Estimating uninsured and underinsured women eligible for Minnesota's Breast Cancer Screening Program.

Since its inception in 1991, the mission of the National Breast and Cervical Cancer Early Detection Program's (NBCCEDP) mission is to improve access to mammography. This program has demonstrated evidence showing that it has improved breast cancer screening rates for women who are uninsured and underinsured. However, the literature has shown that NBCCEDP screenings are decreasing, and only reach a portion of eligible women. Reliable estimates at the sub-county level are needed to identify and reach eligible women. Our work builds upon previous estimates by integrating uninsured and insurance status into spatially adaptive filters. We use spatially adaptive filters to create small area estimates of standardized incidence ratios describing the utilization rate of NBCCEDP services in Minnesota. We integrate the American Community Survey (2010-2014) insurance status data to account for the percentage that an individual is uninsured. We test five models that integrate insurance status by age, sex, and race/ethnicity. Our composite model, which adjusts for age, sex, and race/ethnicity insurance statuses, reduces 95% of the estimation error. We estimate that there approximately 49,913.7 women eligible to receive services for Minnesota. We also create small geography (i.e., county and sub-county) estimates for Minnesota. The integration of the insurance data improved our utilization estimate. The development of these methods will allow state programs to more efficiently use their resources and understand their reach.

Estimating Uninsured and Underinsured Women Eligible for Minnesota's Breast Cancer Screening Program.

The mission of the National Breast and Cervical Cancer Early Detection Program's (NBCCEDP) mission is to improve access to mammography and other health services for underserved women. Since its inception in 1991, this national program has improved breast cancer screening rates for women who are uninsured and underinsured. However, the literature has shown that NBCCEDP screenings are decreasing, and only reach a portion of eligible women. Reliable estimates at the sub-county level are needed to identify and reach eligible women. Our work builds upon previous estimates by integrating uninsured and insurance status into spatially adaptive filters. We use spatially adaptive filters to create small area estimates of standardized incidence ratios describing the utilization rate of NBCCEDP services in Minnesota. We integrate the American Community Survey (2010-2014) insurance status data to account for the percentage that an individual is uninsured. We test five models that integrate insurance status by age, sex, and race/ethnicity. Our composite model, which adjusts for age, sex, and race/ethnicity insurance statuses, reduces 95% of the estimation error. We estimate that there approximately 49,913.7 women eligible to receive services for Minnesota. We also create small geography (i.e., county and sub-county) estimates for Minnesota. The integration of the insurance data improved our utilization estimate. The development of these methods will allow state programs to more efficiently use their resources and understand their reach.

PEARL: A Guide for Developing Community-Engaging and Culturally-Sensitive Education Materials.

Community outreach and engagement has been a regular activity of the National Cancer Institute at its designated Cancer Centers. However, in 2016, community outreach and engagement became a required activity for all cancer centers. Yet there is a gap in the literature that provides guidelines for developing materials that resonate with communities. We developed the PEARL rubric to fulfill that gap from our work developing culturally sensitive breast cancer education materials for African American and Immigrant African women. We conducted a targeted literature review to understand the approaches that have been used for developing education materials for communities. We reviewed the literature and distilled key elements into our PEARL guide for creating culturally appropriate education materials. PEARL consists of five elements: Plain language and understandability, Explicit data, statistics, and graphs, Affirmative framing, Representative content, and Local connection. PEARL is a modern comprehensive guide that researchers can use for creating culturally sensitive materials. It is designed to guide researchers develop educational materials who have little to no experience in community engagement.

The effect of pre-aggregation scale on spatially adaptive filters.

Choropleth mapping continues to be a dominant mapping technique despite suffering from the Modifiable Areal Unit Problem (MAUP), which may distort disease risk patterns when different administrative units are used. Spatially adaptive filters (SAF) are one mapping technique that can address the MAUP, but the limitations and accuracy of spatially adaptive filters are not well tested. Our work examines these limitations by using varying levels of data aggregation using a case study of geocoded breast cancer screening data and a synthetic georeferenced population dataset that allows us to calculate SAFs at the individual-level. Data were grouped into four administrative boundaries (i.e., county, Zip Code Tabulated Areas, census tracts, and census blocks) and compared to individual-level data (control). Correlation assessed the similarity of SAFs, and map algebra calculated error maps compared to control. This work describes how pre-aggregation affects the level of spatial detail, map patterns, and over and under-prediction.

