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1.  Cancer Screening and Haitian Immigrants: The Primary Care Provider Factor 
Haitian immigrants, among the fastest growing immigrant communities in the United States, have low cancer screening rates. Several patient barriers have been identified and associated with low screening rates but little is known on provider barriers for cancer screening. To address this gap, we assessed the cancer screening practices, attitudes, and beliefs of primary care providers serving the Haitian community.
We surveyed a random sample of physicians serving first generation Haitian immigrants in New York City, identified through their zip codes of practice. Participants completed a questionnaire to assess their beliefs, attitudes and practices surrounding cancer screening, and their perceptions of patient barriers to screening.
50 of 87 physicians (58%) consented to participate in the study. Cancer site-specific and overall cancer screening scores were created for breast, cervical, and colorectal cancer screening. 75% of providers followed breast cancer screening guidelines, 16% for cervical cancer, and 30% for colorectal cancer. None of the providers in the sample were following guidelines for all three cancer sites. Additionally, 97% reported recommending digital rectal exam and PSA annually to patients 50 years or older with no family history, and 100% to patients over 50 years old with family history.
The reported practices of providers serving the Haitian immigrant community in New York City are not fully consistent with practice guidelines. Efforts should be made to reinforce screening guideline knowledge in physicians serving the Haitian immigrant community, to increase the utilization of systems that increase cancer screening, and to implement strategies to overcome patient barriers.
PMCID: PMC3315358  PMID: 17647104
Haitian immigrants; Physicians practices; Cancer screening
2.  Language Use and the Receipt of Cancer Screening Recommendations by Immigrant Chinese American Women 
Journal of Women's Health  2009;18(2):201-207.
Cancer screening rates are low among Chinese American women, a mostly immigrant minority population. This is possibly because they do not receive cancer screening recommendations from their physicians. The objective of this study was to determine if the rate at which physicians recommend cancer screening to older Chinese American women differs according to the language used during visits.
Data for the cross-sectional study were collected from a telephone survey of older Chinese American women residing in the Washington, DC, area. A total of 507 asymptomatic Chinese American women aged ≥50 who had a regular physician participated in this study. The main outcome was women's self-reported perception of having received a recommendation from their physician for mammography, Pap tests, or colorectal cancer screening in the past 2 years. The main independent variable was the language used during visits (English vs. Chinese). Patient age, educational level, employment status, cultural views, physician specialty, physician gender, and length of relationship with the physician were included in the multiple logistic regression analyses.
Chinese women who communicated with their physicians in English were 1.71 (95% CI 1.00-2.96) and 1.73 (95% CI 1.00-3.00) times more likely to report having received mammography and colorectal cancer screening recommendations, respectively (p < 0.05). Physicians in family medicine or general practice were 2.11 (95% CI 1.31-3.40) and 1.70 (95% CI 1.06-2.48) times more likely to recommend cancer screening than those in other specialties.
Chinese American women who conversed with their physicians in Chinese were less likely to perceive receiving cancer screening recommendations. Future research is needed to identify physician-specific knowledge, attitude, and cultural barriers to recommending cancer screening.
PMCID: PMC2945721  PMID: 19183091
3.  Cancer screening practices among primary care physicians serving Chinese Americans in San Francisco. 
Western Journal of Medicine  1999;170(3):148-155.
Previous research has reported a lack of regular cancer screening among Chinese Americans. The overall objectives of this study were to use a mail survey of primary care physicians who served Chinese Americans in San Francisco to investigate: a) the attitudes, beliefs, and practices regarding breast, cervical, and colon cancer screening and b) factors influencing the use of these cancer screening tests. The sampling frame for our mail survey consisted of: a) primary care physicians affiliated with the Chinese Community Health Plan and b) primary care physicians with a Chinese surname listed in the Yellow Pages of the 1995 San Francisco Telephone Directory. A 5-minute, self-administered questionnaire was developed and mailed to 80 physicians, and 51 primary care physicians completed the survey. A majority reported performing regular clinical breast examinations (84%) and teaching their patients to do self-breast examinations (84%). However, the rate of performing Pap smears was only 61% and the rate of ordering annual mammograms for patients aged 50 and older was 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. Barriers (patient-specific, provider-specific, and practice logistics) to using cancer screening tests were identified. The data presented in this study provide a basis for developing interventions to increase performance of regular cancer screening among primary care physicians serving Chinese Americans. Cancer screening rates may be improved by targeting the barriers to screening identified among these physicians. Strategies to help physicians overcome these barriers are discussed.
PMCID: PMC1305532  PMID: 10214101
4.  Physician Emigration from Sub-Saharan Africa to the United States: Analysis of the 2011 AMA Physician Masterfile 
PLoS Medicine  2013;10(9):e1001513.
Siankam Tankwanchi and colleagues used the AMA Physician Masterfile and the WHO Global Health Workforce Statistics on physicians in sub-Saharan Africa to determine trends in physician emigration to the United States.
Please see later in the article for the Editors' Summary
The large-scale emigration of physicians from sub-Saharan Africa (SSA) to high-income nations is a serious development concern. Our objective was to determine current emigration trends of SSA physicians found in the physician workforce of the United States.
Methods and Findings
We analyzed physician data from the World Health Organization (WHO) Global Health Workforce Statistics along with graduation and residency data from the 2011 American Medical Association Physician Masterfile (AMA-PM) on physicians trained or born in SSA countries who currently practice in the US. We estimated emigration proportions, year of US entry, years of practice before emigration, and length of time in the US. According to the 2011 AMA-PM, 10,819 physicians were born or trained in 28 SSA countries. Sixty-eight percent (n = 7,370) were SSA-trained, 20% (n = 2,126) were US-trained, and 12% (n = 1,323) were trained outside both SSA and the US. We estimated active physicians (age ≤70 years) to represent 96% (n = 10,377) of the total. Migration trends among SSA-trained physicians increased from 2002 to 2011 for all but one principal source country; the exception was South Africa whose physician migration to the US decreased by 8% (−156). The increase in last-decade migration was >50% in Nigeria (+1,113) and Ghana (+243), >100% in Ethiopia (+274), and >200% (+244) in Sudan. Liberia was the most affected by migration to the US with 77% (n = 175) of its estimated physicians in the 2011 AMA-PM. On average, SSA-trained physicians have been in the US for 18 years. They practiced for 6.5 years before US entry, and nearly half emigrated during the implementation years (1984–1999) of the structural adjustment programs.
