Design and pilot implementation of the Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program in an urban underresourced population.

INTRODUCTION: The Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program is a community-engaged framework to improve mammography maintenance and rates of genetic risk assessment, counseling, and testing using a multilevel approach that enhances patient navigation through mobile health and community education. METHODS: The ACE-ITS program is based on the National Institute of Minority Health and Health Disparities research framework focused on the individual (genetic testing, screening navigation) and community (community-based breast health education) levels and targeted to the biological- (genetic risk), behavioral- (mammography screening), sociocultural- (underserved Black and Hispanic women), and the health care system (patient navigation, automated text messages)-related domains. We further integrate the Practical Robust Implementation and Sustainability Model to describe our program implementation. RESULTS: In collaboration with genetic counselors and community partners, we created educational modules on mammography maintenance and genetic counseling/testing that have been incorporated into the navigator-led community education sessions. We also implemented a universal genetic risk assessment tool and automated text message reminders for repeat mammograms into our mammography navigation workflow. Through the ACE-ITS program implementation, we have collaboratively conducted 22 educational sessions and navigated 585 women to mammography screening over the 2020-2021 calendar years. From January to December 2021, we have also conducted genetic risk assessment on 292 women, of whom 7 have received genetic counseling/testing. CONCLUSIONS: We describe a multilevel, community-engaged quality improvement program designed to reduce screening-related disparities in Black and Hispanic women in our catchment area.

Advancing health equity: A qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations.

Genetic counseling and testing (GCT) inform cancer management for persons at risk for hereditary breast and ovarian cancer (HBOC). Community-based organizations (CBOs) may play a role in identifying at-risk Latinx individuals to connect them to GCT but data are lacking. Two academic centers and their four CBO partners planned to implement a validated questionnaire for HBOC risk screening ("HBOC risk screening tool"). This study aimed to assess CBO's preferences for HBOC risk screening tools, as well as the barriers and facilitators anticipated for future implementation. Pre-implementation focus groups were conducted with CBO's staff. Discussions centered on current practices to identify and refer at-risk patients. During the discussion, staff were asked to select one out of five validated HBOC risk screening tools to implement and to discuss anticipated barriers/facilitators for implementation. The four focus groups were coded and qualitative analyzed following the Consolidated Framework for Implementation Research (CFIR) and Health Equity domains. All CBOs chose the Family History Screen 7 (FHS-7). Participants (N = 35) highlighted how the FHS-7 was easy to adapt to better fit the target population and changing guidelines. They had positive attitudes toward implementing the screening tool, stressed how the culture of the organization positioned them to reach the target population, and noted barriers in different CFIR domains (e.g., low knowledge about HBOC and GCT referrals; scarce available resources). Participants pointed to barriers related to health equity domains including limited access to GCT and follow-up care for uninsured and underinsured populations, challenges obtaining accurate family history, and immigration-related barriers. CBOs highlighted the importance of partnering with other stakeholders to overcome barriers. Findings emphasize the need to develop multi-level implementation strategies to overcome barriers and leverage facilitators. This study can inform the development of implementation toolkits for CBOs to implement HBOC screening tools to advance health equity.

Confidence, Connection & Collaboration: Creating a Scalable Bias Reduction Improvement Coaching Train-the-Trainer Program to Mitigate Implicit Bias across a Medical Center.

