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IntroductionFlavoured tobacco control policy exemptions and electronic cigarette products may contribute to increased youth access and tobacco use disparities.MethodsWe assessed public support among California Central Valley residents for four policies to regulate flavoured tobacco products and e-cigarettes. The probability-based, multimode survey was conducted with English-speaking and Spanish-speaking registered voters (n=845) across 11 counties between 13 and 18 August 2020. Weighted logistic regression analyses measured odds of policy support, adjusting for predictor variables (attitudes and beliefs) and covariates.ResultsThe weighted sample was 50% female and predominantly Latino (30%) or non-Hispanic white (46%); 26% had a high school education or less, and 22% an annual household income DiscussionFindings add to mounting evidence of support for policies to regulate flavoured tobacco and e-cigarette products. Results on attitudes and beliefs elucidate how these factors influence support.

Introduction: Providing cost effective comprehensive survivorship care (SC) remains a major challenge for which optimal delivery models are needed. Group medical visits (GMV) are commonly used in chronic diseases to deliver medical care, education, and empower patients. Pilot GMV studies for breast cancer survivors (BCS) have shown increases in peer support and patient education. This pilot study uses the RE-AIM framework for evaluation of the GMV intervention to support breast cancer survivors. RE-AIM is an efficient framework for systematic evaluation of health care interventions. RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) is the evaluation methodology based on the framework developed by a working team of scholars from health care, public health, and implementation science. Methods: The study was conducted at a public hospital in California. GMV consisted of 4, 2-hour, weekly sessions focused on therapy side effects and prevention, emotional health, sexual health, physical activity, and diet. Patient navigator (PN) recruited 3 consecutive GMV groups of 6 English-speaking BCS (n=18). Results: The Reach was determined by the number and proportion of participants in this study. Our participants were primarily English-speaking and were within 1-5 years of completing active breast cancer treatment. Participants of the GMV were from diverse backgrounds and low-income neighborhoods in San Francisco and were representative of breast cancer survivors in our population. Effectiveness of GMV were assessed through self-reported changes with increased knowledge of survivorship care plans, recognition, and management of long-term side effects of cancer treatments and knowledge of community-based resources. There was an increase from baseline in all these domains and in confidence communicating with their primary care provider. Adoption involved initial stakeholder engagement in the intervention and Implementation was assessed by the consistent content and delivery of the intervention. We did not evaluate Maintenance as it was out of the scope of this study. We found that ongoing need for services is extremely high in our BCS, suggesting that this intervention has the potential to be widely adopted by cancer survivors and survivorship programs. Overall, consistent attendance and active participation indicated that GMV are feasible in this setting. 94% of BCS reported GMV increased their awareness and confidence of SC. Participants reported high satisfaction, felt well-informed, and supported through the availability of GMV. BCS highlighted the benefits of integrating treatment, services, emotional support, and education. BCS suggested GMV should be implemented at time of cancer diagnosis and emphasized the key role of PN in GMV and supporting SC. Conclusions: GMVs were specifically designed to address unmet needs for services that are necessary for SC but not readily available. Our pilot data suggests PN facilitated GMV are a feasible and acceptable model to integrate SC in public hospitals. The evaluation of our intervention using the RE-AIM framework can aid potential adopters in developing and implementing GMV intervention to support BCS. Citation Format: Evelin Trejo, Ana I. Velazquez, Elizabeth Castillo, Barbara Cicerelli, Robin McBride, Nancy J. Burke, Niharika Dixit. Utilization of the RE-AIM frameworkfor evaluating the implementation of group medical visit for low-income breast cancer survivors [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P4-11-19.

Notable barriers exist in the delivery of equitable care for all patients with cancers. Social determinants of health at distal, intermediate, and proximal levels impact cancer care. Patient navigation is a patient-centered intervention that functions across these overlapping determinants to increase access to cancer services throughout the cancer care continuum. There is a need to standardize patient navigation training while remaining responsive to local contexts of care and a need to implement patient navigation programs with a health equity lens to address cancer care inequities.

In the United States, in the wake of health care reform, health care systems have been subject to intensifying demands to increase patient engagement, a term that refers broadly to participation in care. We draw from ethnographic research in urban health care safety-net settings in California to examine efforts to increase patient engagement among chronically ill, marginalized patients who have long been disconnected from outpatient care. We suggest that the work of engagement in this context involved getting people to accept the norms of biomedicine while also reworking these norms to account for the complex circumstances of their lives.

BACKGROUND: Regular mammogram screening for eligible average risk women has been associated with early detection and reduction of cancer morbidity and mortality. Delayed follow-up and resolution of abnormal mammograms limit early detection efforts and can cause psychological distress and anxiety. OBJECTIVE: The goal of this study was to gain insight from women’s narratives into how organizational factors related to communication and coordination of care facilitate or hinder timely follow-up for abnormal mammogram results. DESIGN: We conducted 61 qualitative in-person interviews with women from four race-ethnic groups (African American, Chinese, Latina, and White) in three different healthcare settings (academic, community, and safety-net). PARTICIPANTS: Eligible participants had an abnormal mammogram result requiring breast biopsy documented in the San Francisco Mammography Registry in the previous year. APPROACH: Interview narratives included reflections on experience and suggested improvements to communication and follow-up processes. A grounded theory approach was used to identify themes across interviews. KEY RESULTS: Participants’ experiences of follow-up and diagnosis depended largely on communication processes. Twenty-one participants experienced a follow-up delay (> 30 days between index mammogram and biopsy). Organizational factors, which varied across different institutions, played key roles in effective communication which included (a) direct verbal communication with the ability to ask questions, (b) explanation of medical processes and terminology avoiding jargon, and (c) use of interpretation services for women with limited English proficiency. CONCLUSION: Health organizations varied in their processes for abnormal results communication and availability of support staff and interpretation services. Women who received care from institutions with more robust support staff, such as bilingual navigators, more often than not reported understanding their results and timely abnormal mammogram follow-up. These reports were consistent across women from diverse ethnic groups and suggest the value of organizational support services between an abnormal mammogram and resolution for improving follow-up times and minimizing patient distress.

