Pragmatic trial of an intervention to increase human papillomavirus vaccination in safety-net clinics.

BACKGROUND: Human papillomavirus (HPV) infection has been causally linked to six cancers, and many disproportionately affect minorties. This study reports on the development and effectiveness of an intervention aimed at increasing HPV vaccine uptake among African American and Hispanic pediatric patients in safety-net clinics. METHODS: Formative research, community engagement, and theory guided development of the intervention. A clustered, non-randomized controlled pragmatic trial was conducted in four clinics providing healthcare for the underserved in Tennessee, U.S., with two intervention sites and two usual care sites. Patients aged 9-18 years (N = 408) and their mothers (N = 305) enrolled, with children clustered within families. The intervention consisted of two provider/staff training sessions and provision of patient education materials, consisting of a video/flyer promoting HPV vaccine. Medical records were reviewed before/after the initial visit and after 12 months. RESULTS: At the initial visit, provision of patient education materials and provider recommendation were higher at intervention sites versus usual care sites, and receipt of HPV vaccine was higher at intervention sites (45.4% versus 32.9%) but not significantly after adjusting for patient's age and mother's education. Provider recommendation, but not education materials, increased the likelihood of vaccine receipt at the initial visit, although over one-third of intervention mothers cited the flyer/video as motivating vaccination. Completion of the 3-dose series at follow-up was lower in the intervention arm. CONCLUSIONS: Future interventions should combine patient education, intensive provider/staff education, and patient reminders. Research should compare patient education focusing on HPV vaccine only versus all adolescent vaccines. TRIAL REGISTRATION: Retrospectively registered with ClinicalTrials.gov NCT02808832 , 9/12/16.

The role of fat mass index in determining obesity.

OBJECTIVES: The objective of this study is to compare body mass index (BMI), percent body fat (PBF), and fat mass index (FMI) and to investigate the accuracy of FMI as a convenient tool for assessing obesity. DESIGN: Anthropometric measurements and bioelectrical impedance analyses were performed on 538 Mexican Americans (373 women and 165 men). Correlations between BMI and PBF and between FMI and PBF were investigated. The percentage of persons misclassified as obese using different classifications was calculated. Multiple linear regression analysis was performed to generate predictive models of FMI for males and females separately. RESULTS: BMI and PBF were correlated in men (rho = 0.877; P < 0.0001) and women (rho = 0.966; P < 0.0001); however, 20 and 67.2% of the men and 9.2 and 84.2% of women, classified as normal weight and overweight by BMI, respectively, were diagnosed as obese by PBF. FMI and PBF were also correlated in men (rho = 0.975; P < 0.0001) and women (rho = 0.992; P < 0.0001). Four percent of the men classified as normal weight and 65.5% classified as overweight by BMI were obese by FMI, while 71.3% of women classified as overweight by BMI were obese by FMI. Misclassification of obesity between FMI and PBF categories was observed in 5.4% of men and 7.8% of women. CONCLUSIONS: The discrepancy observed between BMI and PBF reflects a limitation of BMI. Conversely, FMI accurately assessed obesity in our study of Mexican Americans, but further studies are necessary to confirm our findings in different ethnic groups.

Lack of validity of self-reported mammography data.

This qualitative literature review aimed to describe the totality of peer-reviewed scientific evidence from 1990 to 2017 concerning validity of self-reported mammography. This review included articles about mammography containing the words accuracy, validity, specificity, sensitivity, reliability or reproducibility; titles containing self-report, recall or patient reports, and breast or 'mammo'; and references of identified citations focusing on evaluation of 2-year self-reports. Of 45 publications meeting the eligibility criteria, 2 conducted in 1993 and 1995 at health maintenance organisations in Western USA which primarily served highly educated whites provided support for self-reports of mammography over 2 years. Methodological concerns about validity of self-reports included (1) telescoping, (2) biased overestimates particularly among black women, (3) failure to distinguish screening and diagnostic mammography, and (4) failure to address episodic versus consistent mammography use. The current totality of evidence supports the need for research to reconsider the validity of self-reported mammography data as well as the feasibility of alternative surveillance data sources to achieve the goals of the Healthy People Initiative.

Racial/Ethnic Disparities in Diabetes Quality of Care: the Role of Healthcare Access and Socioeconomic Status.

