Health Care Access Factors Research Articles

Disparities in Vision-Related Functional Impairments Among Adults in the United States

ABSTRACT Purpose To investigate the relationships between vision-related functional impairment (VFI) with sociodemographic and healthcare access factors in a representative sample of the United States population. Methods Data from the 2017 National Health Interview Survey (NHIS) were used. The NHIS involves responses from the U.S. civilian, non-institutionalized population aged 18 years or older. It provides self-reported data on demographic characteristics, socioeconomic factors, health status, and healthcare access. NHIS participants who responded to at least one of our target questions about VFI were included in the study. VFI was defined for participants based on their ‘yes’ or ‘no’ responses to target questions about experiencing a VFI. Data analysis was performed through univariable and multivariable logistic regression. Results Overall, 26,711 participants were included, of which 6926 (25.9%) participants reported experiencing a VFI. In univariable analysis, there were greater odds of VFI among females (OR: 1.16, 95% CI: 1.07–1.26, p < 0.001), and participants with less than a high school degree compared to those with an advanced degree (OR: 1.17, 95% CI: 1.02–1.33, p = 0.02). Among economic and healthcare access factors, greater odds of VFI was associated with public health insurance versus private coverage (OR: 1.19, 95% CI: 1.07–1.32, p = 0.001), having delayed medical care due to costs (OR: 1.86, 95% CI: 1.86–2.10, p < 0.001), and being unemployed (OR: 1.39, 95% CI: 1.26–1.53, p < 0.001). Participants whose incomes were lower than the poverty threshold (OR: 1.54, 95% CI: 1.32–1.80, p < 0.001) had higher odds of VFI than those with income >5× poverty threshold. Conclusions Several demographic and economic factors are associated with VFI in a representative sample of the U.S. population. These results highlight the importance of addressing social and economic factors that are associated with the development of VFI.

IMPACTO DA PNEUMONIA NA MORTALIDADE INFANTIL: ANÁLISE HOSPITALAR NO ESTADO DA BAHIA

Introduction: Pneumonia is a severe respiratory infection, often caused by bacteria, viruses, or fungi, that primarily affects the lungs and can impair gas exchange, leading to respiratory difficulties. In Brazil, pneumonia presents a significant public health challenge, with a particular impact on children under five years of age. This issue is especially evident in the state of Bahia, where the infant mortality rate due to pneumonia is one of the highest in the country. The causes of this high mortality are linked to a combination of factors such as lack of access to adequate medical care, low vaccination coverage, poor living conditions, overcrowded homes, and insufficient air quality. Objectives: The main objective of this study is to analyze the impact of pneumonia on infant mortality in the state of Bahia, focusing on hospital data analysis between 2020 and 2024. The research aims to identify the epidemiological trends of the disease, understand the associated risk factors, and encourage the implementation of public policies to reduce infant mortality caused by pneumonia. Justification: This research is relevant to public health because it highlights the persistent high rates of infant mortality due to pneumonia, a critical issue in socially vulnerable areas. The study contributes to understanding the social, economic, and healthcare access factors affecting the child population in Bahia, providing essential data for more effective public health policies. Methodology: The study is of an epidemiological nature, using a quantitative approach. Data were collected from records of pediatric pneumonia cases provided by the Health Department of the State of Bahia (SESAB) and DATASUS, covering the period from 2020 to 2024. Data on incidence, mortality, demographic characteristics (age, sex, race/ethnicity), and regional conditions were analyzed. The analysis was performed using descriptive statistics and techniques such as calculating mortality rates and identifying risk factors. Results and Discussion: The data revealed that between January 2020 and September 2024, there were 295 deaths due to pneumonia in children in Bahia. The highest mortality was observed in the age groups under 1 year (33.6%) and 1 to 4 years (37.3%), indicating extreme vulnerability of these age groups to the disease. Additionally, pneumonia mortality was higher among children of mixed-race (parda) background (76.3%), reflecting socioeconomic and healthcare access inequalities, particularly in peripheral and rural areas. A slight predominance of deaths among girls was also observed, though the gender difference was small (2.37%). Conclusion: This study highlights the social and regional inequalities contributing to high infant mortality from pneumonia in Bahia, emphasizing the difficulties in accessing healthcare services in more vulnerable areas. The analysis revealed that children under 5 years of age, especially those under 1 year old, are the most affected. To reduce these rates, it is urgent to implement public policies focused on improving healthcare access, expanding vaccination coverage, and strengthening living conditions in the most underserved areas of Bahia.

Characteristics of High-Cost Beneficiaries of Prescription Drugs in Kazakhstan: A Cross-Sectional Study of Outpatient Data from 2022.

