Addressing social determinants of health for colorectal cancer in the African American population: STAT (Screen, Trust, Access, Treat) phase I study

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Background: Colorectal cancer (CRC) is the third most common cancer and third leading cause of cancer deaths among African Americans, who have the highest CRC rates compared to other racial/ethnic groups, in the United States. STAT (Screen, Trust, Access, Treat) is a three-phase study assessing attitudes and perceptions related to disparities in CRC screening, treatment and clinical trial participation in the African American population. STAT Phase I surveyed attitudes/perceptions among health care providers (HCPs) and Phase II is ongoing to survey African American patients with CRC; in Phase III, data collected from Phases I/II will be used to design and test multiple interventions to reduce CRC disparities among African Americans. Here we present findings from STAT Phase I. Methods: Using non-probability and convenience sampling methodology, a survey link was exposed to over 3,000 HCPs through partnering non-profit health care organizations. The 20-item survey evaluated practitioner views on strategies for overcoming social determinants of health (SDOH), improving CRC outcomes among African Americans, and barriers/motivators for clinical trial enrolment. Results: Respondents (n = 109) comprised oncologists (53%), primary care providers (29%), gastroenterologists (2%), and representatives from other specialties (16%). They were predominantly White/Caucasian (65%); 22% were Asian/Asian American, 11% were African American/Black, and 6% were Hispanic/Latino. To overcome SDOH disparities, most HCPs used translation/interpreter services (83%), offered patients information in multiple languages (76%), and asked them to repeat back care instructions (73%); however, fewer offered provisions such as SDOH assessments (50%), access to financial assistance (66%), and transportation services (45%). Most HCPs agreed or strongly agreed they were prepared to care for patients from cultures differing from their own (91%), with health beliefs conflicting with Western medicine (71%), and with limited health literacy (83%). Increased community-based education (85%), community access to stool-based cancer screening tests (71%), and improved access to primary care physicians (69%) were viewed by HCPs as the favoured approaches to improve CRC outcomes among African Americans. Lack of awareness (43%) was reported as the predominant barrier to clinical trial enrolment, and HCPs agreed or strongly agreed that a patient eligibility screening system (86%) or clinical trial alert system (73%) would be a motivator to engage in clinical trials. Conclusions: Results from STAT Phase I reveal opportunities for HCPs to overcome inequities due to SDOH. Together with ongoing/planned research in STAT Phases II and III, these findings could inform strategies to reduce existing disparities in CRC care and improve outcomes for the African American population.

Cancer Informatics for Cancer Centers (CI4CC): Building a Community Focused on Sharing Ideas and Best Practices to Improve Cancer Care and Patient Outcomes

Cancer Informatics for Cancer Centers (CI4CC) is a grassroots, nonprofit 501c3 organization intended to provide a focused national forum for engagement of senior cancer informatics leaders, primarily aimed at academic cancer centers anywhere in the world but with a special emphasis on the 70 National Cancer Institute-funded cancer centers. Although each of the participating cancer centers is structured differently, and leaders' titles vary, we know firsthand there are similarities in both the issues we face and the solutions we achieve. As a consortium, we have initiated a dedicated listserv, an open-initiatives program, and targeted biannual face-to-face meetings. These meetings are a place to review our priorities and initiatives, providing a forum for discussion of the strategic and pragmatic issues we, as informatics leaders, individually face at our respective institutions and cancer centers. Here we provide a brief history of the CI4CC organization and meeting highlights from the latest CI4CC meeting that took place in Napa, California from October 14-16, 2019. The focus of this meeting was "intersections between informatics, data science, and population science." We conclude with a discussion on "hot topics" on the horizon for cancer informatics.

Community-level Adverse Experiences and Emotional Regulation in Children and Adolescents

PURPOSE

The association of adverse childhood experiences (ACEs) with negative health outcomes is well established, and the concept of allostatic load has been proposed as a possible causal mechanism. Most studies measure conventional (household) ACE exposures without accounting for non-conventional (community) ACE exposures, which may underrepresent the adversity experienced by racial/ethnic minorities. We address this gap by calculating the prevalence of both types of ACE exposures for racial/ethnic subgroups. We also examine associations of ACE exposures and emotional regulation in school aged children and youth.