INTRODUCTION: Blacks, Hispanics, and Asians are disproportionately affected by diabetes. We assessed the state of racial/ethnic disparities in diabetes quality of care in the USA. METHODS: We analyzed cross-sectional data of adults diagnosed with Type 2 diabetes in the nationally representative 2013 Medical Expenditure Panel Survey. Differences in adherence to five diabetes quality of care recommendations (HbA1c twice yearly, yearly foot exam, dilated eye exam, blood cholesterol test, and flu vaccination) were examined by race/ethnicity while controlling for three social determinants of health (health insurance status, poverty, and education) and other demographic variables. RESULTS: Among adults with diabetes in the USA, 74.9% received two or more HbA1c tests, 69.0% had a foot exam, 64.9% had an eye exam, 85.4% had a cholesterol test, and 65.1% received flu vaccination in 2013. Compared to Whites, all were lower for Hispanics; HbA1c tests, eye exam, and flu vaccination were lower for Blacks; HbA1c tests, foot exam, and eye exam were lower for Asians. In adjusted models, the only remaining disparities in quality of care indicators were HbA1c tests for Hispanics (AOR 0.67, CI = 0.47-0.97), Blacks (AOR 0.59, CI = 0.40-0.88), and Asians (AOR 0.47, CI = 0.42-0.99); foot exams for Hispanics (AOR 0.65, CI = 0.47-0.90); and flu vaccination for Blacks (AOR 0.68, CI = 0.49-0.93). CONCLUSION: Lack of insurance coverage and education explained some of the racial/ethnic disparities observed in diabetes quality of care. Improving quality of diabetes care could help reduce rates of diabetes complications, healthcare costs, and mortality.

A multilevel analysis of socioeconomic status and prostate cancer risk.

PURPOSE: We investigated whether prostate cancer was associated with socioeconomic status (SES) at the individual level, area level, or a combination of both levels. METHODS: This population-based case-control study of prostate cancer in men aged 65 to 79 years was conducted between 2000 and 2002 in South Carolina. Complete interviews were available for 407 incident prostate cancer cases and 393 controls (with respective response rates of 61% and 64%). We used educational level to measure individual-level SES and a composite variable capturing income and education from 2000 Census data to measure area-level SES. RESULTS: After adjustment for race, age, geographic region, and prostate-specific antigen testing, men with some college were at reduced risk for prostate cancer (odds ratio [OR], 0.44; 95% confidence interval [CI], 0.27-0.72), as were men in the highest quartile of area-level SES (OR, 0.52; 95% CI, 0.34-0.80). When assessing individual-level and area-level SES simultaneously and accounting for their nonindependence, the independent negative associations persisted and appeared to be more striking for men with a diagnosis of localized disease, rather than advanced disease. CONCLUSION: The independent effects of area-level and individual-level SES on prostate cancer risk seen in our study may help explain the conflicting results of previous studies conducted at both levels.

Stress, coping, social support, and prostate cancer risk among older African American and Caucasian men.

OBJECTIVES: While psychosocial stress and high effort coping have been associated with reduced immune function, no epidemiologic study has addressed psychological stress and risk of prostate cancer. The purpose of this analysis was to investigate the association between stress, coping, social support, and risk of prostate cancer among older men (age 65-79 years). DESIGN: Population-based case-control study in South Carolina. PARTICIPANTS: Cases were 400 incident, histologically confirmed prostate cancer cases identified through the South Carolina Central Cancer Registry between 1999 and 2001 (70.6% response rate). Controls were 385 men identified through the 1999 Health Care Financing Administration Medicare beneficiary file for South Carolina (63.8% response rate). MAIN OUTCOME MEASURES: Consenting participants completed telephone interviews addressing demographics (age, race, income, education, marital status, body mass index), medical and prostate cancer screening history, stress (Global Perceived Stress), coping (John Henryism Scale), and social support. RESULTS: After adjusting for age, race, and South Carolina region, higher John Henryism scores (>24) were modestly associated with prostate cancer risk relative to lower scores (<24) (adjusted odds ratio 1.63, 95% confidence interval 1.11-2.40). This effect is somewhat more pronounced among those perceiving some stress, yet the effect of John Henryism on prostate cancer risk was reduced among those with high levels of social support. Neither higher stress nor social support alone was associated with prostate cancer risk. CONCLUSIONS: Higher John Henryism scores indicating high-effort coping may be associated with an increase in prostate cancer risk.

Intimate partner violence and disabilities among women attending family practice clinics.

