Native Hawaiian Research Articles

Disparities in cancer stage shifts associated with the COVID-19 pandemic in California, 2020-2021.

The COVID-19 pandemic and associated shutdowns disrupted healthcare access and resulted in decreased cancer screenings. Cancer diagnosis delays have concerning downstream effects on late-stage cancer, especially for marginalized populations. The study population included 349,458 adults in the California Cancer Registry diagnosed with cancer between January 2019-December 2021, during which California experienced two stay-at-home orders. We examined the percentage of late-stage (III-IV) cancer diagnoses across five periods: Pre-Pandemic (January 2019-February 2020), Shutdown #1 (March-June 2020), Post-Shutdown #1 (July-November 2020), Post-Shutdown #2 (December 2020-March 2021), and Post-Vaccine Rollout (April-December 2021). To examine the association between time-period and late-stage diagnoses, we conducted a multivariable log binomial regression model adjusted for sociodemographic and neighborhood factors. The percentage of late-stage cancer diagnoses increased during Shutdown #1 (+5.2%) and returned to baseline Post-Vaccine Rollout. Groups with notably higher increases in the percentage of late-stage cancer (vs. overall population) during Shutdown #1 include: Pacific Islander (+13.7%), Thai (+11.2%), Chinese (+8.1%), Native Hawaiian (+7.4%), Filipino (+6.6%), and uninsured (+7.4%). Uninsured (vs. private insurance) (PR: 1.41), low neighborhood SES (nSES) (vs. high) (PR: 1.19), and racial and ethnic minoritized groups (vs. NH White) (PR's: 1.04-1.19) had higher likelihood for late-stage cancer diagnosis. The pandemic exacerbated late-stage cancer disparities for racial and ethnic minoritized groups, underinsured, and low nSES communities in California (2020-2021). Interventions to improve cancer screening must be focused on racial and ethnic minoritized, underinsured, and low nSES communities, as they are likely to be more vulnerable to healthcare disruptions like the pandemic.

Representation of Native Hawaiian and Pacific Islander Individuals in Clinical Trials

Having diverse participants in clinical trials ensures new drug products work well across different demographic groups, making health care safer and more effective for everyone. Information on the extent of Native Hawaiian and Pacific Islander participation in clinical trials is limited. To examine representation of Native Hawaiian and Pacific Islanders in clinical trials leading to the first US Food and Drug Administration (FDA) approvals for the 10 drug products with the top worldwide sales forecasts in 2024. Cross-sectional secondary analysis of existing data from clinical trials that took place from 2006 to 2021 in the US. All clinical trials that were included in the FDA first approval application for the 10 drug products were evaluated in this study. Data were analyzed from February to August 2024. Participation in a clinical drug trial. Comparison of the proportion of Native Hawaiian and Pacific Islander participation in clinical trials for the 10 drug products with top sales forecasts in 2024 to the Native Hawaiian and Pacific Islander population proportion. In this cross-sectional study of 139 062 individuals, Native Hawaiian and Pacific Islander participation in clinical trials for the 10 drug products with top sales forecasts was either unknown or low. For 6 of the 10 drug products (60%), the number of Native Hawaiian and Pacific Islander participants was not documented. All trials that reported Native Hawaiian and Pacific Islander participation had fewer Native Hawaiian and Pacific Islander participants than would be expected based on their US population proportion, with 2 of the differences being statistically significant. Of the trials that disaggregated Native Hawaiian and Pacific Islander participants from other racial groups, the number of Native Hawaiian and Pacific Islander participants was 8 for risankizumab-rzaa (0.38% of participants vs 0.49% of the population; percentage point difference, -0.11%; 95% CI, -0.37% to -0.15%), 7 for bictegravir/emtricitabine/tenofovir alafenamide (0.38% of participants vs 0.49% of the population; percentage point difference, -0.10%; 95% CI, -0.39% to 0.18%), 27 for 4vHPV/9vHPV (0.15% of participants vs 0.46% of the population; percentage point difference, -0.31%; 95% CI, -0.37% to -0.26%), and 90 for BNT162B2 COVID-19 vaccine (0.20% of participants vs 0.52% of the population; percentage point difference, -0.32; 95% CI, -0.36% to -0.27%). In this cross-sectional study, limited documentation and participation of Native Hawaiian and Pacific Islander individuals in clinical trials for drug products with top sales forecasts was found. This is especially concerning because Native Hawaiian and Pacific Islander individuals have a higher risk than other racial groups for type 2 diabetes, cancer, and several other conditions the products examined in this study treat. Given the importance of enrolling Native Hawaiian and Pacific Islander participants in clinical trials, sites should be established in key geographic regions, such as Hawai'i, and postmarket studies should be conducted within Native Hawaiian and Pacific Islander populations.

