A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / To systematically review all studies examining HPV vaccination acceptability among immigrant and ethnic minority parents and eligible individuals for cervical cancer prevention in the Unites states. MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, EMBASE, and Cochrane database searches were conducted searching for English language, US‐based studies to examine immigrant and ethnic minority population’s acceptability of HPV vaccination. Thirteen of more than 3,098 potentially relevant articles were included in the final analysis. Results. Latinos were statistically more likely to accept vaccination for both their daughters and sons. Foreign‐born adult Latinas were more accepting of the vaccine than U.S.‐born Latinas after controlling for other variables. Overall African American and Asian American parents were less likely to accept HPV vaccination for their daughters than Hispanic and White parents. Of the African American parents who intended to vaccinate their children the majority were significantly non‐Baptist and had higher levels of education. The majority of Haitian immigrants intended to vaccinate daughters and the rest agreed that they would most likely have their daughters vaccinated if their daughters’ physicians recommended it. More research is needed, particularly in the context of health care provider HPV vaccination recommendation to immigrant and ethnic‐minority populations. Acceptance figures so far suggest that the vaccine is generally well received among Hispanic/Latin and Haitian immigrants, but details of ethnic variations among these groups and a qualitative understanding of lower rates of acceptability among African American and Asian American communities are still being awaited. Despite advances in cervical cancer screening rates in the US, cervical cancer remains disproportionately high among low‐income immigrant and minority women, making this subgroup particularly vulnerable to disparities in screening and its detection. The purpose of this study is to examine the qualitative aspects of institutional and community level interventions of Cervical Intraepithelial Neoplasia (CIN) within the immigrant and refugee populations and the use of HPV vaccination as a prevention method. Combinations of the following keywords/phrases will be used: CIN‐ Cervical Intraepithelial Neoplasia, Cervical diseases, Cervical dysplasia, Refugees, Pap smear, Cervical Cancer Screening, HPV‐ Human Papillomavirus, HPV vaccination, Ethnic minorities, Immigrants. Independent reviews of each article will be conducted to assess the study quality and confirm the accuracy, completeness, and consistency of the abstracted data.

Background: Behavioral interventions and evidence based guidelines along the cancer control continuum can reduce the burden of cancer. Objectives: This dissertation aims to increase our understanding of colorectal cancer screening (CRCS) decisional conflict and breast cancer survivorship care. This project: 1) assesses CRCS decisional conflict in a general population, 2) uses the Theory of Triadic Influence to model and evaluate direct and indirect associations between CRCS decisional conflict and colonoscopy adherence, 3) assesses post-treatment breast cancer care. Methods: Data from a questionnaire administered to randomly selected adults, 50-75 years, living in six MN communities (N=1,268) and the 2010 Behavioral Risk Factor Surveillance System (BRFSS) (N=1,024, women ages 27-99) were used. Multivariable logistic regression was used to identify characteristics associated with high CRCS decisional conflict; then structural equation modelling (SEM) was performed to assess direct and indirect associations of CRCS decisional conflict and colonoscopy adherence. Using BRFSS data, multivariable logistic regression was performed to assess the association between years since diagnosis and the type of clinician providing the majority of care for breast cancer survivors after treatment completion. Results: Greater colonoscopy barriers (OR=1.04; 95% CI: 1.02-1.05) and CRCS-specific confusion (OR=1.12; 95% CI: 1.10-1.15) as well as a healthcare provider not discussing CRCS options (OR=1.67; 95% CI: 1.18-2.37) were associated with increased odds of high CRCS decisional conflict. A similar relationship was found in the SEM analyses: both greater levels of perceived colonoscopy barriers and CRCS confusion were associated with higher decisional conflict (standardized total effects=0.42 and 0.39, respectively, p-values < 0.01). CRCS decisional conflict was associated with increased non-adherence to colonoscopy. This relationship was mediated by CRCS-specific self-efficacy and intention (standardized total effect=0.14, p-value <0.01). Among breast cancer survivors, women 0–1 and 2–3 years since diagnosis were 2.1-2.6 times more likely to have a cancer-related clinician providing the majority of care compared to women 6+ years since diagnosis (95% CIs: 1.0-4.3; 1.4-4.6). Conclusions: Decreasing colonoscopy barriers and CRCS-specific confusion could decrease CRCS decisional conflict and ultimately increase CRCS uptake. National policies to move breast cancer follow-up care to a primary care provider might be well-received by cancer survivors.