Limited information is available regarding the distribution of increasing pharmaceutical expenditures within large representative samples of national populations globally. The aim was to investigate the distribution of pharmaceutical costs in outpatient treatment and analyze the primary characteristics of users of expensive drugs within the healthcare system of Kazakhstan. This study utilized data from the Information System for Outpatient Drug Supply, which includes nationally representative data from all regions of Kazakhstan, covering both rural and urban populations. The key explanatory variables in this study included age, gender, number of prescribed medications, disease categories based on ICD-10 codes, and insurance coverage status. These variables were selected to capture demographic, clinical, and healthcare access factors influencing prescription drug costs. In total, 2.2 million people, who were prescribed outpatient medications were included. High-cost users (HCUs) were characterized as individuals whose prescription drug expenses ranked within the highest 5%. The distribution of pharmaceutical costs exhibits significant discrepancy, with 5% of the population receiving prescription drugs covered by the state budget and social medical insurance fund contributing to nearly three-quarters of all costs. Notably, these HCUs tended to be younger than low-cost drug users. HCUs, on average, consumed a greater quantity of medications compared to non-HCUs. Among children, the top diseases contributing to high costs were rare hereditary diseases and malignancies, while in adults, cancer and diabetes were the primary cost drivers. There is a concentration of public drug program spending within a small percentage of beneficiaries with high drug costs in Kazakhstan. This discovery offers valuable insights for shaping policies tailored to this specific population, aiming to mitigate escalating costs and enhance the optimal use of medications.

Abstract C135: The heterogenous impact of healthcare access factors throughout the breast cancer care continuum

Abstract Background: Delays in breast cancer diagnosis and treatment lead to worse survival and quality of life decrements. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (diagnosis, treatment initiation, treatment duration, and genomic testing). Methods: The Carolina Breast Cancer Study Phase 3 (CBCS3) is a population-based cohort (n=2998, 50% Black) with invasive breast cancer diagnoses (2008-2013). We used latent class analysis (LCA) to group participants based on patterns of factors within 3 separate domains: “socio-economic status (SES)”, “care barriers”, and “care use.” These classes were evaluated in association with delayed diagnosis (approximated with stage 3 or 4 at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment – by treatment modality), and receipt of OncotypeDx genomic testing (evaluated among patients with early stage, ER+, HER2- disease). Associations were evaluated using adjusted linear-risk regression to estimate relative frequency differences (RFDs) with 95% confidence intervals (CIs). Results: Overall, 18% of CBCS participants had late stage/delayed diagnosis, 35% had delayed treatment initiation, 48% had prolonged treatment duration, and 62% did not receive OncotypeDx. Black women had greater frequency of each unfavorable care outcome compared to non-Black women, including diagnostic delay (22% vs 15%, RFD= 6.9, 4.1-9.6), treatment initiation delay (39% vs 31%, RFD=7.9, 4.5-11.3), prolonged treatment (50% vs 46%, RFD= 4.3, 0.5-8.2), and OncotypeDx non-receipt (69% vs 57%, RFD= 12.2, 7.3-16.7). We identified 3 latent classes for SES (“high SES”, “moderate SES,” and “low SES”) 2 classes for care barriers (“few barriers”, “more barriers”), and 5 classes for care use (“short travel/high preventive care”, “short travel/low preventive care,” “medium travel,” “variable travel,” and “high travel”). Low-SES and more barriers to care were associated with greater frequency of delayed diagnosis (RFDadj = 5.5, 2.4-8.5; RFDadj =6.7, 2.8-10.7, respectively) and prolonged treatment (RFDadj = 9.7, 4.8-14.6; RFDadj = 7.3, 2.4-12.2, respectively). Variable travel (short time to diagnosis but long time to surgery) was associated with delayed treatment in the entire study population (RFDadj = 10.7, 2.7-18.8) compared to the short travel, high use referent group. The high travel group (representing long travel to both diagnosis and surgery) was associated with delayed treatment only among Black women relative to the same referent group (RFDadj = 10.0, -3.3-23.2). Conclusions: Black patients face more frequent delays throughout the care continuum, likely stemming from different types of access barriers at key junctures. Improving breast cancer care access will require intervention on multiple aspects of SES and healthcare access. Citation Format: Matthew R. Dunn, Didong Li, Marc A Emerson, Caroline A. Thompson, Hazel B Nichols, Sarah C Van Alsten, Mya L. Roberson, Lisa A. Carey, Terry Hyslop, Jennifer Elston Lafata, Melissa A. Troester. The heterogenous impact of healthcare access factors throughout the breast cancer care continuum [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C135.

Abstract C135: The heterogenous impact of healthcare access factors throughout the breast cancer care continuum