Problem: Academic medical centers need to mitigate the negative effects of implicit bias with approaches that are empirically-based, scalable, sustainable, and specific to departmental needs. Guided by Kotter's Model of Change to create and sustain cultural change, we developed the Bias Reduction Improvement Coaching Program (BRIC), a two-year, train-the-trainer implicit bias coaching program designed to meet the increasing demand for bias training across a university medical center. Intervention: BRIC trained a cohort of faculty and staff as coaches during four quarterly training sessions in Year 1 that covered 1) the science of bias, 2) bias in selection and hiring, 3) bias in mentoring, and 4) bias in promotion, retention, and workplace culture. In Year 2, coaches attended two booster sessions and delivered at least two presentations. BRIC raises awareness of bias mitigation strategies in a scalable way by uniquely building capacity through department-level champions, providing programming that addresses the 'local context,' and setting a foundation for sustained institutional change. Context: In a U.S. academic medical center, 27 faculty and staff from 24 departments were trained as inaugural BRIC coaches. We assessed outcomes at multiple levels: BRIC coach outcomes (feedback on the training sessions; coach knowledge, attitudes, and skills), departmental-level outcomes (program attendee feedback, knowledge, and intentions) and institutional outcomes (activities to sustain change). Impact: After Year 1, coaches reported high satisfaction with BRIC and a statistically significant increase in self-efficacy in their abilities to recognize, mitigate, and teach about implicit bias. In Year 2, attendees at BRIC coach presentations reported an increase in bias mitigation knowledge, and the majority committed to taking follow-up action (e.g., taking an Implicit Association Test). Coaches also launched activities for sustaining change at the broader university and beyond. Lessons Learned: The BRIC Program indicates a high level of interest in receiving bias mitigation training, both among individuals who applied to be BRIC coaches and among presentation attendees. BRIC's initial success supports future expansion. The model appears scalable and sustainable; future efforts will formalize the emerging community of practice around bias mitigation and measure elements of on-going institutional culture change.

A culturally targeted video to promote genetic counseling in a community sample of at-risk US Latina women: The role of the concrete mindset.

Latina women, who are at increased risk of hereditary breast and ovarian cancer (HBOC), have lower use of genetic counseling and testing (GCT) than non-Hispanic White women. In a recent study, culturally targeted video improved psychosocial outcomes related to GCT. Additional analyses examine whether the culturally targeted video improved positive reactions in women who focus on difficulties (concrete mindset) versus women who focus on the final goals (abstract mindset). Participants (N = 32) completed surveys before and immediately after watching the video. The surveys measured attitudes, emotions, and women's mindset. Before watching the video, women with a concrete mindset reported more negative attitudes and negative emotions about GCT than women with an abstract mindset. After watching the video, women with a concrete mindset reported negative attitudes and feelings at levels comparable to those of women with an abstract mindset, reflecting a reduction in their negative attitudes and emotions. The sample size limits the power to find statistically significant differences. Results support the relevance of considering the audience's mindset in the development and testing of public health messages to promote the use of GCT.

Community research collaboration to develop a promotores-based hereditary breast cancer education program for Spanish-speaking Latinas.

Breast cancer (BC) is the most common cancer in Latinas and the leading cause of cancer death. Latinas tend to be diagnosed at later stages, receive poorer quality care and have a higher risk of mortality than non-Latina White (NLW) women. Among women with a genetic predisposition to hereditary BC, genetic counseling can be beneficial. Latinas participate in genetic counseling at lower rates than NLW women. The goal of this study was to develop comprehensive, culturally appropriate materials for community health educators (promotores)-led hereditary BC education program for Spanish-speaking Latinas. We developed the curriculum through feedback from 7 focus groups, with a total of 68 participants (35 promotores and 33 community members). We used a mixed-methods approach that relied on quantitative analysis of survey questions and qualitative content analysis of the focus groups transcripts. Pre and post promotores' training survey responses suggested improvement in the promotores' cancer-related knowledge. Themes that emerged from the qualitative analyses were (i) barriers to health education and/or care; (ii) importance of educating the Latino community about BC and genetics and (iii) role of the promotores. Future research will further evaluate the impact of the program in promotores' knowledge and community members' screening behaviors.

The role of psychosocial factors in Black women's self-efficacy in receiving genetic counseling and testing.

