Medical financial hardship in the Southern United States: the struggle continues across generations pre- and post- the Affordable Care Act.

INTRODUCTION: Medical financial hardship in the United States is a growing public health concern. This study aims to assess the south vs. non-south disparities in medical financial hardship among US adults of different generations - Boomers (born between 1946 and 1964), Generation X (born between 1965 and 1980), and the Millennials (born between 1981 and 1996) across periods pre- and post- Affordable Care Act (ACA). METHODS: This observational study utilizes data from multiple waves of the National Health Interview Survey (NHIS) split into three periods: pre-ACA (2011-2013), ii) post ACA (2015-2018), and iii) COVID-19 pandemic (2021-2022). Multivariable logistic regressions were fitted, separately for each generation in each period, to compare the extent of medical financial hardship among those from South to rest of the US, and Karlson-Holm-Breen (KHB) decomposition was applied to analyze whether there was a mediating impact of health insurance coverage. RESULTS: Adults living in the South were more likely to experience medical financial hardship in all three periods. Residing in the South was associated with 1.7 to 2.6% points (pp) higher probability of medical financial hardship among boomers, 1.8 to 4.0 pp among generation Xers, and 1.7 to 2.8 pp among millennials. The relationship was robust after accounting for chronic comorbidities, sociodemographic and socioeconomic attributes and was partially mediated through differences in health insurance coverage. CONCLUSIONS: The problem of medical financial hardship has been deeply rooted in the South across generations, which was partly attributable to the regional differences in health insurance coverage.

Associations Between a Social Determinant of Health Summary Measure and Self-Reported Physical and Mental Health Among Cancer Survivors.

OBJECTIVE: We sought to examine the associations between a social needs measure and physical, and mental health among cancer survivors in the United States. METHODS: We conducted a cross-sectional analysis using the 2022 Behavioral Risk Factor Surveillance System survey involving 16,930 eligible cancer survivors. The primary outcomes of interest were self-reported physical and mental health in the past 30 days. A social needs measure was our primary exposure of interest. Multivariate logistic regression was used to examine the associations of interest. RESULTS: Overall, 56% and 73% survivors with several days of poor physical and mental health, respectively, reported having two or more social needs. In multivariate analysis, those having at least one social need were more likely to report several days of poor physical (one need: OR, 1.62; 95% CI, 1.31-2.00, two or more needs: OR, 3.52; 95% CI, 2.84-4.35) and mental health (one need: OR, 3.07; 95% CI, 2.07-4.57, two or more needs: OR, 9.69; 95% CI, 6.83-13.74). Among survivors with two or more social needs, having exercised in the past 30 days were 41% and 59% less likely to experience poor physical and mental health, respectively (p-value < 0.05). However, having at least one chronic disease was associated with several days of poor physical/mental health among those with two or more needs (p-value < 0.05). CONCLUSION: Having social needs was associated with self-reporting of several days of poor physical and mental health among cancer survivors. Integrated care should include mental/physical health management addressing cancer survivors' various social needs.

Intersection of Poverty and Rurality for Early-Onset Colorectal Cancer Survival.

This cross-sectional study examines poverty, rurality, and the intersection of persistent poverty and rurality on early-onset colorectal cancer survival among adults aged 18 to 49 years.

How effective are church-based weight-loss interventions among Black adults? A systematic review.

OBJECTIVE: Churches are frequently used to reach Black adults to effect weight loss. However, there has been no recent review, to our knowledge, inclusive of solely Black adults in church settings. We sought to comprehensively examine the methodological approaches and weight-loss outcomes of church-based weight-loss lifestyle interventions conducted among Black adults to provide insights on literature gaps and offer suggestions for future research. METHODS: Google Scholar, PubMed, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched for trials conducted in churches that reported weight outcomes at any time point. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guided manuscript development. RESULTS: A total of 15 studies (N = 2285) from 2007 to 2023 met inclusion criteria, and 33% were high-quality randomized trials. The majority were pilot studies (60%) conducted in the Southern United States. Most reported significant postintervention weight loss. The follow-up time points varied from 2 to 12 months. Methodological approaches included the following: cultural adaptations (93%); theory-guided (93%); delivered by community health workers (80%); and delivered in person in a group format (100%). Only one study offered individual-level attention beyond texts/emails. Most participants were well-educated female individuals. CONCLUSIONS: Weight-loss interventions among Black church settings effect statistically significant weight loss, albeit in a small way. Limitations include pilot studies and small samples. More rigorously designed studies are warranted.