Sociodemographic Disparities in 1-Year Outcomes of Children With Community-Acquired Acute Kidney Injury

Racial disparities have been identified in pediatric community-acquired acute kidney injury (CA-AKI), and they are associated with increased risk of child mortality, morbidity, and progression of kidney disease. To assess clinical outcomes at 1 year among children with CA-AKI, stratified by age, race, and ethnicity. This retrospective cohort study is a population-based analysis of deidentified, aggregated electronic health record data collected by 61 large health care organizations from 2003 to 2023 and accessed through the TriNetX platform. Outcomes were assessed at 1 year after a CA-AKI episode. Participants included pediatric patients (aged <18 years) with AKI. Data were accessed in January 2024. A diagnosis of CA-AKI and sociodemographic factors such as race, ethnicity, and age, as reported in electronic health records. The primary end point of this study was to assess differences in clinical outcomes within 1 year of an episode of CA-AKI, including all-cause emergency department (ED) visits, intensive care unit (ICU) admissions, mechanical intubation and ventilation, and mortality. Risk was compared between White children and Asian (including Asian, Native Hawaiian, and Other Pacific Islander), Black, and Hispanic children, stratified by age group. Measures of association, Cox proportional hazard analyses, and Kaplan-Meier survival curves were performed within the TriNetX Advanced Analytics Platform between racial and ethnic groups for each analysis. From the total sample of 18 152 children, those with hospital-acquired AKI, chronic kidney disease, end-stage kidney failure, or dialysis dependence were excluded, leaving a final cohort of 17 125 children (mean [SD] age, 11.2 [5.2] years; 9424 male [55.3%]). Eligible patients were divided into racial and ethnic groups as follows: non-Hispanic Asian, 1169 children (6.5%); non-Hispanic Black, 4636 children (27.3%); Hispanic, 1786 children (10.2%); and non-Hispanic White, 9534 children (55.9%). Patients were further subdivided into groups aged 0 to 9 years (546 Asian children, 1675 Black children, 689 Hispanic children, and 3340 White children) and 10 to 18 years (623 Asian children, 2961 Black children, 1091 Hispanic children, and 6104 White children). Within 1 year of CA-AKI diagnosis, compared with White children, Black children experienced greater rates of ED visits (hazard ratio [HR], 1.53; 95% CI, 1.40-1.67), ICU admissions (HR, 1.31; 95% CI, 1.16-1.47), mechanical ventilation (HR, 1.33; 95% CI, 1.13-1.56), and all-cause mortality (HR, 1.27; 95% CI, 1.09-1.48), as well as the greatest risk for composite outcomes (HR, 1.43; 95% CI, 1.33-1.53). Hispanic children experienced greater rates of ED visits (HR, 1.40; 95% CI, 1.21-1.62) and the greatest risk of all-cause mortality (HR, 1.66; 95% CI, 1.31-2.09), whereas Asian children experienced greater rates of mechanical ventilation (HR, 1.69; 95% CI, 1.26-2.27), compared with White children. Black and Hispanic children aged 0 to 9 years were at greatest risk of experiencing poor clinical outcomes. Black children had a 11.41% lower survival probability and Hispanic children had a 7.14% lower survival probability compared with White children after an initial ED encounter. Among children with an identified episode of CA-AKI diagnosed in an ED, within 1 year, Black and Hispanic children had a poorer survival probability compared with White children. Future studies are needed to understand these disparities and improve awareness and follow-up after emergency care.

Culturally-relevant physical activity for public health promotion: global evidence synthesis

Abstract Background The WHO has noted the importance of cultural insights for health. Culturally-relevant physical activity has a growing evidence base in many regions and specific populations, but the scope and scale for global health promotion is underexplored. Methods A multinational expert team used a critical literature review method to: (1) define culturally-relevant physical activity; (2) delineate relevant characteristics supporting inclusion in population-level health promotion and surveillance; and (3) provide agenda setting in research, policy, and practice from a global public health promotion perspective. The critical review method, which evaluates rather than summarizes literature, was chosen as the research evidence is complex, broad, and has not been synthesized previously from this perspective. Results Culturally-relevant physical activity was defined as practices that include physical activity based on a population’s cultural customs. These can be Indigenous (e.g., hula, an Indigenous dance of Native Hawaiians) or regional (e.g., Shota (Shotë), an Albanian folk dance). Practices have shared characteristics that support multi-dimensional value for health, engagement, and healing. These include a collectivist, intergenerational component, passed from elders and shared forward with children as part of a community. Many have foundations in nature, a strength for health and wellbeing in green and blue spaces. Many include traditional art, clothing, accessories, and music with deep significance, including care for the tools and location of practice (e.g, drums, boats, land). Many practices would not be captured in harmonized public health surveillance systems despite their value. From this synthesis, research hypotheses were created and next steps proposed. Conclusions This evidence synthesis supports engagement, planning, uptake, policy, surveillance, and study of culturally-relevant physical activity for public health promotion locally and globally. Key messages • An important strength of culturally-relevant physical activity is that it is context and population specific. However, this may hide the scope and scale of the existing evidence supporting this work. • This evidence synthesis confirms how culturally-relevant physical activity is valuable globally across shared assets in research and practice, supporting next steps for public health promotion.

