A Systematic Review of the Effectiveness of Cervical Cancer Screening and Prevention Interventions for African American Women: Implications for Promoting Health Equity.

African American women suffer under the burden of cervical cancer as they are first in mortality, diagnosed at later stages, and have a survivorship rate that is lower than the national average. The aim of our review is to evaluate the effectiveness of cervical cancer screening and prevention interventions for African American women living in the United States and to assess their commitment to health equity. A literature search was conducted using PubMed, Embase, CINAHL, and Scopus using MeSH terms related to cervical cancer, human papillomavirus (HPV), screening and prevention, and African Americans. This resulted in 1970 articles. Studies were included if they promoted cervical screening or prevention, sampled African American women aged 18 and over, and evaluated interventions. Among the 23 articles that met inclusion criteria, there were a wide variety of intervention strategies, that is, community health workers, patient navigation, patient reminders, self-sampling collection, and HPV vaccination. Health education interventions, when coupled with patient navigation or community health workers, were effective in promoting screening participation (odds ratio: 2.43, 95% confidence interval: 1.47-4.02). There were mixed results regarding the incorporation of health equity principles. This review supports the importance of incorporating health equity principles and community based methods in screening and prevention interventions. Future research and practice should incorporate African American women's perspectives in intervention development and implementation.

Understanding the role of access in Hispanic cancer screening disparities.

BACKGROUND: Hispanic populations in the United States experience numerous barriers to care access. It is unclear how cancer screening disparities between Hispanic and non-Hispanic White individuals are explained by access to care, including having a usual source of care and health insurance coverage. METHODS: A secondary analysis of the 2019 National Health Interview Survey was conducted and included respondents who were sex- and age-eligible for cervical (n = 8316), breast (n = 6025), or colorectal cancer screening (n = 11,313). The proportion of ever screened and up to date for each screening type was compared.  Regression models evaluated whether controlling for reporting a usual source of care and type of health insurance (public, private, none) attenuated disparities between Hispanics and non-Hispanic White individuals. RESULTS: Hispanic individuals were less likely than non-Hispanic White individuals to be up to date with cervical cancer screening (71.6% vs. 74.6%) and colorectal cancer screening (52.9% vs. 70.3%), but up-to-date screening was similar for breast cancer (78.8% vs. 76.3%). Hispanic individuals (vs. non-Hispanic White) were less likely to have a usual source of care (77.9% vs. 86.0%) and more likely to be uninsured (23.6% vs. 7.1%). In regressions, insurance fully attenuated cervical cancer disparities. Controlling for both usual source of care and insurance type explained approximately half of the colorectal cancer screening disparities (adjusted risk difference: -8.3 [-11.2 to -4.8]). CONCLUSION: Addressing the high rate of uninsurance among Hispanic individuals could mitigate cancer screening disparities. Future research should build on the relative successes of breast cancer screening and investigate additional barriers for colorectal cancer screening. PLAIN LANGUAGE SUMMARY: This study uses data from a national survey to compare cancer screening use those who identify as Hispanic with those who identify as non-Hispanic White. Those who identify as Hispanic are much less likely to be up to date with colorectal cancer screening than those who identify as non-Hispanic White, slightly less likely to be up to date on cervical cancer screening, and similarly likely to receive breast cancer screening. Improving insurance coverage is important for health equity, as is further exploring what drives higher use of breast cancer screening and lower use of colorectal cancer screening.

Racial and Ethnic Disparities in Cervical Cancer Incidence, Survival, and Mortality by Histologic Subtype.