Background; Survivorship care plans (SCPs) are personalized documents, provided at the end of the treatment by patients’ oncology clinicians that summarize the diagnosis and treatment, late and long-term adverse effects, ongoing surveillance for recurrence, screening for new cancers, and health maintenance of cancer survivors. Considered as a tool for cancer survivors, experts in cancer survivorship and accrediting organizations such as Commission on Cancer (CoC) have endorsed the use of SCPs even in the absence of firm evidence of their efficacy. Safety net hospitals are at the forefront of providing care for vulnerable low-income cancer survivors who may also have low educational attainment, low health literacy, and limited English proficiency. Cancer survivors who are racial and ethnic minorities and low income may experience higher symptom burden and limitation of function. Prior work has shown that patients who in safety net health setting, do not benefit from SCPs and only 25% share them with their primary care providers. Methods This study is a pilot randomized clinical trial to assess the role of patient navigation in cancer survivors. Breast cancer survivors were randomized to SCPs with or without patient navigation. In the intervention, arm navigators discussed the survivorship care planning and issues with patients at the time of delivery, 6 weeks by phone, at 3 months and then at 6 months. The primary outcome was breast cancer-related quality of life (QOL) was assessed by FACT B questionnaire. The secondary outcome was self-efficacy. In addition, we conducted focus groups for cancer survivors, patient navigators, and oncology providers to understand their perspective. Cancer survivors who had completed the treatment for breast cancer within 1-5 years were eligible to participate in the study. Participants spoke English(N=20), Chinese (n =10) or Spanish (n=10). Results: There were 20 participants in each arm, 10 English speaking and 5 each Spanish and Chinese speaking. At 6 months and final follow up, 32 patients were available for analysis. One patient developed metastatic cancer, two patients had changes in their insurance status and five were not available for final analysis. We performed Wilcoxon non-parametric analysis to assess changes in all five domains of FACT B. There were trends towards improvement in the change in emotional well-being score, functional well-being score and overall QOL in the intervention arm, but it was not statistically significant. Physical well-being score change was similar. There was no difference in the mean self-efficacy scores for both arms. At baseline, 57.7% breast cancer survivors reported being not all/a little bit satisfied with their sex life and 53.9% reported not all/a little bit feeling sexually attractive. 87.5 % of survivors reported having accepted their illness quite a bit/ very much. Conclusions Our study successfully recruited patient from a diverse patient population in safety net settings. Patient navigation combined with survivorship care showed encouraging trends in improvement in emotional well-being, physical well-being, and QOL, although it was not statistically significant. There was no difference in mean self-efficacy score. We are currently analyzing the qualitative data to assess the implementation of the intervention. Citation Format: Niharika Dixit, Barbara Cicerelli, Roy Cherian, Nancy Burke. Catalyzing navigation for breast cancer survivors (CaNBCS) [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-13-18.

Vietnamese American males have high smoking rates. This study explored social support mechanisms provided by lay health workers (LHWs) and family members through a smoking cessation intervention. Eight focus groups (N = 54) were conducted in Vietnamese stratified by intervention arms (Tobacco [experimental] and healthy living [control]) with 18 smokers, 18 family members, and 18 LHWs. Smokers reported feeling more accountable for their health behaviors, and smoking changes were reinforced by family members, peers, and LHWs through conversations facilitated during and outside the program. Culturally appropriate interventions with multiple social support mechanisms may reduce smoking in minority populations.

As medicine integrates social and structural determinants into health care, some health workers redefine housing as medical treatment. This article discusses how health workers in two U.S. urban safety-net hospitals worked with patients without stable housing. We observed ethnographically how health workers helped patients seek housing in a sharply stratified housing economy. Analyzing in-depth interviews and observations, we show how health workers: (1) understood housing as health care and navigated limits of individual care in a structurally produced housing crisis; and (2) developed and enacted practices of biomedical and sociopolitical stabilization, including eligibilizing and data-tracking work. We discuss how health workers bridged individually focused techniques of clinical care with structural critiques of stratified housing economies despite contradictions in this approach. Finally, we analyze the implications of providers’ extension of medical stabilization into social, economic, and political realms, even as they remained caught in the structural dynamics they sought to address. [homelessness, housing, hospitals, marginalized populations, inequity]

Introduction. Smoking prevalence is disproportionately high among Asian American immigrant men with limited English proficiency. Understanding the role of family support may provide insights into culturally acceptable strategies to promote smoking cessation. Aims. This study examined how family support was associated with readiness to consider smoking cessation among Chinese and Vietnamese American male daily smokers. Methods. We analyzed baseline data ( N = 340 ) from a cluster randomized trial of a family-based healthy lifestyle intervention. We assessed the frequency of receiving family support in various forms (encouraging use of cessation resources, praising efforts, checking in, and reminding of familial role). Multiple regression analysis was used to determine associations between family support areas and readiness to consider smoking cessation, controlling for covariates. Results/Findings. Reporting a higher frequency of receiving praise and encouragement for one’s efforts to quit was positively associated with readiness to consider cessation. Other areas of family support were not significant. Conclusions. These findings provide evidence to explore specific areas of family support in enhancing Asian American smokers’ readiness to consider cessation. As there is high interest from Asian American family members to support their smokers for quitting, culturally specific and acceptable strategies are needed to promote smoking cessation among Asian Americans.

The purpose of this study is to describe Mexican-American parents' experiences navigating the dental care system for their children.Thirty in-depth qualitative interviews were conducted with Spanish-speaking caregivers of young children in an urban county of Northern California, asking about their experiences navigating dental care for their children. Interviews were digitally recorded, translated, transcribed, coded, and analyzed using standard qualitative procedures.Caregivers reported challenges that highlight how various aspects of navigating the health care system are elemental to oral health literacy. These included making appointments, finding a provider they trust, using their dental insurance, and communicating with the dental care provider.When addressing oral health literacy, it is important to consider the navigational components to improve children's oral health literacy.

The COVID-19 pandemic revealed weaknesses in the public health infrastructure of the United States, including persistent barriers to engaging marginalized communities toward inclusion in clinical research, including trials. Inclusive participation in clinical trials is crucial for promoting vaccine confidence, public trust, and addressing disparate health outcomes. A long-standing body of literature describes the value of community-based participatory research in increasing marginalized community participation in research. Community-based participatory research emphasizes shared leadership with community members in all phases of the research process, including in the planning and implementation, interpretation, and dissemination. Shared leadership between academic and industry with marginalized communities can assist with inclusive participation in vaccine trials and increase public trust in the development of the vaccines and other therapies used during public emergencies. Nevertheless, epidemiologic and clinical research do not yet have a strong culture of community partnership in the scientific process, which takes time to build and therefore may be difficult to develop and rapidly scale to respond to the pandemic. We outline practices that contribute to a lack of inclusive participation and suggest steps that trialists and other researchers can take to increase marginalized communities' participation in research. Practices include planning for community engagement during the planning and recruitment phases, having regular dialogues with communities about their priorities, supporting them throughout a study, and navigating complex structural determinants of health. Additionally, we discuss how research institutions can support inclusive practices by reexamining their policies to increase participation in clinical trials and instilling institutional trustworthiness.