DESIGN AND METHODS

This study used data (n = 65,680) for a nationally representative sample of children ages 6 to 17 years in the National Survey of Children's Health (2011-2012). Confirmatory factor analysis, descriptive statistics and regression models were used to examine the relationships between ACEs and emotional regulation.

RESULTS

Community level ACE events disproportionately affect ethnic minorities. Some but not all ACEs were significantly and inversely associated with the ability to emotionally regulate in children. Experiencing racism had the strongest negative effect of all ACE variables. The strength of the child-caregiver relationship was associated with increased odds of emotional regulation, independent of exposure to ACEs.

CONCLUSIONS

The study supports the need to refine and expand ACE health screenings to fully capture the adversity faced by all children. Emotional regulation is identified as a possible intervention point.

PRACTICE IMPLICATIONS

Expansion of programs that strengthen the child-caregiver relationship and reduce ACEs in early childhood may be a key approach to increasing coping abilities in youth.

Human Subjects Protection and Cancer Surveillance Research: Revised Regulations, Expanded Opportunities

On January 19, 2017, the United States federal government issued revisions to the Common Rule under which scientists who receive federal funding conduct research involving human subjects. The revised Common Rule expressly addresses public health surveillance in relation to scientific research and the protection of human subjects, and its impacts are anticipated to contribute to the efficiency of activities, including cancer registration and surveillance, and research that uses cancer registry data. Cancer Res; 77(12); 3140-3. ©2017 AACR.

Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study

BACKGROUND

Taxes on sugar-sweetened beverages (SSBs) meant to improve health and raise revenue are being adopted, yet evaluation is scarce. This study examines the association of the first penny per ounce SSB excise tax in the United States, in Berkeley, California, with beverage prices, sales, store revenue/consumer spending, and usual beverage intake.

METHODS AND FINDINGS

Methods included comparison of pre-taxation (before 1 January 2015) and first-year post-taxation (1 March 2015-29 February 2016) measures of (1) beverage prices at 26 Berkeley stores; (2) point-of-sale scanner data on 15.5 million checkouts for beverage prices, sales, and store revenue for two supermarket chains covering three Berkeley and six control non-Berkeley large supermarkets in adjacent cities; and (3) a representative telephone survey (17.4% cooperation rate) of 957 adult Berkeley residents. Key hypotheses were that (1) the tax would be passed through to the prices of taxed beverages among the chain stores in which Berkeley implemented the tax in 2015; (2) sales of taxed beverages would decline, and sales of untaxed beverages would rise, in Berkeley stores more than in comparison non-Berkeley stores; (3) consumer spending per transaction (checkout episode) would not increase in Berkeley stores; and (4) self-reported consumption of taxed beverages would decline. Main outcomes and measures included changes in inflation-adjusted prices (cents/ounce), beverage sales (ounces), consumers' spending measured as store revenue (inflation-adjusted dollars per transaction) in two large chains, and usual beverage intake (grams/day and kilocalories/day). Tax pass-through (changes in the price after imposition of the tax) for SSBs varied in degree and timing by store type and beverage type. Pass-through was complete in large chain supermarkets (+1.07¢/oz, p = 0.001) and small chain supermarkets and chain gas stations (1.31¢/oz, p = 0.004), partial in pharmacies (+0.45¢/oz, p = 0.03), and negative in independent corner stores and independent gas stations (-0.64¢/oz, p = 0.004). Sales-unweighted mean price change from scanner data was +0.67¢/oz (p = 0.00) (sales-weighted, +0.65¢/oz, p = 0.003), with +1.09¢/oz (p < 0.001) for sodas and energy drinks, but a lower change in other categories. Post-tax year 1 scanner data SSB sales (ounces/transaction) in Berkeley stores declined 9.6% (p < 0.001) compared to estimates if the tax were not in place, but rose 6.9% (p < 0.001) for non-Berkeley stores. Sales of untaxed beverages in Berkeley stores rose by 3.5% versus 0.5% (both p < 0.001) for non-Berkeley stores. Overall beverage sales also rose across stores. In Berkeley, sales of water rose by 15.6% (p < 0.001) (exceeding the decline in SSB sales in ounces); untaxed fruit, vegetable, and tea drinks, by 4.37% (p < 0.001); and plain milk, by 0.63% (p = 0.01). Scanner data mean store revenue/consumer spending (dollars per transaction) fell 18¢ less in Berkeley (-$0.36, p < 0.001) than in comparison stores (-$0.54, p < 0.001). Baseline and post-tax Berkeley SSB sales and usual dietary intake were markedly low compared to national levels (at baseline, National Health and Nutrition Examination Survey SSB intake nationally was 131 kcal/d and in Berkeley was 45 kcal/d). Reductions in self-reported mean daily SSB intake in grams (-19.8%, p = 0.49) and in mean per capita SSB caloric intake (-13.3%, p = 0.56) from baseline to post-tax were not statistically significant. Limitations of the study include inability to establish causal links due to observational design, and the absence of health outcomes. Analysis of consumption was limited by the small effect size in relation to high standard error and Berkeley's low baseline consumption.

