Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial.

Importance: The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. Objective: To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. Design, Setting, and Participants: This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. Exposure: Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. Main Outcomes and Measures: Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. Results: A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). Conclusions and Relevance: In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

Can US Medical Schools Teach About Structural Racism?

Policy Points There need to be sweeping changes to medical school curricula that addresses structural racism in medicine and how to attend to this in medical practice. The Liaison Committee on Medical Education should develop and promulgate specific learning objectives and curricular offerings that require medical schools to teach about structural racism and antiracist medical practice in ways that are robust and standardized. The federal government, through the Health Resources and Services Administration, should prioritize support for antiracism education in medical schools, residency, and continuing medical education in similar ways and with similar effort in scale and scope to its support for primary care, providing technical assistance and grants for programs across the educational spectrum that provide antiracist training. State governments should mandate, as part of continuing education requirements for physicians, 2 or more hours per recertification cycle of antiracist training. CONTEXT: Since the beginning of COVID-19 and the rise of social justice movements sparked by the murders of George Floyd and Breonna Taylor in the summer of 2020, many medical schools have made public statements committing themselves to become antiracist institutions. The notions that US society generally, and medicine, are rife with structural racism no longer seems as controversial in the academic community. Challenges remain, however, in how this basic understanding gets translated into medical education practice. Understanding where the profession must go should start with understanding where we currently are. METHODS: Prior to the events of 2020, in the spring of 2018, we conducted nine key informant interviews to learn about the challenges and best practices from schools deemed to be positive deviants in teaching about structural racism. FINDINGS: Our interviews showed that even those schools deemed positive deviants in the amount of teaching done about structural racism faced significant barriers in providing a robust education. CONCLUSIONS: Significant structural change, perhaps far beyond what most schools consider themselves willing and able to engage in, will be necessary if future US physicians are to fully understand and address structural racism as it affects their profession, their practice, and their patients.

Struggles and Tensions in Antiracism Education in Medical School: Lessons Learned.

PURPOSE: Faculty from different racial and ethnic backgrounds developed and piloted an antiracism curriculum initially designed to help medical students work more effectively with patients of color. Learning objectives included developing stronger therapeutic relationships, addressing the effects of structural racism in the lives of patients, and mitigating racism in the medical encounter. METHOD: The antiracism curriculum was delivered and evaluated in 2019 through focus groups and written input before and after each module. The process and outcome evaluation used a grounded theory approach. RESULTS: Three emergent themes reflect how medical students experienced the antiracism curriculum and inform recommendations for integrating an antiracism curriculum into future medical education. The themes are: 1) the differential needs and experiences of persons of color and Whites, 2) the need to address issues of racism within medical education as well as in medical care, and 3) the need for structures of accountability in medical education. CONCLUSIONS: Medical educators must address racism in medical education before seeking to direct students to address it in medical practice.

Water Source Preferences and Water Quality Perceptions among Women in the Eastern Region, Ghana: A Grounded Theory Study.

Residents in the Eastern Region, Ghana with access to improved water sources (e.g., boreholes and covered wells) often choose to collect water from unimproved sources (e.g., rivers and uncovered wells). To assess why, we conducted two field studies to coincide with Ghana's rainy and dry seasons. During the rainy season, we conducted semi-structured in-depth interviews among a convenience sample of 26 women in four rural communities (including one woman in the dry season). We asked each participant about their attitudes and perceptions of water sources. During the dry season, we observed four women for ≤4 days each to provide context for water collection and water source choice. We used a grounded theory approach considering the multiple household water sources and uses approach to identify three themes informing water source choice: collection of and access to water, water quality perception, and the dynamic interaction of these. Women selected water sources based on multiple factors, including season, accessibility, religious/spiritual messaging, community messaging (e.g., health risks), and ease-of-use (e.g., physical burden). Gender and power dynamics created structural barriers that affected the use of unimproved water sources. A larger role for women in water management and supply decision-making could advance population health goals.

Lessons Learned From the Creating Active Communities and Healthy Environments Toolkit Pilot: A Qualitative Study.

The US Army Public Health Center developed the Creating Active Communities and Healthy Environments (CACHE) Toolkit to help military installations evaluate the quality of their built environments relative to healthy eating, physical activity, and tobacco-free living. This study sought to improve its implementation process and assess subsequent Action Plan Guides' utility at 5 military installations. Baseline data included a knowledge, attitudes, and beliefs survey (N = 34); post-Toolkit implementation data included focus groups (N = 2) and interviews (N = 10). Although >80% of participants agreed the built environment affects healthy living, only 44%, 53%, and 35% agreed their installations' built environments promoted healthy eating, physical activity, and tobacco-free living, respectively. Emerging themes comprised "Opportunities to Improve Toolkit and Action Plan Guide Functionality," the "Sociopolitical Landscape Affects Toolkit Implementation," and the "Sociopolitical and Physical Landscapes Affect the Toolkit's Value and Utility." This study provides concrete lessons for the CACHE Toolkit and other public health-based military initiatives.