PURPOSE: We conducted an integrated population-based analysis of histologic subtype-specific cervical cancer incidence, survival, and incidence-based mortality by race and ethnicity, with correction for hysterectomy prevalence. METHODS: Using the SEER 21 and 18 registries, we selected primary cases of malignant cervical cancer diagnosed among women ≥ 15 years. We evaluated age-adjusted incidence rates among cases diagnosed between 2000 and 2018 (SEER21) and incidence-based mortality rates among deaths from 2005 to 2018 (SEER18), per 100,000 person-years. Rates were stratified by histologic subtype and race/ethnicity (incidence and mortality), and stage, age at diagnosis, and county-level measures of social determinants of health (incidence only). Incidence and mortality rates were corrected for hysterectomy using data from the Behavioral Risk Factor Surveillance System. We estimated 5-year relative survival by histologic subtype and stratified by stage at diagnosis. RESULTS: Incidence rates of cervical squamous cell carcinoma were highest in Black and Hispanic women, while incidence rates of cervical adenocarcinoma (ADC) were highest among Hispanic and White women, particularly for localized ADC. County-level income and education variables were inversely associated with squamous cell carcinoma incidence rates in all racial and ethnic groups but had less influence on ADC incidence rates. Black women had the highest overall mortality rates and lowest 5-year relative survival, irrespective of subtype and stage. Disparities in survival were particularly pronounced for Black women with regional and distant ADC, compared with other racial/ethnic groups. CONCLUSION: Although Black women are less likely to be diagnosed with ADC compared with all other racial/ethnic groups, they experience the highest mortality rates for this subtype, likely attributed to the poor survival observed for Black women with regional and distant ADC.

Racial Disparities Associated with the Prevalence of Vaccine and Non-Vaccine HPV Types and Multiple HPV Infections between Asia and Africa: A Systematic Review and Meta-Analysis.

BACKGROUND/OBJECTIVE: Cervical Cancer is the 6th most common and 3rd most deadly cancer among women. Despite the fact that the majority of the countries in Asia and Africa have a similar economy and low life expectancy, the mean age-standardized incidence rate (ASIR) of cervical cancer is substantially higher in Africa than in Asia. This study identified the correlates of the higher ASIR rates in Africa relative to Asia against two timelines; 2004-2009 and 2010-2017. METHODS: Peer-reviewed articles published between 2004 and 2017 were selected using the PRISMA standard. Sources of articles included Google Scholar, Scopus, PubMed Central, and EMBASE. Search keywords included: HPV genotypes, cervical cancer, HPV vaccine, and multiple infections in Africa and Asia. RESULT: Twenty-nine and seventeen full-length articles were selected from Africa and Asia, respectively. The pooled prevalence of HPV infection up to 2017 was higher in Africa (41.8%; 95% CI: 35.9, 47.7) than in Asia (24.2%; 95% CI: 16.22, 32.2) at p< 0.001. Between 2004-2009 and 2010-2017 timelines, the pooled prevalence of HPV infection decreased from 49.1% to 36.7% (OR': 1.66, 95% CI: 1.51-1.80) in Africa and increased from 16.9% to 20.5% (OR': 0.79, 95% CI: 0.71-0.86) in Asia. However, the pooled prevalence of multiple HPV infections and non-vaccine high-risk HPV infections were higher among African women diagnosed with cancer (30.9% and 5.2%) than their Asian counterparts (21.0% and 2.0%, respectively) at p< 0.001. Additionally, the pooled prevalence of the five most prevalent high-risk HPV types in Africa were HPV16 (35.3%), HPV52 (14.2%), HPV35 (12.4%), HPV18 (10.4%), and HPV58 (10.0%), while that of Asia were HPV16 (37.3%), HPV52 (16.2%), HPV58 (14.7%), HPV33 (7.4%) and HPV18 (7.2%). CONCLUSION: This study suggests that the higher prevalence of HPV, multiple HPV and non-vaccine HPV infections could be responsible for the higher ASIR in Africa than in Asia.

A population study of screening history and diagnostic outcomes of women with invasive cervical cancer.

