Perspectives on Human Papilloma Virus Vaccination Barriers, Knowledge and Beliefs, and Practices: Providers Serving Arab-American Populations.

Little is known of HPV vaccination (HPVV) recommendation practices among healthcare providers who treat the Arab American community. Evidence indicates that HPVV patient uptake is low in this population. A survey was administered to healthcare providers (N = 46, 63% response rate) who treated ≥ 5% Arab American patients aged 9-26 years in areas of New York City and New Jersey with large Arab American populations. They were asked about barriers to HPVV recommendation and uptake among their Arab American patients. Providers (Doctors of Medicine and Osteopathy, Nurse Practitioners, and Physician Assistants) mostly worked in pediatrics (41%), primary care/internal medicine (26%), obstetrics/gynecology (20%), and family medicine (15%). Most (91%) were confident in their ability to effectively counsel their patients on HPVV. The most frequent provider-reported barriers to administering the HPVV to Arab American patients were patient cultural/religious practices (reported by 67%) and patient and provider difficulties with insurance reimbursement (44%). Most providers (84%) agreed that organizations/programs to increase HPVV uptake among Arab American patients were needed. Providers felt that HPVV uptake could be increased with educational materials in the patients' native languages ("very useful," 81%) and provider cultural competency training ("very useful," 65%). In responses to open-ended questions, cultural and religious HPVV barriers were a salient topic, as were linguistic barriers and provider burdens related to HPVV costs and regulations. HPVV uptake could potentially be improved with Arabic language education materials, provider education that is culturally and linguistically tailored to the Arab American community, and policies to address HPVV financial and regulatory burdens.

Patient-reported benefit from proposed interventions to reduce financial toxicity during cancer treatment.

INTRODUCTION: Financial toxicity is common and pervasive among cancer patients. Research suggests that gynecologic cancer patients experiencing financial toxicity are at increased risk for engaging in harmful cost-coping strategies, including delaying/skipping treatment because of costs, or forsaking basic needs to pay medical bills. However, little is known about patients' preferences for interventions to address financial toxicity. METHODS: Cross-sectional surveys to assess financial toxicity [Comprehensive Score for Financial Toxicity (COST)], cost-coping strategies, and preferences for intervention were conducted in a gynecologic cancer clinic waiting room. Associations with cost-coping were determined using multivariate modeling. Unadjusted odds ratios (ORs) explored associations between financial toxicity and intervention preferences. RESULTS: Among 89 respondents, median COST score was 31.9 (IQR: 21-38); 35% (N = 30) scored < 26, indicating they were experiencing financial toxicity. Financial toxicity was significantly associated with cost-coping (adjusted OR = 3.32 95% CI: 1.08, 14.34). Intervention preferences included access to transportation vouchers (38%), understanding treatment costs up-front (35%), minimizing wait times (33%), access to free food at appointments (25%), and assistance with minimizing/eliminating insurance deductibles (23%). In unadjusted analyses, respondents experiencing financial toxicity were more likely to select transportation assistance (OR = 2.67, 95% CI: 1.04, 6.90), assistance with co-pays (OR = 9.17, 95% CI: 2.60, 32.26), and assistance with deductibles (OR = 12.20, 95% CI: 3.47, 43.48), than respondents not experiencing financial toxicity. CONCLUSIONS: Our findings confirm the presence of financial toxicity in gynecologic cancer patients, describe how patients attempt to cope with financial hardship, and provide insight into patients' needs for targeted interventions to mitigate the harm of financial toxicity.

The Use of a Mobile Application to Increase Access to Interpreters for Cancer Patients With Limited English Proficiency: A Pilot Study.

BACKGROUND: Language barriers can influence the quality of health care and health outcomes of limited English proficient patients with cancer. The use of medical interpretation services can be a valuable asset for improving communications in emergency care settings. OBJECTIVE: To evaluate whether a mobile translation application increased call frequency to interpreter services among providers in an Urgent Care Center at a comprehensive cancer center and to assess provider satisfaction of the mobile application. RESEARCH DESIGN: Prospective pre-post nonrandomized intervention of a mobile translation application with access to an over the phone interpreter (OPI) service at the push of a button and poststudy satisfaction survey. SUBJECTS: Sixty-five clinicians working at the Urgent Care Center in a cancer center in New York City. MEASURES: Mean call frequency to OPI services, tested by the nonparametric Wilcoxon Mann Whitney test, and self-reported provider satisfaction descriptives. RESULTS: The mobile application contributed to increasing the frequency of phone calls to OPI services during the intervention period (mean=12.8; P=0.001) as compared with the preintervention period (mean=4.3), and showed continued use during the postintervention period (mean=5.7). Most clinicians were satisfied with the use of the mobile application and access to the OPI services. CONCLUSIONS: The results suggest that mobile application tools contribute to increasing the use and ease of access to language services. This has the potential to improve the quality of communication between medical providers and limited English proficient patients in the delivery of cancer care in urgent care settings.

