Intimate Care Products and Incidence of Hormone-Related Cancers: A Quantitative Bias Analysis.

PURPOSE: Intimate care products may contain substances associated with increased risk of hormone-related cancers. The relationship between genital talc use and ovarian cancer, in particular, has been well studied, but concerns about recall bias and exposure misclassification have precluded conclusions. We examined the association between intimate care products and female hormone-related cancers, accounting for potential biases, using data from a US-based cohort study. METHODS: The Sister Study enrolled 50,884 women who had a sister with breast cancer. Data on genital talc use and douching were collected at enrollment (2003-2009) and follow-up (2017-2019). We used Cox proportional hazards models to estimate hazard ratios (HRs) for associations between intimate care product use and breast, ovarian, and uterine cancers. To account for potential exposure misclassification and recall bias, we conducted quantitative bias analyses under various exposure reassignment assumptions. RESULTS: Across considered scenarios, 41%-64% of participants douched and 35%-56% used genital talc. In models adjusted for exposure misclassification, genital talc use was positively associated with ovarian cancer (HR range, 1.17-3.34) Frequent douching and douching during young adulthood were positively associated with ovarian cancer, but neither douching nor talc was associated with breast or uterine cancer. Differential reporting of talc use by cases and noncases likely produces positive biases, but correcting for error still resulted in HRs above 1.0. For example, HR, 1.40 (95% CI, 1.04 to 1.89) when 25% of exposed cases and 10% of unexposed noncases had talc status reassigned. CONCLUSION: Although results show how differential recall would upwardly bias estimates, corrected results support a positive association between use of intimate care products, including genital talc, and ovarian cancer.

Personal Care Product Use during Puberty and Incident Breast Cancer among Black, Hispanic/Latina, and White Women in a Prospective US-Wide Cohort.

BACKGROUND: Some personal care products (PCPs) contain endocrine-disrupting chemicals that may affect breast cancer (BC) risk. Patterns of use vary by race and ethnicity. Use often starts in adolescence, when rapidly developing breast tissue may be more susceptible to environmental carcinogens. Few studies have examined associations of BC with PCP use during this susceptible window. OBJECTIVES: We characterized race and ethnicity-specific patterns of PCP use at 10-13 years of age and estimated associations of use with incident BC. METHODS: At enrollment (2003-2009), Sister Study participants (n=4,049 Black, 2,104 Latina, and 39,312 White women) 35-74 years of age reported use of 37 "everyday" PCPs during the ages of 10-13 y (did not use, sometimes, or frequently used). We conducted race and ethnicity-specific latent class analyses to separately identify groups of women with similar patterns of beauty, hair, and skincare/hygiene product use. We estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for associations of identified PCP classes and single products with incident BC using Cox proportional hazards regression. RESULTS: During a mean follow-up time of 10.8 y, 280 Black, 128 Latina, and 3,137 White women were diagnosed with BC. Classes of adolescent PCP use were not clearly associated with BC diagnosis among Black, Latina, or White women. HRs were elevated but imprecise for frequent nail product and perfume use in Black women (HR=1.34; 95% CI: 0.85, 2.12) and greater hair product use in Black (HR=1.28; 95% CI: 0.91, 1.80) and Latina (HR=1.42; 95% CI: 0.81, 2.48) women compared with lighter use. In single-product models, we observed higher BC incidence associated with frequent use of lipstick, nail products, pomade, perfume, makeup remover, and acne/blemish products in at least one group. DISCUSSION: This work provides some support for the hypothesis that PCP use during puberty is associated with BC risk. More research is needed to confirm these novel findings. https://doi.org/10.1289/EHP13882.

Association of Fibroids, Endometriosis, and Gynecologic Surgeries with Breast Cancer Incidence and Hormone Receptor Subtypes.