Higher self-efficacy in receiving genetic counseling and testing (GCT) has been associated with greater participation in GCT for women at risk of hereditary breast and ovarian cancer (HBOC), but little is known about correlates of self-efficacy in Black women eligible for GCT. The goal of this secondary analysis was to identify sociodemographic and psychosocial factors regarding GCT. Multivariable regression analysis was conducted to assess the relationship between self-efficacy and correlates of interest. Of the 100 Black women surveyed, most women had a college degree (64%), were employed (84%), and had health insurance (93%). In the multivariable model, greater self-efficacy was associated with more positive attitudes toward GCT (Β = 0.126; CI = 0.01 to 0.25; p = 0.039), greater confidence in the Genetic Information Nondiscrimination Act (GINA) (Β = 0.250; CI = 0.04 to 0.46; p = 0.019), and lower ratings of perceived difficulty obtaining GCT (Β = -0.219; CI = -0.46 to -0.10; p = 0.003). Community-level interventions to promote self-efficacy are needed that address perceived barriers to GCT, with the goals of increasing GINA Law awareness in the general public, increasing accessibility to genetic counseling (e.g., telemedicine), and promoting more positive attitudes about GCT.

Process evaluation of a culturally targeted video for Latinas at risk of hereditary breast and ovarian cancer.

This paper presents a process evaluation of a culturally targeted narrative video about hereditary breast and ovarian cancer (HBOC) for Latina women at risk for HBOC. Spanish-speaking Latina women at risk for HBOC participated in a single arm study (n = 40). Participants watched the video developed by the authors and responded to surveys. We used mixed methods to assess theoretical constructs that are hypothesized mediators of narrative interventions (i.e., transportation or engagement, identification with characters, emotions) and implementation outcomes (e.g., acceptability). Descriptive statistics summarized theoretical constructs and implementation outcomes. We conducted Mann-Whitney U tests to assess the differences in theoretical and implementation outcomes between participants who were affected versus. unaffected and participants with different levels of education and health literacy. We used the consensual qualitative research framework to analyze qualitative data. Participants' mean age was 47.1 years (SD = 9.48). Most participants were high school graduates or less (62.5%). Acceptability of the video was extremely high (Md = 10.0, IQR = 0.2, scale 1-10). Most (82.5%) suggested video dissemination be through social media. Participants were highly engaged (Md = 5.7, IQR = 1.5, scale 1-7), strongly identified with the main character (Md = 8.7, IQR = 2.6, scale 1-10), and reported experiencing mostly positive emotions (Md = 9.5, IQR = 2.8, scale 1-10). Participants with low health literacy and affected participants reported a significantly higher identification with the main character (p<.05). Qualitative data reinforced the quantitative findings. Women reported gaining knowledge, correcting misconceptions, and feeling empowered. Our culturally targeted video is highly acceptable and targets mechanisms of behavior change for narrative interventions. The video is easily disseminable and can be used as an education tool for patients including affected and unaffected women and patients with different education and health literacy levels. Future studies should test the impact of the video in enhancing genetic counseling and testing uptake.

Sociodemographic, clinical, psychosocial, and healthcare-related factors associated with beliefs about adjuvant endocrine therapy among breast cancer survivors.

OBJECTIVE: Adjuvant endocrine therapy (AET) reduces the risk of recurrence and mortality in women with hormone receptor-positive breast cancer. However, adherence to AET remains suboptimal. Women's beliefs about medication have been associated with medication adherence. The purpose of this study was to identify multilevel factors associated with women's beliefs about AET. METHODS: Beliefs about AET, measured using the Belief about Medicines Questionnaire (BMQ), sociodemographic (e.g., age), psychosocial (e.g., religiosity), and healthcare factors (e.g., patient-provider communication), were collected via survey. Clinical data were abstracted from medical records. Two stepwise regression analyses models were performed to assess relationships between variables and necessity and concern beliefs. RESULTS: In our sample of 572 women, mean BMQ concern score was 11.19 and mean necessity score was 13.85 (range 5-20). In the regression models, higher ratings of patient-provider communication were associated with lower concern and higher necessity beliefs. Higher concern beliefs were related to more AET-related symptoms (Β = 0.08; 95% CI 0.06 to 0.10; p < 0.001), lower patient satisfaction (Β = - 0.07; 95% CI - 0.09 to - 0.04; p < 0.001), and higher religiosity (Β = 0.05; 95% CI 0.01 to 0.08; p = 0.007). Higher necessity beliefs were associated with prior chemotherapy use (Β = 0.11; 95% CI 0.06 to 0.16; p < 0.005) and less education (Β = 1.00; 95% CI 0.27 to 1.73; p = 0.008). CONCLUSIONS: Modifiable factors are related to women's AET beliefs. Healthcare interactions may play a key role with regard to shaping women's beliefs about their AET medication.