Beyond translation: Transcreation of a clinicians' guide to structure discussions about health-related values with Latinx patients throughout cancer.

OBJECTIVE: This study aimed to ensure accurate translation and cultural appropriateness of a guide designed to help oncology clinicians provide person-centered care to Spanish-speaking Latinx patients with cancer. METHODS: Initial translation of a clinician-patient values discussion guide in open-ended question format ("Guide") was pretested in interviews with 27 Spanish-speaking individuals, followed by national expert panel review. At three sites, semi-structured, in-depth, audio-recorded interviews in the participant's preferred language (Spanish/English) were then conducted with Latinx patients receiving systemic treatment for a solid tumor malignancy and family joining them at clinic. RESULTS: Interviews of 43 patient/family participants representing diverse Latinx communities addressed the Guide's understandability, acceptability, relevance and responsiveness. Rapid analysis of interviews contributed to cultural adaptation/transcreation of the Guide for a pilot interventional trial. CONCLUSION: Moving beyond translation to transcreation can help promote inclusion, equity, and cultural sensitivity in oncologic care/communication. PRACTICE IMPLICATIONS: Clinicians now have a linguistically- and culturally-adapted guide including questions and prompts to help structure discussions in Spanish or English of health-related values with Latinx patients receiving oncologic care.

Food insecurity among New York City taxi and for-hire vehicle drivers.

BACKGROUND: New York City's (NYC's) taxi/for-hire vehicle (FHV) drivers have occupational and demographic characteristics associated with food insecurity (low income, comorbidities, minority race/ethnicity). OBJECTIVE: To analyze food insecurity rates in a sample of NYC drivers and to identify associated factors. METHODS: At health fairs, we recruited a cross-sectional sample of licensed taxi/FHV drivers willing to receive study text messages. Most lacked a primary care provider. Food insecurity prevalence and associations with health and economic indicators were analyzed. RESULTS: Of 503 participants who completed a 2-item food security screener, 39.2% were food insecure. Significantly fewer food insecure than food secure drivers reported a doctor visit within the past year (48% vs 25%; P < .001). Food insecure drivers had greater weekly traffic ticket expenditure ($34 vs $24; P = .02) and were more likely to report insufficient household income (61% vs 39%; P < .001) and history of depression (14% vs 7%; P = .02), to have elevated (>200) measured total cholesterol (50% vs 37%; P = .02), and to have Perceived Stress Scale scores indicating greater stress than food secure drivers (14 vs 11; P = .002). In a binary logistic regression analysis, drivers who reported that their total household income was enough to meet their basic needs had significantly lower odds of being food insecure (0.695 odds ratio; P = .016). CONCLUSION: Food insecurity was high in this group of taxi/FHV drivers. Food insecurity interventions are needed and could be occupationally based, with worksite screening and resource navigation. Policies should address improving wages and healthcare access.

Household Food Security and Consumption of Sugar-Sweetened Beverages among New York City (NYC) Children: A Cross-Sectional Analysis of 2017 NYC Kids' Data.

Food insecurity is a stressor associated with adverse health outcomes, including the consumption of sugar-sweetened beverages (SSBs). Our study tests the hypothesis that other socioeconomic vulnerabilities may magnify this effect using cross-sectional data from the 2017 New York City (NYC) Kids Survey. Households providing an affirmative response to one or both food security screener questions developed by the US Department of Agriculture were coded as households with low food security. The number of sodas plus other SSBs consumed was standardized per day and categorized as 1 = none, 2 = less than one, and 3 = one or more. We tested the joint effect of low food security with chronic hardship, receipt of federal aid, and immigrant head of household on a sample of n = 2362 kids attending kindergarten and beyond using ordinal logistic regression and accounting for the complex survey design. Only having a US-born parent substantially magnified the effect of low household food security on SSB consumption (OR = 4.2, 95%CI: 2.9-6.3, p < 0.001) compared to the reference group of high household food security with an immigrant parent. The effect of low food security on SSB consumption among NYC children warrants intersectional approaches, especially to elucidate US-based SSB norms in low-food-security settings.