BACKGROUND: Despite advances to prevent and detect cervical cancer, national targets for screening have not been met in the United States. Previous studies suggested that approximately half of women who developed cervical cancer were not adequately screened. This study aimed to provide an updated examination of women's screening and diagnostic practices five years prior to an invasive cervical cancer diagnosis. METHODS: The study included women age 21 years and older diagnosed with invasive cervical cancer in 2013-2016 from three population-based state cancer registries in the United States. Medical records abstraction identified screening history and diagnostic follow-up. A mailed survey provided sociodemographic data. Screening was a Pap or human papillomavirus (HPV) test between 6 months and 5 years before diagnosis. Adequate follow-up was defined per management guidelines. RESULTS: Of the 376 women, 60% (n = 228) had not been screened. Among women who received an abnormal screening result (n = 122), 67% (n = 82) had adequate follow-up. Predictors of: (a) being screened were younger age, having a higher income, and having insurance; (b) adequate follow-up were having a higher income, and (c) stage 1 cervical cancer were being screened and younger age. CONCLUSION: Unlike other cancer patterns of care studies, this study uses data obtained from medical records supplemented with self-report information to understand a woman's path to diagnosis, her follow-up care, and the stage of her cervical cancer diagnosis. This study provides findings that could be used to reach more unscreened or under screened women and to continue lowering cervical cancer incidence in the United States.

A Longitudinal Analysis of Patient-Level Factors Associated with Pap Test Uptake Among Chinese American Women.

The purpose of this study was to longitudinally examine patient-level factors associated with Pap test uptake among middle-aged Chinese American women. The study analyzed data from 498 Chinese American women (1326 person-time-waves) who participated in the Study of Women's Health Across the Nation (SWAN) Series. Generalized estimating equation (GEE) was used to longitudinally examine patient-level factors associated with Pap test uptake over the 7-year period. Of the 1326 person-time-waves, 61% had a Pap test and 39% did not. Higher amounts of time spent by female healthcare providers for female health needs (eb = 3.35, p < 0.01), having a female healthcare provider for female health needs (eb = 3.36, p < 0.01),, and a history of cancer (eb = 6.05, p < 0.01) or fibroids (eb = 1.66, p < 0.01) were positively associated with Pap test uptake among Chinese American women, whereas not having a primary care provider (eb = 0.27, p < 0.05) and not having time to go to the doctor (eb = 0.31, p < 0.05) were negatively associated with Pap test uptake. Health education and health promotion messaging that accentuates the benefits of access to primary care providers and allocation of time to attend to health needs may bolster Chinese American women's acceptability and uptake of routine Pap testing for cervical cancer prevention. If health education and health promotion efforts are not developed, suboptimal rates of Pap testing will widen the disparity gap and contribute to Chinese American women's increased risk of cervical cancer morbidity and mortality in the coming years.

Racial/Ethnic Disparities in the Burden of HIV/Cervical Cancer Comorbidity and Related In-hospital Mortality in the USA.

OBJECTIVE: The purpose of this study was to determine whether cervical cancer is a risk factor for early mortality among women with HIV and whether racial/ethnic disparity predicted in-hospital death among women living with HIV and diagnosed with cervical cancer. METHODS: We conducted a population-based study using the National Inpatient Sample (NIS) database comprising hospitalized HIV-positive women with or without cervical cancer diagnosis, from 2003 through 2015. We compared trends in the rates of cervical cancer, in-hospital death, and years of potential life lost (YPLL) by race/ethnicity. RESULTS: We identified 2,613,696 women with HIV, and among them, 5398 had cervical cancer. The prevalence of cervical cancer (per 10,000) was 9.3 for NH-Whites, 30.9 among NH-Blacks, and 30.2 for Hispanics. Rates of cervical cancer over time diminished significantly only among NH-Whites (average annual percent change (AAPC), - 5.8 (- 9.7, - 1.8)), and YPLL in women with cervical cancer decreased significantly only in NH-Whites (AAPC, - 6.2 (- 10.1, - 2.0)). Cervical cancer was associated with increased odds of in-hospital death overall (OR 2.24 (1.59-3.15)) and among NH-Blacks (OR 2.03 (1.30-3.18)) only. CONCLUSIONS: NH-Blacks and Hispanics with HIV remain at increased risk for concurrent diagnosis of cervical cancer compared with NH-Whites. Moreover, NH-Black women with HIV and cervical cancer are at greatest risk for in-hospital death. The findings emphasize the need for a more robust prevention strategy among minority women to reduce the high burden of HIV/cervical cancer and related mortality.

