Non-white Participants Research Articles

8361 Impact of Social Vulnerability on Glycemic Control in Primary Care Patients with Diabetes

Abstract Disclosure: J.N. Tich: None. S.R. MacLeod: None. V. Zhang: None. T. Love: None. R.J. Fortuna: None. Introduction: According to the CDC, 29.7 million Americans are diagnosed with diabetes (DM), contributing to morbidity, mortality and strain on the healthcare system. The impact of social determinants of health (SDOH) and social vulnerability (SV), as measured by the social vulnerability index (SVI), on DM care and control is evident. In populations with lower educational attainment levels, lower income and higher rates of poverty, prevalence of DM and rates of complications are higher. However, less is understood about how the intersectionality between SDOH/SV and race impacts diabetes control. Aims: We sought to examine the impact of SV and race on DM control in primary care patients in Upstate NY. Methods: We examined 26,010 patients with DM in Upstate NY. We defined DM control based on national HEDIS standards. SVI were calculated for each patient based on census track data. The SVI is calculated based on 16 variables in four themes: socioeconomic status, household characteristics, racial/ethnic minority status, and housing/transportation. SVI scores range from 0 (lowest vulnerability) to 1 (highest vulnerability). In addition to calculated SVI scores, we examined patient-reported SDOH, including food insecurity, housing insecurity, transportation, and social isolation. Race and ethnicity related parameters were self-reported. We report preliminary descriptive data. Results: Overall, 73.6% of patients were controlled with a HgA1c <8% based on the HEDIS definition. Control rates varied based on race (white 75.9% Black 66.1%; Asian 73.7%; other race 66.6%), calculated SVI, and patient reported SDOH. Within each racial category, diabetes control rates worsened with increasing SVI. Patients who expressed food insecurity had lower rates of DM control than those who had no food insecurity (68.8% vs 79.7%). Similarly, patients with housing insecurity had lower control rates (67.5%) compared to those who had greater housing security (80.0%). Patients with unmet transportation needs had lower rates of diabetic control (67.4%) compared to those with stable transportation (80.6%). Additional statistical tests and multivariate regression models are pending. Conclusions: Across a large sample of patients with diabetes, increasing SV was associated with worsening glycemic control across all racial groups studied. In preliminary analyses, both race and SVI appear to be independently associated with DM control. SVI did not fully mitigate the influence of rate on DM control. Within same SVI category, non-white participants appeared to have a more negative impact on DM control compared to white participants. While SDOH are well known influences, these findings specifically demonstrate the link between SV and glycemic control, highlighting the fact that at the same SVI quartile, non-white participants may be more vulnerable to dysglycemia. Presentation: 6/2/2024 6/2/2024

Abstract A023: Immune-related diseases and skin cancer in a racially and ethnically diverse US-based population

Abstract Though the immune system plays a crucial role in skin cancer development, associations between immune-related diseases and skin cancer have not been well studied in racial and ethnic minorities. The goal of this cross-sectional study was to assess the relationship between various immune-related diseases and basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and cutaneous malignant melanoma (MM) diagnoses within the diverse “All of Us” Research Program cohort. It included 307,451 adult participants with electronic health record (EHR) data enrolled from 2017-2023. Participant EHRs were used to determine immune-related diseases and skin cancer diagnoses. Multivariate logistic regression analyses were adjusted for demographic characteristics, lifestyle factors such as smoking history, in addition to health insurance status, educational attainment, history of photosensitivity, history of organ transplant, as well as UV exposure at residence. R v4.0.5 was utilized to conduct the analysis. 8,107 participants with BCC, 4,102 with SCC and 2,461 with MM were identified. Personal history of any immune-related disease was significantly associated with all skin cancer types (odds ratio and 95% confidence intervals -- BCC: 1.27 [1.20-1.33]; SCC:1.38 [1.29-1.49]; MM: 1.55 [1.42-1.69]). Rheumatoid arthritis, hypothyroidism, type I diabetes, Crohn’s disease, and ulcerative colitis were each associated with the three skin cancer types. Multiple sclerosis, Sjogren’s syndrome, hyperthyroidism, dermatomyositis/polymyositis, vitiligo, and psoriasis were associated with at least one skin cancer. Systemic lupus, scleroderma, alopecia areata, and atopic dermatitis were not associated with any skin cancer. In non-White participants alone (n=133,144; 43.3%), history of any immune-related disease was similarly significantly associated with all three skin cancer types. These findings suggest that the history of several immune-related diseases is associated with skin cancer, including among racial/ethnic minorities, and thus increased skin cancer surveillance in these patient populations may be indicated. Citation Format: Erica M. Lin, Sara Ragi, Rachel Lim, Shirley Lin, Isabelle Moseley, Abrar Qureshi, Eunyoung Cho. Immune-related diseases and skin cancer in a racially and ethnically diverse US-based population [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 A023.