Association Between Obesity and Risk of Total and Obesity-Related Cancer in People With Incident Cardiovascular Disease.

BACKGROUND: Cardiovascular disease (CVD) and cancer frequently co-occur due to shared risk factors such as obesity, which is linked to CVD and 14 cancer types. This study explores whether CVD pathophysiologies, combined with obesity, increase cancer risk, impacting clinical management. METHODS AND RESULTS: Data from the ARIC (Atherosclerosis Risk in Communities) study, spanning 28 years, were analyzed. The cohort included 5127 participants with incident CVD (myocardial infarction, stroke, heart failure, coronary heart disease), of whom 1511 developed a first primary cancer. Follow-up began at CVD diagnosis after Visit 1. Obesity was assessed using body mass index, waist circumference, and waist-to-hip ratio. Incidence rate differences between obesity groups were adjusted for age, sex, and center, whereas the obesity-cancer association was estimated using Fine-Gray regression adjusted for shared risk factors including smoking. Cancer incidence in obese individuals with CVD (body mass index: rate differences=226.6/100 000 person-years) was higher than in those with normal weight. Although obesity was not linked to overall cancer after adjusting for shared risk factors, it was nominally associated with obesity-related cancers. Specifically, women with CVD and obesity had increased obesity-related cancer risk (body mass index: hazard ratio, 1.67 [95% CI, 1.17-2.31]). No significant associations were found in men, even after excluding prostate cancer. CONCLUSIONS: This study suggests that obesity is linked to higher obesity-related cancer risk in women with incident CVD, independent of shared risk factors. Further research is needed to eliminate residual confounding, understand sex differences, and explore how CVD pathophysiologies and obesity together influence cancer risk.

Cancer History and Social Support Impact Colorectal Cancer Screening Utilization by Race/Ethnicity.

This study examined the association between cancer history, social support, and up to date colorectal cancer (CRC) screening among four racial/ethnic groups. We conducted a cross-sectional analysis using data on respondents aged 45-75 years from the 2022 Behavioral Risk Factor Surveillance System. Our outcome of interest was CRC screening and exposures of interest were race/ethnicity, cancer history, and social support. Weighted multivariable logistic regression was performed. Among 73,869 adults, the CRC screening rate was 66.8% with the highest rate in non-Hispanic (NH) Whites (72.2%) and the lowest in Hispanics (52.6%). Screening rates were higher in adults with a cancer history (81.9%) and those having social support (69%). Hispanic adults with a cancer history had lower screening use (50.9% vs. 77.4% in no cancer history group; p-value <0.001). Regardless of race/ethnicity, adults without social support had lower screening utilization (p-value<0.05). In effect modification, NH White adults who reported no cancer history and lack of social support were 12% less likely to have CRC screening than those with social support but without cancer history (OR,0.88;95% CI, 0.79-0.98). Similar results were observed among Hispanic adults without a cancer history and social support, with 37% less likely to have CRC screening than those with social support but no cancer history (OR,0.63;95% CI, 0.42-0.93). NH White and Hispanic adults without a cancer history and limited social support were less likely to have CRC screening uptake. By implementing culturally tailored interventions that address social support needs, greater CRC screening compliance may be increased among these populations.

The role of a social determinants of health summary measure on the association between cancer history status and colorectal cancer screening utilization among screening eligible adults.

Objective: We sought to examine the influence of social needs on the relationship between cancer history and colorectal cancer (CRC) screening utilization among adults in the United States. Methods: We conducted a cross-sectional analysis using data from the 2022 Behavioral Risk Factor Surveillance System. Our outcome of interest was utilization of guideline-concordant CRC screening and exposures of interest were cancer history/levels of social needs. Multivariable logistic regression was performed to examine the association. Results: Among 74,743 eligible adults, a majority did not have a personal history of cancer (87.9 %), had at least one social need (58.4 %), and had undergone CRC screening (72.2 %). In multivariable analysis, a history of cancer was positively associated with use of CRC screening (OR = 1.59, 95 %CI, 1.35 - 1.87). Having at least one social need was associated with lower likelihood of being screened (one social need: OR = 0.85 95 %CI, 0.76 - 0.95; two + social needs: OR = 0.77, 95 % CI, 0.69 - 0.87). When exploring the effects of social needs, adults without a history of cancer who reported at least one need were 12-20 % less likely to be screened for CRC. Conclusions: A personal history of cancer was associated with greater utilization of CRC screening, whilst having at least one social need had lower screening use. Having social needs plays an important role in reducing screening uptake among adults without a history of cancer. Integrated care that considers both cancer history and social needs may have implications for improved adherence of CRC screening recommendations.