Novel mapping methods to describe utilization of free breast cancer screening from a state program.

INTRODUCTION: The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) is a cancer screening program whose mission is to reduce cancer morbidities for uninsured and underinsured women. A primary activity is to connect women to breast cancer screening. The eligible population and utilization of NBCCEDP screening services have never been quantified at a sub-state level, which hampers effective program evaluation. Here, the Minnesota NBCCEDP, "Sage", serves as a case study to demonstrate novel spatial analysis methods that depict variation of screening rates at the local level. METHODS: Women who received breast cancer screening through Sage between 2011 and 2015 were geocoded (N = 74,712 screenings); analysis occurred between 2017 and 2019. We determine an eligible population using a synthetic population dataset that provides geographic residence and demographic information. We introduce a novel spatial analysis technique, spatially adaptive filters (SAFs), to create a utilization map of Sage breast screening services by Minnesota women. RESULTS: Between 2011 and 2015, an average of 36,979 women per year were eligible for NBCCEDP breast cancer screening services, representing 3% of the Minnesota female population 40 and older. For Minnesota NBCCEDP eligible women, the state average breast cancer screening utilization rate was 37.2%, but varied considerably by local regions within the state (range 0% to 131%, SD = 18.7%). CONCLUSIONS: This geospatial model estimated screening service utilization at the local level and enables Minnesota's Sage program to target specific areas they have yet to reach. Similar programs could employ this model to direct program activities.

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial.

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

The Efficacy of Direct Mail, Patient Navigation, and Incentives for Increasing Mammography and Colonoscopy in the Medicaid Population: A Randomized Controlled Trial.

Background: Despite lower cancer screening rates and survival rates in the Medicaid population compared with those with private insurance, there is a dearth of population-based, evidence-based interventions targeting Medicaid clients to address this problem.Methods: This study reports results of a population-based randomized controlled trial (RCT) among all individuals enrolled in Minnesota's Medicaid program who were overdue for breast cancer (n = 22,113) and/or colorectal cancer (n = 94,294) screening. Individuals were randomized to intervention or control groups. The intervention group received persuasive and innovative direct mail materials coupled with a $20 incentive for using their Medicaid benefit to get screened. Direct mail materials provided a phone number to a call center staffed by patient navigators who addressed barriers and scheduled appointments via three-way calls. The control group received the intervention 15 months later. Primary outcomes were completion of mammography or colonoscopy within 12 weeks of the intervention. Billing claims served as evidence of screening.Results: Multivariate logistic regression showed significant differences for both breast cancer (P < 0.001) and colorectal cancer (P < 0.01). The odds of receiving a mammogram for the treatment group were significantly higher than the control group [OR = 1.30; 95% confidence interval (95% CI) = 1.16-1.46], and the treatment group was more likely to receive a colonoscopy than the control group (OR = 1.12; 95% CI = 1.04-1.21).Conclusions: This population-based intervention increased breast cancer and colorectal cancer screening in a Medicaid population overdue for screening.Impact: These findings may have broad application for reaching individuals who generally remain outside the health care system despite having public health insurance. Cancer Epidemiol Biomarkers Prev; 27(9); 1047-56. ©2018 AACR.

Precocious quantitative cognition in monkeys.

Basic quantitative abilities are thought to have an innate basis in humans partly because the ability to discriminate quantities emerges early in child development. If humans and nonhuman primates share this developmentally primitive foundation of quantitative reasoning, then this ability should be present early in development across species and should emerge earlier in monkeys than in humans because monkeys mature faster than humans. We report that monkeys spontaneously make accurate quantity choices by 1 year of age in a task that human children begin to perform only at 2.5 to 3 years of age. Additionally, we report that the quantitative sensitivity of infant monkeys is equal to that of the adult animals in their group and that rates of learning do not differ between infant and adult animals. This novel evidence of precocious quantitative reasoning in infant monkeys suggests that human quantitative reasoning shares its early developing foundation with other primates. The data further suggest that early developing components of primate quantitative reasoning are constrained by maturational factors related to genetic development as opposed to learning experience alone.

The origins of counting algorithms.

