Sarah Lyons

Relationship Between Health Literacy and Unintentional and Intentional Medication Nonadherence in Medically Underserved Patients With Type 2 Diabetes

Purpose The purpose of this study was to investigate the relationship between health literacy and overall medication nonadherence, unintentional nonadherence, and intentional nonadherence. Limited health literacy may be associated with worse diabetes outcomes, but the literature shows mixed results, and mechanisms remain unclear. Medication adherence is associated with diabetes outcomes and may be a mediating factor. Distinguishing between unintentional and intentional nonadherence may elucidate the relationship between health literacy and nonadherence in patients with type 2 diabetes. Methods Cross-sectional study of 208 patients with type 2 diabetes recruited from a primary care clinic in St. Louis, Missouri. Information was obtained from written questionnaire and patient medical records. Bivariate and multivariable regression were used to examine predictors of medication nonadherence. Results The majority of patients in the study were low income, publicly insured, and African American, with limited health literacy and a high school/GED education or less. In multivariable models, limited health literacy was significantly associated with increased unintentional nonadherence but not intentional nonadherence. Conclusions Results suggest differences in factors affecting intentional and unintentional nonadherence. The findings also suggest interventions are needed to decrease unintentional nonadherence among patients with type 2 diabetes and limited health literacy. Efforts to address unintentional medication nonadherence among patients with type 2 diabetes with limited health literacy may improve patient health.

Racial Composition Over the Life Course: Examining Separate and Unequal Environments and the Risk for Heart Disease for African American Men.

PURPOSE Studies have demonstrated the effects of segregated social and physical environments on the development of chronic diseases for African Americans. Studies have not delineated the effects of segregated environments specifically on the health of African American men over their lifetime. This study examines the relationship between life course measures of racial composition of social environments and diagnosis of hypertension among African American men. DESIGN We analyzed cross-sectional data from a convenience sample of African American men seeking health care services in an outpatient primary care clinic serving a medically underserved patient population (N=118). Multivariable logistic regression analyses were used to examine associations between racial composition of multiple environments across the life course (eg, junior high school, high school, neighborhood growing up, current neighborhood, place of employment, place of worship) and hypertension diagnosis. RESULTS The majority (86%) of participants were not currently in the workforce (retired, unemployed, or disabled) and more than half (54%) reported an annual household income of <

Mammograms on-the-go—predictors of repeat visits to mobile mammography vans in St Louis, Missouri, USA: a case–control study

9,999; median age was 53. Results suggest that African American men who grew up in mostly Black neighborhoods (OR=4.3; P=.008), and worked in mostly Black environments (OR=3.1; P=.041) were more likely to be diagnosed with hypertension than those who did not. CONCLUSION We found associations between mostly Black residential and workplace settings and hypertension diagnoses among African American men. Findings suggest exposure to segregated environments during childhood and later adulthood may impact hypertension risk among African American men over the life course.

Using Small-Area Analysis to Estimate County-Level Racial Disparities in Obesity Demonstrating the Necessity of Targeted Interventions

Objectives Among women, breast cancer is the most common non-cutaneous cancer and second most common cause of cancer-related death. The purpose of this study was to determine the extent to which women use mobile mammography vans for breast cancer screening and what factors are associated with repeat visits to these vans. Design A case–control study. Cases are women who had a repeat visit to the mammography van. (n=2134). Participants Women who received a mammogram as part of Siteman Cancer Centers Breast Health Outreach Program responded to surveys and provided access to their clinical records (N=8450). Only visits from 2006 to 2014 to the mammography van were included. Outcome measures The main outcome is having a repeat visit to the mammography van. Among the participants, 25.3% (N=2134) had multiple visits to the mobile mammography van. Data were analysed using χ2 tests, logistic regression and negative binomial regression. Results Women who were aged 50–65, uninsured, or African-American had higher odds of a repeat visit to the mobile mammography van compared with women who were aged 40–50, insured, or Caucasian (OR=1.135, 95% CI 1.013 to 1.271; OR=1.302, 95% CI 1.146 to 1.479; OR=1.281, 95% CI 1.125 to 1.457), respectively. However, the odds of having a repeat visit to the van were lower among women who reported a rural ZIP code or were unemployed compared with women who provided a suburban ZIP code or were employed (OR=0.503, 95% CI 0.411 to 0.616; OR=.868, 95% CI 0.774 to 0.972), respectively. Conclusion This study has identified key characteristics of women who are either more or less likely to use mobile mammography vans as their primary source of medical care for breast cancer screening and have repeat visits.