Food Insecurity Among People With Cancer: Nutritional Needs as an Essential Component of Care.

A cancer diagnosis can upend work and family life, leading patients to reallocate resources away from essentials such as food. Estimates of the percentage of people navigating a cancer diagnosis and food insecurity range between 17% and 55% of the cancer patient population. The complexity of addressing food insecurity among those diagnosed with cancer during different phases of treatment is multifactorial and often requires an extensive network of support throughout each phase. This commentary explores the issue of food insecurity in the context of cancer care, explores current mitigation efforts, and offers a call to action to create a path for food insecurity mitigation in the context of cancer. Three programs that address food insecurity among those with cancer at various stages of care are highlighted, drawing attention to current impact and actionable recommendations to make programs like these scalable and sustainable. Recommendations are grounded in the National Academies of Sciences, Engineering, and Medicine social care framework through 5 essential domain areas: awareness, adjustment, assistance, alignment, and advocacy. This commentary seeks to highlight opportunities for the optimization of cancer care and reframe food access as an essential part of treatment and long-term care plans.

Language discordance and testing for latent tuberculosis infection among recent Asian and Latino immigrants.

The foreign-born population is disproportionately affected by tuberculosis (TB). Testing to identify persons with latent TB infection is critical. The aim of this study was to assess clinic-based testing for latent tuberculosis infection among recent Asian and Latino immigrants. A randomized controlled trial of interpreting methods and their impact on medical outcomes was conducted at the primary care clinic of a New York City municipal hospital. This study is a nested cohort of recruited patients with an indication to receive tuberculin testing, based on recent migration to the US from endemic areas. Medical record data were abstracted to determine referral for, and completion of, tuberculin testing. Bivariate analyses were used to test for differences in tuberculin testing between language concordant and discordant groups. Seven hundred and eighty-two patients were enrolled. One hundred and ninety-one had migrated within 5 years of enrollment from endemic areas. None spoke English as a primary language. Seventy percentage of patient-provider encounters were language discordant. Seventeen of 191 were referred for testing. Fifteen (88%) completed testing. Six (40%) had positive results. There were no significant differences between language concordant and discordant patients. In this at-risk population, every patient in clinical care should be considered for testing if indicated by country of origin.

Use of patient-reported controls for secular trends to study disparities in cancer-related job loss.

PURPOSE: Racial/ethnic minorities experience greater job loss than whites during periods of economic downturn and after a cancer diagnosis. Therefore, race/ethnicity-matched controls are needed to distinguish the impact of illness on job loss from secular trends METHODS: Surveys were administered during and 4-month post-completion of breast cancer treatment. Patients were pre-diagnosis employed women aged 18-64, undergoing treatment for stage I-III breast cancers, who spoke English, Chinese, Korean, or Spanish. Each patient was asked to: (1) nominate peers who were surveyed in a corresponding timeframe (active controls), (2) report a friend's work status at baseline and follow-up (passive controls). Both types of controls were healthy, employed at baseline, and shared the nominating patient's race/ethnicity, language, and age. The primary outcome was number of evaluable patient-control pairs by type of control. A patient-control pair was evaluable if work status at follow-up was reported for both individuals. RESULTS: Of the 180 patients, 25% had evaluable active controls (45 patient-control pairs); 84% had evaluable passive controls (151 patient-control pairs). Although patients with controls differed from those without controls under each strategy, there was no difference in the percentage of controls who were working at follow-up (96% of active controls; 91% of passive controls). However, only 65% of patients were working at follow-up. CONCLUSIONS: The majority of patients had evaluable passive controls. There was no significant difference in outcome between controls ascertained through either method IMPLICATIONS FOR CANCER SURVIVORS: Passive controls are a low-cost, higher-yield option to control for secular trends in racially/ethnically diverse samples.

A randomized controlled trial of a multilevel intervention to increase colorectal cancer screening among Latino immigrants in a primary care facility.