PURPOSE: To estimate the frequency and type of disabilities preventing work among those experiencing intimate partner violence (IPV) compared with those never experiencing IPV. METHODS: We used a large cross-sectional survey of women, ages 18-65, attending family practice clinics from 1997 through 1998. Participation included a 5-10-minute in-clinic survey assessing IPV experience and a longer telephone survey assessing health status and chronic disabilities that prevented work outside the home or housework. RESULTS: Of 1,152 eligible women surveyed, 54% experienced some type of IPV, and 24% were currently in a violent relationship. Women who had ever experienced IPV were more than twice as likely to report a disability (adjusted odds ratio [aOR] = 2.2, 95% confidence interval [CI] 1.6, 3.0). The most commonly reported disabilities were those associated with heart or circulatory disease (4.9%), followed by back problems (3.5%), chronic pain (3.4%), arthritis (3.0%), nerve system damage (2.4%), asthma or another respiratory problem including emphysema (1.7%), and either depression (1.6%) or another mental illness (1.0%). Women ever experiencing IPV were more likely to report a disability due to generalized chronic pain (aOR = 2.5, 95% CI 1.5, 4.3) and mental illness (aOR = 4.5, 95% CI 1.5, 13.1). IPV-related injuries were associated in a dose-dependent manner with having any disability and with disability from chronic pain, asthma and other respiratory diseases, mental illness, and chronic diseases. CONCLUSIONS: Primary care-based efforts to screen for IPV and effectively intervene to reduce the impact of IPV on women's lives must be a public health priority to reduce the shortterm and long-term health effects, including disabilities.

Results of a Health Education Message Intervention on HPV Knowledge and Receipt of Follow-up Care among Latinas Infected with High-risk Human Papillomavirus.

A clinic-based intervention study was conducted among high-risk human papillomavirus (HPV)-infected Latinas aged 18-64 years between April 2006 and May 2008 on the Texas-Mexico border. Women were randomly assigned to receive a printed material intervention (n=186) or usual care (n=187) and were followed at three months, six months, and 12 months through telephone surveys and review of medical records. The HPV knowledge of nearly all women had increased greatly, but only two-thirds of women reported they had received follow-up care within one year of diagnosis regardless of additional health education messaging. Our findings suggest that, regardless of type of health education messaging, Latinas living on the Texas-Mexico border are aware that follow-up care is recommended, but they may not receive this care. Individual, familial and medical care barriers to receipt of follow-up care may partially account for the higher rates of cervical cancer mortality in this region.

Mammography Screening Among the Elderly: A Research Challenge.

BACKGROUND: Randomized trials demonstrate clear benefits of mammography screening in women through age 74 years. We explored age- and race-specific rates of mammography screening and breast cancer mortality among women aged 69 to 84 years. METHODS: We analyzed Medicare claims data for women residing within Surveillance, Epidemiology and End Results geographic areas from 1995 to 2009 from 64,384 non-Hispanic women (4886 black and 59,498 white) and ascertained all primary breast cancer cases diagnosed between ages 69 and 84 years. The exposure was annual or biennial screening mammography during the 4 years immediately preceding diagnosis. The outcome was breast cancer mortality during the 10 years immediately after diagnosis. RESULTS: After adjustment for stage at diagnosis, radiation therapy, chemotherapy, comorbid conditions, and contextual socioeconomic status, hazard ratios (and 95% confidence intervals) for breast cancer mortality relative to no/irregular mammography at 10 years for women aged 69 to 84 years at diagnosis were 0.31 (0.29-0.33) for annual mammography and 0.47 (0.44-0.51) for biennial mammography among whites and 0.36 (0.29-0.44) for annual mammography and 0.47 (0.37-0.58) for biennial mammography among blacks. Trends were similar at 5 years overall and stratified by ages 69 to 74 years, 75 to 78 years, and 79 to 84 years. CONCLUSIONS: In these Medicare claims and Surveillance, Epidemiology and End Results data, elderly non-Hispanic women who self-selected for annual mammography had lower 10-year breast cancer mortality than corresponding women who self-selected for biennial or no/irregular mammography. These findings were similar among black and white women. The data highlight the evidentiary limitations of data used for current screening mammography recommendations.

Co-morbidity associated with dementia.

PURPOSE: The purpose of this study was to identify common co-morbid conditions associated with dementia subtypes and to evaluate the association of hypertension, diabetes mellitus, atrial fibrillation, congestive heart failure, and anemia with dementia subtypes relative to controls. METHODS: Hospital discharge data were used to identify 15,013 subjects from South Carolina with a diagnosis of dementia between 1998 and 1999. A control group of 15,013 persons without dementia was randomly sampled from hospital discharge records and matched to persons with dementia on the basis of age, race, and gender. Multiple hospitalizations for each patient were merged, and repeated diagnoses during separate hospitalizations were counted once. RESULTS: After adjusting for age, race, and gender, persons with Alzheimer's disease and dementia associated with medical conditions were less likely to be diagnosed with hypertension, diabetes, congestive heart failure, and atrial fibrillation than were controls. Patients with multi-infarct dementia were also less likely to have congestive heart failure, but were more likely to have diabetes. Anemia was not associated with any dementia subtype. CONCLUSIONS: There are distinct differences in comorbid conditions among dementia subtypes. Our research does not support previous studies that suggest a circulatory component to the development of Alzheimer's disease.