Allostatic Load/Chronic Stress and Cardiovascular Outcomes in Patients Diagnosed With Breast, Lung, or Colorectal Cancer.

BACKGROUND: Cardiovascular disease and cancer share a common risk factor: chronic stress/allostatic load (AL). A 1-point increase in AL is linked to up to a 30% higher risk of major cardiac events (MACE) in patients with prostate cancer. However, AL's role in MACE in breast cancer, lung cancer, or colorectal cancer remains unknown. METHODS AND RESULTS: Patients ≥18 years of age diagnosed with the mentioned 3 cancers of interest (2010-2019) and followed up at a large, hybrid academic-community practice were included in this retrospective cohort study. AL was modeled as an ordinal measure (0-11). Adjusted Fine-Gray competing risks regressions estimated the impact of AL precancer diagnosis on 2-year MACE (a composite of heart failure, ischemic stroke, acute coronary syndrome, and atrial fibrillation). The effect of AL changes over time on MACE was calculated via piecewise Cox regression (before, and 2 months, 6 months, and 1 year after cancer diagnosis). Among 16 467 patients, 50.5% had breast cancer, 27.9% had lung cancer, and 21.4% had colorectal cancer. A 1-point elevation in AL before breast cancer diagnosis corresponded to a 10% heightened associated risk of MACE (adjusted hazard ratio, 1.10 [95% CI, 1.06-1.13]). Similar findings were noted in lung cancer (adjusted hazard ratio, 1.16 [95% CI, 1.12-1.20]) and colorectal cancer (adjusted hazard ratio, 1.13 [95% CI, 1.08-1.19]). When considering AL as a time-varying exposure, the peak associated MACE risk occurred with a 1-point AL rise between 6 and 12 months post- breast cancer, lung cancer, and colorectal cancer diagnosis. CONCLUSIONS: AL warrants investigation as a potential marker in these patients to identify those at elevated cardiovascular risk and intervene accordingly.

Cancer health awareness through screening and education: A community approach to healthy equity.

BACKGROUND: The Cancer Health Awareness through screeNinG and Education (CHANGE) initiative delivers cancer awareness education with an emphasis on modifiable risk factors and navigation to screening for prostate, breast, and colorectal cancers to residents of public housing communities who experience significant negative social determinants of health. METHODS: Residents of five communities participated. Community advisory board members were recruited and provided feedback to local environmental change projects, recruitment, and community engagement at each site. At each site, four education sessions were provided by trained facilitators on cancer risk factors and etiology, racial disparities, eligibility for cancer screening, and participation in clinical trials. Attendance, knowledge, attitudes and beliefs about cancer, and height, weight, and waist circumference were measured at baseline and 1-week post-CHANGE sessions. RESULTS: 90 residents (60% 65 and older years old, 33% male, 60% High School education, 93% AA) participated in the program. 95% completed post-intervention evaluation. Participants were eligible for breast (n = 12), prostate (n = 15), and colorectal screening (n = 25) based on American Cancer Society guidelines, and 22 for tobacco cessation; 21 participants accepted navigation assistance for these services. At post-test, participants significantly increased in knowledge and behaviors around obesity/overweight risk for cancer, nutrition, and physical activity. Colorectal, prostate, and breast cancer knowledge scores also increased, but were not significant. CONCLUSIONS: CHANGE participants demonstrated improved health knowledge and intentions to improve their modifiable health behaviors. Participants reported being motivated and confident in seeking preventive care and satisfaction with community engagement efforts. Replication of this project in similar communities may improve knowledge and health equity among underserved populations.

Investigating the role of county-level colorectal cancer screening rates on stage at diagnosis of colorectal cancer in rural Georgia.