Background: Screening for breast and cervical cancers is important because early detection increases cancer survival. Since 1991, the U.S. government has helped finance a national early detection program for breast and cervical cancer among uninsured low-income women, known in Virginia (VA) as Every Woman's Life (EWL).Objectives: This study aims to determine whether there are differences in the prevalence of breast and cervical cancer screening based on insurance coverage, assess the prevalence of screening by health district, and evaluate the ability of EWL to effectively reach its target population.Methods: Cross-sectional data from the 2005 Behavioral Risk Factor Surveillance System survey were analyzed. Using population weights, descriptive statistics were generated and multiple regression was performed to assess the association between insurance coverage and screening prevalence among VA women 40 to 64 years of age (n=1,627). Adjusted screening prevalence by health district was also calculated. EWL client (n=4,959) and provider data from the VA Department of Health was obtained to create screening density maps with Geographic Information Systems.Results: After adjustment, women with insurance were significantly more likely to have a mammogram within the last two years compared to those without insurance (78% vs. 50%, pConclusion: The results of this study will be used to assist EWL in recruitment of additional screening and/or diagnostic sites in underserved areas of Virginia.

Vietnamese women experience cancer screening disparities and inconsistent adherence to screening guidelines. The goal of this study was to implement and evaluate a breast and cervical cancer screening intervention to promote cancer screening knowledge, attitudes, self-efficacy, intention, and behavior for Vietnamese women. Secondary objectives of the study included examining the relationships between cultural variables (e.g., acculturation, ethnic identity, religiosity, and collectivism) and cancer screening variables. The study enrolled 102 women from the greater Richmond metropolitan area. Participants were assigned to an intervention group or a print material control group. In the intervention session, participants were exposed to information on female cancers and were taught how and where to access Pap tests and clinical breast exams (CBE). Follow-up data were collected six months after the intervention to determine whether or not there were longer-term program effects. Intervention participants also took part in focus groups that examined their reactions, thoughts, feelings, and experiences in regards to the intervention. In addition, focus groups explored participants’ sources of motivation for cancer screening and whether they shared information obtained in the sessions with other individuals. The intervention was effective in promoting immediate and longer-term gains in breast and cervical cancer knowledge, attitudes towards screening, self-efficacy for screening, and actual screening behaviors. The study’s findings indicated that acculturation was linked to higher levels of self-efficacy and screening behavior and less positive attitudes towards screening. Personal and social extrinsic religiosity were associated with more positive attitudes towards screening. Social extrinsic religiosity was also associated with more self-efficacy for screening and screening behavior. Intrinsic religiosity was linked to lower levels of self-efficacy for screening. Focus group discussions revealed that the women shared cancer-related information with friends, female family members, and husbands. Focus group discussions also revealed that emphasis on caretaking roles may help increase women’s adherence to screening guidelines. This study provides evidence for the effectiveness of culturally-tailored strategies in developing cancer screening interventions for the Vietnamese population. This study also demonstrates how health information is transmitted across informal channels within faith-based communities.

Introduction: Shared decision making (SDM) has been advocated as an optimal approach to medical decision-making. Yet, little is known about how patients perceive SDM and whether patient-defined SDM is associated with patient outcomes. Methods: This three-manuscript dissertation used a mixed-methods approach including a systematic literature review and both qualitative and quantitative research methods. The aims were to: (1) systematically review the patient outcomes studied in relation to SDM and identify under what measurement contexts SDM is associated with which types of patient outcomes; (2) use in-depth, qualitative interviews to develop a conceptual model of patient-defined SDM and compare this to recent decisions that patients labeled as shared; and (3) apply the model of patient-defined SDM to the context of colorectal cancer screening. Results: Study 1 found that 39 studies measured SDM and evaluated it with a patient outcome, and only 43% of patient outcomes assessed were significantly associated with SDM. Patient reports of SDM were most likely to be associated with outcomes. Study 2 found that patients’ conceptual definition of SDM included four components: exchange of information, active listening, patient-self advocacy, and a personalized physician recommendation. Patient descriptions of recent decisions labeled as shared ranged from very simple recommendations through complex interactions, with the only commonality among shared decisions being that the patient and physician ultimately agreed. Study 3 found that the most commonly observed component of patient-defined SDM was patient self-advocacy (76%) and least common was a personalized physician recommendation (23%). Only 9% visits contained all four patient-defined SDM components. In adjusted models, physician provision of information around the process and potential side effects of colorectal cancer screening was associated with an increase in screening. There were differences in screening rates by the patient’s initial verbal response to the physician recommendation with those who initially refused being least likely to be screened (40%) and patients who did not verbalize a response to the recommendation being most likely to be screened (70%). Discussion: Findings across the three studies highlight the complexity of studying and measuring SDM and emphasize the importance of the patient’s perspective on SDM.

