Lauren D. Arnold

Are Racial Disparities in Pancreatic Cancer Explained by Smoking and Overweight/Obesity?

Between 2001 and 2005, Blacks from the United States experienced a 32% higher pancreatic cancer death rate than Whites. Smoking, diabetes, and family history might explain some of this disparity, but prospective analyses are warranted. From 1984 to 2004, there were 6,243 pancreatic cancer deaths among Blacks (n = 48,525) and Whites (n = 1,011,864) in the Cancer Prevention Study II cohort. Multivariate Cox proportional hazards models yielded hazards ratios (HR) for known and suspected risk factors. Population attributable risks were computed and their effect on age-standardized mortality rates were evaluated. Blacks in this cohort had a 42% increased risk of pancreatic cancer mortality compared with Whites (HR, 1.42; 95% confidence intervals (CI), 1.28-1.58). Current smoking increased risk by >60% in both races; although Blacks smoked less intensely, risks were similar to Whites (HRBlack, 1.67; 95% CI, 1.28-2.18; HRWhite, 1.82; 95% CI, 1.7-1.95). Obesity was significantly associated with pancreatic cancer mortality in Black men (HR, 1.66; 95% CI, 1.05-2.63), White men (HR, 1.42; 95% CI, 1.25-1.60), and White women (HR, 1.37; 95% CI, 1.22-1.54); results were null in Black women. The population attributable risk due to smoking, family history, diabetes, cholecystectomy, and overweight/obesity was 24.3% in Whites and 21.8% in Blacks. Smoking and overweight/obesity play a substantial a role in pancreatic cancer. Variation in the effect of these factors underscores the need to evaluate disease on the race-sex level. The inability to attribute excess disease in Blacks to currently known risk factors, even when combined with suspected risks, points to yet undetermined factors that play a role in the disease process. (Cancer Epidemiol Biomarkers Prev 2009;18(9):2397–405)

African American Parents’ HPV Vaccination Intent and Concerns

This study describes attitudes and social and environmental factors that affect African American parents’ intent to vaccinate their daughters against human papillomavirus (HPV). Thirty African American parents of daughters aged nine to 17 years and no history of HPV infection completed semi-structured interviews. Interviews addressed factors that influenced intent to vaccinate, perception of community norms related to vaccination, vaccination scenarios involving place of vaccination, and vaccination prior to or after the child’s initiation of sexual activity. A recurring theme was the influence of physician recommendation on African American parents’ intent to obtain HPV vaccination for their daughters. Most parents reported that they could overcome barriers to vaccination, except vaccine costs and lack of insurance. While religious beliefs were important to parents, they reported that they would not interfere with vaccination decisions; fears of early sexuality due to vaccination were limited. The implications of these findings are discussed.

The acceptability of self-sampled screening for HPV DNA: a systematic review and meta-analysis.

Objective To examine whether or not self-sampled cervical screening for human papillomavirus (HPV) DNA is acceptable and if women prefer self-sampling to clinician-based sampling. Design Systematic review and meta-analysis. Data sources Thirty-seven primary studies obtained through a comprehensive search of six electronic bibliographic databases from 1986 to 2014 and other sources. Search keywords included HPV, screening, DNA testing, vaginal testing, self-collected specimen, self-collected sample, self-sampling, self-screening, preferences and acceptability. Review methods Studies eligible for analysis included those that had participants perform self-sampling, evaluated participant acceptance of or preference for self-sampled vaginal HPV DNA and reported data to calculate an effect size. There were no exclusion criteria for publication status or geographical location. Meta-analytic methods were used to quantitatively synthesise effect sizes across studies. Results The 37 studies included 18 516 female participants from 24 countries across five continents. Overall, there was a high level of acceptability of self-sampling among the participants. Participants reported preference for self-sampling over clinician sampling due to attractive characteristics such as ease and privacy. Conclusions The overall acceptability of self-sampled cervical screening, coupled with economic and effective care, provides opportunities for expanding screening services. Importantly, this can provide a creative screening alternative for women who do not participate in traditional cytological screening, and may ultimately reduce health disparities and prevent cervical disease.

Competing causes of death in the head and neck cancer population.

