Rachel C. Shelton

Parental Decision Making about the HPV Vaccine

Background: Prophylactic human papillomavirus (HPV) vaccines are available, but uptake is suboptimal. Information on factors influencing parental decisions regarding vaccination will facilitate the development of successful interventions. Methods: Parents of girls ages 9 to 17 years (n = 476; cooperation rate = 67%) from a panel of U.S. households completed online surveys between September 2007 and January 2008, documenting vaccine knowledge, attitudes, and intentions. Results: Among those aware of the vaccine, 19% had already vaccinated their daughter(s), 34% intended to, 24% were undecided, and 24% had decided against vaccination. Awareness of HPV was high but knowledge levels were suboptimal (mean 72%, SEM 0.8%). Black and Hispanic parents were significantly less likely to be aware of the vaccine compared with White parents. In multivariate analyses, compared with parents who opposed vaccination, those who had already vaccinated their daughter(s) or who intended to do so had more positive attitudes, reported fewer barriers, and were more likely to perceive that family and friends would endorse vaccination. They also reported higher levels of trust in pharmaceutical companies that produce the vaccine. Conclusions: Despite limited knowledge, most parents had decided to vaccinate their daughter(s). Given evidence of diminished access to information among Black and Hispanic parents, programs should focus on reaching these groups. Interventions should address parental concerns about behavioral consequences, reduce structural barriers, and promote the perception that vaccination is endorsed by significant others. Moreover, interventions may need to address mistrust of pharmaceutical companies. Impact Statement: This study documents factors associated with parental decisions about HPV vaccination for their daughter(s) and provides direction for intervention development. Cancer Epidemiol Biomarkers Prev; 19(9); 2187–98. ©2010 AACR.

An Investigation Into the Social Context of Low-Income, Urban Black and Latina Women Implications for Adherence to Recommended Health Behaviors

Understanding factors that promote or prevent adherence to recommended health behaviors is essential for developing effective health programs, particularly among lower income populations who carry a disproportionate burden of disease. We conducted in-depth qualitative interviews (n = 64) with low-income Black and Latina women who shared the experience of requiring diagnostic follow-up after having a screening mammography with abnormal findings. We found that in addition to holding negative and fatalistic cancer-related beliefs, the social context of these women was largely defined by multiple challenges and major life stressors, factors that may interfere with their ability to attain health. Factors commonly mentioned included competing health issues, economic hardship, demanding caretaking responsibilities and relationships, insurance-related challenges, distrust of health care providers, and inflexible work policies. Black women also reported discrimination and medical mistrust, whereas Latinas experienced difficulties associated with immigration and social isolation. These results suggest that effective health interventions not only address change among individuals but must also change health care systems and social policies in order to reduce health disparities.

The Association Between Social Factors and Physical Activity Among Low-Income Adults Living in Public Housing

OBJECTIVES We sought to examine the association between structural, functional, and normative social factors and physical activity among urban, low-income, racially/ethnically diverse adults. METHODS We conducted a baseline cross-sectional survey among residents of 12 low-income housing communities in metropolitan Boston, Massachusetts. Participants were also asked to wear a pedometer for 5 days. We analyzed complete data from 1112 residents (weighted n = 1635). RESULTS Residents with smaller social networks were significantly less physically active than were residents with larger social networks (b = -1503.7; P = .01) and residents with conflicting demands were more active than were residents with none (b = 601.6; P = .01), when we controlled for employment status, gender, poverty level, current health status, age, and perceived safety. Social networks were most strongly associated with physical activity among Hispanics and younger residents (aged 18-35 years). CONCLUSIONS These findings indicate that social factors, including social networks and role-related conflicting demands, may be important drivers of physical activity among low-income populations. Researchers and practitioners should consider social factors in developing multilevel physical activity interventions for this population.

Associations between perceived social environment and neighborhood safety: Health implications.

This study examined the associations between social networks, social support, social cohesion, and perceived neighborhood safety among an ethnically diverse sample of 1352 residents living in 12 low-income public housing sites in Boston, Massachusetts. For males and females, social cohesion was associated with perceived safety. For males, a smaller social network was associated with greater feelings of safety. Social support was not a significant predictor of perceived safety. The findings reported here are useful in exploring a potential pathway through which social environmental factors influence health and in untangling the complex set of variables that may influence perceived safety.

The Influence of Sociocultural Factors on Colonoscopy and FOBT Screening Adherence among Low-income Hispanics

Few studies have examined barriers and facilitators to colorectal cancer (CRC) screening among Hispanics, particularly sociocultural factors that may be relevant. This paper examines the influence of sociocultural factors on adherence to fecal occult blood testing (FOBT) and colonoscopy. A survey was conducted among a sample of 400 low-income Hispanics in East Harlem, New York. Fatalism and health literacy were both significantly associated with colonoscopy screening adherence in bivariate models, though fatalism became non-significant and health literacy became less significant in multivariable models. With respect to adherence to colonoscopy or FOBT, both fatalism and health literacy were associated in bivariate models, though only fatalism remained significant in multivariable models (p=.03; OR: .94; 95% CI: .881-.992). These findings suggest fatalism and health literacy may play a role in shaping CRC screening adherence among low-income Hispanics. Researchers should continue investigating how sociocultural factors influence screening adherence among Hispanics, using larger and more geographically diverse samples.