BeWell: quality assurance health promotion pilot.

PURPOSE: The purpose of this paper is to determine the experience participating in a health promotion program for refugee and asylum seekers and torture survivors in a safety net clinical setting. DESIGN/METHODOLOGY/APPROACH: Refugee and asylum seeker torture survivors participated in a seven-week health promotion program at a safety-net clinic. Participants interviewed before, during and after the program was designed to improve and maintain health promotion program quality. FINDINGS: Six major themes emerged: social networks; tools/techniques/skills; wellness planning; spiritualism; health maintenance; and social/group interaction. Preliminary results suggest that this multi-pronged approach is feasible and acceptable to foreign-born torture survivors. RESEARCH LIMITATIONS/IMPLICATIONS: Torture impacts many facets of one's life. A program which addresses health from a multidisciplinary perspective has promise to facilitate healing. PRACTICAL IMPLICATIONS: The impact of torture and human rights violations significantly affects many facets of peoples' lives including emotional, social, physical and spiritual dimensions. Therefore a program which utilizes a multidisciplinary integrated bio-psychosocial and spiritual approach has the potential to simultaneously address many domains facilitating healing. ORIGINALITY/VALUE: BeWell, a bio-psychosocio-spiritual health promotion strategy aimed at improving health service quality and increasing patient satisfaction to support positive health outcomes by implementing in-classroom/person modules for patients, to the authors' knowledge is unique in its efforts to encompass multiple domains simultaneously and fully integrate an approach to wellbeing.

Where Are the Fresh Fruits and Vegetables?: A Systematic Exploration of Access to Food Stores Offering Fresh Fruits and Vegetables as Told by Midwestern African American Women.

This exploratory study systematically examined Midwestern African American women's (n = 273) access to food stores offering more than 5 fresh fruits and vegetables daily. Access to potential (within 0.5 miles of household) and realized (where participant buys fruits and vegetables most often) food stores was assessed. Descriptive analyses revealed that participants lived closer to food stores not offering more than 5 fresh fruits and vegetables daily. Participants purchased fresh fruits and vegetables from food stores that were an average of 1.2 miles further than the closest food stores offering more than 5 fresh fruits and vegetables daily to their household. Results highlight complexities of the food environment and the need to further investigate factors influencing food-related behaviors.

Understanding African American women's decisions to buy and eat dark green leafy vegetables: an application of the reasoned action approach.

OBJECTIVE: Examine intentions to buy and eat dark green leafy vegetables (DGLV). DESIGN: Cross-sectional survey assessing demographics, behavior, intention, and Reasoned Action Approach constructs (attitude, perceived norm, self-efficacy). SETTING: Marion County, Indiana. PARTICIPANTS: African American women responsible for buying and preparing household food. MAIN OUTCOME MEASURE(S): Reasoned Action Approach constructs explaining intentions to buy and eat DGLV. ANALYSIS: Summary statistics, Pearson correlations, and multiple regression analyses. RESULTS: Among participants (n = 410, mean age = 43 y), 76% and 80%, respectively, reported buying and eating DGLV in the past week. Mean consumption was 1.5 cups in the past 3 days. Intentions to buy (r = 0.20, P < .001) and eat (r = 0.23, P < .001) DGLV were positively associated with consumption. Reasoned Action Approach constructs explained 71.2% of the variance in intention to buy, and 60.9% of the variance in intention to eat DGLV. Attitude (ß = .63) and self-efficacy (ß = .24) related to buying and attitude (ß = .60) and self-efficacy (ß = .23) related to eating DGLV explained significant amounts of variance in intentions to buy and eat more DGLV. Perceived norm was unrelated to either intention to buy or eat DGLV. CONCLUSIONS AND IMPLICATIONS: Interventions designed for this population of women should aim to improve DGLV-related attitudes and self-efficacy.

Viral hepatitis in a homeless shelter in Hawai'i.

