated with screening behavior and other known structural determinants of screening adherence, potentially compounding its influence. Novel strategies are needed to reach avoiders, including health communication messaging that disrupts avoidance and interventions external to the healthcare system, with which avoiders are less engaged.

Increased experiences of loneliness during the COVID-19 pandemic, emotional distress and changes in perceived physical and mental health: A structural equation model

AIM

To explore how experiences of increased loneliness during the COVID-19 pandemic affected emotional distress and changes in perceptions of physical and mental health.

DESIGN

Cross-sectional study.

METHODS

Data from the Socio-Economic Impacts of Covid-19 Survey, a national survey administered to 5033 adults in August and September 2020 in the United States, was utilized in this study. Structural equation modelling was used to analyse the associations between increased experiences of loneliness during the pandemic, emotional distress and changes in perceptions of physical and mental health.

RESULTS

Among the 47% of participants who reported increased experiences of loneliness during the pandemic, 31% reported a poorer perceived change in mental health and 12% reported a poorer perceived change in physical health. Increased experiences of loneliness during the pandemic were significantly associated with emotional distress and poorer perceived mental and physical health changes. Emotional distress significantly mediated the effect between increased experiences of loneliness during the pandemic and poorer perceived mental and physical health changes. These findings highlight the importance of producing preventative actions to combat increased loneliness and emotional distress during and after future pandemics in order to improve health perceptions, which can result in negative health outcomes over time.

What Do Medicaid Members Want From Their Health Plan? Insights From a Qualitative Study to Improve Engagement in Case Management

PURPOSE OF STUDY

Managed care organizations (MCOs) provide case management services to address unmet health and social needs among their members. Few studies have examined factors influencing members' decision to participate in these programs. The purpose of the present study was to describe the life circumstances of Medicaid members offered case management, what they wanted from their MCO, and their perceptions of case management and barriers to participation. Results will inform practice to raise the awareness, engagement, and impact of case management programs.

PRIMARY PRACTICE SETTINGS

Case management offered through a Midwestern Medicaid MCO.

METHODOLOGY AND SAMPLE

Adult members who had been offered case management services in the 6 months preceding the study were eligible for the study. Fifteen people from each strata were recruited: members who engaged with case management, declined it, or declined it initially but later engaged (N = 45). Participants completed a qualitative interview by phone and a brief health survey online.

RESULTS

Across strata, only 22 participants recalled engagement with case management. Members described a variety of life challenges (e.g., chronic health conditions, caregiver responsibilities, and limited finances) and services they desired from their MCO (e.g., stipends for over-the-counter health expenses, improved transportation services, and caregiver assistance). Participants identified direct communication, emotional support, and referrals for resources as benefits of case management.

Describing the Lived Experience and Resource Needs of Individuals With Long COVID

Individuals with long COVID report diverse symptoms lasting weeks or months after initial infection, causing significant psychosocial distress. Navigating health care interactions are often difficult for these individuals due to the diffuse nature of their symptoms, a lack of effective treatment options, and skepticism from some providers. To better understand these challenges, this study sought to further describe the lived experience of individuals with long COVID. A survey was conducted with individuals evaluated for long COVID at a specialty clinic (n = 200), which included questions about prior conditions, symptoms, use of medical and support services, and information and resource needs. Participants reported a mean of 10.75 persistent symptoms, the most common being fatigue and difficulty concentrating, with broad effects on daily functioning. Participants saw a mean of 5.92 providers for treatment of their symptoms, and 88.5% identified health care providers as a trusted source of information. Interest in research findings (60.5%) and opportunities for participation (47.5%) were moderate and varied by COVID vaccination status. Unvaccinated individuals (n = 27) also reported less trust in government sources of information, less college education, lower household income, and greater likelihood of having public insurance. Our findings suggest that individuals with long COVID experience many ongoing and complex symptoms with diverse effects on daily living; that health care providers are an important source for public health messaging about long COVID; and that unvaccinated individuals are likely to have differing needs and receptiveness to information than vaccinated individuals with long COVID.

Trusted sources for COVID-19 testing and vaccination: lessons for future health communication

BACKGROUND

Promoting COVID-19 vaccination (both the primary series and boosters) remains a priority among healthcare professionals and requires understanding the various sources people trust for acquiring COVID-19 information.

METHOD

From October 2021 to May 2022, we interviewed 150 people who called 2-1-1 helplines in Connecticut and North Carolina about their COVID-19 testing and vaccination experiences in order to (1) better understand where people obtain trusted COVID-19 health information and (2) identify how public health professionals can share emergency health information in the future. We used a mixed methods approach in which semi-structured qualitative interviews and survey data were collected in parallel and analyzed separately.

RESULTS

Participants were mostly female (74.0%), Black (43.3%) or White (38.0%), and had a high school degree or higher (88.0%). Most had prior COVID-19 testing experience (88.0%) and were vaccinated (82.7%). A variety of information sources were rated as being very trustworthy including medical professionals and social service organizations. We found that repetition of information from multiple sources increased trust; however, perceived inconsistencies in recommendations over time eroded trust in health communication, especially from government-affiliated information sources. Observations such as seeing long lines for COVID-19 testing or vaccination became internalized trusted information.

CONCLUSIONS

Public health professionals can leverage the reach and strong community ties of existing, reputable non-government organizations, such as physician groups, schools, and pharmacies, to distribute COVID-19 information about vaccination and testing.

Development, construct validity, and measurement invariance of the Modified Classes of Racism Frequency of Racial Experiences Measure (M-CRFRE) to capture direct and indirect exposure to perceived racism-based police use of force for Black emerging adults

OBJECTIVES

To utilize focus groups, cognitive interviews, content expert panel, and computer-assisted surveys to develop and pilot survey items assessing exposure to perceived racism-based police violence to enhance the Classes of Racism Frequency of Racial Experiences (CRFRE).

METHOD

Focus groups and cognitive interviews were conducted with Black emerging adults (n = 44) in St. Louis, Missouri. Utilizing a grounded theory approach, a thematic analysis of the focus group and cognitive interview transcripts was conducted to identify key items to be added to the CRFRE. Three content experts assessed the face and content validity of survey items. Computer-assisted surveys were conducted to pilot the modified CRFRE with a sample of Black emerging adults (n = 300). Confirmatory factor analyses and structural paths were used to examine the construct validity of the modified CRFRE.

RESULTS

Participant's qualitative data and suggestions from content experts resulted in the development of 16 additional survey items regarding exposure to perceived racism-based police violence across three domains (victim, witness in person, and seen in media). The modified CRFRE measure showed construct validity, internal reliability, and measurement invariance between men and women.

CONCLUSIONS

This study advances our epidemiological methodology for quantifying exposure to perceived racism-based police violence. Future research is necessary to assess the prevalence of exposure to perceived racism-based police violence and associated mental and behavioral outcomes for Black emerging adults in the U.S. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Understanding Associations of Personal Values With Support for Tobacco and Alcohol Control Policies

INTRODUCTION

This cross-sectional analysis of the 2020 Health Information National Trends Survey (N=3,604) examines the associations of personal values with tobacco and alcohol control policy support, which may inform policy-related communication efforts.

METHODS

Respondents selected which of 7 value options they considered most important in their daily life and rated their support for 8 proposed tobacco and alcohol control policies (1=strongly oppose, 5=strongly support). Weighted proportions for each value were described across sociodemographic characteristics, smoking status, and alcohol use. Weighted bivariate and multivariable regressions tested the associations of values with mean policy support (alpha=0.89). Analyses occurred from 2021 to 2022.

RESULTS

The most frequently selected values were assuring my family is safe and secure (30.2%), being happy (21.1%), and making my own decisions (13.6%). Selected values varied across sociodemographic and behavioral characteristics. For example, people with lower education and incomes were overrepresented among those selecting making my own decisions and keeping myself in good health. After adjusting for sociodemographics, smoking, and alcohol use, people selecting family safety (β=0.20, 95% CI=0.06, 0.33) or religious connection (β=0.34, 95% CI=0.14, 0.54) as most important reported higher policy support than those selecting making their own decisions, the value associated with the lowest mean policy support. Mean policy support did not significantly differ across any other value comparisons.