Latinas' knowledge of and experiences with genetic cancer risk assessment: Barriers and facilitators.

Disparities in genetic cancer risk assessment (GCRA) uptake persist between Latinas and Non-Hispanic Whites. This study utilized a mental model approach to interview 20 Latinas (10 affected, 10 unaffected) at increased risk for hereditary breast and ovarian cancer (HBOC). Participants were asked about their knowledge and perceptions of GCRA, HBOC, risk, benefits, motivators, barriers, challenges, and experiences with GCRA. Using the Consensual Qualitative Analysis Framework, two authors independently coded the interviews and applied the final codes upon consensus. Additionally, interviews were coded to identify whether participants spontaneously brought up certain topics without a prompt. Findings identified multiple barriers and facilitators to GCRA uptake in this population, including patient level psychosocial/cultural factors (e.g., limited knowledge, worry about relatives' risk) and healthcare system factors (e.g., receiving no referrals). There were notable differences in awareness and knowledge between affected and unaffected women (e.g., genetic testing awareness), as well as knowledge gaps that were evident in both groups (e.g., age of diagnosis as a risk factor). To reduce disparities in GCRA uptake, interventions should address identified facilitators and barriers. Differences in knowledge and awareness between affected and unaffected women support the development of targeted interventions that address specific knowledge gaps. This study was registered in ClinicalTrials.gov (NCT03075540) by Alejandra Hurtado de Mendoza, Ph.D.

Applying the theory of planned behavior to examine adjuvant endocrine therapy adherence intentions.

OBJECTIVE: Adherence to adjuvant endocrine therapy (AET) in breast cancer survivors is suboptimal. Using the theory of planned behavior (TPB), this study aimed to identify the strongest predictors from the TPB of AET intentions and past behavior and assessed whether ambivalence and anticipatory emotions increased the predictive capacity of TPB. METHODS: Two hundred eighty women diagnosed with hormone positive (HR+) breast cancer who filled at least one prescription of AET responded to a survey measuring TPB constructs, attitudinal ambivalence, and anticipatory emotions. The outcomes were intentions to adhere to AET and past medication adherence (previous 2 weeks). RESULTS: The TPB explained 66% of intentions to adhere to AET (P < 0.001). Ambivalence did not improve the TPB model's predictive value. When emotions were included with TPB, the model explained 70% of adherence intentions F11,226  = 52.84, P < 0.001 (R2c  = .70). This increase of 4% in predictability was statistically significant (ΔR2  = 0.04), F6, 226  = 7.90, P < 0.001. Women who self-reported nonadherence in the past 2 weeks differed significantly in the TPB variables, ambivalence, and anticipatory emotions from adherent women. Nonadherent participants reported lower-future intentions to adhere F1, 236  = 5.63, P = 0.018. CONCLUSIONS: Results suggest key concepts, such as anticipatory positive emotions that should be addressed in future interventions to enhance AET adherence and survivorship.

Psychometric Properties of the Medical Mistrust Index (MMI) in Latina Immigrants.

