Beliefs and knowledge related to human papillomavirus (HPV) vaccine among African Americans and African immigrants young adults.

BACKGROUND: Despite the disparate human papillomavirus (HPV) infection rates among sexually active Black young adults, HPV vaccine uptake remains low among this population. This study aimed to explore HPV beliefs, attitudes, and knowledge among Black young adults and provide recommendations on ways to improve vaccine uptake. METHODS: We used a mixed-method, convergent design to conduct five focus groups and administered a 40-item electronic survey that was developed with health belief model (HBM) constructs. We assessed HPV and vaccine knowledge, barriers, and attitudes toward vaccination. We analyzed quantitative data using descriptive statistics and bivariate methods. Focus group transcripts were analyzed using content analysis. Results were integrated to obtain a better understanding of the topic. RESULTS: Forty individuals participated in the study. The mean age was 22.2 ± 4.5 years and 55% identified as African immigrants. Integrated data revealed themes mapped to relevant HBM constructs. Almost one third (32.5%) of participants were unaware of their susceptibility to HPV infection and its severity. From focus group discussions, the majority (75%) believed that vaccines are beneficial. Major cues to action include promoting HPV vaccine uptake via community wide informational sessions, provider recommendation, and social and mass media campaigns. CONCLUSION: Barriers to vaccine uptake, limited HPV knowledge, and lack of vaccine recommendation are important factors contributing to low vaccine uptake among Black young adults. Interventions to decrease barriers to HPV vaccination, increase HPV knowledge, address misconceptions, and unfavorable beliefs are needed to promote HPV vaccine uptake.

HPV vaccination and cervical cancer screening promotion among Black individuals: social ecological perspectives from key informants interviews.

OBJECTIVES: Rates of HPV infection and HPV-related cancers are elevated in the Black population of the US. Efforts to promote HPV vaccination and cervical cancer screening are important to reducing the cancer burden among Black populations. The purpose of this qualitative descriptive study guided by social ecological model (SEM) was to describe from the perspective of key informants, the challenges and opportunities for HPV vaccination and cervical cancer screening promotion among Black adults. DESIGN: Twenty-three key informants participated in individual interviews over zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy prior to data analysis. Two qualitatively trained researchers analyzed the data using content analysis. RESULTS: Participants were aged 50 ± 4.1 years, 12 were females, and 18 identified as Black. Participants included health care providers, teachers, church and community leaders. Themes included HPV and cancer literacy, influence of religion, health care provider recommendations, social and cultural influences, accessibility and availability of services, economic constraints, limited community resources, and HPV vaccine mandates. CONCLUSIONS: SEM factors contribute to low HPV vaccine uptake and cervical cancer screening and these factors need to be addressed. Interventions addressing SEM factors peculiar to Black populations may promote HPV vaccination and cancer screening in this population.

A New Look at Barriers to Clinical Care Among Appalachian Residents Living With Diabetes.

In the United States, diabetes is the seventh leading cause of death and continues to rise in prevalence, with type 2 diabetes accounting for 90-95% of all cases. Rates of diabetes in Kentucky, and, in particular, the Appalachian region, are among the highest in the nation and are increasing faster than the national average. Despite this disproportionate burden, barriers to clinical appointment attendance have not been fully explored in this population. This article examines the association among perceived barriers to clinical attendance, glycemic control, and diabetes self-care as part of an ongoing study. We used a 25-item checklist developed using the Chronic Care Model to assess participants' barriers to clinic attendance. Glycemic control was assessed via A1C measurement. Diabetes self-care was assessed using the Summary of Diabetes Self-Care Activities measure. At the time of analysis, 123 of the 356 participants (34.6%) did not report any barriers to clinic attendance. For the remainder, the major reported barriers included forgetting appointments, inability to afford medicines or other treatment, and placing faith above medical care. The average A1C was 7.7%, and the average diabetes self-care summary score was 17.1 out of 35 points (with higher values indicating better self-care). Missing clinic appointments is associated with lower health outcomes, especially in vulnerable populations. This study can help educate clinic staff on perceived barriers to type 2 diabetes management among people with diabetes in Appalachia.

Engagement With a Youth Community Advisory Board to Develop and Refine a Facebook HPV Vaccination Promotion Intervention (#HPVvaxtalks) for Young Black Adults (18-26 years old).