CONCLUSIONS

Personal values are associated with support for alcohol and tobacco control policies, with making my own decisions associated with the lowest policy support. Future research and communication efforts may consider aligning tobacco and alcohol control policies with the idea of supporting autonomy.

Helping low-income smokers quit: findings from a randomized controlled trial comparing specialized quitline services with and without social needs navigation

Background

Quitting smoking is especially challenging for low-income smokers due to high stress, high smoking prevalence around them, and limited support for quitting. This study aimed to determine whether any of three interventions designed specifically for low-income smokers would be more effective than standard tobacco quitline services: a specialized quitline, the specialized quitline with social needs navigation, or the standard quitline with social needs navigation.

Methods

Using a randomized 2 × 2 factorial design, low-income daily cigarette smokers (n = 1944) in Missouri, USA who called a helpline seeking assistance with food, rent or other social needs were assigned to receive Standard Quitline alone (n = 485), Standard Quitline + Social Needs Navigation (n = 484), Specialized Quitline alone (n = 485), or Specialized Quitline + Social Needs Navigation (n = 490). The target sample size was 2000, 500 per group. The main outcome was 7-day self-reported point prevalence abstinence at 6-month follow-up. Multiple imputation was used to impute outcomes for those missing data at 6-month follow-up. Binary logistic regression analyses were used to assess differences between study groups.

Findings

Participants were recruited from June 2017 to November 2020; most were African American (1111 [58%]) or White (666 [35%]), female (1396 [72%]), and reported <$10,000 (957 [51%]) or <$20,000 (1529 [82%]) annual pre-tax household income. At 6-month follow-up (58% retention), 101 participants in the Standard Quitline group reported 7-day point prevalence abstinence (20.8% of those assigned at baseline, 38.1% after imputation). Quit rates in the Specialized Quitline (90 quitters, 18.6%, 38.1%) and Specialized Quitline + Social Needs Navigation (103 quitters, 21.0%, 39.8%) were not different from the Standard Quitline. Quit rates for Standard Quitline + Social Needs Navigation (74 quitters, 15.3%, 30.1%) were significantly lower than Standard Quitline (OR = 0.70, 95% CI = 0.50-0.98).

Interpretation

A specialized version of a state tobacco quitline was no more effective than standard quitline services in helping low-income smokers quit. Adding social needs navigation to a standard quitline decreased its effectiveness.

Trial registration

ClinicalTrials.gov Identifier: NCT03194958.

Funding

National Cancer Institute: R01CA201429.

Diabetes distress in a Medicaid sample: The role of psychosocial and health-related factors

AIMS

Diabetes-related distress can negatively affect disease management leading to worse complications, especially among marginalized populations. Prior studies mostly focus on distress' impact on diabetes outcomes, with few examining distress predictors. The current study examined the impact of social needs on distress on its own and after controlling for other socio-demographic, psychosocial, and health factors.

METHODS

Adult Medicaid beneficiaries with type 2 diabetes and a recent HbA1c test documented in claims data (<120 days) were recruited for a 12-month social needs intervention trial. Baseline survey data assessed diabetes distress, social needs, psychosocial factors and health factors. Descriptive statistics were obtained, and bivariate and multivariable logistic regression analyses were used to identify predictors of moderate to severe distress.

RESULTS

Bivariate analyses revealed social needs, stress, depression, comorbidity and comorbidity burden, poor self-rated health, insulin use, a self-reported HbA1c ≥ 9.0, and difficulty remembering to take diabetes medications were all positively associated with greater odds of diabetes distress; greater social support, diabetes self-efficacy, and age were negatively associated. Four variables remained significant in the multivariate model: depression, diabetes self-efficacy, self-reported HbA1c ≥ 9.0, and younger age.

CONCLUSIONS

Targeted distress screening efforts might prioritize people with HbA1c values >9.0, greater depression, and worse diabetes self-efficacy.

Gestational diabetes knowledge improves with interactive online training modules: a pre-post analysis

Background

The risk of developing type 2 diabetes mellitus (T2DM) is up to 50% among women with gestational diabetes mellitus (GDM). GDM also increases risks for pre-term birth, macrosomia, fetal hypoglycemia, and C-section delivery. Education for expectant mothers with GDM about nutrition, exercise, and the risks of developing T2DM after delivery enhances the probability of postpartum diabetes screening. However, the availability of diabetes education is limited. To bridge this gap, our team developed four training modules on GDM tailored for nurses and community health workers. This pilot study assesses changes in knowledge, self-efficacy for providing diabetes education, attitudes, and intentions to recommend diabetes prevention before and after training completion.

Methods

These interactive online modules, each lasting 45-60 minutes and featuring engaging case studies and integrated knowledge assessment questions, were disseminated through various professional organizations to clinical staff providing care for women with GDM. Optional pre- and post-training surveys were conducted to gauge the effectiveness of the modules. Collected data did not follow a normal distribution pattern. We provided an overview of the baseline characteristics of the population, self-efficacy, attitudes, intentions, and GDM knowledge by calculating the median scores and interquartile ranges. We assessed the changes in scores on self-efficacy, attitudes, intentions, and GDM knowledge before and after training using non-parametric Wilcoxon matched-pair signed rank tests.

Results

Eighty-two individuals completed baseline evaluation and 20 individuals accessed all modules and completed post-training assessments. Among those completing the training, improvement was noted in GDM knowledge [56.5% (16.0) v. 78.3% (22.0), p < 0.001], Self-efficacy for providing diabetes education [6.60 (2.73) v. 9.33 (0.87), p < 0.001], attitudes toward the value of tight control [4.07 (0.79) v. 4.43 (0.86), p = 0.003], and intentions to recommend diabetes prevention measures [4.81 (0.63) v. 5.00 (0.00), p = 0.009)].

Conclusions

Completion of our interactive online modules improved knowledge, intention to recommend diabetes prevention methods, self-efficacy to provide diabetes education, and attitudes toward the value of tight control among individuals caring for women with GDM. Enhanced accessibility to such curricula is crucial to improve access to diabetes education.

Trial registration

This study was registered at clinicaltrials.gov, identifier: NCT04474795.

Expanding population-level interventions to help more low-income smokers quit: Study protocol for a randomized controlled trial

BACKGROUND

Low-income Americans have higher rates of smoking and a greater burden of smoking-related disease. In the United States, smokers in every state can access evidence-based telephone counseling through free tobacco quitlines. However, quitlines target smokers who are ready to quit in the next 30 days, which can exclude many low-income smokers. A smoke-free homes intervention may help engage smokers in tobacco control services who are not yet ready to quit. Previous research in low-income populations suggests that receiving a smoke-free homes intervention is associated with higher quit rates. This study tests whether, at a population level, expanding on quitlines to include a smoke-free homes intervention for smokers not ready to quit could engage more low-income smokers and increase long-term cessation rates.

METHODS

In a Hybrid Type 2 design, participants are recruited from 211 helplines in 9 states and randomly assigned to standard quitline or quitline plus smoke-free homes intervention arms. Participants in both arms are initially offered quitline services. In the quitline plus smoke-free homes condition, participants who decline the quitline are then offered a smoke-free homes intervention. Participants complete a baseline and follow-up surveys at 3 and 6 months. Those who have not yet quit at the 3-month follow-up are re-offered the interventions, which differ by study arm. The primary study outcome is self-reported 7-day point prevalence abstinence from smoking at 6-month follow-up.

CONCLUSION

This real-world cessation trial involving 9 state tobacco quitlines will help inform whether offering smoke-free homes as an alternative intervention could engage more low-income smokers with evidence-based interventions and increase overall cessation rates. This study has been registered at ClinicalTrials.gov (Study Identifier: NCT04311983).