Abstract Background: Delays in breast cancer diagnosis and treatment lead to worse survival and quality of life decrements. Racial disparities in care timeliness have been reported, but few studies have examined access at multiple points along the care continuum (diagnosis, treatment initiation, treatment duration, and genomic testing). Methods: The Carolina Breast Cancer Study Phase 3 (CBCS3) is a population-based cohort (n=2998, 50% Black) with invasive breast cancer diagnoses (2008-2013). We used latent class analysis (LCA) to group participants based on patterns of factors within 3 separate domains: “socio-economic status (SES)”, “care barriers”, and “care use.” These classes were evaluated in association with delayed diagnosis (approximated with stage 3 or 4 at diagnosis), delayed treatment initiation (more than 30 days between diagnosis and first treatment), prolonged treatment duration (time between first and last treatment – by treatment modality), and receipt of OncotypeDx genomic testing (evaluated among patients with early stage, ER+, HER2- disease). Associations were evaluated using adjusted linear-risk regression to estimate relative frequency differences (RFDs) with 95% confidence intervals (CIs). Results: Overall, 18% of CBCS participants had late stage/delayed diagnosis, 35% had delayed treatment initiation, 48% had prolonged treatment duration, and 62% did not receive OncotypeDx. Black women had greater frequency of each unfavorable care outcome compared to non-Black women, including diagnostic delay (22% vs 15%, RFD= 6.9, 4.1-9.6), treatment initiation delay (39% vs 31%, RFD=7.9, 4.5-11.3), prolonged treatment (50% vs 46%, RFD= 4.3, 0.5-8.2), and OncotypeDx non-receipt (69% vs 57%, RFD= 12.2, 7.3-16.7). We identified 3 latent classes for SES (“high SES”, “moderate SES,” and “low SES”) 2 classes for care barriers (“few barriers”, “more barriers”), and 5 classes for care use (“short travel/high preventive care”, “short travel/low preventive care,” “medium travel,” “variable travel,” and “high travel”). Low-SES and more barriers to care were associated with greater frequency of delayed diagnosis (RFDadj = 5.5, 2.4-8.5; RFDadj =6.7, 2.8-10.7, respectively) and prolonged treatment (RFDadj = 9.7, 4.8-14.6; RFDadj = 7.3, 2.4-12.2, respectively). Variable travel (short time to diagnosis but long time to surgery) was associated with delayed treatment in the entire study population (RFDadj = 10.7, 2.7-18.8) compared to the short travel, high use referent group. The high travel group (representing long travel to both diagnosis and surgery) was associated with delayed treatment only among Black women relative to the same referent group (RFDadj = 10.0, -3.3-23.2). Conclusions: Black patients face more frequent delays throughout the care continuum, likely stemming from different types of access barriers at key junctures. Improving breast cancer care access will require intervention on multiple aspects of SES and healthcare access. Citation Format: Matthew R. Dunn, Didong Li, Marc A Emerson, Caroline A. Thompson, Hazel B Nichols, Sarah C Van Alsten, Mya L. Roberson, Lisa A. Carey, Terry Hyslop, Jennifer Elston Lafata, Melissa A. Troester. The heterogenous impact of healthcare access factors throughout the breast cancer care continuum [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr C135.

Epidemiology of eye diseases in Bangladesh

Bangladesh is densely populated country in South Asia, faces significant challenges in eye health due to various socioeconomic, environmental, and healthcare access factors. Limited access to quality eye care services, poor hygiene practices, prevalence of infectious diseases, and a high burden of non-communicable diseases contribute to the prevalence of eye disorders in the region. This study aims to comprehensively analyze the prevalence, distribution, and risk factors associated with various eye diseases among the population of Bangladesh. A systematic review and meta-analysis were conducted to gather data on the epidemiology of eye diseases in Bangladesh. Published studies, national surveys, and reports from relevant health organizations were reviewed to compile data on the prevalence, distribution, and risk factors of common eye conditions, including cataracts, refractive errors, conjunctivitis, glaucoma, diabetic retinopathy, and age-related macular degeneration. The prevalence of eye diseases in Bangladesh is relatively high, with conditions such as refractive errors, cataracts, glaucoma, and corneal diseases being major concerns. Refractive errors, including myopia, hyperopia, and astigmatism, affect a substantial portion of the population, particularly among children and young adults. Cataracts, a leading cause of blindness worldwide, also pose a significant burden in Bangladesh, with prevalence increasing with age. While the prevalence of glaucoma in Bangladesh is lower compared to some other countries, the condition remains a cause of concern due to its impact on quality of life and the healthcare system. Diabetic retinopathy, a complication of diabetes mellitus, affects the retina and is a leading cause of vision loss and blindness globally in the elderly. In Bangladesh, the rising prevalence of diabetes, fueled by changing lifestyles and an aging population, has contributed to an increasing burden of diabetic retinopathy. Conjunctivitis is prevalent, particularly in densely populated urban areas and rural communities with limited access to clean water and sanitation facilities.Collaborative efforts involving government agencies, healthcare providers, non-governmental organizations, and the community are essential to effectively address the burden of eye diseases in Bangladesh. By implementing preventive measures and improving access to quality eye care services, it is possible to mitigate the impact of these eye diseases and improve visual health outcomes for the population.

Understanding the determinants of self-reported asthma in Turkey: insights from national data on individual, lifestyle, socioeconomic, and healthcare access factors

Asthma, influenced by genetic, environmental, and social factors is leading to poor outcomes and preventable mortality due to inadequate care and limited access to effective treatments. This study aimed to analyze self-reported asthma prevalence in Turkey, focusing on its determinants, such as individual factors, lifestyle, socioeconomic status, and healthcare access.This study conducts a secondary analysis of the 2019 Turkiye Health Survey (THS), employing a nationally representative cross-sectional design by the Turkish Statistical Institute. The sampling utilized a stratified, two-stage cluster sampling method, with data from 16,976 adults (aged 15 years and older) analyzed for asthma determinants. The independent variables are categorized into four domains: individual factors, lifestyle assessment, socioeconomic factors, and access to the healthcare services.The prevalence of asthma is 9.8%, varying significantly across demographics. Higher asthma rates are observed among older, divorced/widowed individuals, those with communication difficulties, and obese individuals. Cost-related unmet healthcare needs and appointment scheduling delays increase asthma risk. Logistic regression models identified age, marital status, obesity, education level, and healthcare access as significant predictors of asthma.This study underscores the multifaceted determinants of asthma in Turkey, highlighting the necessity for targeted interventions addressing individual, lifestyle, socioeconomic, and healthcare access factors.

Clinical Characteristics and Patterns of Immune Responses in COVID-19 Patients From a Rural Community Hospital.