Adherence to Cervical Cancer Screening in Korean American Immigrant Women: Identifying Malleable Variables for Intervention Development.

Introduction. Despite Korean American women having a high incidence rate of cervical cancer, many are unaware of the significance of Pap test. The purpose of this research was to examine the rates of Pap test receipt and factors associated with the uptake. Method. The study was guided by Andersen's Model of Health Service Use and used a cross-sectional research design. A sample of 230 women residing in metro-Atlanta, Georgia, participated in this study. Results. Slightly more than half (55.7%) had lifetime Pap tests while less than half (45.7%) had it within the last 3 years. Binary logistic regression indicated that marital status, monthly income, and annual checkups were significantly correlated with receiving Pap tests. Discussion. Special attention is needed for women who are unmarried and have low income to increase Pap test receipt. Suggested intervention programs include better communication strategies, extended Medicare coverage, and outreach programs within Korean American community.

Patterns of HIV testing among women diagnosed with invasive cervical cancer in the New Jersey Medicaid Program.

PURPOSE: Practice-based guidelines recommend HIV testing during initial invasive cervical cancer (ICC) workup. Determinants of HIV testing during diagnosis of AIDS-defining cancers in vulnerable populations, where risk for HIV infection is higher, are under-explored. METHODS: We examine factors associated with patterns of HIV testing among Medicaid enrollees diagnosed with ICC. Using linked data from the New Jersey State Cancer Registry and New Jersey Medicaid claims and enrollment files, we evaluated HIV testing among 242 ICC cases diagnosed from 2012 to 2014 in ages 21-64 at (a) any point during Medicaid enrollment (2011-2014) and (b) during cancer workup 6 months pre ICC diagnosis to 6 months post ICC diagnosis. Logistic regression models identified factors associated with HIV testing. RESULTS: Overall, 13% of women had a claim for HIV testing during ICC workup. Two-thirds (68%) of women did not have a claim for HIV testing (non-receipt of HIV testing) while enrolled in Medicaid. Hispanic/NH-API/Other women had lower odds of non-receipt of HIV testing compared with NH-Whites (OR: 0.40; 95% CI: 0.17-0.94). Higher odds of non-receipt of HIV testing were observed among cases with no STI testing (OR: 4.92; 95% CI 2.27-10.67) and < 1 year of Medicaid enrollment (OR: 3.07; 95% CI 1.14- 8.26) after adjusting for other factors. CONCLUSIONS: Few women had HIV testing claims during ICC workup. Opportunities for optimal ICC care are informed by knowledge of HIV status. Further research should explore if lack of HIV testing claims during ICC workup is an accurate indicator of ICC care, and if so, to assess testing barriers during workup.

Self-reported breast and cervical cancer screening practices among women in Ghana: predictive factors and reproductive health policy implications from the WHO study on global AGEing and adult health.

BACKGROUND: Breast and cervical cancers constitute the two leading causes of cancer deaths among women in Ghana. This study examined breast and cervical screening practices among adult and older women in Ghana. METHODS: Data from a population-based cross-sectional study with a sample of 2749 women were analyzed from the study on global AGEing and adult health conducted in Ghana between 2007 and 2008. Binary and multivariable ordinal logistic regression analyses were performed to assess the association between socio-demographic factors, breast and cervical screening practices. RESULTS: We found that 12.0 and 3.4% of adult women had ever had pelvic screening and mammography respectively. Also, 12.0% of adult women had either one of the screenings while only 1.8% had both screening practices. Age, ever schooled, ethnicity, income quantile, father's education, mother's employment and chronic disease status were associated with the uptake of both screening practices. CONCLUSION: Nationwide cancer awareness campaigns and education should target women to improve health seeking behaviours regarding cancer screening, diagnosis and treatment. Incorporating cancer screening as a benefit package under the National Health Insurance Scheme can reduce financial barriers for breast and cervical screening.