BACKGROUND: To examine the impact of county-level colorectal cancer (CRC) screening rates on stage at diagnosis of CRC and identify factors associated with stage at diagnosis across different levels of screening rates in rural Georgia. METHODS: We performed a retrospective analysis utilizing data from 2004 to 2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes were used to identify rural Georgia counties. The 2004-2010 National Cancer Institute small area estimates for screening behaviors were applied to link county-level CRC screening rates. Descriptive statistics and multinominal logistic regressions were performed. RESULTS: Among 4,839 CRC patients, most patients diagnosed with localized CRC lived in low screening areas; however, many diagnosed with regionalized and distant CRC lived in high screening areas (p-value = 0.009). In multivariable analysis, rural patients living in high screening areas were 1.2-fold more likely to be diagnosed at a regionalized and distant stage of CRC (both p-value < 0.05). When examining the factors associated with stage at presentation, Black patients who lived in low screening areas were 36% more likely to be diagnosed with distant diseases compared to White patients (95% CI, 1.08-1.71). Among those living in high screening areas, patients with right-sided CRC were 38% more likely to have regionalized disease (95% CI, 1.09-1.74). CONCLUSION: Patients living in high screening areas were more likely to have a later stage of CRC in rural Georgia. IMPACT: Allocating CRC screening/treatment resources and improving CRC risk awareness should be prioritized for rural patients in Georgia.

Racial disparities in the relationship of regional socioeconomic status and colorectal cancer survival in the five regions of Georgia.

INTRODUCTION: The study's purpose was to examine 5-year colorectal cancer (CRC) survival rates between White and Black patients. We also determined whether regional socioeconomic status (SES) is associated with CRC survival between White and Black patients in the Clayton, West Central, East Central, Southeast, and Northeast Georgia public health districts. METHODS: We performed a retrospective cohort analysis using data from the 1975 to 2016 Surveillance, Epidemiology, and End Results program. The 2015 United States Department of Agriculture Economic Research Services county typology codes were used to identify region-level SES with persistent poverty, low employment, and low education. Kaplan-Meier method and Cox proportional hazard regression were performed. RESULTS: Among 10,876 CRC patients (31.1% Black patients), 5-year CRC survival rates were lower among Black patients compared to White patients (65.4% vs. 69.9%; p < 0.001). In multivariable analysis, White patients living in regions with persistent poverty had a 1.1-fold increased risk of CRC death (HR, 1.12; 95% CI, 1.00-1.25) compared to those living in non-persistent poverty regions. Among Black patients, those living in regions with low education were at a 1.2-fold increased risk of CRC death (HR, 1.19; 95% CI, 1.01-1.40) compared to those living in non-low education regions. DISCUSSION AND CONCLUSIONS: Black patients demonstrated lower CRC survival rates in Georgia compared to their White counterparts. White patients living in regions with persistent poverty, and Black patients living in regions with low education had an increased risk of CRC death. Our findings provide important evidence to all relevant stakeholders in allocating health resources aimed at CRC early detection and prevention and timely referral for CRC treatment by considering the patient's regional SES in Georgia.

County-level colorectal cancer screening rates on colorectal cancer survival in the state of Georgia: Does county-level rurality matter?

PURPOSE: Investigating CRC screening rates and rurality at the county-level may explain disparities in CRC survival in Georgia. Although a few studies examined the relationship of CRC screening rates, rurality, and/or CRC outcomes, they either used an ecological study design or focused on the larger population. METHODS: We conducted a retrospective analysis utilizing data from the 2004-2010 Surveillance, Epidemiology, and End Results Program. The 2013 United States Department of Agriculture rural-urban continuum codes and 2004-2010 National Cancer Institute small-area estimates for screening behaviors were used to identify county-level rurality and CRC screening rates. Kaplan-Meier method and Cox proportional hazard regression were performed. RESULTS: Among 22,160 CRC patients, 5-year CRC survival rates were lower among CRC patients living in low screening areas in comparison with intermediate/high areas (69.1% vs. 71.6% /71.3%; p-value = 0.030). Patients living in rural high-screening areas also had lower survival rates compared to non-rural areas (68.2% vs. 71.8%; p-value = 0.009). Our multivariable analysis demonstrated that patients living in intermediate (HR, 0.91; 95% CI, 0.85-0.98) and high-screening (HR, 0.92; 95% CI, 0.85-0.99) areas were at 8%-9% reduced risk of CRC death. Further, non-rural CRC patients living in intermediate and high CRC screening areas were 9% (HR, 0.91; 95% CI, 0.83-0.99) and 10% (HR, 0.90; 95% CI, 0.82-0.99) less likely to die from CRC. CONCLUSIONS: Lower 5-year survival rates were observed in low screening and rural high-screening areas. Living in intermediate/high CRC screening areas was negatively associated with the risk of CRC death. Particularly, non-rural patients living in intermediate/high-screening areas were 8%-9% less likely to die from CRC. Targeted CRC screening resources should be prioritized for low screening and rural communities.