Human papillomavirus (HPV) vaccination rates remain suboptimal among young Black adults (18-26 years). Research focused on HPV vaccination among young Black adults is limited. Guided by the Theory of Planned Behavior, we developed #HPVvaxtalks, a theoretically grounded and culturally appropriate Facebook intervention in collaboration with a youth community advisory board (YCAB) to increase awareness of HPV risk factors, risk perception, HPV vaccine-related knowledge, vaccination intention, and uptake for Black individuals. Engagement with YCAB members fostered opportunity to discuss priorities reflecting the community's interest and make #HPVvaxtalks more relevant. This article describes the YCAB engagement and collaborative process in the development and refinement of posts/messages for #HPVvaxtalks. Five young Black adults (18-26 years of age) were invited to become members of a YCAB. YCAB reviewed the preliminary version of #HPVvaxtalks intervention materials and provided critiques and suggestions for refinement. Following the completion of the collaborative process, YCAB members completed individual interviews to reflect on the process. Feedback from YCAB participants focused on the relevance, engagement, clarity, and organization of the content and the media utilized. Participants suggested using "memes" to improve cultural relevance and engagement for young Black individuals. All YCAB members expressed satisfaction with the development process. Collaboration with a YCAB was crucial in developing a culturally relevant and acceptable #HPVvaxtalks intervention, which includes 40 messages/posts for young Black adults. Undergoing the iterative process of intervention development and refinement with the priority population can be an essential component in the design and implementation of health promotion activities.

Social support and cervical cancer screening among sub-Saharan African immigrant (SAI) women.

BACKGROUND: Low rates of Papanicolaou (Pap) screening among sub-Saharan African immigrant (SAI) women in the US contribute to cancer diagnoses at late stages and high mortality rates. This study was conducted to examine if social support, positively associated with preventive health practices, was predictive of Pap screening in a sample of SAI women. METHODS: We conducted a cross-sectional study with SAI women who recently immigrated to the US. Participants completed a survey to assess ever having had Pap screening and social support using the Medical Outcomes Study Social Support Survey. RESULTS: Among the 108 SAI women in our study, Pap screening uptake was 65.7%. Affectionate and positive social support were each associated with Pap screening [adjusted odds ratio (AOR) = 1.73 (1.05, 2.87) and 1.68 (1.01, 2.78), respectively]. DISCUSSION: These findings suggest that consideration should be given to strengthening certain aspects of social support to increase uptake of Pap screening among SAI women.

Qualitative assessment of attitudes toward cervical cancer (CC) screening and HPV self-sampling among African American (AA) and Sub Saharan African Immigrant (SAI) women.

OBJECTIVES: Despite the availability of preventive methods for cervical cancer (CC), uptake has been low among African American and Sub-Saharan Immigrant (AA/SAI) women. The purpose of this study was to understand AA/SAI women's values and beliefs of CC screening and explore willingness, acceptability, and concerns related to the HPV self-sampling method for CC. DESIGN: Thirty AA/SAI women participated in one of six focus groups, each lasted 60-90 min, and were held over Zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy by research staff prior to data analysis. Transcripts were content analyzed by two qualitatively trained research staff. NVivo software was used for data management and analysis. RESULTS: The average age of participants was 33.67 ± 9.03, more than half were not married (53.3%), and less than half reported having health insurance coverage (46.7%). Participants included 16 AA and 14 SAI. Three main themes emerged from data analysis. (1) Beliefs and values related to CC Screening, (2) perceived barriers to attending CC screening, (3) recommendations to motivate regular CC screening. In addition, three factors emerged in the discussion on the HPV self-sampling method: confidence in ability to self-sample for CC, willingness to use HPV self-sampling kit, and result delivery. CONCLUSIONS: This study identified a variety of reasons for the disproportionately low utilization of CC prevention services among AA/SAI women. Multidimensional approaches including educational and community engagement programs for this population could improve CC screening uptake and adoption of HPV self-sampling among AA/SAI women.

The mediating/moderating role of cultural context factors on self-care practices among those living with diabetes in rural Appalachia.

