Intersectional analysis of inequalities in self-reported breast cancer screening attendance using supervised machine learning and PROGRESS-Plus framework

BackgroundBreast cancer is a critical public health concern in Spain, and organized screening programs have been in place since the 1990s to reduce its incidence. However, despite the bi-annual invitation for breast cancer screening (BCS) for women aged 45–69, significant attendance inequalities persist among different population groups. This study employs a quantitative intersectional perspective to identify intersectional positions at risk of not undergoing breast cancer screening in Spain.MethodsWomen were selected from the 2020 European Health Interview Survey in Spain, which surveyed the adult population (> 15 years old) living in private households (N = 22,072; 59% response rate). Inequality indicators based on the PROGRESS-Plus framework were used to disentangle existing social intersections. To identify intersectional groups, decision tree models, including classification and regression trees (CARTs), chi-squared automatic interaction detector (CHAID), conditional inference rees (CITs), and C5.0, along with an ensemble algorithm, extreme gradient boosting (XGBoost), were applied.ResultsXGBoost (AUC 78.8%) identified regional differences (Autonomous Community) as the most important factor for classifying BCS attendance, followed by education, age, and marital status. The C5.0 model (balanced accuracy 81.1%) highlighted that the relative importance of individual characteristics, such as education, marital status, or age, for attendance differs based on women’s place of residence and their degree of interaction. The highest risk of not attending BCS was observed among illiterate older women in lower social classes who were born in Spain, were residing in Asturias, Cantabria, Basque Country, Castile and León, Extremadura, Galicia, Madrid, Murcia, La Rioja, or Valencian Community, and were married, divorced, or widowed. Subsequently, the risk of not attending BCS extends to three other groups of women: women living in Ceuta and Melilla; single or legally separated women living in the rest of Spain; and women not born in Spain who were married, divorced, or widowed and not residing in Ceuta or Melilla.ConclusionThe combined use of decision trees and ensemble algorithms can be a valuable tool in identifying intersectional positions at a higher risk of not utilizing public resources and, thus, can aid substantially in developing targeted interventions to increase BCS attendance

Socioeconomic differences in animal food consumption: education rather than income makes a difference

BACKGROUND/AIMS: Evidence points toward more sustainable and health-conscious dietary behaviors among individuals with higher socioeconomic status. However, these differences vary considerably depending on which indicator of socioeconomic status is examined. Here, we present a systematic parallel investigation of multiple indicators of socioeconomic status as predictors of animal food consumption frequency and selected food-related behaviors in Germany. METHODS: Data from the German subsample of two large representative European consumer studies (Study 1 n = 1,954; Study 2 n = 2,045) was used. We assessed the associations between the socioeconomic indicators income, current occupation as well as education and consumption frequency of animal foods and selected food-related behaviors in separate ordinal logistic regressions. RESULTS: Individuals with higher educational attainment engaged in more sustainable and health-conscious dietary behaviors, indicated by significant associations between educational attainment and the consumption frequency of animal foods. Low- and middle-income participants consumed processed meat more frequently (Study 1 only; medium income: OR 1.5, CI 1.09–2.05, p = 0.012; low income: OR 1.43, CI 1.01–2.05, p = 0.047) and fish less frequently (Study 2 only; medium income: OR 0.76, CI 0.59–0.97, p = 0.026; low income: OR 0.061, CI 0.46–0.82, p < 0.001) than participants with high income. Current occupation did not predict the consumption of animal foods or food-related behaviors. Intake frequency of animal-based foods indicates that most participants exceeded national dietary recommendations for meat and processed meat and remained below recommendations for fish and dairy/eggs intake. CONCLUSION: Educational attainment appears to be the strongest and most consistent socioeconomic indicator of sustainable dietary choices in Germany based on current large, representative studies. Future efforts should be directed toward education interventions about nutrition and interpretation of food labels to compensate for differences in dietary behavior among groups with different levels of education

Individual differences in self-affirmation: distinguishing self-affirmation from positive self-regard

