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1.  Assessing Cancer Stage and Screening Disparities Among Native American Cancer Patients 
SYNOPSIS
Objective
Disparities in cancer-related health outcomes exist among Native Americans. This article assesses barriers to timely and effective cancer care among Native American cancer patients.
Methods
We conducted a community-based participatory survey of newly diagnosed cancer patients to assess their basic knowledge of cancer screening and their beliefs about cancer management. Sociodemographic and cancer-related information was obtained from medical records. Mean scores for correct answers to the screening knowledge battery were tabulated and analyzed by race/ethnicity and sociodemographic characteristics. Multivariable regression models were used to adjust for sociodemographic characteristics in evaluating the association between screening knowledge and race/ethnicity.
Results
The survey response rate was 62%. Of 165 patients, 52 were Native American and 113 were white. Native Americans with cancers for which a screening test is available presented with significantly higher rates of advanced-stage cancer (p=0.04). Native Americans scored lower on the cancer screening knowledge battery (p=0.0001). In multivariable analyses adjusting for age, gender, income, education level, employment status, and geographic distance from the cancer center, Native American race/ethnicity was the only factor significantly predictive of lower screening knowledge. Native Americans expressed more negative attitudes toward cancer treatment in some of the items regarding impacts and burden of cancer treatment.
Conclusions
Native American cancer patients presented with higher rates of advanced-stage disease for screening-detectable cancers, lower levels of basic cancer screening knowledge, and more negative attitudes about cancer treatment than white patients. Public health interventions regarding screening and cancer education are needed.
PMCID: PMC2602933  PMID: 19413030
2.  Assessing Cancer Stage and Screening Disparities Among Native American Cancer Patients 
Public Health Reports  2009;124(1):79-89.
SYNOPSIS
Objective
Disparities in cancer-related health outcomes exist among Native Americans. This article assesses barriers to timely and effective cancer care among Native American cancer patients.
Methods
We conducted a community-based participatory survey of newly diagnosed cancer patients to assess their basic knowledge of cancer screening and their beliefs about cancer management. Sociodemographic and cancer-related information was obtained from medical records. Mean scores for correct answers to the screening knowledge battery were tabulated and analyzed by race/ethnicity and sociodemographic characteristics. Multivariable regression models were used to adjust for sociodemographic characteristics in evaluating the association between screening knowledge and race/ethnicity.
Results
The survey response rate was 62%. Of 165 patients, 52 were Native American and 113 were white. Native Americans with cancers for which a screening test is available presented with significantly higher rates of advanced-stage cancer (p=0.04). Native Americans scored lower on the cancer screening knowledge battery (p=0.0001). In multivariable analyses adjusting for age, gender, income, education level, employment status, and geographic distance from the cancer center, Native American race/ethnicity was the only factor significantly predictive of lower screening knowledge. Native Americans expressed more negative attitudes toward cancer treatment in some of the items regarding impacts and burden of cancer treatment.
Conclusions
Native American cancer patients presented with higher rates of advanced-stage disease for screening-detectable cancers, lower levels of basic cancer screening knowledge, and more negative attitudes about cancer treatment than white patients. Public health interventions regarding screening and cancer education are needed.
PMCID: PMC2602933  PMID: 19413030
3.  Knowledge and beliefs regarding oral health among pregnant women 
Background
Racial or ethnic and economic disparities exist in terms of oral diseases among pregnant women and children. The authors hypothesized that women of a racial or ethnic minority have less oral health knowledge than do women not of a racial or ethnic minority. Therefore, the authors conducted a study to assess and compare maternal oral health knowledge and beliefs and to determine if maternal race and ethnicity or other maternal factors contributed to women’s knowledge or beliefs.
Methods
The authors administered a written oral health questionnaire to pregnant women. The authors calculated the participants’ knowledge and belief scores on the basis of correct answers or answers supporting positive oral health behaviors. They conducted multivariable analysis of variance to assess associations between oral health knowledge and belief scores and characteristics.
Results
The authors enrolled 615 women in the study, and 599 (97.4 percent) completed the questionnaire. Of 599 participants, 573 (95.7 percent) knew that sugar intake is associated with caries. Almost one-half (295 participants [49.2 percent]) did not know that caries and periodontal disease are oral infections. Median (interquartile range) knowledge and belief scores were 6.0 (5.5–7.0) and 6.0 (5.0–7.0), respectively. Hispanic women had median (interquartile range) knowledge and belief scores significantly lower than those of white or African American women (6.0 [4.0–7.0] versus 7.0 [6.0–7.0] versus 7.0 [6.0–7.0], respectively [P < .001]; and 5.0 [4.0–6.0] versus 6.0 [5.0–7.0] versus 6.0 [5.0–7.0], respectively [P < .001]). Multivariable analysis of variance results showed that being of His-panic ethnicity was associated significantly with a lower knowledge score, and that an education level of eighth grade or less was associated significantly with a lower belief score.
Conclusions
Pregnant women have some oral health knowledge. Knowledge varied according to maternal race or ethnicity, and beliefs varied according to maternal education. Including oral health education as a part of prenatal care may improve knowledge regarding the importance of oral health among vulnerable pregnant women, thereby improving their oral health and that of their children.
Clinical Implications
Including oral health education as a part of prenatal care should be considered.
PMCID: PMC4380017  PMID: 22041414
Oral health knowledge; pregnancy
4.  Clinical Trial Awareness Among Racial/Ethnic Minorities in HINTS 2007: Sociodemographic, Attitudinal, and Knowledge Correlates 
Journal of health communication  2010;15(0 3):92-101.
The purpose of this study was (1) to examine the association of race/ethnicity on clinical trial awareness, controlling for several sociodemographic, attitudinal, and knowledge variables, and (2) to inform future communication campaigns to increase clinical trial awareness and participation. Secondary analysis was conducted among 6,754 Hispanic, Black, and White adult respondents to the National Cancer Institute’s 2007 Health Information National Trends Survey (HINTS). The dependent variable was awareness of clinical trials. Logistic regression was used to examine possible correlates of clinical trial awareness including sociodemographics, trust of sources of health information, beliefs about safety of health information, family/personal history of cancer, health seeking information, and awareness of three health agencies. Compared with Whites, Blacks and Hispanics were significantly less likely to have heard of a clinical trial. Other significant correlates of clinical trial awareness included education, income, belief that health information is safely guarded, family history of cancer, awareness of the Centers for Disease control, trust of health information from the Internet and charitable organizations, and distrust of health information from religious institutions. Blacks and Hispanics are significantly less aware of clinical trials. Campaigns that exploit unique beliefs and delivery channels for racial/ethnic subgroups should be considered.
doi:10.1080/10810730.2010.525296
PMCID: PMC4013828  PMID: 21154086
5.  Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study 
PLoS Medicine  2007;4(11):e323.
Background
While ethnic disparities in health and health care are increasing, evidence on how to enhance quality of care and reduce inequalities remains limited. Despite growth in the scope and application of guidelines on “cultural competence,” remarkably little is known about how practising health professionals experience and perceive their work with patients from diverse ethnic communities. Using cancer care as a clinical context, we aimed to explore this with a range of health professionals to inform interventions to enhance quality of care.