PURPOSE/OBJECTIVES The increasing survivorship of head and neck squamous cell carcinoma (HNSCC) comes with a risk of death from other causes, known as competing causes. The demographics of HNSCC are also evolving with increasing incidence of Human Papillomavirus (HPV) associated tumors. This study describes competing causes of death for the HNSCC population compared to the general population and identifies associated risk factors. METHODS Adult patients with first mucosal HNSCC (2004-2011) were identified from the Surveillance, Epidemiology and End Result database. Competing causes of death were compared to reference populations using proportion of deaths and Standardized Mortality Ratios (SMR). A multivariable competing risk survival analysis yielded subdistribution hazard ratios (HR) for competing mortality. RESULTS Of 64,598 HNSCC patients, 24,602 (38.1%) were deceased including 7142 deaths (29.0%) from competing causes. The most common were cardiovascular disease, lung cancer, and other cancers. All relative mortality rates were elevated, especially liver disease (SMR 38.7; 95% CI: 29.4-49.3), suicide (SMR 37.1; 95% CI: 26.1-48.6), and subsequent primary cancers (SMR 7.5; 95% CI: 6.78-8.32). Demographic and tumor factors independently increased risk of competing mortality, including age (HR per 5years 1.24; 95% CI: 1.22-1.25), sex (male HR 1.23; 95% CI: 1.16-1.32), race (Black HR 1.17; 95% CI: 1.09-1.26), insurance (uninsured HR 1.28; 95% CI: 1.09-1.50), and marital status (single HR 1.29; 95% CI: 1.21-1.37). CONCLUSION Nearly one in three HNSCC patients died from competing causes. When developing long term survivorship regimens for HNSCC patients, clinicians should be familiar with this populations specific risks.

The Impact of Intimate Partner Violence on Women’s Physical Health Findings From the Missouri Behavioral Risk Factor Surveillance System

Intimate partner violence (IPV) is a significant public health problem. It has far reaching consequences such as social and economic costs, as well as a negative impact on women’s health outcomes. This study assessed the relationship between IPV and health risk factors, health behaviors, and poor mental health in Missouri women utilizing 2005 Missouri Behavioral Risk Factor Surveillance System (BRFSS) data (n = 3,110). Moderators (demographic indicators) of the relationship between IPV and health risk factors (high blood pressure, high cholesterol, and obesity) and health behaviors (physical inactivity, smoking, and binge drinking) were also examined. Women with a history of IPV were more likely to engage in health-compromising behaviors such as smoking and binge drinking, be obese, and report more poor mental health days compared with women without a history of IPV. Demographic variables moderated the relationship between IPV, obesity, smoking, high blood pressure, and high cholesterol. These findings underscore the importance that clinics, community, or other health care settings can play in identifying women who are victims of or have a history of IPV and provide them with appropriate resources as well as targeted interventions to reduce morbidity in this population.

Daily Hassles' Role in Health Seeking Behavior among Low- income Populations

OBJECTIVES To adapt a daily hassles measure for a low-income population and assess the relationship between hassles and health seeking behavior. METHODS The mixed methods approach used cognitive interviews (N = 23) to inform an adapted measure of daily hassles. The adapted scale was then tested via surveys (N = 144) in community health centers; multivariate logistic regression models were used to assess relationships among variables. RESULTS Hassle concerning having enough money for emergencies (76.5%) and worrying about personal health (68.8%) were among the most common. Increased health-related hassles were associated with an increased likelihood to delay needed care. CONCLUSIONS Findings suggest daily hassles are unique among low-income populations and should be considered in health behavior interventions.

Cognitive testing of human papillomavirus vaccine survey items for parents of adolescent girls.

Objective Many studies have been conducted to understand what factors are associated with human papillomavirus (HPV) vaccine acceptability and completion of the 3-dose vaccination series, but few have examined whether people understand the survey items used to assess these relationships. Through a multisite collaborative effort, we developed and cognitively tested survey items that represent constructs known to affect vaccine acceptability and completion. Materials and Methods Investigators from 7 research centers in the United States used cognitive interviewing techniques and in-person and telephone interviews to test 21 items. Four rounds of testing, revising, and retesting were conducted among racially and ethnically diverse parents (n = 62) of girls between the ages of 9 and 17 years. Results The final survey contained 20 items on attitudes and beliefs relevant to HPV vaccine. Some parents misinterpreted statements about hypothetical vaccine harms as statements of fact. Others were unwilling to answer items about perceived disease likelihood and perceived vaccine effectiveness, because they said the items seemed to have a “right” answer that they did not know. On the basis of these and other findings from cognitive testing, we revised the wording of 14 questions to improve clarity and comprehension. We also revised instructions, response options, and item order. Conclusions Cognitive testing of HPV vaccine survey items revealed important differences between intended and ascribed item meaning by participants. Use of the tested survey questions presented here may increase measurement validity and researchers’ ability to compare findings across studies and populations. Additional testing using quantitative methods can help to further validate these items.