Physician emigration from SSA to the US is increasing for most SSA source countries. Unless far-reaching policies are implemented by the US and SSA countries, the current emigration trends will persist, and the US will remain a leading destination for SSA physicians emigrating from the continent of greatest need.
Please see later in the article for the Editors' Summary
Editors' Summary
Population growth and aging and increasingly complex health care interventions, as well as existing policies and market forces, mean that many countries are facing a shortage of health care professionals. High-income countries are addressing this problem in part by encouraging the immigration of foreign health care professionals from low- and middle-income countries. In the US, for example, international medical graduates (IMGs) can secure visas and permanent residency by passing examinations provided by the Educational Commission of Foreign Medical Graduates and by agreeing to provide care in areas that are underserved by US physicians. Inevitably, the emigration of physicians from low- and middle-income countries undermines health service delivery in the emigrating physicians' country of origin because physician supply is already inadequate in those countries. Physician emigration from sub-Saharan Africa, which has only 2% of the global physician workforce but a quarter of the global burden of disease, is particularly worrying. Since 1970, as a result of large-scale emigration and limited medical education, there has been negligible or negative growth in the density of physicians in many countries in sub-Saharan Africa. In Liberia, for example, in 1973, there were 7.76 physicians per 100,000 people but by 2008 there were only 1.37 physicians per 100,000 people; in the US, there are 250 physicians per 100,000 people.
Why Was This Study Done?
Before policy proposals can be formulated to address global inequities in physician distribution, a clear picture of the patterns of physician emigration from resource-limited countries is needed. In this study, the researchers use data from the 2011 American Medical Association Physician Masterfile (AMA-PM) to investigate the “brain drain” of physicians from sub-Saharan Africa to the US. The AMA-PM collects annual demographic, academic, and professional data on all residents (physicians undergoing training in a medical specialty) and licensed physicians who practice in the US.
What Did the Researchers Do and Find?
The researchers used data from the World Health Organization (WHO) Global Health Workforce Statistics and graduation and residency data from the 2011 AMA-PM to estimate physician emigration rates from sub-Saharan African countries, year of US entry, years of service provided before emigration to the US, and length of time in the US. There were 10,819 physicians who were born or trained in 28 sub-Saharan African countries in the 2011 AMA-PM. By using a published analysis of the 2002 AMA-PM, the researchers estimated that US immigration among sub-Saharan African-trained physicians had increased over the past decade for all the countries examined except South Africa, where physician emigration had decreased by 8%. Overall, the number of sub-Saharan African IMGs in the US had increased by 38% since 2002. More than half of this increase was accounted for by Nigerian IMGs. Liberia was the country most affected by migration of its physicians to the US—77% of its estimated 226 physicians were in the 2011 AMA-PM. On average, sub-Saharan African IMGs had been in the US for 18 years and had practiced for 6.5 years before emigration. Finally, nearly half of the sub-Saharan African IMGs had migrated to US between 1984 and 1995, years during which structural adjustment programs, which resulted in deep cuts to public health care services, were implemented in developing countries by international financial institutions as conditions for refinancing.
What Do These Findings Mean?
Although the sub-Saharan African IMGs in the 2011 AMA-PM only represent about 1% of all the physicians and less than 5% of the IMGs in the AMA-PM, these findings reveal a major loss of physicians from sub-Saharan Africa. They also suggest that emigration of physicians from sub-Saharan Africa is a growing problem and is likely to continue unless job satisfaction for physicians is improved in their country of origin. Moreover, because the AMA-PM only lists physicians who qualify for a US residency position, more physicians may have moved from sub-Saharan Africa to the US than reported here and may be working in other jobs incommensurate with their medical degrees (“brain waste”). The researchers suggest that physician emigration from sub-Saharan Africa to the US reflects the complexities in the labor markets for health care professionals in both Africa and the US and can be seen as low- and middle-income nations subsidizing the education of physicians in high-income countries. Policy proposals to address global inequities in physician distribution will therefore need both to encourage the recruitment, training, and retention of health care professionals in resource-limited countries and to persuade high-income countries to train more home-grown physicians to meet the needs of their own populations.
Additional Information
Please access these websites via the online version of this summary at
The Foundation for Advancement of International Medical Education and Research is a non-profit foundation committed to improving world health through education that was established in 2000 by the Educational Commission for Foreign Medical Graduates
The Global Health Workforce Alliance is a partnership of national governments, civil society, international agencies, finance institutions, researchers, educators, and professional associations dedicated to identifying, implementing and advocating for solutions to the chronic global shortage of health care professionals (available in several languages)
Information on the American Medical Association Physician Masterfile and the providers of physician data lists is available via the American Medical Associations website
The World Health Organization (WHO) annual World Health Statistics reports present the most recent health statistics for the WHO Member States
The Medical Education Partnership Initiative is a US-sponsored initiative that supports medical education and research in sub-Saharan African institutions, aiming to increase the quantity, quality, and retention of graduates with specific skills addressing the health needs of their national populations
CapacityPlus is the USAID-funded global project uniquely focused on the health workforce needed to achieve the Millennium Development Goals
Seed Global Health cultivates the next generation of health professionals by allying medical and nursing volunteers with their peers in resource-limited settings
"America is Stealing the Worlds Doctors", a 2012 New York Times article by Matt McAllester, describes the personal experience of a young doctor who emigrated from Zambia to the US
Path to United States Practice Is Long Slog to Foreign Doctors, a 2013 New York Times article by Catherine Rampell, describes the hurdles that immigrant physicians face in practicing in the US
PMCID: PMC3775724  PMID: 24068894
Ethnicity & health  2009;14(6):575-589.