Bystander Motivations and Barriers to Helping Intoxicated Peers.

We examined the prevalence of self-reported motivations and barriers to helping intoxicated peers among emerging adults (N = 377; Mage = 18.64; 75% women, 88% White) attending a Southeastern university and whether motivations and barriers differed by age, gender, race, and class standing. Respondents aged 19-24 were more likely to endorse the motivation item "Because it was your "turn" to be the helper/designated driver (DD) that night" than eighteen-year-olds. Race differences were also reported for the motivation item, "Because the person was your friend", where White participants were more likely to endorse this item than non-White participants. Men also reported more Burden/Hassles-related barriers than did women.

P-470 How much do the general population know regarding the menstrual cycle and conception?

Abstract Study question How much do the general population know regarding the menstrual cycle and conception? Summary answer There is a lack of basic knowledge regarding key menstrual cycle and conception facts which could lead to missed reproductive opportunities. What is known already Although the human menstrual cycle is a “normal” biological process, stigma remains regarding open discussion of periods, and there is limited research surrounding the public understanding of the menstrual cycle and conception. Infertility rates are rising globally. With people commencing a family later in life, it is essential that the knowledge needed to make informed decisions regarding conception is prevalent. The primary aim of this study was to determine the general populations’ knowledge regarding the menstrual cycle and conception. Study design, size, duration A prospective, voluntary, anonymous, self-completed ethically approved questionnaire was distributed internationally online via various social media platforms over a period of 3 months. Participants/materials, setting, methods In total, 676 fully completed questionnaires were analysed. 84.9% of participants identified as female, 13.5% identified as male, and a small remainder of the participants identified as non-binary (1.6%). Most participants were white (87%), lived in the UK (92%) and had a university education (62.1%). 12% of the respondents were healthcare workers of any type and 31.7% had biological children. Main results and the role of chance Female participants selected correct answers at higher rates than both males and non-binary participants for 88.9% of the questions. No differences in correct answers were seen when people with and without children were compared and those with university education versus those without. Some questions received a high number of correct answers by all participants; ‘What is menopause?’ (98.8% correct), ‘What does PMS stand for?’ (86% correct), ‘How many days does the average menstrual cycle last?” (89.2% correct), ‘Is it possible to get pregnant on your period?’ (77.4% correct). Whereas other questions were answered poorly by most participants; ‘How many days per month, on average is it possible to get pregnant?’ (40.9% correct), ‘What counts as the first day of a new menstrual cycle?’ (54.71% correct), and ‘How many days does the average period last?’ (56% correct). Limitations, reasons for caution The majority of participants were white, lived in the UK and the questionnaire was accessed through an online medium. Responses from non-white participants, outside of the UK and from those without access to the internet may have captured further themes in relation to the menstrual cycle and conception knowledge. Wider implications of the findings Increased education is urgently needed to ensure knowledge is sufficient for people to access healthcare when required and understand the principles of conception and fertility to fulfill or prevent when coveted. This data will facilitate the understanding that there is a need for sexual and reproductive education among the public. Trial registration number NA

Assessing Patient Perspectives and the Health Equity of a Digital Cancer Symptom Remote Monitoring and Management System.

People with cancer experience poorly controlled symptoms that persist between treatment visits. Automated digital technology can remotely monitor and facilitate symptom management at home. Essential to digital interventions is patient engagement, user satisfaction, and intervention benefits that are distributed across patient populations so as not to perpetuate inequities. We evaluated Symptom Care at Home (SCH), an automated digital platform, to determine patient engagement, satisfaction, and whether intervention subgroups gained similar symptom reduction benefits. 358 patients with cancer receiving a course of chemotherapy were randomly assigned to SCH or usual care (UC). Both groups reported daily on 11 symptoms and completed the SF36 (Short Form Health Survey) monthly. SCH participants received immediate automated self-care coaching on reported symptoms. As needed, nurse practitioners followed up for poorly controlled symptoms. The average participant was White (83%), female (75%), and urban-dwelling (78.6%). Daily call adherence was 90% of expected days. Participants reported high user satisfaction. SCH participants had lower symptom burden than UC in all subgroups: age, sex, race, income, residence type, diagnosis, and stage (all P < .001 effect size 0.33-0.65), except for stages I and II cancers. Non-White and lower-income SCH participants gained a higher magnitude of symptom reduction than White participants and higher-income participants. Additionally, SCH men gained higher SF36 mental health (MH) benefit. There were no differences on other SF36 indices. Participants were highly satisfied and consistently engaged the SCH platform. SCH men gained large MH improvements, perhaps from increased comfort in sharing concerns through automated interactions. Although all intervention subgroups benefited, non-White participants and those with lower income gained higher symptom reduction benefit, suggesting that systematic care through digital tools can overcome existing disparities in symptom care outcomes.

