Racial Disparities in Triple Negative Breast Cancer: Toward a Causal Architecture Approach

Background: Triple negative breast cancer (TNBC) is an aggressive subtype of invasive breast cancer that disproportionately affects Black women and contributes to racial disparities in breast cancer mortality. Prior research has suggested that neighborhood effects may contribute to this disparity beyond individual risk factors.Methods: The sample included a cohort of 3,316 breast cancer cases diagnosed between 2012 and 2020 in New Castle County, Delaware, a geographic region of the US with elevated rates of TNBC. Multilevel methods and geospatial mapping evaluated whether the race, income, and race/income versions of the neighborhood Index of Concentration at the Extremes (ICE) metric could efficiently identify census tracts (CT) with higher odds of TNBC relative to other forms of invasive breast cancer. Odds ratios (OR) and 95% confidence intervals (CI) were reported; p-values <0.05 were significant. Additional analyses examined area-level differences in exposure to metabolic risk factors, including unhealthy alcohol use and obesity.Results: The ICE-Race, -Income-, and Race/Income metrics were each associated with greater census tract odds of TNBC on a bivariate basis. However, only ICE-Race was significantly associated with higher odds of TNBC after adjustment for patient-level age and race (most disadvantaged CT: OR= 2.09; 95%CI=1.40-3.13), providing support for neighborhood effects. Higher counts of alcohol and fast-food retailers, and correspondingly higher rates of unhealthy alcohol use and obesity, were observed in CTs that were classified into the most disadvantaged ICE-Race quintile and had the highest odds of TNBC. Conclusion: The use of ICE can facilitate the monitoring of cancer inequities and advance the study of racial disparities in breast cancer.

A Novel Computer-Based Virtual Counselor-Delivered Alcohol Reduction Intervention: Acceptability, Adaptability and Feasibility among Adults with HIV or TB in Indian Clinical Settings (Preprint)

BACKGROUND Unhealthy alcohol use is associated with increased morbidity and mortality among persons with HIV and/or TB. Computer-Based interventions (CBI) can reduce unhealthy alcohol use, are scalable, and may improve outcomes among patients with HIV or TB. OBJECTIVE We assessed the acceptability, adaptability, and feasibility of a novel CBI for alcohol reduction in HIV and TB clinical settings in Pune, India. METHODS We conducted 10 in-depth interviews (IDIs) with persons with alcohol use disorder (AUD); [TB (n=6), HIV (n=2), HIV-TB co-infected (n=1) selected using convenience sampling method, No HIV or TB disease (n=1)], one focus group (FG) with members of alcoholics anonymous (AA) (n=12, and two FGs with health care providers (HCPs) of a tertiary care hospital (n=22). All participants reviewed and provided feedback on a CBI for AUD delivered by a 3-D virtual counselor. Qualitative data were analyzed using structured framework analysis. RESULTS Majority (n=9) of IDI respondents were male with median age 42 (IQR; 38-45) years. AA FG participants were all male (n=12) and HCPs FG participants were predominantly female (n=15). Feedback was organized into 3 domains: 1) Virtual counselor acceptability; 2) Intervention adaptability; and 3) feasibility of CBI intervention in clinic settings. Overall IDI participants found the virtual counselor to be acceptable and felt comfortable honestly answering alcohol-related questions. All FG participants preferred a human virtual counselor to an animal virtual counselor so as to potentially increase CBI engagement. Additionally, interaction with a live human counselor would further enhance the program’s effectiveness by providing more flexible interaction. HCP FGs noted the importance of adding information on the effects of alcohol on HIV and TB outcomes because patients were not viewed as appreciating these linkages. For local adaptation, more information on types of alcoholic drinks, additional drinking triggers, motivators and activities to substitute for drinking alcohol were suggested by all FG participants. Intervention duration (~20 minutes) and pace were deemed appropriate. HCPs reported that CBI provides systematic, standardized counseling. All FG and IDI reported that CBI could be implemented in Indian clinical settings with assistance from HIV or TB program staff. CONCLUSIONS With cultural tailoring to patients with HIV and TB in Indian clinical care settings, a virtual counselor-delivered alcohol intervention is acceptable, appears feasible to implement, particularly if coupled with person-delivered counseling.