Medical mistrust measures have not been validated in Latino immigrants. This study examined the psychometric properties of the Medical Mistrust Index and its association with health care satisfaction in a sample of Latina immigrants. Participants were 168 self-identified Latinas ≥40 years old. Women were recruited from three Latino-serving health clinics and through a Latino radio program. A bilingual interviewer administered the Medical Mistrust Index in Spanish along with items pertaining to sociodemographic and health care factors. Principal component extraction method was used to evaluate internal consistency reliability to examine Medical Mistrust Index underlying factors. Construct validity was assessed by analyzing the relationship between the Medical Mistrust Index with three related measures (racism, discrimination, trust in doctors). To assess the criterion validity of the Medical Mistrust Index, a logistic regression model examined whether medical mistrust was associated with Latina women's satisfaction with health care controlling for sociodemographic and health care factors. Participants were 51 years old on average, around half had completed High school or less and were uninsured. Most were monolingual Spanish speakers. Two factors: competence and suspicion explained 40% of the total Medical Mistrust Index variance. Internal consistency was favorable and construct validity was supported. Results support the reliability and validity of the Medical Mistrust Index and its association with Latina's satisfaction with health care.

Sentiment Analysis of an Online Breast Cancer Support Group: Communicating about Tamoxifen.

A better understanding of the breast cancer online narrative is important for a clearer conceptualizing of the role of online platforms in mediating health-related support. Sentiment analysis was conducted on a breast cancer online support group regarding Tamoxifen to understand users' emotions and opinions. This analysis was then contextualized within online social support literature. Out of the 498 users, the most active users were 80% more positive than least active users, while least active users were 48% more negative than most active ones; both differences were statistically significant. The higher the stage of cancer a user had, the less likelihood that she would have posted, and if she were to post, the post would have focused on her side effects and the anxiety/sadness that tailgates those side effects. The lower the stage of cancer a user had, the more likelihood that she would have posted, additionally remained active on the forum, and encouraged more (online) social support. This finding suggests that the online support platform may provide a context that exacerbates support for like-minded users where stronger ties are created around a specific sentiment within the community with less connection from those with dissimilar sentiments to the dominant group.

Understanding Breast Cancer Survivors' Beliefs and Concerns About Adjuvant Hormonal Therapy: Promoting Adherence.

Adjuvant hormonal therapy is recommended for women with hormone receptor (HR)-positive breast cancer. Though critical, many patients are non-adherent to this therapy. Few scales have been developed to specifically address beliefs about adjuvant hormonal therapy. This study explores the clarity and relevance of the Beliefs about Medicine Questionnaire (BMQ) in the context of adherence behaviors to hormonal therapy in Black and White breast cancer survivors. We recruited women diagnosed with HR-positive cancer from the Washington, DC, area. An interviewer administered a standardized survey and conducted a cognitive interview. Participants rated the BMQ across three areas: relevance, difficulty, and clarity. We coded whether the comments identified item level issues: limited applicability, unclear reference, unclear perspective, or wording or tone. In-depth interviews were conducted with women who prematurely discontinued hormone therapy. The sample (n = 30) was equally split between Black and White survivors. On average, women were 57.9 years old (SD = 9.0). Overall 77% rated scale as relevant. Cognitive interviews revealed areas of perceived limited acceptability such as the notion of becoming too dependent or the notion of becoming worse if not taking the medication. Women who discontinued hormonal therapy (n = 2) felt ambivalent towards hormonal therapy as they reported having both positive and negative beliefs about the medication. Our study findings suggest new areas for further research and instrument development to accurately measure self-reported beliefs about hormonal therapy by HR-positive breast cancer survivors.

The Role of Knowledge on Genetic Counseling and Testing in Black Cancer Survivors at Increased Risk of Carrying a BRCA1/2 Mutation.