Methods and Findings
We conducted a qualitative study involving 18 focus groups with a purposeful sample of 106 health professionals of differing disciplines, in primary and secondary care settings, working with patient populations of varying ethnic diversity in the Midlands of the UK. Data were analysed by constant comparison and we undertook processes for validation of analysis. We found that, as they sought to offer appropriate care, health professionals wrestled with considerable uncertainty and apprehension in responding to the needs of patients of ethnicities different from their own. They emphasised their perceived ignorance about cultural difference and were anxious about being culturally inappropriate, causing affront, or appearing discriminatory or racist. Professionals' ability to think and act flexibly or creatively faltered. Although trying to do their best, professionals' uncertainty was disempowering, creating a disabling hesitancy and inertia in their practice. Most professionals sought and applied a knowledge-based cultural expertise approach to patients, though some identified the risk of engendering stereotypical expectations of patients. Professionals' uncertainty and disempowerment had the potential to perpetuate each other, to the detriment of patient care.
Conclusions
This study suggests potential mechanisms by which health professionals may inadvertently contribute to ethnic disparities in health care. It identifies critical opportunities to empower health professionals to respond more effectively. Interventions should help professionals acknowledge their uncertainty and its potential to create inertia in their practice. A shift away from a cultural expertise model toward a greater focus on each patient as an individual may help.
From a qualitative study, Joe Kai and colleagues have identified opportunities to empower health professionals to respond more effectively to challenges in their work with patients from diverse ethnic communities.
Editors' Summary
Background.
Communities are increasingly diverse in terms of ethnicity (belonging to a group of people defined by social characteristics such as cultural tradition or national origin) and race (belonging to a group identified by inherited physical characteristics). Although health professionals and governments are striving to ensure that everybody has the same access to health care, there is increasing evidence of ethnic inequalities in health-care outcomes. Some of these inequalities reflect intrinsic differences between groups of people—Ashkenazi Jews, for example, often carry an altered gene that increases their chance of developing aggressive breast cancer. Often, however, these differences reflect inequalities in the health care received by different ethnic groups. To improve this situation, “cultural competence” has been promoted over recent years. Cultural competence is the development of skills by individuals and organizations that allow them to work effectively with people from different cultures. Health professionals are now taught about ethnic differences in health beliefs and practices, religion, and communication styles to help them provide the best service to all their patients.
Why Was This Study Done?
Numerous guidelines aim to improve cultural competency but little is known about how health professionals experience and perceive their work with patients from diverse ethnic groups. Is their behavior influenced by ethnicity in ways that might contribute to health care disparities? For example, do doctors sometimes avoid medical examinations for fear of causing offence because of cultural differences? If more were known about how health professionals handle ethnic diversity (a term used here to include both ethnicity and race) it might be possible to reduce ethnic inequalities in health care. In this qualitative study, the researchers have explored how health professionals involved in cancer care are affected by working with ethnically diverse patients. A qualitative study is one that collects nonquantitative data such as how doctors “feel” about treating people of different ethnic backgrounds; a quantitative study might compare clinical outcomes in different ethnic groups.
What Did the Researchers Do and Find?
The researchers enrolled 106 doctors, nurses, and other health-related professionals from different health-service settings in the Midlands, an ethnically diverse region of the UK. They organized 18 focus groups in which the health professionals described their experiences of caring for people from ethnic minority backgrounds. The participants were encouraged to recall actual cases and to identify what they saw as problems and strengths in their interactions with these patients. The researchers found that the health professionals wrestled with many challenges when providing health care for patients from diverse ethnic backgrounds. These challenges included problems with language and with general communication (for example, deciding when it was acceptable to touch a patient to show empathy). Health professionals also worried they did not know enough about cultural differences. As a result, they said they often felt uncertain of their ability to avoid causing affront or appearing racist. This uncertainty, the researchers report, disempowered the health professionals, sometimes making them hesitate or fail to do what was best for their patient.
What Do These Findings Mean?
These findings reveal that health professionals often experience considerable uncertainty when caring for ethnically diverse patients, even after training in cultural competency. They also show that this uncertainty can lead to hesitancy and inertia, which might contribute to ethnic health care inequalities. Because the study participants were probably already interested in ethnic diversity and health care, interviews with other health professionals (and investigations of patient experiences) are needed to confirm these findings. Nevertheless, the researchers suggest several interventions that might reduce health care inequalities caused by ethnic diversity. For example, health professionals should be encouraged to recognize their uncertainty and should have access to more information and training about ethnic differences. In addition, there should be a shift in emphasis away from relying on knowledge-based cultural information towards taking an “ethnographic” approach. In other words, health professionals should be helped to feel able to ask their patients about what matters most to them as individuals about their illness and treatment.
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0040323.
Information on cultural competence and health care is available from the US National Center for Cultural Competence (in English and Spanish) and DiversityRx
PROCEED (Professionals Responding to Cancer in Ethnic Diversity) is a multimedia training tool for educators within the health and allied professions developed from the results of this study; a press release on PROCEED is available from the University of Nottingham
Transcultural Health Care Practice: An educational resource for nurses and health care practitioners is available on the web site of the UK Royal College of Nursing
doi:10.1371/journal.pmed.0040323
PMCID: PMC2071935  PMID: 18001148
6.  A National Survey of Medical Students’ Beliefs and Knowledge in Screening for Prostate Cancer 
Background
Today’s medical students are being educated at a time when there are no evidence-based guidelines for prostate cancer screening.
Objective
To examine medical students’ knowledge and beliefs concerning prostate cancer screening and specific determinants for their beliefs.
Design, Setting, and Participants
One thousand six hundred and forty four students were sampled at 20 medical schools using a web-based, cross-sectional survey.
Main Outcome Measures
Basic knowledge and beliefs about prostate cancer testing, epidemiology, and therapy were ascertained.
Results
Four of 8 knowledge items were answered incorrectly by 50% or more of students. Seven of 8 students believe that early diagnosis from screening can improve survival from prostate cancer. Second- and third-year students were more likely than fourth-year students to believe that the digital rectal exam (DRE) and the prostate-specific antigen test were accurate, adjusted odds ratio (AOR) 1.8; 95% confidence interval (CI), 1.2 to 2.7 and 1.7; 1.3 to 2.2 for second and third years, respectively, for the DRE. Black and Hispanic students were no more likely than white students to agree that early screening diagnosis improves survival, but blacks were more likely to agree with screening black or Hispanic men (AOR 7.8; 95% CI, 5.3 to 11.4 and 3.2; 2.2 to 4.7, respectively). More knowledgeable students were less likely to believe in the benefit of early detection and the accuracy of the prostate-specific antigen (AOR 0.3; 95%CI, 0.2 to 0.5).
Conclusions
Medical students generally are very optimistic about the benefits of screening for prostate cancer. Increased knowledge about prostate cancer is associated with a more conservative view of screening. Other predictors are independent of this knowledge.
doi:10.1007/s11606-006-0015-1
PMCID: PMC1824714  PMID: 17351844
prostate cancer; screening; medical students
7.  A National Survey of Medical Students’ Beliefs and Knowledge in Screening for Prostate Cancer 
Background
Today’s medical students are being educated at a time when there are no evidence-based guidelines for prostate cancer screening.
