Implementing and Enhancing Social and Economic Needs Screening at a Federally Qualified Health Center.

BACKGROUND: Programs to screen for social and economic needs (SENs) are challenging to implement. AIM: To describe implementation of an SEN screening program for patients obtaining care at a federally qualified health center (FQHC). SETTING: Large Chicago-area FQHC where many patients are Hispanic/Latino and insured through Medicaid. PROGRAM DESCRIPTION: In the program's phase 1 (beginning April 2020), a prescreening question asked about patients' interest in receiving community resources; staff then called interested patients. After several refinements (e.g., increased staffing, tailored reductions in screening frequency) to address challenges such as a large screening backlog, program phase 2 began in February 2021. In phase 2, a second prescreening question asked about patients' preferred modality to learn about community resources (text/email versus phone calls). PROGRAM EVALUATION: During phase 1, 8925 of 29,861 patients (30%) expressed interest in community resources. Only 40% of interested patients were successfully contacted and screened. In phase 2, 5781 of 21,737 patients (27%) expressed interest in resources; 84% of interested patients were successfully contacted by either text/email (43%) or phone (41%). DISCUSSION: Under one-third of patients obtaining care at an FQHC expressed interest in community resources for SENs. After program refinements, rates of follow-up with interested patients substantially increased.

Examining How Social Risk Factors Are Integrated Into Clinical Settings Using Existing Data: A Scoping Review.

PURPOSE: Integrating social care into clinical care requires substantial resources. Use of existing data through a geographic information system (GIS) has the potential to support efficient and effective integration of social care into clinical settings. We conducted a scoping literature review characterizing its use in primary care settings to identify and address social risk factors. METHODS: In December 2018, we searched 2 databases and extracted structured data for eligible articles that (1) described the use of GIS in clinical settings to identify and/or intervene on social risks, (2) were published between December 2013 and December 2018, and (3) were based in the United States. Additional studies were identified by examining references. RESULTS: Of the 5,574 articles included for review, 18 met study eligibility criteria: 14 (78%) were descriptive studies, 3 (17%) tested an intervention, and 1 (6%) was a theoretical report. All studies used GIS to identify social risks (increase awareness); 3 studies (17%) described interventions to address social risks, primarily by identifying relevant community resources and aligning clinical services to patients' needs. CONCLUSIONS: Most studies describe associations between GIS and population health outcomes; however, there is a paucity of literature regarding GIS use to identify and address social risk factors in clinical settings. GIS technology may assist health systems seeking to address population health outcomes through alignment and advocacy; its current application in clinical care delivery is infrequent and largely limited to referring patients to local community resources.

ACR Appropriateness Criteria® Supplemental Breast Cancer Screening Based on Breast Density.

Mammography remains the only validated screening tool for breast cancer, however, there are limitations to mammography. One of the limitations of mammography is the variable sensitivity based on breast density. Supplemental screening may be considered based on the patient's risk level and breast density. For average-risk women with nondense breasts, the sensitivity of digital breast tomosynthesis (DBT) screening is high; additional supplemental screening is not warranted in this population. For average-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhanced mammography, screening ultrasound (US), breast MRI, or abbreviated breast MRI. In intermediate-risk women, there is emerging evidence suggesting that women in this population may benefit from breast MRI or abbreviated breast MRI. In intermediate-risk women with dense breasts, given the decreased sensitivity of mammography/DBT, this population may benefit from additional supplemental screening with contrast-enhancedmammography or screening US. There is strong evidence supporting screening high-risk women with breast MRI regardless of breast density. Contrast-enhanced mammography, whole breast screening US, or abbreviated breast MRI may be also considered. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

ACR Appropriateness Criteria® Transgender Breast Cancer Screening.