Background Although demographic and clinical factors such as age, certain comorbidities, and sex have been associated with COVID-19 outcomes, these studies were largely conducted in urban populations affiliated with large academic medical centers. There have been very few studies focusing on rural populations that also characterize broader changes in inflammatory cytokines and chemokines. Methodology A single-center study was conducted between June 2020 and March 2021 in Abilene, Texas, USA.Patients were included if they presented to the hospital for treatment of COVID-19, had extra biological materials from routine care available, and were between the ages of 0 to 110 years. There were no exclusion criteria. Patient characteristics, symptom presentation, and clinical laboratory results were extracted from electronic health records. Blood specimens were analyzed by protein microarray to quantitate 40 immunological biomarkers. Results A total of 122 patients were enrolled, of whom 81 (66%) were admitted to the general non-critical inpatient unit, 37 (30%) were admitted to the intensive or critical care units, and four (3.2%) were treated outpatient. Most hospitalized COVID-19 patients in this rural population were elderly, male, obese, and retired individuals. Predominant symptoms for non-critical patients were shortness of breath, fever, and fatigue. Ferritin levels for outpatient patients were lower on average than those in an inpatient setting and lactate dehydrogenase (LDH) levels were noted to be lower in non-critical and outpatient than those in the intensive care unit setting. Inflammatory biomarkers were positively correlated and consistent with inflammatory cascade. Interleukin (IL)-10 was positively correlated while platelet-derived growth factor was negatively correlated with inflammatory biomarkers. Patients ≥65 years had significantly higher levels of LDH and seven cytokines/chemokines (granulocyte-macrophage colony-stimulating factor (GM-CSF), interleukin IL-1b, IL-6, IL-10, IL-11, macrophage inflammatory protein (MIP)-1d, and IL-8) while levels of five other immune molecules (intercellular adhesion molecule 1 (ICAM-1), monocyte chemoattractant protein 1 (MCP-1), tissue inhibitor of metalloproteinase 2 (TIMP-2), IL-2, and IL-4) were significantly lower compared to those <65 years. Females had significantly higher levels of LDH and 10 cytokines/chemokines (GM-CSF, IL-1b, IL-6, IL-10, IL-11, IL-15, IL-16, MIP-1a, MIP-1d, and IL-8) while levels of TIMP-2 and IL-4 were significantly lower than male patients. Conclusions The clinical characteristics of this rural cohort of hospitalized patients differed somewhat from nationally reported data. The contributions of social, environmental, and healthcare access factors should be investigated. We identified age and sex-associated differences in immunological response markers that warrant further investigation to identify the underlying molecular mechanisms and impact on COVID-19 pathogenesis.

Racial and ethnic disparities in prostate cancer screening following the 2018 US Preventive Services Task Force recommendation statement.

In 2018, the United States Preventive Services Task Force promoted shared decision making between healthcare provider and patient for men aged 55 to 69. This study aimed to analyze rates of prostate-specific antigen (PSA) testing across racial and ethnic groups following this new recommendation. A secondary analysis was conducted of the 2020-2021 Behavioral Risk Factor Surveillance System database to assess men aged 55 or older without a history of prostate cancer. We defined four race-ethnicity groups: non-Hispanic Whites (NHWs), non-Hispanic Blacks (NHBs), Hispanics, and Other. The primary outcome was the most recent PSA test (MRT), defined as the respondent's most recent PSA test occurring pre-2018 or post-2018 guidelines. Logistic regression adjusted for covariates including age, socioeconomic status factors, marital status, smoking history, and healthcare access factors. In the age 55 to 69 study sample, NHW men had the greatest proportion of MRT post-2018 guidelines (n = 15,864, 72.5%). NHB men had the lowest percentage of MRT post-2018 guidelines (n = 965, 66.6%). With NHW as referent, the crude odds of the MRT post-2018 guidelines was 0.68 (95% confidence interval (CI) = 0.53-0.90) for NHB. The maximally adjusted odds ratio was 0.78 (0.59-1.02). We found that NHB aged 55 to 69 reported decreased rates of PSA testing after 2018 when compared to NHW. This was demonstrated on crude analysis but not after adjustment. Such findings suggest the influence of social determinants of health on preventative screening for at-risk populations.

Hypertension subtypes at high altitude in Peru: Analysis of the Demographic and Family Health Survey 2016-2019.

The prevalence of hypertension in Peru has increased over the years. Approximately one third of the Peruvian population lives at high altitudes. This population presents particular physiological, genetic and environmental characteristics that could be related to the prevalence of hypertension and its subtypes. To assess the association between altitude and hypertension in the Peruvian population through an analysis of a nationally representative survey. We conducted a cross-sectional analysis of the Demographic and Family Health Survey for the period 2016-2019. We included 122,336 individuals aged 18 years and older. Hypertension was defined according to the JNC-7 guidelines. High-altitude location was defined as a residential cluster located above 2,500 meters above sea level. We utilized generalized linear models from the Poisson family with a log-link function to assess the magnitude of the association between high altitude and hypertension. Additionally, we employed multinomial regression models to analyze the association between high altitude and subtypes of hypertension, including isolated systolic hypertension (ISH), isolated diastolic hypertension (IDH), and systolic-diastolic hypertension (SDH). In the adjusted Poisson regression model, we found that the prevalence of hypertension among participants living at high altitudes was lower compared to those living at low altitudes (aPR: 0.89; 95% CI: 0.86-0.93). In the adjusted multinomial regression model, we observed a lower prevalence rate of ISH among participants residing at high altitudes (aRPR: 0.68; 95% CI: 0.61-0.73) and a higher prevalence rate of IDH among participants residing at high altitudes (aRPR: 1.60; 95% CI: 1.32-1.94). Residents at high altitudes in Peru have a lower prevalence rate of ISH and a higher prevalence rate of IDH compared to those living at low altitudes. Further studies are needed to determine the influence of other biological, environmental, and healthcare access factors on this relationship.