Inequities in atrial fibrillation trials: An analysis of participant race, ethnicity, and sex over time

BackgroundDespite the importance of racial and ethnic representation in clinical trials, limited data exist regarding the enrollment trends of these groups in atrial fibrillation (AF) trials over time. ObjectivesThe purpose of this study is to examine the characteristics of contemporary AF clinical trials and evaluate their association with race and ethnicity over time. MethodsWe performed a systematic search of all completed AF trials registered in ClinicalTrials.gov between conception to December 31, 2023 and manually extracted composition of race/ethnicity. We stratified trials by study characteristics, including impact factor, publication status, funding source, and location. We calculated the participation prevalence ratio (PPR) by dividing the percentage of non-White participants by the percentage of non-White participants among the disease population (PPR 0.8-1.2 suggests proportional representation) over time. ResultsWe identified 277 completed AF trials encompassing a total of 1,933,441 adults, with a median proportion of non-White at 12% (IQR: 6-27), 121 (43.7%) device-focused, and 184 (66.4%) funded by industry. Only 36.1% of trials reported comprehensive race information. Overall, non-White participants were underrepresented (PPR = 0.511; P < 0.001), including Black (PPR = 0.263) and Hispanic (PPR = 0.337) participants. The proportion of non-White participants did not change significantly between 2000 and 2023 (11% vs 9%; P = 0.343). ConclusionDespite greater awareness, race/ethnicity reporting and representation of non-White groups in AF clinical trials are poor and have not improved significantly over time. These findings demand additional recruitment efforts and novel recruitment policies to ensure adequate representation of these demographic subgroups in future AF clinical trials.

Uptake of germline cancer genetic services in a randomized trial of remote telehealth services as compared to usual care: A report from the Childhood Cancer Survivor Study (CCSS).

10009 Background: Limited access to genetic services in community practices, leaves many childhood cancer survivors who are genetic carriers unidentified and at risk for subsequent malignant neoplasms (SMNs) due to therapy or an inherited cancer predisposition. The ENGaging and Activating cancer survivors in Genetic services (ENGAGE) study evaluated the effectiveness of an in-home, collaborative PCP (primary care provider) model of remote centralized telehealth services to increase uptake of cancer genetic services in survivors compared to usual care. Methods: 414 survivors were randomized to remote services by phone or videoconference (n = 281) or usual care (n = 133). The primary outcome was uptake of genetic counseling or testing at 6 months. In secondary analyses we evaluated baseline characteristics and patient reported outcomes associated with uptake of services. We used Fisher’s Exact tests, Chi-squared tests, and T-tests for analyses. Results: Participants were identified through the NCI-funded Childhood Cancer Survivor Study and included 189 (45.7%) male, 88 (21.1%) nonwhite participants with mean age 52 years (SD 0.65), recruited from over 40 states with a history of CNS tumors (n = 190, 46%), sarcoma (n = 116, 28%), or SMN or a family history of cancer (n = 108, 26%). At 6 months, 40% (n = 113) of survivors in the remote telehealth services arms utilized genetic services as compared to 16% (n = 21) in the usual care arm (p &lt; 0.001). Factors associated with uptake of services included lower baseline genetic knowledge score (31.0, SD 5.8 without uptake versus 29.7, SD 5.1 with uptake, p = 0.025), having more relatives with cancer (1.6, SD 1.5, without uptake versus 2.0, SD 1.8 with uptake, p = 0.019), having a higher perceived risk of cancer on a Likert scale (3.6, SD 1.0 without uptake versus 3.9, SD 0.8 with uptake, p = 0.011), having a history of internet use (35% uptake with use versus 0% without use, p = 0.040), and not having a high deductible plan (30% uptake with high plan versus 42% without, p = 0.025). Having a higher positive attitude toward genetic testing score (e.g. higher perceived value, lower perception of high cost and lower anticipated distress) was associated with uptake of services (29.5, SD 4.3 without uptake versus 31.2, SD 4.4 with uptake, p &lt; 0.001). Conclusions: These data suggest that offering remote centralized telehealth genetic services increases the uptake of genetic services in survivors of childhood cancer across the US using a collaborative PCP model. Although uptake was higher than usual care, barriers to uptake of genetic services remain, including concerns about cost and negative perceptions about genetic testing. Strategies to address multi-level barriers to genetic services are needed to realize the potential of genetic testing in childhood cancer survivors and patients in community practices. Clinical trial information: NCT04455698 .