The role of defensive information processing in population-based colorectal cancer screening uptake

BACKGROUND

Internationally, colorectal cancer screening participation remains low despite the availability of home-based testing and numerous interventions to increase uptake. To be effective, interventions should be based on an understanding of what influences individuals' decisions about screening participation. This study investigates the association of defensive information processing (DIP) with fecal immunochemical test (FIT)-based colorectal cancer screening uptake.

METHODS

Regression modeling of data from a cross-sectional survey within a population-based FIT screening program was conducted. The survey included the seven subdomains of the McQueen DIP measure. The primary outcome variable was the uptake status (screening user or nonuser). Multivariable logistic regression was used to estimate the odds ratio (OR) for screening nonuse by DIP (sub)domain score, with adjustments made for sociodemographic and behavioral factors associated with uptake.

RESULTS

Higher scores (equating to greater defensiveness) on all DIP domains were significantly associated with lower uptake in the model adjusted for sociodemographic factors. In the model with additional adjustments for behavioral factors, the suppression subdomains of "deny immediacy to be tested" (OR, 0.53; 95% confidence interval [CI], 0.43-0.65; p < .001) and "self-exemption" (OR, 0.80; 95% CI, 0.68-0.96; p < .001) independently predicted nonuse of FIT-based screening.

CONCLUSIONS

This is the first study outside the United States that has identified DIP as a barrier to colorectal cancer screening uptake, and it is the first focused specifically on FIT-based screening. The findings suggest that two suppression barriers, namely denying the immediacy to be tested and self-exempting oneself from screening, may be promising targets for future interventions to improve uptake.

Appeal of Tobacco Quitline Services Among Low-Income Smokers

INTRODUCTION

State tobacco quitlines are delivering cessation assistance through an increasingly diverse range of channels. However, offerings vary from state to state, many smokers are unaware of what is available, and it is not yet clear how much demand exists for different types of assistance. In particular, the demand for online and digital cessation interventions among low-income smokers, who bear a disproportionate burden of tobacco-related disease, is not well understood.

METHODS

We examined interest in using 13 tobacco quitline services in a racially diverse sample of 1,605 low-income smokers in 9 states who had called a 2-1-1 helpline and participated in an ongoing intervention trial from June 2020 through September 2022. We classified services as standard (used by ≥90% of state quitlines [eg, calls from a quit coach, nicotine replacement therapy, printed cessation booklets]) or nonstandard (mobile app, personalized web, personalized text, online chat with quit coach).

RESULTS

Interest in nonstandard services was high. Half or more of the sample reported being very or somewhat interested in a mobile app (65%), a personalized web program (59%), or chatting online with quit coaches (49%) to help them quit. In multivariable regression analyses, younger smokers were more interested than older smokers in digital and online cessation services, as were women and smokers with greater nicotine dependence.

CONCLUSION

On average, participants were very interested in at least 3 different cessation services, suggesting that bundled or combination interventions might be designed to appeal to different groups of low-income smokers. Findings provide some initial hints about potential subgroups and the services they might use in a rapidly changing landscape of behavioral interventions for smoking cessation.

Leveling the Playing Field: Mailing Pharmacotherapy to Medicaid Members Who Smoke

INTRODUCTION

Smoking rates differ by insurance type; rates are often double for Medicaid and uninsured compared with that for Medicare or privately insured. State-funded tobacco quitlines' provision of free nicotine replacement therapy varies. In some states, Medicaid beneficiaries must obtain nicotine replacement therapy from a physician, whereas others get nicotine replacement therapy mailed to them.

METHODS

This secondary analysis examined the differences in the source and use of cessation treatment by insurance type and their impacts on cessation. The parent trial excluded people who were pregnant, had private insurance, or were not ready to quit. From June 1, 2017 to November 15, 2020, a total of 1,944 low-income people who smoke daily completed a baseline survey and were enrolled in a quitline program; 1,380 (71%) completed a 3-month follow-up. Analyses were completed in August 2022. Participants were classified as Medicaid/dual (55%), Medicare/Veterans Affairs (14%), or uninsured (31%). Nine months into the trial, owing to a system error, the quitline provided nicotine replacement therapy to all study participants regardless of insurance type.

RESULTS

Before error versus after error, Medicaid participants reported lower nicotine replacement therapy receipt (3.2% vs 50.8%) and use (32.4% vs 52.6%). The odds of quitting (7-day point prevalence) by 3 months increased for people who smoke who completed more quitline calls and used any (36% quit) versus used no (20% quit) pharmacotherapy, but quitting did not differ by insurance classifications (27%-29%). Getting and using nicotine replacement therapy from the quitline produced the highest quit rates (38%).

CONCLUSIONS

Results illustrate the benefit of receiving nicotine replacement therapy from the quitline on cessation. Mailing nicotine replacement therapy to all people who smoke should be standard practice to reduce smoking disparities.

"I'm Not Fighting Anymore So What Do I Do Now?" Young Women's Challenges While Transitioning Out of Active Breast Cancer Treatment and into Survivorship

Young women (18-45 years of age) with breast cancer often view the end of active treatment as a significant milestone. While completing treatment is largely celebrated, little is known about the immediate time after completing active treatment. The purpose of this qualitative, descriptive study was to explore the needs of young women survivors transitioning out of active breast cancer treatment and into survivorship. We used a qualitative design with convenience sampling of young women who completed active breast cancer treatment within the last 5 years to participate in semi-structured online focus groups from November 2020 to May 2021. Thematic analysis was used to reveal the needs as women transitioned out of active treatment and into survivorship. Thirty-three young women breast cancer survivors (75.8% White, 12.1% Black, 12.1% other) participated in 7 online focus groups each lasting approximately 90 min. Three dominant themes with accompanying subthemes emerged from the data: (1) "feeling like a different kind of woman" (physical [cognitive, weight, sexual] changes, emotional changes [defining normal, loss of purpose]); (2) lingering emotional trauma (active treatment, survivorship); and (3) recommendations (services needed, content needed). Participants in this study did not feel prepared for the physical and emotional changes associated with the transition from active treatment and into survivorship as identified in our 2 main themes of "feeling like a different kind of woman" and lingering emotional trauma. Participants recommended more thorough communication about expectations in survivorship focusing on physical aspects like cognitive, weight, and sexual changes as well emotional challenges like loss of identity in survivorship. More communication specific to young women could assist in the transition to survivorship.

Examining Psychosocial Correlates of a Home Smoking Ban Among Low-income Smokers: Analysis of Social Support, Unmet Social Needs, Perceived Stress, and Depressive Symptoms

Home smoking bans reduce exposure to second-hand smoke. Understanding how psychosocial factors are related to having a home smoking ban may lead to better interventions for populations less likely to have home smoking bans, including low-income smokers. In this study, we used baseline data from 1,944 participants in a randomized trial of low-income smokers in Missouri to explore psychosocial correlates of a total home smoking ban. Using logistic regression, we examined associations between psychosocial variables (social support, unmet social needs [e.g., food, housing], perceived stress, and depressive symptoms) and a total home smoking ban. 72% of participants were female, and 58% were Black/African American; 26% reported a home smoking ban. In unadjusted and adjusted models, greater social support was associated with greater likelihood of a home smoking ban. Stress was negatively associated with a ban in adjusted models only. The fact that most participants did not have a home smoking ban highlights the need for further intervention in this population. Results suggest links between social support and having a home smoking ban, although effect sizes were small. Smoke-free home interventions that increase social connectedness or leverage existing support may be especially effective. Tobacco control planners may also consider partnering with agencies addressing social isolation.

Social Needs Are Associated With Greater Anticipated Needs During an Emergency and Desire for Help in Emergency Preparedness Planning

OBJECTIVE

Most emergency preparedness planning seeks to identify vulnerable population subgroups; however, focusing on chronic conditions alone may ignore other important characteristics such as location and poverty. Social needs were examined as correlates of anticipated needs and desire for assistance during an emergency.

METHODS

A retrospective, secondary analysis was conducted using assessments of 8280 adult Medicaid beneficiaries in Louisiana, linked with medical (n = 7936) and pharmacy claims (n = 7473).