BACKGROUND: The aim of this study was to examine whether cultural factors, such as religiosity and social support, mediate/moderate the relationship between personal/psychosocial factors and T2DM self-care in a rural Appalachian community. METHODS: Regression models were utilized to assess for mediation and moderation. Multilevel linear mixed effects models and GEE-type logistic regression models were fit for continuous (social support, self-care) and binary (religiosity) outcomes, respectively. RESULTS: The results indicated that cultural context factors (religiosity and social support) can mediate/moderate the relationship between psychosocial factors and T2DM self-care. Specifically, after adjusting for demographic variables, the findings suggested that social support may moderate the effect of depressive symptoms and stress on self-care. Religiosity may moderate the effect of distress on self-care, and empowerment was a predictor of self-care but was not mediated/moderated by the assessed cultural context factors. When considering health status, religiosity was a moderately significant predictor of self-care and may mediate the relationship between perceived health status and T2DM self-care. CONCLUSIONS: This study represents the first known research to examine cultural assets and diabetes self-care practices among a community-based sample of Appalachian adults. We echo calls to increase the evidence on social support and religiosity and other contextual factors among this highly affected population. TRIAL REGISTRATION: US National Library of Science identifier NCT03474731. Registered March 23, 2018, www.clinicaltrials.gov .

Access to Care as a Barrier to Mammography for Black Women.

Racial disparities in breast cancer screening, morbidity, and mortality persist for Black women. This study examines Black women's mammography beliefs and experiences with specific focus on barriers to mammography access in an urban city in the South East, United States. This retrospective, qualitative study used Penchansky and Thomas' conceptualization of health care access as the framework for the data analysis. In-depth, semistructured interviews were conducted with 39 Black women. Structural and personal factors continue to create barriers to mammography among Black women. Barriers to mammography were identified for each of the Penchansky and Thomas five dimensions of access to care: accessibility, affordability, availability, accommodation, and acceptability. Clinical practice strategies to increase mammography screening in Black women must be multifactorial, patient-centered, and culturally congruent. Policy development must address the structural barriers to mammography screening through expansion of health insurance coverage and increased accessibility to health care.

Training Community Health Workers in Motivational Interviewing to Promote Cancer Screening.

Health disparities researchers attempting to engage and effectively deliver interventions to underserved populations often encounter a number of challenges ranging from geographical considerations to more complex issues of medical mistrust. While there are a number of strategies researchers may employ to address these challenges, one of the most successful of these has been the use of community health workers (CHWs). Despite the documented success of CHWs, little information exists on the use of theory-driven intervention strategies with these community partners. Researchers who have partnered with CHWs tend to provide brief descriptions of training strategies and provide little discussion of the challenges and barriers to training a lay population in the delivery of technical interventions, including ensuring fidelity to the intervention protocol. The purpose of this article is to describe the feasibility of training CHWs to deliver a motivational interviewing intervention to promote cancer screening in underserved populations. With this article we present an innovative way to use motivational interviewing delivered by CHWs. Specifically, we will detail the development of the training protocol, the implementation of that training in a variety of research settings, and the development and implementation of fidelity protocols. We will use examples from two research studies where CHWs were successfully trained to use MI to promote cancer screening in underserved communities to highlight the challenges and barriers faced in developing and implementing the training and strategies used to overcome these challenges during the refinement of the intervention.

Spousal support and knowledge related to cervical cancer screening: Are Sub-Saharan African immigrant men interested?

Sub-Saharan African immigrant (SSAI) men have significant influence on the health-seeking behavior including cervical cancer screening uptake by their female partners/wives. We conducted a qualitative descriptive study with 21 SSAI men to explore knowledge, perceptions, and support related to cervical screening. Participants were aged 36 ± 9 years, college educated (88%), and 53% have lived in the U.S. > 5 years. Three themes emerged; inadequate cervical cancer knowledge, willingness and strategies for support, and shared versus autonomous decision making for screening. Social structure with emphasis on male leadership could be leveraged in cervical cancer screening promotion for SSAI women.

Social support and breast cancer screening in rural Appalachia.