Surfing a culturally-relevant physical activity: a new wave for health promotion

Abstract Background Surfing originated with Native Hawaiians prior to Western contact. It has since gained worldwide popularity, with an estimated 50 million surfers globally, and recently became an official Olympic sport. Associations have been reported between surfing and mental and physical health outcomes, greater community cohesion, and stronger intra-family relationships. Despite this evidence, surfing is deeply understudied in the context of health promotion. Purpose Surfing was analyzed from a mixed methods perspective to explore factors associated with lifetime participation and current engagement, including gender, race/ethnicity, chronic disease, social context, meaning, and average time of participation. Methods Hawai’i adult residents (n = 1066) completed an online or phone questionnaire. Modified Poisson regression models were fit for lifetime engagement and having a self-reported chronic disease, adjusting for primary race/ethnicity, age, gender, and education. Results Over their lifetime, 42% of respondents (50% men and 37% women) had participated in surfing. Engagement was highest during youth and young adulthood, and decreased with age, yet trends varied notably by race/ethnicity, gender, and generation. Lifetime surfing engagement was significantly related to lower likelihood of diabetes (aPR:0.72; 95%CI:0.56-0.92;p=0.009). Individuals who regularly participated in surfing typically did so with friends (78%) or family (61%); average surfing session duration was 209 minutes. Qualitative results revealed the relevance of surfing across levels of influence for health and wellbeing from physical fitness to community, culture, history and spirituality. Conclusions This work provides insights on the health promotion opportunities of surfing across the life-course and populations, including disease prevention and management. This study has implications for planning and policy locally and globally to achieve optimal community and planetary health. Key messages • Surfing is not only a sport for elite athletes, but also an activity that can support community and individual health and wellbeing in many populations over the lifespan. • Promotion of surfing and public ocean access can support multidimensional influences for wellbeing and should be a focus of cross sector collaborations for optimal community and planetary health.

The cultural adaptation and psychometric evaluation of the Mothers on Respect Index for Native Hawaiians and Pacific Islanders

BackgroundNative Hawaiian and Pacific Islanders (NHPI) are disproportionately burdened by pregnancy-related deaths in the United States and have the lowest engagement in prenatal care compared to all other US racial groups. Aside from access barriers, studies suggest that NHPI face challenges with patient-clinician communication, perceived discrimination, and cultural conflicts within healthcare settings. This paper describes the cultural adaptation of the 14-item Mothers On Respect index for NHPI, originally developed by Vedam et al. (2017) for diverse communities in British Columbia, Canada, and reports the findings of the preliminary psychometric assessment of the adapted measure.MethodsData from 26 interviews with NHPI women, expert, and cognitive interviews were conducted to inform the adaptation. An online survey was administered to a sample of 90 NHPI women to assess construct validity, convergent validity, and internal reliability of the adapted measure using exploratory and confirmatory factor analyses.ResultsThe adaptation resulted in substantial changes to the original measure, mainly by the addition of items related to ‘feeling cared for by and connected to the provider’ and ‘perceived threats hindering communication.’ The psychometric analyses identified a three-factor structure for the culturally adapted index and confirmatory factor analyses were employed to refine the measure. The result was a 25-item index with acceptable goodness of fit indices, high internal reliability (Cronbach’s alpha of 0.96, 95% CI = .94-.97) and convergent validity with a related scale. Overall, participants in this sample indicated high levels of respectful care; however, people who received < 8 prenatal care visits had significantly lower ratings on average.ConclusionsOur findings suggest that the elements valued by NHPI are not fully captured in existing measures of respectful maternity care. Efforts to assess more discrete aspects of the patient-provider relationship for culturally distinct and racialized groups could help improve the quality of care and advance equity in maternal and perinatal health marginalized communities.

The role of ethnic enclaves and neighborhood socioeconomic status in invasive breast cancer incidence rates among Asian American, Native Hawaiian, and Pacific Islander females in California.

Few studies have examined whether the incidence rates of invasive breast cancer among Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations differ by the neighborhood social environment. Thus, we examined associations of ethnic enclave and neighborhood socioeconomic status (nSES) with breast cancer incidence rates among AANHPI females in California. A total of 14,738 AANHPI females diagnosed with invasive breast cancer in 2008-2012 were identified from the California Cancer Registry. AANHPI ethnic enclaves (culturally distinct neighborhoods) and nSES were assessed at the census tract level using 2007-2011 American Community Survey data. Breast cancer age-adjusted incidence rates and incidence rate ratios (IRRs) were estimated for AANHPI ethnic enclave, nSES, and their joint effects. Subgroup analyses were conducted by stage of disease. The incidence rate of breast cancer among AANHPI females living in lowest ethnic enclave neighborhoods (quintile (Q)1) were 1.21 times (95% Confidence Interval (CI) 1.11, 1.32) that of AANHPI females living highest ethnic enclave neighborhoods (Q5). In addition, AANHPI females living in highest vs. lowest SES neighborhoods had higher incidence rates of breast cancer (Q5 vs. Q1 IRR = 1.30, 95% CI 1.22 to 1.40). The incidence rate of breast cancer among AANHPI females living in low ethnic enclave + high SES neighborhoods was 1.32 times (95% CI 1.25, 1.39) that of AANHPI females living in high ethnic enclave + low SES neighborhoods. Similar patterns of associations were observed for localized and advanced stage disease. For AANHPI females in California, incidence rates of breast cancer differed by nSES, ethnic enclave, when considered independently and jointly. Future studies should examine whether the impact of these neighborhood-level factors on breast cancer incidence rates differ across specific AANHPI ethnic groups and investigate the pathways through which they contribute to breast cancer incidence.

