Stepped-care to improve mental health outcomes among underserved patients with lung and head and neck cancer.

BACKGROUND: The comparative effectiveness study (ClinicalTrials.gov, NCT03016403) assessed the effects of a stepped-care intervention versus usual care on mental health outcomes, including anxiety, depression, coping self-efficacy, emotional distress (anxiety and depression combined), health-related quality of life (HRQoL), and perceived stress among underserved patients (i.e., low-income, uninsured, underinsured) with lung cancer (LC) and head-and-neck cancer (HNC). METHODS: In a randomized controlled trial, we investigated if 147 patients who received the stepped-care intervention had better mental health outcomes compared to 139 patients who received usual care. Using an intent-to-treat approach, we analyzed outcomes with linear mixed models. RESULTS: For the primary outcomes estimated mean differences (denoted by "Δ"), depression (Δ = 1.75, 95% CI = 0.52, 2.98, p = 0.01) and coping self-efficacy (Δ = -15.24, 95% CI = -26.12, -4.36, p = 0.01) were better for patients who received the intervention compared to patients who received usual care, but anxiety outcomes were not different. For secondary outcomes, emotional distress (Δ = 1.97, 95% CI: 0.68, 3.54, p =< 0.01) and HRQoL (Δ = -4.16 95% CI: -7.45, -0.87, p = 0.01) were better for patients who received the intervention compared to usual care patients, while perceived stress was not different across groups. CONCLUSIONS: The stepped-care intervention influenced depression and coping self-efficacy, important outcomes for patients with acute illnesses like LC and HNC. Although differences in emotional distress met the minimally important differences (MID) previously reported, depression and HRQoL were not above the MID threshold. Our study is among a few to report differences in mental health outcomes for underserved LC and HNC patients after receiving a psychological intervention. GOV IDENTIFIER: NCT03016403.

Ethnicity, socioeconomic status, income inequality, and colorectal cancer outcomes: evidence from the 4C2 collaboration.

PURPOSE: National Cancer Institute (NCI)-Designated Cancer Centers are required to assess and address the needs of their catchments. In rural regions, catchment areas are vast, populations small, and infrastructure for data capture limited, making analyses of cancer patterns challenging. METHODS: The four NCI-Designated Comprehensive Cancer Centers in the southern Rocky Mountain region formed the Four Corners Collaboration (4C2) to address these challenges. Colorectal cancer (CRC) was identified as a disease site where disparities exist. The 4C2 leaders examined how geographic and sociodemographic characteristics were correlated to stage at diagnosis and survival in the region and compared those relationships to a sample from the surveillance, epidemiology, and end results (SEER) program. RESULTS: In 4C2, Hispanics were more likely to live in socioeconomically disadvantaged areas relative to their counterparts in the SEER program. These residency patterns were positively correlated with later stage diagnosis and higher mortality. Living in an area with high-income inequality was positively associated with mortality for Non-Hispanic whites in 4C2. In SEER, Hispanics had a slightly higher likelihood of distant stage disease, and disadvantaged socioeconomic status was associated with poor survival. CONCLUSION: CRC interventions in 4C2 will target socioeconomically disadvantaged areas, especially those with higher income inequality, to improve outcomes among Hispanics and Non-Hispanic whites. The collaboration demonstrates how bringing NCI-Designated Cancer Centers together to identify and address common population catchment issues provides opportunity for pooled analyses of small, but important populations, and thus, capitalize on synergies among researchers to reduce cancer disparities.

Elderly Black Non-Hispanic Patients With Head and Neck Squamous Cell Cancer Have the Worst Survival Outcomes.