PURPOSE: Women in the Appalachian region have a high mortality rate attributable to cancer in spite of lower incidence of cancer compared with the general US population. Empirical evidence suggests that social support influences cancer outcomes, including adherence to screening guidelines and treatment recommendations. The purpose of this study is to examine the impact of social support on breast cancer screening patterns in a sample of rural Appalachian women. METHODS: This paper reports the results of analyses of baseline cross-sectional data on breast cancer screening collected during a community-based group-randomized trial. We used the 2010 National Health Institute Survey questionnaires and the Medical Outcomes Study Social Support Survey to assess screening behavior and perceived social support, respectively. Data were analyzed using ANCOVA and ANOVA to assess the mean social support on breast cancer screening patterns (frequently, irregularly, and rarely/never) and relevant sociodemographic variables. FINDINGS: Of the eligible participant records analyzed (N = 289), 50% were married, 36% were employed, 20% attended college, 40% had no mammogram in 6 years, and 20% never had mammograms. Overall social support score was high at 73.1 (SD = 18.2). Association between breast cancer screening patterns and social support scores was not statistically significant at α < 0.05 (P value = 0.09). CONCLUSIONS: Although social support as it measured in this study does not show significant associations with screening patterns, it is important to understand how social network structures may influence screening patterns. Familial and social roles/responsibilities that result in reported social support may also be the barrier to cancer screening and other prevention health behaviors.

Analysis of Kentucky's Law Protecting the Rights of Schoolchildren With Type 1 Diabetes Mellitus: Application of Kingdon's Policy Stream Model.

Type 1 diabetes mellitus is a chronic, life-threatening disorder that affects children of all ages. Based on data from 2008 to 2009, the Centers for Disease Control and Prevention estimates that in the United States, 191,986 youth younger than age 20 require treatment for diabetes, the majority of whom have Type 1 diabetes mellitus. These children require assistance with counting carbohydrates, testing blood glucose, and administering subcutaneous insulin. Establishing appropriate diabetes care models in schools is necessary for children's immediate safety, long-term well-being, and optimal academic performance. Kentucky House Bill 98 was passed by the state legislature in 2014 to allow unlicensed school personnel to assist children with diabetes care. The purpose of this article is to apply Kingdon's policy streams model to an analysis of a state policy allowing unlicensed school personnel to assist children with diabetes care. The article covers potential policy alternatives and concludes with a discussion of implications for nursing practice.

Perceived Barriers to Pap Screening Influence Adherence to Screening Recommendations Among Black Women.

Objectives: The aim of this study was to determine the Health Belief Model (HBM) constructs associated with Pap screening adherence among a sample of African American and sub-Saharan African immigrant women in the United States. Methods: A descriptive cross-sectional study was conducted via an online survey. Participants were recruited from central Kentucky counties. Ninety-one eligible women participated (mean age 38 ± 12 years), 49.5% identified as African American. Twenty-nine percent indicated never being screened or not being up-to-date. Self-reported demographic data, HBM constructs for Pap screening, and Pap screening history were collected. Bivariate and logistic regressions were performed. Results: There was a significant negative association between perceived barriers and being up-to-date. For every one-point increase in perceived barriers, the odds of being up-to-date decreased by 81%, (p = 0.004; CI: 0.06-0.60), findings from further evaluation of the barrier construct showed that barriers significantly associated with screening include items related to lack of knowledge about where to get a Pap screening, lack of time to attend the screening, screening-associated shame and pain, negligence, and age. There were no other significant HBM constructs associated with up-to-date Pap screening status. There was no difference in perceived barriers between African American and sub-Saharan African women. Conclusions: Despite public health efforts to decrease screening barriers, a perception of barriers exists among Black women. Continued efforts to address screening barriers as well as the perception of barriers are warranted among Black women.

Champions to enhance implementation of clinical and community-based interventions in cancer: a scoping review.

BACKGROUND: Champions are integral across research in cancer, yet studies exploring their roles are limited and have produced mixed results. The current review examines and synthesizes descriptions of how champions emerged and the types of activities they most often performed. By examining evidence from across the translational research continuum, this scoping review aims to characterize the role of champions and strategies that facilitate their involvement in the implementation of cancer care interventions in both clinical and community-based settings. METHODS: This scoping review was designed and implemented in compliance with PRISMA-ScR. The review focused on peer-reviewed articles in English-language journals. We searched five databases: PubMed (including MEDLINE), Scopus (including EMBASE), CINAHL, PsycINFO, and the Cochrane Library. Articles published from 1971 to 2022 were included. Two members of the team reviewed in duplicate each article and then a single member of the team extracted the data in Covidence, with a second member comparing the extraction to the original article. Qualitative and quantitative data were extracted and then synthesized. These data were used to summarize core champion activities and implementation strategies and to characterize barriers and facilitators to using champions in research. RESULTS: A total of 74 articles were included in the review. The qualitative synthesis highlighted facilitators and barriers to the effective use of champions. Facilitators included consideration of an individual's characteristics when identifying champions, time spent planning for the specific responsibilities of champions, working within a supportive environment, and identifying champions embedded in the target setting. Major barriers included constrained time, low self-efficacy among champions, inadequate training, high turnover rates of champions, and a lack of buy-in from organizational leadership toward the intervention. Champions also were mostly assigned their roles, had varied core activities, and used complementary strategies to empower their target populations. Champions' most frequent core activities include facilitation, outreach/promotion, and recruitment of participants into studies. CONCLUSIONS: Champions were used in research of many cancer types and often serve similar roles regardless of where they are located within the translational research process. Despite their critical role, evidence is lacking on the impact of champions specifically on outcomes of many of the research studies that include them. Future research is needed to understand the nuances of champion-driven approaches across diverse cancer care settings.