Humans' ability to count by verbally labeling discrete quantities is unique in animal cognition. The evolutionary origins of counting algorithms are not understood. We report that nonhuman primates exhibit a cognitive ability that is algorithmically and logically similar to human counting. Monkeys were given the task of choosing between two food caches. First, they saw one cache baited with some number of food items, one item at a time. Then, a second cache was baited with food items, one at a time. At the point when the second set was approximately equal to the first set, the monkeys spontaneously moved to choose the second set even before that cache was completely baited. Using a novel Bayesian analysis, we show that the monkeys used an approximate counting algorithm for comparing quantities in sequence that is incremental, iterative, and condition controlled. This proto-counting algorithm is structurally similar to formal counting in humans and thus may have been an important evolutionary precursor to human counting.

Extraneous color affects female macaques' gaze preference for photographs of male conspecifics.

Humans find members of the opposite sex more attractive when their image is spatially associated with the color red. This effect even occurs when the red color is not on the skin or clothing (i.e. is extraneous). We hypothesize that this extraneous color effect could be at least partially explained by a low-level and biologically innate generalization process, and so similar extraneous color effects should be observed in non-humans. To test this possibility, we examined the influence of extraneous color in rhesus macaques (Macaca mulatta). Across two experiments, we determined the influence of extraneous red on viewing preferences (assessed by looking time) in free-ranging rhesus monkeys. We presented male and female monkeys with black and white photographs of the hindquarters of same and opposite sex conspecifics on either a red (experimental condition) or blue (control condition) background. As a secondary control, we also presented neutral stimuli (photographs of seashells) on red and blue backgrounds. We found that female monkeys looked longer at a picture of a male scrotum, but not a seashell, on a red background (Experiment 1), while males showed no bias. Neither male nor female monkeys showed an effect of color on looking time for female hindquarters or seashells (Experiment 2). The finding for females viewing males suggests that extraneous color affects preferences among rhesus macaques. Further, it raises the possibility that evolutionary processes gave rise to extraneous color effects during human evolution.

Inherently Analog Quantity Representations in Olive Baboons (Papio anubis).

Strong evidence indicates that non-human primates possess a numerical representation system, but the inherent nature of that system is still debated. Two cognitive mechanisms have been proposed to account for non-human primate numerical performance: (1) a discrete object-file system limited to quantities <4, and (2) an analog system which represents quantities comparatively but is limited by the ratio between two quantities. To test the underlying nature of non-human primate quantification, we asked eight experiment-naive olive baboons (Papio anubis) to discriminate between number pairs containing small (<4), large (>4), or span (small vs. large) numbers of food items presented simultaneously or sequentially. The prediction from the object-file hypothesis is that baboons will only accurately choose the larger quantity in small pairs, but not large or span pairs. Conversely, the analog system predicts that baboons will be successful with all numbers, and that success will be dependent on numerical ratio. We found that baboons successfully discriminated all pair types at above chance levels. In addition, performance significantly correlated with the ratio between the numerical values. Although performance was better for simultaneous trials than sequential trials, evidence favoring analog numerical representation emerged from both conditions, and was present even in the first exposure to number pairs. Together, these data favor the interpretation that a single, coherent analog representation system underlies spontaneous quantitative abilities in primates.

Solving small spaces: investigating the use of landmark cues in brown capuchins (Cebus apella).

Some researchers have recently argued that humans may be unusual among primates in preferring to use landmark information when reasoning about some kinds of spatial problems. Some have explained this phenomenon by positing that our species' tendency to prefer landmarks stems from a human-unique trait: language. Here, we test this hypothesis-that preferring to use landmarks to solve such tasks is related to language ability-by exploring landmark use in a spatial task in one non-human primate, the brown capuchin monkey (Cebus apella). We presented our subjects with the rotational displacement task, in which subjects attempt to relocate a reward hidden within an array of hiding locations which are subsequently rotated to a new position. Over several experiments, we varied the availability and the salience of a landmark cue within the array. Specifically, we varied (1) visual access to the array during rotation, (2) the type of landmark, (3) the consistency of the landmark qualities, and (4) the amount of exposure to the landmark. Across Experiments 1 through 4, capuchins did not successfully use landmarks cues, suggesting that non-linguistic primates may not spontaneously use landmarks to solve some spatial problems, as in this case of a small-scale dynamic spatial task. Importantly, we also observed that capuchins demonstrated some capacity to learn to use landmarks in Experiment 4, suggesting that non-linguistic creatures may be able to use some landmarks cues in similar spatial tasks with extensive training.