An Equitable Communication and Dissemination Model for Linking Culturally Diverse Communities to COVID-19 Services.

In 2020, the Office of Minority Health (OMH) funded the establishment of the National COVID-19 Resiliency Network (NCRN) to engage priority communities that included African American, American Indian, Alaska Native, Asian, Hispanic, Native Hawaiian, and Pacific Islander persons to aggregate culturally relevant messages, education tools, and national data sources. A mobile application and Web site supported a culturally sensitive, equity-focused communication and dissemination initiative to link communities to COVID-19 clinical, social, and behavioral health services to address health determinants. (Am J Public Health. Published online ahead of print October 16, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307813).

Did Biden-Harris’s reforms on the Paycheck Protection Program reduce racial disparities in lending?

AbstractIntroduced under the Trump-Pence Administration, the Paycheck Protection Program (PPP) provided short-term relief loans to small American businesses during the peak of the Coronavirus pandemic. The initial design of the PPP faced significant criticism from researchers due to racial disparities, among other issues, in its lending process. Minority groups received smaller PPP loan amounts during the original two tranches released in 2020. To increase equitable access for all, in February 2021 the Biden-Harris Administration enforced swift changes to the initial PPP aimed at favouring access to PPP loans for minority-owned small businesses that had been disadvantaged by the program’s original design under the Trump-Pence Administration. By exploiting a granular dataset of 1,759,270 PPP loans granted between Q2 2020 and Q2 2021 and by implementing a difference-in-differences approach (DID), this paper provides novel evidence on the effectiveness of the Biden reforms in reducing racial disparities within the Paycheck Protection Program. Indeed, we observe a significant increase in the volume of PPP loans granted to minority-owned businesses in the period following the Biden-Harris Administration’s reforms. Furthermore, among different minority groups, the reforms appear most effective for Native American minority groups (including American Indians, Alaska Natives, Native Hawaiians and/or Other Pacific Islanders), followed by Black Americans and Asian business owners. Our findings offer novel contributions to the existing literature on institutional discrimination, particularly regarding the initial PPP design. Our findings are especially valuable for policy makers as they underscore the importance of radical changes in addressing racial disparities. Our paper also offers evidence of how a public credit guarantee program should be designed to empower and promote economic inclusion for all, regardless of ethnicity, aligning with the UN’s Sustainable Development Goals.

Treatment and Survival Disparities in Asian Americans With Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death in the United States and globally. The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) population has often been studied as one homogenous cohort despite its heterogeneity. We aim to understand differences in treatment modality and mortality among AANHPI patients with early-stage HCC. Methods: The National Cancer Database was queried between 2004 and 2019. Patients with early-stage HCC eligible for liver transplantation (LT) were included. AANHPI patients were further disaggregated into subgroups, and non-Hispanic White (NHW) patients were included as reference. χ2 was used for categorical variables and the Student t test was used for continuous variables. Survival curves were generated using Kaplan-Meier estimates. Results: A total of 3039 (8.5%) AANHPI and 32,845 (91.5%) NHW were included. Among the AANHPI, 1368 (45.0%) were East Asian (EA), 1229 (40.4%) were Southeast Asian (SEA), 302 (9.9%) were South Asian (SA), and 140 (4.6%) were Native Hawaiian and other Pacific Islander (NHPI). Compared with NHW, AANHPI patients were less likely to undergo LT but had lower mortality. When disaggregated, SA patients were more likely to receive LT (HR: 2.70), and SEA (HR: 1.43) and NHPI (HR: 1.90) patients had higher mortality when compared with EA, all P&lt;0.01. Conclusions: AANHPI with early-stage HCC had better survival as a cohort. However, when disaggregated, there were notable disparities among different subgroups. AANHPI represents an incredibly diverse group of individuals, and it is imperative for physicians, researchers, and policy makers to appreciate the true heterogeneity of this population.

Amygdala Subregion Volumes and Apportionment in Preadolescents - Associations with Age, Sex, and Body Mass Index.