Abstract 2147: Genetic ancestry associations with prostate adenocarcinoma mutational profiles: New Insights from a diverse 5,959-patient real-world cohort

Abstract In prostate cancer, Black men face higher incidence rates, more advanced diagnoses and worse outcomes than White men. These disparities partially stem from environmental, socioeconomic, and healthcare access factors. Recent data highlight racial differences in prostate cancer molecular profiles, with tumors from Black men showing increased SPOP and decreased PIK3CA mutations and amplified androgen receptor signaling and inflammatory pathway activations. Thus, somatic mutation patterns may also contribute to these disparities. We sought to identify associations of mutational profiles in prostate adenocarcinoma (PRAD) with genetic ancestry instead of race and ethnicity categories, analyzing a de-identified cohort of 5,959 patients who underwent the Tempus xT 648-gene NGS tumor profiling test. We used 654 ancestry-informative markers to estimate genetic ancestry by calculating similarity to reference populations for five regions: Africa (AFR), Americas (AMR), East Asia (EAS), Europe (EUR), and South Asia (SAS). Associations between genetic ancestry proportions and somatic variants were assessed for 67 PRAD-related genes using logistic regression models. Analyses included copy number alterations (CNAs), oncogenic gene fusions, small splice and non-synonymous mutations (NS), OncoKB L1/2 &amp; R1, and small missense driver somatic mutations predicted with boostDM. Likelihood ratio tests were employed to compare models with and without ancestry terms. The Benjamini-Hochberg method was utilized to adjust p-values and control the FDR at 5%. We confirmed reported associations in PRAD between AFR ancestry and SPOP NS mutations (OR=1.03 per doubling of AFR ancestry proportion, p=0.03) and decreased AFR with PIK3CA OncoKB and driver mutations (OR=0.94, p=0.02), PTEN CNAs (OR=0.95, p=0.0001), and TMPRSS2-ERG fusions (OR=0.95, p&amp;lt;0.0001). However, we also observed negative associations between AFR and AR CNAs (OR=0.95, p=0.004), EAS and PTEN CNAs (OR=0.96, p=0.01), and EAS and TMPRSS2-ERG fusions (OR=0.97, p=0.02). Additionally, a negative association was found between EAS and TP53 driver NS mutations (OR=0.96, p=0.04), while positive associations with driver mutations in FOXA1 (OR=1.06, p=0.03) and NS mutations in the PI3K/AKT/mTOR pathway genes (OR=1.04, p=0.01) were noted. Lastly, we identified novel positive associations between AMR and driver mutations in PIK3C3A (OR=1.12, p=0.0003) as well as small NS mutations or CNAs in the PI3K/AKT/mTOR pathway genes (OR=1.03, p=0.04). By analyzing a large, diverse real-world cohort and leveraging NGS-inferred genetic ancestry, our study confirms known associations between somatic alterations in PRAD cancer genes and race and ethnicity, while unveiling novel associations in understudied populations of potential significance for understanding disparities in disease outcomes. Citation Format: Brooke Rhead, Yannick Pouliot, Francisco M. De La Vega, David W. Craig, John Carpten. Genetic ancestry associations with prostate adenocarcinoma mutational profiles: New Insights from a diverse 5,959-patient real-world cohort [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2147.

Abstract 4858: Examining state- and race-specific five-year prostate cancer mortality rates (2016-2020) and their association with prostate-specific antigen screening