Screening for social determinants of health among patients with advanced and metastatic cancer undergoing comprehensive genomic profiling in underserved communities.

e13545 Background: Many patients with advanced and metastatic cancer, who are potentially eligible for biomarker-directed targeted agents, do not receive them, with biomarker undertesting reported as a major factor. Little is known about non-medical factors that negatively impact treatment and outcomes, particularly in underserved communities. This study implemented screening for social determinants of health (SDOH) to identify barriers to precision medicine beyond biomarker testing for these patients. Methods: Four community oncology practice sites (GA, SC, FL), selected for their focus on underserved populations, consented patients to a prospective clinico-genomic database registry (May 2021-Dec 2023). Registry participants completed an SDOH questionnaire at the time of comprehensive genomic profile (CGP) test order. Questionnaire items were grouped by SDOH domain (economic stability, education, health care access, neighborhood/built environment, and social/community), with each potential response coded as either a positive or negative indicator for patient health. Negative indicators were summed at the item, domain, and survey levels for each patient, and aggregate frequencies tabulated. Results: Among 447 CGP-tested registry participants (24 solid tumor types, stage III/IV), 331 (74%) completed SDOH screening. Although non-White registry participants were highly represented among patients who completed SDOH screening (31.7%), unscreened patients had an even higher frequency of non-Whites (49.1%), particularly Black (14.2% v 24.8%) and American Indian/Alaska Native (10.3% v 18.1%) patients. Nearly all patients (99%) reported having health insurance, most frequently Medicare (69.2%). A small number of patients (5.4%) reported transportation issues that kept them from medical appointments. By domain, negative indicators for economic stability (46.2%), and social and community context (42.3%) were the most frequently reported, while healthcare access (14.5%), and neighborhood and built environment (9.4%) were the least common. Lack of socialization (27.5%), depression (21.5%), and very low income &lt;$1200/month (20.8%), were the most frequently reported individual indicators. Overall, 74.5% of CGP-tested patients harboring genomic variants for oncology practice guideline-indicated therapies and/or marker-driven clinical trials reported having at least one negative indicator. Conclusions: SDOH-screening in community practice is feasible and identifies specific interventional areas among disadvantaged, vulnerable, advanced cancer patients. Increased screening among underserved, particularly for non-White patients, is needed to address their support needs beyond health insurance and biomarker testing, and improve their access to and participation in precision medicine clinical trials.

Integrating Cultural Humility into Medical Education Using a Structured and Interactive Workshop.

Cultural humility is a lifelong commitment to self-evaluation, redressing power imbalances in patient-physician relationships and developing mutually trusting beneficial partnerships. The objective of this study was to determine the feasibility and efficacy of cultural humility training. From July 2020-March 2021, 90-minute educational workshops attended by 133 medical students, resident physicians and medical education faculty included 1) pre- and post- intervention surveys; 2) interactive presentation on equity and cultural humility principles; 3) participants explored sociocultural identities and power; and 4) reflective group discussions. There were significant increases from pre to post intervention assessments for perception scores (3.89 [SEM= 0.04] versus 4.22 [0.08], p<0.001) and knowledge scores (0.52 [0.02] versus 0.67 [0.02], p<0.001). Commonest identities participants recognized as changing over time were personality = 40%, appearance = 36%, and age =35%. Commonest identities experienced as oppressed/subjugated were race/ethnicity = 54%, gender = 40% and religion = 28%; whilst commonest identities experienced as privileged were gender= 49%, race/ethnicity = 42% and appearance= 25%. Male participants assigned mean power score of 73% to gender identity compared to mean power score of -8% by female participants (P<0.001). Non-Hispanic Whites had mean power score for race identity of 62% compared to 13% for non-white participants (p<0.001). English as a second language was only acknowledged as an oppressed/subjugated identity by those born outside the United States (p<0.001). An interactive educational workshop can increase participants' knowledge and perceptions regarding cultural humility. Participants can self-reflect to recognize sociocultural identities that are oppressed/subjugated or privileged.