Breast cancer screening recommendations for transgender and gender nonconforming individuals are based on the sex assigned at birth, risk factors, and use of exogenous hormones. Insufficient evidence exists to determine whether transgender people undergoing hormone therapy have an overall lower, average, or higher risk of developing breast cancer compared to birth-sex controls. Furthermore, there are no longitudinal studies evaluating the efficacy of breast cancer screening in the transgender population. In the absence of definitive data, current evidence is based on data extrapolated from cisgender studies and a limited number of cohort studies and case reports published on the transgender community. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Identifying and addressing social determinants of health in outpatient practice: results of a program-wide survey of internal and family medicine residents.

BACKGROUND: Up to 60% of preventable mortality is attributable to social determinants of health (SDOH), yet training on SDOH competencies is not widely implemented in residency. The objective of this study was to assess internal and family medicine residents' competence at identifying and addressing SDOH. METHODS: Residents' perceived competence at identifying, discussing, and addressing SDOH in outpatient settings was assessed using a single questionnaire administered in March 2017. In this cross-sectional analysis, bivariate associations of resident characteristics with the following outcomes were examined: identifying, discussing, and addressing patients' challenges related to SDOH through referrals. RESULTS: The survey was completed by 129 (84%) residents. Twenty residents (16%) reported an annual income of less than $50,000 during childhood. Overall, 108 residents (84%) reported previous SDOH training. Two-thirds had outpatient practices in Veterans Affairs or safety-net clinics. Thirty-nine (30%) intended to pursue a career in primary care. The following numbers of residents reported high levels of competence for performing these outcomes: identifying patients' challenges related to SDOH: 37 (29%); discussing them with patients: 18 (14%); and addressing these challenges through referrals to internal and external resources: 13 (10%) and 11 (9%), respectively. Factors associated with higher competence included older age, lower childhood household income, prior education about SDOH, primary practice site and intention to practice primary care. CONCLUSIONS: Most residents had previous SDOH training, yet only a small proportion of residents reported being highly competent at identifying or addressing SDOH. Providing opportunities for practical training may be a key component in preparing medical residents to identify and address SDOH effectively in outpatient practice.

Developing Equity Report Cards for Residents Training in Primary Care.

BACKGROUND: Most residency programs do not provide trainees with health equity data for their clinic patients. METHODS: Equity report cards were developed for internal and family medicine residents in a large health system. After considering which equity indictors were available, how to attribute patients to residents, and what level of granularity was feasible, equity reports were created for five ambulatory quality measures. Chi-square tests were used to test the significance of differences in quality measure satisfaction between groups. RESULTS: Attributing patients to the physician who had seen them for the greatest proportion of encounters performed best. Creating equity reports for individual resident panels was not possible due to insufficient numbers. Most measures had sufficient patients when combining all residents' patients. Inequities were identified for four of five examined measures. CONCLUSION: Creating aggregate equity reports for all primary care residents across multiple equity indicators was feasible, documenting disparities in health care quality.

Identifying and Addressing Social Determinants of Health in the Primary Care Clinical Training Environment: A Survey of the Landscape.

INTRODUCTION: This study surveyed the use of systematic strategies to address social determinants of health in the primary care clinical training environment. METHODS: We designed a 51-item questionnaire targeting medical educators from internal medicine, pediatrics, and family practice to assess strategies to identify and mitigate social needs, the role of trainees in this process, and barriers/facilitators to systematic approaches. RESULTS: The survey was completed by 104 medical educators from 77 institutions. Of the 104 respondents, 28% were not familiar with any standardized tools used for screening for social needs, 27% use geospatial (GIS) or geographic information system (GIG) data, and 35% reported that trainees were not involved in any part of assisting. CONCLUSION: Nearly one third of medical educators lack familiarity with standardized screening tools for social needs. More than one third reported that trainees are not involved with mitigating social needs. Geospatial and GIS data are not utilized frequently.

Screening for Recurrence and Secondary Cancers.

