The effect of mailed outreach on FIT completion among patients aged 45-50 in a safety net healthcare system.

PURPOSE: Colorectal cancer screening is recommended starting at age 45, but there has been little research on strategies to promote screening in patients younger than 50. METHODS: An outreach program quasi-randomly assigned patients aged 45-50 without recent fecal immunochemical test (FIT), colonoscopy or contraindications to screening to two intervention arms: electronic outreach with email and text (electronic outreach only) versus electronic outreach plus mailed outreach with FIT, an instructional letter and a prepaid return envelope (mailed + electronic outreach). In response to known disparities in screening uptake, all Black patients were assigned to receive mailed + electronic outreach. RESULTS: Among patients quasi-randomly assigned to an intervention (non-Black patients), the 180-day FIT completion rate was 18.8% in the electronic outreach only group (n = 1,318) and 25.0% in the mailed + electronic outreach group (n = 1,364) (difference 6.2% [95% CI 3.0, 9.4]). FIT completion was 16.6% among Black patients (n = 469), 8.4% (95% CI 4.1, 12.6) lower than among non-Black patients also assigned to mailed + electronic outreach. CONCLUSION: Among patients aged 45-50, mailed + electronic outreach had a greater effect on FIT completion than electronic outreach alone. Crossover between intervention groups likely lead to an underestimation of the effect of mailed outreach.

HPV Self-Sampling in the Workplace: A Qualitative Study of Benefits, Barriers, and Opportunities for Improvement Perceived by Health Professionals and Managers.

AIM: To inform the implementation of Human Papillomavirus Self-Sampling (HPV-SS) in the workplace, we assessed the perspectives of healthcare professionals and managers on the benefits, barriers, and opportunities for improvement of a pilot program. METHODS: A qualitative descriptive study based on in-depth telephone interviews was conducted between June and August 2023. Data were analyzed through inductive thematic analysis. Fifteen health professionals from different companies and fifteen managers from the Mexican Institute of Social Security (IMSS) were interviewed. RESULTS: Participants identified several benefits of the HPV-SS, including ease of use, privacy, convenience, affordability, reduced workplace absences, and promotion of a prevention culture. However, there were also individual and organizational barriers to program implementation. The former consisted of women's concerns about collecting a reliable sample or injuring themselves, lack of confidence in the HPV test, fear of positive results, and discomfort caused by the brush used to collect the sample. Organizational barriers included failure to follow up on positive test results, lack of knowledge of program indicators, perceived negative impact on the established Pap smear cervical cancer screening indicator, and the lack of government regulations supporting HPV testing. To improve the program, participants suggested disseminating information through mass media campaigns and social networks, providing companies with additional support from IMSS preventive staff, extending the work hours of IMSS Family Medicine clinics, and training IMSS health staff on the follow-up of women with HPV test results. CONCLUSIONS: The study findings suggest potential areas for improvement in HPV-SS programs.

The Cervical Cancer Treatment Gap in Mexico Under Seguro Popular, 2006-2016.

From 2005 to 2019, the Mexican government financed cervical cancer treatment for individuals without social security insurance through Seguro Popular's Fund for Protection against Catastrophic Health Expenses. To better understand the impact of this program on access to treatment, we estimated the cervical cancer treatment gap (the proportion of patients with cervical cancer in this population who did not receive treatment). To calculate the expected number of incident cervical cancer cases we used national surveys with information on insurance affiliation and incidence estimates from the Global Burden of Disease study. We used a national claims database to determine the number of cases whose treatment was financed by Seguro Popular. From 2006 to 2016, the national cervical cancer treatment gap changed from 0.61 (95% CI 0.59 to 0.62) to 0.45 (95% CI 0.43 to 0.48), with an average yearly reduction of -0.012 (95% CI -0.024 to -0.001). The gap was greater in states with higher levels of marginalization and in the youngest and oldest age groups. Although the cervical cancer treatment gap among individuals eligible for Seguro Popular decreased after the introduction of public financing for treatment, it remained high. Seguro Popular was eliminated in 2019; however, individuals without social security have continued to receive cancer care financed by the government in the same healthcare facilities. These results suggest that barriers to care persisted after the introduction of public financing for treatment. These barriers must be reduced to improve cervical cancer care in Mexico, particularly in states with high levels of marginalization.

Mammography prevalence in Mexico from 2001-2018: Results from the Mexican Health and Aging study.