CONCLUSIONS

One year following implementation of the nation's first large SSB tax, prices of SSBs increased in many, but not all, settings, SSB sales declined, and sales of untaxed beverages (especially water) and overall study beverages rose in Berkeley; overall consumer spending per transaction in the stores studied did not rise. Price increases for SSBs in two distinct data sources, their timing, and the patterns of change in taxed and untaxed beverage sales suggest that the observed changes may be attributable to the tax. Post-tax self-reported SSB intake did not change significantly compared to baseline. Significant declines in SSB sales, even in this relatively affluent community, accompanied by revenue used for prevention suggest promise for this policy. Evaluation of taxation in jurisdictions with more typical SSB consumption, with controls, is needed to assess broader dietary and potential health impacts.

Age, period, and cohort effects in adult lifetime asthma prevalence in California: an application of hierarchical age-period-cohort analysis

PURPOSE

Using 27 years of survey data, the contributions of age, period, and cohort effects on the increase in adult lifetime asthma prevalence in California were examined.

METHODS

Lifetime asthma diagnosis for adults was assessed in 1984-1992 and 1995-2011 through the California Behavioral Risk Factor Surveillance System, an annual, cross-sectional, population-based survey (n = 144,100). Using date of survey and date of birth, we classified 18,305 adult respondents with lifetime asthma into 7 age groups, 6 periods, and 17 cohorts. Using hierarchical, cross-classified random effects models, birth cohort, period, and age patterns in adult lifetime asthma prevalence were analyzed.

RESULTS

After adjusting for sex, ethnicity, education, and smoking, age effects peak in young adulthood, flatten from 40 to 60 years old, and then decrease in older adulthood. A significant positive trend in asthma prevalence was observed in the two earliest survey periods (1984-1993; P value < .0001). Survey period trends appear to flatten beginning in 2004. Although the overall birth cohort effect was statistically significant, the magnitude of the effect for each birth cohort category was small (P value = .0005).

CONCLUSIONS

We observed that strong age and period effects have been driving the increase in lifetime asthma prevalence in California over the past 3 decades.

Support for Policies to Improve the Nutritional Impact of the Supplemental Nutrition Assistance Program in California

The Supplemental Nutrition Assistance Program (SNAP) provides a vital buffer against hunger and poverty for 47.6 million Americans. Using 2013 California Dietary Practices Survey data, we assessed support for policies to strengthen the nutritional influence of SNAP. Among SNAP participants, support ranged from 74% to 93% for providing monetary incentives for fruits and vegetables, restricting purchases of sugary beverages, and providing more total benefits. Nonparticipants expressed similar levels of support. These approaches may alleviate the burden of diet-related disease in low-income populations.