The population of adult cancer survivors is increasing over time and they are at risk of developing recurrent and secondary cancers, even years after completion of treatment. Post-treatment care of survivors is increasingly the responsibility of primary care providers. Surveillance for recurrence and screening for secondary malignancies related to treatment depend largely on the primary malignancy, treatment regimen, and presence of a hereditary cancer syndrome, such as a BRCA mutation. This article presents surveillance strategies for the most common malignancies.

Increasing screening mammography among predominantly Spanish speakers at a federally qualified health center using a brief previsit video.

OBJECTIVE: Assess the impact of a 5min video on screening mammogram referrals and completion. METHODS: We recruited women ages 40 years or older without a current mammogram at a federally qualified community health center (FQHC). Women were assigned to the intervention or usual care. Immediately prior to their appointments, women in the intervention group viewed a brief video that included a demonstration of how patients may request a mammogram referral. All women completed a pre- and post-visit telephone survey about knowledge of breast cancer screening and patient activation. RESULTS: Mean age was 52 years, 50% had less than a high school education and 75% preferred Spanish. The proportion of mammogram referrals in the intervention group was significantly higher than the control group, 37% vs. 15%, respectively (p<0.01). Similarly, the intervention group had a higher proportion of completed mammograms, 33% vs. 13% (p<0.02). There were no differences in breast cancer knowledge or patient activation between the intervention and control groups. CONCLUSIONS: A brief, pre-visit video significantly increased screening mammography referrals and completion in this mostly Spanish-speaking FQHC population. PRACTICE IMPLICATIONS: Our intervention demonstrates the effectiveness of a brief-video intervention in a population with low education and low English language proficiency.

Disparities in registration and use of an online patient portal among older adults: findings from the LitCog cohort.

OBJECTIVE: To document disparities in registration and use of an online patient portal among older adults. MATERIALS AND METHODS: Data from 534 older adults were linked with information from the Northwestern Medicine Electronic Data Warehouse on patient portal registration and use of functions (secure messaging, prescription reauthorizations, checking test results, and monitoring vital statistics). Age, gender, race, education, self-reported chronic conditions, and the Newest Vital Sign health literacy measure were available from cohort data. RESULTS: Most patients (93.4%) had a patient portal access code generated for them, and among these 57.5% registered their accounts. In multivariable analyses, White patients (P < .001) and college graduates were more likely to have registered their patient portal (P = .015). Patients with marginal (P = .034) or adequate (P < .001) health literacy were also more likely to have registered their patient portal. Among those registering their accounts, most had messaged their physician (90%), checked a test result (96%), and ordered a reauthorization (55%), but few monitored their vital statistics (11%). Adequate health literacy patients were more likely to have used the messaging function (P = .003) and White patients were more likely to have accessed test results (P = .004). Higher education was consistently associated with prescription reauthorization requests (all P < .05). DISCUSSION: Among older American adults, there are stark health literacy, educational, and racial disparities in the registration, and subsequent use of an online patient portal. These population sub-group differences may exacerbate existing health disparities. CONCLUSIONS: If patient portals are implemented, intervention strategies are needed to monitor and reduce disparities in their use.

Asthma beliefs are associated with medication adherence in older asthmatics.

BACKGROUND: Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics. OBJECTIVE: To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics. DESIGN: An observational study of asthma beliefs and self-management among older adults. PARTICIPANTS: Asthmatics ages ≥ 60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago. MAIN MEASURES: Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence. KEY RESULTS: The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the "no symptoms, no asthma" belief (58.7 % vs. 31.7 %, respectively, p < 0.001), "will not always have asthma" belief (34.8 % vs. 12.5 %, p < 0.001), and the "MD can cure asthma" belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a "no symptoms, no asthma" belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment. CONCLUSIONS: Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.

Patient reported barriers to enrolling in a patient portal.