RESULTS

The sample was 73% female; 47% Black; 34% White; mean age 41 y. Many had at least 1 chronic condition (75.9%), prescription (90.3%), and social need (45.2%). Across assessments, many reported food (40%), housing (34%), and transportation (33%) needs. However, far more people anticipated social needs during an emergency than in the next month. Having social needs increased the odds of anticipating any need (odds ratio [OR] = 1.5, 1.44-1.56) and desire for assistance during an emergency, even after controlling for significant covariates including older age, race, geographic region, Medicaid plan type, and prescriptions. Chronic conditions were significantly correlated with all anticipated needs in bivariate analyses, but only modestly associated (OR = 1.03, 1.01-1.06) with anticipated medication needs in multivariable analyses.

CONCLUSIONS

Identifying individuals with social needs, independent of their chronic disease status, will benefit emergency preparedness outreach efforts.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

ZIP11 Regulates Nuclear Zinc Homeostasis in HeLa Cells and Is Required for Proliferation and Establishment of the Carcinogenic Phenotype

Zinc (Zn) is an essential trace element that plays a key role in several biological processes, including transcription, signaling, and catalysis. A subcellular network of transporters ensures adequate distribution of Zn to facilitate homeostasis. Among these are a family of importers, the Zrt/Irt-like proteins (ZIP), which consists of 14 members (ZIP1-ZIP14) that mobilize Zn from the extracellular domain and organelles into the cytosol. Expression of these transporters varies among tissues and during developmental stages, and their distribution at various cellular locations is essential for defining the net cellular Zn transport. Normally, the ion is bound to proteins or sequestered in organelles and vesicles. However, though research has focused on Zn internalization in mammalian cells, little is known about Zn mobilization within organelles, including within the nuclei under both normal and pathological conditions. Analyses from stomach and colon tissues isolated from mouse suggested that ZIP11 is the only ZIP transporter localized to the nucleus of mammalian cells, yet no clear cellular role has been attributed to this protein. We hypothesized that ZIP11 is essential to maintaining nuclear Zn homeostasis in mammalian cells. To test this, we utilized HeLa cells, as research in humans correlated elevated expression of ZIP11 with poor prognosis in cervical cancer patients. We stably knocked down ZIP11 in HeLa cancer cells and investigated the effect of Zn dysregulation in vitro. Our data show that ZIP11 knockdown (KD) reduced HeLa cells proliferation due to nuclear accumulation of Zn. RNA-seq analyses revealed that genes related to angiogenesis, apoptosis, mRNA metabolism, and signaling pathways are dysregulated. Although the KD cells undergoing nuclear Zn stress can activate the homeostasis response by MTF1 and MT1, the RNA-seq analyses showed that only ZIP14 (an importer expressed on the plasma membrane and endocytic vesicles) is mildly induced, which may explain the sensitivity to elevated levels of extracellular Zn. Consequently, ZIP11 KD HeLa cells have impaired migration, invasive properties and decreased mitochondrial potential. Furthermore, KD of ZIP11 delayed cell cycle progression and rendered an enhanced senescent state in HeLa cells, pointing to a novel mechanism whereby maintenance of nuclear Zn homeostasis is essential for cancer progression.

Re-examining phone counseling for smoking cessation: Does the evidence apply to low-SES smokers?

INTRODUCTION

A 2019 Cochrane review concluded telephone counseling is an effective intervention for smoking cessation. However, the review did not assess the role of socioeconomic status (SES) indicators on the effectiveness of telephone counseling.

METHODS

We reviewed 65 U.S. studies from the Cochrane review. We abstracted data on education, income, employment status and insurance status, and examined associations with targeted recruitment, intervention uptake, attrition, and cessation outcomes.

RESULTS

Except for education, SES indicators were seldom reported or used in analysis: 61 studies reported education, 24 reported insurance status, 23 reported employment status, and 17 reported income. Nine studies exclusively recruited low-SES samples. Thirteen studies examined associations between SES and smoking cessation. Among these, two reported lower education predicted greater cessation and two reported higher education predicted greater cessation. Other studies found higher income (n = 2) or employment type (n = 1) predicted cessation.

CONCLUSIONS

Evidence supporting telephone counseling for cessation is less clear when applied to low-SES smokers. Future research should directly assess intervention effectiveness in this priority population.

PRACTICE IMPLICATIONS

Given the evidence, it may be hard to justify future studies not focusing on low-SES populations. Innovative counseling solutions from providers helping low-income smokers quit should be evaluated to inform best practice.

Low housing quality, unmet social needs, stress and depression among low-income smokers

•

Over 60% of low-income smokers reported housing quality problems.

•

Problems with housing quality were among the most common social needs.

•

Housing quality problems were associated with worse measures of health.

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Poor housing quality may exacerbate health disparities for low-income smokers.

Smokers are at greater risk of multiple health conditions that are exacerbated by environmental hazards associated with low housing quality. However, little is known about the prevalence of low housing quality among low-income smokers. Using correlations and logistic regression, we examined associations among eight housing quality indicators – pests, water leaks, mold, lead paint, and working smoke detectors, appliances, heating, and air conditioning – and between housing quality and social needs, depressive symptoms, perceived stress, sleep problems, and self-rated health in a community-based sample of 786 low-income smokers from 6 states. Most participants were female (68%), and White (45%) or African-American (43%). One in four (27%) completed less than high school education, and 41% reported annual pre-tax household income of less than $10,000. Housing quality problems were common. Most participants (64%) reported at least one problem in their home, and 41% reported two or more problems, most commonly pest infestations (40%), water leaks (22%), lack of air conditioning (22%) and mold (18%). Lack of heat and air conditioning were correlated, as were water leaks and mold. Using logistic regression analyses controlling for participant demographic characteristics, we found that reporting more housing quality problems was associated with greater odds of worse mental and physical health outcomes. Multiple health threats, including housing quality, depressive symptoms, stress, poor sleep, and financial strain may be mutually reinforcing and compound the health consequence of smoking. Future research should seek to replicate these findings in other samples, and examine associations longitudinally to better understand causality.

Transportation and other social needs as markers of mental health conditions

Objective

The study sought to determine whether reporting a history of depression, anxiety, PTSD, bipolar disorder, drug or alcohol use disorder, ADHD, schizophrenia, or current depressive symptoms was associated with requesting help for any of 12 social needs.

Methods

A community-based sample of 1,944 low-income adult smokers in Missouri who had called a telephone helpline for social needs were recruited between June 1, 2017 and November 15, 2020. Helpline data on callers' requests for assistance with utilities, housing, food, household goods, healthcare, transportation, adult care, financial assistance, employment, legal assistance, personal safety and childcare were merged with self-reported mental health data collected in a subsequent phone survey with the same callers. Using binary logistic regression, we examined which mental health conditions were associated with each social need.

Results

Reporting mental health conditions were associated with greater odds of requests for assistance with transportation, food, healthcare and personal safety. Of these, the strongest and most consistent associations were with transportation needs. In post-hoc analyses, most associations between transportation needs and mental health remained significant after adjusting for possible confounders.

Conclusions

Compared to participants who did not report histories of mental health conditions, those who reported mental health conditions were more likely to call 2-1-1 seeking transportation assistance. Community-based agencies providing transportation or mental health services could partner to provide linkages between services and increase capacity to address transportation and mental health needs.

