Diet quality, ultra-processed food consumption, and quality of life in a cross-sectional cohort of adults and teens with celiac disease.

BACKGROUND: Coeliac disease (CeD), a common autoimmune condition, requires strict adherence to a gluten-free diet (GFD). Adherence to the GFD has been associated with quality of life (QOL). However, there may be other diet-related concerns, such as overall diet patterns, including diet quality or ultra-processed food (UPF) consumption, possibly associated with QOL among people with CeD following a GFD that have not been examined. METHODS: Diet quality was determined based on 24-h diet recalls of a cross-sectional prospectively recruited sample of 80 participants (50 adults and 30 teens) with biopsy-confirmed CeD ('Study Sample') using the Healthy Eating Index and Alternate Mediterranean Diet score. The amount of UPF consumed was assessed using Nova, a food processing classification system. QOL was measured using Celiac Disease-Specific Quality of Life (CDQOL) and Celiac Disease Pediatric-Specific Quality of Life (CDPQOL). The Study Sample's diet patterns were compared with National Health and Nutrition Examination Survey (NHANES) groups (25 adults reporting prior CeD and GFD; 51 adults with new CeD and no GFD; 15,777 adults and 2296 teens without CeD). The relationship of the Study Sample's diet patterns with CDQOL/CDPQOL was assessed using analysis of covariance. RESULTS: The Study Sample's diet patterns were suboptimal but generally favourable compared with all NHANES groups. Compared to Study Adults with the highest tertile of UPF, those with the lowest tertile had significantly higher CDQOL (mean: 67.6 vs. 78.3, p < 0.001). Compared to Study Teens with the lowest tertile of AMED, those with the highest tertile had significantly higher CDPQOL (mean: 67.0 vs. 79.9, p < 0.01). CONCLUSIONS: Maintaining high diet quality and minimising UPF may be important for CeD-specific QOL among individuals with CeD maintaining a GFD.

Impact of Celiac Disease on Dating.

BACKGROUND/AIMS: When seeking a romantic partner, individuals with celiac disease (CD) must navigate challenging social situations. We aimed to investigate dating-related behaviors in adults with CD. METHODS: A total of 11,884 affiliates of the Celiac Disease Center at Columbia University were invited to participate in an online survey. Adults (≥ 18 years) with biopsy-diagnosed CD were included. Among the 5,249 who opened the email, 538 fully completed the survey (10.2%). The survey included a CD-specific dating attitudes/behaviors questionnaire, a Social Anxiety Questionnaire (SAQ), a CD-specific quality of life instrument (CD-QOL), and a CD Food Attitudes and Behaviors scale (CD-FAB). RESULTS: Respondents were primarily female (86.8%) and the plurality (24.4%) was in the 23-35 year age range. 44.3% had dated with CD, and among them, 68.4% reported that CD had a major/moderate impact on their dating life. A major/moderate impact was more commonly reported among females (69.3%, p < 0.001), 23-35-year-olds (77.7%, p = 0.015), those with a household income < $50 K (81.7%, p = 0.019), and those with a lower CD-QOL score (50.5 vs. 73.4, p = 0.002). While on dates, 39.3% were uncomfortable explaining precautions to waiters, 28.2% engaged in riskier eating behaviors, and 7.5% intentionally consumed gluten. 39.0% of all participants were hesitant to kiss their partner because of CD; females more so than males (41.1% vs. 22.7%, p = 0.005). CONCLUSIONS: The majority of participants felt that CD had a major/moderate impact on their dating life. This impact may result in hesitation toward dating and kissing, decreased QOL, greater social anxiety, and less adaptive eating attitudes and behaviors. CD and the need to adhere to a gluten free diet have a major impact on dating and intimacy.

Navigating celiac disease and the gluten-free diet in China.