Genetic counseling and testing (GCT) for hereditary breast and ovarian cancers (HBOC) can inform treatment decisions in survivors. Black women at risk of HBOC have lower GCT engagement. There is limited data about Black survivors' experiences. The goals of this study were to: 1) examine the factors associated with HBOC knowledge and 2) assess the impact of knowledge on GCT engagement in a sample of Black survivors at risk of HBOC. Fifty Black at-risk breast/ovarian cancer survivors participated in a telephone-based survey. GCT use was measured across a continuum (awareness, referral, and use). The primary predictor variable was HBOC knowledge. Other clinical, socio-demographic, and psychosocial variables were included. Multiple linear and ordinal regression models (knowledge as the outcome and GCT as the outcome) assessed the predictors of knowledge and GCT engagement. Less than half (48 %) of survivors were referred to or used GCT services. Knowledge was moderate (M = 7.78, SD = 1.61). In the multivariable analysis, lower age (ß = -.34, p = .01) and lower stage (ß = -.318, p = .017) were associated with higher knowledge. Higher knowledge (ß = .567, p = .006) and higher self-efficacy (ß = .406, p = .001) were significantly associated with GCT engagement. Future interventions directed at increasing knowledge, self-efficacy, and improving the referral process are warranted.

Do coping strategies mediate the effects of emotional support on emotional well-being among Spanish-speaking Latina breast cancer survivors?

OBJECTIVE: This study aimed to assess the relationship between emotional social support and emotional well-being among Latina immigrants with breast cancer and test whether two culturally relevant coping strategies, fatalism and acceptance, mediate this relationship. METHODS: One hundred fifty Spanish-speaking Latinas within 1 year of breast cancer diagnosis participating in a randomized trial of a stress management intervention were assessed in person at baseline and via telephone 6 months later. Survey measures included baseline emotional support, fatalism, and acceptance and emotional well-being 6 months later. Generalized linear models estimated direct effects of emotional support on emotional well-being and indirect effects through fatalism and acceptance. RESULTS: Mean age was 50.1 (SD = 10.9) years; most women had low education and acculturation levels. Emotional support was negatively associated with fatalism (r = -0.24, p < 0.01) and positively associated with acceptance (r = 0.30, p < 0.001). Emotional support (r = 0.23, p = 0.005) and acceptance (r = 0.28, p = 0.001) were positively associated with emotional well-being, whereas fatalism (r = -0.36, p < 0.0001) was negatively associated with emotional well-being. In multivariable models, emotional support was associated with emotional well-being (b = 0.88, 95% CI: 0.24, 1.52). This direct effect remained significant when additionally controlling for fatalism (b = 0.66, 95% CI: 0.03, 1.30) and acceptance (b = 0.73, 95% CI: 0.09, 1.37) in separate models. There was a significant indirect effect of emotional support on emotional well-being through fatalism (b = 0.21, 95% CI: 0.04, 0.51) as well as a marginally significant effect through acceptance (b = 0.15, 95% CI: 0.001, 0.43). CONCLUSIONS: Emotional support may increase well-being among Spanish-speaking Latina cancer survivors by reducing cancer fatalism.Copyright © 2015 John Wiley & Sons, Ltd.

Risk-reduction opportunities in breast cancer survivors: capitalizing on teachable moments.

PURPOSE: With advancements in detection and treatment, the number of breast cancer survivors is growing. To reduce mortality among survivors, tailored health-promotion programs are needed to combat comorbidities. However, the demand for such programs exceed that which is available for a vastly diverse population of survivors. The goal of the present study was to describe the prevalence of comorbidities in a group of breast cancer survivors and to examine associations between biological proximal factors of and the more distal individual-level factors on the number and types of comorbidities. METHODS: In addition to medical chart reviews, breast cancer survivors (N = 369) from hospitals in two urban locations completed self-report measures. Bivariate analyses examined the relationship between distal and proximal predictors and the outcomes: number of comorbidities and comorbidity types. RESULTS: Both proximal and distal factors were associated with comorbidities. African American, women with lower education attainment, and older women were more likely to be obese and have more comorbidities than their counterparts. In particular, they were more at risk for cardiovascular disease. Those who initiated hormonal therapy, chemotherapy, and radiation therapy were more likely to have comorbidities. Several psychosocial variables were related to proximal psychosocial factors. CONCLUSIONS: The present findings highlight the need for targeted health-promotion treatments for breast cancer survivors, particularly for African Americans, those with lower education attainment, those who are obese, and those who may be older. Given the relationships between specific comorbidities and proximal psychosocial factors, future interventions may benefit from tailored approaches. IMPLICATIONS FOR CANCER SURVIVORS: Tailored interventions for survivors may be more effective when accounting for factors associated with health-promotion engagement.