It is estimated that as many as 21,000 people in the state of Hawai'i may be infected with HCV Most of those infected with viral hepatitis are unaware they are infected. Complications from viral hepatitis include liver cirrhosis and hepatocellular carcinoma. Hawai'i has the highest incidence of hepatocellular carcinoma in the United States. In 2003 there were over 6000 homeless and over 155,000 people at-risk of becoming homeless living in the state of Hawai'i. Risk factors for hepatitis, such as drug use, tattoos, sexual contact, and sharing of personal hygiene equipment are more prevalent in the homeless population. To determine the incidence of hepatitis B and C among a population of homeless individuals, a health fair was held at a Honolulu area homeless shelter with approximately 200 residents. The incidence of hepatitis B and C was determined by anti-HCV and HBsAg blood tests. A survey was also conducted regarding risk factors and basic demographics. Fifty-nine homeless adults volunteered for testing and took the survey. Thirty-one (52%) volunteers were born in Micronesia, twenty-four (41%) were born in the United States, two (3%) were born in Samoa, one (2%) was born in the Philippines, and one (2%) was born in the Marshall Islands. Forty adults were tested for Hepatitis C antibody, three of which tested positive. The primary risk factor among this group was jail time (100%), followed by illegal drug injection (67%), tattoos (67%), ear/body piercing (67%), snorting drugs (33%), blood transfusions (33%), and a sex partner with hepatitis (33%). Forty adults were also tested for HBsAg, One of which tested positive. This was a recent immigrant from Micronesia. Homeless people in Hawai'i are more likely to have hepatitis B or C because risk factors are common among this population. Additionally a large proportion of Hawai'i's homeless people come from the Pacific Islands, where the prevalence of hepatitis B is one of the highest in the world. In addition there are significant risks of hepatitis spread among the homeless and into the general population as many homeless do not realize they are infected. The health fair approach was an effective means for screening homeless people for hepatitis B and C. Our preliminary information suggests homeless shelters may be a good place for education, screening, and possibly interventions as well.

A fresh look at esophageal cancer incidence among Asian/Pacific Islanders and Caucasians.

This is a retrospective study comparing esophageal cancer incidence among Asian/Pacific Islanders and Caucasians between Hawai'i and nationally, identifying patterns specific to Hawai'i. SEER*SAT was used for statistical analysis. In Hawai'i, esophageal cancer incidence between the two study groups were similar, but nationally higher in Caucasians. These findings are unique to Hawai'i. More detailed and consistent registries are needed.

Culturally sensitive strategies designed to target the silent epidemic of hepatitis B in a Filipino community.

Hepatitis B is frequent in the Philippines. A high rate of immigration to the United States has brought many Filipinos with infections who are asymptomatic yet will go on to develop liver cancer and cirrhosis unless diagnose and evaluated. Interventions are necessary to educate this ethnic community, identify those infected, and offer therapy. In an effort to reach this high risk population in Hawai'i an intervention program was designed to address the silent epidemic of hepatitis. Ethnic barriers were crossed through involvement of trusted, key stakeholders and individuals within the Filipino health care and church communities, along with groups that had joint missions to address viral hepatitis. After extensive planning and meetings with faith-based organizations and health care providers in the Filipino community, it was decided to hold a community health fair in the Filipino community to provide culturally appropriate health information and services. More than 500 individuals attended the health fair; 167 participated in a survey and were tested for hepatitis B. Significant knowledge gaps were found in relation to risk factors, prevention strategies, and transmission. Five individuals tested positive; all were immigrants and did not know of their disease. The objective to educate people and test them for hepatitis was successful through utilizing ethnic community leaders, religious organizations, health care professionals, and a collaborative health fair.

Elevated prevalence of hepatitis C infection in users of United States veterans medical centers.

Several studies suggest veterans have a higher prevalence of hepatitis C virus infection than nonveterans, possibly because of military exposures. The purpose of this study was to estimate the prevalence of anti-hepatitis C antibody and evaluate factors associated with infection among users of Department of Veterans Affairs medical centers. Using a two-staged cluster sample, 1288 of 3863 randomly selected veterans completed a survey and underwent home-based phlebotomy for serological testing. Administrative and clinical data were used to correct the prevalence estimate for nonparticipation. The prevalence of antihepatitis C antibody among serology participants was 4.0% (95% CI, 2.6%-5.5%). The estimated prevalence in the population of Veterans Affairs medical center users was 5.4% (95% CI, 3.3%-7.5%) after correction for sociodemographic and clinical differences between participants and nonparticipants. Significant predictors of seropositivity included demographic factors, period of military service (e.g., Vietnam era), prior diagnoses, health care use, and lifestyle factors. At least one traditional risk factor (transfusion or intravenous drug use) was reported by 30.2% of all subjects. Among those testing positive for hepatitis C antibody, 78% either had a transfusion or had used injection drugs. Adjusting for injection drug use and nonparticipation, seropositivity was associated with tattoos and incarceration. Military-related exposures were not found to be associated with infection in the adjusted analysis. In conclusion, the prevalence of hepatitis C in these subjects exceeds the estimate from the general US population by more than 2-fold, likely reflecting more exposure to traditional risk factors among these veterans.