BACKGROUND: Fibroids and endometriosis are sex hormone-mediated and exhibit cancer-like behavior. Breast cancer may be more common in women who have had these conditions, but the literature is conflicting and does not always address factors like hysterectomy/oophorectomy status, race/ethnicity, menopause, and hormone receptor subtypes. METHODS: Data are from the Sister Study, a cohort of 50,884 U.S. women enrolled in 2003 to 2009 and followed through 2020. Cox proportional hazards models with time-varying exposures and covariates assessed the relationship of fibroids or endometriosis with breast cancer. Logistic regression examined the association with estrogen receptor (ER) status among cases. RESULTS: Fibroids (19,932 cases) were positively associated with breast cancer [fully adjusted HR: 1.07; 95% confidence interval (CI): 1.01-1.14], notably among Black participants (HR: 1.34; 95% CI: 1.07-1.69) and women who had a hysterectomy (HR: 1.18; 95% CI: 1.05-1.31). Endometriosis (3,970 cases) was not associated with breast cancer (HR: 0.99; 95% CI: 0.91-1.08). Among 4,419 breast cancer cases, fibroids were positively associated with ER+ subtypes (OR: 1.34; 95% CI: 1.10-1.65), while endometriosis was negatively associated with ER+ subtypes (OR: 0.78; 95% CI: 0.61-1.01). CONCLUSIONS: We observed a modest positive association between fibroids and breast cancer, particularly ER+ breast cancer. No relationship with endometriosis and breast cancer incidence was found. IMPACT: Fibroids, even in those with a family history of breast cancer, might modify breast cancer risk stratification tools. Future studies should further assess this link and interrogate shared risk factors.

Opportunities, challenges, and future directions for simulation modeling the effects of structural racism on cancer mortality in the United States: a scoping review.

PURPOSE: Structural racism could contribute to racial and ethnic disparities in cancer mortality via its broad effects on housing, economic opportunities, and health care. However, there has been limited focus on incorporating structural racism into simulation models designed to identify practice and policy strategies to support health equity. We reviewed studies evaluating structural racism and cancer mortality disparities to highlight opportunities, challenges, and future directions to capture this broad concept in simulation modeling research. METHODS: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review Extension guidelines. Articles published between 2018 and 2023 were searched including terms related to race, ethnicity, cancer-specific and all-cause mortality, and structural racism. We included studies evaluating the effects of structural racism on racial and ethnic disparities in cancer mortality in the United States. RESULTS: A total of 8345 articles were identified, and 183 articles were included. Studies used different measures, data sources, and methods. For example, in 20 studies, racial residential segregation, one component of structural racism, was measured by indices of dissimilarity, concentration at the extremes, redlining, or isolation. Data sources included cancer registries, claims, or institutional data linked to area-level metrics from the US census or historical mortgage data. Segregation was associated with worse survival. Nine studies were location specific, and the segregation measures were developed for Black, Hispanic, and White residents. CONCLUSIONS: A range of measures and data sources are available to capture the effects of structural racism. We provide a set of recommendations for best practices for modelers to consider when incorporating the effects of structural racism into simulation models.

Association of genital talc and douche use in early adolescence or adulthood with uterine fibroids diagnoses.

BACKGROUND: Genital talc and douching are practices that can involve exposure to chemical compounds linked to certain gynecologic cancers. However, it is unclear if they are associated with fibroid risk or age at fibroid diagnosis among women. OBJECTIVE: This study aimed to evaluate the impact of early-adolescence genital talc use and douching on prevalence of fibroids diagnosed before the age of 35 and 50 years among Black/African American and non-Hispanic White women. STUDY DESIGN: Data were derived from the Sister Study (2003-2020), a prospective cohort of 50,884 US women aged 35 to 74 years at enrollment. Participants were asked if they ever had a fibroid diagnosis and at what age, and if they used genital talc and/or douched between the ages of 10 and 13 years or in the past 12 months. After applying predefined exclusion criteria, our analytical sample size was n=46,316 (Black, n=4310; non-Hispanic White, n=42,006). Multivariable logistic regression was used to compute adjusted odds ratios and 95% confidence intervals for having vs not having early-onset fibroids diagnosed before age 35 among women aged 35 to 74 years at enrollment, and fibroids diagnosed before age 50 among women aged 50 to 74 years at enrollment. We adjusted for early life factors (in utero diethylstilbestrol exposure, singleton or multiple birth, fed soy formula during infancy), childhood socioeconomic status, and relative weight and height compared with peers at age 10. We used multiple imputation (<10% missing in all analyses). Results were stratified by race/ethnicity given that Black women are more likely to develop fibroids at a younger age than non-Hispanic White women. RESULTS: Among Black/African American women, 29% had fibroids diagnosed before age 35. Both genital talc use at age 10 to 13 (adjusted odds ratio, 1.23; confidence interval, 1.06-1.41) and douching (adjusted odds ratio, 1.19; 95% confidence interval, 0.95-1.48) were associated with higher odds of having a fibroid diagnosed before age 35. Douching without talc use was not associated with increased odds, but combined use of genital talc and douche was associated with 52% increased odds of fibroids (confidence interval, 1.14-2.01). Among non-Hispanic White women, 9% reported fibroids diagnosed before age 35. Genital talc use (1.31; 1.20-1.44) but not douching (0.96; 0.77-1.20) at age of 10 to 13 years was associated with having a fibroid diagnosed before age 35. We observed similar patterns for non-Hispanic White women when we considered fibroids diagnosed before age 50, but neither practice was associated with fibroids diagnosed before age 50 in Black women. CONCLUSION: Genital talc use in early adolescence, alone and in combination with douching (but not douching alone), is associated with prevalence of fibroids diagnosed before age 35 among Black/African American women and before ages 35 and 50 among non-Hispanic White women. Early adolescence may be a window of susceptibility for fibroid development, suggesting that adolescent girls should be educated on abstention from or alternatives to talc use and douching.