The amygdala, a key limbic structure, plays a critical role in emotional, social, and appetitive behaviors that develop throughout adolescence. Composed of a heterogeneous group of nuclei, questions remain about potential differences in the maturation of its subregions during development. To characterize the associations between developmental variables and amygdala subregion volumes during preadolescence. Cross-sectional Adolescent Brain Cognitive Development SM (ABCD®) Study data was collected from 3,953 9- and 10-year-old children between September 1, 2016, and October 15, 2018. Data analysis was conducted between June 1, 2023, and July 30, 2024. Using the CIT168 Amygdala Atlas , nine amygdala subregion volumes were quantified from high-quality MRI scans. Linear mixed-effects models were used to examine the effects of age, sex, pubertal stage, and body mass index z-score (BMIz) on subregion volumes and their relative apportionment within the amygdala. The study population consisted of 3,953 preadolescents (mean [SD] age, 120 [7.41] months; 1,763 [44.6%] female; 57 [1.4%] Asian, 527 [13.3%] Black, 740 [18.7%] Hispanic, 2,279 [57.7%] white, and 350 [8.9%] from other racial/ethnic groups [identified by parents as American Indian/Native American, Alaska Native, Native Hawaiian, Guamanian, Samoan, other Pacific Islander, or other race]). Distinct associations were observed between age, sex, and BMIz and whole amygdala volume, subregion volumes, and subregion apportionment. Pubertal stage was not related to amygdala subregion volumes. Age was associated with near-global expansion of amygdala subregions during this developmental period. Female sex was linked to smaller volumes in most amygdala subregions, with larger relative apportionment in dorsal amygdala subregions and smaller apportionment in the basolateral ventral paralaminar subregion. Higher BMIz was associated with smaller volumes in large laterobasal subregions, with increased relative apportionment in smaller subregions. This cross-sectional study suggests that age, but not pubertal stage, is associated with near-global expansion of the amygdala at ages 9 and 10, while sex and BMIz are linked to distinct changes in amygdala subregions that explain observed differences in total volumes. These findings provide a foundational context for understanding how developmental variables influence amygdala structure in preadolescents, with implications for understanding future risk for brain disorders.

Racial and Ethnic Disparities in Age-Specific All-Cause Mortality During the COVID-19 Pandemic

The end of the COVID-19 public health emergency (PHE) provides an opportunity to fully describe pandemic-associated racial and ethnic mortality disparities. Age-specific excess mortality differences have important downstream implications, especially in minoritized race and ethnicity populations. To characterize overall and age-specific all-cause excess mortality by race and ethnicity during the COVID-19 PHE and assess whether measured differences reflected changes from prepandemic disparities. This cross-sectional study analyzed data of all US residents and decedents during the COVID-19 PHE, aggregated by observed race and ethnicity (at time of death) and age. Statistical analysis was performed from March 2020 to May 2023. COVID-19 PHE period (March 2020 to May 2023). All-cause excess mortality (incident rates, observed-to-expected ratios) and all-cause mortality relative risks before and during the PHE. For the COVID-19 PHE period, data for 10 643 433 death certificates were available; mean (SD) decedent age was 72.7 (17.9) years; 944 318 (8.9%) were Hispanic; 78 973 (0.7%) were non-Hispanic American Indian or Alaska Native; 288 680 (2.7%) were non-Hispanic Asian, 1 374 228 (12.9%) were non-Hispanic Black or African American, 52 905 (0.5%) were non-Hispanic more than 1 race, 15 135 (0.1%) were non-Hispanic Native Hawaiian or Other Pacific Islander, and 7 877 996 (74.1%) were non-Hispanic White. More than 1.38 million all-cause excess deaths (observed-to-expected ratio, 1.15 [95% CI, 1.12-1.18]) occurred, corresponding to approximately 23 million years of potential life lost (YPLL) during the pandemic. For the total population (all ages), the racial and ethnic groups with the highest observed-to-expected all-cause mortality ratios were the American Indian or Alaska Native (1.34 [95% CI, 1.31-1.37]) and Hispanic (1.31 [95% CI, 1.27-1.34]) populations. However, higher ratios were observed in the US population aged 25 to 64 years (1.20 [95% CI, 1.18-1.22]), greatest among the American Indian or Alaska Native (1.45 [95% CI, 1.42-1.48]), Hispanic (1.40 [95% CI, 1.38-1.42]), and Native Hawaiian or Other Pacific Islander (1.39 [95% CI, 1.34-1.44]) groups. In the total population aged younger than 25 years, the Black population accounted for 51.1% of excess mortality, despite representing 13.8% of the population. Had the rate of excess mortality observed among the White population been observed among the total population, more than 252 000 (18.3%) fewer excess deaths and more than 5.2 million (22.3%) fewer YPLL would have occurred. In this cross-sectional study of the US population during the COVID-19 PHE, excess mortality occurred in all racial and ethnic groups, with disparities affecting several minoritized populations. The greatest relative increases occurred in populations aged 25 to 64 years. Documented differences deviated from prepandemic disparities.

Community-Level Social Vulnerability and Hip and Knee Joint Replacement Surgery Receipt Among Medicare Enrollees With Arthritis.

(1) Explore associations between county minority health social vulnerability index (MH-SVI) and total joint replacement (TJR), and (2) assess associations by individual-level race/ethnicity. An expanded understanding of relevant social determinants of health is essential to inform policies and practices that promote equitable access to hip and knee TJR. Retrospective cohort study of Medicare enrollees. Centers for Medicare and Medicaid Services claims data were linked with MH-SVI. Multivariable logistic regression models were used to evaluate the odds of TJR according to the MH-SVI quartile in which enrollees resided. A total of 10,471,413 traditional Medicare enrollees in 2018 aged 67 years or older with arthritis. The main outcome was enrollee primary TJR during hospitalization. The main exposure was the MH-SVI (composite and 6 themes) for the county of enrollee residence. Results were stratified by enrollee race/ethnicity. Asian American, Native Hawaiian, or Pacific Islander (AANHPI), Black or African American (Black), and Hispanic enrollees comparatively had 26%-41% lower odds of receiving TJR than White enrollees. Residing in counties within the highest quartile of composite and socioeconomic status vulnerability measures were associated with lower TJR overall and by race/ethnicity. Residing in counties with increased medical vulnerability for Black and White enrollees, housing type and transportation vulnerability for AANHPI and Hispanic enrollees, minority status and language theme for AANHPI enrollees, and household composition vulnerability for White enrollees were also associated with lower TJR. Higher levels of social vulnerability were associated with lower TJR. However, the association varied by individual race/ethnicity. Implementing multisectoral strategies is crucial for ensuring equitable access to care.