BACKGROUND: Little is known about celiac disease (CeD) diagnosis and management in China. AIM: This pilot aimed to be the first study to describe, quantitatively and qualitatively, how individuals living in China navigate CeD and the gluten-free diet (GFD). METHODS: Participants were 13 adults and four parents of children with reported CeD, recruited from 11 mainland China cities via an online GFD support group. CeD-specific quality of life (CD-QOL and CD-PQOL) and diet adherence (CDAT) were assessed. In-depth interviews addressed experiences with CeD and the GFD. RESULTS: Six of 17 participants reported biopsy- or serology-confirmed CeD. The mean (SD) adult CDAT score was 15.2 (3.6), > 13 indicating inadequate GFD adherence. The mean adult CD-QOL score was 62.1 (24.1) out of 100, in the "medium" to "good" range. Results were similar in children. Major interview themes included: (1) a challenging journey to obtain diagnosis; (2) social and structural barriers to maintaining the GFD; and (3) reliance on self in management of CeD. CONCLUSION: Obtaining a diagnosis, maintaining a GFD, and living with CeD can be extremely challenging in mainland China. Results suggest an urgent need for CeD-specific education and Asian-adapted GFD guidance for both healthcare practitioners and patients.

Impact of a Child's Celiac Disease Diagnosis and Management on the Family.

BACKGROUND: Little attention has been paid to family-wide repercussions of a child's celiac disease diagnosis and concomitant gluten-free diet management. AIMS: We quantitatively and qualitatively describe positive and negative family-wide effects of a child's celiac disease diagnosis and disease management. METHODS: We interviewed 16 families with at least one child currently following a gluten-free diet, with a biopsy-confirmed celiac disease diagnosis ≥ 1 year prior. Mothers and fathers independently rated child's dietary adherence, concern about child's health status, burden in caring for child's dietary needs, and level of change in various aspects of life post- diagnosis. Children rated their own celiac-specific quality of life through a validated scale. Seventy-one in-depth semi-structured interviews were conducted with 16 children with celiac disease, 31 parents, and 24 siblings. RESULTS: Mothers and fathers rated the effects of their child's celiac disease differently, with mothers reporting more lifestyle changes and heavier burden. Negative and positive themes emerged from the interviews. Mothers felt the burden of managing a gluten-free diet. Fathers felt guilty for carrying a celiac disease-associated gene and both fathers and siblings regretted limited food choices at restaurants and home. The need to be a more creative cook was seen as a positive effect by mothers. Fathers appreciated new family traditions. Siblings felt they had developed empathy for others. A framework is proposed to illustrate these family-wide interactions. CONCLUSIONS: A child's celiac disease diagnosis and disease management affects the entire family. Our results will inform family-centered interventions that maximize quality of life for families.

Anxiety after coeliac disease diagnosis predicts mucosal healing: a population-based study.

BACKGROUND: Coeliac disease has been linked to anxiety and depression. However, their association with mucosal healing is unknown. AIM: To examine the relationship between anxiety, depression and mucosal healing in coeliac disease. METHODS: Between 1969 and 2008, we collected data on all small intestinal biopsies with villous atrophy from Sweden's 28 pathology departments. We restricted our cohort to individuals with data on follow-up biopsy (either persistent villous atrophy [n = 3317] or mucosal healing [n = 4331]). Through Cox regression, we estimated hazard ratios (HRs) for anxiety or depression. RESULTS: During follow-up, 123 (2.8/1000 person-years) individuals with mucosal healing had developed anxiety, compared to 94 (2.1/1000 person-years) with persistent villous atrophy. Mucosal healing was hence associated with a higher risk of future anxiety (HR = 1.49; 95% CI = 1.12-1.96). Similarly, 167 (3.8/1000 person-years) individuals with mucosal healing developed depression, compared to 148 (3.3/1000 person-years) with persistent villous atrophy, corresponding to a HR of 1.25 (95% CI = 0.99-1.59). Mucosal healing was more common in individuals with prior diagnoses of anxiety or depression before follow-up biopsy. Anxiety diagnosed between diagnostic and follow-up biopsy for coeliac disease was associated with an almost nine-fold increased chance of mucosal healing (odds ratio = 8.94; 95%CI = 2.03-39.27). CONCLUSION: Anxiety and depression are more common in coeliac disease patients with mucosal healing, both before and after follow-up biopsy, an association potentially mediated through more vigilant compliance with a gluten-free diet. This finding raises concern that achieving the goal of mucosal healing may come at a cost of an increased risk of mood disorders.

Hypervigilance to a Gluten-Free Diet and Decreased Quality of Life in Teenagers and Adults with Celiac Disease.