Recent US data indicate that women of Vietnamese descent have higher cervical cancer incidence rates than women of any other race/ethnicity, and lower levels of Pap testing than white, black, and Latina women. Our objective was to provide information about Pap testing barriers and facilitators that could be used to develop cervical cancer control intervention programs for Vietnamese American women.
We conducted a cross-sectional, community-based survey of Vietnamese immigrants. Our study was conducted in metropolitan Seattle, Washington. A total of 1,532 Vietnamese American women participated in the study. Demographic, health care, and knowledge/belief items associated with previous cervical cancer screening participation (ever screened and screened according to interval screening guidelines) were examined.
Eighty-one percent of the respondents had been screened for cervical cancer in the previous three years. Recent Pap testing was strongly associated (p<0.001) with having a regular doctor, having a physical in the last year, previous physician recommendation for testing, and having asked a physician for testing. Women whose regular doctor was a Vietnamese man were no more likely to have received a recent Pap smear than those with no regular doctor.
Our findings indicate that cervical cancer screening disparities between Vietnamese and other racial/ethnic groups are decreasing. Efforts to further increase Pap smear receipt in Vietnamese American communities should enable women without a source of health care to find a regular provider. Additionally, intervention programs should improve patient-provider communication by encouraging health care providers (especially male Vietnamese physicians serving women living in ethnic enclaves) to recommend Pap testing, as well as by empowering Vietnamese women to specifically ask their physicians for Pap testing.
PMCID: PMC2788032  PMID: 19626504
Cervical cancer; Immigrants; Pap testing; Vietnamese
6.  Mammography Screening among Chinese-American Women 
Cancer  2003;97(5):1293-1302.
Breast carcinoma is the most common major malignancy among several Asian-American populations. This study surveyed mammography screening knowledge and practices among Chinese-American women.
In 1999, the authors conducted a cross-sectional, community-based survey in Seattle, Washington. Bilingual and bicultural interviewers administered surveys in Mandarin, Cantonese, or English at participants’ homes.
The survey cooperation rate (responses among reachable and eligible households) was 72% with 350 eligible women (age ≥ 40 years with no prior history of breast carcinoma or double mastectomy). Seventy-four percent of women reported prior mammography screening, and 61% of women reported screening in the last 2 years. In multivariate analysis, a strong association was found between mammography screening and recommendations by physicians and nurses (prior screening: odds ratio [OR], 16.0; 95% confidence interval [95% CI], 7.8–35.0; recent screening: OR, 7.0; 95% CI, 3.8–13.6). This finding applied to both recent immigrants (< 15 years in the U.S.) and earlier immigrants (≥ 15 years in the U.S.). Thirty-two percent of women reported that the best way to detect breast carcinoma was a modality other than mammogram.
The authors recommend a multifaceted approach to increase mammography screening by Chinese-American women: recommendations from the provider plus targeted education to address the effectiveness of screening mammography compared with breast self examination and clinical breast examination.
PMCID: PMC1618781  PMID: 12599238
mammography; screening; Asian; Chinese
7.  Primary care physician characteristics associated with cancer screening: a retrospective cohort study in Ontario, Canada 
Cancer Medicine  2014;4(2):212-223.
Primary care physicians can serve as both facilitators and barriers to cancer screening, particularly for under-screened groups such as immigrant patients. The objective of this study was to inform physician-targeted interventions by identifying primary care physician characteristics associated with cancer screening for their eligible patients, for their eligible immigrant patients, and for foreign-trained physicians, for their eligible immigrant patients from the same world region. A population-based retrospective cohort study was performed, looking back 3 years from 31 December 2010. The study was performed in urban primary care practices in Ontario, Canada's largest province. A total of 6303 physicians serving 1,156,627 women eligible for breast cancer screening, 2,730,380 women eligible for cervical screening, and 2,260,569 patients eligible for colorectal screening participated. Appropriate breast screening was defined as at least one mammogram in the previous 2 years, appropriate cervical screening was defined as at least one Pap test in the previous 3 years, and appropriate colorectal screening as at least one fecal occult blood test in the previous 2 years or at least one colonoscopy or barium enema in the previous 10 years. Just fewer than 40% of physicians were female, and 26.1% were foreign trained. In multivariable analyses, physicians who attended medical schools in the Caribbean/Latin America, the Middle East/North Africa, South Asia, and Western Europe were less likely to screen their patients than Canadian graduates. South Asian-trained physicians were significantly less likely to screen South Asian women for cervical cancer than other foreign-trained physicians who were seeing region-congruent patients (adjusted odds ratio: 0.56 [95% confidence interval 0.32–0.98] versus physicians from the USA, Australia and New Zealand). South Asian patients were the most vulnerable to under-screening, and decreasing patient income quintile was consistently associated with lower likelihood of screening, although less so for immigrant patients. This study highlights certain physician characteristics that are associated with cancer screening for eligible patients, including immigrant patients, and that should be considered when designing physician-targeted interventions. We have also highlighted an ethnic community, South Asians, which requires particular attention, both among its patients and its primary care providers. Future research should further explore the reasons for these findings.
PMCID: PMC4329005  PMID: 25430885
Cancer screening; immigrant health; primary care; socioeconomic status
8.  Physical Distress and Cancer Care Experiences Among Chinese-American and Non-Hispanic White Breast Cancer Survivors 
Gynecologic Oncology  2011;124(3):383-388.
The number of Chinese-American breast cancer survivors (BCS) is increasing as a result of increasing incidence rates. There has been little research on Chinese BCS’ follow-up cancer care. This qualitative study aims to understand how Chinese-American BCS experience and cope with physical distress relative to non-Hispanic White (NHW) survivors.
Seventy-one BCS (37 Chinese immigrant, 7 US-born Chinese, 27 NHW) were recruited from the Greater Bay Area Cancer Registry to participate in focus group discussions or one-on-one interviews about their survivorship experiences. All BCS were diagnosed with breast cancer at stage 0-IIA between 2006-2009, and had survived for 1-4 years without recurrence. Interviews were conducted in Cantonese, Mandarin, or English. Data analyses followed established qualitative methods of content analysis.