BACKGROUND: Previous studies of patient portals have found low rates of enrollment and significant disparities in enrollment by race and ethnicity. As the reasons for these findings are unclear, we sought to identify patient reported barriers to enrollment in a patient portal. METHODS: We conducted a telephone survey of patients in one urban general internal medicine clinic. Patients were eligible if they did not enroll within 30 days of receiving an electronic order inviting participation. Our primary outcomes were: (a) reasons for not enrolling in the patient portal; (b) reasons for not attempting enrollment; and (c) perceived benefits of the portal. RESULTS: Participants' (N=159) mean age was 51 years, 48% were black, 72% female, and 70% had a college degree or greater. 63% of respondents not enrolling reported never attempting enrollment despite remembering receiving an order. Most of these 63% did not attempt enrollment because of lack of information or motivation. Smaller proportions reported not attempting enrollment because of negative attitudes toward the portal (30%) or computer related obstacles (8%). Overall, respondents favorably viewed most patient portal features, however black respondents were less likely than white respondents to consider features assisting self-management such as getting test results (69% vs 86%; p<0.05) as important. Adjusting for age, gender, education, and chronic disease did not substantially change results. CONCLUSION: Strategies to increase enrollment in patient portals need to ensure patients understand patient portal features and receive follow-up reminders. Interventions to reduce racial disparities in enrollment must address attitudinal barriers and not focus solely on improving access.

Disparities in enrollment and use of an electronic patient portal.

BACKGROUND: With emphasis on the meaningful use of electronic health records, patient portals are likely to become increasingly important. Little is known about patient enrollment in, and use of, patient portals after explicit invitation from providers. OBJECTIVES: To examine enrollment in, and use of, an electronic patient portal by race/ethnicity, gender and age. DESIGN: Observational, cross sectional study. PARTICIPANTS: Patients with attending physicians seen at one urban, academic primary care practice between May 2008 and October 2009 who received electronic orders inviting their participation in an electronic patient portal. MAIN MEASURES: (a) Enrollment in the patient portal, (b) Solicitation of provider advice among enrollees, (c) Requests for medication refills among enrollees. KEY RESULTS: Overall, 69% of 7,088 patients enrolled in the patient portal. All minority patients were significantly less likely to enroll than whites: 55% blacks, 64% Latinos and 66% Asians compared with 74% whites (chi-square p < 0.05 for all pairwise comparisons). These disparities persisted in adjusted analyses, although differences for Asians were no longer significant. In addition, the oldest patients were less likely to enroll than the youngest (adjusted OR 0.79, 95% CI 0.65-0.97). Although there were no racial/ethnic disparities in use of the patient portal among enrollees, we found differences by age and gender. The youngest patients were significantly less likely to solicit provider advice or request medication refills than any other age group in unadjusted and adjusted analyses. Similarly, male patients were less likely to solicit provider advice than women in all analyses. CONCLUSION: Large racial/ethnic disparities were seen in enrollment in our patient portal. Among enrollees, use of the portal was similar by race/ethnicity, but not by age or gender. Future efforts to expand use of the patient portal need to address potential mechanisms for these disparities to ensure this technology is accessible to diverse patient populations.

Development and pilot testing of a culturally sensitive multimedia program to improve breast cancer screening in Latina women.

OBJECTIVE: Our study goal was to assess the effects of a brief patient video on breast cancer knowledge and attitudes among Latina women at a community health center. METHODS: We conducted pre- and post-testing of knowledge and attitudes in women aged 40 years or older with active screening referrals (n=91). We compared pre- and post-test knowledge and attitudes overall and by baseline values. RESULTS: Mean knowledge increased from 5.8/10 to 6.9/10 (p<0.05), with the greatest increases in those with low baseline knowledge (p<.001). There were no changes in mean attitudes, which were high at baseline (3.8/5); however, among the 16 women with negative/neutral attitudes, 50% developed positive attitudes after watching the video (p<0.05). Baseline intention to complete screening was high at 98%. CONCLUSION: Although the overall effects were modest, the greatest improvements were in those with low baseline knowledge scores and negative/neutral baseline attitudes. Future testing should examine the effects in a community-based sample. PRACTICE IMPLICATIONS: A brief patient video has promise for influencing patient knowledge and perhaps attitudes while being amenable to integration into clinical flow.