Douching and Genital Talc Use: Patterns of Use and Reliability of Self-reported Exposure.

BACKGROUND: Feminine hygiene products contain chemicals that may be harmful to human health. Observational studies of the long-term health effects of such products largely rely on self-reported, recalled exposure. We sought to capture patterns of use over the life course and evaluate the reliability of self-reported data. METHODS: We collected retrospective data on douching and genital talc use in the US-based Sister Study at two-time points and evaluated the consistency of reporting. At enrollment (2003-2009), participants were asked to report use in the last year and during ages 10-13. On a follow-up questionnaire (2017-2019), participants were asked about their use of douche or genital talc over their lifetimes. RESULTS: Among 36,202 women who completed both questionnaires, 14% initially reported ever douching and 27% initially reported ever using genital talc. On the follow-up questionnaire, 51% of participants reported ever douching and 32% reported ever using genital talc. Comparisons across the two questionnaires for use in the year before enrollment showed good consistency, with 90% providing the same responses about douching and 87% providing the same responses about genital talc use. Reliability did not vary by cancer status, race and ethnicity, attained education, or age, though there was some evidence of recall bias for genital talc use among ovarian cancer survivors. CONCLUSIONS: Classification of ever use of feminine hygiene products may be recalled with good consistency, but agreement was lower for specific time periods and trends may vary by subgroup. These potential differences warrant careful consideration in future studies.

A comparative analysis of histologic types of thyroid cancer between career firefighters and other occupational groups in Florida.

BACKGROUND: Florida Firefighters experience a higher risk of thyroid cancer than non-firefighters. This study examines whether the histologic types and tumor stage of thyroid cancer is different among firefighters compared to other occupational groups. METHODS: Eligible cases were firefighters (n = 120) identified in a linkage of Florida Cancer Data System (FCDS) registry records (1981-2014) and Florida State Fire Marshal's Office employment and certification records, and non-firefighters classified into: blue-collar (n = 655), service (n = 834), white-collar (n = 4,893), and other (n = 1,789). Differences in thyroid histologic type (papillary, follicular, and rare/other less common forms of thyroid cancer), tumor stage, and age at diagnosis were evaluated using multinomial logistic regression models comparing blue-collar, service, white-collar, and other occupational groups with firefighters. Univariate odds ratios as well as odds ratios adjusted for age, gender, race, tumor stage, and year of diagnosis (aOR) and 95% confidence intervals (95%CI) were reported. RESULTS: Service (aOR = 4.12; 95%CI: 1.25-13.65), white-collar (aOR = 3.51; 95%CI: 1.08-11.36), and blue-collar (aOR = 4.59; 95%CI: 1.40-15.07) workers had significantly higher odds of being diagnosed with rare histologic types of thyroid cancer vs papillary type compared to firefighters. Service (aOR = 0.42; 95%CI: 0.27-0.66), white-collar (aOR = 0.39; 95%CI: 0.26-0.59), blue-collar (aOR = 0.36; 95%CI: 0.23-0.56), and other (aOR = 0.34; 95%CI: 0.22-0.53) occupational groups have a significantly lower odds of being diagnosed with rare vs papillary type at a younger age (30-49 years) vs 50-69 years compared to firefighters. However, stage at diagnosis was not significantly different among occupational groups. CONCLUSION: Firefighters diagnosed with thyroid cancer experience a higher odds of papillary compared to rare histologic types of thyroid cancer relative to other workers; there is no evidence of an increased odds of late-stage diagnosis in firefighters relative to other worker groups. Firefighters may benefit from routine screening and active surveillance of suspected thyroid tumors especially given the excellent treatment outcomes available for those diagnosed with early-stage papillary thyroid tumors.