Identification of High-Incidence Populations in the United States for anti-Epstein Barr Virus Serologic Screening for Nasopharyngeal Carcinoma.

In the United States (US), Epstein-Barr Virus (EBV)-associated nasopharyngeal carcinoma (NPC) disproportionately impacts Asian Americans (AA) and Native Hawaiians and other Pacific Islanders (NHPI) who have no access to screening. EBV-based screening trials in Asia have detected most cases at early stages. We sought to identify a US target population for NPC screening and hypothesized that once-lifetime screening could be cost-effective. We obtained NPC incidence data from the SEER Asian and Pacific Islander datasets. We estimated the number needed to screen, mortality reduction, and resource utilization using a validated model and performance data from trials. Six evaluated strategies incorporated serology, nasopharyngeal swab PCR, and endoscopy or MRI. Intermediate-incidence and high-incidence populations accounted for 10.7% of US person-years yet 42.7% of cases. Anti-BNLF2b screening with selective endoscopy was the preferred strategy. In high-incidence populations, the median NNS to detect one case was 1,992, with a median of 7.12 NPC deaths averted per 100,000 screened. Screening met the willingness-to-pay threshold in all five high-incidence populations (median ICER/GDP 0.82) and among men in intermediate-incidence populations. Nearly half of NPC in the US arises among the 10% with AA or NHPI ethnicity. A suitable target population for US screening trials would be men and women age 35-65 of Chinese, Sāmoan, or Southeast Asian ethnicity, or men age 35-60 of Guamanian/Chamorro, Filipino, or Native Hawaiian ethnicity. Once-lifetime anti-BNLF2b screening could be cost-effective. These data may aid the design of US screening trials. Targeted NPC screening might mitigate health disparities.

Race and ethnicity representation in phase 2/3 oncology clinical trial publications in the United States: A systematic review.

20 Background: The five 1997 Office of Management and Budget (OMB) races in the US include American Indian or Alaskan Native (AI/AN), Asian, Black or African American, Native Hawaiian or Other Pacific Islander (NHPI), and White, with Hispanic ethnicity. Despite the Affordable Care Act (ACA) mandating OMB-based collecting/reporting standards, race and ethnicity publishing in medical journals is inconsistent, despite being necessary to achieve health equity. We aimed to quantify race and ethnicity reporting rates and calculate representation quotients (RQs) in published oncology clinical trials. Methods: In this systematic review, PubMed/Embase were queried for phase 2/3 clinical trials of the 6 most common noncutaneous solid malignancies, published between 2012-2022, in 4 high-impact journals. Trial characteristics were recorded. The RQs for each race and ethnicity were calculated by dividing the percent of representation in clinical trial publications by the percent of year-matched, site-specific incident cancers in the US, compared with Kruskal-Wallis tests with Bonferroni Correction (BC). Reporting was compared between journal publications and ClinicalTrials.gov. Results: Among 1,202 publications evaluated, 364 met inclusion criteria: 16 JAMA , 241 JCO , 19 Lancet , and 88 NEJM . Publications included 268,209 patients (171,132 women [64%]), with a median of 356 (IQR, 131-800) patients per publication. Reported race and ethnicity included AI/AN in 52 (14%) publications, Asian in 196 (54%), Black or African American in 215 (59%), Hispanic in 67 (18%), NHPI in 28 (8%), and White in 254 (70%). Median RQ varied across race (P &lt; .001 BC) with 1.04 (IQR, 0.09-4.77) for Asian, 0.98 (IQR, 0.86-1.06) for White, 0.42 (IQR, 0.12-0.75) for Black or African American, and 0.00 (IQR, 0.00-0.00) for both AI/AN and NHPI patients. Sensitivity analyses showed similar findings upon subset analysis for US-only clinical trials. There was significantly less race and ethnicity reporting in the clinical trial publications compared with ClinicalTrials.gov documentation for AI/AN (14% vs 45%, P &lt; .001 per McNemar χ 2 with continuity correction [MC]) and NHPI (7.7% vs 43%; P &lt; .001 MC). Conclusions: While most phase 2/3 oncology clinical trials published in high-impact journals report race and ethnicity, most did not report AI/AN and NHPI racial categories. Our findings support a call to action for consistent journal policies and transparent race and ethnicity reporting, in alignment with ACA-concordant race and ethnicity federal reporting requirements.

Ensuring precision medicine for veterans with lung cancer: A randomized clinical trial.