Applying behavioral economics to understand changes in alcohol outcomes during the transition to adulthood: Longitudinal relations and differences by sex and race.

Population drinking trends show clear developmental periodicity, with steep increases in harmful alcohol use from ages 18 to 22 followed by a gradual decline across the 20s, albeit with persistent problematic use in a subgroup of individuals. Cross-sectional studies implicate behavioral economic indicators of alcohol overvaluation (high alcohol demand) and lack of alternative substance-free reinforcers (high proportionate alcohol-related reinforcement) as potential predictors of change during this developmental window, but longitudinal evidence is sparse. Using a sample of emerging adults (N = 497, Mage = 22.61 years, 62% female, 48.69% White, 40.44% Black), this study examined prospective, bidirectional relations between both past-week heavy drinking days (HDD) and alcohol problems and proportionate alcohol-related reinforcement (reinforcement ratio), alcohol demand intensity (consumption at zero price), alcohol demand Omax (maximum expenditure), and change in demand elasticity (rate of change in consumption across escalating price) over five assessments (every 4 months) using random intercept cross-lagged panel models. Alcohol problems and HDD decreased across assessments. Significant between-person effects indicated that each behavioral economic variable was associated with increased drinking risk. Change in reinforcement ratio was positively associated with decreases in alcohol problems. Multigroup invariance modeling revealed distinct risk pathways in that change in demand intensity and Omax predicted change in alcohol problems for male participants and change in intensity predicted change in alcohol problems for non-White participants. The study provides consistent support for proportionate alcohol-related reinforcement and mixed support for demand as within-person predictors of reductions in drinking. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Abstract PO5-17-08: Real world outcomes of neoadjuvant chemotherapy in ER-positive/PR-positive, HER2-negative breast cancer

Abstract Background: Neoadjuvant chemotherapy is utilized to downstage locally-advanced estrogen receptor-positive (ER+)/progesterone receptor-positive (PR+), HER2-negative breast cancer despite modest pathological complete response (pCR) rates. The two most commonly utilized regimens include docetaxel plus cyclophosphamide (TC) or dose-dense doxorubicin and cyclophosphamide followed by paclitaxel (ddAC-T). Given few head-to-head comparisons of neoadjuvant TC with ddAC-T in this population, we performed a real world data analysis. Methods: 148 patients with ER+/PR+, HER2-negative breast cancer were included in the analysis. The patients were divided into two groups based on the neoadjuvant chemotherapy regimen used (TC vs ddAC-T) and the clinical responses to chemotherapy were categorized as complete, partial, no response/stable, or progressive disease. We examined the differences or associations in demographics, clinical characteristics, overall survival (OS), and invasive disease-free survival (IDFS) between TC and ddAC-T neoadjuvant chemotherapy. pCR was defined as the absence of invasive carcinoma in breast and lymph nodes (ypT0/ypTis and ypN0). Partial response was defined as a decrease in either or both T and/or N stage, compared to pre-treatment evaluation; no response was defined as no change in either T or N categories; and progressive disease was defined as an increase in either the T or N staging at time of pathologic evaluation. Results: The median age of participants was 55 years (range 28-78 years). 67% had clinical stage II disease, while 26% had stage III. 130 participants received neoadjuvant ddAC-T while 18 participants received TC. The ddAC-T group had 7% patients who achieved a pCR and 37% with a partial response, compared to the TC group with 0% of patients with a pCR and 33% with a partial response. The TC group had a higher rate of progressive disease, compared to the ddAC-T group (67% versus 20%). On univariate analysis, the choice of neoadjuvant chemotherapy was not predictive of pathologic response (p = 0.3864). As expected, premenopausal status was associated with a higher likelihood of a pathologic response with an odds ratio of 2.917 (95% CI: 1.465-5.809). On multivariate analysis, chemotherapy regimen was not predictive of pathologic response (p = 0.6047), after controlling the effects of age and menopausal status. No significant difference was noted in OS or IDFS at 24 and 48 months between the ddAC-T and TC groups. On multivariate analysis, controlling for BMI, ER, PR, race, and ECOG performance status, the choice of chemotherapy was not predictive of IDFS. Non-white participants appeared to have inferior IDFS (HR = 2.956, 95% CI: 1.208, 7.238, p-value = 0.0177). Conclusion: In this single-center retrospective analysis, we show real world outcomes of the use of neoadjuvant chemotherapy regimens among patients with ER+/PR+, HER2-negative breast cancer. Both ddAC-T and TC had low pCR rates, 5.98% and 0%, respectively. However, there was no statistical difference between IDFS or OS when comparing the two chemotherapy regimens. More data are needed to optimize neoadjuvant treatment in this patient population and to determine whether anthracyclines can be avoided. Table. Pathologic responses The results (summarized by odds ratio (OR) and its 95% CI) from logistic regression on the pathological responses (complete and partial). Citation Format: Matthew Kurian, Marcus Trybula, Kanchi Patell, Gregory Guzik, Seunghee Margevicius, Pingfu Fu, Alberto Montero, James Martin. Real world outcomes of neoadjuvant chemotherapy in ER-positive/PR-positive, HER2-negative breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-17-08.