Associations among social needs, health and healthcare utilization, and desire for navigation services among US Medicaid beneficiaries with type 2 diabetes

The purpose of this study was to better understand the number and types of social needs experienced by Medicaid beneficiaries with type 2 diabetes, and how their social needs are associated with key health indicators. Also examined were factors that influence patients' interest in navigation services for health and social needs to inform future interventions and service delivery. The study expands upon prior research, much of which has focused on only one social need (e.g., food insecurity) or one health outcome. The hypothesis was that among individuals with type 2 diabetes, those with a greater number of social needs would report more health-related problems and be more interested in receiving social needs navigation services. Participants completed a cross-sectional survey by phone (n = 95) or online (n = 14). Most (85%) reported having at least one social need (M = 2.5, SD = 2.2), most commonly not having enough money for unexpected expenses (68%) or necessities like food, shelter and clothing (31%), medical costs (24%), and utilities (23%). Results supported our comprehensive conceptual model. Having more social needs was associated with greater perceived stress, diabetes distress, problems with sleep and executive and cognitive functioning, less frequent diabetes self-care activities, more days of poor mental health and activity limitations, worse self-reported health and more hospitalisations. Number of social needs also was positively associated with interest in having a social needs navigator. Social needs were not associated with days of poor physical health, BMI, self-reported A1C or smoking status. Social needs were associated with a wide range of indicators of poor health and well-being. Participants with the greatest social need burden were most open to intervention.

Observational study to estimate the proportion of surgical site infection following excision of ulcerated skin tumours (OASIS study)

BACKGROUND

Ulceration is a recognized risk factor for surgical site infection (SSI); however, the proportion of patients developing SSI after excision of an ulcerated skin cancer is unknown.

AIM

To determine the proportion of participants with SSI after surgical excision of an ulcerated skin cancer. A secondary aim was to assess feasibility outcomes to inform the design of a randomized controlled trial to investigate the benefits and harms of perioperative antibiotics following excision of ulcerated tumours.

METHODS

This was a multicentre, prospective, observational study of patients undergoing excision of an ulcerated skin cancer between March 2019 and March 2020. Prior to surgical excision, surface swabs of the ulcerated tumours of participants recruited from one centre were undertaken to determine organism growth. At 4 weeks after surgery, all participants were e-mailed or posted the Wound Healing Questionnaire (WHQ) to determine whether they had developed SSI.

RESULTS

In total, 148 participants were recruited 105 (70.9%) males; mean ± SD age 77.1 ± 12.3 years. Primary outcome data were available for 116 (78.4%) participants, of whom 35 (30.2%) were identified as having an SSI using the WHQ with a cutoff score of 8, and 47 (40.5%) were identified with a cutoff score of 6. Using the modified WHQ in participants with wounds left to heal by secondary intention, 33 (28.4%) and 43 (37.1%) were identified to have SSI respectively.

CONCLUSION

This prospective evaluation of SSI identified with the WHQ following excision of ulcerated skin cancers demonstrated a high proportion with SSI. The WHQ was acceptable to patients; however, further evaluation is required to ensure validity in assessing skin wounds.

Correlates of smoking discarded cigarettes in a sample of low-income adults

INTRODUCTION

Unconventional smoking behaviors such as smoking used or discarded cigarettes may increase the risk of nicotine dependence and exposure to toxins. To better understand low-income smokers who smoke discarded cigarettes and to inform effective tobacco cessation strategies, the current study examined potential correlates not considered in prior studies.

METHODS

This secondary analysis examined baseline data from 1936 low-income smokers participating in a randomized cessation trial. To assess smoking discarded cigarettes, participants were asked: "In the past 30 days, have you smoked what's left of a cigarette that someone else left behind?" Unadjusted and adjusted logistic regression were used to explore associations between smoking discarded cigarettes and social needs, social environment, mental and physical health, other smoking-related behaviors, and demographic characteristics.

RESULTS

One in six participants reported smoking discarded cigarettes. Younger smokers, men, smokers with lower incomes and those who were not employed were more likely to smoke discarded cigarettes. Other correlates included having unmet social needs (transportation, food, housing, physical safety, and neighborhood safety), living with other smokers, worse mental health, greater perceived stress, heavier smoking, using other tobacco products, and bumming cigarettes from others. In a multivariable model, income, social environment, and other smoking behaviors emerged as significant correlates.

CONCLUSIONS

In addition to financial hardship, mental health, and nicotine dependence, the social needs, social environment, and other smoking behaviors of low-income smokers are important correlates of smoking discarded cigarettes. Future research to understand and address tobacco health disparities should examine these relationships longitudinally.

Intention to vaccinate children for COVID-19: A segmentation analysis among Medicaid parents in Florida

COVID-19 vaccines have been granted emergency use authorization for children ages 5 years and older. To understand how racially and ethnically diverse parents of young children enrolled in Medicaid feel about a prospective COVID-19 vaccine for their children, we administered an online survey that included both close-ended and open-ended items to a statewide sample in Florida (n = 1951). We used quantitative responses to conduct a statistical audience segmentation analysis that identified five distinct sub-groups that varied widely in the likelihood that they would get a COVID-19 vaccine for their child. Qualitative responses were used to illustrate differences between the groups. The youngest Black and White mothers were least likely to vaccinate their child (24%), followed by Black and White mothers in their early 30s (36%), younger Hispanic and mixed-race or other race parents (45%), older mothers (48%) and older fathers (71%). Unique challenges to building vaccine confidence emerged for each group. The youngest Black and White mothers were more likely to report their lives being worse during the COVID-19 pandemic, were far more negative and less positive about a COVID-19 vaccine, and were more concerned about paying bills than preventing COVID-19. Younger Hispanic and mixed-race parents were less negative, but more likely to use emotional language (e.g., scared, nervous, worried) talking about a COVID-19 vaccine, and more likely to report that protecting their child's health was their top concern. Recommendations are made for applying the insights gained in outreach and education efforts.

Assessing Racial and Ethnic Discrimination in Children: A Scoping Review of Available Measures for Child Health Disparities Research

Objectives: To characterize the availability, content, and psychometric properties of self-reported measures that assess race/ethnicity-related discrimination or psychosocial stress and have potential relevance to studies of health disparities in children and adolescents.

Design: Using PRISMA extension guidelines for scoping reviews, we searched Ovid Medline, CINAHL, PsychInfo, and Scopus databases from 1946 to April 20, 2020, using the search terms “stress,” “child,” “adolescents,” “discrimination,” and “psychometrics.” We limited the search to articles in English, with children and adolescents, in the United States. For each measure, we extracted information about the content, reliability, and construct validity.

Results: The 12 measures that met inclusion criteria assessed discrimination or stress from racial discrimination in African American children and adolescents (n=8), acculturative stress in Hispanic/Latino children (n=1), or bicultural stress in Mexican American adolescents (n=2), and one measure assessed both discrimination-related and acculturative stress in Hispanic/Latino children. The majority (n=7) articles were published between 2001 and 2010. All discrimination measures evaluated individual experiences of discrimination and one also evaluated stressfulness of discrimination and coping. The acculturative stress measures assessed general stress and immigration-related discrimination, and the bicultural stress measures evaluated many different aspects of biculturalism.

Conclusions: Despite the recent increased interest in the racial discrimination and stress as a contributor to racial or ethnic health disparities affecting U.S. children and adolescents, the small number of eligible measures identified and incomplete coverage of various types of racial and ethnic discrimination within and across population groups indicates a currently inadequate capacity to conduct child health disparity studies on this issue.

Stress, depression, sleep problems and unmet social needs: Baseline characteristics of low-income smokers in a randomized cessation trial

BACKGROUND

Low-income Americans smoke cigarettes at higher rates and quit less than other groups.

METHODS

To increase their engagement in and success using evidence-based cessation methods, we tested two interventions using a 2x2 randomized factorial design: (1) telephone navigation to reduce financial strain and address social needs such as food, rent and utility payment; and (2) a specialized tobacco quitline designed for low-income smokers. From June 2017 to November 2020, we enrolled 1,944 low-income smokers in Missouri, USA, recruited through the Missouri 2-1-1 helpline, into the trial. This paper describes recruitment, key characteristics and life circumstances of this high-risk population.

RESULTS

After eligibility screening, 1,944 participants completed baseline and were randomized. Participants were racially diverse (58% African American), poor (51% < $10,000 annual pre-tax household income) and many reported less than high school education (30%). They reported a mean of 2.5 unmet social needs, especially childcare and paying bills, had high rates of stress, depressive symptoms and sleep problems, and most were in fair or poor health. There were few differences between these variables, and no differences between tobacco use and cessation variables, across the four study groups and between participants recruited pre and during the COVID-19 pandemic.