Background: The current adherence to colorectal cancer screening (CRCS) guidelines is suboptimal. How neighborhood characteristics, e.g., racial residential segregation (RRS), area-level socioeconomic status (SES) and physician composition, affect CRCS adherence are not fully understood. We assessed associations between facility proximity to RRS areas, area-level SES, physician composition, and CRCS adherence. Methods: Data sources included 2013 Minnesota Community Measurement, 2009-2013 American Community Survey, 2012 U.S. and 2012-2013 Washington State Behavioral Risk Factor Surveillance System data, and 2013-2014 Area Health Resource File. Logistic regressions and weighted multilevel logistic regressions were used to assess the association between facility proximity to RRS areas and CRCS adherence, and association between area-level SES, physician composition and CRCS adherence, respectively. Results: Facility proximity to RRS areas was positively associated with low CRCS performance, e.g., facilities located < 2 miles away from Hispanic-segregated areas were 3 times more likely to have low CRCS performance than those at ≥5 miles away (odds ratio (OR): 2.83, 95% confidence interval (CI): 1.29, 6.24). Most area-level SES measures showed negative bivariate associations between deprivation and colonoscopy/overall adherence, and measures such as education had relatively strong associations, although few of fully-adjusted associations remained statistically significant. Further, a one-unit increase in the percentage of gastroenterologists among physicians was associated with 3% increase in the odds of colonoscopy (OR: 1.03, 95% CI: 1.01-1.04) and overall adherence (OR: 1.03, 95% CI: 1.01-1.04) in the rural-metropolitan areas. Conclusions: Developing culturally tailored CRCS programs, increasing percentage of gastroenterologists, and targeting deprived communities may improve CRCS adherence.

Thesis advisor: James Lubben / In 2011, an estimated 12,710 women suffered from cervical cancer and 4,290 died from it in the U.S. HPV vaccination (HPV-V) and PAP screening (PAP-S) could reduce this burden. Using 2010 National Health Interview Survey data, current disparities in the use of PAP-S and HPV-V in U.S. women aged 18-30 years were investigated. An adapted Behavioral Model of Health Care Utilization guided the study. Main outcomes were PAP-S in prior year and ever-HPV-V, both initiation and completion. Adjusted predictor estimates were obtained through multivariate logistic regressions with appropriate statistical procedures and weights for complex survey design. A sub-analysis focused on unvaccinated women. The sample had 3,129 women aged 18-30 years, representing about 27 million women of similar age in the U.S. PAP-S, HPV-V initiation and completion rates were 53.5%, 17.9%, and 10.3%, respectively. Hispanics were 33% less likely than Non-Hispanic-Whites to initiate HPV-V. Non-Hispanic-Blacks were 55% more likely and 57% less likely than Non-Hispanic-Whites to receive PAP-S and complete HPV-V, respectively. Non-Hispanic Asians were 36% less likely than Non-Hispanic-Whites to receive PAP-S, but this result was borderline significant. Younger age and being unmarried were predictors of lower PAP-S but higher HPV-V. Ever gave birth was a predictor of higher PAP-S but lower HPV-V. Preventative behaviors (PAP-S and flu vaccination) were predictors of higher HPV-V. STI-history was a predictor of higher HPV-V and PAP-S. Not having health insurance for over one year or recent health provider visit were predictors of lower PAP-S and HPV-V. Living in the South was a predictor of lower HPV-V. Household income was not a predictor of any outcomes. Most common reported reason for no HPV-V was "no need." Study findings indicate interventions to mitigate disparities in cervical cancer prevention are needed. Tailored education interventions for both women and health care providers along with opportunities associated with the 2010 Affordable Care Act, such as broader access to health care, emphasis on health information technology, and initiatives with PAP screening and adult vaccination as potential quality indicators for performance/payment, can reduce these disparities. Future research should focus on the feasibility of alternative venues for receiving HPV-V and PAP-S. / Thesis (PhD) — Boston College, 2013. / Submitted to: Boston College. Graduate School of Social Work. / Discipline: Social Work.