Role of life satisfaction, emotional support, and feeling of social isolation on adherence to breast cancer screening recommendations among US women.

BACKGROUND: Psychosocial factors can play important roles in promoting preventive health behaviors. This study aimed to assess how life satisfaction, receipt of emotional support, and feeling of social isolation were associated with adherence to the USPSTF recommendation of breast cancer screening in a nationally representative US population. METHODS: Using data on 71,583 women aged 50 to 74 years, from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) survey, we estimated multivariable logistic regressions to assess the odds of adherence across different categories of the respective psychosocial constructs. We accounted for various demographic and socioeconomic correlates and checked the robustness of the relationship within income and educational sub-groups. RESULTS: We found that women who were dissatisfied with their life were 52.0% less likely to adhere compared to women who reported to be very satisfied. Similarly, women who rarely/never got emotional support and who always/usually felt socially isolated were 51.6% and 39.9% less likely to adhere, compared to women who always got support and never felt isolated, respectively. These results were robust across different levels of income and educational attainment. CONCLUSION: Our findings demonstrated a strong association between social environment, psychological wellbeing, and adherence to breast cancer screening, and thus suggested scope of potential psychosocial interventions to improve adherence. POLICY SUMMARY: Efforts to improve women's psychosocial wellbeing could facilitate compliance with breast cancer screening recommendations.

COVID-19 and health care-related financial toxicity in the United States: Evidence from the 2022 National Health Interview Survey.

BACKGROUND: Despite the common perception of the socioeconomic burden of the COVID-19 pandemic, quantification of the relationship between COVID-19 and indicators of health care-related financial toxicity in the general population has been limited. This study aimed to provide estimates of these relationships in a nationally representative sample of the US adult population. METHODS: Using the data on 27,480 adults from the 2022 National Health Interview Survey, we fitted multivariable logistic regression models to assess the differential risks of financial toxicity as manifested by the financial hardship in paying medical bills, delayed and forgone medical care, and medication nonadherence, by COVID-19 diagnosis, severity, and duration of symptoms. RESULTS: We found that compared to individuals not having COVID-19, individuals with severe symptoms of COVID-19 were 1.86, 1.50, 1.76, and 1.77 times more likely to experience financial hardship, delay medical care, forgo medical care, and skip/delay/take less medication, respectively. Similarly, individuals with symptoms lasting for 3 or more months were 1.94, 1.65, 1.87, and 2.20 times more likely to experience these measures of financial toxicity, respectively. CONCLUSIONS: The estimates of the relationship between COVID-19 and financial toxicity will facilitate effective communications for policy actions aimed at alleviating the burden of the COVID-19 pandemic.

Perceived Social Support and Cardiovascular Risk Among Nonelderly Adults in the United States.

Hypertension, diabetes mellitus, dyslipidemia, and obesity are major risk factors of cardiovascular diseases. A recent study projected a marked surge in these cardiometabolic conditions in the United States by the year 2060, posing a challenge for cardiovascular disease management in the coming years. This study aimed to explore and quantify the relation of a key psychosocial factor, social support, with the cardiovascular risk factors among nonelderly US adults (aged 18 to 64 years). Using data on 19,827 adults from the 2021 National Health Interview Survey, we assessed whether lower level of social support was associated with higher likelihood of having cardiovascular risks. We found that for subjects who "rarely/never" received social support, the adjusted odds of having hypertension, high cholesterol, and diabetes were 1.42 (95% confidence interval [CI] 1.20 to 1.67), 1.39 (95% CI 1.18 to 1.65), and 1.53 (95% CI 1.22 to 1.91) times those of subjects "always" receiving support, respectively. Further, compared with the base outcome of no CV risk, the adjusted relative risks of having 3+ cardiovascular risks for subjects "rarely/never" receiving support were 1.91 (95% CI 1.49 to 2.46) times that of those "always" receiving support. These results were robust across socioeconomic status condition sub-groups manifested by educational attainment and income. In conclusion, our findings suggest that social support may be considered as a critical part of the comprehensive efforts to mitigate the future burden of cardiovascular diseases in the United States.