Qualitative assessment of knowledge and attitudes towards cervical cancer screening among male Latino immigrants in Houston, Texas.

BACKGROUND: Male spouses and partners play an important role in determining a woman's willingness to participate in cervical cancer screening. However, the attitudes and behaviors by which they influence a woman's decision to undergo Pap testing remain poorly understood. METHODS: A series of semi-structured, qualitative interviews were conducted in Spanish with 19 recent Latino immigrants in Houston, Texas. The interview format was designed to establish each individual's pattern of engagement with the United States healthcare system, assess baseline knowledge of cervical cancer screening and evaluate attitudes and patterns of communication with their female partners regarding health care. Interview questions were constructed using principles of the Theory of Reasoned Action. All interviews were conducted in Spanish. After translation, responses were coded and scored with the goal of identifying themes and key observations. RESULTS: Most subjects reported few, if any, interactions with the healthcare system since their arrival in the United States. Although most participants reported being aware that women should be seen by their doctors regularly, fewer than half could clearly indicate the purpose of a Pap test or could state with certainty the last time their female partner had undergone screening. Multiple subjects expressed a general distrust of the health care system and concern for its costs. Approximately half of subjects reported that they accompanied their female partner to the health care provider's office and none of the participants reported that they were present in examination rooms at the time their partner underwent screening. Multiple participants endorsed that there may be some concerns within their community regarding women receiving frequent gynecologic care and distrust of the healthcare system. Almost all interviewed subjects stated that while they would allow their female partners to see male physicians, they also expressed the opinion that other men might be uncomfortable with this and that women would likely be more comfortable with female physicians. CONCLUSIONS: Strategies to enhance knowledge of HPV and cancer screening and improve trust in the health care system among male spouses or partners should be explored with the goal of promoting cervical cancer screening among immigrant Latinx populations.

Socio-demographic characteristics and associated factors influencing cervical cancer screening among women attending in St. Paul's Teaching and Referral Hospital, Ethiopia.

BACKGROUND: In Ethiopia, cervical cancer is the second most frequent cancer among women aged 15 to 44 years old. Cervical cancer screening is an effective measure to enhance the early detection of cervical cancer for prevention. However, the magnitude of cervical cancer screening is less than 1%. This study aimed to determine the influence of sociodemographic characteristics and related factors on screening. METHOD: A hospital-based cross-sectional study has been conducted from July to September 2017. Data have been collected using interviewer-administered questioner among 425 women (18-49 years age) who visited the family health department at St. Paul's Hospital. Descriptive statistics, chi-square, univariate and multivariate logistic regression were used for data analysis. RESULT: Of the 425 study participants, only 12.2% of women have been screened within the past 3 years. Women in the age range of 40-49 years old were more likely to be screened (36.1%) than women age 18-29 years (8%). Women living in urban were more likely to be screened (15.9%) than women living in rural (3.9%). Other factors including low monthly income, unlikely chance of having cancer, lack of knowledge, and fear test outcome were significantly associated with the low uptake of screening. CONCLUSION: This study revealed that the uptake of cervical cancer screening was low. Women in the potential target population of cervical cancer screening were just a proportion of all studied age groups and screening in them was more common than in younger women. Besides, rural residence, low monthly income, and lack of knowledge were important predictors for low utilization of cervical cancer screening practice.

Wealth-related inequalities of women's knowledge of cervical cancer screening and service utilisation in 18 resource-constrained countries: evidence from a pooled decomposition analysis.