BACKGROUND: Latino immigrants face a higher burden of colorectal cancer (CRC) and screening rates are low. OBJECTIVE: To assess the effectiveness of a multilevel intervention in increasing the rate of CRC screening among Latino immigrants. DESIGN: A randomized controlled trial, with randomization at the physician level. PARTICIPANTS: Pairs of 65 primary care physicians and 65 Latino immigrant patients participated, 31 in the intervention and 34 in the control group. INTERVENTION: CRC educational video in Spanish on a portable personal digital video display device accompanied by a brochure with key information for the patient, and a patient-delivered paper-based reminder for their physician. MEASUREMENTS: Completed CRC screening, physician recommendation for CRC screening, and patient adherence to physician recommended CRC screening. RESULTS: The overall rate of completed screening for CRC was 55% for the intervention and 18% for the control group (p = 0.002). Physicians recommended CRC screening for 61% of patients in the intervention group versus 41% in the control group (p = 0.08). Of those that received a recommendation, 90% in the intervention group adhered to it versus 26% in the control group (p = 0.007). CONCLUSIONS: The intervention was successful in increasing rates of completed CRC screening primarily through increasing adherence after screening was recommended. Additional efforts should focus on developing new strategies to increase physician recommendation for CRC screening, while employing effective patient adherence interventions.

Reducing clinical errors in cancer education: interpreter training.

Over 22 million US residents are limited English proficient. Hospitals often call upon untrained persons to interpret. There is a dearth of information on errors in medical interpreting and their impact upon cancer education. We conducted an experimental study of standardized medical interpreting training on interpreting errors in the cancer encounter, by comparing trained and untrained interpreters, using identical content. Nine interpreted cancer encounters with identical scripts were recorded and transcribed. Using an "Error Analysis Tool," a bilingual linguist and two bilingual medical providers scored the transcripts for interpreting errors made, including their potential clinical severity. Trained interpreters were 70% less likely to have clinical errors than untrained ones. The likelihood of medical error increased with the length of the concept and decreased with the precision of vocabulary. It is important to train medical interpreters and to ensure their availability in cancer education encounters to minimize the risk for errors.

Development of a Medically Tailored Hospital-based Food Pantry System.

Fifty-six percent of high-needs NYC cancer patients are food insecure, at times choosing between medical treatment and food. We describe FOOD (Food to Overcome Outcome Disparities), an innovative intervention, which has established eleven medically tailored food pantries in NYC cancer centers and distributed the equivalent of 307,080 meals since 2011.

"You Have to Keep a Roof Over Your Head": A Qualitative Study of Housing Needs Among Patients With Cancer in New York City.

PURPOSE: Housing status can become compromised in the wake of financial hardship for some patients with cancer and become a source of disparity. This qualitative study describes the types of housing issues experienced by patients with cancer and survivors of cancer in New York City. METHODS: Semistructured interviews were conducted with a volunteer sample of 21 patients with cancer or survivors of cancer treated in New York City who reported housing needs in the period after diagnosis through survivorship. Nine supplemental interviews were conducted with cancer and housing key informants. Conventional content analysis was conducted on transcripts to create a codebook describing types of housing needs. RESULTS: Patients and survivors most commonly had breast (n = 9) and blood (n = 4) cancers and ranged from recently diagnosed to many years posttreatment. Twenty-nine distinct housing-related issues were identified, which were grouped into the following six major categories: housing costs (eg, rent, mortgage), home loss, doubled up or unstable housing, housing conditions, accessibility (eg, stairs, proximity to amenities), and safety. Issues were often interrelated. Housing needs sometimes predated cancer diagnosis. Other issues newly emerged in the wake of cancer-related physical limitations and disruption to finances. Needs ranged in severity and caused patients and survivors considerable burden during a difficult period of poor health and financial strain. CONCLUSION: This study contributes depth to current understandings of housing needs among patients with cancer and survivors by providing detailed disaggregated descriptions. We recommend increasing availability of services responsive to these needs and exploring promising options such as patient navigation and legal services. Findings also highlight the importance of creative solutions addressing ecologic-level factors such as housing affordability.

Women With Breast Cancer Who Work For Accommodating Employers More Likely To Retain Jobs After Treatment.