Objective
To examine medical students’ knowledge and beliefs concerning prostate cancer screening and specific determinants for their beliefs.
Design, Setting, and Participants
One thousand six hundred and forty four students were sampled at 20 medical schools using a web-based, cross-sectional survey.
Main Outcome Measures
Basic knowledge and beliefs about prostate cancer testing, epidemiology, and therapy were ascertained.
Results
Four of 8 knowledge items were answered incorrectly by 50% or more of students. Seven of 8 students believe that early diagnosis from screening can improve survival from prostate cancer. Second- and third-year students were more likely than fourth-year students to believe that the digital rectal exam (DRE) and the prostate-specific antigen test were accurate, adjusted odds ratio (AOR) 1.8; 95% confidence interval (CI), 1.2 to 2.7 and 1.7; 1.3 to 2.2 for second and third years, respectively, for the DRE. Black and Hispanic students were no more likely than white students to agree that early screening diagnosis improves survival, but blacks were more likely to agree with screening black or Hispanic men (AOR 7.8; 95% CI, 5.3 to 11.4 and 3.2; 2.2 to 4.7, respectively). More knowledgeable students were less likely to believe in the benefit of early detection and the accuracy of the prostate-specific antigen (AOR 0.3; 95%CI, 0.2 to 0.5).
Conclusions
Medical students generally are very optimistic about the benefits of screening for prostate cancer. Increased knowledge about prostate cancer is associated with a more conservative view of screening. Other predictors are independent of this knowledge.
doi:10.1007/s11606-006-0015-1
PMCID: PMC1824714  PMID: 17351844
prostate cancer; screening; medical students
8.  Breast Cancer Screening Knowledge and Perceived Health Beliefs among Immigrant Women in Korea 
Journal of Breast Cancer  2014;17(3):279-286.
Purpose
Recently, through international marriage, immigrant women have rapidly increased throughout Korea. This study was performed to identify health beliefs and practices related to breast cancer screening in immigrant women in Korea.
Methods
A cross-sectional survey was carried out between March and July 2012, and study population included immigrant females from six other Asian countries (Cambodia, China, Japan, Mongolia, Vietnam, and the Philippines). We surveyed 197 women and categorized them into four groups according to home countries. The questionnaire consisted of 55 items, including demographic and socioeconomic factors, breast cancer-related knowledge regarding risk factors and symptoms, beliefs and attitudes towards health and breast cancer, perceived susceptibility, barriers, and benefits of screening.
Results
Japanese participants were significantly older and had resided in Korea for more years than other country-of-origin groups (all p<0.001), and showed higher screening rates without statistical significance (p=0.392). In multivariate analysis, country of origin showed a significant correlation with knowledge (p=0.001), positive beliefs (p=0.002), and perceived benefits (p=0.025) of breast cancer screening. The group with the lowest household income showed a significantly lower score of perceived benefits (p=0.022). Through analysis to identify factors affecting participation in screening mammography, we found that education level (p=0.009), occupation status (p=0.006), and Korean language fluency (p=0.002) were independent predictors for screening behavior.
Conclusion
This study identified conditions related to breast cancer screening knowledge, perception, and behavior of immigrant women in Korea. The results reflect the need for increased social aids to remove barriers to medical services and more educational programs to facilitate higher rates of screening.
doi:10.4048/jbc.2014.17.3.279
PMCID: PMC4197359  PMID: 25320627
Breast neoplasms; Emigrants and immigrants; Health behavior; Health knowledge; Mass screening
9.  Perceptions of Cancer Controllability and Cancer Risk Knowledge: The Moderating Role of Race, Ethnicity, and Acculturation 
Literature suggests racial/ethnic minorities, particularly those who are less-acculturated, have stronger fatalistic attitudes toward cancer than do non-Latino Whites. Knowledge of cancer prevention is also lower among racial/ethnic minorities. Moreover, low knowledge about cancer risk factors is often associated with fatalistic beliefs. Our study examined fatalism and cancer knowledge by race/ethnicity and explored whether race/ethnicity moderate the association of fatalism with knowledge of cancer prevention and risk factors. We analyzed data from the Health Information National Trends Survey (2008), a national probability survey, to calculate population estimates of the associations among race/ethnicity, fatalistic beliefs, and knowledge about cancer from multivariable logistic regression. Racial/ethnic minorities had higher odds of holding fatalistic beliefs and lower odds of having knowledge of cancer risk factors than non-Hispanic Whites, and important differences by acculturation among Latinos were observed. Limited evidence of the moderating effect of race/ethnicity on the relationship between fatalistic beliefs and cancer risk factor knowledge was observed. Knowledge of cancer risk factors is low among all race/ethnicities, while fatalistic beliefs about cancer are higher among racial/ethnic minorities compared with non-Hispanic Whites. Implications for cancer education efforts are discussed.
doi:10.1007/s13187-013-0450-8
PMCID: PMC4758124  PMID: 23355279
Cancer fatalism; Health communication; Disparities; Communication inequalities
10.  Parent Health Beliefs, Social Determinants of Health, and Child Health Services Utilization among US School-Age Children with Autism 
Objective
Substantial variation exists in ASD care by race, ethnicity, and socioeconomic status; however, the role of parent health beliefs in this variation is poorly understood. Study goals were to (1) examine variation in parent beliefs about ASD prognosis and treatment according to social determinants of health (SDH) and (2) assess whether this variation was associated with variable health services utilization, among 1420 children with special health care needs (CSHCN) having autism spectrum disorder (ASD).
Methods
We used linked data from the 2011 Survey of Pathways to Diagnosis and Treatment and the 2009/10 National Survey of Children with Special Health Care Needs. Bivariate and multivariate analyses assessed variation in parent beliefs according to race/ethnicity, household income, and parent educational attainment. Further analyses assessed whether variation in beliefs was associated with use of psychotropic medication, traditional therapy, or complementary/alternative therapy for ASD.
Results
Parents of lower educational attainment or who had lower income were more likely to think that their child’s condition was a mystery. Near-poor families were less likely to feel they had the power to change the child’s condition. Parents of minority children were more likely than white children to view their child’s condition as temporary. However, these differences in beliefs only had modest associations with variation in use of the health services analyzed.
Conclusions
Some SDH-related variation exists in health beliefs among parents of children with ASD, but these differences may not be the main factors accounting for ASD health care disparities.
doi:10.1097/DBP.0000000000000136
PMCID: PMC4382377  PMID: 25741947
autism spectrum disorder; health services; health beliefs; healthcare disparities; social determinants of health
11.  Men and women: beliefs about cancer and about screening 
BMC Public Health  2009;9:431.
Background
Cancer screening programmes in England are publicly-funded. Professionals' beliefs in the public health benefits of screening can conflict with individuals' entitlements to exercise informed judgement over whether or not to participate. The recognition of the importance of individual autonomy in decision making requires greater understanding of the knowledge, attitudes and beliefs upon which people's screening choices are founded. Until recently, the technology available required that cancer screening be confined to women. This study aimed to discover whether male and female perceptions of cancer and of screening differed.