178 Background: National guidelines recommend molecular testing for patients with non-small cell lung cancer, yet this is not routinely completed in practice. In prior work, we identified barriers to testing in the Veterans Affairs. First, physicians are unaware if and when testing has occurred. Second, patients are unaware of testing and the implications on treatment and clinical outcomes. In response, in collaboration with a Veteran and Caregiver Advisory Board, we created a multilevel intervention led by a peer volunteer who: 1) provides tailored education of molecular testing for 1 month for Veterans newly diagnosed with lung cancer and, 2) alerts clinicians via secure messaging if tumor samples have not been tested. We conducted this randomized clinical trial to assess whether the intervention improves patient knowledge of molecular testing and patient activation and increases receipt of molecular genomic testing compared with usual care. Methods: All veterans &gt;18 years old with a new diagnosis of any stage non-small cell lung cancer were eligible. Exclusions included inability to consent. All participants completed baseline assessments at randomization and at 1-month follow-up comprised of a 3-question validated precision medicine knowledge questionnaire and a 13-question validated patient activation measure. Genomic testing was assessed by chart review at 6-months follow-up. We used regression models to assess differences in mean knowledge and activation scores over time between groups and compared rates of genomic testing. Results: 75 Veterans were screened with 46 eligible. All 46 consented to participate, with 23 in each group. All were male (100%), had mean age of 76.3+/-5.54 years; 31 (67.4%) were Latinx; 2 (4.4%) Asian; 11 (23.9%) Black; 1 (2.2%) Native Hawaiian; 32 (69.6%) White; 32 (69.6%) had Stage 4 disease. At 1 month follow-up mean knowledge scores increased over time in the intervention group and remained stable in the control group (mean score 2.30 +/- 0.97 versus 1.16 +/- 1.15, p=0.014). At 1-month follow-up, patient activation increased for the intervention group more than the control group (46.7 +/- 11.3 versus 37.6 +/- 9.26, p=0.002). There were no significant differences in tumor testing between groups (intervention: 95.6% versus control: 86.9%, p=0.62) or time to first treatment course from biopsy (intervention: 28.2 days versus control 36.2 days). Conclusions: A volunteer led effort improved patient education regarding precision medicine and patient activation among Veterans as compared with usual care alone. Interventions that include volunteers and other support can enhance care and clinical outcomes among veterans with lung cancer. Clinical trial information: NCT05795959 .

Closing Gaps or Holding Steady? The Affordable Care Act, Medicaid Expansion, & Racial Disparities in Coverage, 2010-2021.

The Affordable Care Act's (ACA) Medicaid expansion produced major gains in coverage. However, findings on racial and ethnic disparities are mixed and may depend on how disparities are measured. This study examines both absolute and relative changes in uninsurance from 2010-2021 by race and ethnicity, stratified by Medicaid expansion status. The sample contained all respondents under age 65 (N = 30,339,104) from the American Community Survey, 2010-2021. Absolute and relative differences in uninsurance, compared to White Non-Hispanic individuals, were calculated for Hispanic; Black; Asian-American, Pacific Islander and Native Hawaiian (AANHPI); American Indian and Alaska Native (AIAN); and multiracial individuals. States were stratified into ever-expanded vs. non-expansion status. After the ACA, three patterns of coverage disparities emerge. For Hispanic and Black individuals, relative to White individuals, absolute disparities in uninsurance declined but relative disparities were largely unchanged, in both expansion and non-expansion states. For AANHPI individuals, disparities were eliminated entirely in both expansion and non-expansion states. For AIAN individuals, disparities declined in absolute terms but grew in relative terms, particularly in expansion states. All groups experienced coverage gains post-ACA, but with heterogeneity in changes in disparities. Focused interventions are needed to improve coverage rates for Black, Hispanic, and AIAN individuals.

Trends in Postpartum Hemorrhage Prevalence and Comorbidity Burden: Insights from the ENACT Network Aggregated Electronic Health Record Data.

The goal of this study was to assess trends in postpartum hemorrhage (PPH), its risk factors, and maternal comorbidity burden in the United States using aggregate data from the Evolve to Next-Gen Accrual to Clinical Trials (ENACT) network. This federated network employs interactive querying of electronic health record data repositories in academic medical centers nationwide. We conducted repeated annual cross-sectional analyses to evaluate PPH occurrence and comorbidities across various ethnoracial and sociodemographic groups, starting with a large cohort of 1,287,675 unique delivery hospitalizations collected from 22 ENACT sites between 2005 and 2022. During this time, there was a statistically significant increasing trend in the prevalence of PPH, rising from 5,634 to 10,504 PPH per 100,000 deliveries (P trend <0.001). Our findings revealed a continuous upward trend in PPH rates that remained consistent among women with ≥ 1 comorbid conditions (P trend <0.001) and those with ≥ 1 maternal risk factor (P trend <0.001). This result aligns with prior studies and extends beyond the time periods previously reported. Overall, Native Hawaiian or Other Pacific Islander women had the highest PPH prevalence (~ 13%), followed by Asian (9.8%), American Indian or Alaska Native (8.9%), multirace (8.6%), Black or African American (8.4%) and White (7.4%) women. The top PPH risk factor identified was placenta previa or accreta, while the top comorbidity was antepartum hemorrhage / placental abruption. The most common cause of PPH, namely uterine atony, was prevalent in ENACT data. Our analysis highlights significant ethnoracial disparities and underscores the need for targeted preventative interventions.