BACKGROUND AND AIMS: Avoidance of gluten is critical for individuals with celiac disease (CD), but there is also concern that "extreme vigilance" to a strict gluten-free diet may increase symptoms such as anxiety and fatigue, and therefore, lower quality of life (QOL). We examined the associations of QOL with energy levels and adherence to, and knowledge about, a gluten-free diet. METHODS: This is a cross-sectional prospective study of 80 teenagers and adults, all with biopsy-confirmed CD, living in a major metropolitan area. QOL was assessed with CD-specific measures. Dietary vigilance was based on 24-h recalls and an interview. Knowledge was based on a food label quiz. Open-ended questions described facilitators and barriers to maintaining a gluten-free diet. RESULTS: The extremely vigilant adults in our sample had significantly lower QOL scores than their less vigilant counterparts [(mean (SD): 64.2 (16.0) vs 77.2 (12.2), p = 0.004]. Extreme vigilance was also associated with greater knowledge [5.7 (0.7) vs 5.1 (0.8), p = 0.035]. Adults with lower energy levels had significantly lower overall QOL scores than adults with higher energy levels [68.0 (13.6) vs 78.9 (13.0), p = 0.006]. Patterns were similar for teenagers. Cooking at home and using internet sites and apps were prevalent strategies used by the hypervigilant to maintain a strict gluten-free diet. Eating out was particularly problematic. CONCLUSION: There are potential negative consequences of hypervigilance to a strict gluten-free diet. Clinicians must consider the importance of concurrently promoting both dietary adherence and social and emotional well-being for individuals with CD.

Patient and Physician Factors Associated with Undisclosed Prostate Cancer Screening in a Sample of Predominantly Immigrant Black Men.

Medical guidelines do not recommend prostate cancer screening, particularly without informed and shared decision making. This study investigates undisclosed opportunistic screening using prostate specific antigen (PSA) testing in black immigrant and African American men. Participants (N = 142) were insured urban men, 45- to 70-years old. Patients' reports of testing were compared with medical claims to assess undisclosed PSA testing. Most (94.4 %) men preferred to share in screening decisions, but few (46.5 %) were aware PSA testing was performed. Four factors predicted being unaware of testing: low formal education, low knowledge about prostate cancer, no intention to screen, and no physician recommendation (all p's < .05). Undisclosed PSA testing was common. Both patient and provider factors increased risk of being uninformed about prostate cancer screening. Interventions combining patient education and physician engagement in shared decision making may better align practice with current prostate cancer screening guidelines.

Failure of Colonoscopy Knowledge to Predict Colonoscopy Uptake.

UNLABELLED: Despite an increase in colorectal cancer screening uptake, a substantial minority of individuals over 50 years of age remains unscreened. In the context of an RCT evaluating three educational interventions to increase CRC screening uptake, we examined the relationship of baseline colonoscopy knowledge and both intention to receive a colonoscopy and documented receipt of colonoscopy. Colonoscopy knowledge score, generally high, was positively associated with intention to receive colonoscopy but not with receipt of colonoscopy within 1 year post-randomization. Knowledge score was, however, positively associated with certain perceived barriers to colonoscopy: embarrassment and having to take a powerful laxative. CONCLUSION: Knowledge is not sufficient to trigger colonoscopy uptake. If CRC screening promotion campaigns fail to acknowledge and address patients' emotional barriers to colonoscopy, CRC screening rates will not improve. CLINICAL TRIALS: gov: Identifier: NCT02392143.

Fear as a Barrier to Asymptomatic Colonoscopy Screening in an Urban Minority Population with Health Insurance.

This study identified barriers to colonoscopy in a high-risk population and examined associations between barriers and both intention to comply with physician recommendation to receive colonoscopy and documented receipt of colonoscopy. Participants, enrollees in a randomized controlled trial assessing the effectiveness of educational interventions to promote colorectal cancer screening, were all 50+ years old and out of compliance with recommended screening guidelines. Direct financial cost of the procedure was not a barrier. The most commonly cited barriers were being afraid of the colonoscopy procedure (43.1 %), embarrassment (42.3 %), having to take a powerful laxative (36.2 %), fear of cancer (31.2 %), and fear of sedation (30.3 %). There were dose-response relationships between barriers and both intention to comply with physician recommendation of colonoscopy: 0, 1, 2, 3 barriers, 88.9, 79.0, 69.2 and 60.0 % intending to comply, respectively (linear trend χ(2) = 27.9, p = .000) and documented receipt of a colonoscopy: 0, 1, 2, 3 barriers, 21.7, 21.6, 8.5, 12.0 %, respectively (linear trend χ(2) = 8.4, p = .004). Only 6.9 % of the 102 expressing both fear of procedure and concern about taking a powerful laxative had a colonoscopy. These findings highlight the need to address patients' fear and suggest the importance of offering alternative colorectal cancer screening tests. ClinicalTrials.gov Identifier: NCT02392143.