Background: Complex Care Management (CCM) programs record patients’ progress toward health and healthcare utilization goals using a tracking tool in order to ascertain whether the patient is ready to transition to routine primary care. High-need, high-cost (HNHC) patients enrolled in CCM programs make progress, but existing tracking tools do not register the kinds of progress they make, suggesting that current tools may not be suitable in safety-net settings.Methods: We developed the Contextual Health Assessment of Social Stability (CHAOSS), which incorporates a patient’s social circumstances to capture patient experiences that affect their program participation. We used cognitive interviewing methods to test CHAOSS. We sought to understand if the CHAOSS tool could be used to track the kinds of progress CCM patients and providers find clinically relevant, would patients understand the questions and could the questions show meaningful distinctions in patient circumstances.Results: To set up the need for CHAOSS, we document the demographic and clinical characteristics of HNHC patients enrolled in CCM programs in safety-net settings. HNHC patients had extremely poor and volatile health, were economically vulnerable, and experienced challenges such as chronic homelessness. We found that CCM patients understood the CHAOSS questionnaire and generated an array of responses.Conclusion: CHAOSS appears to be a suitable tool for capturing HNHC patient experiences enrolled in CCM programs in safety-net settings.

Purpose The current number of breast cancer survivors (BCS) in the United States is approximately 3.8 million, and this number is further expected to increase with improvement in treatments. Survivorship care plans (SCPs) are patient-centered tools that are designed to meet cancer survivors' informational needs about their treatment history, recommended health care, and health maintenance. However, the data on SCP benefits remain uncertain, especially in low-income and racial and ethnic minority cancer survivors. Patient navigation is an effective intervention to improve patient adherence and experience of interdisciplinary breast cancer treatment. Objectives This study sought to understand the role of lay patient navigators (LPN) in survivorship care planning for BCS in safety-net settings. Methods This study is a mixed methods pilot randomized clinical trial to understand the role of patient navigation in cancer survivorship care planning in a public hospital. We invited BCS who had completed active breast cancer treatment within 5 years. LPNs discussed survivorship care planning and survivorship care-related issues with BCS in the intervention arm over a 6-month intervention period and accompanied patients to their primary care appointment. LPNs also encouraged survivors to discuss health care issues with oncology and primary care providers. The primary objective was to assess BCS’ health-related quality of life (HRQOL). The secondary objectives were self-efficacy and implementation. We assessed implementation with 45–60-min semi-structured interviews with 15 BCS recruited from the intervention arm and 60-min focus groups with the oncologists and separately with LPNs. Results We enrolled 40 patients, 20 randomized to usual care and 20 randomized to LPN navigation. We did not find a statistically significant difference between the two arms in HRQOL. There was also no difference in self-efficacy between the two arms. Qualitative analysis identified implementation barriers to intervention that may have contributed to less effective intervention. Implications for Cancer Survivors Future survivorship care planning interventions need to consider: Cancer survivors’ needs and preferences, the need for dedicated resources, and the role of electronic health records in survivorship care plan delivery.

In January 2020 the Cuban government launched a rapid and comprehensive multisectoral response to the threat posed by SARS-CoV-2. This response built upon the strengths of the nation’s public health infrastructure, including an expansive health professional workforce experienced with prior epidemics (e.g., dengue, HIV, and Ebola). It also revealed the challenges posed by the vulnerabilities of aging and weak municipal infrastructures. Deteriorating housing, poor airflow, and sweltering heat undermined adherence to lockdown measures, putting those over age sixty—an increasingly large proportion of Cuba’s population—at particular risk. I discuss challenges posed by a rapidly graying population, vulnerabilities and increasing inequality stemming from Raul Castro’s 2009 economic reforms, and the island’s struggle to address its precarious housing stock to highlight the severe difficulties sheltering in place posed for the most vulnerable: elderly Cubans living without family support. The COVID-19 pandemic crisis has underscored the multiple forms infrastructure—including pipes, energy grids, and social networks—takes on the island, and the implications infrastructural strain and weakness have for maintenance of the socialist state and its continued provision of universal health care, housing, and nutrition.

BackgroundPrimary care providers (PCPs) are critical to the provision of comprehensive care for cancer survivors, yet there is very little data on the practices and quality of survivorship care occurring in safety net primary care settings. This study aimed to assess the knowledge and attitudes of PCPs and preferences for care models for breast and colon cancer survivors in a safety net health network.MethodsA modified National Cancer Institute Survey of Physician Attitudes Regarding the Care of Cancer Survivors was sent electronically to 220 PCPs in 12 primary care clinics in the San Francisco Health Network affiliated with Zuckerberg San Francisco General Hospital and Trauma Center.ResultsThe response rate was 50% (110/220). About half of PCPs strongly/somewhat agreed (vs. strongly/somewhat disagreed) that PCPs have the knowledge needed to provide follow-up care related to breast (50%) and colon cancer (54%). Most providers (93%) correctly reported recommended frequency of mammography, however, frequency of blood tests and other imaging surveillance were not as well recognized for breast or colon cancer. Recognition of long-term side effects of chemotherapy drugs ranged from 12% for oxaliplatin to 44% for doxorubicin. Only 33% of providers reported receiving any survivorship training. The most preferred model for survivorship care was shared care model (40%).ConclusionsSafety net PCPs prefer a shared care model for care of cancer survivors but are limited by lack of training, poor communication, and poor delineation of roles. Patient-centered survivorship care can be improved through effective oncologist-PCP-patient partnerships and coordination.

BACKGROUND: Immigrants tend to live in areas with higher co-ethnic density, and the effect of neighborhood ethnic composition could be particularly salient for health. This study explored associations between neighborhood ethnic composition and self-rated health among Asian immigrants. METHODS: We analyzed data collected at baseline from 670 Chinese and Vietnamese immigrants enrolled in a lifestyle intervention trial. Residential addresses were geocoded and combined with neighborhood socio-demographic profiles based on census data. We used generalized linear mixed models to examine neighborhood ethnic composition and self-rated health. RESULTS: Independent of individual-level factors, living in neighborhoods more densely populated by whites was associated with poor/fair self-rated health. Neighborhood household income and density of participants’ own ethnic group were not associated with poor/fair self-rated health. DISCUSSION: More research is warranted to disentangle reasons why Asian immigrants living in white-concentrated neighborhoods reported poorer self-rated health, including investigating effects of discrimination, relative deprivation, and availability of social resources.