Evaluating the Association Between Depressive Symptoms and Glycemic Control Among Residents of Rural Appalachia.

Introduction: Type 2 diabetes mellitus (T2DM) is associated with a range of co-morbid physical and psychological conditions, including depression. Yet there is a dearth of evidence regarding the prevalence of depression among those in Appalachia living with T2DM; this gap persists despite the higher regional prevalence of T2DM and challenging social determinants of health. Purpose: This study aimed to provide greater detail about the relationships between T2DM and depressive symptoms in adults living in Appalachia Kentucky. Methods: The present study was a cross-sectional analysis of baseline data derived from an ongoing study of Appalachia Kentucky adults living with T2DM. Outcome data included demographics, Center for Epidemiologic Studies Depression Scale, point-of-care HbA1c, and the Summary of Diabetes Self-Care Activities. Bivariate analysis was conducted using Pearson's correlation to determine the statistically significant relationships between variables which were then included in a multiple regression model. Results: The sample (N=365), consisted primarily of women (n=230, 64.6%) of mean age 64 years (±10.6); almost all (98%) were non-Hispanic White (n=349), and most were married (n=208, 59.1%). The majority (47.2%) reported having two comorbid conditions (n=161), including T2DM, and the mean HbA1c was 7.7% (1.7). Nearly 90% were nonsmokers (n=319). Depressive symptoms were reported in 25% (n=90) of participants. A higher number of comorbid conditions, increased age, Medicaid insurance, tobacco use, lower financial status, female sex, and disability compared to fully employed status all were correlated with a higher rate of depressive symptoms (r ≤ 0.2). The regression indicated that depressive symptoms were associated with age (ß = -0.010, p = 0.001); full-time employment status compared to those who are disabled (ß = -.0209, p = 0.18); men compared to women (ß = -0.122, p = 0.042), and those who smoke compared to nonsmokers (ß = 0.175, p = 0.038). Implications: Depressive symptoms were correlated with T2DM among this sample of Appalachian residents with poorly controlled T2DM, especially among women. Given the vast number of social determinants (e.g., poverty, food insecurity, and rurality) affecting this population, healthcare providers must assess for depression and consider its negative influence on the patient's ability to achieve glycemic control.

"I don't think I have a chance to get it": International university student HPV knowledge and preventive behaviors.

Objective: Half of new human papilloma virus ( (HPV)) infections occur between the ages of 15 and 24. As preventive measures are underutilized globally; international university students are at particular risk for HPV infection and sequelae. The study aim was to explore HPV knowledge and preventive behaviors in this population. Participants: Eighty-one undergraduate and graduate international university students (49 females, 32 males) at a southeastern university. Methods: Exploratory sequential mixed methods guided by the Health Belief Model. Results: Integrated qualitative/quantitative data revealed four themes mapped to relevant HBM constructs: Perceived susceptibility to HPV; Perceived benefits/Perceived barriers to HPV prevention; Cues to Action; and Likelihood of Engaging in Health-Promoting Behavior. Over half believed they were not at risk for HPV/sequelae. Only a quarter had received HPV vaccination. Conclusions: International university students represent an important catch-up population for HPV screening/vaccination. Results can be used to design and tailor interventions for this vulnerable population.

A Motivational Interviewing Intervention to Promote CRC Screening: A Pilot Study.