Implementation of culturally targeted patient navigation system for screening colonoscopy in a direct referral system

Low-income minorities often face system-based and personal barriers to screening colonoscopy (SC). Culturally targeted patient navigation (CTPN) programs employing professional navigators (Pro-PNs) or community-based peer navigators (Peer-PNs) can help overcome barriers but are not widely implemented. In East Harlem, NY, USA, where approximately half the residents participate in SC, 315 African American patients referred for SC at a primary care clinic with a Direct Endoscopic Referral System were recruited between May 2008 and May 2010. After medical clearance, 240 were randomized to receive CTPN delivered by a Pro-PN (n = 106) or Peer-PN (n = 134). Successful navigation was measured by SC adherence rate, patient satisfaction and navigator trust. Study enrollment was 91.4% with no significant differences in SC adherence rates between Pro-PN (80.0%) and Peer-PN (71.3%) (P = 0.178). Participants in both groups reported high levels of satisfaction and trust. These findings suggest that CTPN Pro-PN and Peer-PN programs are effective in this urban primary care setting. We detail how we recruited and trained navigators, how CTPN was implemented and provide a preliminary answer to our questions of the study aims: can peer navigators be as effective as professionals and what is the potential impact of patient navigation on screening adherence?

Identifying Barriers to Colonoscopy Screening for Nonadherent African American Participants in a Patient Navigation Intervention

African Americans have a higher rate of colorectal cancer (CRC) mortality than other racial/ethnic groups. This disparity is alarming given that CRC is largely preventable through the use of endoscopy (screening colonoscopy or sigmoidoscopy), yet rates of CRC screening among African Americans is suboptimal. Only 48.9% of African Americans are screened for CRC through endoscopy or fecal occult blood testing. As such, researchers have focused their efforts on the prevention of CRC through patient navigation (PN) services for colonoscopy screening. Although PN has been successful in increasing colonoscopy screening rates, screening rates of navigated participants could still be improved. Thus, the purpose of this exploratory study was to understand why patients, who received PN services, did not complete a colonoscopy. Sixteen participants were interviewed to identify salient themes related to noncompletion of the colonoscopy procedure. Major themes identified included the following: a lack of knowledge about CRC; fear/anxiety about the procedure, including unknown expectations, fear of pain, and fear of cancer diagnosis; inadequate physician communication about CRC and the colonoscopy exam; and believing that cancer leads to death. Participants felt that greater communication and explanation from their physician might help allay their fears. Our findings also suggest that a universal approach to PN, even within culturally targeted interventions, may not be appropriate for all individuals. Future interventions should consider gender-specific navigation and combining PN with nonmedical interventions to address other identified barriers.

Esperanza y Vida: A Culturally and Linguistically Customized Breast and Cervical Education Program for Diverse Latinas at Three Different United States Sites

Breast cancer is the most common cause of cancer and the leading cause of cancer death among Latinas in the United States. In addition, Latinas experience a disproportionate burden of cervical cancer incidence, morbidity, and mortality compared with non-Hispanic White women. Lower use of breast and cervical cancer screening services may contribute to these disparities. To address the underutilization of breast and cervical cancer screening among diverse subgroups of Latinas, a peer-led education program called Esperanza y Vida (“Hope and Life”) was developed and administered at 3 sites (2 in New York and 1 in Arkansas). Immigrant Latina women and their partners were educated about the importance of breast and cervical cancer screening, with the goals of increasing their knowledge about these cancers and their screening behavior. An analysis of the interventions findings at baseline among female participants demonstrated significant sociodemographic, interpersonal, cultural, health care system, and program variability in 3 distinct geographic regions in the United States. These data indicate the need for and feasibility of customizing cancer outreach and educational programs for diverse Latina subgroups living in various U.S. regions, with implications for informing the expansion and replication of the program in other regions of the country.

Training Experiences of Lay and Professional Patient Navigators for Colorectal Cancer Screening

Patient navigation (PN) is increasingly used in cancer care, but little is known about the identification and training of patient navigators. PN may be implemented by professional health care providers, paraprofessionals, or lay health workers and, therefore, presents an opportunity to compare professional and lay interventionist experiences. The goal of the current report is to compare the training experiences of four professional (Pro) and five lay (LHW) patient navigators enlisted to increase colonoscopy adherence among African American primary care patients. The results of early assessments showed that LHWs’ intervention-related knowledge was significantly lower than that of Pros. However, there were no significant differences in knowledge scores between LHWs and Pros for most subsets of knowledge items in later assessments. Furthermore, there were no significant differences in LHWs’ and Pros’ reported self-efficacy and satisfaction with training. Findings support the use of diverse strategies to train and prepare LHWs as patient navigators.

Racial Discrimination and Physical Activity Among Low-Income–Housing Residents

BACKGROUND Although discrimination has been identified as a potential determinant of existing racial/ethnic health disparities, no studies have investigated whether racial discrimination contributes to disparities in physical activity. PURPOSE The primary aim of the current study was to examine the association between interpersonal racial discrimination and physical activity. METHODS Baseline data were collected during 2004-2005 among a predominately black and Hispanic sample of adult residents living in 12 low-income-housing sites in Boston MA (n=1055). Residents reported experiences of lifetime racial discrimination during interviewer-administered surveys and wore a pedometer for 5 days to measure physical activity. For analyses, performed in 2009, linear regression models with a cluster design were conducted to predict physical activity, measured as steps per day. RESULTS Nearly 48% of participants reported ever experiencing racial discrimination, and discrimination was most commonly experienced on the street or in a public setting. No association was found between discrimination and physical activity, when examined in bivariate, multivariable, or race-stratified models. CONCLUSIONS The current results indicate that self-reported racial discrimination is not a key determinant of physical activity among residents living in low-income housing. However, additional research is warranted to address current limitations of this study.