Research into self-affirmation has almost exclusively employed experimental manipulations. In this paper we address individual differences in the tendency to respond to threats with self-affirming cognitions and distinguish this from two overlapping constructs: habitual positive self-thought and trait self-esteem. Items we designed to measure self-affirmation were represented by three first-order factors and loaded on a higher-order factor, creating the Spontaneous Self-Affirmation Measure (SSAM). The SSAM correlated moderately with self-esteem and habitual positive self-thought. In competitive analyses, the SSAM was an independent predictor of a large number of outcomes. The studies provide evidence about the correlates of individual differences in reported spontaneous self-affirmation in response to threat and the contribution made to this response by habitual positive self-thought and trait self-esteem

Interventions to promote health literacy among working-age populations experiencing socioeconomic disadvantage: systematic review

BackgroundExperiencing financial insecurity and being underserved is often associated with low health literacy, i.e., the ability to identify, obtain, interpret and act upon health information, which may result in poor health outcomes. Little is known about effective interventions for promoting health literacy among underserved populations. The objective of this systematic review is to summarize the literature on such interventions and identify characteristics that differentiate more effective interventions.MethodsFollowing PRISMA guidelines we searched the databases SCOPUS, Pubmed, Web of Science core collection and CINAHL. We included primary studies with a quantitative study design and control groups testing interventions to increase health literacy or health knowledge in underserved populations between 18 and 65 years. Where possible, we converted effect sizes into Cohen’s d and compared mean differences of intervention and control groups. Albatross plots were created to summarize the results according to different health literacy and health knowledge outcomes.ResultsWe screened 3,696 titles and abstracts and 206 full texts. In total, 86 articles were analyzed, of which 55 were summarized in seven albatross plots. The majority of the studies (n = 55) were conducted in the United States and had a randomized controlled study design (n = 44). More effective intervention approaches assessed needs of participants through focus group discussions prior to conducting the intervention, used bilingual educational materials, and included professionals fluent in the first languages of the study population as intervention deliverers. Additionally, the use of educational materials in video and text form, fotonovelas and interactive group education sessions with role playing exercises were observed to be effective.DiscussionAlthough the outcomes addressed in the included studies were heterogeneous, effective intervention approaches were often culturally sensitive and developed tailored educational materials. Interventions aiming to promote health literacy in underserved populations should hence consider applying similar approaches.Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=323801, PROSPERO registration ID: CRD42022323801

Analysis of the Breast Cancer Journey in Namibia.

IMPORTANCE: Breast cancer (BC) is the leading cancer among women in Namibia. Examining the BC journey in this multiracial country where inequalities remain large is needed to inform effective interventions to reduce BC mortality. OBJECTIVE: To describe the entire BC journey of Namibian women by race, utilizing the World Health Organization Global Breast Cancer Initiative (GBCI) framework. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used the Namibian subset of the African Breast Cancer-Disparities in Outcomes prospective cohort. Participants were all Namibian residents with confirmed incident BC who presented at the main national public oncology center of the Windhoek Central Hospital (WCH). Follow-up started from recruitment (September 8, 2014, to October 5, 2016) and ended up to 3 years after diagnosis (December 13, 2014, to September 27, 2019). Data analysis was conducted from June 2022 to August 2023. EXPOSURES: Participants' self-reported ethnicities were aggregated into 3 population groups: Black, mixed ancestry, and White. MAIN OUTCOMES AND MEASURES: Three-year overall survival (OS) was examined using Cox models, and summary statistics were used to describe women's BC journey, including GBCI pillar key performance indicators: (1) early stage (TNM I or II) diagnosis (population benchmark ≥60%), (2) prompt diagnosis, ie, 60 days or less to first health care practitioner visit (population benchmark 100%), and (3) completion of recommended multimodal treatment (MT, ie, surgery plus chemotherapy) (population benchmark ≥80%). RESULTS: Of 405 women, there were 300 (74%) Black (mean [SD] age, 53 [15] years), 49 (12%) mixed ancestry (mean [SD] age, 53 [7] years), and 56 (14%) White (mean [SD] age, 59 [12] years) patients. Three-year OS was lowest in Black women (60% [95% CI, 54%-66%]; mixed ancestry: 80% [95% CI, 65%-89%]; White: 89% [95% CI, 77%-95%]), who had lower prevalence of early stage diagnosis (Black: 37% [95% CI, 31%-42%]; mixed ancestry and White: 75% [95% CI, 66%-83%]) and timely diagnosis (Black: 60% [95% CI, 54%-66%]; mixed ancestry and White: 77% [95% CI, 69%-85%]), while MT completion (Black: 53% [95% CI, 46%-59%]; mixed ancestry and White: 63% [95% CI, 50%-73%]) was low in all women. CONCLUSIONS AND RELEVANCE: In this cohort study of 405 Namibian residents with BC, marked racial disparities in survival were paralleled by inequities all along the BC journey. To improve BC survival, interventions are needed to promote earlier diagnosis in Black Namibian women and to increase MT initiation and completion in all women