BACKGROUND: Appalachian Kentuckians suffer a disproportionate incidence and mortality from colorectal cancer (CRC) and are screened at lower rates (35%) compared with 47% of Kentuckians. OBJECTIVE: The aim of this study was to evaluate the efficacy of a motivational interviewing intervention delivered by trained Lay Health Advisors on CRC screening. METHOD: Eligible participants recruited from an emergency department (ED) completed a baseline survey and were randomized to either the control or the motivational interviewing intervention provided by Lay Health Advisors. Follow-up surveys were administered 3 and 6 months after baseline. To evaluate potential differences in treatment and control groups, t tests, χ2, and Mann-Whitney U tests were used. RESULTS: At either the 3- or 6-month assessment, there was no difference in the CRC screening by group (χ2 = 0.13, P = .72). There was a significant main effect for the study group in the susceptibility to CRC model; regardless of time, those in the intervention group reported approximately 1-point higher perceived susceptibility to CRC, compared with controls (est. b = 0.68, P = .038). Age and financial adequacy had a significant effect related to CRC screening. Older participants (est. b = 0.09, P = .014) and those who reported financial inadequacy (est. b = 2.34, P = .002) reported more screening barriers. CONCLUSION: This pilot study elucidated important factors influencing the uptake of CRC for an ED transient population and this may be useful in the design of future interventions using motivational interviewing in EDs. IMPLICATIONS FOR PRACTICE: Nurses can provide information about CRC screening guidelines and provide referrals to appropriate screening resources in the community.

HPV Testing Behaviors and Willingness to Use HPV Self-sampling at Home Among African American (AA) and Sub-Saharan African Immigrant (SAI) Women.

BACKGROUND: HPV self-sampling is an emerging HPV testing method that offers reliable identification of cervical precancer and cancer. To determine the feasibility of HPV self-sampling in the USA, information is needed regarding women's use of HPV test and willingness to use self-sampling, especially among disparate groups such as African American (AA) and sub-Saharan African immigrant (SAI) women. The purpose of this study was to examine factors associated with having had at least one HPV test and willingness to use HPV self-sampling among AA and SAI women. METHODS: AA and SAI women (n = 91) recruited from community settings completed a survey in a cross-sectional study. Data included sociodemographics, HPV and HPV testing knowledge, and willingness to use a HPV self-sampling test at home. Logistic regressions were performed to evaluate associations with having had a HPV test and willingness to use self-sampling. RESULTS: Respondents mean age was 38.2 years (SD = 12.6) and 65% were SAIs. The majority (84%) reported having had at least one Pap test and (36%) had at least one HPV test. Sixty-seven percent were willing to self-sample at home. Age, education, and HPV testing knowledge were associated with having had a HPV test. Being uninsured and likelihood to accept a Pap test if recommended were associated with willingness to use self-sampling at home for an HPV test. CONCLUSIONS: Health care providers have an important role in recommending cervical cancer screening according to current guidelines. HPV self-sampling may be a promising strategy to reach older, less educated, uninsured, and underinsured Black women.

Psychological factors among Appalachian women with abnormal Pap results.

PURPOSE: Women who receive an abnormal Pap result may experience negative psychological factors. The purpose of this study is to assess the baseline occurrence of negative psychological factors and evaluate the relationships between psychological factors and demographic characteristics among Appalachian women who received abnormal Pap results. METHODS: We conducted a secondary analysis of data collected from Appalachia Kentucky women (N = 521) ages ≥18 enrolled in an intervention. Data included sociodemographics, Beck depression and anxiety inventories, fatalism, and personal control measures. Multiple variable logistic regression was used to investigate the association between demographics and psychological factors. FINDINGS: Participants were predominantly White (96.2%), with mean age 28.93 ± 11.03 years, and the majority (77%) had yearly income below $20,000. Depression was reported by 34.6% (n = 173); 10% (n = 50) experienced moderate or severe anxiety; 20.6% (n = 107) had fatalistic beliefs; and 55.1% (n = 289) believed they lacked personal control over cancer. Women with lower income had higher occurrence of depression (P = .003). Women with moderate to severe anxiety were significantly older than those with low to moderate depression (34.44 vs 28.34, P < .001). Controlling for other variables, as age increased, the odds of fatalistic beliefs increased, OR (95%) = 1.042 (1.022, 1.062). When education level increased, the odds of fatalistic beliefs decreased, OR (95%) = 0.873 (0.800, 0.952). CONCLUSIONS: Given the high occurrence of depression, anxiety, and fatalistic beliefs among this population, health care providers should assess for underlying mental health diagnoses and psychological distress during each patient encounter and provide recommendations to address them.