The peer-reviewed literature on undergraduate education for public health in the United States, 2004-2014

The education of undergraduate college students in the field of public health has burgeoned over the past decade. Professional literature in peer-reviewed journals is one indicator of the status of a field of study and its related body of knowledge. It is also a mechanism for sharing information among professionals about challenges, issues, experiences, and best practices. The purpose of the literature review conducted here was to describe the status of the peer-reviewed literature over the past decade pertaining to the education of undergraduates about the field of public health in the United States (U.S.). A literature search was conducted of three databases: PubMed, Scopus, and ERIC. Inclusion criteria were publication date from January 1, 2004 through July 31, 2014; written in the English language; pertaining to undergraduate education in the U.S.; and a focus on public health as the primary discipline. Public health was searched as an overarching discipline; articles focused on sub-disciplines or other health professions disciplines were excluded. The search resulted in 158 articles. Each of the authors reviewed the abstracts for all articles and read full articles when necessary. The result was 23 articles that were then considered in depth. The articles were categorized according to their primary theme: curriculum, courses, learning objectives (N = 14); evaluation of teaching method (N = 3); case study (N = 3); career path and advising (N = 2); accreditation (N = 1). Year of publication and journal were also examined. The results of the literature search lead to several observations about how the peer-reviewed literature has been used to date and how it could be used to advance the emerging field of undergraduate education for public health.

A training programme to build cancer research capacity in low- and middle-income countries: findings from Guatemala

PROBLEM Guatemala is experiencing an increasing burden of cancer but lacks capacity for cancer prevention, control and research. APPROACH In partnership with a medical school in the United States of America, a multidisciplinary Cancer Control Research Training Institute was developed at the Instituto de Cancerología (INCAN) in Guatemala City. This institute provided a year-long training programme for clinicians that focused on research methods in population health and sociocultural anthropology. The programme included didactic experiences in Guatemala and the United States as well as applied training in which participants developed research protocols responsive to Guatemalas cancer needs. LOCAL SETTING Although INCAN is the point of referral and service for Guatemalas cancer patients, the institutes administration is also interested in increasing cancer research - with a focus on population health. INCAN is thus a resource for capacity building within the context of cancer prevention and control. RELEVANT CHANGES Trainees increased their self-efficacy for the design and conduct of research. Value-added benefits included establishment of an annual cancer seminar and workshops in cancer pathology and qualitative analysis. INCAN has recently incorporated some of the programmes components into its residency training and established a research department. LESSONS LEARNT A training programme for clinicians can build cancer research capacity in low- and middle-income countries. Training in population-based research methods will enable countries such as Guatemala to gather country-specific data. Once collected, such data can be used to assess the burden of cancer-related disease, guide policy for reducing it and identify priority areas for cancer prevention and treatment.

Inadequate Cancer Screening: Lack of Provider Continuity is a Greater Obstacle than Medical Mistrust

Abstract:Background. Racial minorities and low-income individuals are generally less likely to have adequate cancer screening than Whites or higher-income individuals. Purpose. To examine the roles of medical mistrust and lack of provider continuity in cancer screening in a low-income minority population. Methods. A total of 144 urban federally qualified health center patients completed a cross-sectional survey that included the Group Based Medical Mistrust Scale and questions on provider continuity and cancer-screening-history. Results. Breast cancer screening was associated with continuity of care but not mistrust (respectively p = .002, p > .05); colon cancer screening was not significantly associated with either factor (p > .05). Conclusions. Findings suggest that among low-income minority adults continuity of care is more strongly associated with screening than medical mistrust. Shifting focus from medical mistrust—a patient-level issue—to establishing health care homes—a system-level issue—may be a more effective strategy for reducing racial and socioeconomic disparities in cancer screening.