CONCLUSIONS

Trial recruitment through the 2-1-1 helpline is feasible for reaching a population of low-income smokers. Low-income smokers face myriad daily challenges beyond quitting smoking. Cessation interventions need to account for and address these life circumstances.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03194958.

195 The Application of Radiomics in Laryngeal Cancer: The Forgotten Cohort

Background

Radiomics is a novel method of extracting data from medical images that is difficult to visualise through the naked eye. This technique transforms digital images that hold information on pathology into high-dimensional-data for analysis. Radiomics has the potential to enhance laryngeal cancer care and to date, has shown promise in various other specialties.

Aim

The aim of this review is to summarise the applications of this technique to laryngeal cancer and potential future benefits.

Method

A comprehensive systematic review-informed search of the MEDLINE and EMBASE online databases was undertaken. Keywords ‘laryngeal cancer’ OR ‘larynx’ OR ‘larynx cancer’ OR ‘head and neck cancer’ were combined with ‘radiomic’ OR ‘signature’ OR ‘machine learning’ OR ‘artificial intelligence’. Additional articles were obtained from bibliographies using the ‘snowball method’.

Results

Seventeen articles were identified that evaluated the role of radiomics in laryngeal cancer. Two studies affirmed the value of radiomics in improving the accuracy of staging, whilst fifteen studies highlighted the potential prognostic value of radiomics in laryngeal cancer. Twelve (of thirteen) studies incorporated an array of different head and neck cancers in the analysis and only one study assessed laryngeal cancer exclusively.

Conclusions

Literature to date has various limitations including, small and heterogeneous cohorts incorporating patients with head and neck cancers of distinct anatomical subsites and stages. The lack of uniform data on solely laryngeal cancer and radiomics means drawing conclusions is difficult, although these studies have affirmed its value. Further large prospective studies exclusively in laryngeal cancer are required to unlock its true potential.

Expressed and unexpressed social needs in low-income adults in the U.S

Many healthcare organisations are now routinely screening patients for social needs such as food and housing. It is largely unknown whether the needs they identify would have been expressed by the patient in the absence of screening. To better understand expressed and unexpressed social needs, we administered a social needs screener to 1,397 low-income adults who called a 2-1-1 helpline in Missouri seeking assistance with social needs between June 2017 and October 2019. Merging data from the screener and 2-1-1, we found that the screener identified all of the social needs expressed to 2-1-1 for about half the participants, and on average identified at least one social need not expressed to 2-1-1 (i.e., unexpressed needs). Certain social needs (utility payment assistance, housing) were much more likely to be expressed than unexpressed, while others (childcare, employment, personal safety) were almost universally unexpressed. In regression analyses, having certain expressed needs significantly increased the odds of having certain unexpressed needs. For example, those seeking transportation assistance from 2-1-1 had greater odds of unexpressed needs for food (OR = 3.19; 95% CI = 1.45-7.02) and healthcare (OR = 2.18; 95% CI = 1.06-4.48) than those not expressing transportation needs. Those seeking employment assistance from 2-1-1 had greater odds of unexpressed needs for personal safety (OR = 3.04; 95% CI = 1.20-7.68) and healthcare (OR = 2.58; 95% CI = 1.15-5.77) than those not expressing employment needs. Implications for healthcare (screening detects expressed and unexpressed needs) and social service organisations (certain requests may be markers for other needs) are discussed.

Assessing The Capacity Of Local Social Services Agencies To Respond To Referrals From Health Care Providers

Health care providers are increasingly screening low-income patients for social needs and making referrals to social services agencies to assist in resolving them. A major assumption of this approach is that local social services providers have the capacity and resources to help. To explore this assumption, we examined 711,613 requests related to fifty different social needs received from callers to 211 helplines in seven states during 2018. Our analyses focused on the proportion of requests for which referrals could not be made because of low capacity in the social services system. We examined the extent to which the capacity of this system varied by type of social need, ZIP code, and time of year, and we classified social needs in a new typology based on prevalence and system capacity. It is clear that health care's current screening and referral approach is appropriate for some social needs but not others.

Social Needs, Chronic Conditions, and Health Care Utilization among Medicaid Beneficiaries

Health care organizations are increasingly assessing patients' social needs (eg, food, utilities, transportation) using various measures and methods. Prior studies have assessed social needs at the point of care and many studies have focused on correlates of 1 specific need (eg, food). This comprehensive study examined multiple social needs and medical and pharmacy claims data. Medicaid beneficiaries in Louisiana (n = 10,275) completed a self-report assessment of 10 social needs during July 2018 to June 2019. Chronic health conditions, unique medications, and health care utilization were coded from claims data. The sample was predominantly female (72%), Black (45%) or White (32%), had a mean age of 42 years, and at least 1 social need (55%). In bivariate analyses, having greater social needs was associated with greater comorbidity across conditions, and each social need was consistently associated with mental health and substance use disorders. In multivariable logistic analyses, having ≥2 social needs was positively associated with emergency department (ED) visits (OR = 1.39, CI = 1.23 - 1.57) and negatively associated with wellness visits (OR = 0.87, CI = 0.77 - 0.98), inpatient visits (OR = 0.87, CI = 0.76 - 0.99), and 30-day rehospitalization (OR = 0.66, CI = 0.50 - 0.87). Findings highlight the greater concomitant risk of social needs, mental health, and substance use. Admission policies may reduce the impact of social needs on hospitalization. Chronic disease management programs offered by health plans may benefit from systematically assessing and addressing social needs outside point-of-care interactions to impact health outcomes and ED utilization. Behavioral health care management programs would benefit from integrating interventions for multiple social needs.

Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health

There has been an explosion of interest in addressing social needs in health care settings. Some efforts, such as screening patients for social needs and connecting them to needed social services, are already in widespread practice. These and other major investments from the health care sector hint at the potential for new multisector collaborations to address social determinants of health and individual social needs. This article discusses the rapidly growing body of research describing the links between social needs and health and the impact of social needs interventions on health improvement, utilization, and costs. We also identify gaps in the knowledge base and implementation challenges to be overcome. We conclude that complementary partnerships among the health care, public health, and social services sectors can build on current momentum to strengthen social safety net policies, modernize social services, and reshape resource allocation to address social determinants of health.

Translating Cancer Risk Prediction Models into Personalized Cancer Risk Assessment Tools: Stumbling Blocks and Strategies for Success

Cancer risk prediction models such as those published in Cancer Epidemiology, Biomarkers, and Prevention are a cornerstone of precision medicine and public health efforts to improve population health outcomes by tailoring preventive strategies and therapeutic treatments to the people who are most likely to benefit. However, there are several barriers to the effective translation, dissemination, and implementation of cancer risk prediction models into clinical and public health practice. In this commentary, we discuss two broad categories of barriers. Specifically, we assert that the successful use of risk-stratified cancer prevention and treatment strategies is particularly unlikely if risk prediction models are translated into risk assessment tools that (i) are difficult for the public to understand or (ii) are not structured in a way to engender the public's confidence that the results are accurate. We explain what aspects of a risk assessment tool's design and content may impede understanding and acceptance by the public. We also describe strategies for translating a cancer risk prediction model into a cancer risk assessment tool that is accessible, meaningful, and useful for the public and in clinical practice.