BCS experienced pain and side effects from radiation, surgery, and hormonal therapy. Physical distress subsequently caused emotional concerns about recurrence or metastasis. Most BCS consulted physicians about their physical distress. Chinese immigrant BCS were less likely to have their issues resolved compared to NHW and US-born Chinese who were more likely to question physicians, ask for referrals, and make repeat attempts if their problems were not resolved. Some Chinese immigrant BCS turned to Traditional Chinese Medicine for relief or accepted the idea that physical distress was part of survivorship.
Chinese immigrant BCS may be at risk for greater distress compared with US-born Chinese and NHW BCS because of cultural norms that make them less inclined to express their needs to physicians or challenge physicians when their needs are not met. Furthermore, they may express symptoms in culturally unique ways (e.g., hot-cold imbalances). Further research is needed to determine how to best improve survivorship care experiences in this understudied population, with the goal of decreasing BCS’ physical distress and improving quality of life.
PMCID: PMC3298543  PMID: 22115854
9.  A Comprehensive Screening And Treatment Model For Reducing Disparities In Hepatitis B 
Health Affairs (Project Hope)  2011;30(10):1974-1983.
Chronic hepatitis B affects Asian Americans at a much higher rate than the general US population. Appropriate care can limit morbidity and mortality from hepatitis B. However, access to care for many Asian Americans and other immigrant groups is limited by their lack of knowledge about the disease, as well as cultural, linguistic, and financial challenges. This article describes the results of BfreeNYC, a New York City pilot program that, from 2004 to 2008, provided hepatitis B community education and awareness, free screening and vaccinations, and free or low-cost treatment primarily to immigrants from Asia, but also to residents from other racial and ethnic minority groups. The program was the largest citywide screening program in the United States, reaching nearly 9,000 people, and the only one providing comprehensive care to those who were infected. During the program, new hepatitis B cases reported annually from predominantly Asian neighborhoods in the city increased 34 percent. More than two thousand people were vaccinated; 57 percent of the 1,162 patients who tested positive for hepatitis B and were evaluated by program clinical services were still in care at the end of the program. Our analysis found that the program was effective in reaching the target population and providing care. Although follow-up care data will be needed to demonstrate long-term costeffectiveness, the program may serve as a useful prototype for addressing hepatitis B disparities in communities across the United States.
PMCID: PMC3333793  PMID: 21976342
10.  U.S. Primary Care Physicians’ Lung Cancer Screening Beliefs and Recommendations 
No high-quality study to date has shown that screening reduces lung cancer mortality, and expert groups do not recommend screening for asymptomatic individuals. Nevertheless, lung cancer screening tests are available in the U.S., and primary care physicians (PCPs) may have a role in recommending them to patients.
This study describes U.S. PCPs’ beliefs about and recommendations for lung cancer screening, and examines characteristics of PCPs who recommend screening.
A nationally representative survey of practicing PCPs was conducted in 2006–2007. Mailed questionnaires assessed PCPs’ beliefs about lung cancer screening guidelines and the effectiveness of screening tests, and whether PCPs would recommend screening for asymptomatic patients. Data were analyzed in 2009.
Nine hundred and sixty-two PCPs completed the survey (absolute response rate=70.6%; cooperation rate=76.8%). One quarter said that major guidelines support lung cancer screening. Two thirds said that low–radiation dose spiral CT (LDCT) is very or somewhat effective in reducing lung cancer mortality in current smokers; LDCT was perceived as more effective than chest × ray or sputum cytology. Responding to vignettes describing asymptomatic patients of varying smoking exposure, 67% of PCPs recommended lung cancer screening for at least one of the vignettes. Most PCPs recommending screening said they would use chest × ray; up to 26% would use LDCT. In adjusted analyses, PCPs’ beliefs and practice style were strongly associated with their lung cancer screening recommendations.
Many PCPs’ lung cancer screening beliefs and recommendations are inconsistent with current evidence and guidelines. Provider education regarding lung cancer screening’s evidence base and guideline content is indicated.
PMCID: PMC3133954  PMID: 20965378
11.  Physician barriers to population-based, fecal occult blood test-based colorectal cancer screening programs for average-risk patients 
Colorectal cancer (CRC) screening is an efficacious but underused means to reduce the burden of CRC. Population-based CRC screening programs are currently being implemented in Canada and physicians are key partners in increasing screening uptake. The current study identified physician attitudes and barriers that need to be addressed by provincial programs.
A mailed survey of primary care physicians in Alberta.
The survey response rate was 42.4% (806 of 1903). The majority of physicians suggested CRC screening as part of a routine periodic examination; however, the approach to test selection and the type of tests recommended varied by geographical region. The majority of physicians agreed (48%) or strongly agreed (36%) that a province-wide screening program is the best approach to reducing mortality from CRC. However, there were many serious concerns identified – the most common was endoscopic capacity for follow-up of patients with a positive fecal occult blood test (FOBT), which was cited by 55% to 69% of the physicians surveyed. The barriers to three commonly available tests (FOBT, flexible sigmoidoscopy and colonoscopy) varied according to health region, and the types of barriers identified varied according to the specific test.
Screening for CRC is gradually being accepted among primary care physicians in Alberta. A key finding of the present descriptive study was the regional variation in practices, perceived barriers and concerns about provincial population-based screening programs based on FOBT as the primary screening test. Provincial programs will need to address the issue of endoscopic capacity and perceived barriers to FOBT to gain primary care physician acceptance of FOBT-based CRC screening programs.
PMCID: PMC2898489  PMID: 20559577
Colorectal cancer; Health surveys; Mass screening; Primary care
12.  Identifying Older Chinese Immigrants at High Risk for Osteoporosis 
Data about whether Asian Americans are a high-risk or a low-risk group for osteoporosis are limited and inconsistent. Few previous studies have recognized that the heterogeneity of the Asian American population, with respect to both nativity (foreign- vs U.S.-born) and ethnicity, may be related to osteoporosis risk.