Thesis (MPA.) -- University of Limpopo, 2018 / Background: Cancer of the cervix is the fourth most common cancer affecting women worldwide and is currently considered as a sexually transmitted cancer. This type of cancer is caused in most cases by a viral infection, Human Papilloma Virus (HPV) strains 16 and 18. Cervical screening aims to prevent invasive cervical carcinoma by detection and treatment of its precursors cervical intraepithelial neoplasia grade 2 (CIN2) and, particularly, grade 3 (CIN3). The current study aimed at determining the distribution of cervical cancer and the association of cervical cancer with HIV infection in Limpopo Province. Methods: The current study used quantitative retrospective method to systematically review the available data on Papanicolaou (Pap) smears from National Health Laboratory Services at Polokwane hospital from the year 2013 to 2015. The data was kept anonymously by not using the names of the patients and ethical clearance was received from the Turfloop Research Committee of University of Limpopo in consideration of section 14, 15, 16, and 17 of National Health Act 61 of 2004. The data was exported to excel spreadsheet and cleaned before exported into SPSS 23.0 software which was used for data analysis. Results: The findings from the current study show a decline of 33% in the number of Pap smears that were submitted for cytology between 2013 (82 041) and 2015 (23 527) in Limpopo province. However, the study revealed that there is an increase in prevalence of cervical cancer from 16.7% in 2013 to 19.2% in 2015 in Limpopo Province. In the same period this rural province already demonstrates a high burden of cervical cancer among the middle aged women. The positive cervical smears were classified as cervical intraepithelial neoplasia (CIN) I, II, or III and therefore, 78.5% were CIN I, 21% CIN II and 0,5% CIN III. HIV infections have been found to be associated with cervical cancer as the prevalence of cervical cancer among HIV positive women was found to be 25% and most of the affected women are the middle aged group. vi Conclusion: The screening coverage for cervical cancer has decreased in Limpopo Province but the prevalence of cervical cancer has increased by 2.5% therefore, this translates to the need for community awareness about prevention of cervical cancer. Majority of the cases were classified as CIN 1 at 78.5% which can be cured if treatment started early. The Limpopo Province should therefore strengthen strategies to integrate HIV and cervical cancer services as it was found that there is a strong association between the HIV and cervical cancer.

African Americans bear a disproportionately high burden of cancer incidence and mortality in this country. The purpose of this dissertation was to investigate factors associated with African-American men, who are incarcerated, making informed health decisions about participation in prostate cancer screening, as well as exploring factors that reduce modifiable risk factors for cancer. The United States incarcerates more people per capita than any country in the world and African American men are overrepresented in the U.S. prison system This dissertation is composed of three manuscripts. The first paper reviews the current literature about the factors that influence African-American males in making informed decisions about whether to participate in prostate cancer screening. The second paper uses existing data from a sample of 129 incarcerated African American men to examine the value of an intervention aimed at reducing modifiable risks for cardiovascular disease – and by extension, cancer – in inmates. The third paper explores predictors of intent to screen (or not) for prostate cancer in incarcerated African-American males, as well as those factors that influence informed decision-making in this population. These papers provide an overview of factors that influence incarcerated African-American men’s health decisions (health literacy, having a relative with previous diagnosis). These findings can be used to guide future research that addresses African-American male decision-making about personal health outcomes.

Background. CRC risk can be reduced though lifestyle modification and regular screenings. Providing CRC risk feedback that promotes preventive behaviors to those at average risk has the potential to significantly reduce CRC morbidity and mortality. Purpose. The purpose of this dissertation was to examine the impact of CRC risk assessment feedback among adults aged 50-75 with no personal or family history of the disease. The specific aims were to: (1a) test personalized (vs. generic) risk assessment feedback on individuals’ risk perceptions and intentions to engage in three risk-reducing behaviors (e.g., physical activity, diet, and screening); (1b) determine if the provision of CRC risk information influences breast cancer risk perceptions and mammography intentions; (2a) examine individuals’ accuracy of perceived lifetime risk of CRC; (2b) assess whether improved accuracy following risk assessment was associated with changes in behavioral intentions; and finally, (3) evaluate the use of a unique sampling procedure designed to increase diversity of survey respondents. Methods. A pre-post parallel, two arm randomized controlled trial examined the effects of providing CRC risk assessment feedback that included lifetime risk estimates and information about CRC risk factors that was either personalized (treatment) or generic (control). N=419 average risk adults between the ages of 50-75 were recruited from a commercial online panel. Results. There were no differences in risk perception between study arms. Overall participants, perceived lifetime risk of CRC lowered at post-test and seemingly produced a spillover effect in lowered perceived lifetime risk of breast cancer among females. CRC screening intentions increased in both study arms and mammography intentions increased in the control arm. Accuracy of lifetime risk improved at post-test, but was not associated with changes in intentions to perform risk reducing behaviors. Quota sampling acquired a targeted and diverse sample quickly and efficiently. Conclusion. Communicating CRC risk information to average risk adults can improve CRC risk perception accuracy and enhance colorectal and mammography screening intentions. Risk assessment feedback did not consistently influence intentions to improve diet and physical activity.