Sex and gender-based analysis and diversity metric reporting in acute care trials published in high-impact journals: a systematic review

ObjectiveTo characterise sex and gender-based analysis (SGBA) and diversity metric reporting, representation of female/women participants in acute care trials and temporal changes in reporting before and after publication of the...

Use of complementary and alternative medicine in vitiligo: a cross-sectional survey.

Vitiligo is characterized by skin depigmentation, which can lead to profound psychological effects and decreased quality of life, especially for those with skin of color. Individuals with vitiligo may utilize complementary and alternative medicine (CAM) due to limited treatment options with varying efficacy.An anonymous, multiple-choice, cross-sectional questionnaire was distributed to participants with vitiligo in the United States through online forums. Data on disease characteristics, use of prescription medications, use of topical therapies, supplements, and diets, and perceptions of CAM were collected.In total, 625 respondents completed the survey. Overall, 32.5% of participants (203/625) have tried CAM. Commonly reported CAM include supplements of vitamin D (57.7%, 116/203), vitamin B12 (46.3%, 93/203), vitamin C (27.4%, 55/203), topical Nigella sativa oil (26.4%, 53/203), oral omega-3 fatty acids (24.9%, 50/203), folic acid (22.9%, 46/203), and vitamin E (22.9%, 46/203). Frequently cited reasons for CAM use include desire to try "new" (40.4%, 82/203) or "more natural" (26.6%, 54/203) therapies, "frustration with conventional medicine" (24.6%, 50/203), and fear of "adverse side effects of conventional medicine" (23.6%, 48/203). Non-White participants were more likely than their White counterparts to report CAM use and have more positive perceptions of CAM therapies. Less than half (43.3%, 88/203) of CAM users reported that they disclosed their use of CAM with their physician.Dermatologists should be mindful of CAM and ask patients about their use. Further investigation of the role of CAM as adjuvant therapy for vitiligo is warranted to better advise patients.

Mediation analysis using incomplete information from publicly available data sources.

Our work was motivated by the question whether, and to what extent, well-established risk factors mediate the racial disparity observed for colorectal cancer (CRC) incidence in the United States. Mediation analysis examines the relationships between an exposure, a mediator and an outcome. All available methods require access to a single complete data set with these three variables. However, because population-based studies usually include few non-White participants, these approaches have limited utility in answering our motivating question. Recently, we developed novel methods to integrate several data sets with incomplete information for mediation analysis. These methods have two limitations: (i) they only consider a single mediator and (ii) they require a data set containing individual-level data on the mediator and exposure (and possibly confounders) obtained by independent and identically distributed sampling from the target population. Here, we propose a new method for mediation analysis with several different data sets that accommodates complex survey and registry data, and allows for multiple mediators. The proposed approach yields unbiased causal effects estimates and confidence intervals with nominal coverage in simulations. We apply our method to data from U.S. cancer registries, a U.S.-population-representative survey and summary level odds-ratio estimates, to rigorously evaluate what proportion of the difference in CRC risk between non-Hispanic Whites and Blacks is mediated by three potentially modifiable risk factors (CRC screening history, body mass index, and regular aspirin use).

'Working me to life': longitudinal perceptions from adults with heart failure with preserved ejection fraction enrolled in an exercise training clinical trial.