Patient Test Preference for Colorectal Cancer Screening and Screening Uptake in an Insured Urban Minority Population.

The study examines the role of patient colorectal cancer (CRC) screening test preference and CRC screening uptake in an insured, urban minority population. Study subjects were enrolled in a randomized controlled trial to promote CRC screening. The interventions were educational, with an emphasis on colonoscopy screening. Subjects were 50+ years of age, fully insured for CRC screening, and out of compliance with current CRC screening recommendations. This paper includes those who answered a question about CRC screening test preference and indicated that they intended to receive such a test in the coming year (n = 453). CRC screening uptake was ascertained from medical claims data. Regardless of test preference, few received CRC screening (22.3 %). Those preferring the home stool test (HST) were less likely to get tested than those preferring a colonoscopy (16.6 vs 29.9 %, χ(2) = 9.9, p = .002). Preference for HST was more strongly associated with beliefs about colonoscopy than with knowledge about colonoscopy. In the context of an RCT emphasizing colonoscopy screening for CRC, patients expressing a preference for HST are at heightened risk of remaining unscreened. Colonoscopy should be recommended as the preferred CRC test, but HSTs should be accessible and encouraged for patients who are averse to colonoscopy.Clinical trials.gov: Identifier: NCT02392143.

Acceptability of Physician Directed Academic Detailing to Increase Colorectal Cancer Screening: an Application of the RESPECT Approach.

BACKGROUND: In developing effective interventions to increase colorectal cancer (CRC) screening in at risk populations, a necessary first requirement is feasibility. This paper describes how the RESPECT approach to health education guided the conceptualization and implementation of physician-directed academic detailing (AD) to increase practice-wide CRC screening uptake. METHODS: Physician-directed AD was one intervention component in a large educational randomized controlled trial to increase CRC screening uptake. Study participants, primarily urban minority, were aged 50 or older, insured for CRC screening with no out-of-pocket expense and out of compliance with current screening recommendations. The trial was conducted in the New York City metropolitan area. Participants identified their primary care physician; 564 individuals were recruited, representing 459 physician practices. Two-thirds of the physician practices were randomized to receive AD. The RESPECT approach, modified for AD, comprises: 1) Rapport, 2) Educate, but don't overwhelm, 3) Start with physicians where they are, 4) Philosophical orientation based on a humanistic approach to education, 5) Engagement of the physician and his/her office staff, 6) Care and show empathy, and 7) Trust. Feasibility was assessed as rate of AD delivery. RESULTS: The AD was delivered to 283 (92.5%) of the 306 practices assigned to receive it; 222/283 (78.4%) delivered to the doctor. CONCLUSION: The AD was feasible and acceptable to implement across a range of clinical settings. The RESPECT approach offers a framework for tailoring educational efforts, allowing flexibility, as opposed to strict adherence to a highly structured script or a universal approach.

Motivating factors associated with receipt of asymptomatic colonoscopy screening.

BACKGROUND: Colonoscopy is the preferred screening method for colorectal cancer (CRC). This study aimed to identify factors motivating a beneficial health behavior, that is, the decision to complete a colonoscopy. METHODS: We surveyed 91 primarily urban minority health care workers who were ineligible for a large randomized controlled trial due to self-reported asymptomatic colonoscopy screening. Participants were asked an open-ended question about what made them get screened. Responses were classified as external or internal motivations. RESULTS: The most commonly reported external motivation was a primary care physician's recommendation (n = 60, 65.9%). Other external motivations were familiarity with CRC or polyps through family or work (n = 16, 17.6%) and pressure from relatives or friends (n = 8, 8.8%). Seventeen respondents were deemed self-motivated; these individuals were more likely have income over $50K/year (P < 0.05) and to be US born (P = 0.05); they were more likely to mention being age-appropriate for screening (P < 0.05); knew more people who had colonoscopies (P < 0.001); they were less likely to believe that most of the age-appropriate population in New York City has been screened (P < 0.01) and less likely to be deterred from colonoscopy by work schedule (P < 0.001) or by having to take a powerful laxative (P < 0.001). CONCLUSIONS: A primary care physician's recommendation may be the most prevalent motivating factor in patients' decisions to receive a colonoscopy, but a subgroup seeks CRC screening on their own. Analysis of the motivations of individuals who have sought colonoscopy screening may offer useful insights into motivating those who have not.