Communication about behavioral health risks: a study of videotaped encounters in 2 internal medicine practices.

BACKGROUND: As behavioral health risks account for the major causes of preventable morbidity and mortality in the United States, national guidelines recommend that physicians routinely screen patients for risk factors, and counsel as appropriate. OBJECTIVES: To assess the scope of health risk screening and characterize the communication content of counseling for health behavior change in 2 general internal medicine practices. DESIGN AND PARTICIPANTS: We studied videotapes of 125 new patient visits to General Internists affiliated with academic medical centers in Chicago, IL (70%) and Burlington, VT (30%). All videotapes were content analyzed to examine (1) the incidence and outcome of screening for diet, exercise, tobacco, alcohol, drugs, sex, seatbelt use, helmet use, firearms, smoke detectors, and sun exposure; (2) the content of counseling for at-risk behaviors, with a focus on 11 counseling tasks associated with health behavior change. RESULTS: Patient age in these 125 initial visits ranged from 22 to 85 years. Within the 91 visits that included at least 1 screening attempt, there were a total of 361 distinct screening discussions (mean=3.9, SD=2.2, range=1 to 9). Seventy-four (20.5%) of the 361 screening discussions revealed an at-risk behavior. On average, 2.4 of the 11 counseling tasks were accomplished for each of the 74 behavioral health risks (SD=2.2, range 0 to 9); only education about the problem (56.8%) and general advice about the solution (62.2%) were evident in more than half of the counseling attempts. CONCLUSIONS: This observational study reveals that communication tasks associated with successful counseling were relatively infrequent occurrences during initial visits in 2 primary care practices.

Trends in breast conserving surgery among Asian Americans and Pacific Islanders, 1992-2000.

BACKGROUND: Breast-conserving surgery (BCS) has been the recommended treatment for early-stage breast cancer since 1990 yet many women still do not receive this procedure. OBJECTIVE: To examine the relationship between birthplace and use of BCS in Asian-American and Pacific-Islander (AAPI) women, and to determine whether disparities between white and AAPI women persist over time. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Women with newly diagnosed stage I or II breast cancer from 1992 to 2000 in the Surveillance, Epidemiology, and End Results program. OUTCOME: Receipt of breast -conserving surgery for initial treatment of stage I or II breast cancer. MAIN RESULTS: Overall, AAPI women had lower rates of BCS than white women (47% vs 59%; P<.01). Foreign-born AAPI women had lower rates of BCS than U.S.-born AAPI and white women (43% vs 56% vs 59%; P<.01). After adjustment for age, marital status, tumor registry, year of diagnosis, stage at diagnosis, tumor size, histology, grade, and hormone receptor status, foreign-born AAPI women (adjusted OR [aOR], 0.49; 95% CI, 0.32 to 0.76) and U.S.-born AAPI women (aOR, 0.77; 95% CI, 0.62 to 0.95) had lower odds of receiving BCS than white women. Use of BCS increased over time for each racial/ethnic group; however, foreign-born AAPI women had persistently lower rates of BCS than non-Hispanic white women. CONCLUSIONS: AAPI women, especially those who are foreign born, are less likely to receive BCS than non-Hispanic white women. Of particular concern, differences in BCS use among foreign-born and U.S.-born AAPI women and non-Hispanic white women have persisted over time. These differences may reflect inequities in the treatment of early-stage breast cancer for AAPI women, particularly those born abroad.

Obesity among US immigrant subgroups by duration of residence.