INTRODUCTION: Resource-constrained countries (RCCs) have the highest burden of cervical cancer (CC) in the world. Nonetheless, although CC can be prevented through screening for precancerous lesions, only a small proportion of women utilise screening services in RCCs. The objective of this study was to examine the magnitude of inequalities of women's knowledge and utilisation of cervical cancer screening (CCS) services in RCCs. METHODS: A total of 1,802,413 sample observations from 18 RCC's latest national-level Demographic and Health Surveys (2008 to 2017-18) were analysed to assess wealth-related inequalities in terms of women's knowledge and utilisation of CCS services. Regression-based decomposition analyses were applied in order to compute the contribution to the inequality disparities of the explanatory variables for women's knowledge and utilisation of CCS services. RESULTS: Overall, approximately 37% of women had knowledge regarding CCS services, of which, 25% belonged to the poorest quintile and approximately 49% from the richest. Twenty-nine percent of women utilised CCS services, ranging from 11% in Tajikistan, 15% in Cote d'Ivoire, 17% in Tanzania, 19% in Zimbabwe and 20% in Kenya to 96% in Colombia. Decomposition analyses determined that factors that reduced inequalities in women's knowledge of CCS services were male-headed households (- 2.24%; 95% CI: - 3.10%, - 1.59%; P < 0.01), currently experiencing amenorrhea (- 1.37%; 95% CI: - 2.37%, - 1.05%; P < 0.05), having no problems accessing medical assistance (- 10.00%; 95% CI: - 12.65%, - 4.89%; P < 0.05), being insured (- 6.94%; 95% CI: - 9.58%, - 4.29%; P < 0.01) and having an urban place of residence (- 9.76%; 95% CI: - 12.59%, - 5.69%; P < 0.01). Similarly, factors that diminished inequality in the utilisation of CCS services were being married (- 8.23%;95% CI: - 12.46%, - 5.80%; P < 0.01), being unemployed (- 14.16%; 95% CI: - 19.23%, - 8.47%; P < 0.01) and living in urban communities (- 9.76%; 95% CI: - 15.62%, - 5.80%; P < 0.01). CONCLUSIONS: Women's knowledge and utilisation of CCS services in RCCs are unequally distributed. Significant inequalities were identified among socioeconomically deprived women in the majority of countries. There is an urgent need for culturally appropriate community-based awareness and access programs to improve the uptake of CCS services in RCCs.

Prevalence of human papillomavirus (HPV)-vaccine types by race/ethnicity and sociodemographic factors in women with high-grade cervical intraepithelial neoplasia (CIN2/3/AIS), Alameda County, California, United States.

We evaluated racial/ethnic differences in prevalence of oncogenic HPV types targeted by the quadrivalent HPV vaccine (16/18) and nonavalent HPV vaccine (31/33/45/52/58) in women diagnosed with CIN2/3/AIS after quadrivalent HPV vaccine introduction (2008-2015). Typing data from 1810 cervical tissue specimen from HPV-IMPACT (Alameda County, California, US), a population-based CIN2/3/AIS surveillance effort, were analyzed. Using log-binomial regression, we calculated adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) comparing type prevalence by race/ethnicity, adjusted for health insurance, age, CIN2/3/AIS grade, and time period, overall and in the "early vaccine era" (2008-2011) and "later vaccine era" (2012-2015). Overall, oncogenic HPV16/18 prevalence was significantly lower among black (43%) and Hispanic (43%) women compared with white (52%) women (aPR (95% CI): 0.80 (0.70, 0.93) and 0.80 (0.70, 0.91), respectively). In 2008-2011, proportion of HPV16/18 detected was significantly lower in black (47%), Hispanic (46%), and Asian (42%) women compared to white (58%) women (aPR (95% CI): 0.80 (0.67, 0.96), 0.75 (0.63, 0.90), and 0.73 (0.58, 0.90), respectively). There were no significant differences in 2012-2015. Between the two eras, HPV16/18 prevalence declined in white (-11%), black (-9%), and Hispanic (-6%) women, and increased in Asian women (12%). Decreasing HPV 16/18 prevalence in CIN2/3/AIS lesions in white, black, and Hispanic women may suggest benefit from quadrivalent vaccination. In our unadjusted analysis of HPV31/33/45/52/58, prevalence did not differ significantly by race/ethnicity, but was significantly higher among Hispanic women (32%) compared to white women (27%) after adjustment (aPR (95%CI): 1.22 (1.02, 1.47). Prevalence was also non-significantly higher among black (32%) and Asian (33%) women. This analysis suggests that the nonavalent vaccine's potential for impact against cervical precancers will not be lower in women of color compared to white women. These data underscore the importance of equitable vaccination in facilitating continued declines of vaccine-preventable HPV types among all women.