Design and development of a Telemedicine Assessment Toolkit (TAT) for the assessment of audiovisual telemedicine encounters.

Although the use of audiovisual telemedicine has grown in recent years especially during recent COVID-19-related lockdowns, evidence shows there is still a lack of tools that can be used for the assessment of telemedicine encounters. The few validated questionnaires that are available for assessing telemedicine encounters are not often used. Non-validated questionnaires dominate research, leading to results that cannot be compared or extrapolated to other research or medical sites. Development of standard measures for the assessment of telemedicine encounters has been advocated by stakeholders. The objective of this study is to provide a comprehensive set of measures by developing a conceptual approach and a preliminary Telemedicine Assessment Toolkit (TAT) for the assessment of audiovisual telemedicine encounters. A two-step conceptual approach was used to identify potential domains and sub-domains by qualitative analysis of a pool of questions from studies published from 2016 to 2021. Questions were adopted from validated questionnaires or generated to represent the underlying concept of each sub-domain, resulting in a core block of comprehensive questions. A toolkit is proposed with question-measures that cover the sub-domains relevant to the assessment of telemedicine encounters. This study recommended 11 domains to be used for the assessment of telemedicine encounters: "usability," "patient satisfaction," "patient-provider interaction," "patient perspectives," "telemedicine readiness," "qualitative feedback," "comparison to standard (in-person) care," "privacy," "technology," "patient feeling," and "patient costs." Of the 11 domains, 26 underlying sub-domains were created. From the subdomains, a 30-question core block was proposed. The core-block together with a precursor block aimed to retrieve demographic/patient characteristics and, together with a customizable clinical outcomes block, complete the comprehensive toolkit. The toolkit, upon testing and validation, would enable researchers and system owners to assess patient-oriented aspects of audiovisual telemedicine encounters more accurately and accelerate the adoption of common audiovisual telemedicine assessment measures.

Preventive behaviors and behavioral risk factors among gynecologic cancer survivors: Results from the 2020 Behavioral Risk Factor Surveillance System Survey.

BACKGROUND: Maintaining a healthy lifestyle is an important factor in promoting positive outcomes for gynecologic cancer survivors. METHODS: We examined preventive behaviors among gynecologic cancer survivors (n = 1824) and persons without a history of cancer in a cross-sectional analysis, using data from the 2020 Behavioral Risk Factor Surveillance System survey (BRFSS). BRFSS is a cross-sectional telephone-based survey of U.S. residents 18 years of age and older, which collects information about health-related factors and use of preventive services. RESULTS: The prevalence rates of colorectal cancer screening were respectively 7.9 (95% CI: 4.0-11.9) and 15.0 (95% CI: 4.0-11.9) %-points higher among gynecologic and other cancer survivors compared to that of 65.2% among those without any history of cancer. However, no differences were observed in breast cancer screening between gynecologic cancer survivors (78.5%) and respondents without any history of cancer (78.7%). Coverage of influenza vaccination among gynecologic cancer survivors were 4.0 (95% CI: 0.3-7.6) %-points higher than that of the no cancer group, but 11.6 (95% CI: 7.6-15.6) %-points lower than that of the other cancer group. Pneumonia vaccination rate among gynecologic cancer survivors, however, was not statistically different than that of other cancer survivors and respondents with no history of cancer. When examining modifiable risk behaviors, the prevalence of smoking among gynecologic cancer survivors was 12.8 (95% CI: 9.5-16.0) and 14.2 (95% CI: 10.8-17.7) %-points higher than smoking prevalence among other cancer survivors and respondents without any history of cancer. The rate differentials were even higher in rural areas, 17.4 (95% CI: 7.2-27.6) and 18.4 (95% CI: 7.4-29.4) %-points respectively. There were no differences in the prevalence of heavy drinking across the groups. Lastly, gynecologic and other cancer survivors were less likely to be physically active (Δ = -12.3, 95% CI: -15.8 to -8.8 and Δ = -6.9, 95% CI: -8.5 to -5.3, respectively) than those without any history of cancer. CONCLUSION: Smoking prevalence among gynecologic cancer survivors is alarmingly high. Intervention studies are needed to identify effective ways to assist gynecologic cancer survivors to quit smoking and refrain from hazardous alcohol consumption. In addition, women with gynecologic malignancies should made aware of the importance of physical activity.

Inequities in routine preventive care utilization among persons with overweight/obesity in the United States: An analysis of nativity, racial and ethnic identity, and socioeconomic status.