BACKGROUND: In this population study, we compared head and neck cancer (HNC) prognosis and risk factors in 2 underserved minority groups (Hispanic and Black non-Hispanic patients) with those in other racial/ethnicity groups. METHODS: In this SEER-Medicare database study in patients with HNC diagnosed in 2006 through 2015, we evaluated cancer-specific survival (CSS) between different racial/ethnic cohorts as the main outcome. Patient demographics, tumor factors, socioeconomic status, and treatments were analyzed in relation to the primary outcomes between racial/ethnic groups. RESULTS: Black non-Hispanic patients had significantly worse CSS than all other racial/ethnic groups, including Hispanic patients, in unadjusted univariate analysis (Black non-Hispanic patients: hazard ratio, 1.48; 95% CI, 1.33-1.65; Hispanic patients: hazard ratio, 1.12; 95% CI, 0.99-1.28). To investigate the association of several variables with CSS, data were stratified for multivariate analysis using forward Cox regression. This identified socioeconomic status, cancer stage, and receipt of treatment as predictive factors for the survival differences. Black non-Hispanic patients were most likely to present at a later stage (odds ratio, 1.62; 95% CI, 1.38-1.90) and to receive less treatment (odds ratio, 0.67; 95% CI, 0.55-0.81). Unmarried status, high poverty areas, increased emergency department visits, and receipt of healthcare at non-NCI/nonteaching hospitals also significantly impacted stage and treatment. CONCLUSIONS: Black non-Hispanic patients have a worse HNC prognosis than patients in all other racial/ethnic groups, including Hispanic patients. Modifiable risk factors include access to nonemergent care and prevention measures, such as tobacco cessation; presence of social support; communication barriers; and access to tertiary centers for appropriate treatment of their cancers.

Puente para cuidar (bridge to caring): A palliative care patient navigator and counseling intervention to improve distress in Latino/as with advanced cancer.

OBJECTIVE: Interventions are needed to improve mental health (ie, depression, anxiety) and palliative care (ie, symptoms, goals of care, and advance care planning) outcomes in Latino/as with advanced cancer. METHODS: An interprofessional study team used the ecological validity model and a participatory approach to adapt an evidence-based counseling intervention for Latino/as and integrate the counseling intervention with an evidence-based patient navigator intervention. Next, a small pilot study was conducted to understand and improve the feasibility of the integrated puente para cuidar intervention. RESULTS: Adaptations were made to language, literacy, and content of the counseling intervention, and video vignettes of the counseling case studies were produced on the recommendation of Latino/a stakeholders. Bicultural, bilingual patient navigators were used as "cultural brokers" between Latino/a patients and the counselor. The pilot study of puente para cuidar demonstrated feasibility based on participant perception of helpfulness and acceptability and nearing goal visit completion rates. CONCLUSIONS: A culturally adapted intervention to address mental health and palliative care needs in Latino/as with advanced cancer was developed from prior evidenced-based interventions using a cultural adaptation model and a participatory approach. The intervention is ready for effectiveness testing.

Treatment challenges and support needs of underserved Hispanic patients diagnosed with lung cancer and head-and-neck cancer.

Purpose: We explored the treatment challenges and support needs that Hispanic underserved lung cancer and head-and-neck cancer patients face while undergoing cancer treatment.Design: Qualitative design - ethnography.Sample: Using a sample of 29 participants, we conducted semi-structured interviews with nine lung cancer and head-and-neck cancer survivors and seven health care providers and focus group interviews with six caregivers and seven patient navigators.Method: Relevant themes were extracted with Ethnographic content analysis.Findings: Participants reported treatment challenges and support needs in four areas: medical, financial, socio-cultural, and mental health. Health care providers and navigators primarily identified medical and financial challenges that impact treatment adherence, while patients and caregivers expressed the need for support for mental health problems (i.e., depression, anxiety).Implications for psychosocial providers: Understanding the experiences of underserved Hispanic cancer survivors can aid in creating psychosocial interventions that successfully target treatment-related challenges and provide them with the support they need.

Development of the Brief Social Capital for Youth Sexual and Reproductive Health Scale: Exploratory and Confirmatory Factor Analysis.

Social capital plays an important role in sexual and reproductive health among youth, yet few measures to assess this concept have been developed and tested for this population. We developed and examined the factor structure of the Brief Social Capital for Youth Sexual and Reproductive Health Scale. Drawing on the empirical literature, we identified item content to assess an overall construct of social capital in relationship to youth's sexual and reproductive health, including condom self-efficacy, civic engagement, and adult and community support. We conducted exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) with a sample of 200 youth, predominately low-income and ethnic minority in Denver, Colorado. EFA with geomax rotation yielded a three-factor solution. CFA provided an adequate model fit with acceptable standardized factor loadings. This study provides a validated measure for future research to further examine social capital and youth sexual and reproductive health.

Determinants of Treatment Delays Among Underserved Hispanics With Lung and Head and Neck Cancers.