Correlates of Positive Thyroid Peroxidase Antibodies Among Firefighters: A Cross-Sectional-Study.

Context: Exposure to endocrine disrupting chemicals (EDCs) are associated with underactive thyroid glands, and possibly autoimmunity. Firefighters are exposed to EDCs from flame retardants; however, the prevalence and risk factor associations of thyroid antibodies among firefighters are unknown. Context: We aimed to determine the prevalence of thyroid peroxidase antibodies (TPOAb) and associated sociodemographic and occupational risk factors among firefighters. Methods: Firefighters attending professional health and safety conferences between November 2018 and January 2020, and with no prior diagnosis of thyroid disease were invited (n = 278) to submit a health survey, blood samples, and complete a thyroid ultrasound. The survey assessed for sociodemographic and occupational characteristics, including a history of familial thyroid disease, smoking, firefighter tenure, and job rank, radiation exposure, and mitigation practices of occupational exposures. Serum thyroid peroxidase antibody (TPOAb) was also assessed. Results: Approximately 39.9% of firefighters evaluated had a positive TPOAb test. The mean age for those TPOAb positive was lower than those who tested negative (41.4 ±â€…7.9 vs 43.1 ±â€…7.9 years, P = 0.07) but this difference was not significant. Firefighters with a family history of thyroid disease had a statistically significant higher prevalence of TPOAb compared with those without a family history (60.0% vs 37.5%, P = 0.02); this association remained significant after adjusting for sociodemographic and occupational factors (odds ratio 2.99; CI, 1.31-6.85). Conclusion: The prevalence of TPOAb is high among firefighters in our study, and family history is a significant determinant of testing positive for TPOAb. Firefighters may benefit from TPOAb and thyroid stimulating hormone tests, and screening for family history of thyroid disease at baseline employee medical check-ups. This finding suggests the need for further studies.

A Socio-Ecological Framework for Cancer Prevention in Low and Middle-Income Countries.

Cancer incidence and mortality rates continue to rise globally, a trend mostly driven by preventable cancers occurring in low-and middle-income countries (LMICs). There is growing concern that many LMICs are ill-equipped to cope with markedly increased burden of cancer due to lack of comprehensive cancer control programs that incorporate primary, secondary, and tertiary prevention strategies. Notably, few countries have allocated budgets to implement such programs. In this review, we utilize a socio-ecological framework to summarize primary (risk reduction), secondary (early detection), and tertiary (treatment and survivorship) strategies to reduce the cancer burden in these countries across the individual, organizational, community, and policy levels. We highlight strategies that center on promoting health behaviors and reducing cancer risk, including diet, tobacco, alcohol, and vaccine uptake, approaches to promote routine cancer screenings, and policies to support comprehensive cancer treatment. Consistent with goals promulgated by the United Nations General Assembly on Noncommunicable Disease Prevention and Control, our review supports the development and implementation of sustainable national comprehensive cancer control plans in partnership with local communities to enhance cultural relevance and adoption, incorporating strategies across the socio-ecological framework. Such a concerted commitment will be necessary to curtail the rising cancer and chronic disease burden in LMICs.

Characterizing the Health and Safety Concerns of U.S. Rideshare Drivers: A Qualitative Pilot Study.