Numerous studies have assessed individual-level factors associated with intention to quit smoking. However, fewer studies have assessed how neighborhood and built environment also contribute towards individual-level behavior. We used baseline data of 340 Chinese and Vietnamese male daily smokers from August 2015 to November 2017 living in the San Francisco Bay Area, who enrolled in a lifestyle intervention trial. The outcome variable was intention to quit in 30days. To understand the role of contextual factors participants' residential addresses were geocoded, and neighborhood median income, ethnic composition, and tobacco retail density were computed. Individual level analysis suggested that Vietnamese American men had greater intention to quit smoking (OR=2.90 CI=1.59, 5.26) in comparison to Chinese Americans. However, after adding neighborhood level factors to the model, no ethnic group difference was observed. Neighborhood household median income (OR=0.74, CI=0.64, 0.86) and tobacco retail counts (OR=0.79, CI=0.67, 0.94) were negatively associated with intention to quit. Years lived in the U.S. was the only individual level factor associated with intention to quit. By comparing two Asian American groups that live in heterogeneous neighborhoods, we identify key environmental and policy drivers that are associated with quit intention. Future studies aimed at influencing individual-level behavior should take into consideration the neighborhood context and built environment characteristics.

Summary Prior studies have supported the effectiveness of the use of Lay Health Workers (LHWs) as an intervention model for managing chronic health conditions, yet few have documented the mechanisms that underlie the effectiveness of the interventions. This study provides a first look into how LHWs delivered a family-based intervention and the challenges encountered. We utilize observation data from LHW-led educational sessions delivered as part of a randomized controlled trial (RCT) designed to test a LHW outreach family-based intervention to promote smoking cessation among Vietnamese American smokers. The RCT included experimental (smoking cessation) and control (healthy living) arms. Vietnamese LHWs were trained to provide health information in Vietnamese to groups of family dyads (smoker and family member). Bilingual, bicultural research team members conducted unobtrusive observations in a subset of LHW educational sessions and described the setting, process and activities in structured fieldnotes. Two team members coded each fieldnote following a grounded theory approach. We utilized Atlas.ti qualitative software to organize coding and facilitate combined analysis. Findings offer a detailed look at the ‘black box’ of how LHWs work with their participants to deliver health messages. LHWs utilized multiple relational strategies, including preparing an environment that enables relationship building, using recognized teaching methods to engage learners and co-learners as well as using humor and employing culturally specific strategies such as hierarchical forms of address to create trust. Future research will assess the effectiveness of LHW techniques, thus enhancing the potential of LHW interventions to promote health among underserved populations.

Hospitals throughout the United States are implementing new forms of care delivery meant to address social needs for structurally vulnerable patients as a strategy to prevent emergency department visits and hospitalizations and to thereby reduce costs. This article examines how the deployment of social assistance within a neoliberal institutional logic involves the negotiation and alignment of economistic values with ethics of care. We focus on care practices meant to stabilize the socioeconomic conditions of the most expensive patients in the health care system-the "super-utilizers"-through the provisioning of basic resources such as housing, food, transportation, and social support. These patients typically suffer from multiple chronic illnesses accompanied by conditions of poverty, housing and food insecurity, exposure to violence and trauma, and associated substance use and mental health problems. We offer an account of how practices of social assistance are being forged within contexts defined by neoliberal governance.

Background: Nipple-areola tattoos can provide restoration of a natural looking breast that more closely resembles its pre-surgical appearance while avoiding additional surgeries. To date, the majority of nipple-areola tattoo procedures are performed by healthcare providers with minimal training in tattoo procedures. Substandard results explain the high rates of dissatisfaction among women who receive nipple-areola tattoos. In response, professional tattoo artists have emerged as an alternative provider for women seeking reconstruction. However, few studies have examined expectations and experiences of women undergoing nipple-areola tattoo procedures provided by a professional tattoo artist outside of the traditional healthcare setting. Methods: In-depth interviews were conducted with a racially/ethnically diverse group of 30 women who had undergone nipple-areola tattooing in the past 0-2 years. Interviews were conducted in English, Spanish, Chinese, and Arabic, recorded, and translated and transcribed into English for analysis. A team of three researchers conducted iterative reviews of the data which included closely reading each transcript, coding, running queries of codes, and developing summary documents to highlight recurrent concepts and patterns which were shared and discussed in group meetings. Results: Interview narratives addressed the often unexpected impact nipple-areola tattooing had on body image, self-esteem, emotional well-being, and interpersonal relationships. Women described their decision-making processes as weighing concern about the needle, the pain, and uncertainty about the tattoo artist, setting for the procedure, and outcome with the opportunity to return to a more “normal” appearance without further surgeries. Women discussed how their initial preconceptions of tattoos and tattoo parlors were ameliorated by the spa-like setting and the tattoo artist's anticipation of such concerns which enhanced her ability to put them at ease and provide professional and compassionate care. Participants noted the integral role the tattoo artist played in their positive experiences, describing her as both an “artist” and “caregiver.” The manner in which she guided them through the decision-making process regarding the color, size, shape, and placement of their nipple-areola tattoo was noted as particularly significant and empowering. Conclusions: Nipple-areola tattooing is an acceptable and meaningful reconstruction process for medically underserved public hospital patients. Our results indicate that women should be informed of nipple-areola tattooing as an alternative to more invasive, surgical reconstruction options. Results also illustrate how the healthcare system can extend beyond the traditional healthcare setting to include and leverage non-clinical and non-traditional specialists to provide appropriate care and positive breast health outcomes for women. In order to increase access and legitimacy to these services, additional research is needed to understand how to bring tattoo artists “in-house” (i.e., into the medical setting) and how to incorporate tattoo artists into breast health teams. Citation Format: Napoles TM, Guerra C, Orenstein F, Luce JA, Merritt S, Burke NJ. Healing art: Breast cancer survivor experiences with nipple-areola tattoo procedures during breast reconstruction [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-12-19.