Demographic factors associated with perceptions about water safety and tap water consumption among adults in Santa Clara County, California, 2011

The objective of this study was to examine differences in tap water consumption and perceptions of bottle versus tap water safety for Hispanics and non-Hispanic whites, as well as associations with other demographic characteristics. Data are from the Santa Clara County, California, Dietary Practices Survey (2011; N = 306). We used logistic regression to examine associations between demographic characteristics and 1) perceptions that bottled water is safer than tap and 2) primarily consuming tap water. Hispanics were less likely than non-Hispanic whites to primarily drink tap water (OR = 0.33; 95% CI, 0.11–0.99), although there was no significant difference in perceptions that bottled water is safer between these groups (OR = 0.50; 95% CI, 0.11–2.27). Hispanics may be an important population for interventions promoting tap water consumption.

Current depression among women in California according to residence in the California-Mexico border region

OBJECTIVE

To estimate the prevalence of current depression; examine the relationship between current depression and immigration, health status, health care access, and health behaviors; and assess differences by California-Mexico border region (Imperial and San Diego Counties) among women in California.

METHODS

Using a cross-sectional, representative sample of adult women from the California Women's Health Survey (n = 13 454), a statewide telephone survey, prevalence of current depression and predictors of depression were examined in California and according to border region residence. Depression was assessed with the eight-item Patient Health Questionnaire.

RESULTS

The prevalence of current depression for women in California was 12.0%. It was similar in the border (13.0%) and the nonborder (11.9%) regions. Odds of current depression in women were lower among recent immigrants (< 5 years or 5 to < 10 years in the United States) than in women born in the United States and in immigrants who had been living in the United States for 10 to < 15 years or longer (P < 0.05). Odds ratios for current depression and health status, health care access, and binge drinking were larger in the border region than outside the border region.

CONCLUSIONS

Similar prevalences of current depression were observed among those who live in the border region of California and in those who do not, but the relationship between depression and health status, health care access, and binge drinking varied by border region residence. Ideally, future surveillance of depression and its predictors along the Mexico-California border will be conducted binationally to inform interventions and tracking such as the Healthy Border Program's objectives.

Patterns of clinically significant symptoms of depression among heavy users of alcohol and cigarettes

INTRODUCTION

Depression is among the most prevalent and treatable diseases, and it is associated with cigarette smoking and heavy alcohol use. This study estimates the prevalence of depression, its variation among demographic subgroups, and its association with heavy alcohol use and cigarette smoking in California.

METHODS

The 2006 California Behavioral Risk Factor Surveillance System (BRFSS) includes the 8-item Patient Health Questionnaire, a standardized instrument used to measure depressive symptoms. We used findings from the 2006 BRFSS to calculate the prevalence of depression in California; we used logistic models to explore the relationships between depression, alcohol use, and smoking.

RESULTS

We found that 9.2% of adults in California had clinically significant depressive symptoms. Logistic models indicated that daily smokers were more than 3 times more likely to have clinically significant depressive symptoms than were nonsmokers, and heavy drinkers were approximately 3 times more likely to have clinically significant depressive symptoms than were nondrinkers.

CONCLUSION

Because heavy alcohol use and daily smoking are each associated with depression, people who do both may be at an increased risk for depression. This is a public health issue because people who drink alcohol often also smoke and vice versa. Intervention efforts might target persons who are users of both these drugs, and practitioners should be aware that smokers who are heavy alcohol users are at an increased risk for depression.