BACKGROUND: Despite the growth and popularity of gig work, limited information exists about the occupational health and safety concerns faced by individuals who are employed through ridesharing online applications. In this qualitative study, we characterized the perceived health and safety concerns of drivers employed by rideshare companies. METHODS: During September-October 2019, we requested car rides, using digital rideshare platforms. During the ride, drivers responded verbally to a brief closed-end sociodemographic and work characteristics survey. A semi-structured interview script was used to collect rideshare driver perceptions on health and safety risks. FINDINGS: A total of 35 rideshare drivers of group mean age of 43.1 ± 11.2 years were interviewed, of whom 77.1% were male and 82.9% identified as Latino. Sixty percent of participants reported rideshare as their primary job, working an average of 47.9 ± 19.6 hours weekly (minimum = 6 hours, maximum = 84 hours). Drivers enjoyed job autonomy yet faced stressors such as passenger risky behavior, car accidents, and lack of policies that protect the driver. Rideshare drivers also raised concerns about their current health status, economic pressures, and worker safety. CONCLUSION/APPLICATION TO PRACTICE: Drivers are forced to extend work hours to support themselves financially, exacerbating their current health concerns and safety risks as it means more time spent working in their sedentary job, compromising their mental and physical health as well as their safety. Occupational health and safety programs geared toward workers in the gig economy are needed.

Metabolic syndrome and risk of breast cancer mortality by menopause, obesity, and subtype.

PURPOSE: To investigate the association between metabolic syndrome (MetS) and risk of breast cancer mortality by menopausal status, obesity, and subtype. METHODS: Data from 94,555 women free of cancer at baseline in the National Institute of Health-American Association of Retired Persons Diet and Health Study cohort (NIH-AARP) were used to investigate the prospective associations of baseline MetS and components with risk of breast cancer mortality using Cox proportional hazard regression models adjusted for baseline behavioral and demographic covariates. RESULTS: During a mean follow-up duration of 14 years, 607 women in the cohort died of breast cancer. Overall, MetS was associated with a 73% increased risk of breast cancer mortality (HR 1.73; 95% CI 1.09-2.75); the association remained significant among post-menopausal women overall (HR 2.07, 95% CI 1.32, 3.25), and among those with overweight/obesity (HR 1.15, 95% CI 0.81, 1.64). MetS was associated with increased risk of breast cancer mortality for ER+/PR+ (HR 1.28, 95% CI 0.52, 3.16) and lower risk for ER-/PR- (HR 0.44, 95% CI 0.11, 1.75) subtypes; however, the associations were not statistically significant. Of the individual MetS components, high waist circumference (HR 1.32, 95% CI 1.03, 1.70), high cholesterol (HR 1.24, 95% CI 1.05, 1.46), and hypertension (HR 1.24, 95% CI 1.05, 1.46) were independently associated with increased risk of breast cancer mortality. CONCLUSIONS: MetS was associated with increased risk of breast cancer mortality, especially among post-menopausal women. Further studies with larger sample sizes are needed to definitively determine the extent to which these associations vary by breast cancer subtype.

Association between life-course socio-economic status and prevalence of cardio-metabolic risk ractors in five middle-income countries.

BACKGROUND: The burden of non-communicable diseases has increased rapidly in low- and middle-income countries. Past studies have reported an association between socioeconomic status (SES) and cardio-metabolic risk factors, but most have focused on upper income countries. The purpose of this study is to examine the association between SES over the life-course and the burden of cardio-metabolic risk factors in middle-income countries. METHODS: A total of 38 297 adults from China, Mexico, India, South Africa and Russia were included in this cross-sectional study. Life-course SES was defined based on maternal and participant education, and data on blood pressure, body mass index (BMI), self-reported diabetes and hypertension were obtained by trained interviewers. Descriptive, age standardized and multivariable adjusted analyses were conducted using survey weighted statistical procedures in SAS 9.4 (SAS Institute, Cary, NC, USA). RESULTS: Although 14% of men and 12% of women had current hypertension based on blood pressure measurements, only 2% of men and 4% of women were aware of their hypertensive status. Men with stable high life-course SES had higher odds of being overweight/obese (odds ratio OR = 2.01, 95% confidence interval (CI) = 1.30-3.10), diabetic (OR = 4.82, 95% CI = 2.07-11.2) and hypertensive based on self-report (OR = 3.42, 95% CI = 1.85-6.32) compared to men of low life-course SES. Among women, the odds of being overweight/obese were significantly higher among women with high life-course SES (OR = 1.50, 95% CI = 1.08-2.08). CONCLUSIONS: Higher life-course SES for both men and women was associated with increased odds of overweight/ obesity, and additionally diabetes and hypertension for men in middle income countries.