A Randomized Trial to Compare Alternative Educational Interventions to Increase Colorectal Cancer Screening in a Hard-to-Reach Urban Minority Population with Health Insurance.

This randomized controlled trial assessed different educational approaches for increasing colorectal cancer screening uptake in a sample of primarily non-US born urban minority individuals, over aged 50, with health insurance, and out of compliance with screening guidelines. In one group, participants were mailed printed educational material (n = 180); in a second, participants' primary care physicians received academic detailing to improve screening referral and follow-up practices (n = 185); in a third, physicians received academic detailing and participants received tailored telephone education (n = 199). Overall, 21.5% of participants (n = 121) received appropriate screening within one year of randomization. There were no statistically significant pairwise differences between groups in screening rate. Among those 60 years of age or older, however, the detailing plus telephone education group had a higher screening rate than the print group (27.3 vs. 7.7%, p = .02). Different kinds of interventions will be required to increase colorectal cancer screening among the increasingly small population segment that remains unscreened. ClinicalTrials.gov Identifier: NCT02392143.

Diet-Related Colorectal Cancer Prevention Beliefs and Dietary Intakes in an Urban Minority Population.

In the United States, colorectal cancer (CRC) is the third leading cause of cancer-related death and third most commonly diagnosed cancer among adults. This study is the first to examine the relationship between diet-related beliefs for colorectal cancer prevention and dietary intake among an urban, predominantly Black population (n = 169). More than two-thirds reported diet-related CRC prevention beliefs. Those with diet-related CRC prevention beliefs had healthier intakes for dietary fiber (p = .005), fruit, vegetable, bean (p = .027), red meat (p = .032), vitamin C (p = .039), and cholesterol (p = .045). Most people may already have diet-related CRC prevention beliefs and having them is associated with a more healthful dietary intake.

Screening colonoscopy bowel preparation: experience in an urban minority population.

METHODS: Suboptimal bowel preparation, present in over 20% of colonoscopies, can severely compromise the effectiveness of the colonoscopy procedure. We surveyed 93 primarily urban minority men and women who underwent asymptomatic 'screening' colonoscopy regarding their precolonoscopy bowel-preparation experience. RESULTS: Print materials alone (39.8%) and in-person verbal instructions alone (35.5%) were reportedly the most common modes of instruction from the gastroenterologists. Liquid-containing laxative (70.6%) was the most common laxative agent; a clear liquid diet (69.6%) the most common dietary restriction. Almost half of the participants mentioned 'getting the laxative down' as one of the hardest parts of the preparation; 40.9% mentioned dietary restrictions. The 24.7% who mentioned 'understanding the instructions' as one of the hardest parts were more likely to be non-US born and to have lower education and income. There was no relationship between difficulty in understanding instructions and mode of instruction or preparation protocol. One quarter suggested that a smaller volume and/or more palatable liquid would have made the preparation easier. Three quarters agreed that it would have been helpful to have someone to guide them through the preparation process. CONCLUSIONS: These findings suggest a variety of opportunities for both physician- and patient-directed educational interventions to promote higher rates of optimal colonoscopy bowel preparation.

Informed decision making about prostate cancer testing in predominantly immigrant black men: a randomized controlled trial.

BACKGROUND: Decision support interventions have been developed to help men clarify their values and make informed decisions about prostate cancer testing, but they seldom target high-risk black and immigrant men. PURPOSE: This study evaluated the efficacy of a decision support intervention focused on prostate cancer testing in a sample of predominantly immigrant black men. METHODS: Black men (N = 490) were randomized to tailored telephone education about prostate cancer testing or a control condition. RESULTS: Post-intervention, the intervention group had significantly greater knowledge, lower decision conflict, and greater likelihood of talking with their physician about prostate cancer testing than the control group. There were no significant intervention effects on prostate specific antigen testing, congruence between testing intention and behavior, or anxiety. CONCLUSIONS: A tailored telephone decision support intervention can promote informed decision making about prostate cancer testing in black and predominantly immigrant men without increasing testing or anxiety.