BACKGROUND: Evidence is lacking to explain the reasons why treatment is delayed among disadvantaged Hispanic patients diagnosed with lung and head and neck cancers. Data indicate that treatment delays beyond 46 days increase the risk of death for individuals with these cancers. METHODS: A mixed-methods design was used to explore determinants of treatment delays by analyzing data from the medical records of 40 Hispanic patients and data from interviews with 29 Hispanic patients, caregivers, health care professionals, and patient navigators from a safety-net hospital. RESULTS: Of the 40 Hispanic patients, 35% initiated treatment 46 days or more after being diagnosed, but women experienced longer delays than men (average of 48 days). Women with few comorbid diseases (≤ 4) were more likely to experience treatment delays. Institutional-related determinants at publicly funded hospitals appear to delay treatment for patients at the safety-net hospital, and patient-related determinants common to underserved patients (eg, no health insurance coverage) are likely to further contribute to these delays. CONCLUSIONS: Delayed treatment is associated with poor outcomes and low rates of survival in patients with lung and head and neck cancers. Therefore, action should be taken to improve the time between diagnosis and the initiation of treatment for disadvantaged Hispanic patients.

The combined influence of psychosocial factors on illness behavior among women.

Distinctions in illness behavior for women, such as use of health services, may result from gender-specific biological risks for disease but could also be explained by the relationships among social, psychological, and behavioral factors. The purpose of this study was to determine if illness behavior in women might be related to associations among social support satisfaction, perceived health status, coping skills, and perceived stress. Data were collected November-December 2005 from 205 female college students through self-report using questionnaires. Structural equation modeling was used to test relationships among psychosocial factors. The final model revealed associations between psychosocial factors and illness behavior for women along two paths. First, high perceived stress and poor perceived health status were associated with more reported illness behavior. Second, greater use of total coping skills, greater social support satisfaction, and good perceived health status were associated with less reported illness behavior. Consideration of multiple health-related factors may provide a more complete picture of how psychosocial factors are related to illness behavior for women. Specifically, interactions among stress, coping, social support, and perceived health status may be important to women's health. Our results suggest that interventions should focus on skill-building and strategies to improve self-perception of health.

#4Corners4Health Social Media Cancer Prevention Campaign for Emerging Adults: Protocol for a Randomized Stepped-Wedge Trial.

BACKGROUND: Many emerging adults (EAs) are prone to making unhealthy choices, which increase their risk of premature cancer morbidity and mortality. In the era of social media, rigorous research on interventions to promote health behaviors for cancer risk reduction among EAs delivered over social media is limited. Cancer prevention information and recommendations may reach EAs more effectively over social media than in settings such as health care, schools, and workplaces, particularly for EAs residing in rural areas. OBJECTIVE: This pragmatic randomized trial aims to evaluate a multirisk factor intervention using a social media campaign designed with community advisers aimed at decreasing cancer risk factors among EAs. The trial will target EAs from diverse backgrounds living in rural counties in the Four Corners states of Arizona, Colorado, New Mexico, and Utah. METHODS: We will recruit a sample of EAs (n=1000) aged 18 to 26 years residing in rural counties (Rural-Urban Continuum Codes 4 to 9) in the Four Corners states from the Qualtrics' research panel and enroll them in a randomized stepped-wedge, quasi-experimental design. The inclusion criteria include English proficiency and regular social media engagement. A social media intervention will promote guideline-related goals for increased physical activity, healthy eating, and human papillomavirus vaccination and reduced nicotine product use, alcohol intake, and solar UV radiation exposure. Campaign posts will cover digital and media literacy skills, responses to misinformation, communication with family and friends, and referral to community resources. The intervention will be delivered over 12 months in Facebook private groups and will be guided by advisory groups of community stakeholders and EAs and focus groups with EAs. The EAs will complete assessments at baseline and at 12, 26, 39, 52, and 104 weeks after randomization. Assessments will measure 6 cancer risk behaviors, theoretical mediators, and participants' engagement with the social media campaign. RESULTS: The trial is in its start-up phase. It is being led by a steering committee. Team members are working in 3 subcommittees to optimize community engagement, the social media intervention, and the measures to be used. The Stakeholder Organization Advisory Board and Emerging Adult Advisory Board were formed and provided initial input on the priority of cancer risk factors to target, social media use by EAs, and community resources available. A framework for the social media campaign with topics, format, and theoretical mediators has been created, along with protocols for campaign management. CONCLUSIONS: Social media can be used as a platform to counter misinformation and improve reliable health information to promote health behaviors that reduce cancer risks among EAs. Because of the popularity of web-based information sources among EAs, an innovative, multirisk factor intervention using a social media campaign has the potential to reduce their cancer risk behaviors. TRIAL REGISTRATION: ClinicalTrials.gov NCT05618158; https://classic.clinicaltrials.gov/ct2/show/NCT05618158. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/50392.