Decision role preferences for return of results from genome sequencing amongst young breast cancer patients

Data on the national and state levels is often used to inform policy decisions and strategies designed to reduce racial disparities in obesity. Obesity-related health outcomes are realized on the individual level, and policies based on state and national-level data may be inappropriate due to the variations in health outcomes within and between states. To examine county-level variation of obesity within states, we use a small-area analysis technique to fill the void for county-level obesity data by race. Five years of Behavioral Risk Factor Surveillance System data are used to estimate the prevalence of obesity by county, both overall and race-stratified. A modified weighting system is used based on demographics at the county level using 2010 census data. We fit a multilevel reweighted regression model to obtain county-level prevalence estimates by race. We compare the distribution of prevalence estimates of non-Hispanic Blacks to non-Hispanic Whites. For 25 of the 26 states included in our analysis there is a statistically significant difference between within-state county-level average obesity prevalence rates for non-Hispanic Whites and non-Hispanic Blacks. This study provides information needed to target disparities interventions and resources to the local areas with greatest need; it also identifies the necessity of doing so.

How Segregation Makes Us Fat: Food Behaviors and Food Environment as Mediators of the Relationship Between Residential Segregation and Individual Body Mass Index

OBJECTIVE To better understand decision role preferences in women diagnosed with breast cancer at a young age for return of results of genome sequencing in research and clinical settings. METHODS Participants were surveyed about communication and decision-making preferences related to genome sequencing results and factors that may affect these preferences. The primary outcome was decision role preference (Control Preference Scale) for selecting what results to receive within medical care or within a research study. RESULTS For results returned as part of medical care, most patients preferred a collaborative (N = 481, 45%) or active (N = 488, 45%) role with only 107 (10%) choosing a passive role. When making the decision as part of a research study, most patients preferred an active role (N = 617, 57%), 350 (33%) choosing a collaborative role, and110 (10%) choosing a passive role. CONCLUSION Most women in this study preferred to share in decision making. Participants had somewhat different role preferences for clinical and research contexts, with greater preference for active roles in the research context. PRACTICE IMPLICATIONS We advocate for practice guidelines that incorporate discussion of decision role as an integral part of patient centered care and shared decision-making and recognize that more work is needed to inform guidelines.

Abstract C73: A mobile mammography outreach program to increase screening in medically underserved areas in Missouri

Objectives Racial residential segregation affects food landscapes that dictate residents’ food environments and is associated with obesity risk factors, including individual dietary patterns and behaviors. We examine if food behaviors and environments mediate the association between segregation and body mass index (BMI). Methods Non-Hispanic Whites and Blacks living in the St. Louis and Kansas City metro regions from 2012 to 2013 were surveyed on dietary behaviors, food environment, and BMI (n = 1,412). These data were combined with the CDC’s modified retail food environment index and 2012 American Community Survey data to calculate racial segregation using various evenness and exposure indices. Multi-level mediation analyses were conducted to determine if dietary behavior and food environment mediate the association between racial residential segregation and individual BMI. Results The positive association between racial segregation and individual BMI is partially mediated by dietary behaviors and fully mediated by food environments. Conclusion Racial segregation (evenness and exposure) is associated with BMI, mediated by dietary behaviors and food environment. Elements of the food environment, which form the context for dietary behaviors, are potential targets for interventions to reduce obesity in residentially segregated areas.

Abstract C12: An examination of intention to donate biospecimen among women considering consent models and health care discrimination

Background : Breast cancer screening rates still lag behind US Preventive Services Task Force recommendations. Mobile health units are one common strategy to address barriers to mammography screening. Mobile mammography programs improve screening rates in medically underserved and rural communities by reducing barriers such as cost and travel distance. The aim of this study was to evaluate the characteristics of women who participated in a mobile mammography screening program affiliated with a comprehensive cancer center in Missouri. Methods : The Alvin J. Siteman Cancer Center (SCC) at Washington University School of Medicine initiated a Mammography Outreach Registry to assess the effectiveness of mammography services among the medically underserved. The Breast Health Center is housed within the SCC and provides on-site service as well as off-site care through use of a single mobile mammography van (MMV). The Registry database included women who received a mammogram on the MMV between April 2006 and July 2015. The total sample included 10,523 women. The sample was stratified to examine women served by the MMV who lived in designated Medically Underserved Areas (MUAs) versus non-MUAs. Results : The MMV traveled throughout much of the eastern portion of Missouri, serving both the urban St. Louis region as well as rural areas in the southeastern “Bootheel” region. The total sample included 57% non-Hispanic Black, 33% non-Hispanic White, and 10% of other races, with a mean age of 52 years old. The majority (72%) of women had no insurance and were unemployed (67%). Over three-quarters (77%) reported annual household income less than