Methods
Data on the public's cancer beliefs were collected by means of a postal survey (anonymous questionnaire). Two general practices based in Nottingham and in Mansfield, in east-central England, sent questionnaires to registered patients aged 30 to 70 years. 1,808 completed questionnaires were returned for analysis, 56.5 per cent from women.
Results
Women were less likely to underestimate overall cancer incidence, although each sex was more likely to cite a sex-specific cancer as being amongst the most common cancer site. In terms of risk factors, men were most uncertain about the role of stress and sexually-transmitted diseases, whereas women were more likely to rate excessive alcohol and family history as major risk factors. The majority of respondents believed the public health care system should provide cancer screening, but significantly more women than men reported having benefiting from the nationally-provided screening services. Those who were older, in better health or had longer periods of formal education were less worried about cancer than those who had illness experiences, lower incomes, or who were smokers. Actual or potential participation in bowel screening was higher amongst those who believed bowel cancer to be common and amongst men, despite women having more substantial worries about cancer than men.
Conclusion
Our results suggest that men's and women's differential knowledge of cancer correlates with women's closer involvement with screening. Even so, men were neither less positive about screening nor less likely to express a willingness to participate in relevant screening in the future. It is important to understand gender-related differences in knowledge and perceptions of cancer, if health promotion resources are to be allocated efficiently.
doi:10.1186/1471-2458-9-431
PMCID: PMC2789733  PMID: 19930703
12.  Genetic and lifestyle causal beliefs about obesity and associated diseases among ethnically diverse patients: a structured interview study 
Public health genomics  2012;16(3):83-93.
Background
New genetic associations with obesity are rapidly being discovered. People’s causal beliefs about obesity may influence their obesity-related behaviors. Little is known about genetic compared to lifestyle causal beliefs regarding obesity, and obesity-related diseases, among minority populations. This study examined genetic and lifestyle causal beliefs about obesity and three obesity-related diseases among a low-income, ethnically diverse patient sample.
Methods
Structured interviews were conducted with patients attending an inner-city hospital outpatient clinic. Participants (n=205) were asked how much they agreed that genetics influence risk of obesity, type 2 diabetes, heart disease and cancer. Similar questions were asked regarding lifestyle causal beliefs (overeating, eating certain types of food, chemicals in food, not exercising, smoking). Forty-eight percent of participants were Non-Hispanic Black, 29% Hispanic, and 10% Non-Hispanic White.
Results
Over two thirds (69%) of participants believed genetics cause obesity ‘some’ or ‘a lot’, compared to 82% for type 2 diabetes, 79% for heart disease, and 75% for cancer. Participants who held genetic causal beliefs about obesity held more lifestyle causal beliefs in total than those who did not hold genetic causal beliefs about obesity (4.4 vs. 3.7 lifestyle causal beliefs respectively, possible range 0 to 5, p=0.025). There were few associations between causal beliefs and socio-demographic characteristics.
Conclusions
Higher beliefs in genetic causation of obesity and related diseases are not automatically associated with decreased lifestyle beliefs. Future research efforts are needed to determine whether public health messages aimed at reducing obesity and its consequences in racially and ethnically diverse urban communities may benefit from incorporating an acknowledgement of the role of genetics in these conditions.
doi:10.1159/000343793
PMCID: PMC4351705  PMID: 23235350
Attitudes; Community genetics; Complex diseases; Genomics; Lay understanding; Translational research Obesity; Causal beliefs; Behavior; Diet; Exercise
13.  Differences in Knowledge, Attitudes, Beliefs, and Perceived Risks Regarding Colorectal Cancer Screening Among Chinese, Korean, and Vietnamese Sub-Groups 
Journal of community health  2014;39(2):248-265.
Background
Asian ethnic subgroups are often treated as a single demographic group in studies looking at cancer screening and health disparities.
Purpose
To evaluate knowledge and health beliefs associated with colorectal cancer (CRC) and CRC screening among Chinese, Korean, and Vietnamese subgroups.
Methods
A survey assessed participants’ demographic characteristics, healthcare utilization, knowledge, beliefs, attitudes associated with CRC and CRC screening. Exploratory factor analysis identified six factors accounting >60% of the total variance in beliefs and attitudes. Cronbach’s alpha coefficients assessed internal consistency. Differences among Asian subgroups were assessed using a chi-square, Fisher’s exact, or Kruskal-Wallis test. Pearson’s correlation coefficient assessed an association among factors.
Results
654 participants enrolled: 238 Chinese, 217 Korean, and 199 Vietnamese. Statistically significant differences existed in demographic and health care provider characteristics, knowledge, and attitude/belief variables regarding CRC. These included knowledge of CRC screening modalities, reluctance to discuss cancer, belief that cancer is preventable by diet and lifestyle, and intention to undergo CRC screening. Chinese subjects were more likely to use Eastern medicine (52% Chinese, 25% Korean, 27% Vietnamese; p < 0.001); Korean subjects were less likely to see herbs as a form of cancer prevention (34% Chinese, 20% Korean, 35% Vietnamese; p < 0.001). Vietnamese subjects were less likely to consider CRC screening (95% Chinese, 95% Korean, 80% Vietnamese; p < 0.0001).
Conclusion
Important differences exist in knowledge, attitudes, and health beliefs among Asian subgroups. Understanding these differences will enable clinicians to deliver tailored, effective health messages to improve CRC screening and other health behaviors.
doi:10.1007/s10900-013-9776-8
PMCID: PMC3943615  PMID: 24142376
14.  Association of eHealth Literacy With Colorectal Cancer Knowledge and Screening Practice Among Internet Users in Japan 
Background
In rapidly developing Internet-user societies, eHealth literacy has become important in promoting wellness. Although previous studies have observed that poor health literacy is associated with less knowledge and screening practice of colorectal cancer (CRC), little is known about whether eHealth literacy is associated with these variables.
Objective
The present study examined associations between eHealth literacy, knowledge of CRC, and CRC screening practices.
Methods
Data were analyzed for 2970 Japanese adults (men, 49.9%; mean age ± SD, 39.7 ± 10.9 years) who responded to an Internet-based cross-sectional survey. Knowledge of the definition of CRC, its risk factors and screening practice, previous experience of CRC screening, score on the Japanese version of the eHEALS (J-eHEALS), sociodemographic attributes (sex, age, marital status, educational attainment, and household income level), and frequency of Internet usage were obtained. Sociodemographic attributes and frequency of Internet usage were used as control variables in the multiple regression and logistic regression models.
Results
eHealth literacy was positively associated with CRC knowledge (β = .116, < .001), when the covariables of both eHealth literacy and CRC knowledge were used in the multiple regression model. Moreover, after controlling for sociodemographic factors, which were significantly associated with eHealth literacy and CRC screening practice, an increase of 1 point in the eHEALS score signified that participants were 1.03 times (95% CI = 1.01–1.05) more likely to undergo CRC screening.