Background: Underserved breast cancer survivors are typically offered fewer opportunities to participate in cancer research. To address this disparity, a community based navigator program, Shanti's Margot Murphy Breast Cancer Program (Shanti) initiated a collaboration with UCSF researchers and BreastCancerTrials.org (BCT), a nonprofit clinical trials matching service to explore the potential role of a trusted community-based organization as a source of culturally appropriate education and access to clinical trial information. Through formative research, we developed the Health Research Engagement Intervention (HREI), a one-on-one navigator-client education session emphasizing the range of treatment and non-treatment quality-of-life and observational studies, conducted at a time when the participant is not in the initial crisis of diagnosis. The HREI ends by providing participants with an information card listing BCT and other organizations that provide information about health research for breast cancer patients and survivors. Methods: We tested the HREI in a randomized controlled trial, comparing the HREI to simply providing the information card. Pre and post intervention surveys one month apart measured our primary outcome of health research information-seeking behavior. Secondary outcomes include health research knowledge, attitudes towards research participation, and health empowerment. All Shanti clients who spoke English, Cantonese or Spanish and had “low care navigation needs” (either completed treatment or no longer in the crisis of initial diagnosis and/or burdened by treatment protocols) were eligible. Results: We recruited 133 Shanti Clients, including 59 who spoke English, 48 Cantonese, and 26 Spanish; 66 were randomized to the intervention arm and 67 to the control arm, and 130 completed both pre- and post-test surveys. Almost one-third of participants in both the intervention and control arms reported having talked to someone about health research or having called a telephone number or visited a website listed on the card (30% vs. 30%, p=0.94); a smaller proportion of participants confirmed that their information-seeking was related to the content of the educational materials (17% vs. 9%, p=0.22). On average the change from pre- to post-test in a 5-item knowledge score, adjusted for pre-test knowledge, was greater in the intervention group than in the control group (p=0.028), but the proportion of participants who were very confident that they could find health research information (had health empowerment) remained essentially unchanged in both study arms (intervention: 20% post vs. 21% pre, p=0.76; control: 25% post vs. 25% pre, p=1.00). Women were more likely to seek information if they had higher pre-test knowledge scores (odds ratio [OR]=3.5 per item, 95% confidence interval [CI] 1.5-8.4) or a greater increase in knowledge from pre- to post-test (OR=2.2 per item, 95% CI 1.1-4.7); there was no association between information-seeking and health empowerment (OR=0.6, 95% CI 0.2-2.5) or study arm (OR=1.6, 95% CI 0.5-4.9). Conclusion: The HREI had a positive impact on knowledge of health research but did not significantly affect health empowerment or health research information-seeking behavior. Citation Format: Joseph G, Nickell A, Cohen E, Burke NJ, Colen S, Lawlor K, Guerra C, Stewart SL. Engaging linguistically and ethnically diverse low income women in health research: A randomized controlled trial [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-05.

This article explores the complicated and often-contradictory notions of choice at play in complex care management (CCM) programmes in the US healthcare safety net. Drawing from longitudinal data collected over two years of ethnographic fieldwork at urban safety-net clinics, our study examines the CCM goal of transforming frequent emergency department (ED) utilisers into 'active' patients who will reduce their service utilisation and thereby contribute to a more rational, cost-effective healthcare system. By considering our data alongside philosopher Annemarie Mol's (2008) conceptualisation of the competing logics of choice and care, we argue that these premises often undermine CCM teams' efforts to support patients and provide the care they need - not only to prevent medical crises, but to overcome socio-economic barriers as well. We assert that while safety-net CCM programmes are held accountable for the degree to which their patients successfully transform into self-managing, cost-effective actors, much of the care CCM staff provide in fact involves attempts to intervene on structural obstacles that impinge on patient choice. CCM programmes thus struggle between an economic imperative to get patients to make better health choices and a moral imperative to provide care in the face of systemic societal neglect. (A virtual abstract of this paper can be viewed at: https://www.youtube.com/channel/UC_979cmCmR9rLrKuD7z0ycA).

Objectives Early-phase clinical trials play a pivotal role in drug development. However, limited data are available on outcomes of gastrointestinal (GI) cancer patients enrolled in phase I clinical trials. Here, we evaluated the characteristics associated with survival in GI cancer patients participating in phase I clinical trials and attempted to validate previously established prognostic models. Materials and methods All consecutive patients with advanced GI tumors who participated in phase I clinical trials at our institution from January 2007 to December 2013 and received at least 1 dose of the study drug were included. Cox regression models were used to estimate multivariable-adjusted hazard ratio (HR) and 95% confidence interval. Results In 243 study patients (median age, 62 y [range, 26 to 82 y]; 55% male), treatment included chemotherapy only (14%), targeted therapy (41%), chemotherapy+targeted therapy (42%), and others (2%) for the following disease types: pancreatic (42%), colorectal (34%), gastroesophageal (10%), hepatobiliary (13%), and others (2%). Response rate was 4%, with 38% achieving stable disease and 42% having progressive disease. Median survival was 5.8 months (range, 0.2 to 52.4 mo). Our multivariable Cox regression analyses included the following as predictors of survival: Eastern Cooperative Oncology Group performance score ≥1 (HR=1.76), prior systemic therapies ≥2 (HR=1.63), lactate dehydrogenase >618 IU/L (HR=1.85), sodium >135 mmol/L (HR=0.46), and white blood count >6×10/L (HR=1.5). Our data set was consistent with previous prognostic scores. Conclusions This is the largest study to assess clinical outcomes in this patient population. Phase I trials provide clinical benefit to patients with advanced GI malignancies and should be recommended as a treatment option in appropriate patients.

Objective To explore 1) attitudes and priorities among physicians and patients that inform shared decision-making about lung cancer screening in real-world settings and 2) physician and patient perceptions of shared decision-making in real-world lung cancer screening (LCS) practice. Materials and methods We conducted a qualitative study of 12 physicians and 30 patients meeting LCS screening criteria established by the US Preventative Services Task Force (USPSTF) from two academic primary care practices; one university clinic and one safety net clinic. Interview guides focused on knowledge and attitudes about LCS and experiences with patient-physician communication. Results Physicians offered LCS inconsistently and were ambivalent about screening because of potential harms, including false positive results, incidental findings, and radiation exposure. Physicians felt that they were incorporating shared decision-making into screening, although they acknowledged that challenges with screening communication posed barriers to shared decision-making. Patients were generally accepting of lung cancer screening. They expressed fewer concerns about screening-related harms but more personal or emotional concerns related to lung cancer. Patients perceived limited shared decision-making in their encounters, but were generally satisfied with the more physician-directed decision-making process. Conclusion Physicians and patients expressed different concerns about LCS and different perceptions about the use of shared decision-making. Findings from this real-world population of screening-eligible patients can be used to inform the design of future interventions to facilitate communication and decision-making tailored to perspectives of both physicians and patients.