To assess whether older foreign-born Chinese Americans living in an urban ethnic enclave are at high risk of osteoporosis and to refer participants at high risk for follow-up care.
Cross-sectional survey and osteoporosis screening, undertaken as a collaborative project by the Chinese American Service League and researchers at the University of Chicago.
Chicago's Chinatown.
Four hundred sixty-nine immigrant Chinese American men and women aged 50 and older.
Chinese Americans in this urban setting are generally recent immigrants from south China with limited education and resources: mean age at immigration was 54, 56% had primary only or no education, and 57% reported “fair” or “poor” self-rated health. Eighteen percent are uninsured and 55% receive Medicaid. Bone mineral density (BMD) of the calcaneus was estimated using quantitative ultrasound. Immigrant Chinese women in the study had lower average BMD than reference data for white women or U.S.-born Asian Americans. BMD for immigrant Chinese men in the study was similar to white men at ages 50 to 69, and lower at older ages. Low body mass index, low educational attainment and older age at immigration were all associated with lower BMD.
Foreign-born Chinese Americans may be a high-risk group for osteoporosis.
PMCID: PMC1494886  PMID: 12848833
bone density; Asian Americans; Chinese Americans; osteoporosis; emigration and immigration
13.  Patients’ anxiety and expectations 
Canadian Family Physician  2005;51(12):1659.
To compare the influence of physicians’ recommendations and patients’ anxiety or expectations on the decision to order four cancer screening tests in clinical situations where guidelines were equivocal: screening for prostate cancer with prostate-specific antigen for men older than 50; breast cancer screening with mammography for women 40 to 49; colorectal cancer screening with fecal occult blood testing; and colorectal cancer screening with colonoscopy for patients older than 40.
Cross-sectional mailed survey with clinical vignettes.
British Columbia, Alberta, Ontario, Quebec, and Prince Edward Island.
Of 600 randomly selected family physicians in active practice approached, 351 responded, but 35 respondents were ineligible (response rate 62%).
Decisions to order cancer screening tests, physicians’ perceptions of recommendations, patients’ anxiety about cancer, and patients’ expectation to be tested.
For all screening situations, physicians most likely to order the tests believed that routine screening with the test was recommended; physicians least likely to order tests believed routine screening was not. Patients’ expectations or anxiety, however, markedly increased screening by physicians who did not believe that routine screening was recommended. In regression models, the interaction between physicians’ recommendations and patients’ anxiety or expectation was significant for all four screening tests. When patients had no anxiety or expectations, physicians’ beliefs about screening strongly predicted test ordering. Physicians who believed routine screening was recommended ordered the test in most cases regardless of patient characteristics. But patients’ anxiety or expectations markedly increased the probability that the test would be ordered. The probability of test ordering went from 0.28 to 0.54 for prostate-specific antigen (odds ratio [OR] = 1.9), from 0.15 to 0.44 for mammography (OR = 2.8), from 0.33 to 0.79 for fecal occult blood testing (OR = 2.4), and from 0.29 to 0.65 for colonoscopy (OR = 2.2).
Differences in clinical judgment about recommended practice lead to practice variation, but physicians are also influenced by nonmedical factors, such as patients’ anxiety and expectations of receiving tests. In terms of magnitude of influence, clinical judgment is more powerful than nonmedical patient factors, but patient factors are also powerful drivers of family physicians’ decisions about cancer screening when practice guidelines are equivocal.
PMCID: PMC1479496  PMID: 16926946
14.  Colorectal Cancer Screening by Primary Care Physicians 
Primary care physicians (hereafter, physicians) play a critical role in the delivery of colorectal cancer (CRC) screening in the U.S. This study describes the CRC screening recommendations and practices of U.S. physicians and compares them to findings from a 1999–2000 national provider survey.
Data from 1266 physicians responding to the 2006–2007 National Survey of Primary Care Physicians' Recommendations and Practices for Breast, Cervical, Colorectal, and Lung Cancer Screening (cooperation rate=75%) were analyzed in 2008. Descriptive statistics were used to examine physicians' CRC screening recommendations and practices as well as the office systems used to support screening activities. Sample weights were applied in the analyses to obtain national estimates.
Ninety-five percent of physicians routinely recommend screening colonoscopy to asymptomatic, average-risk patients; 80% recommend fecal occult blood testing (FOBT). Only a minority recommend sigmoidoscopy, double-contrast barium enema, computed tomographic colonography, or fecal DNA testing. Fifty-six percent recommend two screening modalities; 17% recommend one. Nearly all physicians who recommend endoscopy refer their patients for the procedure. Four percent perform sigmoidoscopy, a 25-percentage-point decline from 1999–2000. Although 61% of physicians reported that their practice had guidelines for CRC screening, only 30% use provider reminders; 15% use patient reminders.
Physicians' CRC screening recommendations and practices have changed substantially since 1999–2000. Colonoscopy is now the most frequently recommended test. Most physicians do not recommend the full menu of test options prescribed in national guidelines. Few perform sigmoidoscopy. Office systems to support CRC screening are lacking in many physicians' practices. Given ongoing changes in CRC screening technologies and guidelines, the continued monitoring of physicians' CRC screening recommendations and practices is imperative.
PMCID: PMC2727732  PMID: 19442479
15.  Primary Care Physicians’ Cancer Screening Recommendation Practices and Perceptions of Cancer Risk of Asian Americans 
Asian Americans experience disproportionate incidence and mortality rates of certain cancers, compared to other racial/ethnic groups. Primary care physicians are a critical source for cancer screening recommendations and play a significant role in increasing cancer screening of their patients. This study assessed primary care physicians’ perceptions of cancer risk in Asians and screening recommendation practices. Primary care physicians practicing in New Jersey and New York City (n=100) completed a 30-question survey on medical practice characteristics, Asian patient communication, cancer screening guidelines, and Asian cancer risk. Liver cancer and stomach cancer were perceived as higher cancer risks among Asian Americans than among the general population, and breast and prostate cancer were perceived as lower risks. Physicians are integral public health liaisons who can be both influential and resourceful toward educating Asian Americans about specific cancer awareness and screening information.