Abstract Background: In 2023, 34,000 US men will die from prostate cancer. The impact of prostate cancer mortality varies greatly across states. Racial differences in state populations may explain some but not all of this variability. This study examined prostate cancer mortality rates by state and race and their associations with state-level prostate-specific antigen (PSA) screening prevalence. Methods: We obtained race-specific, state level five-year average age-standardized prostate cancer mortality rates from 2016-2020 from the NCI State Cancer Profiles. Data on race-specific, state level PSA screening prevalence in 2010 were obtained from the Behavioral Risk Factor Surveillance System. We compared mortality rate ratios (RR, 95% confidence intervals [CI]) of state level prostate cancer mortality rates of Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaskan Native men to White men. We generated descriptive statistics (median and range) on state level mortality rates to quantify the variability within racial/ethnic groups. We fit univariable Poisson regression models to explore associations between prostate cancer mortality rates and PSA screening prevalence, for White, Black, and Hispanic men, but omitted Asian and American Indian men due to sparse data. Results: Mortality data were available for 50 states and the District of Columbia (D.C.) for White, 40 states and D.C. for Black, 36 states for Hispanic, 24 states for Asian, and 11 states for American Indian men. The US average prostate cancer mortality rate was 18.8 deaths per 100,000 per year. As expected, rates were higher among Black than White men (RR 2.07; 1.90, 2.24), while rates among Hispanic (RR 0.75; 0.68, 0.84) and Asian (RR 0.48; 0.41, 0.56) men were lower. Rates among American Indian men were slightly higher than White men (RR 1.12; 0.96, 1.29). Variability of state-level mortality rates within each race was quite high, with largest ranges for Black and American Indian men. Black men had a median (range) state-level prostate cancer mortality rate of 37.9 (23.9 to 49.2), and American Indian men had a median rate of 20.4 (7.7 to 28.9). Median (range) rates were 17.7 (11.3 to 22.3) for White, 8.3 (4.3 to 17.4) for Asian, and 13.5 (8.9 to 22.5) for Hispanic men. Associations between a 5-percentage point increase in PSA screening prevalence and prostate cancer mortality rates were RR 0.92 (95% CI: 0.84, 0.99) in White, RR 0.96 (0.88, 1.05) in Black, and 0.98 (0.90, 1.07) in Hispanic men. Conclusion: There is considerable variability in prostate cancer mortality rates across states, both between and within racial/ethnic groups, highlighting complexity of racial disparities. PSA screening may weakly contribute to this variability, but other factors such as health care access, social determinants, and lifestyle factors that vary between states should be considered in future studies. Citation Format: Hannah E. Guard, Jane B. Vaselkiv, Ethan Ecsedy, Florian Kuechen, Nareg Minassian, James Dun Rappaport, Zhiyu Qian, Michelle O. Sodipo, Kathryn L. Penney, Konrad H. Stopsack, Lorelei A. Mucci. Examining state- and race-specific five-year prostate cancer mortality rates (2016-2020) and their association with prostate-specific antigen screening [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4858.

Intersectional Model of Service Use: Understanding Transgender and Nonbinary Healthcare Access

Transgender and nonbinary (TNB) people often have difficulty accessing healthcare services because of the systemic forces of transphobia and cisgenderism. Despite this, there is little theory specifically designed to examine healthcare access among TNB people. We conducted a literature review to identify studies examining TNB healthcare access. We screened a total of 2,050 unique articles for inclusion, resulting in a final sample of 46 articles that met the review criteria. Theories used and key findings were coded to inform the development of the Intersectional Model of Service Use (IMSU) for TNB people. The IMSU builds upon current theoretical frameworks including the Behavioral Model for Vulnerable Populations (BMVP), which proposes that predisposing, enabling, and need factors drive healthcare utilization among vulnerable populations. The IMSU combines the predisposing, enabling, and need factors of the BMVP with TNB-specific healthcare access factors identified through this integrative review. The findings from this review suggest its effectiveness in informing research and interventions aimed at improving healthcare access among TNB people.

Lack of leisure time physical activity and variations in cardiovascular mortality across US communities: a comprehensive county-level analysis (2011–2019)

ObjectivesTo investigate the associations between county-level proportions of adults not engaging in leisure-time physical activity (no LTPA) and age-adjusted cardiovascular mortality (AACVM) rates in the overall US population and across...

Prevalence of Discrimination and the Association Between Employment Discrimination and Health Care Access and Use - National HIV Behavioral Surveillance Among Transgender Women, Seven Urban Areas, United States, 2019-2020.

Transgender women experience discrimination in many settings, including in employment. Because employment and health insurance are intertwined in the United States, employment discrimination might be related to lower health insurance coverage and health care use, including gender-affirming care. This analysis used data from transgender women (N = 1,608) in seven urban areas in the United States collected during 2019-2020 to present the prevalence of six discrimination types (employment, housing, bathroom, businesses, health care, and abuse) and to measure the association between employment discrimination (defined as trouble getting a job or fired due to being transgender) and sociodemographic characteristics, health care access, and health care use. Log-linked Poisson regression models were conducted to estimate adjusted prevalence ratios and 95% CIs. Seven in 10 transgender women experienced at least one type of discrimination during the past 12 months. During the same period, 9.9% of transgender women were fired and 32.4% had trouble getting a job because of being transgender. Employment discrimination was associated with younger age and lower socioeconomic status. Having trouble getting a job was associated with health care access and health care use factors, including having no health insurance or having Medicaid only, having an unmet medical need because of cost, never having transgender-specific care, and having an unmet need for gender-affirming procedures. These findings suggest that employment discrimination contributes to transgender women's economic marginalization and their ability to obtain adequate health insurance coverage and achieve their transition goals. These findings might help guide efforts that protect transgender women's right to pursue their work, health, and life goals without discrimination.

Social determinants of low uptake of childhood vaccination in high-risk squatter settlements in Karachi, Pakistan – A step towards addressing vaccine inequity in urban slums