Prevalence of Fruit and Vegetable Consumption and Physical Activity by Gender and Race/Ethnicity - California, 2005-2006

Diets high in fruits and vegetables and participation in regular physical activity are associated with a lower risk for several chronic diseases and conditions. The present study analyzed the combined prevalence of these two activities by race/ethnicity and gender among adults in California and among adults in California at or below 130% of the federal poverty level (FPL), using self-reported data from the 2005 and 2006 California Behavioral Risk Factor Surveillance System (BRFSS). Findings for California were similar to findings for the nation, showing gender and racial/ethnic differences for each of these variables, singly and in combination. Also, low-income men had a significantly lower prevalence of goal-level fruit and vegetable consumption than did low-income women. Although some demographic disparities are evident among Californians, the prevalence of achievement of two key healthy lifestyle behaviors concurrently remains quite low. These results emphasize the need for promoting diets high in fruits and vegetables and regular physical activity among all Californians.

Intimate partner violence and housing instability

BACKGROUND

The mental and physical health consequences of intimate partner violence (IPV) have been well established, yet little is known about the impact of violence on a woman's ability to obtain and maintain housing. This cross-sectional study examines the relationship between recent IPV and housing instability among a representative sample of California women. It is expected that women who have experienced IPV will be at increased risk for housing instability as evidenced by: (1) late rent or mortgage, (2) frequent moves because of difficulty obtaining affordable housing, and/or (3) without their own housing.

METHODS

Data were taken from the 2003 California Women's Health Survey, a population-based, random-digit-dial, annual probability survey of adult California women (N=3619). Logistic regressions were used to predict housing instability in the past 12 months, adjusting for the following covariates; age, race/ethnicity, education, poverty status, marital status, children in the household, and past year IPV.

RESULTS

In the multivariate model, age, race/ethnicity, marital status, poverty, and IPV were significant predictors of housing instability. After adjusting for all covariates, women who experienced IPV in the last year had almost four times the odds of reporting housing instability than women who did not experience IPV (adjusted odds ratio=3.98, 95% confidence interval: 2.94-5.39).

CONCLUSIONS

This study found that IPV was associated with housing instability among California women. Future prospective studies are needed to learn more about the nature and direction of the relationship between IPV and housing instability and the possible associated negative health consequences.

Contraceptive use and risk of unintended pregnancy in California

California is home to more than one out of eight American women of reproductive age. Because California has a large, diverse and growing population, national statistics do not necessarily describe the reproductive health of California women. This article presents risk for pregnancy and sexually transmitted infections among women in California based on the California Women's Health Survey. Over 8900 women of reproductive age who participated in this survey between 1998 and 2001 provide estimates of access to care and use of family-planning methods in the state. We find that 49% of the female population aged 18-44 in California is at risk of unintended pregnancy. Nine percent (9%) of women at risk of an unintended pregnancy are not using any method of contraception, primarily for method-related reasons, such as a concern about side effects or a dislike of available contraceptive methods. Among women at risk for unintended pregnancy, we find disparities by race/ethnicity and education in use of contraceptive methods.

Knowledge of emergency contraception among women aged 18 to 44 in California

OBJECTIVE

The State of California has taken several steps to make emergency contraceptives (ECs) available to women in the state. By using data from the 1999-2001 California Women's Health Survey, we estimated the knowledge of emergency contraception among adult women of reproductive age at risk of pregnancy (n=6209).

STUDY DESIGN

This study is based on 3 years of data (1999-2001) from the California Women's Health Survey (CWHS), an annual population-based survey of more than 4000 randomly selected adult women (aged 18 years and older) in California. A total of 6198 women aged 18 to 44 responded to the 2 emergency contraception questions: "To the best of your knowledge, if a woman has unprotected sex is there anything she can do in the 3 days after intercourse that will prevent pregnancy?" and "What can she do?"

RESULTS

We find that 38% of California women were able to correctly identify emergency contraception. Most importantly, the women who are most likely to need emergency contraception-those who are at risk of an unintended pregnancy but not using any method of contraception-have among the lowest levels of knowledge (only 29% identified a method of ECs).

CONCLUSION

Results show that family planning providers may be reaching their clients, but broader outreach to the public has not yet achieved sufficiently high information levels among women in greatest need of the method.