Conclusions
Internet users with high eHealth literacy are more likely to have knowledge and previous screening practice related to CRC compared to those with low eHealth literacy.
doi:10.2196/jmir.1927
PMCID: PMC3510729  PMID: 23149453
eHealth Literacy; Internet; Colorectal Neoplasms; Consumer Health Information; Health Promotion
15.  Contribution of Psychosocial Factors to the Association between Socioeconomic Position and Takeaway Food Consumption 
PLoS ONE  2014;9(9):e108799.
Objective
To examine whether psychosocial factors mediate (explain) the association between socioeconomic position and takeaway food consumption.
Design
A cross-sectional postal survey conducted in 2009.
Setting
Participants reported their usual consumption of 22 takeaway food items, and these were grouped into a “healthy” and “less healthy” index based on each items' nutritional properties. Principal Components Analysis was used to derive three psychosocial scales that measured beliefs about the relationship between diet and health (α = 0.73), and perceptions about the value (α = 0.79) and pleasure (α = 0.61) of takeaway food. A nutrition knowledge index was also used. Socioeconomic position was measured by highest attained education level.
Subjects
Randomly selected adults (n = 1,500) aged between 25–64 years in Brisbane, Australia (response rate  =  63.7%, N = 903).
Results
Compared with those with a bachelor degree or higher, participants with a diploma level of education were more likely to consume “healthy” takeaway food (p = 0.023) whereas the least educated (high school only) were more likely to consume “less healthy” choices (p = 0.002). The least educated were less likely to believe in a relationship between diet and health (p<0.001), and more likely to have lower nutritional knowledge compared with their highly educated counterparts (p<0.001). Education differences in beliefs about the relationship between diet and health partly and significantly mediated the association between education and “healthy” takeaway food consumption. Diet- and health-related beliefs and nutritional knowledge partly and significantly mediated the education differences in “less healthy” takeaway food consumption.
Conclusions
Interventions that target beliefs about the relationship between diet and health, and nutritional knowledge may reduce socioeconomic differences in takeaway food consumption, particularly for “less healthy” options.
doi:10.1371/journal.pone.0108799
PMCID: PMC4182602  PMID: 25268899
16.  Low-Income US Women Under-informed of the Specific Health Benefits of Consuming Beans 
PLoS ONE  2016;11(1):e0147592.
Background
Bean consumption can reduce chronic disease risk and improve nutrition status. Consumer knowledge of bean health benefits could lead to increased intakes. Low-income women have poorer health and nutrition, but their level of knowledge about bean health benefits is unknown. Beans are a familiar food of reasonable cost in most settings and are cultural staples for Hispanics and other ethnicities. Study objectives were to assess awareness of bean health benefits among low-income women, and to evaluate any differences by acculturation status for Hispanic women in the Southwestern United States.
Methods
A convenience sample of 406 primarily Mexican-origin (70%) low-income women completed a survey on knowledge of bean health benefits and general food behaviors. Principal components analysis of responses identified two summary scale constructs representing “bean health benefits” and “food behaviors.” Acculturation level was the main independent variable in chi-square or ANOVA.
Results
The survey completion rate was 86% (406/471). Most women agreed or strongly agreed that beans improved nutrition (65%) and were satiating (62%). Over 50% answered ‘neutral’ to statements that beans could lower LDL cholesterol (52%), control blood glucose (56%) or reduce cancer risk (56%), indicating indifference or possible lack of knowledge about bean health benefits. There were significant differences by acculturation for beliefs that beans aid weight loss and intestinal health. Scores on the bean health benefits scale, but not the food behavior scale, also differed by acculturation.
Conclusions
Limited resource women have a favorable view of the nutrition value of beans, but the majority did not agree or disagreed with statements about bean health benefits. Greater efforts to educate low-income women about bean health benefits may increase consumption and improve nutrition.
doi:10.1371/journal.pone.0147592
PMCID: PMC4731067  PMID: 26820889
17.  Breast Cancer Knowledge Assessment in Female Chinese Immigrants in New York 
Cancer nursing  2004;27(5):407-412.
The purpose of this study was to examine the relationships between acculturation level and perceptions of health access, Chinese health beliefs, Chinese health practices, and knowledge of breast cancer risk. This descriptive, correlational cross-sectional study used a survey approach. The sample included 135 Chinese women from the New York City metropolitan area. Data were analyzed using correlational techniques and polytomous regression. There were no significant relationships between acculturation and health access, Chinese health beliefs, Chinese health practices, and breast cancer risk knowledge. Only “years of education,” “marital status,” and “household income” significantly predicted breast cancer risk knowledge level. The data indicate that women with a better knowledge of breast cancer risk are twice as likely to have higher income and have more education. The most knowledgeable women are less likely to be married and less likely to have partners compared to least knowledgeable group. Providers need to promote health knowledge and provide information about as well as access to preventive health practices to the immigrant population, given that acculturation to the new dominant society is inevitable.
PMCID: PMC3653178  PMID: 15525869
Acculturation; Breast cancer; Chinese medicine; Immigrants; Knowledge
18.  Smoking is associated with pessimistic and avoidant beliefs about cancer: results from the International Cancer Benchmarking Partnership 
British Journal of Cancer  2015;112(11):1799-1804.
Background:
Smoking cessation is the key cancer prevention behaviour for smokers; nonetheless, smokers can still benefit from earlier diagnosis of cancer. However, fewer smokers participate in screening despite their increased risk, which may reflect different beliefs about cancer.
Methods:
A UK population-representative sample of ⩾50 year-olds (n=6965) was surveyed using the Awareness and Beliefs about Cancer measure. These analyses examine six items on cancer beliefs (e.g., ‘cancer can often be cured'), and four on help-seeking barriers (e.g., ‘I would be too embarrassed').
Results:
Smokers were more likely to hold pessimistic cancer beliefs than never-smokers or former-smokers on four of six items. For example, 34% agreed ‘a cancer diagnosis is a death sentence', compared with 24% of non/former-smokers (P<0.001). More smokers (18%) than non/former-smokers (11%) would not want to know if they had cancer (P<0.01). The only barrier to symptomatic help-seeking differing by smoking status was ‘worry about what the doctor might find' (36% vs 28%, P<0.01). Associations were independent of demographics, self-rated health and cancer experience.
Conclusions:
Smokers held more pessimistic and avoidant beliefs about cancer, which could deter early-detection behaviour. A better understanding of these beliefs is needed to increase engagement in early diagnosis by this high-risk group.
doi:10.1038/bjc.2015.148
PMCID: PMC4647255  PMID: 25950385
smoking; cancer; attitudes; early detection; avoidance; pessimism
19.  The Association of Health Literacy with Illness and Medication Beliefs among Patients with Chronic Obstructive Pulmonary Disease 
PLoS ONE  2015;10(4):e0123937.
Background
Low health literacy is associated with low adherence to self-management in many chronic diseases. Additionally, health beliefs are thought to be determinants of self-management behaviors. In this study we sought to determine the association, if any, of health literacy and health beliefs among elderly individuals with COPD.