Community readiness to promote Latinas' participation in breast cancer prevention clinical trials.

The high breast cancer (BC) mortality rates that exist among Hispanic women (Latinas) are a health disparity burden that needs to be addressed. Prevention clinical trials are a burgeoning area of cancer prevention efforts and may serve to promote parity. Unfortunately, Latinas, along with other ethnic minority women, continue to be under-represented in this form of research. Previous studies have examined individual barriers to ethnic minorities' participation, but none have assessed community factors contributing to Latinas' under-representation in these studies. The present study addressed these limitations from a community perspective by exploring which factors might inhibit Latinas' participation in clinical trials, specifically BC prevention trials. Using the Community Readiness Model (CRM), 19 key informants were interviewed in four communities, two rural and two urban, in Colorado, USA. The key informant assessment involved a semistructured interview that measured the level of community readiness to encourage participation in BC prevention activities. The results reflected a community climate that did not recognise BC as a health problem that affected Latinas in participating communities. Compared to other healthcare priorities, participation in BC prevention clinical trials was considered a low priority in these communities. Overall, leadership and community resources were not identified or allocated to encourage the participation of Latinas. The results highlight the lack of awareness regarding clinical trials among both community members and leaders. According to the CRM, strategies to enhance awareness at multiple levels in the community are necessary. This study demonstrates how the CRM can be used to better understand a community's perspective on BC, and specifically, the under-representation of Latinas in clinical trials.

Entertainment-Education Narrative Versus Nonnarrative Interventions to Educate and Motivate Latinas to Engage in Mammography Screening.

BACKGROUND: The evidence is limited comparing the effects of entertainment-education (E-E) narrative versus nonnarrative interventions to educate and motivate Latinas to engage in mammography screening. AIMS: This study compared an E-E narrative intervention to two nonnarrative interventions' effects among Latinas on breast cancer knowledge and motivation, as measured by changes in self-efficacy, behavioral norms, and behavioral intentions to engage in mammography screening. METHOD: A sample of 141 Spanish-speaking Latinas was randomly assigned to one of three arms: an E-E narrative video, a nonnarrative educational video, and printed educational materials. Using a repeated measures design, the influence of the E-E narrative on pretest to posttest measures was assessed and compared to the influence of the other two interventions. RESULTS: The E-E narrative and nonnarrative interventions significantly increased Latinas' breast cancer knowledge, mammography self-efficacy, and behavioral norms from pretest to posttest. However, the E-E narrative participants' pretest to posttest difference in mammography self-efficacy was significantly higher when compared to the difference of the other two interventions. The effect of the E-E narrative intervention on self-efficacy and behavioral norms was moderated by the participants' absorption in the story and identification with the story characters. CONCLUSION: E-E narrative and nonnarrative interventions significantly educated and motivated Latinas to engage in mammography screening. The effects on mammography self-efficacy, an important precursor to behavior change, can be more strongly influenced by E-E narratives. DISCUSSION: Although E-E narrative and nonnarrative interventions were effective, the need still exists to assess if they can ultimately influence lifesaving breast cancer screening behaviors.

An exploration of Latino smokers and the use of pharmaceutical aids.