PMCID: PMC3800694  PMID: 23679307
Asian Americans; cancer; primary care physician; health disparities
16.  Guideline-Inconsistent Breast Cancer Screening for Women over 50: A Vignette-Based Survey 
Professional organizations have issued guidelines recommending breast cancer screening for women 50 years of age.
This study examines the percent of U.S. primary care physicians who report breast cancer screening practices that are not consistent with guidelines, and the characteristics of physicians who reported offering extra test modalities.
We analyzed a subset of a 2008 cross-sectional Women’s Health Care survey sent to primary care physicians randomly selected from the national American Medical Association (AMA) Physician Masterfile. A subset of physicians received a survey that presented a vignette of a health maintenance visit for an asymptomatic 51-year-old woman who was not at high risk for breast cancer. Responses were weighted to represent physicians nationally.
1,654 U.S. family physicians, general internists, and obstetrician-gynecologists under age 65, who practiced in office or hospital based settings (62.8 % response rate). After exclusions, 553 study physicians remained for analysis.
Physician self-report of breast cancer screening practices that are not consistent with the recommendations of the U.S. Preventive Services Task Force (USPSTF), the American College of Obstetrics and Gynecology (ACOG), and the American Cancer Society (ACS), defined as almost always offering mammography.
36.0 % (95 % CI: 31.8 %–40.5 %) of physicians reported offering breast cancer screening tests inconsistent with national guidelines, with most offering extra tests (magnetic resonance imaging [MRI] and/or ultrasound) (33.2 %, 95 % CI 29.1 %–37.6 %). In adjusted analysis, risk-averse physicians and those who believed in the clinical effectiveness of MRI were more likely to offer extra breast cancer screening tests.
Physicians often report offering breast cancer screening test modalities beyond those recommended for a 51-year-old woman. Strategies, such as academic detailing regarding appropriate use of technology and provision of clinical decision support for breast cancer screening, could decrease overuse of resources.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-013-2567-1) contains supplementary material, which is available to authorized users.
PMCID: PMC3889955  PMID: 23943421
breast cancer; cancer screening; guidelines; physician behavior; primary care; prevention; malpractice; risk assessment
17.  NYC Condom Use and Satisfaction and Demand for Alternative Condom Products in New York City Sexually Transmitted Disease Clinics 
In 2007, via a high-profile media campaign, the New York City Department of Health and Mental Hygiene (NYC DOHMH) introduced the “NYC Condom,” the first specially packaged condom unique to a municipality. We conducted a survey to measure NYC Condom awareness of and experience with NYC Condoms and demand for alternative male condoms to be distributed by the DOHMH. Trained interviewers administered short, in-person surveys at five DOHMH-operated sexually transmitted disease (STD) clinics in Spring 2008. We systematically sampled eligible patients: NYC residents aged ≥18 years waiting to see a physician. We approached 539; 532 agreed to be screened (98.7% response rate); 462 completed the survey and provided NYC zip codes. Most respondents were male (56%), non-Hispanic black (64%), aged 18–24 years (43%) or 25–44 years (45%), employed (65%), and had a high school degree/general equivalency diploma or less (53%). Of those surveyed, 86% were aware of the NYC Condom, and 81% of those who obtained the condoms used them. NYC Condom users were more likely to have four or more sexual partners in the past 12 months (adjusted odds ratio [AOR] = 2.0, 95% confidence interval [CI] = 1.0–3.8), use condoms frequently (AOR = 2.1, 95% CI = 1.3–3.6), and name an alternative condom for distribution (AOR = 2.2, 95% CI = 1.3–3.9). The most frequently requested condom types respondents wanted DOHMH to provide were larger size (28%), ultra thin/extra sensitive (21%), and extra strength (16%). We found high rates of NYC Condom use. NYC Condom users reported more sexual partners than others, suggesting the condom initiative successfully reached higher-risk persons within the STD clinic population. Study results document the condom social marketing campaign’s success.
PMCID: PMC3157509  PMID: 21792691
Condom social marketing; HIV prevention; Condom use and satisfaction
18.  Access to and use of sexual and reproductive health services provided by midwives among rural immigrant women in Spain: midwives’ perspectives 
Global Health Action  2013;6:10.3402/gha.v6i0.22645.
There is insufficient information regarding access and participation of immigrant women in Spain in sexual and reproductive health programs. Recent studies show their lower participation rate in gynecological cancer screening programs; however, little is known about the participation in other sexual and reproductive health programs by immigrant women living in rural areas with high population dispersion.
The objective of this study is to explore the perceptions of midwives who provide these services regarding immigrant women's access and participation in sexual and reproductive health programs offered in a rural area.
A qualitative study was performed, within a larger ethnographic study about rural primary care, with data collection based on in-depth interviews and field notes. Participants were the midwives in primary care serving 13 rural basic health zones (BHZ) of Segovia, a region of Spain with high population dispersion. An interview script was designed to collect information about midwives’ perceptions on immigrant women's access to and use of the healthcare services that they provide. Interviews were recorded and transcribed with participant informed consent. Data were analyzed based on the qualitative content analysis approach and triangulation of results with fieldwork notes.
Midwives perceive that immigrants in general, and immigrant women in particular, underuse family planning services. This underutilization is associated with cultural differences and gender inequality. They also believe that the number of voluntary pregnancy interruptions among immigrant women is elevated and identify childbearing and childrearing-related tasks and the language barrier as obstacles to immigrant women accessing the available prenatal and postnatal healthcare services.
Immigrant women's underutilization of midwifery services may be linked to the greater number of unintended pregnancies, pregnancy terminations, and the delay in the first prenatal visit, as discerned by midwives. Future research should involve samples of immigrant women themselves, to provide a deeper understanding of the current knowledge, attitudes, and practices of the immigrant population regarding reproductive and sexual health to provide better health services.
PMCID: PMC3822087  PMID: 24206651
gender; health services accessibility; immigrants; midwives; primary health care; qualitative research; rural population; sexual and reproductive health; utilization; women's health
19.  Colorectal cancer screening practices in Saskatchewan 
Canadian Family Physician  2013;59(12):e558-e563.