BackgroundRoutine vaccination has remained historically low in major urban pockets of Pakistan, and now lags behind rural vaccination rates. Grossly insufficient publicly funded primary healthcare infrastructure, heterogeneous mix of providers and multi-ethnicity of populations pose challenges in the delivery of essential health services. This paper ascertains factors associated with uptake of routine childhood vaccination, using Pentavalent-3 vaccine, as a proxy indicator for completion of age-appropriate vaccines in urban slums of Karachi, at high risk of Polio and vaccine preventable disease outbreaks. MethodsData was drawn from baseline assessment of an urban immunization delivery pilot project in urban slums of Karachi, Pakistan. The study sample comprised of 2,097 households with children aged 4–12 months, sampled through a cross-sectional cluster survey, applying a structured questionnaire. Multivariable logistic regression was used to determine the association between Penta-3 vaccination, as the outcome variable, and predictor variables including socio-demographic characteristics and healthcare access factors. ResultsThe findings showed that the likelihood of being immunized with Penta-3 was higher for non-Pashtun ethnicity [adjusted odds ratio (aOR) 1.69; 95% CI 1.33–2.14], children of educated mothers, secondary or higher [aOR 2.95, 95% CI 2.34–3.71], and those whose fathers were formally employed (aOR 1.53; 95% CI 1.19–1.97). No association was seen by gender of child [aOR 0.89; 95% CI 0.73–1.08], and place of new born delivery [aOR 1.01; 95% CI 0.83–1.24]. ConclusionPockets of critically low under-vaccinations within the urban slums of Karachi are associated with Pashtun ethnicity, distance to the vaccination centre, lack of mothers’ education and lack of stable family income as in the case of unemployed and daily wage-earning fathers. Recognition of these factors is required in designing contextually appropriate strategies to address vaccine inequity in urban settings.

Understanding household-level risk factors for zero dose immunization in 82 low- and middle-income countries.

In 2021, an estimated 18 million children did not receive a single dose of routine vaccinations and constitute the population known as zero dose children. There is growing momentum and investment in reaching zero dose children and addressing the gross inequity in the reach of immunization services. To effectively do so, there is an urgent need to characterize more deeply the population of zero dose children and the barriers they face in accessing routine immunization services. We utilized the most recent DHS and MICS data spanning 2011 to 2020 from low, lower-middle, and upper-middle income countries. Zero dose status was defined as children aged 12-23 months who had not received any doses of BCG, DTP-containing, polio, and measles-containing vaccines. We estimated the prevalence of zero-dose children in the entire study sample, by country income level, and by region, and characterized the zero dose population by household-level factors. Multivariate logistic regressions were used to determine the household-level sociodemographic and health care access factors associated with zero dose immunization status. To pool multicountry data, we adjusted the original survey weights according to the country's population of children 12-23 months of age. To contextualize our findings, we utilized United Nations Population Division birth cohort data to estimate the study population as a proportion of the global and country income group populations. We included a total of 82 countries in our univariate analyses and 68 countries in our multivariate model. Overall, 7.5% of the study population were zero dose children. More than half (51.9%) of this population was concentrated in African countries. Zero dose children were predominantly situated in rural areas (75.8%) and in households in the lowest two wealth quintiles (62.7%) and were born to mothers who completed fewer than four antenatal care (ANC) visits (66.5%) and had home births (58.5%). Yet, surprisingly, a considerable proportion of zero dose children's mothers did receive appropriate care during pregnancy (33.5% of zero dose children have mothers who received at least 4 ANC visits). When controlled for other factors, children had three times the odds (OR = 3.00, 95% CI: 2.72, 3.30) of being zero dose if their mother had not received any tetanus injections, 2.46 times the odds (95% CI: 2.21, 2.74) of being zero dose if their mother had not received any ANC visits, and had nearly twice the odds (OR = 1.87, 95% CI: 1.70, 2.05) of being zero dose if their mother had a home delivery, compared to children of mothers who received at least 2 tetanus injections, received at least 4 ANC visits, and had a facility delivery, respectively. A lack of access to maternal health care was a strong risk factor of zero dose status and highlights important opportunities to improve the quality and integration of maternal and child health programs. Additionally, because a substantial proportion of zero dose children and their mothers do receive appropriate care, approaches to reach zero dose children should incorporate mitigating missed opportunities for vaccination.

Abstract B121: Racial disparities in the association between adverse childhood experiences and history of self-reported depression among cancer survivors

Abstract Introduction. Depression is experienced by 25% of cancer survivors in the United States, and there are racial differences in how adverse childhood experiences (ACEs) affect depression. While previous studies have examined association between ACEs and depression in general population, studies focusing on cancer survivors are lacking. The purpose of this study was to assess the association between ACEs and history of self-reported depression among cancer survivors in different race groups. Methods. This study was a cross-sectional analysis of the 2020 Behavioral Risk Factor Surveillance System among 19,241 cancer survivors. The ACE category (zero, one, two-three, ≥four) included questions assessing exposure to eight types of adverse childhood experiences: three types of abuse (physical, emotional, and sexual) and five types of household challenges (household member substance misuse, incarceration, mental illness, parental divorce, or witnessing intimate partner violence) before age 18 years. The outcome is self-reported history of depression (yes/no). Three weighted multivariable logistic regression models were used to examine the association between ACE and depression for each race group: Non-Hispanic White (NHW), Non-Hispanic Black (NHB) and Hispanics, adjusting for age, sex, smoking status, income, education, marital status, body mass index, health status. Results. In this sample of cancer survivors, 41%, 22%, 21% and 16% reported having experienced zero, one, two-three, and &amp;gt;=4 ACEs respectively. Majority of survivors were NHW (82.5%) while 6.2%, 6.4% and 4.9% were NHB, Hispanics, and Others respectively. Personal history of depression was reported by 21% of survey respondents. Among survivors experiencing &amp;gt;=4 ACEs, depression was reported by 46.9 % of NHW, 55.2% of NHB and 50.6% of Hispanics. In the adjusted models, among NHW survivors with 1 ACE (aOR: 1.7, 95% CI. 1.3– 2.2), 2-3 ACEs (aOR: 1.9, 95% CI. 1.5– 2.4), or &amp;gt;=4 ACES (aOR: 4.2, 95% CI. 3.3– 5.5) had higher odds of depression compared with those with zero ACEs. Among NHB, survivors with &amp;gt;=4 ACEs had higher odds of depression (aOR: 2.5, 95% CI. 1.2– 5.0) compared with those with zero ACEs; no significant difference was observed for survivors with 1 or 2-3 ACEs. Similarly, among Hispanics, survivors with &amp;gt;=4 ACEs had higher odds of depression (aOR: 11.3, 95% CI. 5.4– 23.8) compared with those with zero ACEs whiles no significant difference was observed for survivors with 1 or 2-3 ACEs. Conclusion. Persons with ACEs may represent an important targeted prevention group to reduce risk of depression among cancer survivors. While there is a relationship between all categories of ACE and depression among NHW cancer survivors, only those with &amp;gt;=4 ACEs had association with depression among NHB and Hispanics. Potential variation by race warrants additional studies regarding potential for selective prevention and identification of resilient, cultural, and healthcare access factors. Citation Format: Oluwole A. Babatunde, Melanie S. Jefferson, Swann A. Adams, Chanita Hughes Halbert, Frank Clark, Anusuiya Nagar, Nosayaba Osazuwa-Peters, Eric A. Boakye. Racial disparities in the association between adverse childhood experiences and history of self-reported depression among cancer survivors [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr B121.