After introducing guidelines for breast cancer screening in 2003, Mexico began to prioritize the implementation of mammography screening nationally. Since then, there have been no studies assessing changes in mammography in Mexico using the two-year prevalence interval that corresponds to national guidelines for screening frequency. The present study analyzes the Mexican Health and Aging Study (MHAS), a national population-based panel study of adults aged 50 and older, to evaluate changes in 2-year mammography prevalence among women aged 50 to 69 across five survey waves from 2001 to 2018 (n = 11,773). We calculated unadjusted and adjusted mammography prevalence by survey year and health insurance type. Overall prevalence increased substantially from 2003 to 2012 and leveled off in the period from 2012 to 2018 (2001: 20.2 % [95 % CI 18.3, 22.1]; 2003: 22.7 % [20.4, 25.0]; 2012: 56.5 % [53.2, 59.7]; 2015: 62.0 % [58.8, 65.2]; 2018: 59.4 % [56.7,62.1]; unadjusted prevalence). Prevalence was higher among respondents with social security insurance, who are more likely to work in the formal economy, than among respondents without social security, who are more likely to work in the informal economy or be unemployed. The overall prevalence estimates observed were higher than previously published estimates of mammography prevalence in Mexico. More research is needed to confirm findings regarding two-year mammography prevalence in Mexico and to better understand the causes of observed disparities.

Neighborhood socioeconomic status and the effectiveness of colorectal cancer screening outreach with mailed fecal immunochemical tests within a safety net healthcare system in San Francisco, CA: A subgroup analysis of a randomized controlled trial.

Neighborhood context shapes opportunities and barriers for residents to access healthcare and cancer screening. Neighborhood socioeconomic status (nSES) is associated with disparities in colorectal cancer (CRC) screening, but the extent to which the effectiveness of specific screening interventions vary by nSES has not been studied. The original trial conducted in San Francisco, CA from 2016 to 2017 randomly assigned patients eligible for CRC screening either to a multicomponent intervention including advanced notification, mailed fecal immunochemical test (FIT) kits and reminders or to a control group receiving usual care. For the nSES analysis addresses for 9699 patients were geocoded and stratified by city-wide nSES quintile (Q1 lowest, Q5 highest) using an established index at the census tract level. Compared to usual care, the outreach intervention improved FIT test completion at one year (58.7% vs 38.4%; OR 2.32 [2.14, 2.52]) but its effectiveness did not vary substantially by nSES quintile (adjusted OR Q1 2.64 [2.30, 3.04]; Q2 2.43 [2.04, 2.90]; Q3 2.31 [1.84, 2.89]; Q4 2.47 [1.86, 3.28]; Q5 2.64 [1.83, 3.81]; Wald test for interaction p = 0.87). The implementation of mailed FIT outreach has the potential to increase CRC screening completion without leading to disparities in screening related to nSES (ClinicalTrials.gov NCT02613260).

Behind Closed Doors: A Thematic Analysis of Diabetes Community Health Worker Home Visit Content.

The present work studies how community health workers (CHWs) perform the role of educator and how this relates to the implementation of other CHW roles, skills, and qualities. Prior studies on this topic have relied on interviews or focus groups rather than analysis of CHW interactions. We conducted a thematic analysis of 24 transcripts of conversations occurring between CHWs and participants during home visits as part of the Mexican American Trial of Community Health Workers, a randomized controlled trial that improved clinical outcomes among low-income Mexican American adults with type 2 diabetes. Three themes describing interactions related to diabetes self-management education accounted for about half of encounter content. The other half of encounter content was dedicated to interactions not explicitly related to diabetes described by 4 subthemes. In a successful CHW intervention, focused educational content was balanced with other interactions. Interactions not explicitly related to diabetes may have provided space for the implementation of core CHW roles, skills, and qualities other than educator, particularly those related to relationship building. It is important that interventions provide CHWs with sufficient time and flexibility to develop strong relationships with participants.

Diabetes multimorbidity combinations and disability in the Mexican Health and Aging Study, 2012-2015.

PURPOSE: The aim of this study was to investigate the relationship between specific combinations of chronic conditions and disability in Mexican older adults with diabetes. METHODS: This was a prospective cohort study of Mexican adults (n = 2558) with diabetes and aged 51 or older that used data from the 2012 and 2015 waves of the Mexican Health and Aging Study. The main outcome was an index that measured ability to perform activities of daily living and instrumental activities of daily living. The main independent variables were diabetes multimorbidity combinations, defined as diabetes and at least one other chronic condition. The authors calculated the prevalence of each multimorbidity combination present in the sample in 2012 and used negative binomial regression models to estimate the association of the most prevalent of these combinations with disability incidence in 2015. RESULTS: The three most prevalent combinations were: 1) diabetes-hypertension (n = 637, 31.9%) 2) diabetes-hypertension-depression (n = 388, 19.4%) and 3) diabetes-depression (n = 211, 10.6%). In fully adjusted models comparing participants with specific multimorbidity combinations to participants with diabetes alone, the combinations that had an increased association with disability were diabetes-hypertension-depression, diabetes-depression and diabetes-hypertension-arthritis-depression. In nested models, the addition of arthritis to combinations including depression increased this association. CONCLUSIONS: Consistent with prior studies, multimorbidity combinations including depression were associated with increased risk of disability. However, the effect size of this relationship was lower than what had been previously been reported internationally. This highlights the need for globally oriented multimorbidity research.