To evaluate current colorectal cancer (CRC) screening practices in Saskatchewan and identify barriers to screening with the goal of improving current practice.
Survey of family physicians.
A total of 773 family physicians were surveyed.
Main outcome measures
Demographic characteristics, individual screening practices, and perceived barriers to screening.
The response rate to the survey was 44.5%. When asked what method they used for fecal occult blood testing, almost 40% of respondents were either unsure or did not answer the question. Of those who did respond, 35.8% employed hemoccult testing following digital rectal examination, a practice not recommended for CRC screening. Screening guidelines for average-risk patients were generally well adhered to, with 79.9% of respondents recommending screening beginning at age 50. For screening patients at increased risk of CRC owing to family history, only 64.2% of respondents began screening 10 years before the age of the index patient at diagnosis. Physicians who were more likely to follow guidelines were female, in practice fewer than 10 years, trained in Canada, and practising in urban areas. More than 90% of family physicians agreed that a standard provincewide screening program would be beneficial.
We have identified considerable knowledge gaps with regard to CRC screening. There is confusion about which fecal occult blood tests are recommended for screening. Also, screening guidelines for patients with a family history of CRC are poorly understood. These findings suggest that better physician education about CRC screening is required. Introduction of a provincewide screening program should improve overall screening success.
PMCID: PMC3860946  PMID: 24336561
20.  Primary care physicians' reported use of pre-screening discussions for prostate cancer screening: a cross-sectional survey 
BMC Family Practice  2009;10:19.
Professional medical organizations recommend individualized patient decision making about prostate cancer screening. Little is known about primary care physicians' use of pre-screening discussions to promote informed decision making for prostate cancer screening. The aim of this study is to explore physicians' use of pre-screening discussions and reasons why physicians would or would not try to persuade patients to be screened if they initially refuse testing.
Primary care physicians completed a self-administered survey about prostate cancer screening practices for informed decision making.
Sixty-six physicians (75.9%) completed the survey, and 63 were used in the analysis. Thirteen physicians (20.6%) reported not using prescreening discussions, 45 (71.4%) reported the use of prescreening discussions, and 3 (4.8%) reported neither ordering the PSA test nor discussing it with patients. Sixty-nine percent of physicians who reported not having discussions indicated they were more likely to screen African American patients for prostate cancer, compared to 50% of physicians who reported the use of discussions (Chi-square(1) = 1.62, p = .20). Similarly, 91% of physicians who reported not having discussions indicated they are more likely to screen patients with a family history of prostate cancer, compared to 46% of those who reported the use of discussion (Chi-square(1) = 13.27, p < .001). Beliefs about the scientific evidence and efficacy of screening, ethical concerns regarding patient autonomy, and concerns about time constraints differed between physicians who would and would not try to persuade a patient to be tested.
Although guidelines recommend discussing the risks and benefits of prostate cancer screening, physicians report varying practice styles. Future research needs to consider the nature of discussions and the degree to which informed decision making is being achieved in clinical practice.
PMCID: PMC2666644  PMID: 19296843
21.  Caring for survivors of breast cancer: perspective of the primary care physician 
Current Oncology  2011;18(5):e218-e226.
Background and Objectives
Increasing numbers of women are surviving breast cancer, and survivorship care is becoming more complex. Primary care physicians provide care for most survivors of breast cancer in the Canadian province of British Columbia. The present study offers insight into the confidence of primary care physicians in their abilities to provide such care. It also explores potential ways to assist those providers in enhancing this aspect of their practice.
A questionnaire was mailed to 1000 primary care physicians caring for survivors of breast cancer. The questionnaire explored the perspectives of the responding physicians on their ability to manage various aspects of survivorship care for breast cancer patients, identified preferences for the content and format of communication from oncologists at the time of transition from active oncology treatment to survivorship, and determined the means most commonly used to obtain knowledge about breast cancer. This 1-page, 31-item checkbox and open-answer questionnaire assessed the perceptions of primary care physicians about the care of breast cancer survivors after completion of active treatment and their personal preferences for resources providing information about breast cancer.
The questionnaire response rate was 59%. Primary care physicians reported being most confident in screening for recurrence and managing patient anxiety; they were least confident in managing lymphedema and providing psychosocial counselling. Compared with physicians following fewer survivors of breast cancer, those who followed more breast cancer survivors had higher confidence in managing the biomedical aspects of follow-up and in providing counselling about nutrition and exercise. Most physicians found discharge letters from oncologists to be useful. Point-form discharge information was preferred by 43%; detailed description, by 19%; and both formats, by 38%. The most useful information items identified for inclusion in a discharge letter were a diagnosis and treatment summary and the recommended surveillance and endocrine therapy. Continuing medical education events and online resources were the means most commonly used to obtain knowledge about breast cancer.
Primary care physicians who provide follow-up for survivors of breast cancer report that they are confident in managing care and satisfied with discharge letters containing a diagnosis and treatment summary, and recommendations for surveillance and endocrine treatment. At the time of patient discharge, additional information about common medical and psychosocial issues in this patient population would be useful to primary care physicians. Preferred means to access current breast cancer information include continuing medical education events and online resources.
PMCID: PMC3185903  PMID: 21980253
Breast cancer survivors; primary care physician perspective; follow-up cancer care; survivorship care plans
22.  Implementing academic detailing for breast cancer screening in underserved communities 
African American and Hispanic women, such as those living in the northern Manhattan and the South Bronx neighborhoods of New York City, are generally underserved with regard to breast cancer prevention and screening practices, even though they are more likely to die of breast cancer than are other women. Primary care physicians (PCPs) are critical for the recommendation of breast cancer screening to their patients. Academic detailing is a promising strategy for improving PCP performance in recommending breast cancer screening, yet little is known about the effects of academic detailing on breast cancer screening among physicians who practice in medically underserved areas. We assessed the effectiveness of an enhanced, multi-component academic detailing intervention in increasing recommendations for breast cancer screening within a sample of community-based urban physicians.