Methods
We enrolled a cohort of patients with COPD from two academic urban settings in New York, NY and Chicago, IL. Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Using the framework of the Self-Regulation Model, illness and medication beliefs were measured with the Brief Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ). Unadjusted analyses, with corresponding Cohen’s d effect sizes, and multiple logistic regression were used to assess the relationships between HL and illness and medication beliefs.
Results
We enrolled 235 participants, 29% of whom had low health literacy. Patients with low health literacy were more likely to belong to a racial minority group (p<0.001), not be married (p = 0.006), and to have lower income (p<0.001) or education (p<0.001). In unadjusted analyses, patients with low health literacy were less likely to believe they will always have COPD (p = 0.003, Cohen’s d = 0.42), and were more likely to be concerned about their illness ((p = 0.04, Cohen’s d = 0.17). In analyses adjusted for sociodemographic factors and other health beliefs, patients with low health literacy were less likely to believe that they will always have COPD (odds ratio [OR]: 0.78, 95% confidence interval [CI]: 0.65–0.94). In addition, the association of low health literacy with expressed concern about medications remained significant (OR: 1.20, 95% CI: 1.05–1.37) though the association of low health literacy with belief in the necessity of medications was no longer significant (OR: 0.92, 95% CI: 0.82–1.04).
Conclusions
In this cohort of urban individuals with COPD, low health literacy was prevalent, and associated with illness beliefs that predict decreased adherence. Our results suggest that targeted strategies to address low health literacy and related illness and medications beliefs might improve COPD medication adherence and other self-management behaviors.
doi:10.1371/journal.pone.0123937
PMCID: PMC4411058  PMID: 25915420
20.  Sun Protection Beliefs among Hispanics in the US 
Journal of Skin Cancer  2014;2014:161960.
Purpose. We reviewed the literature on sun protection beliefs in Hispanics living in the United States to explore what challenges are faced by area of research. Method. A review of PubMED, PsycINFO, and CINAHL databases was performed. Studies were published in peer-reviewed journals (in all years available) and written in English. The search terms used were [“skin cancer” OR “sun protection”] AND [“Latino” OR “Hispanic”] AND “beliefs.” Eligible papers were included in the final analysis after meeting the following inclusion criteria: (1) the records had to quantitatively examine and report sun protection beliefs in Hispanics, (2) the number of Hispanic participants in the sample had to be clearly specified, and (3) studies reporting differences in sun protection beliefs between Hispanics and other racial and ethnic groups were included in the review. Results. Of the 92 articles identified, 11 met inclusion criteria and addressed sun protection beliefs regarding skin cancer seriousness and susceptibility, and benefits and barriers of sun protection and skin cancer risk behaviors. Characteristics of studies and results were examined. Conclusion. There is insufficient evidence to determine a pattern of sun protection beliefs among Hispanics in the United States. More quality studies are needed which focus on sun protection beliefs in Hispanics.
doi:10.1155/2014/161960
PMCID: PMC4241737  PMID: 25431673
21.  Communication Inequalities, Social Determinants, and Intermittent Smoking in the 2003 Health Information National Trends Survey 
Preventing Chronic Disease  2009;6(2):A40.
Introduction
Intermittent smokers account for a large proportion of all smokers, and this trend is increasing. Social and communication inequalities may account for disparities in intermittent smoking status.
Methods
Data for this study came from 2,641 ever-smokers from a 2003 nationally representative cross-sectional survey. Independent variables of interest included race/ethnicity, sex, household income, education, health media attention, and cancer-related beliefs. The outcome of interest was smoking status categorized as daily smoker, intermittent smoker, or former smoker. Analyses used 2 sets of multivariable logistic regressions to investigate the associations of covariates with intermittent smokers compared with former smokers and with daily smokers.
Results
People with high education and high income, Spanish-speaking Hispanics, and women were the most likely to be intermittent rather than daily smokers. Women and Spanish-speaking Hispanics were the most likely to be intermittent rather than former smokers. Attention to health media sources increased the likelihood that a person would be an intermittent smoker instead of a former or daily smoker. Believing that damage from smoking is avoidable and irreversible was associated with lower odds of being an intermittent smoker rather than a former smoker but did not differentiate intermittent smoking from daily smoking.
Conclusion
The results indicate that tailoring smoking-cessation campaigns toward intermittent smokers from specific demographic groups by using health media may improve the effect of these campaigns and reduce social health disparities.
PMCID: PMC2687846  PMID: 19288983
22.  Risk Prediction for Breast, Endometrial, and Ovarian Cancer in White Women Aged 50 y or Older: Derivation and Validation from Population-Based Cohort Studies 
PLoS Medicine  2013;10(7):e1001492.
Ruth Pfeiffer and colleagues describe models to calculate absolute risks for breast, endometrial, and ovarian cancers for white, non-Hispanic women over 50 years old using easily obtainable risk factors.
Please see later in the article for the Editors' Summary
Background
Breast, endometrial, and ovarian cancers share some hormonal and epidemiologic risk factors. While several models predict absolute risk of breast cancer, there are few models for ovarian cancer in the general population, and none for endometrial cancer.
Methods and Findings
Using data on white, non-Hispanic women aged 50+ y from two large population-based cohorts (the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial [PLCO] and the National Institutes of Health–AARP Diet and Health Study [NIH-AARP]), we estimated relative and attributable risks and combined them with age-specific US-population incidence and competing mortality rates. All models included parity. The breast cancer model additionally included estrogen and progestin menopausal hormone therapy (MHT) use, other MHT use, age at first live birth, menopausal status, age at menopause, family history of breast or ovarian cancer, benign breast disease/biopsies, alcohol consumption, and body mass index (BMI); the endometrial model included menopausal status, age at menopause, BMI, smoking, oral contraceptive use, MHT use, and an interaction term between BMI and MHT use; the ovarian model included oral contraceptive use, MHT use, and family history or breast or ovarian cancer. In independent validation data (Nurses' Health Study cohort) the breast and ovarian cancer models were well calibrated; expected to observed cancer ratios were 1.00 (95% confidence interval [CI]: 0.96–1.04) for breast cancer and 1.08 (95% CI: 0.97–1.19) for ovarian cancer. The number of endometrial cancers was significantly overestimated, expected/observed = 1.20 (95% CI: 1.11–1.29). The areas under the receiver operating characteristic curves (AUCs; discriminatory power) were 0.58 (95% CI: 0.57–0.59), 0.59 (95% CI: 0.56–0.63), and 0.68 (95% CI: 0.66–0.70) for the breast, ovarian, and endometrial models, respectively.
Conclusions
These models predict absolute risks for breast, endometrial, and ovarian cancers from easily obtainable risk factors and may assist in clinical decision-making. Limitations are the modest discriminatory ability of the breast and ovarian models and that these models may not generalize to women of other races.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In 2008, just three types of cancer accounted for 10% of global cancer-related deaths. That year, about 460,000 women died from breast cancer (the most frequently diagnosed cancer among women and the fifth most common cause of cancer-related death). Another 140,000 women died from ovarian cancer, and 74,000 died from endometrial (womb) cancer (the 14th and 20th most common causes of cancer-related death, respectively). Although these three cancers originate in different tissues, they nevertheless share many risk factors. For example, current age, age at menarche (first period), and parity (the number of children a woman has had) are all strongly associated with breast, ovarian, and endometrial cancer risk. Because these cancers share many hormonal and epidemiological risk factors, a woman with a high breast cancer risk is also likely to have an above-average risk of developing ovarian or endometrial cancer.