Service Level Factors Associated with Cervical Screening in Aboriginal and Torres Strait Islander Primary Health Care Centres in Australia.

Aboriginal and Torres Strait Islander women have significantly higher cervical cancer incidence and mortality than other Australian women. In this study, we assessed the documented delivery of cervical screening for women attending Indigenous Primary Health Care (PHC) centres across Australia and identified service-level factors associated with between-centre variation in screening coverage. We analysed 3801 clinical audit records for PHC clients aged 20-64 years from 135 Indigenous PHC centres participating in the Audit for Best Practice in Chronic Disease (ABCD) continuous quality improvement (CQI) program across five Australian states/territories during 2005 to 2014. Multilevel logistic regression models were used to identify service-level factors associated with screening, while accounting for differences in client-level factors. There was substantial variation in the proportion of clients who had a documented cervical screen in the previous two years across the participating PHC centres (median 50%, interquartile range (IQR): 29-67%), persisting over years and audit cycle. Centre-level factors explained 40% of the variation; client-level factors did not reduce the between-centre variation. Screening coverage was associated with longer time enrolled in the CQI program and very remote location. Indigenous PHC centres play an important role in providing cervical screening to Aboriginal and Torres Strait Islander women. Thus, their leadership is essential to ensure that Australia's public health commitment to the elimination of cervical cancer includes Aboriginal and Torres Strait Islander women. A sustained commitment to CQI may improve PHC centres delivery of cervical screening; however, factors that may impact on service delivery, such as organisational, geographical and environmental factors, warrant further investigation.

Personal and Neighborhood Attributes Associated with Cervical and Colorectal Cancer Screening in an Urban African American Population.

INTRODUCTION: Assessing individual social determinants of health in primary care might be complemented by consideration of population attributes in patients' neighborhoods. We studied associations between cervical and colorectal cancer screening and neighborhood attributes among an African American population in Philadelphia. METHODS: We abstracted demographic and cancer screening information from records of patients seen during 2006 at 3 federally qualified health centers and characterized patients' census tracts of residence by using census, survey, and other data to define population metrics for poverty, racial segregation, educational attainment, social capital, neighborhood safety, and violent crime. We used generalized estimating equations to obtain adjusted relative risks of screening associated with individual and census tract attributes. RESULTS: Among 1,708 patients for whom colorectal cancer screening was recommended, screening was up to date for 41%, and among 4,995 women for whom cervical cancer screening was recommended, screening was up to date for 75%. After controlling for age, sex (for colorectal cancer screening), insurance coverage, and clinic site, people living in the most racially segregated neighborhoods were nearly 10% more likely than others to be unscreened for colorectal cancer. Other census tract population attributes were not associated with differences in screening levels for either cancer. CONCLUSIONS: The association between lower rates of colorectal cancer screening and neighborhood racial segregation is consistent with known barriers to colonoscopy among African Americans combined with effects of segregation on health-related behaviors. Recognition of the association between segregation and lower colorectal cancer screening rates might be useful in informing and targeting community outreach to improve screening.

Disparities Among Cervical Cancer Patients Receiving Brachytherapy.