BACKGROUND: Latino smokers are less likely than white non-Latino smokers to use nicotine replacement therapy (NRT) or bupropion when trying to quit smoking. The current study explored sociocultural and psychosocial factors related to nonuse of smoking-cessation medications among Latino smokers. METHODS: Structured discussions were held with six separate focus groups of current smokers (n =49) who self-identified as Latino, had attempted to quit in the past 12 months, and were aged 35 to 64 years. Participants were recruited from Latino-serving health clinics, community events, and community organizations. Session recordings were transcribed, and content analysis was used to organize themes into categories. RESULTS: Six thematic categories emerged across most or all discussion groups: (1) smoking is a weakness rather than an illness, (2) pharmaceuticals are generally avoided, (3) NRT is mistrusted, (4) bupropion is widely rejected, (5) views are mixed regarding ethnic dimensions of smoking and quitting, and (6) misconceptions are common regarding smoking and cessation. CONCLUSIONS: Cognitive reframing strategies should be developed and tested for Latino smokers who decline pharmacologic smoking-cessation assistance for reasons other than well-informed autonomous choice.

Breast cancer detection among older Latinas: is it worth the risk?

Fifty-eight Latinas participated in focus group interviews to assess their perceptions about screening to detect breast cancer (BC). Grounded theory methods helped uncover a cultural explanatory model that explained how cultural and psychosocial dynamics influence BC screening decisions. According to this model, Latinas generally perceived BC screening as a risky behavior. Three themes emerged that influenced the amount and type of perceived risks: feeling healthy (i.e., perceptions about the etiology of the illness and its nature), feeling indecent (i.e., the behaviors involved in screening), and feeling threatened (i.e., the anticipated consequences of BC detection). Screening was perceived as risky because of many personal and interpersonal consequences associated with detecting BC. Latinas' subjective assessment that detecting BC is too risky might influence their participation in screening procedures. Health education programs should aim at helping Latinas perceive that the early detection of BC is a life-saving benefit that outweighs its perceived risks.

Utilization across the continuum of long-term care services.

PURPOSE: This study presents an analysis of the influence of consumers' predisposing, enabling, and need characteristics on the utilization of long-term care (LTC) services in nursing facilities (NFs), assisted living facilities, or home- and community-based services (HCBS). DESIGN AND METHODS: Data were gathered through a record review of a cross-sectional sample of 1,968 consumers aged 60 years or older receiving formal LTC services. RESULTS: Need contributes the most to differential LTC use. Those with the most need are more likely to be in a NF or HCBS. Enabling characteristics such as Medicaid eligibility and geopolitical region of the state were associated with higher use of NFs. Predisposing and enabling characteristics had a moderating influence on need. IMPLICATIONS: Although high need predicts care in NFs, some of the most impaired elders are also being cared for at home. Because Medicaid increases the likelihood of NF placement, public financing of LTC should reflect the capacity of the system to serve elders at home.

Feeling frugal: socioeconomic status, acculturation, and cultural health beliefs among women of Mexican descent.

Psychosocial and socioeconomic variables are often confounded. The authors combined quantitative with grounded theory analysis to investigate influences of acculturation, socioeconomic status (SES), and cultural health beliefs on Mexican-descent women's preventive health behaviors. In 5 focus group interviews sampling across levels of acculturation and SES, women expressing more traditional Mexican health beliefs about breast cancer screening were of lower SES and were less U.S. acculturated. However, SES and acculturation were uncorrelated with screening behaviors. Qualitative analysis generated hypotheses about joint influences of SES and traditional health beliefs; for example, low-SES women may learn frugal habits as part of their cultural traditions that influence their health care decision making, magnifying SES-imposed structural restrictions on health care access.

The role of physician involvement in Latinas' mammography screening adherence.

BACKGROUND: Disparities in breast cancer (BC) screening continue to affect Latinas significantly, but the factors that explain these disparities remain unclear. OBJECTIVE: The objective of this study was to investigate whether physician's instruction on breast examination and mammography recommendations predicted Latinas' adherence to mammography screening above and beyond other influential variables. METHODS: A cross-sectional, descriptive design was utilized. Convenience and snowball sampling techniques were followed to recruit 344 Latinas aged 41 years and older from predominantly Latino neighborhoods in Denver, Colorado. MAIN OUTCOME MEASURES: Latinas' adherence to mammography screening recommendations by the American Cancer Society. RESULTS: Characteristics that were significantly associated with mammography adherence were age, Pap smear adherence, physician's breast examination instructions, and physician's mammography recommendations. CONCLUSION: The study provides evidence that the BC screening disparities that significantly affect Latinas can be addressed by increasing physician's involvement through BC screening instruction and referral.

The Latina Breast Cancer Screening Sacle: beliefs about breast cancer and breast cancer screening.