Why Was This Study Done?
Several statistical models (for example, the Breast Cancer Risk Assessment Tool) have been developed that estimate a woman's absolute risk (probability) of developing breast cancer over the next few years or over her lifetime. Absolute risk prediction models are useful in the design of cancer prevention trials and can also help women make informed decisions about cancer prevention and treatment options. For example, a woman at high risk of breast cancer might decide to take tamoxifen for breast cancer prevention, but ideally she needs to know her absolute endometrial cancer risk before doing so because tamoxifen increases the risk of this cancer. Similarly, knowledge of her ovarian cancer risk might influence a woman's decision regarding prophylactic removal of her ovaries to reduce her breast cancer risk. There are few absolute risk prediction models for ovarian cancer, and none for endometrial cancer, so here the researchers develop models to predict the risk of these cancers and of breast cancer.
What Did the Researchers Do and Find?
Absolute risk prediction models are constructed by combining estimates for risk factors from cohorts with population-based incidence rates from cancer registries. Models are validated in an independent cohort by testing their ability to identify people with the disease in an independent cohort and their ability to predict the observed numbers of incident cases. The researchers used data on white, non-Hispanic women aged 50 years or older that were collected during two large prospective US cohort studies of cancer screening and of diet and health, and US cancer incidence and mortality rates provided by the Surveillance, Epidemiology, and End Results Program to build their models. The models all included parity as a risk factor, as well as other factors. The model for endometrial cancer, for example, also included menopausal status, age at menopause, body mass index (an indicator of the amount of body fat), oral contraceptive use, menopausal hormone therapy use, and an interaction term between menopausal hormone therapy use and body mass index. Individual women's risk for endometrial cancer calculated using this model ranged from 1.22% to 17.8% over the next 20 years depending on their exposure to various risk factors. Validation of the models using data from the US Nurses' Health Study indicated that the endometrial cancer model overestimated the risk of endometrial cancer but that the breast and ovarian cancer models were well calibrated—the predicted and observed risks for these cancers in the validation cohort agreed closely. Finally, the discriminatory power of the models (a measure of how well a model separates people who have a disease from people who do not have the disease) was modest for the breast and ovarian cancer models but somewhat better for the endometrial cancer model.
What Do These Findings Mean?
These findings show that breast, ovarian, and endometrial cancer can all be predicted using information on known risk factors for these cancers that is easily obtainable. Because these models were constructed and validated using data from white, non-Hispanic women aged 50 years or older, they may not accurately predict absolute risk for these cancers for women of other races or ethnicities. Moreover, the modest discriminatory power of the breast and ovarian cancer models means they cannot be used to decide which women should be routinely screened for these cancers. Importantly, however, these well-calibrated models should provide realistic information about an individual's risk of developing breast, ovarian, or endometrial cancer that can be used in clinical decision-making and that may assist in the identification of potential participants for research studies.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001492.
This study is further discussed in a PLOS Medicine Perspective by Lars Holmberg and Andrew Vickers
The US National Cancer Institute provides comprehensive information about cancer (in English and Spanish), including detailed information about breast cancer, ovarian cancer, and endometrial cancer;
Information on the Breast Cancer Risk Assessment Tool, the Surveillance, Epidemiology, and End Results Program, and on the prospective cohort study of screening and the diet and health study that provided the data used to build the models is also available on the NCI site
Cancer Research UK, a not-for-profit organization, provides information about cancer, including detailed information on breast cancer, ovarian cancer, and endometrial cancer
The UK National Health Service Choices website has information and personal stories about breast cancer, ovarian cancer, and endometrial cancer; the not-for-profit organization Healthtalkonline also provides personal stories about dealing with breast cancer and ovarian cancer
doi:10.1371/journal.pmed.1001492
PMCID: PMC3728034  PMID: 23935463
23.  Predictors of Human Papillomavirus Awareness and Knowledge in 2013 
Background
Nearly 80 million people in the U.S. are currently infected with at least one of two strains of human papillomavirus (HPV), which is associated with 70% of cervical cancers. Greater cervical cancer mortality has been observed among women of lower SES and those living in rural, versus urban, areas. African American and Hispanic women are significantly more likely to die from cervical cancer than non-Hispanic white women.
Purpose
To assess current population awareness of and knowledge about HPV and the HPV vaccine, as well as the contribution of sociodemographic characteristics to disparities in HPV awareness and knowledge.
Methods
Cross-sectional data were obtained from the National Cancer Institute’s 2013 Health Information National Trends Survey (HINTS; N=3,185). Multivariable logistic regression was employed to identify gaps in awareness and knowledge by sex, education, income, race/ethnicity, geographic area, and other important sociodemographic characteristics. Analyses were conducted in 2014.
Results
Sixty-eight percent of Americans had heard of HPV and the HPV vaccine. Consistent with the Knowledge Gap Hypothesis, awareness and knowledge were patterned by sex, age, education, and other important sociodemographic factors. Those in rural areas were less likely than those in urban areas to know that HPV causes cervical cancer. Less than 5% of Americans were aware that HPV often clears on its own without treatment.
Conclusions
Although awareness and knowledge of HPV is increasing, there are opportunities to target communication with populations for whom knowledge gaps currently exist, in order to promote dialogue about the vaccine among patients and their providers.
doi:10.1016/j.amepre.2014.10.024
PMCID: PMC4380806  PMID: 25700651
24.  Deficiencies in public understanding about tobacco harm reduction: results from a United States national survey 
Background
Tobacco products differ in their relative health harms. The need for educating consumers about such harms is growing as different tobacco products enter the marketplace and as the FDA moves to regulate and educate the public about different products. However, little is known about the patterns of the public’s knowledge of relative harms.
Methods
Data were analyzed from the Health Information National Trends Survey (HINTS) 4 Cycle 2, a population-representative survey of US adults conducted between October 2012 and January 2013 (N = 3630). Participants reported their perceptions of the relative risks of e-cigarettes, smokeless tobacco, and different types of cigarettes compared to “traditional” cigarettes. Relative risk perceptions for each product type, as well as the consistency and accuracy of harm reduction beliefs, were analyzed.
Results
About 65 % of the respondents accurately reported that no cigarettes were less harmful than any others. Slightly more than half of US adults perceived e-cigarettes to be safer than regular cigarettes, a belief in line with current scientific evidence. By contrast, only 9 % of respondents perceived some smokeless tobacco products to be safer, a belief strongly supported by the evidence. Only 3.5 % of respondents had patterns of relative risk perceptions in line with current scientific evidence for all three modalities.