Client Perspectives on Health Coaching: Insight for Improved Program Design

Objective: In this paper, we examine client perspectives of health coaching programs and differences by insurance type. Methods: We used descriptive coding and directed content analysis to analyze semi-structured qualitative in-person interviews that assessed preferred health coach qualifications and experience, desirable attributes for coaches, and interest in having a coach. We recruited participants (N = 140 adults: 61 commercial insurance, 79 Medicaid) without consideration of prior health coaching experience. Results: Participants viewed physicians as the experts on health and valued coaches as supporters of behavior-change efforts that could take a patient's life context into account. Empathetic coaches were expected to motivate and hold patients accountable without taking too much time or being too "pushy." Participants preferred some in-person interaction and differed in preferences for program referral and enrollment approaches. Medicaid beneficiaries had less prior exposure to health coaching, more interest in having a coach, and preferred coaches to provide medical education. Conclusions: Irrespective of prior coaching experience or insurance type, participants agreed on many preferred characteristics of coaches and coaching programs. Understanding client preferences and expectations can help refine the role of health coaches, making them more effective and shaping the way they are presented to potential participants to enhance their appeal and use.

How Do Social Needs Cluster Among Low-Income Individuals?

Social needs screening in health care settings reveals that many low-income individuals have multiple unmet social needs at the same time. Having multiple simultaneous social needs greatly increases the odds of experiencing adverse health outcomes. To better understand how and which social needs cluster in these cases, the authors examined data from 14,749 low-income adults who completed a social needs assessment in one of 4 separate studies conducted between 2008 and 2019 in the United States. Participants were Medicaid beneficiaries, helpline callers, and daily smokers. Findings were strikingly consistent across the 4 studies. Participants with ≥2 social needs (n = 5621; 38% of total) experienced more stress, depressive symptoms, sleep problems, and chronic diseases and were more likely to rate their health as fair or poor. Social needs reflecting financial strain were highly correlated, such as needing help paying utility bills and needing money for necessities such as food, shelter, and clothing (r = .49 to .71 across studies). Participants experienced 351 distinct combinations of ≥2 social needs. The 10 most common combinations accounted for more than half of all participants with ≥2 needs. Clusters of social needs varied by subgroups. Women with children were more likely than others to need more space in their home and help paying utility bills; low-income men were more likely to be physically threatened and need a place to stay; older, sicker adults were more likely to need money for necessities and unexpected expenses, as well as transportation. Findings are discussed in the context of creating smarter, more efficient social needs interventions.

Improving Adherence to Colorectal Cancer Screening: A Randomized Intervention to Compare Screener vs. Survivor Narratives

Interventions are needed to increase colorectal cancer screening (CRCS) uptake. Narratives may have advantages over didactic information. We tested different narratives for increasing CRCS intentions and behaviors, and examined their mechanisms of influence. We randomized 477 unscreened adults 50-75 years old to one of three groups: CRCS information only (1) or CRCS information plus a photo and text narrative of a CRC survivor (2) or CRC screener who did not have cancer (3). Photos were tailored on participants' sex, age group, and race/ethnicity. Participants completed online surveys before and after intervention exposure, and 1-, 6-, and 12-months follow-up. Thirty percent of participants completed CRCS. Narrative conditions (vs. information only) were negatively associated with intention, but also positively influenced intentions through greater emotional engagement. Survivor (vs. screener) narratives were positively associated with CRCS, and had mixed effects on intention - positively through emotional engagement and negatively through self-referencing engagement to self-efficacy. Survivor narratives elicited more negative affect, which had positive and negative influences on intention. Continued research using path models to understand the mechanisms of narrative effects will inform theory development and message design. Additional measurement evaluation is needed to adequately capture and then compare the effects of different components of narrative engagement.

Adapting a self-affirmation intervention for use in a mobile application for smokers

Self-affirmation interventions can reduce defensive responses to threats to the self, but have had limited reach to the general population. We sought to create an effective and feasible version of the Kindness Questionnaire self-affirmation intervention for use on a mobile device outside the traditional university laboratory setting and by non-student participants. In an online experiment, 603 cigarette smokers (M_age= 37.5 years, SD = 10.2) were randomly assigned to one of six conditions in a 2 (Self-Affirmation: Self-Affirmation, No Self-Affirmation Control) × 3 (Example Type: Written, Imagined, No Examples) fully-crossed design. Participants read a message about the health harms of smoking. None of the self-affirmation variations were effective or feasible: the self-affirmation showed null effects on the primary outcomes of message acceptance, perceived message effectiveness, and reactance. It also backfired by reducing intentions to quit smoking and risk perceptions. Participants spent little time reading the health message, and those in the written self-affirmation condition infrequently provided detailed responses. Translating interventions developed and tested for efficacy in laboratory settings to "real-world" settings is necessary but challenging.

Specialized tobacco quitline and basic needs navigation interventions to increase cessation among low income smokers: Study protocol for a randomized controlled trial

Smoking in the United States follows a clear socioeconomic gradient: low-income Americans smoke more and quit less than those with more education and income. Evidence-based interventions like tobacco quitlines are designed to make effective cessation services available on a population basis to all smokers. However, these interventions do not address many of the unique challenges faced by low-income smokers, including unmet basic needs like food, housing, personal safety and money for necessities that often supersede health needs. Research is needed to maximize the use and effectiveness of tobacco quitlines in low-income populations. This paper details the rationale, design and methods for a 2 × 2 randomized controlled trial currently underway comparing the effects of Standard and Specialized Tobacco Quitlines with and without Basic Needs Navigation on intervention engagement and smoking cessation among low-income smokers. Smokers are recruited from United Way 2-1-1 in Missouri and all participants receive tobacco quitline services from Optum. Quitline and navigation services are provided for 3 months. Participants complete telephone surveys at baseline, 3- and 6-month follow up. The primary study outcome is self-reported 7-day point prevalence abstinence at 6-month follow up. Embedding the study in practice agencies will accelerate dissemination and scalability should our findings demonstrate intervention effectiveness.

Social Needs and Health-Related Outcomes Among Medicaid Beneficiaries

Unmet social needs-including food, housing, and utilities-have been associated with negative health outcomes, but most prior research has examined the health associations with a single unmet need or analyzed samples that were homogeneous along one or more dimensions (e.g., older adults or patients with chronic health conditions). We examined the association between unmet social needs and psychosocial and health-related outcomes in a sample of Medicaid beneficiaries from 35 U.S. states. In 2016-2017, 1,214 people completed an online survey about social needs, demographics, and health-related and psychosocial outcomes. Seven items assessing social needs formed an index in which higher scores indicated higher levels of unmet needs. Participants were eligible if they were ≥18 years and had Medicaid. The sample was predominantly female (87%). Most (71%) lived with at least one child ≤18 years, and 49% were White and 33% were African American. Average age was 36 years ( SD = 13). The most common unmet needs were not enough money for unexpected expenses (54%) and not enough space in the home (25%). Analyses controlling for recruitment method and demographics showed that increasing levels of unmet social needs were positively associated with stress, smoking, and number of chronic conditions, and negatively associated with future orientation, attitudes toward prevention, days of exercise/week, servings of fruits or vegetables/day, and self-rated health (all p < .01). Results add to the evidence about the relationship between unmet social needs and health. Interventions to help meet social needs may help low-income people improve both their economic situations and their health.

Perceptions of Health Coaching for Behavior Change Among Medicaid and Commercially Insured Adults

Use of health coaching to help individuals make and sustain changes in health behavior and disease management is increasing, and early evidence about its effects is promising. However, few studies assess participants' preferences and expectations about health coaches, the use of the term health coach, and the coaching relationship. To help inform the design of future health coaching programs, we conducted qualitative interviews with 50 U.S. adults (25 with Medicaid, 25 commercially insured) to assess their (1) sources of health information; (2) familiarity with, preferences for, and associations with 32 terms that could describe "someone who uses experience and one-on-one communication to help others change behaviors to improve their health;" and (3) perceptions of how well different terms apply across different health behaviors and for nonhealth concerns (e.g., financial, career). Results showed wide variability in preferences for different coaching terms and mental models of coaching that differed by insurance type. Commercially insured participants made a distinction between experts and supporters as different categories of coaches. Medicaid participants associated coach with sports and viewed the term as less professional. All participants preferred terms such as advisor and specialist, and all wanted content experts who could also appreciate the broader context of their life.

Reducing "I Don't Know" Responses and Missing Survey Data: Implications for Measurement

BACKGROUND

"I don't know" (DK) responses are common in health behavior research. Yet analytic approaches to managing DK responses may undermine survey validity and researchers' ability to interpret findings.