Demographic, presentation, and treatment factors and racial disparities in ovarian cancer hospitalization outcomes.

BACKGROUND: This study examines whether racial disparities in hospitalization outcomes persist between African-American and White women with ovarian cancer after matching on demographic, presentation, and treatment factors. METHODS: Using data from the Nationwide Inpatient Sample database, 5,164 African-American ovarian cancer patients were sequentially matched with White patients on demographic (e.g., age, income), presentation (e.g., stage, comorbidities), and treatment (e.g., surgery, radiation) factors. Racial differences in-hospital length of stay, post-operative complications, and in-hospital mortality were evaluated using conditional logistic regression models. RESULTS: White ovarian cancer patients had relatively higher odds of post-operative complications when matched on demographics (OR 1.35, 95% CI 1.05, 1.74), and presentation (OR 1.28, 95% CI 1.00, 1.65) but not when additionally matched on treatment (OR 1.03, 95% CI 0.78, 1.35). African-American patients had longer in-hospital length of stay (6.96 ± 7.21 days) compared with White patients when matched on demographics (6.37 ± 7.07 days), presentation (6.48 ± 7.16 days), and treatment (6.53 ± 7.59 days). Compared with African-American patients, White patients experienced lower odds of in-hospital mortality when matched on demographics (OR 0.78, 95% CI 0.66, 0.92), but this disparity was no longer significant when additionally matched on presentation (OR 0.88, 95% CI 0.75, 1.04) and treatment (OR 0.95, 95% CI 0.81, 1.12). CONCLUSION: Racial disparities in ovarian cancer hospitalization outcomes persisted after adjusting for demographic and presentation factors; however these differences were eliminated after additionally accounting for treatment factors. More studies are needed to determine the factors driving racial differences in ovarian cancer treatment in otherwise similar patient populations.

Sequential matched analysis of racial disparities in breast cancer hospitalization outcomes among African American and White patients.

BACKGROUND: The purpose of this study is to determine if racial disparities in inpatient outcomes persist among hospitalized patients comparing African American and White breast cancer patients matched on demographics, presentation and treatment. METHODS: A total of 136,211 African American and White breast cancer patients from the Healthcare Cost and Utilization Project - Nationwide Inpatient Sample (HCUP-NIS) database, matched on demographics alone, demographics and presentation or demographics, presentation and treatment were studied. Conditional logistic regression was conducted to evaluate post-surgical complications, length of stay and in-hospital mortality outcomes. Analysis was further stratified by age (≤65 years and >65years) to evaluate whether disparities were larger in younger or older patients. All analysis was conducted using SAS 9.3. RESULTS: White women had significantly shorter hospital length of stay when matched on demographics (ß=-0.87, p-value=<0.0001), demographics and presentation (ß=-0.63, p-value=<0.0001), and demographics, presentation and treatment (ß=-0.51, p-value=<0.0001) compared with African Americans. White women also had lower odds of mortality compared with African American women when matched on demographics (OR: 0.72, 95% CI: 0.65-0.79), demographics and presentation (OR: 0.77, 95% CI: 0.71-0.85), or matched on demographics, presentation and treatment (OR: 0.80, 95% CI: 0.73-0.88). The racial difference observed in length of stay and mortality was larger in the age group ≤65 years compared with >65years CONCLUSION: African American women experienced higher odds of inpatient mortality and longer length of stay compared with White women even after accounting for differences in demographics, presentation and treatment characteristics.

Lifecourse socioeconomic status and cancer-related risk factors: Analysis of the WHO study on global ageing and adult health (SAGE).