OBJECTIVE: To evaluate the effects of race and insurance status on the use of brachytherapy for treatment of cervical cancer. METHODS: This is a retrospective cohort study of the National Cancer Database. We identified 25,223 patients diagnosed with stage IB2 through IVA cervical cancer who received radiation therapy during their primary treatment from 2004 to 2015. A univariate analysis was used to assess covariate association with brachytherapy. A multivariable regression model was used to evaluate the effect of race and insurance status on rates of brachytherapy treatment. The Cox proportional hazards model and the multiplicative hazard model were used to evaluate overall survival. P<.05 indicated a statistically significant difference for comparisons of primary and secondary outcomes. RESULTS: Non-Hispanic black patients received brachytherapy at a significantly lower rate than non-Hispanic white patients (odds ratio [OR] 0.93; 95% CI 0.86-0.99; P=.036); Hispanic (OR 0.93; 95% CI 0.85-1.02; P=.115) and Asian (OR 1.13; 95% CI 0.99-1.29; P=.074) patients received brachytherapy at similar rates. Compared with patients with private insurance, those who were uninsured (OR 0.72; 95% CI 0.65-0.79; P<.001), had Medicaid (OR 0.83; 95% CI 0.77-0.89; P<.001) or Medicare insurance (OR 0.85; 95% CI 0.78-0.92; P<.001) were less likely to receive brachytherapy. Brachytherapy was not found to be a mediator of race and insurance-related disparities in overall survival. CONCLUSION: Racial and insurance disparities exist for those who receive brachytherapy, with many patients not receiving the standard of care, but overall survival was not affected.

Barriers and innovative interventions for early detection of cervical cancer.

Cervical cancer has decreased significantly over the past 30 years in some countries. However, it remains among the leading causes of cancer deaths in low-income, and racial/ethnic minority women. Cervical cancer prevention technologies are not always available. Laboratories are often not well equipped to use them. HPV information has not been widely disseminated. WHO guidelines, and US and Latin American data provide context for strategies on effective interventions to reduce cervical cancer disparities. Systemic, personal and cultural barriers, combined with decision-making guidelines, and impactful messaging can accelerate reductions in cervical cancer health inequities in the Americas.

El cáncer cervicouterino ha disminuido significativamente en los últimos 30 años, pero sigue siendo una de las principales causas de muerte entre mujeres de bajos recursos y minorías raciales/étnicas. Las tecnologías preventivas del cáncer cervicouterino no están siempre disponibles y los laboratorios no están siempre bien equipados para utilizarlas. La información sobre el VPH no ha sido difundida ampliamente. La OMS y datos de EEUU y Latinoamérica ofrecen estrategias para reducir el cáncer cervicouterino. El entendimiento de las barreras sistémicas, personales y culturales, dentro de un marco de toma de decisiones, y mensajes innovadores puede reducir las barreras asociadas con el cáncer cervicouterino en las Américas.

Associations of health belief and health literacy with Pap smear practice among Asian immigrant women.

PURPOSE: To examine associations of health belief and health literacy with Pap smear practice among Asian immigrant women in South Korea. METHODS: This study used a descriptive, cross-sectional study design. A survey was conducted among 196 migrant women who were married to South Korean men, using a questionnaire translated into English, Chinese, Vietnamese, and Korean. Trained research assistants read the questionnaire and the participants gave their answers. RESULTS: The most common birthplace of the immigrant women was Vietnam (43.0%), followed by China (12.2%) and the Philippines (5.6%). Of the participants, 76.5% answered that they had never had a Pap smear test. Multiple logistic regression analysis revealed that age and functional health literacy were associated with Pap smear practice among Asian immigrant women. With a one-year increase in participants' age, Pap smear practice increased 1.15 times (OR = 1.15, 95% CI: 1.07, 1.23). Furthermore, with a one point increase in functional health literacy, Pap smear practice increased 1.18 times (OR = 1.18, 95% CI: 1.02, 1.37). CONCLUSIONS: Results suggest that more information about Pap smear tests should be provided to young immigrant women. Health providers should be made aware that Pap smear practice among young immigrant women might be infrequent and should actively recommend that they receive the tests. To improve Pap smear practice among immigrant women, it is also crucial for educational strategies to include functional health literacy. Nurses could play an important role in explaining and recommending the Pap smear test through communication with immigrant women.