Objective Evaluate a community-based navigator intervention to increase breast cancer patients’ and survivors’ access to information about health research participation opportunities. Methods In the context of a Community Based Participatory Research collaboration, we conducted a prospective randomized controlled trial of the Health Research Engagement Intervention with pre- and post-intervention surveys (n = 133). The primary outcome was health research information-seeking behavior. Secondary outcomes were health research knowledge, willingness to participate in health research, and health empowerment. Qualitative interviews (n = 11) elucidated participant perspectives on the intervention. Results There was no statistically significant difference between intervention and control groups’ information-seeking behavior. Knowledge that not all health research studies are about drugs or treatments increased significantly from pre- to post-test among intervention group participants (32% to 48%, p = 0.012), but not in the control group (43% to 30%, p = 0.059); the difference between arms was statistically significant (p = 0.0012). Although survey responses indicated willingness to participate, qualitative interviews identified competing priorities that limited participants’ motivation to seek enrollment information. Conclusions and Practice Implications Community-based navigators are a trusted, and therefore promising link between health research and low-income underserved communities. However, systemic barriers in health research infrastructures need to be addressed to include low income, LEP and immigrant populations.

A survey was conducted to assess the pesticide knowledge, attitudes, and practices of small-scale Hmong farmers in the Fresno area of the San Joaquin Valley of California. Hmong farmers in this region were found to cultivate 35 crops, most of which were Asian specialty crops with economic significance. The majority of farmers used pesticides on their farms, primarily to control diseases and insects. Long beans and sweet peas were perceived to require more pesticides than other crops. Participants were aware of pesticide-related health risks, yet 71% had no formal education. Most participants used proper personal protection equipment (PPE) and followed safe application practices, yet 84% reported that they wear work clothing from the farm into their home, which could contribute to the take home pesticide exposure pathway. Seventy-five percent of participants were not familiar with the concept of integrated pest management (IPM) as a formal pest management practice; however, many participants were using some components of IPM such as crop rotation. Nearly all participants (96%) requested more pesticide safety training be made available in Hmong. This study contributes to the understanding of potential pesticide exposure and health risks of Hmong farmers in the San Joaquin Valley of California, and the need for additional pest management training for the community.

Culture is essential for humans to exist. Yet surprisingly little attention has been paid to identifying how culture works or developing standards to guide the application of this concept in health research. This paper describes a multidisciplinary effort to find consensus on essential elements of a definition of culture to guide researchers in studying how cultural processes influence health and health behaviors. We first highlight the lack of progress made in the health sciences to explain differences between population groups, and then identify 10 key barriers in research impeding progress in more effectively and rapidly realizing equity in health outcomes. Second, we highlight the primarily mono-cultural lens through which health behavior is currently conceptualized, third, we present a consensus definition of culture as an integrating framework, and last, we provide guidelines to more effectively operationalize the concept of culture for health research. We hope this effort will be useful to researchers, reviewers, and funders alike.

Background: The benefits of 3D nipple tattooing include restoration of a natural looking breast as well as the avoidance of additional surgeries to create a breast that more closely resembles its pre-surgical appearance. 3D nipple tattooing forms part of completion of the physical reconstruction process, offers women opportunity for a greater sense of closure around the loss of their breast, and plays an important role in helping a woman feel "whole again" physically, sexually and emotionally. The project's aim was to evaluate the experience of 3D-nipple/areola tattooing for medically underserved women who have undergone breast reconstruction and remain without a nipple or areola. Methods: In-depth interviews were conducted with 20 women who had undergone 3D-nipple/areola tattooing. Interviews were conducted in English and Spanish, recorded, translated and transcribed into English for analysis. Two research team members coded all interview transcripts and the research team met monthly to discuss emergent themes. Results: Interview narratives addressed the often unexpected impact 3D nipple-tattooing had on body image, self-esteem, emotional well-being, intimacy, and inter-personal relationships. Women described their decision-making processes as weighing concern about the needle, the pain, and the uncertainty of the outcome with the opportunity for returning to a more 'normal' appearance. Women also discussed the impact of the experience on their survivorship and sexuality in positive ways. Conclusions: 3-D nipple and/or areola tattooing is an acceptable and meaningful reconstruction process for medically underserved public hospital patients. The decision to undergo 3-D nipple and /or areola tattooing can be complex and is impacted by a women's surgical history and outcomes. The emotional response and positive impacts of the tattooing on body image and self-esteem illustrate the value of the procedure in the context of women's lives. Citation Format: Burke NJ, Orenstein F, Napoles T, Chaumette S, Luce J. Assessing the impact of post-surgery areola repigmentation and 3-dimensional nipple tattoo procedures on body image and quality of life among medically underserved breast cancer survivors. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-11.

Introduction Smoking prevalence remains high among Asian American immigrant men, particularly those with limited English proficiency. Understanding ways to promote serious quit attempts (defined as a quit attempt lasting at least 24 h) could be crucial for reducing tobacco-related health disparities in this population. This study examines correlates of serious past year quit attempts among Chinese and Vietnamese American male daily smokers. Methods Baseline survey data were collected between 2015 and 2017 from a lifestyle intervention trial (N = 340 Chinese and Vietnamese male daily smokers). Data analysis was conducted in 2019. Multivariable logistic regression analysis was used to identify factors associated with serious past year quit attempts. Results Less than half (43.2%) of the study participants had at least one serious past year quit attempt. Significant correlates of serious quit attempts included utilizing evidence-based methods (OR = 12.83, 95% CI 5.17–31.84) or other methods (OR = 3.92, 95% CI 3.92–13.73) to facilitate quitting compared to those who did not attempt to quit. Also, participants who had a physician encounter in the past year were more likely to have had a serious quit attempt (OR = 2.25, 95% CI 1.12–4.53). Discussing smoking during a past year doctor's visit, however, was not a significant correlate of serious quit attempts. Conclusions Our findings underscore the importance of promoting the use of smoking cessation resources, and potentially utilizing healthcare encounters to facilitate cessation. Investigations are warranted to understand better how patient-physician interactions can enhance smoking cessation.