Adults with heart failure with preserved ejection fraction (HFpEF) responded more favourably to an exercise intervention compared with those with reduced ejection fraction. This study explores factors that contributed to this response, focusing on the qualitative perceptions of adults with HFpEF enrolled in an exercise intervention. This qualitative descriptive study is a secondary analysis of longitudinal interviews collected at 3, 6, 12, and 18 months from participants with HFpEF enrolled in a randomized controlled trial testing an intervention to promote adherence to exercise. We included participants with at least two interviews. Interviews were examined across and within participants and time points using thematic analysis. Analyses included 67 interviews from 21 adults with HFpEF enrolled in the intervention arm. The sample consisted of 52% (11/21) males and over 47% (10/21) non-White participants. Mean age at enrolment was 63.7 ± 9.9 years. We identified four major themes: (1) overcoming negative attitudes, barriers, and injury, (2) motivations to exercise, (3) exercise-the panacea for HFpEF symptoms and quality of life, and (4) advice for others with HFpEF. Our findings suggest that for many adults with HFpEF, initial hesitancy, fear, and negative attitudes about exercise can be overcome. Exercise coaching using social cognitive constructs, medical fitness centre memberships, and heart rate self-monitoring are successful strategies of engaging adults with HFpEF in long-term unsupervised exercise training. ClinicalTrials.gov, NCT01658670.

Early Exposure to Orthopaedic Surgery.

Disparities in early orthopaedic experiences among medical students prompt a critical examination of factors influencing the availability and nature of these exposures. While the current body of literature underscores the significance of early surgical exposure and mentorship in medical education, a notable gap exists in investigating early orthopaedic exposure and its specific impact on students from diverse backgrounds. A 16-item questionnaire, approved by our institutional review board, was administered to fourth-year medical students (MS4) and first-year orthopaedic residents (PGY-1) across U.S. orthopaedic surgery programs during the 2022-2023 application cycle. The questionnaire assessed participants' initial orthopaedic exposures and factors influencing interest in the field. Two-proportion Z-test analyses were conducted to analyze the data, and thematic analysis was used to assess qualitative data involving free-response questions. Out of 72 total respondents, the study revealed that 83% of respondents encountered orthopaedics before medical school, with initial exposures stemming from various sources such as familial connections (28%), athletics(17%), and high school or college exposures (15%), including shadowing, athletics participation, and occupation-related exposure. Disparities were observed in the availability of orthopaedic mentors and early exposure opportunities between demographic groups. Statistical analyses highlighted significant differences in access to mentors who reflected students' identities between male and non-male participants (70% vs. 39%, p=0.02) and between white and non-white participants (69% vs. 36%, p=0.02). White participants were also more likely to first interact with a surgeon who treated them or their family members than non-white participants (35% vs 7%, p=0.04). Non-white participants were more likely than white participants to come by their first orthopaedic opportunity by searching for it independently (21% vs. 4%, p=0.03). Family and friend connections in orthopaedics were found to be influential in motivating students to pursue orthopaedics, with 40% of respondents indicating personal connections in medicine and 12% reporting family members who are orthopaedic surgeons. Research experiences were identified as important contributors to students' initial interest and motivation to ultimately pursue orthopaedics, especially those with diverse backgrounds. The findings underscore the importance of early orthopaedic exposures in shaping students' interest in the field, highlighting the need for more immersive pre-clinical year opportunities and enhanced mentorship programs. Addressing disparities in mentorship access and early exposure opportunities requires systemic changes and increased support for underrepresented minorities in orthopaedics. Initiatives like mentorship programs and research opportunities can help bridge gaps in access to early orthopaedic experiences. Medical schools should prioritise targeted early access to orthopaedic exposures for all students, regardless of background. This initiative aims to promote inclusivity and cultivate a more diverse orthopaedic workforce capable of meeting the evolving healthcare needs of society.

Development of a Phthalate Environmental Reproductive Health Literacy (PERHL) Scale.

Substantial evidence exists linking phthalate exposure to adverse reproductive health outcomes. Current US federal regulations of consumer product chemicals place the onus on individuals to mitigate their exposure to phthalates, with assumptions of sufficient environmental health literacy (EHL). Few validated scales for people of reproductive age exist to evaluate phthalate-specific EHL. Our objective is to develop a multidimensional scale characterizing latent factors of phthalate knowledge, risk perception, and self-efficacy to inform individual-level interventions for reducing phthalate exposure. We distributed a survey with 31 items to 117 participants in the Environmental Reproductive and Glucose Outcomes (ERGO) cohort who gave birth within the last 5 years. Exploratory factor analysis (EFA) was used to identify underlying latent factors. Internal reliability was assessed via omega hierarchical coefficient. Average sum scores for each latent factor and the overall Phthalate Environmental Reproductive Health Literacy (PERHL) score were calculated. Associations between latent factors, overall PERHL score, and sociodemographic characteristics were explored using linear models. Six latent factors were identified as follows: "Awareness of Phthalate Reproductive Health Impacts," "Uncertainty," "Protective Behavior/Risk Control," "Regulatory Interest," "Awareness of Phthalate Exposure Pathways," and "General Phthalate Knowledge." Each factor demonstrated acceptable to strong internal reliability, with coefficients ranging between 0.63 and 0.93. Non-white participants had lower scores for the "Awareness of Phthalate Reproductive Health Impacts" [: , 95% confidence interval (CI): , ], "Awareness of Phthalate Exposure Pathways" (: , 95% CI: , ), and "General Phthalate Knowledge" (: , 95% CI: , ), but no significant difference in scores on "Uncertainty" (: 0.17, 95% CI: , 0.50), "Protective Behavior/Risk Control" (: , 95% CI: , 0.28), or "Regulatory Interest" (: , 95% CI: , 0.09). No associations were seen for age or educational attainment and latent or sum factors. Six latent factors were identified for the PERHL scale. Non-white race and ethnicity was associated with lower scores for knowledge-related scale factors. https://doi.org/10.1289/EHP13128.