Rotational displacement skills in rhesus macaques (Macaca mulatta).

Rotational displacement tasks, in which participants must track an object at a hiding location within an array while the array rotates, exhibit a puzzling developmental pattern in humans. Human children take an unusually long time to master this task and tend to solve rotational problems through the use of nongeometric features or landmarks as opposed to other kinds of spatial cues. We investigated whether these developmental characteristics are unique to humans by testing rotational displacement skills in a monkey species, the rhesus macaque (Macaca mulatta), using a looking-time method. Monkeys first saw food hidden in two differently colored boxes within an array. The array was then rotated 180° and the boxes reopened to reveal the food in an expected or unexpected location. Our first two experiments explored the developmental time-course of performance on this rotational displacement task. We found that adult macaques looked longer at the unexpected event, but such performance was not mirrored in younger-aged macaques. In a third study, we systematically varied featural information and visible access to the array to investigate which strategies adult macaques used in solving rotational displacements. Our results show that adult macaques need both sets of information to solve the task. Taken together, these results suggest both similarities and differences in mechanisms by which human and nonhuman primates develop this spatial skill.

Social tolerance in a despotic primate: co-feeding between consortship partners in rhesus macaques.

Food sharing among nonkin-one of the most fascinating cooperative behaviors in humans-is not widespread in nonhuman primates. Over the past few years, a large body of work has investigated the contexts in which primates cooperate and share food with unrelated individuals. This work has successfully demonstrated that species-specific differences in temperament constrain the extent to which food sharing emerges in experimental situations, with despotic species being less likely to share food than tolerant ones. However, little experimental work has examined the contexts that promote food sharing and cooperation within a species. Here, we examine whether one salient reproductive context-the consortship dyad-can allow the necessary social tolerance for co-feeding to emerge in an extremely despotic species, the rhesus macaque (Macaca mulatta). We gave naturally formed male-female rhesus macaque pairs access to a monopolizable food site in the free-ranging population at Cayo Santiago, Puerto Rico. Using this method, we were able to show that tolerated co-feeding between unrelated adults can take place in this despotic species. Specifically, our results show that consort pairs co-fed at the experimental food site more than nonconsort control pairs, leading females to obtain more food in this context. These results suggest that co-feeding is possible even in the most despotic of primate species, but perhaps only in contexts that specifically promote the necessary social tolerance. Researchers might profit from exploring whether other kinds of within-species contexts could also generate cooperative behaviors.

Familiarity affects the assessment of female facial signals of fertility by free-ranging male rhesus macaques.

Animals signal their reproductive status in a range of sensory modalities. Highly social animals, such as primates, have access not only to such signals, but also to prior experience of other group members. Whether this experience affects how animals interpret reproductive signals is unknown. Here, we explore whether familiarity with a specific female affects a male's ability to assess that female's reproductive signals. We used a preferential looking procedure to assess signal discrimination in free-ranging rhesus macaques, a species in which female facial luminance covaries with reproductive status. We collected images of female faces throughout the reproductive cycle, and using faecal hormone analysis to determine ovulation, categorized images as coming from a female's pre-fertile, ovulating, or post-fertile period. We printed colour-calibrated stimuli of these faces, reproducing stimuli perceptually the same in colour and luminance to the original appearance of females. These images were presented to males who were either unfamiliar or familiar with stimuli females. Overall, males distinguished ovulatory from pre-ovulatory faces. However, a significant proportion of males did so only among males familiar with stimuli females. These experiments demonstrate that familiarity may increase a receiver's ability to use a social partner's signals to discern their reproductive status.

Economic cognition in humans and animals: the search for core mechanisms.

Over the past few decades, research in judgment and decision-making has revealed that decision-makers, though not always rational, are often quite predictable. Here, we attempt to explore the nature of this systematicity with a different approach to decision-making. Specifically, we propose that some of the systematicity of human decision-making may result from the operation of core knowledge mechanisms, domain-specific learning mechanisms with characteristic processing limitations. In this review, we describe the core knowledge approach and argue that at least some aspects of human decision-making have the signature characteristics of a core knowledge system, namely, such strategies develop early in ontogeny and are shared with closely related primate relatives.