The Latina Breast Cancer Screening (LBCS) was developed to measure Latinas' culturally-shared health beliefs about breast cancer and breast cancer screening. A 60-item LBCS scale was tested with 288 participants and reduced to 35 items using principal components analyses. The 35-item LBCS scale and other measures were administered to a second sample of 147 participants to establish the scale's validity and reliability. A six-factor solution suggested six LBCS sub-scales. The LBCS in its entirety displayed strong internal consistency (alpha =.93) with adequate estimates of convergent, discriminant, and predictive validity. The LBCS scale appears to be a valid and reliable measure.

Characteristics associated with mammography screening among both Hispanic and non-Hispanic white women.

AIMS: This study explores whether certain population characteristics are associated with adherence to mammography screening guidelines among Hispanic and non-Hispanic white (NHW) women living in the southwestern United States. METHODS: Participants in a population-based study (4-Corners' Breast Cancer Study) included in this analysis were 790 Hispanic women and 1,441 NHW women. Multivariate logistic regression was used to compute the ethnic-specific adjusted odds ratios (OR) and 95% confidence intervals (CI) for the association of the outcome variable (adherent vs. nonadherent) and its correlates. Women were adherent if they had obtained their first mammogram between 41 and 50 years of age and had received at least one mammogram per 2 years or less. RESULTS: Ethnic-specific associations were observed with certain population characteristics and mammography adherence. Specifically, characteristics that were significantly associated with adherence among Hispanic women were younger age (50-59 years), having a family history of breast cancer, nulliparity, hormone replacement therapy (HRT) use, nonsteroidal anti-inflammatory drug (NSAID) use, and performing regular breast self-examinations (BSE). Among NHW women, younger age (50-59 years), family history of breast cancer, obesity, consuming moderate amounts of alcohol, and taking HRT were associated with mammography adherence. When adjusting for the evaluated population characteristics, the relationship between ethnicity and mammography adherence was no longer apparent. CONCLUSIONS: Ethnic-specific characteristics appear to explain differences in mammography adherence among Hispanic and NHW women. Disparities in screening rates, late-stage disease and breast cancer mortality that impact Hispanic women could potentially be addressed more effectively by interventions that specifically target the unique characteristics of the Hispanic population.

Using a community readiness model to help overcome breast health disparities among U.S. Latinas.

The aim of this article is to illustrate how investigators can use a strength-based model, such as the Community Readiness Model (CRM), to help overcome breast health disparities among Latinas living in the United States. In this effort, I describe a CRM study conducted between the years 2001 and 2002 in four predominantly Latino communities in Colorado. First, 19 key informants were interviewed to assess their perceived level of community readiness to encourage Latinas participation in breast cancer prevention and control activities. Next, 33 Latinas over the age of 50 participated in focus groups to further examine perceptions of barriers and facilitative factors to participate in the activities. Lastly, 14 one-on-one interviews were conducted to clarify and expand on the information provided by key informants and focus group participants. We bridged this research to practice by creating and testing (with 22 Latinas) breast health educational materials that address in a culturally sensitive manner Latinas' main concerns about participating in these lifesaving activities.

Where's Maria? A video to increase awareness about breast cancer and mammography screening among low-literacy Latinas.

BACKGROUND: The need exists to educate and motivate medically disadvantaged Latinas to engage in regular mammography screening to reduce their high breast cancer (BC) mortality risk due to the illness' late detection. METHODS: Qualitative research methods [e.g., focus groups, key informants] were primarily used during the basic and formative research phases in preproducing and producing a breast cancer educational video for low-literacy Latinas. RESULTS: An 8-min video was created in an Entertainment-Education soap opera format. The purpose of the video is to create awareness about breast cancer and to motivate low-literacy Latinas who are at the precontemplation stage of behavior change to consider engaging in mammography screening. Thus, the video presents a compelling story of a Latina with whom the target audience can identify and become involved with the unfolding events of her story as she realizes her risk for breast cancer and struggles with the decision to engage in mammography. The content and format of the video include culturally relevant clues and modeling to influence Latinas' cognitive and subjective processes involved in making the decision to change. CONCLUSIONS: Complex attitudinal and behavioral issues can be effectively targeted to decrease the influence that psychological barriers exert in Latinas low breast cancer screening rates.