Extant literature documented various health disparities among immigrants and racial and ethnically marginalized individuals in the United States. However, health disparities in the intersection of nativity and race are generally less visited. This cross-sectional study assessed utilization of routine preventive care among adults with overweight/obesity at the junction of their nativity, racial/ethnic identity, and socioeconomic status (i.e., income and education). Pooling data on 120,184 adults with overweight/obesity from the 2013-2018 waves of the National Health Interview Survey (NHIS), we estimated modified Poisson regressions with robust standard errors to obtain adjusted prevalence rates of preventive care visit, receiving flu shot, and having blood pressure, cholesterol and blood glucose screened. We found that immigrant adults with overweight/obesity had lower rates of utilization of all five preventive care services. However, these patterns varied by racial and ethnic sub-populations. While White immigrants had comparable rates of cholesterol and blood glucose screening, they had 2.7%, 2.9%, and 14.5% lower rates of preventive care visit, blood pressure screening, and getting a flu shot respectively, compared to native-born Whites. These patterns were similar for Asian immigrants as well. Black immigrants, on the other hand, had comparable rates of getting a flu shot and blood glucose screening, and had 5.2%, 4.9%, and 4.9% lower rates of preventive care visit, blood pressure screening, and cholesterol screening respectively. Lastly, the rates of utilization among Hispanic immigrants were significantly lower (ranging from 9.2% to 20%) than those of their native-born counterparts for all five preventive care services. These rates further varied by education, income, and length of stay in the US, within the racial and ethnic subgroups. Our findings thus suggest a complex relationship between nativity and racial/ethnic identity in relation to preventive care utilization among adults with overweight/obesity.

Current ethical and social issues in epidemiology.

PURPOSE: The American College of Epidemiology held its 2021 Annual Meeting virtually, September 8-10, with a conference theme of 'From Womb to Tomb: Insights from Health Emergencies'. The American College of Epidemiology Ethics Committee hosted a symposium session in recognition of the ethical and social challenges brought to light by the coronavirus disease 2019 pandemic and on the occasion of the publication of the third edition of the classic text, Ethics and Epidemiology. The American College of Epidemiology Ethics Committee invited the book editor and contributing authors to present at the symposium session titled 'Current Ethical and Social Issues in Epidemiology.' The purpose of this paper is to further highlight the ethical challenges and presentations. METHODS: Three speakers with expertise in ethics, health law, health policy, global health, health information technology, and translational research in epidemiology and public health were selected to present on the social and ethical issues in the current landscape. Dr. S Coughlin presented on the 'Ethical and Social Issues in Epidemiology', Dr. L Beskow presented on 'Ethical Challenges in Genetic Epidemiology', and Dr. K Goodman presented on the 'Ethics of Health Informatics'. RESULTS: New digital sources of data and technologies are driving the ethical challenges and opportunities in epidemiology and public health as it relates to the three emerging topic areas identified: (1) digital epidemiology, (2) genetic epidemiology, and (3) health informatics. New complexities such as the reliance on social media to control infectious disease outbreaks and the introduction of computing advancements are requiring re-evaluation of traditional bioethical frameworks for epidemiology research and public health practice. We identified several cross-cutting ethical and social issues related to informed consent, benefits, risks and harms, and privacy and confidentiality and summarized these alongside more nuanced ethical considerations such as algorithmic bias, group harms related to data (mis)representation, risks of misinformation, return of genomic research results, maintaining data security, and data sharing. We offered an integrated synthesis of the stages of epidemiology research planning and conduct with the ethical issues that are most relevant in these emerging topic areas. CONCLUSIONS: New realities exist for epidemiology and public health as professional groups who are faced with addressing population health, and especially given the recent pandemic and the widespread use of digital tools and technologies. Many ethical issues can be understood in the context of existing ethical frameworks; however, they have yet to be clearly identified or connected with the new technical and methodological applications of digital tools and technologies currently in use for epidemiology research and public health practice. To address current ethical challenges, we offered a synthesis of traditional ethical principles in public health science alongside more nuanced ethical considerations for emerging technologies and aligned these with lifecycle stages of epidemiology research. By critically reflecting on the impact of new digital sources of data and technologies on epidemiology research and public health practice, specifically in the control of infectious outbreaks, we offered insights on cultivating these new areas of professional growth while striving to improve population health.