Two medically underserved communities were matched and randomized to intervention and control arms. Ninety-four primary care community (i.e., not hospital based) physicians in northern Manhattan were compared to 74 physicians in the South Bronx neighborhoods of the New York City metropolitan area. Intervention participants received enhanced physician-directed academic detailing, using the American Cancer Society guidelines for the early detection of breast cancer. Control group physicians received no intervention. We conducted interviews to measure primary care physicians' self-reported recommendation of mammography and Clinical Breast Examination (CBE), and whether PCPs taught women how to perform breast self examination (BSE).
Using multivariate analyses, we found a statistically significant intervention effect on the recommendation of CBE to women patients age 40 and over; mammography and breast self examination reports increased across both arms from baseline to follow-up, according to physician self-report. At post-test, physician involvement in additional educational programs, enhanced self-efficacy in counseling for prevention, the routine use of chart reminders, computer- rather than paper-based prompting and tracking approaches, printed patient education materials, performance targets for mammography, and increased involvement of nursing and other office staff were associated with increased screening.
We found some evidence of improvement in breast cancer screening practices due to enhanced academic detailing among primary care physicians practicing in urban underserved communities.
PMCID: PMC2266776  PMID: 18086311
23.  Diabetes Screening Among Immigrants 
Diabetes Care  2012;35(4):754-761.
To examine diabetes screening, predictors of screening, and the burden of undiagnosed diabetes in the immigrant population and whether these estimates differ by ethnicity.
A population-based retrospective cohort linking administrative health data to immigration files was used to follow the entire diabetes-free population aged 40 years and up in Ontario, Canada (N = 3,484,222) for 3 years (2004–2007) to determine whether individuals were screened for diabetes. Multivariate regression was used to determine predictors of having a diabetes test.
Screening rates were slightly higher in the immigrant versus the general population (76.0 and 74.4%, respectively; P < 0.001), with the highest rates in people born in South Asia, Mexico, Latin America, and the Caribbean. Immigrant seniors (age ≥65 years) were screened less than nonimmigrant seniors. Percent yield of new diabetes subjects among those screened was high for certain countries of birth (South Asia, 13.0%; Mexico and Latin America, 12.1%; Caribbean, 9.5%) and low among others (Europe, Central Asia, U.S., 5.1–5.2%). The number of physician visits was the single most important predictor of screening, and many high-risk ethnic groups required numerous visits before a test was administered. The proportion of diabetes that remained undiagnosed was estimated to be 9.7% in the general population and 9.0% in immigrants.
Overall diabetes-screening rates are high in Canada’s universal health care setting, including among high-risk ethnic groups. Despite this finding, disparities in screening rates between immigrant subgroups persist and multiple physician visits are often required to achieve recommended screening levels.
PMCID: PMC3308303  PMID: 22357181
24.  Knowledge, Cultural, and Attitudinal Barriers to Mammography Screening among Non-Adherent Immigrant Chinese Women: Ever versus Never Screened Status 
Cancer  2009;115(20):4828-4838.
Chinese-American women have much lower mammography screening rates than the general population. This study examined the collective impact of knowledge, cultural views, and health beliefs on intentions to obtain mammography among Chinese women who had not had a mammogram in the previous year.
Five-hundred, sixty-six immigrant Chinese women from the Washington, DC and New York metropolitan areas completed baseline assessments for a longitudinal intervention study. Validated surveys were used to measure variables of interest. The outcomes were 1) past mammography use (ever versus never) and 2) future screening intention.
Only 35% of the participants reported intentions to obtain mammograms, with approximately 19% of the never users reporting intentions (vs. 44% ever users). Ever users had higher knowledge (OR 1.13, 95% CI 1.03–1.25), less Eastern cultural views (OR 0.78, 95% CI 0.70–0.87), and perceived fewer barriers (OR 0.78, 95% CI 0.70–0.87) than never users, controlling for covariates. Never users were more likely to be recent immigrants, have low income and English ability, and lack regular sources of care than ever users (all p<.001). Multivariate models showed that ever users who were employed, received physician recommendations, had less Eastern views, and perceived higher susceptibility were more likely to have intentions. Among never users, only being ages 40–49 and perceiving fewer barriers led to increased intention.
Understanding cultural patterns and health beliefs in Chinese women is critical to changing their screening behaviors. Interventions that address their common beliefs and specific group barriers are optimal for promoting mammography adherence.
PMCID: PMC2761518  PMID: 19645031
Mammography adherence; Chinese-American women; Cultural views; Health Belief Model
25.  Association of Regional Variation in Primary Care Physicians’ Colorectal Cancer Screening Recommendations with Individual Use of Colorectal Cancer Screening 
Preventing Chronic Disease  2007;4(4):A90.
Studies show that the recommendations of a primary care physician for colorectal cancer screening may be one important influence on an individual's use of screening. However, another possible influence, the effect of regional differences in physicians' beliefs and recommendations on screening use, has not been assessed.
We linked data from the National Health Interview Survey on the use of colorectal cancer screening by respondents aged 50 years or older, by hospital-referral region, with data from the Survey of Colorectal Cancer Screening Practices on the colorectal cancer screening recommendations of primary care physicians, by region. Our principal independent variables were the proportion of physicians in a region who recommended screening at age 50 and continuing screening at the recommended frequency.
On average, 53.3% of physicians in a region correctly recommended initiating colorectal cancer screening, and 64.8% advised screening at the recommended frequency. Of adults who lived in regions where less than 30% of physicians correctly recommended initiating screening, 47.3% had been screened, in contrast to 54.8% in areas where 70% or more of physicians made correct recommendations. Seventy-one percent of respondents living in regions where less than 30% of physicians advised screening at the recommended frequency were current on screening, in contrast to 79.9% of respondents living in regions where 70% or more of physicians made this recommendation. These differences were statistically significant after adjustment for individual characteristics.
Strategies to improve colorectal cancer screening recommendations of primary care physicians may improve the use of screening for millions of Americans.
PMCID: PMC2099288  PMID: 17875265

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