The STUN (STop UNhealthy) Alcohol Use Now trial: study protocol for an adaptive randomized trial on dissemination and implementation of screening and management of unhealthy alcohol use in primary care

Background Unhealthy alcohol use is a leading cause of preventable deaths in the USA and is associated with many societal and health problems. Less than a third of people who visit primary care providers in the USA are asked about or ever discuss alcohol use with a health professional. Methods/design This study is an adaptive, randomized, controlled trial to evaluate the effect of primary care practice facilitation and telehealth services on evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use in small-to-medium-sized primary care practices. Study participants will include primary care practices in North Carolina with 10 or fewer providers. All enrolled practices will receive a practice facilitation intervention that includes quality improvement (QI) coaching, electronic health record (EHR) support, training, and expert consultation. After 6 months, practices in the lower 50th percentile (based on performance) will be randomized to continued practice facilitation or provision of telehealth services plus ongoing facilitation for the next 6 months. Practices in the upper 50th percentile after the initial 6 months of intervention will continue to receive practice facilitation alone. The main outcome measures include the number (and %) of patients in the target population who are screened for unhealthy alcohol use, screen positive, and receive brief counseling. Additional measures include the number (and %) of patients who receive pharmacotherapy for AUD or are referred for AUD services. Sample size calculations determined that 35 practices are needed to detect a 10% increase in the main outcome (percent screened for unhealthy alcohol use) over 6 months. Discussion A successful intervention would significantly reduce morbidity among adults from unhealthy alcohol use by increasing counseling and other treatment opportunities. The study will produce important evidence about the effect of practice facilitation on uptake of evidence-based screening, counseling, and pharmacotherapy for unhealthy alcohol use when delivered on a large scale to small and medium-sized practices. It will also generate scientific knowledge about whether embedded telehealth services can improve the use of evidence-based screening and interventions for practices with slower uptake. The results of this rigorously conducted evaluation are expected to have a positive impact by accelerating the dissemination and implementation of evidence related to unhealthy alcohol use into primary care practices. Trial registration ClinicalTrials.govNCT04317989. Registered on March 23, 2020.

Digital Health Screening in Persons with HIV in Uganda to Increase Alcohol Reporting (Preprint)

BACKGROUND Alcohol brief interventions are effective for reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often under-reported. Self-administered digital health screeners may improve reporting. OBJECTIVE Our first aim was to develop a brief touch-screen tablet based health screener to be administered in an HIV clinic waiting room, to increase reporting of unhealthy alcohol use for persons with HIV in Uganda. Our second aim was to pilot test the health screener developed in Aim 1 to examine acceptability, ease of use, comfort with reporting, and to discuss how the results of such screening might be used. METHODS We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener assessed behaviors regarding general health, HIV care, mental health, as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions (FGD) with clinicians and patients of the Mbarara ISS Clinic with HIV who consume alcohol to obtain input on the need for, content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener and conducted individual semi-structured in-depth interviews (IDIs) with 20 prior alcohol study participants, including those who previously under-reported use and those with low literacy. RESULTS Forty-five people (five clinicians and forty Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% were male, 43% had low literacy, and all had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing staff burden, and mitigating patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information. In pilot tests of the prototype, patients liked the feature of a recorded voice in the local language, found the screener easy to use, although many required help. CONCLUSIONS We found a self-administered digital health screener to be appealing to patients and clinicians, and usable in a busy HIV clinic setting, albeit there were concerns about confidentiality and training. Such a screener may be useful to improve reporting of unhealthy alcohol use for referral to interventions. CLINICALTRIAL N/A

An Ethnographic study of unhealthy alcohol use in a Danish Emergency Department

Background Emergency Departments (EDs) are important arenas for the detection of unhealthy substance use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) for unhealthy alcohol use has been used in some ED settings with funding support from external sources. However, widespread sustained implementation is uncommon, and research aimed at understanding culture as a determinant for implementation is lacking. This study aims to explore cultural practices concerning the handling of patients with unhealthy alcohol use admitted to an ED. Methods An ethnographic study was conducted in an ED in the Capital Region of Denmark. The data consists of participant observations of Health Care Professionals (HCPs) and semi-structured interviews with nurses. Data was collected from July 2018 to February 2020. A cultural analysis was performed by using Qualitative Content Analysis as an analytic tool. Results 150 h of observation and 11 interviews were conducted. Three themes emerged from the analysis: (1) Setting the scene describes how subthemes “flow,” “risky environment,” and “physical spaces and artefacts” are a part of the contextual environment of an ED, and their implications for patients with unhealthy alcohol use, such as placement in certain rooms; (2) The encounter presents how patients’ and HCPs’ encounters unfold in everyday practice. Subtheme “Professional differences” showcases how nurses and doctors address patients’ alcohol habits differently, and how they do not necessarily act on the information provided, due to several factors. These factors are shown in remaining sub-themes “gut-feeling vs. clinical parameters,” “ethical reasoning,” and “from compliance to zero-tolerance”; and (3) Collective repertoires shows how language shapes the perception of patients with unhealthy alcohol use, which may cause stigma and stereotyping. Subthemes are “occupiers” and “alcoholic or party animal?”. Conclusions Unhealthy alcohol use in the ED is entangled in complex cultural networks. Patients with severe and easily recognizable unhealthy alcohol use—characterized by an alcohol diagnosis in the electronic medical record, intoxication, or unwanted behavior—shape the general approach and attitude to unhealthy alcohol use. Consequently, from a prevention perspective, this means that patients with less apparent unhealthy alcohol use tend to be overlooked or neglected, which calls for a systematic screening approach.