Few studies have examined cancer-related risk factors in relation to SES across the lifecourse in low to middle income countries. This analysis focuses on adult women in India, China, Mexico, Russia and South Africa, and examines the association between individual, parental and lifecourse SES with smoking, alcohol, BMI, nutrition and physical activity. Data on 22,283 women aged 18 years and older were obtained from the 2007 WHO Study on Global Aging and Adult Health (SAGE). Overall, 34% of women had no formal education, 73% had mothers with no formal education and 73% of women had low lifecourse SES. Low SES women were almost four times more likely to exceed alcohol use guidelines (OR: 3.86, 95% CI: 1.23-12.10), and 68% more likely to smoke (OR: 1.68, 95% CI: 1.01-2.80) compared with higher SES. Women with low SES mothers and fathers were more likely to have poor nutrition (Mothers OR: 1.59, 95% CI: 1.17-2.16; Fathers OR: 1.33, 95% CI: 1.11-1.59) and more likely to smoke (Mothers OR: 1.46, 95% CI: 1.15-1.87; Fathers OR: 2.17, 95% CI: 1.80-2.63) compared with those with high SES parents. Women with stable low lifecourse SES were more likely to smoke (OR: 2.55, 95% CI: 1.47-4.43), while those with declining lifecourse SES were more likely to exceed alcohol use guidelines (OR: 3.63, 95% CI: 1.07-12.34). Cancer-related risk factors varied significantly by lifecourse SES, suggesting that cancer prevention strategies will need to be tailored to specific sub-groups in order to be most effective.

Information, regulation and coordination: realist analysis of the efforts of community health committees to limit informal health care providers in Nigeria.

One of the consequences of ineffective governments is that they leave space for unlicensed and unregulated informal providers without formal training to deliver a large proportion of health services. Without institutions that facilitate appropriate health care transactions, patients tend to navigate health care markets from one inappropriate provider to another, receiving sub-optimal care, before they find appropriate providers; all the while incurring personal transaction costs. But the top-down interventions to address this barrier to accessing care are hampered by weak governments, as informal providers are entrenched in communities. To explore the role that communities could play in limiting informal providers, we applied the transaction costs theory of the firm which predicts that economic agents tend to organise production within firms when the costs of coordinating exchange through the market are greater than within a firm. In a realist analysis of qualitative data from Nigeria, we found that community health committees sometimes seek to limit informal providers in a manner that is consistent with the transaction costs theory of the firm. The committees deal not through legal sanction but by subtle influence and persuasion in a slow and faltering process of institutional change, leveraging the authority and resources available within their community, and from governments and NGOs. First, they provide information to reduce the market share controlled by informal providers, and then regulation to keep informal providers at bay while making the formal provider more competitive. When these efforts are ineffective or insufficient, committees are faced with a "make-or-buy" decision. The "make" decision involves coordination to co-produce formal health services and facilitate referrals from informal to formal providers. What sometimes results is a quasi-firm-informal and formal providers are networked in a single but loose production unit. These findings suggest that efforts to limit informal providers should seek to, among other things, augment existing community responses.

Life-course socioeconomic status and breast and cervical cancer screening: analysis of the WHO's Study on Global Ageing and Adult Health (SAGE).

OBJECTIVES: Socioeconomic differences in screening have been well documented in upper-income countries; however, few studies have examined socioeconomic status (SES) over the life-course in relation to cancer screening in lower-income and middle-income countries. Here, we examine individual, parental and life-course SES differences in breast and cervical cancer screening among women in India, China, Mexico, Russia and South Africa. SETTING: Data from the WHO's Study on Global Ageing and Adult Health (SAGE) 2007-2008 data were used for survey-weighted multivariable regression analysis. We examined the association between individual, parental and life-course SES in relation to breast and cervical cancer screening using education-based and employment-based measures of SES. PARTICIPANTS: 22 283 women aged 18-65 years, recruited from China, India, Mexico, Russia and South Africa. RESULTS: Having a college degree (OR 4.18; 95% CI 2.36 to 7.40) increased the odds of breast cancer screening compared with no formal education. Women with higher parental SES were almost 10 times more likely to receive breast cancer screening (OR 9.84; 95% CI 1.75 to 55.5) compared with women with low parental SES. Stable higher life-course (OR 3.07; 95% CI 1.96 to 4.79) increased breast cancer screening by threefold and increased cervical cancer screening by more than fourfold (OR 4.35; 95% CI 2.94 to 6.45); however, declining life-course SES was associated with reduced breast cancer screening (OR 0.26; 95% CI 0.08 to 0.79) compared to low life-course SES. CONCLUSIONS: Higher individual, parental and life-course SES was positively associated with breast and cervical cancer screening, although education-based SES measures were stronger predictors of screening compared with employment-based measures. Improving knowledge of the benefits of cancer screening and integrating cancer screening into routine healthcare practice for low SES women are actionable strategies that may significantly improve screening rates in low-income and middle-income countries.