Rethinking agency and medical adherence technology: applying Actor Network Theory to the case study of Digital Pills.

Much literature surrounding medical technology and adherence posits that technology is a mechanism for social control. This assumes that the medical establishment can take away patients' agency. Although power relationships and social control can play a key role, medical technology can also serve as an agentive tool to be utilized. We (1) offer the alternative framework of Actor Network Theory to view medical technology, (2) discuss the literature on medication adherence and technology, (3) delve into the ramifications of looking at adherence as a network and (4) use Digital Pills as a case study of dispersed agency.

Addressing cancer control needs of African-born immigrants in the US: a systematic literature review.

Compared to non-Hispanic Whites, African immigrants have worse cancer outcomes. However, there is little research about cancer behaviors and/or interventions in this growing population as they are generally grouped with populations from America or the Caribbean. This systematic review examines cancer-related studies that included African-born participants. We searched PsycINFO, Ovid Medline, Pubmed, CINHAL, and Web of Science for articles focusing on any type of cancer that included African-born immigrant participants. Twenty articles met study inclusion criteria; only two were interventions. Most articles focused on one type of cancer (n=11) (e.g., breast cancer) and were conducted in disease-free populations (n=15). Studies included African participants mostly from Nigeria (n=8) and Somalia (n=6). However, many papers (n=7) did not specify nationality or had small percentages (<5%) of African immigrants (n=5). Studies found lower screening rates in African immigrants compared to other subpopulations (e.g. US-born). Awareness of screening practices was limited. Higher acculturation levels were associated with higher screening rates. Barriers to screening included access (e.g. insurance), pragmatic (e.g. transportation), and psychosocial barriers (e.g. shame). Interventions to improve cancer outcomes in African immigrants are needed. Research that includes larger samples with diverse African subgroups including cancer survivors is necessary to inform future directions.

African American women's limited knowledge and experiences with genetic counseling for hereditary breast cancer.

Genetic counseling and testing for hereditary breast cancer have the potential benefit of early detection and early interventions in African American women. However, African American women have low use of these services compared to White women. We conducted two focus groups with African American women diagnosed with breast cancer (affected group, n = 13) and women with at least one first-degree relative with breast/ovarian cancer (unaffected group, n = 8). A content analysis approach was employed to analyze interview data. Breast cancer survivors had more knowledge about genetic counseling and testing than participants who were unaffected with cancer. However, knowledge about genetic counseling was limited in both groups. Barriers to pursuing genetic counseling and testing included poor understanding of the genetic counseling and testing process, fear of carrying the mutation, concerns about discrimination, and cost. Motivators to participate in genetic counseling and testing included desire to help family members, insurance coverage, and potential of benefiting the larger African American community. Education efforts are needed to increase genetic counseling and testing awareness in the African American community.

Social isolation and perceived barriers to establishing social networks among Latina immigrants.

Research has identified numerous mechanisms through which perceived social isolation and lack of social support negatively impact health. Little research attention has been dedicated to factors that influence the development of social networks, which have the potential to decrease perceptions of social isolation and provide social support. There is mixed evidence concerning the availability of supportive social networks for Latinos in the US. This study explores trauma-exposed Latina immigrants' experiences of social isolation in the US and its perceived causes. Twenty-eight Latina immigrant women participated in an interview about traumatic experiences. Informal help seeking and the availability of friendships in the US were also queried. Frequent comparisons between experiences in their home countries and in the US shaped the emerging themes of social isolation and lack of social support. Women reported feeling lonely, isolated, closed-in, and less free in the US due to family separation and various obstacles to developing and maintaining relationships. Socioeconomic, environmental, and psychosocial barriers were offered as explanations for their limited social networks in the US. Understanding experiences of social isolation as well as barriers to forging social networks can help inform the development of social support interventions that can contribute to improved health among Latinos.