Our paper explores how legal status stratification shapes the health and health care of low-income patients with chronic illnesses in the U.S. healthcare safety net. Drawing on data from over two years of ethnographic fieldwork at urban safety-net clinics, we examine efforts by Complex Care Management (CCM) teams to stabilize patients with uncontrolled chronic illnesses through primary care-integrated support. We show that stratified citizenship and geographic variability correspond to different possibilities for health care. We suggest an approach to immigration as a structural determinant of health that accounts for the complex, stratified, and changing nature of citizenship status. We also highlight how geographical differences and interactions among local, state, and federal policies support the notion that citizenship is stratified across multiple tiers with distinctive possibilities and constraints for health. While county-based health plans at each of the study sites include residents with varying legal status, lack of formal legal status remains a substantial obstacle to care. Many immigrants are unable to take full advantage of primary and specialty care, resulting in unnecessary morbidity and mortality. In some cases, patients have returned to their country of origin to die. While CCM teams provide an impressive level of support to assist immigrant patients in navigating healthcare and immigration bureaucracies, legal and geographic stratification limit their ability to address broader aspects of these patients’ social context.

This study's purpose was to explore how content and format of children's oral health instruction in the dental clinic is perceived by parents and might affect parents' knowledge and behaviors.Thirty low-income Mexican immigrant parents of children age five years and under were recruited from dental clinics in 2015 to 2016. In-person qualitative interviews in Spanish about their children's and their own experiences of dental care and home oral hygiene practices were conducted, digitally recorded, translated, and transcribed. Data analysis involved iteratively reading text data and developing and refining codes to find common themes.Twenty-five of 30 parents recalled receiving oral hygiene instruction, and 18 recalled receiving nutrition instruction and were included in analyses. The format and effectiveness of instruction varied. More engaging educational approaches were recalled and described in more detail than less engaging educational approaches. As a result of oral hygiene and nutritional instruction, most parents reported changing their oral hygiene home behaviors for their children; half aimed to reduce purchasing sugary foods and drinks.Most parents recalled receiving oral hygiene and nutrition instruction as part of their child's dental visit and reported incorporating the instruction and recommendations they received into their children's home routine.

The goal of this project was to explore family communication dynamics and their implications for smoking cessation. We conducted 39 in-depth dyadic and individual qualitative interviews with 13 immigrant smoker–family member pairs of Vietnamese ( n = 9 dyads, 18 individuals) and Chinese ( n = 4 dyads, 8 individuals) descent, including seven current and six former smokers and 13 family members. All 13 dyadic and 26 individual interviews were analyzed using a collaborative crystallization process as well as grounded theory methods. We identified three interrelated pathways by which tobacco use in immigrant Vietnamese and Chinese families impacts family processes and communication dynamics. Using a two-dimensional model, we illustrate how the shared consequences of these pathways can contribute to a dynamic of avoidance and noncommunication, resulting in individual family members “suffering in silence” and ultimately smoking being reinforced. We discuss the implications of these findings for development of smoking cessation interventions.

This consultation about the ethics of offering a clinical trial to an undocumented and uninsured immigrant with a diagnosis of myelofibrosis raises two primary questions. One is posed by the case p...

In this paper, we delineate how staff of two complex care management (CCM) programs in urban safety net hospitals in the United States understand trauma. We seek to (1) describe how staff in CCM programs talk about trauma in their patients' lives; (2) discuss how trauma concepts allow staff to understand patients’ symptoms, health-related behaviors, and responses to care as results of structural conditions; and (3) delineate the mismatch between long-term needs of patients with histories of trauma and the short-term interventions that CCM programs provide. Observation and interview data gathered between February 2015 and August 2016 indicate that CCM providers define trauma expansively to include individual experiences of violence such as childhood abuse and neglect or recent assault, traumatization in the course of accessing health care and structural violence. Though CCM staff implement elements of trauma-informed care, the short-term design of CCM programs puts pressure on the staff to titrate their efforts, moving patients towards graduation or discharge. Trauma concepts enable clinicians to name structural violence in clinically legitimate language. As such, trauma-informed care and structural competency approaches can complement each other.

We sought to examine the literature using the Patient Activation Measure (PAM) or the Patient Enablement Instrument (PEI) with high-need, high-cost (HNHC) patients receiving care in urban safety net settings. Urban safety net care management programs serve low-income, racially/ethnically diverse patients living with multiple chronic conditions. Although many care management programs track patient progress with the PAM or the PEI, it is not clear whether the PAM or the PEI is an effective and appropriate tool for HNHC patients receiving care in urban safety net settings in the United States. We searched PubMed, EMBASE, Web of Science, and PsycINFO for articles published between 2004 and 2015 that used the PAM and between 1998 and 2015 that used the PEI. The search was limited to English-language articles conducted in the United States and published in peer-reviewed journals. To assess the utility of the PAM and the PEI in urban safety net care settings, we defined a HNHC patient sample as racially/ethnically diverse, low socioeconomic status (SES), and multimorbid. One hundred fourteen articles used the PAM. All articles using the PEI were conducted outside the U.S. and therefore were excluded. Nine PAM studies (8%) included participants similar to those receiving care in urban safety net settings, three of which were longitudinal. Two of the three longitudinal studies reported positive changes following interventions. Our results indicate that research on patient activation is not commonly conducted on racially and ethnically diverse, low SES, and multimorbid patients; therefore, there are few opportunities to assess the appropriateness of the PAM in such populations. Investigators expressed concerns with the potential unreliability and inappropriate nature of the PAM on multimorbid, older, and low-literacy patients. Thus, the PAM may not be able to accurately assess patient progress among HNHC patients receiving care in urban safety net settings. Assessing progress in the urban safety net care setting requires measures that account for the social and structural challenges and competing demands of HNHC patients.

Introduction Low-income, chronically ill adults disproportionately experience poor health outcomes despite increased health care use and costs. Complex care management (CCM) programs are an innovative approach to improving outcomes for these patients, but little is known about the patients' experiences in CCM programs in safety net primary care settings. Method The authors conducted semistructured interviews with 13 CCM participants in a safety net primary care clinic to explore their perceptions of their health and their experiences with CCM. Interviews were recorded, transcribed, independently coded, and analyzed through an iterative process using grounded theory methodology to identify themes in the participants' experiences. Results From our interviews, 3 themes emerged-(a) participants mourned the loss of physical function and social well-being as a result of poor health; (b) participants reported increased health-related motivation due to relationships with the care team; and (c) participants experienced a newfound sense of control as a result of improved care navigation and self-management. Discussion Complex care management improved health-related motivation and provided a renewed sense of control for study participants, who were experiencing the loss of physical function and social well-being due to their chronic diseases. These findings support the importance of relationship-centered care models in programs for low-income, chronically ill patients. Future research should focus on identifying and spreading best practices that effectively empower patients to feel more in control of their health. (PsycINFO Database Record

San Francisco Bay Area Filipinas with breast cancer underutilize support services. Our partnership engaged in community-based participatory research (CBPR) that involved formation of a community advisory board (CAB) representing low-income, low-English-proficient Filipinas with breast cancer. While CABs are a standard component of CBPR projects, the process of establishing and fostering CAB involvement has been under studied. This commentary explores the process our team used—building upon the Filipino cultural method of pakikisama which stresses making the other feel welcome, safe, and nurtured—to overcome barriers to active engagement. Challenges included minimizing power imbalances between the research team and CAB, and the establishment of an environment of familiarity, trust and caring among CAB members. We recorded all CAB meetings, transcribed them verbatim, and Tagalog portions were transcribed into English for analysis. Mobilizing pakikisama supported partnership building and allowed CAB members to engage in inclusive dialogue and formulate a culturally relevant support model. (Global Health Promotion, 2014; 21(1): 68-72).