OBJECTIVE

Compare the usefulness of a methodological strategy for reducing DK responses to 3 analytic approaches: 1) excluding DKs as missing data, 2) recoding them to the neutral point of the response scale, and 3) recoding DKs with the mean.

METHODS

We used a 4-group design to compare a methodological strategy, which encourages use of the response scale after an initial DK response, to 3 methods of analytically treating DK responses. We examined 1) whether this methodological strategy reduced the frequency of DK responses, and 2) how the methodological strategy compared to common analytic treatments in terms of factor structure and strength of correlations between measures of constructs.

RESULTS

The prompt reduced DK response frequency (55.7% of 164 unprompted participants vs. 19.6% of 102 prompted participants). Factorial invariance analyses suggested equivalence in factor loadings for all constructs throughout the groups. Compared to excluding DKs, recoding strategies and use of the prompt improved the strength of correlations between constructs, with the prompt resulting in the strongest correlations (.589 for benefits and intentions, .446 for perceived susceptibility and intentions, and .329 for benefits and perceived susceptibility).

LIMITATIONS

This study was not designed a priori to test methods for addressing DK responses. Our analysis was limited to an interviewer-administered survey, and interviewers did not probe about reasons for DK responses.

CONCLUSION

Findings suggest that use of a prompt to reduce DK responses is preferable to analytic approaches to treating DK responses. Use of such prompts may improve the validity of health behavior survey research.

The role of physical activity enjoyment in the pathways from the social and physical environments to physical activity of early adolescent girls

Most girls experience a notable decline in physical activity (PA) in early adolescence, increasing their risk for harmful health outcomes. Enjoyment for PA (i.e., positive feelings toward PA) is a determinant of PA among girls during adolescence and sustained PA throughout adulthood. Previous studies recommended increasing girls' PA enjoyment in order to increase their PA, but did not include environmental-level strategies for how families, schools, or communities do this. To gain insight on such strategies, this study examines the role of PA enjoyment as a mediator of social and physical environments to moderate-to-vigorous intensity PA of early adolescent girls. Cross-sectional, secondary analyses, using structural equation modeling, were conducted on a U.S. national dataset of 1721 sixth grade girls from the Trial of Activity for Adolescent Girls in 2003. Mediation model fit parameters included χ2 (292, N = 1721) = 947.73 p < 0.001, CFI = 0.95, RMSEA = 0.04 (90% CI = 0.03, 0.04), and SRMR = 0.037 suggesting overall good fit. There were no indirect effects on PA through PA enjoyment from the social or physical environmental factors. To PA, there were significant direct effects only from social support from friends (β = 0.15, CI = 0.09, 0.22). To PA enjoyment, there were significant direct effects from social support from family (β = 0.15, CI = 0.08, 0.23), school climate (teachers β = 0.15, CI = 0.10, 0.21 and boys β = 0.15, CI = 0.09, 0.20), and neighborhood environment (β = 0.10, CI = 0.04, 0.17). The findings of this study identified several direct effects of the social and physical environment on PA enjoyment that can begin to inform environmental-level strategies for increasing PA enjoyment among early adolescent girls.

Results from a psychometric assessment of a new tool for measuring evidence-based decision making in public health organizations

BACKGROUND

In order to better understand how to improve evidence-based decision making (EBDM) in state health departments, measurement tools are needed to evaluate changes in EBDM. The purpose of this study was to test the psychometric properties of a new measurement tool to assess EBDM in public health practice settings.

METHODS

A questionnaire was developed, pilot-tested and refined in an iterative process with the input of public health practitioners with the aim of identifying a set of specific measures representing different components of EBDM. Data were collected in a national survey of state health department chronic disease practitioners. The final dataset (n=879) for psychometric testing was comprised of 19 EBDM items that were first examined using exploratory factor analysis, and then confirmatory factor analysis.

RESULTS

The final model from confirmatory factor analysis includes five latent factors representing components of EBDM: capacity for evaluation, expectations and incentives for EBDM, access to evidence and resources for EBDM, participatory decision making, and leadership support and commitment.

CONCLUSIONS

This study addresses the need for empirically tested and theory-aligned measures that may be used to assess the extent to which EBDM is currently implemented, and further, to gauge the success of strategies to improve EBDM, in public health settings. This EBDM measurement tool may help identify needed supports for enhanced capacity and implementation of effective strategies.

Abstract C45: Rural-urban and access to care differences in cervical cancer stage at diagnosis

Purpose: Rural women are less likely to have regular Pap smears and often have less access to care than their urban peers, which may lead to more advanced stage at diagnosis of cervical cancer. We sought to evaluate the relationship of rural-urban status and access to care on cervical cancer stage at diagnosis.

Methods: We extracted 2007 to 2013 Surveillance Epidemiology and End Results (SEER) 18 data on cervical cancer cases diagnosed in women aged 21 to 65 (n=19,492), the age recommended for Pap smears. SEER 18 registries include roughly 30% of the U.S. population. Case-level variables included rural-urban status, stage at diagnosis, age, race/ethnicity, insurance status, and marital status. Staging was categorized as I, II, III, IV, or unknown. We also examined county-level socioeconomic factors matched to cases' county of residence (% below poverty, median household income, and % of adults without a high school education) extracted from SEER. Using data from the Area Health Resource File, we calculated the mean density of both primary care physicians and obstetricians/gynecologists per 100,000 women aged 20-65 in each SEER 18 county. We also classified each county by its designation as a health professional shortage area for primary care. We performed chi-square analysis to compare stage at diagnosis, demographic, socioeconomic, and access to care characteristics of cases by rural-urban status. Socioeconomic and access to care variables were categorized by quartiles. We performed multivariable, modified Poisson regression to calculate the relative risk (RR) of Stage I to II (early vs. moderate early) and Stage I to III/IV (early vs. advanced) by rural, demographic, socioeconomic and access to care variables. RRs were also calculated stratified by rural-urban status.

Results: Rural cancer cases were poorer, were more likely to be on Medicaid or be uninsured, and had less access to primary care physicians and obstetricians/gynecologists than urban cases, but there was no rural-urban difference in stage or age at diagnosis. Age, black race, insurance status, being single/divorced/widowed, and county-level poverty were associated with more advanced stage at diagnosis. For example, compared to privately insured cases, women with Medicaid or who were uninsured were more likely to be diagnosed at an advanced stage (RR= 1.45; 95% confidence interval (CI)1.39-1.51 and RR=1.47; 95% CI 1.36-1.57, respectively). Among urban cervical cancer cases, age, black race, and being single/divorced/widowed were associated with both moderate early and advanced stage. The highest quartile of poverty and the lowest density of primary care physicians also was associated with advanced stage at diagnosis. Among rural cervical cancer cases, age and insurance status were associated with both moderate early and advanced stage at diagnosis. The effect of age on advanced staging was of greater magnitude in rural cases than in urban cases. In urban women, compared to women aged 20-29, cases aged 30-39 and 40-65 were at greater risk for advanced stage cancer (RR=1.37; 95% CI 1.23-1.54 and RR=2.24, 95% CI 2.00-2.51, respectively). In rural women, cases aged 30-39 (RR=2.31, 95% CI 1.49-3.59) and 40-65 (RR=3.51, 95% CI 2.27-5.43) had more than two to three times the risk, respectively, of advanced staged cervical cancer than their younger peers.

Conclusions: We did not find rural-urban or access to care disparities in stage at diagnosis. However, other socio-demographic factors were associated with more advanced stage, and the magnitude of such factors differed by rural-urban status. Future research should be performed to elucidate the relationship between these factors and staging, and interventions should be targeted by rural-urban specific factors.

Citation Format: Whitney Zahnd, Amy McQueen, Rebecca Lobb, Paula Diaz-Sylvester, Laurent Brard. Rural-urban and access to care differences in cervical cancer stage at diagnosis. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C45.