Abstract P1-11-13: An evaluation of mobile mammography outreach in urban and rural communities

20,000 and 74% had completed 12 years or less of education. About one-quarter of women reported a family history of breast cancer and presented for their first mammogram (21%). Approximately 25% of women who received MMV services were from MUAs, mainly in St. Louis City, northern St. Louis County, and the rural Bootheel region. MUAs had a statistically significantly higher prevalence of women who are Black, unmarried, have lower education and lower income, and who are current cigarette smokers compared to non–MUAs. Conclusions : The MMV improved access to breast cancer screening among a largely vulnerable uninsured population, reaching women in both urban and rural areas in Missouri. In particular, the MMV successfully engaged economically disadvantaged women in MUAs including women without health insurance, who had never had a mammogram, and those with a family history of breast cancer. While much of the research on MMVs illustrates the impact on improving access to mammography in rural areas, this study highlights there is an unmet need for low/no-cost preventive services in both urban and rural areas. In states such as Missouri, with a large number of health professional shortage areas and that did not expand Medicaid under the Affordable Care Act, MMVs are even more imperative to provide mammography screening to populations that do not routinely access preventive health services. MMVs should work closely with community-based partners and safety net health clinics in both urban and rural MUAs to maximize MMVs outreach efforts. Further, given the higher number of women in MUAs reported as current smokers, outreach conducted by MMV staff may also coordinate efforts to create interventions tailored to women who smoke in MUAs to address smoking cessation. Citation Format: Goldie Komaie, Sarah Lyons, Catherine Appleton, Katherine Glover-Collins, Christine Marx, Graham Colditz. A mobile mammography outreach program to increase screening in medically underserved areas in Missouri [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C73.

Abstract P3-07-16: Does annual mammogram screening incur lower healthcare costs for breast cancer women after diagnosis?

The purpose of this study is to examine the influence of different consent models on the intention to donate a biospecimen for use in secondary research, accounting for having experienced racial health care discrimination. Specifically, the influence of the notice, broad consent, and study-specific consent models is explored. Biospecimen donation is important for the advancement of medical cancer research. Discrimination may impede biospecimen donation. The analyses presented offer some indication of the type of consent model that may have the strongest potential to minimize negative effects of health care discrimination on intentions to donate biospecimen. In this study, self-identified non-Hispanic White and non-Hispanic Black women age 35 and older were recruited to complete a survey that was primarily self-administered. The Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R) component of the survey was administered by trained research staff. In addition to baseline questions, the survey included a randomized component, which involved participants seeing three brochures explaining each of the consent models in a randomized order. Participants were asked to indicate their intentions to donate following exposure to each of the models and asked to pick their preferred model after having viewed all three. Preliminary chi-square analyses suggest discrimination negatively influences willingness to consent to donate. Specifically, there is a significant difference by general intention to donate as well as intention to donate to multiple studies, Washington University studies, and studies in which Protected Health Information (PHI) is attached to the sample. Of note, those having experienced health care discrimination are significantly different regarding general intentions to donate from those who had not experienced health care discrimination in intentions to donate after receiving brochures about both notice (p=0.0101) and broad consent (p=0.0002) models. Also, participants who reported experiencing health care discrimination are significantly different from those who had not reported experiencing health care discrimination for intention to donate to multiple studies and if PHI was attached to the sample across all consent model types - notice, broad, and study-specific. In each case, noticeably smaller percentages of those who reported experiencing at least some health care discrimination indicated intentions to definitely consent to donate. These preliminary findings suggest health care discrimination can negatively affect the potential benefits of cancer research via hindering biospecimen donation. In additional analyses, we will be able to determine the influence of additional sociodemographic factors on the relationship between the experience of health care discrimination and intentions to donate biospecimen. Ultimately, reducing the likelihood and actual occurrences of health care discrimination through addressing the root causes of health care discrimination is an important goal. Examining the influence of consent model types on the relationships between health care discrimination and intentions to donate biospecimen can provide cues as to models of information to provide that can minimize the impact of discrimination on biospecimen donation. Appropriate models of information to provide may vary by study type. Citation Format: Karyn Stewart, Katherine Brown, Bettina Drake, Sarah Gehlert, Leslie Wolf, James Dubois, Hannah Perkins, Sarah Lyons, Melody Goodman, Kimberly Kaphingst. An examination of intention to donate biospecimen among women considering consent models and health care discrimination. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr C12.