Between 1988 and 1995, the first randomized controlled trial (RCT) of breast self-exam (BSE) was conducted in Shanghai, China. Subsequent policy recommendations transformed the landscape of breast cancer screening in North America as practice guidelines shifted from "BSE" toward "breast awareness." Critiques of the study raised issues of race, regionalism, and difference. I turn to Margaret Lock's concept "local biology" to tease out the complexities of these arguments, and expand upon it to consider the impact of local ecologies of screening on receipt and implementation of international behavioral clinical trial results. The case study of the Shanghai trial illuminates conflicts and controversies around what constitutes evidence in breast cancer prevention research, and for whom. [Keywords: Clinical trials, biomedicalization, breast cancer screening, China]Foreign Language Translations:Local Biologies and Ecologies of Screening: Tracing the Aftereffects of the "Shanghai Study"[Keywords: Clinical trials, biomedicalization, breast cancer screening, China]Biologias Locais e Ecologias de Rastreamento: Tracando as Sequelas do "Estudo de Xangai"[Palavras-chave: Ensaios clinicos, biomedicalizacao, rastreio do cancro da mama, China]...Local Biologies and Ecologies of Screening: Tracing the Aftereffects of the "Shanghai Study"...(ProQuest: ... denotes non-US-ASCII text omitted.)In 1993, the National Institutes of Health (NIH) passed the NIH Inclusion Act, designed to address the overwhelming reliance on white middle class men for pharmaceutical drug development by requiring the inclusion of women and ethnic minorities in all NIH-funded studies. Since then, a proliferation of research into the how, why, and why not of clinical trial participation and recruitment has led to what Steven Epstein (2008, 2009) has characterized as a new field of study-recruitment science or recruitmentology. Interest in the mechanics and mechanisms of research participation has produced a plethora of studies reporting ethnically-defined differences in attitudes toward research-including barriers such as historically-based mistrust in the healthcare system, fears of experimentation, and "mis"understandings of scientific methods such as randomization (Ford et al. 2005; Christian and Trimble 2003; Corbie-Smith, Miller, and Ransohoff2004; Cox and McGarry 2003; Noah 2003; Yancey, Ortega, and Kumanyika 2006). While this interest in the "representativeness"-in terms of ethnicity and race-of research participants is largely focused on pharmaceutical treatment trials, the underlying logic of inclusion and difference (Epstein 2009) informs responses to health behavior trials as well. This article traces responses to one such randomized controlled trial (RCT) of breast self-exam (BSE)-the largest of its kind, conducted between 1988 and 1995 in Shanghai, China-and to the policy recommendations which followed reporting of the study findings.Medical anthropologists have ethnographically explored the globalization and localization of pharmaceutical clinical trials, detailing ethical variability in the conduct of research (Petryna 2005, 2007b, 2009), professionalization of research participation (Abadie 2010, Fisher 2009), and the pharmaceuticalization of public health through trial access (Petryna 2007a; Biehl 2007, 2009). Recently, Fisher questioned the assumed and often touted low participation of ethnic minorities in clinical trials, showing instead that Black and Latino men make up the majority of participants in Phase I trials recruiting healthy volunteers, some of the riskiest trials available (Fisher and Kalbaugh 2011). This research points to the importance of differentiations between and attention to the particulars of trials (e.g., participating in a Phase I trial of a new chemotherapy agent is very different in terms of risk than participation in a Phase III study comparing two different forms of anti-depressants). …

Cambodian Americans have high rates of chronic hepatitis B virus (HBV) infection. However, only about one-half of Cambodian Americans have been serologically tested for HBV. We conducted a randomized controlled trial to evaluate the impact of a lay health worker (LHW) intervention on HBV testing and knowledge levels among Cambodian Americans. The study group included 250 individuals who participated in a community based survey in metropolitan Seattle and had not been tested for HBV. Experimental group participants received a LHW intervention addressing HBV and control group participants received a LHW intervention addressing physical activity. Trial participants completed a follow-up survey 6 months after randomization. Over four-fifths (82 %) of randomized individuals participated in a LHW home visit and the follow-up survey response rate was 80 %. Among participants with follow-up data, 22 % of the experimental group and 3 % of the control group reported HBV testing (p < 0.001). The experimental and control group testing difference remained significant in an intent-to-treat analysis. The experimental group was significantly more likely than the control group to know that Cambodians have higher rates of HBV infection than whites, HBV cannot be spread by eating food prepared by an infected person, HBV cannot be spread by sharing chopsticks, and HBV cannot be spread by shaking hands. Our findings indicate LHW interventions are acceptable to Cambodian Americans and can positively impact both HBV testing and knowledge levels.

Increasing "patient engagement" has become a priority for health care organizations and policy-makers seeking to reduce cost and improve the quality of care. While concepts of patient engagement have proliferated rapidly across health care settings, little is known about how health care providers make use of these concepts in clinical practice. This paper uses 20 months of ethnographic and interview research carried out from 2015 to 2016 to explore how health care providers working at two public, urban, safety-net hospitals in the United States define, discuss, and assess patient engagement. We investigate how health care providers describe engagement for high cost patients-the "super-utilizers" of the health care system-who often face complex challenges related to socioeconomic marginalization including poverty, housing insecurity, exposure to violence and trauma, cognitive and mental health issues, and substance use. The health care providers in our study faced institutional pressure to assess patient engagement and to direct care towards engaged patients. However, providers considered such assessments to be highly challenging and oftentimes inaccurate, particularly because they understood low patient engagement to be the result of difficult socioeconomic conditions. Providers tried to navigate the demand to assess patient engagement in care by looking for explicit positive and negative indicators of engagement, while also being sensitive to more subtle and intuitive signs of engagement for marginalized patients.