CONTEXT: The prevalence of obesity has increased substantially since the 1980s. While immigrants are the fastest growing segment of the US population, little is known about obesity or clinician counseling about diet and exercise in this group. OBJECTIVES: To estimate the prevalence of obesity among immigrant subgroups and quantify the magnitude of the association with duration of US residence, and to describe reported diet and exercise counseling by birthplace, race, and ethnicity. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study using data from the 2000 National Health Interview Survey. MAIN OUTCOME MEASURES: Body mass index (BMI, measured as weight in kilograms divided by the square of height in meters) based on self-reported height and weight measurements, and self-reported rates of diet and exercise counseling. RESULTS: Of 32,374 respondents, 14% were immigrants. The prevalence of obesity was 16% among immigrants and 22% among US-born individuals. The age- and sex-adjusted prevalence of obesity was 8% among immigrants living in the United States for less than 1 year, but 19% among those living in the United States for at least 15 years. After adjusting for age, sociodemographic, and lifestyle factors, living in the United States for 10 to 15 and at least 15 years was associated with BMI increases of 0.88 and 1.39, respectively. The association for 15 years or more was significant for all immigrant subgroups except foreign-born blacks. Additionally, immigrants were less likely than US-born individuals to report discussing diet and exercise with clinicians (18% vs 24%, P<.001; 19% vs 23%, P<.001, respectively). These differences were not accounted for by sociodemographic characteristics, illness burden, BMI, or access to care among some subgroups of immigrants. CONCLUSIONS: Among different immigrant subgroups, number of years of residence in the United States is associated with higher BMI beginning after 10 years. The prevalence of obesity among immigrants living in the United States for at least 15 years approached that of US-born adults. Early intervention with diet and physical activity may represent an opportunity to prevent weight gain, obesity, and obesity-related chronic illnesses.

Racial and ethnic disparities in cancer screening: the importance of foreign birth as a barrier to care.

CONTEXT: Racial/ethnic groups comprised largely of foreign-born individuals have lower rates of cancer screening than white Americans. Little is known about whether these disparities are related primarily to their race/ethnicity or birthplace. OBJECTIVE: To determine whether foreign birthplace explains some racial/ethnic disparities in cancer screening. DESIGN, SETTING, AND SUBJECTS: Cross-sectional study using 1998 data from the National Health Interview Survey. MAIN OUTCOME MEASURES: Completion of cervical, breast, or colorectal cancer screening. RESULTS: Of respondents, 15% were foreign born. In analyses adjusted for sociodemographic characteristics and illness burden, black respondents were as or more likely to report cancer screening than white respondents; however, Hispanic and Asian-American and Pacific Islander (AAPI) respondents were significantly less likely to report screening for most cancers. When race/ethnicity and birthplace were considered together, U.S.-born Hispanic and AAPI respondents were as likely to report cancer screening as U.S.-born whites; however, foreign-born white (adjusted odds ratio [AOR], 0.58; 95% confidence interval [CI], 0.41 to 0.82), Hispanic (AOR, 0.65; 95% CI, 0.53 to 0.79), and AAPI respondents (AOR, 0.28; 95% CI, 0.19 to 0.39) were less likely than U.S.-born whites to report Pap smears. Foreign-born Hispanic and AAPI respondents were also less likely to report fecal occult blood testing (FOBT); AORs, 0.72; 95% CI, 0.53 to 0.98; and 0.61; 95% CI, 0.39 to 0.96, respectively); and sigmoidoscopy (AORs, 0.70; 95% CI, 0.51 to 0.97; and 0.63; 95% CI, 0.40 to 0.99, respectively). Furthermore, foreign-born AAPI respondents were less likely to report mammography (AOR, 0.49; 95% CI, 0.28 to 0.86). Adjusting for access to care partially attenuated disparities among foreign-born respondents. CONCLUSION: Foreign birthplace may explain some disparities previously attributed to race or ethnicity, and is an important barrier to cancer screening, even after adjustment for other factors. Increasing access to health care may improve disparities among foreign-born persons to some degree, but further study is needed to understand other barriers to screening among the foreign-born.