Individual, socioeconomic and healthcare access factors influencing the delays in leprosy presentation, diagnosis and treatment: a qualitative study.

This study investigated the factors influencing the presentation, diagnosis and treatment of leprosy in primary healthcare. Qualitative research was conducted on patients undergoing treatment in a priority hyperendemic region for leprosy control in northeastern Brazil. Interviews were conducted between September and December 2020 at primary healthcare centers. Data were analysed based on the basic interpretive qualitative structure according to Andersen and Newman's model of healthcare utilisation. Knowledge of leprosy symptoms influenced patients' search for a diagnosis. Unfavorable socioeconomic conditions experienced by patients made diagnosis and treatment difficult. Incorrect evaluations by health professionals caused difficulties and delays in obtaining a diagnosis of leprosy. Perceptions about the disease, such as non-acceptance of the disease and the adverse effects of the medications, affected treatment seeking and treatment continuity. Patients with leprosy faced delays and healthcare access barriers related to knowledge of the disease, socioeconomic conditions and the structure of healthcare services, which must be considered when creating care plans, surveillance and control actions against leprosy. Appropriate interventions are necessary to reduce delays and better control the disease.

Genetic ancestry associations with somatic mutations in a real-world cohort of over 3,000 patients with prostate cancer.

5034 Background: Disparities in incidence and outcomes of prostate cancer among racial groups have been reported. Black men have a higher incidence of prostate cancer compared to White men and are more likely to be diagnosed at a later stage, resulting in poorer outcomes. These differences are likely due to a combination of genetic, socioeconomic, and healthcare access factors. Furthermore, evidence has revealed racial differences in molecular profiles of prostate cancer, such as a higher incidence of ERF mutations and increased transcriptional activation of the androgen receptor signaling and inflammatory pathways in tumors derived from Black men compared to White men, suggesting that underlying biology may contribute to these disparities. Here, we aimed to identify differences in the mutational profiles of prostate cancers by race and genetic ancestry in a de-identified real-world cohort of 3,804 patients that underwent the Tempus xT 648-gene NGS tumor profiling test. Methods: We used 654 ancestry-informative markers to estimate continental ancestry likelihoods for five regions: Africa (AFR), Americas (AMR), East Asia (EAS), Europe (EUR), and South Asia (SAS). We imputed Asian (ASN, n=122), Hispanic/Latino/Native American (HLN, n=300), Non-Hispanic Black (NHB, n=619) and Non-Hispanic White (NHW, n=2,679) categories using genetic ancestry thresholds based on literature and validated with available metadata. Associations between either race/ethnicity categories or continental ancestry proportions and somatic variants (copy number alterations (CNAs), small nonsynonymous, OncoKB L1/2 &amp; R1, and predicted driver somatic mutations) were assessed for 109 prostate cancer-related genes using logistic regression models. Likelihood ratio tests were used to compare models with and without race/ethnicity or ancestry terms, and the Benjamini-Hochberg method was used to adjust p-values and control the FDR at 5%. Results: NHB and ASN men had lower odds of having a PTEN CNA compared to NHW men (OR=0.58 and 0.40, p=0.0001 and 0.009, respectively). Confirming this finding was a positive association between EUR ancestry and PTEN CNAs (OR=1.07 per doubling of EUR ancestry proportion, p=0.0007). NHB men were also less likely to have actionable OncoKB somatic mutations in the PIK3CA gene when compared to NHW men (OR=0.48, p=0.03). Increased AFR ancestry was associated with the presence of nonsynonymous predicted driver mutations in SPOP (OR=1.04, p=0.04), while both EAS and SAS ancestries were associated with fewer such mutations in TP53 (OR=0.95 in both cases, p=0.02 and 0.003). Conclusions: Analysis of a large real-world cohort leveraging genetic ancestry inferred from NGS data confirms previously known associations between the presence of somatic alterations in prostate cancer genes and race/ethnicity, and identifies novel associations of potential precision therapeutic relevance.