Breast cancer affects one in eight women across the United States, and low-income minority survivors of breast cancer are at increased risk of job loss, compared to higher-income white survivors. Employer accommodations, such as schedule flexibility, have been associated with job retention in higher-income whites, but the role of such accommodations in job retention among low-income minorities is not well understood. We conducted a longitudinal study of 267 employed women ages 18-64 who were undergoing treatment for early-stage breast cancer and spoke English, Chinese, Korean, or Spanish. We categorized patients by income level and by race/ethnicity. The category with the lowest job retention after treatment was low-income women (57 percent). Job retention varied widely by race/ethnicity, ranging from 68 percent among Chinese women to 98 percent among non-Latina whites. Women who had accommodating employers were more than twice as likely to retain their jobs as those without accommodating employers. Low-income women were less likely than higher-income women to have accommodating employers, however. More uniform implementation of accommodations across low- and high-paying jobs could reduce disparities in employment outcomes among workers with a cancer diagnosis. Additional research is needed to better understand the barriers that employers, particularly those with low-income workers, may face in providing accommodations.

Interpreting at the End of Life: A Systematic Review of the Impact of Interpreters on the Delivery of Palliative Care Services to Cancer Patients With Limited English Proficiency.

CONTEXT: Language barriers can influence the health quality and outcomes of limited English proficiency (LEP) patients at end of life, including symptom assessment and utilization of hospice services. OBJECTIVES: To determine how professional medical interpreters influence the delivery of palliative care services to LEP patients. METHODS: We conducted a systematic review of the literature in all available languages of six databases from 1960 to 2014. Studies evaluated use of language services for LEP patients who received palliative care services. Data were abstracted from 10 articles and collected on study design, size, comparison groups, outcomes, and interpreter characteristics. RESULTS: Six qualitative and four quantitative studies assessed the use of interpreters in palliative care. All studies found that the quality of care provided to LEP patients receiving palliative services is influenced by the type of interpreter used. When professional interpreters were not used, LEP patients and families had inadequate understanding about diagnosis and prognosis during goals of care conversations, and patients had worse symptom management at the end of life, including pain and anxiety. Half of the studies concluded that professional interpreters were not used adequately, and several studies suggested that premeetings between clinicians and interpreters were important to discuss topics and terminology to be used during goals of care discussions. CONCLUSION: LEP patients had worse quality of end-of-life care and goals of care discussions when professional interpreters were not used. More intervention studies are needed to improve the quality of care provided to LEP patients and families receiving palliative services.

Parental education and text messaging reminders as effective community based tools to increase HPV vaccination rates among Mexican American children.

OBJECTIVE: Latino populations, particularly Mexican-Americans who comprise 65% of the Latinos in the U.S., are disproportionately affected by HPV-related diseases. The HPV vaccination completion rates remain low, well below the Healthy People 2020 goal. In this study we assessed the effect of parental education and a text messaging reminder service on HPV vaccine completion rates among eligible children of Mexican American parents. STUDY DESIGN: Nonequivalent group study of Mexican parents of HPV vaccine eligible children attended the Health Window program at the Mexican Consulate in New York City, a non-clinical, trusted community setting, during 2012-2013. 69 parents received HPV education onsite, 45 of whom also received a series of text message vaccination reminders. We measured HPV vaccination completion of the youngest eligible children of Mexican parents as the main outcome. RESULTS: 98% of those in the education plus text messaging group reported getting the first dose of the vaccine for their child and 87% among those in the educational group only (p = 0.11). 88% of those receiving the 1st dose in the text messaging group reported completing the three doses versus 40% in the educational group only (p = 0.004). CONCLUSIONS: Parental text messaging plus education, implemented in a community based setting, was strongly associated with vaccine completion rates among vaccine-eligible Mexican American children. Although pilot in nature, the study achieved an 88% series completion rate in the children of those who received the text messages, significantly higher than current vaccination levels.

An academic dental center grapples with oral cancer disparities: current collaboration and future opportunities.

This article reviews the epidemiology of oral cancer in the United States, explores the complex reasons for its disproportionate burden in minority groups, and describes the efforts of New York University's College of Dentistry to address these oral cancer disparities. These efforts include the development of state and regional consortia and networks, public education and community screening efforts, undergraduate dental curriculum development, professional education, intensive research efforts, and significant dental-medical collaborations. Future directions include the need to develop and assess oral cancer education/awareness programs, specifically customized to the various dental-medical professionals/trainees and to populations at risk. Improving the quality of life of patients during and following treatment for oral cancer is another important area that has great opportunity for dental-medical collaboration.