Distinguishing factors for asymptomatic colonoscopy screening.

Demographic, medical history, physician factors, knowledge, beliefs and perceived barriers related to colorectal cancer (CRC) and CRC screening were compared for age-eligible individuals who received asymptomatic colonoscopy screening (n=100) versus those who did not receive any kind of CRC screening (n=142). All participants had health insurance that covered the full cost of colonoscopy screening. Screeners were more likely to have lower levels of income and education, to know the purpose of a colonoscopy, believe it was more normative, and report fewer barriers. Addressing these and other factors associated with CRC screening warrant testing as empirically based interventions.

Food label use and its relation to dietary intake among US adults.

Rates of diet-related chronic disease combined with the lack of current data on patterns of food label use by the US population warrant re-examination of the use and potential influence of this public health tool. The purpose of this study was to describe the prevalence of food label use and the association between food label use and nutrient intake in a nationally representative sample of US adults who participated in the 2005-2006 National Health and Nutrition Examination Survey. Data on food label use were collected during the interview portion of the survey, and nutrient intake was estimated using the average of two 24-hour dietary recalls. In this sample, 61.6% of participants reported using the Nutrition Facts panel, 51.6% looked at the list of ingredients, 47.2% looked at serving size, and 43.8% reviewed health claims at least sometimes when deciding to purchase a food product. There were significant differences (P<0.05) in food label use across all demographic characteristics examined. Significant differences (P<0.05) in mean nutrient intake of total energy, total fat, saturated fat, cholesterol, sodium, dietary fiber, and sugars were observed between food label users and non-users with label users reporting healthier nutrient consumption. The greatest differences observed were for total energy and fat and for use of specific nutrient information on the food label. Despite food label use being associated with improved dietary factors, label use alone is not expected to be sufficient in modifying behavior ultimately leading to improved health outcomes.

Tailored telephone education to promote awareness and adoption of fruit and vegetable recommendations among urban and mostly immigrant black men: a randomized controlled trial.

BACKGROUND: Fruit and vegetable (FV) intake in black men are far below national recommendations. METHODS: Urban, primarily immigrant, black men (n=490) from the New York City metropolitan area participating in the Cancer Awareness and Prevention (CAP) Trial (2005-2007) were randomly assigned to one of two intervention groups: 1) FV Education (FVE) or 2) Prostate Education (PE). Both interventions entailed a mailed brochure plus two tailored telephone education (TTE) calls. Outcomes, measured at baseline and at eight months, included knowledge of FV recommendations, perceived benefits, stage of readiness to adopt recommendations and self-reported FV consumption. RESULTS: At follow-up, the FVE group consumed an average of 1.2 more FV servings per day than the PE group (P<0.001; adjusted for baseline). The FVE group also demonstrated increases in knowledge about recommended FV amounts (P<0.01) and appropriate serving sizes (P<0.05), and in the percent of participants moving from a lower to a higher stage of readiness to adopt FV recommendations (P<0.05). The FVE group did not demonstrate increases in knowledge related to the importance of eating a colorful variety or in the ability to name potential health benefits. CONCLUSIONS: TTE can be a practical and moderately effective intervention for raising awareness of FV recommendations and for promoting FV consumption in urban and primarily immigrant black men.

Facilitating factors for colorectal cancer screening.

BACKGROUND: In this retrospective study, we examined factors that facilitated receipt of colorectal cancer (CRC) screening in a sample of low-income, predominantly African Americans participating in a tailored telephone education intervention. METHODS: A total of 61 individuals who received CRC screening were matched on age and sex with 61 individuals who had not received screening. Using records collected as part of the intervention, we identified facilitating factors and compared them between groups. RESULTS: We identified 8 facilitating factors, of which there were significant bivariate relationships with 6 factors. These 6 factors were stated familiarity with CRC test, seemed to only need reminder calls, seemed ready to screen, primary care physician (PCP) encouraged CRC screening, had an upcoming PCP appointment, and being prevention oriented. CONCLUSIONS: Identifying facilitating factors in those who receive screening may lead to insights about what factors need to be cultivated in those who do not receive screening.