Conclusions
The discrepancy between current evidence and public perceptions of relative risk of various tobacco/nicotine products was marked; for most tobacco types, a large proportion of the population held inaccurate harm reduction beliefs. Although there was substantial awareness that no cigarettes were safer than any other cigarettes, there could be benefits from increasing the percentage of the public that appreciates this fact, especially among current smokers. Given the potential benefits of tobacco risk reduction strategies, public health education efforts to increase understanding of basic harm reduction principles are needed to address these misperceptions.
doi:10.1186/s12954-015-0055-0
PMCID: PMC4487951  PMID: 26135116
Tobacco harm reduction; Cigarettes; Smokeless tobacco; Electronic cigarettes; Public health education; Risk perception; Health communication
25.  Healthy Eating and Risks of Total and Cause-Specific Death among Low-Income Populations of African-Americans and Other Adults in the Southeastern United States: A Prospective Cohort Study 
PLoS Medicine  2015;12(5):e1001830.
Background
A healthy diet, as defined by the US Dietary Guidelines for Americans (DGA), has been associated with lower morbidity and mortality from major chronic diseases in studies conducted in predominantly non-Hispanic white individuals. It is unknown whether this association can be extrapolated to African-Americans and low-income populations.
Methods and Findings
We examined the associations of adherence to the DGA with total and cause-specific mortality in the Southern Community Cohort Study, a prospective study that recruited 84,735 American adults, aged 40–79 y, from 12 southeastern US states during 2002–2009, mostly through community health centers that serve low-income populations. The present analysis included 50,434 African-Americans, 24,054 white individuals, and 3,084 individuals of other racial/ethnic groups, among whom 42,759 participants had an annual household income less than US$15,000. Usual dietary intakes were assessed using a validated food frequency questionnaire at baseline. Adherence to the DGA was measured by the Healthy Eating Index (HEI), 2010 and 2005 editions (HEI-2010 and HEI-2005, respectively). During a mean follow-up of 6.2 y, 6,906 deaths were identified, including 2,244 from cardiovascular disease, 1,794 from cancer, and 2,550 from other diseases. A higher HEI-2010 score was associated with lower risks of disease death, with adjusted hazard ratios (HRs) of 0.80 (95% CI, 0.73–0.86) for all-disease mortality, 0.81 (95% CI, 0.70–0.94) for cardiovascular disease mortality, 0.81 (95% CI, 0.69–0.95) for cancer mortality, and 0.77 (95% CI, 0.67–0.88) for other disease mortality, when comparing the highest quintile with the lowest (all p-values for trend < 0.05). Similar inverse associations between HEI-2010 score and mortality were observed regardless of sex, race, and income (all p-values for interaction > 0.50). Several component scores in the HEI-2010, including whole grains, dairy, seafood and plant proteins, and ratio of unsaturated to saturated fatty acids, showed significant inverse associations with total mortality. HEI-2005 score was also associated with lower disease mortality, with a HR of 0.86 (95% CI, 0.79–0.93) when comparing extreme quintiles. Given the observational study design, however, residual confounding cannot be completely ruled out. In addition, future studies are needed to evaluate the generalizability of these findings to African-Americans of other socioeconomic status.
Conclusions
Our results showed, to our knowledge for the first time, that adherence to the DGA was associated with lower total and cause-specific mortality in a low-income population, including a large proportion of African-Americans, living in the southeastern US.
In a prospective cohort study, Wei Zheng and colleagues study the association between adherence to dietary guidelines and mortality in low-income US adults, two thirds of whom are African-Americans.
Editors' Summary
Background
Certain parts of the population, including women, children, ethnic and racial minorities, and poor people, are often underrepresented in clinical trials and in epidemiological studies (which examine the patterns, causes, and effects of health and disease conditions). In the US population, the link between diet and health has mostly been studied in non-Hispanic white individuals from middle- and high-income households. Such studies formed the basis for the Dietary Guidelines for Americans (DGA), and more recently have shown that adherence to the DGA is associated with lower levels of obesity, as well as lower risks for diabetes, cardiovascular disease (such as heart attacks and strokes), and certain cancers. To measure adherence to the DGA, the Center for Nutrition Policy and Promotion at the US Department of Agriculture developed the Healthy Eating Index (HEI) in 1995. The DGA and the HEI have been updated several times, and the HEI-2010—the latest version—reflects the 2010 DGA.
Why Was This Study Done?
Because research participants are often not representative of the entire US population, it is unknown whether the results of many studies are valid for all Americans. To remedy this situation, efforts have been made to recruit participants from previously underrepresented parts of the population and to address important health questions in such groups. For this study, the researchers wanted to examine whether adherence to the DGA was associated with better health outcomes in poor people and African-Americans, consistent with the results in wealthier non-Hispanic white individuals.
What Did the Researchers Do and Find?
The researchers analyzed data from the Southern Community Cohort Study (SCCS). The SCCS was funded by the National Cancer Institute and was initiated in 2001 with the goal of addressing unresolved questions about the causes of cancer and other chronic diseases, as well as reasons for health disparities. The SCCS recruited most of its participants from community health centers in 12 states in the southeastern US. These centers serve predominantly poor and uninsured people, including many African-Americans. Of approximately 85,000 SCCS participants, over two-thirds were African-American, and over half were poor, with an annual household income of less than US$15,000.
For this study, the researchers used a food frequency questionnaire that was designed to capture foods commonly consumed in the southeastern US, and from this calculated HEI-2010 scores for each participant. They also collected other health- and lifestyle-related information. They then followed all participants for whom they had complete information (over 77,000) for a number of years (half of them for over 6.2 years). During that period, 6,906 participants died; including 2,244 from cardiovascular disease, 1,794 from cancer, and 2,550 from other diseases. When the researchers tested for a possible association between HEI-2010 and death (controlling for other relevant factors such as age, weight, exercise, smoking, and the presence of specific chronic diseases), they found that participants with a higher HEI-2010 score (reflecting better adherence to the DGA) had a lower risk of dying in the follow-up period. Participants with the healthiest diet (those in the top one-fifth of HEI-2010 scores) had only about 80% of the risk of death of those with the unhealthiest diets (those in the bottom one-fifth of HEI-2010 scores). This reduction in the risk of death by approximately 20% was true for death from any disease, death from cancer, and death from cardiovascular disease.
What Do These Findings Mean?
The results support the validity of the DGA for healthy eating across the US population. However, the study had some limitations. For example, participants were asked only once—when they first joined the SCCS—about their diet, their household income, and other factors that can change over time, such as exercise habits and diseases they have been diagnosed with. Besides such changes, there could be other factors not captured in the study that might influence the association between diet and death. Despite these uncertainties, the findings suggest that adherence to the DGA is associated with lower total mortality and mortality from cancer or cardiovascular disease in poor US Americans in general, and in low-income African-Americans.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001830.
Information is available online about the Southern Community Cohort Study
The US Department of Agriculture’s Center for Nutrition Policy and Promotion has information on the Healthy Eating Index, which is based on the Dietary Guidelines for Americans
The World Health Organization provides information on diet as part of its global strategy for diet, physical activity, and health, as well as a factsheet on healthy diet
Wikipedia has a page on race and health in the US (note that Wikipedia is a free online encyclopedia that anyone can edit)
doi:10.1371/journal.pmed.1001830
PMCID: PMC4444091  PMID: 26011727

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