Abstract PR012: Social and Structural Influences of Preventive Cancer Screenings for Native Hawaiian and Pacific Islander Adults in Hawaiʻi

Abstract Background: Native Hawaiians and Pacific Islanders (NHPI) are hindered by sociocultural, geographic, and environmental factors that contribute to cancer health disparities, often masked by aggregated data with Asian Americans. An average of 7,393 Hawai‘i residents are diagnosed with invasive cancer yearly, and rates are disproportionate ethnically; . Native Hawaiians and Micronesians suffer higher mortality rates for breast cancer (24.9 and 21.6 per 100,000) than White women (17.0). This study aims to investigate social drivers of health behaviors among NHPI in Hawaiʻi by examining social factors that influence cancer screenings through mixed methods. Methods: This mixed methods study is a follow-up to a cross-sectional survey administered in 2018 to 3 Pacific Islander ethnic subgroups: Native Hawaiians, Chuukese, and Marshallese in Hawaiʻi using Respondent Driven Sampling within public housing (N=1,010 NHPI). Disparate cancer screening practices were uncovered within these groups when compared to Hawaiʻi state data. Logistic regression was used to analyze predictors of colon, breast, and cervical cancer screenings. The Gelberg Behavioral Model for Vulnerable Populations and socio-ecological model served as the theoretical models. To triangulate the findings, 16 semi-structured interviews with adults living within the communities first surveyed were conducted in 2023 to uncover any additional drivers of health behaviors that the regression missed. Results: Quantitative findings include cultural/linguistic misunderstandings between NHPI and healthcare providers. Participants who indicated difficulty understanding a provider’s instructions because of language were 51% less likely to be screened for cervical cancer (p = .04). Individuals who hold neutral acculturation to both their ethnic and American culture are less likely to be screened for cancer. Those whose responses fell in a neutral category were 40% less likely than those with a high ethnic identity to have had a colon cancer screening (p = .02). Qualitative findings demonstrate differing views among Pacific Islander groups including competition for resources between groups within public housing. All of the interviewees highlight the role of God and faith in decision making. Informational exchanges take place mainly within the family and cohabitants. From triangulating the findings, there is a lack of strong social ties/networks that could facilitate health-based resources and knowledge. Families are not discussing self-care or family histories of disease, which are instrumental in the early detection of cancers and missed within the regression. Conclusion: This study provides insight into the social drivers of cancer screenings for NHPI communities in Hawaiʻi. Novel insights for the fields of medical sociology and public health are highlighted by influential social processes to NHPI cancer screening behaviors. Recommendations include further research and programs that focus on and foster social dynamics of these communities in relation to cancer screenings. Citation Format: Mark L. Willingham Jr., Kevin Cassel, Wei Zhang, Tressa P. Diaz, Angela Sy, Ian Pagano, Munirih R. Ta'afaki, Angelina G. Mummert. Social and Structural Influences of Preventive Cancer Screenings for Native Hawaiian and Pacific Islander Adults in Hawaiʻi [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 PR012.

Abstract A072: Lung cancer survival disparities: A disaggregated AANHPI study of the SEER database

Abstract Cancer is the overall leading cause of death in Asian American, Native Hawaiian, and Pacific Islander (AANHPI) populations, with lung cancer specifically being the leading cause of cancer- related mortality. The AANHPI population has historically been treated as a "monolith" in scientific literature. However, an accurate understanding of AANHPI communities is needed to address disparities in cancer outcomes. Thus, it is necessary to analyze disaggregated data to identify unique factors and barriers for each unique subpopulation. Our study aims to explore lung cancer survival disparities between Asian American, Native Hawaiian, and Pacific Islander (AANHPI) subpopulations and non-Hispanic Whites (NHW) using SEER Research Data from 2000-2020. Cohorts were developed in order to disaggregate the AANHPI population. Due to the small sample size between nationalities, cohorts were grouped by geographical similarity. Cox regression analysis revealed a generally lower risk of death for AANHPI individuals compared to NHW. However, notable differences were observed within AANHPI subpopulations. South Asians demonstrate a 34.2% lower likelihood of lung cancer mortality compared to NHW, while East Asians show an 18.3% reduced risk. Native Hawaiian and Pacific Islanders saw similar survival, though it was not statistically significant. These disparities could indicate the influence of genetic, environmental, and lifestyle factors and differences in offered treatment on lung cancer prognosis. Our study highlights the importance of recognizing the diversity within AANHPI groups when assessing cancer risk and survival and the necessity for further investigation into the specific factors influencing survival differences. A more nuanced understanding will facilitate more targeted healthcare strategies to address the unique needs of each subpopulation. Citation Format: Christopher Huy Doan, James Chen, Peter Wang, David Wang, Brian Mai. Lung cancer survival disparities: A disaggregated AANHPI study of the SEER database [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 A072.