Diabetes, physical activity and breast cancer among Hispanic women.

PURPOSE: We assessed the association between diabetes and breast cancer and whether physical activity modified the effect of diabetes on breast cancer in Hispanic women. METHODS: We used data from a case-control study of breast cancer among Hispanic women aged 30-79 conducted between 2003 and 2008 on the Texas-Mexico border. In-person interviews were completed with 190 incident breast cancer cases ascertained through surgeons and oncologists, and 979 controls who were designated as both high-risk (n=511) and low-risk (N=468) for breast cancer (with respective response rates of 97%, 83% and 74%). RESULTS: After adjustment for menopausal status and mammography screening, there was no effect of diabetes on breast cancer risk (high-risk control group odds ratio [OR] 1.02, 95% confidence interval [CI] 0.71-1.48; low-risk control group OR 0.87, 0.58-1.30). Women who had a diabetes history and did not exercise were at no risk of breast cancer (OR 0.96, 95% CI 0.63-1.48) or a slightly reduced breast cancer risk (low-risk control group OR 0.72, 95% CI 0.46-1.15) depending on the control group used, while women with diabetes who did exercise had significantly reduced breast cancer risk (OR 0.41, 95% CI 0.21-0.83) regardless of the control group used (high-risk control group p-value for interaction=0.013, low-risk control group p-value for interaction 0.183). CONCLUSIONS: Should other studies confirm our results, physical activity should be explored as a means of reducing breast cancer risk in diabetic women.

HPV vaccine acceptance among Latina mothers by HPV status.

OBJECTIVE: We investigated whether Latina mothers who were and were not human papillomavirus (HPV) positive differed in their knowledge and acceptance of the HPV vaccine for their children. METHODS: We conducted a cross-sectional survey among women aged 18-64 years between April 2007 and April 2008. Data collectors conducted in-person interviews in community clinics with 215 HPV-negative women and 190 HPV-positive women (with respective response rates of 64% and 84%). Most (83%) HPV-positive women were recruited at dysplasia clinics. Although no HPV-negative women were recruited at dysplasia clinics, they were recruited at other low-income public and private clinics. RESULTS: After adjustment for age, marital status, and health insurance, women who were HPV positive were more likely than HPV-negative women to have heard about the HPV vaccine, to indicate they would have their daughters and sons vaccinated against cervical cancer even if they had to pay themselves, and to be in favor of the proposed Texas law requiring girls to receive the HPV vaccine before entry into sixth grade but less likely to be in favor of girls receiving the vaccine at age > or =13. CONCLUSIONS: Our findings indicate that >90% of Latinas living on the Texas-Mexico border find the HPV vaccine acceptable for their own daughters and sons.

Lifestyle and prostate cancer among older African-American and Caucasian men in South Carolina.

OBJECTIVE: We investigated the association between lifestyle and prostate cancer risk among Caucasian and African-American men, separately. METHODS: This population-based case-control study of prostate cancer among men aged 65-79 years was conducted between 2000 and 2002 in South Carolina. Telephone interviews were completed with 416 incident prostate cancer cases ascertained through the South Carolina Central Cancer Registry, and 429 controls identified through the Health Care Financing Administration Medicare beneficiary file (with respective response rates of 71% and 64%). RESULTS: Caucasian men working in production, transportation, and material moving had increased prostate cancer risk (odds ratio [OR] = 2.04, 95% confidence interval [CI] 1.17-3.54), while African-American men in the military had reduced prostate cancer risk (OR = 0.19, 95% CI 0.05-0.76). Having five or more prostate specific antigen (PSA) tests within the past five years was associated with prostate cancer among Caucasian men; however, African-American men with prostate cancer tended to have fewer PSA tests. Increasing lycopene consumption was associated with a reduced risk of prostate cancer among Caucasian men (p = 0.03), but not among African-American men. CONCLUSIONS: In this population-based case-control study conducted in South Carolina we did not find marked differences in lifestyle factors associated with prostate cancer by race.