Patterns of delta 8 THC and cannabis uptake in Nebraska: A cannabis prohibition state

BackgroundFollowing the passage of the 2018 Farm Bill, derived psychoactive cannabis products containing delta 8 tetrahydrocannabinol (THC) have become increasingly popular across the US, particularly in states that lack medical or recreational cannabis programs. Despite this, little is known about patterns of delta 8 THC use. MethodsA sample of Nebraska residents (a state without legal medical or recreational cannabis) were surveyed to gather data on substance use, including delta 8 THC and cannabis, across the state. Then, logistic regressions were used to calculate relative odds ratios to understand the factors that increased the likelihood at which Nebraska residents use delta 8 THC or cannabis products. ResultsAnalysis revealed that younger adults have higher odds of delta 8 THC use but not cannabis and that non-white participants had higher odds of delta 8 use than white non-Hispanic groups but there was no difference for cannabis use. Political affiliation, sexual orientation, access, and knowledge of friends who used cannabis were also associated with cannabis use but not delta 8 THC use. Past substance use and personal opinion regarding cannabis use increased likelihood for both delta 8 THC and cannabis use. ConclusionThese results illuminate several factors which affect cannabis and delta 8 THC use while providing insight on the people that are most likely to be impacted by the potential consequences of substance use, especially when considering the inconsistent laws governing cannabis and delta 8 THC use across the US.

Time to normalise protected characteristics in written assessments: A mixed methods study

Background Despite increasing endeavours to incorporate teaching material on healthcare for minority groups into medical school curricula, including cultural competency, there is a lack of research exploring medical students' comprehension of this. With age and gender as the only demographic information routinely provided in undergraduate single best answer (SBA) questions, the diversity of patients encountered by doctors in clinical practice is not fairly represented in assessments. This study examined the impact of not declaring gender or explicitly indicating LGBT+ identities and ethnicity, on how medical students evaluate clinical scenarios through SBA questions. Methods 200 medical students across clinical years completed 15 SBA questions in an online simulated exam. Participants were randomised to control and test groups testing different types of patient demographic information in question stems. Results Linear regression modelling demonstrated overall statistically nonsignificant differences between groups. The largest effect size was seen in the LGBT+ question intervention group, which had the fewest white and postgraduate participants. Older and more senior medical students performed better generally. White participants overall significantly outperformed non-white participants; this difference was eliminated when answering a mix of question styles. Using a mix of question styles produced statistically significant differences, with participants scoring worse on LGBT+ and ethnicity style questions. Conclusion Increased depth and breadth of clinical experience enables medical students to approach clinical scenarios with more flexibility. Unfamiliarity with minority patient groups may have impacted their performance in this study. For medical education to remain contemporary in preparing future clinicians to interact with diverse patient groups, assessments need to normalise the presence of these patients.

Challenging color-evasion in democratic dialogue: using critical race discourse analysis to generate practical theory for facilitators*

ABSTRACT Guided by Critical Race Discourse Analysis and Grounded Practical Theory this paper analyzes interaction during classroom dialogs to examine how democratic inclusion is undermined by color-evasion. Too often color-evasion as a discursive technique perpetuates exclusion, inhibits democratic values under the guise of inclusion, and consequently, protects whiteness and puts undue burden on non-white participants. Thus, we argue that democratic facilitators who are concerned with inclusion should listen for and disrupt color-evasiveness. We offer a practical theory to guide facilitators recognizing and challenging color-evasion through questions that encourage the group to contend with why evading talk about race undermines democratic dialogue.