Self-reported arm and shoulder problems in breast cancer survivors in Sub-Saharan Africa: the African Breast Cancer-Disparities in Outcomes cohort study

BACKGROUND: Arm and shoulder problems (ASP), including lymphedema, were common among women with breast cancer in high-income countries before sentinel lymph node biopsy became the standard of care. Although ASP impair quality of life, as they affect daily life activities, their frequency and determinants in Sub-Saharan Africa remain unclear. METHODS: All women newly diagnosed with breast cancer at the Namibian, Ugandan, Nigerian, and Zambian sites of the African Breast Cancer-Disparities in Outcomes (ABC-DO) cohort study were included. At each 3-month follow-up interview, women answered the EORTC-QLQ-Br23 questionnaire, including three ASP items: shoulder/arm pain, arm stiffness, and arm/hand swelling. We estimated the cumulative incidence of first self-reported ASP, overall and stratified by study and treatment status, with deaths treated as competing events. To identify determinants of ASP, we estimated cause-specific hazard ratios using Cox models stratified by study site. RESULTS: Among 1476 women, up to 4 years after diagnosis, 43% (95% CI 40-46), 36% (33-38) and 23% (20-25), respectively, self-reported having experienced arm/shoulder pain, stiffness and arm/hand swelling at least once. Although risks of self-reported ASP differed between sites, a more advanced breast cancer stage at diagnosis, having a lower socioeconomic position and receiving treatment increased the risk of reporting an ASP. CONCLUSION: ASP are very common in breast cancer survivors in Sub-Saharan Africa. They are influenced by different factors than those observed in high-income countries. There is a need to raise awareness and improve management of ASP within the African setting

Maternally Orphaned Children and Intergenerational Concerns Associated With Breast Cancer Deaths Among Women in Sub-Saharan Africa.

IMPORTANCE: Low breast cancer survival in sub-Saharan Africa's young population increases the likelihood that breast cancer deaths result in maternal orphans, ie, children (<18 years) losing their mother. OBJECTIVE: To estimate the number of maternal orphans and their ages for every 100 breast cancer deaths in sub-Saharan African settings during 2014-2019 and to describe family concerns about the orphaned children. DESIGN, SETTING, AND PARTICIPANTS: Deaths occurring between September 1, 2014, and July 1, 2019, in the African Breast Cancer-Disparities in Outcomes (ABC-DO) were examined in a cohort of women diagnosed with breast cancer during 2014-2017 at major cancer treatment hospitals in Namibia, Nigeria, Uganda, and Zambia. The cohort was actively followed up for vital status via a trimonthly mobile phone call to each woman or her next of kin (typically a partner, husband, or child). MAIN OUTCOMES AND MEASURES: The number (Poisson counts) and ages of new orphans at the time of maternal death. RESULTS: This cohort study found that a total of 795 deaths resulted in 964 new maternal orphans, with deaths occurring in women younger than 50 years accounting for 85% of the orphans. For every 100 deaths in women younger than 50 years, there were 210 new orphans (95% CI, 196-225) overall, with country-specific estimates of 189 in Nigerian, 180 in Namibian, 222 in Ugandan, and 247 in Zambian Black women. For every 100 deaths of the women at any age, there were 121 maternal orphans, 17% of whom were younger than 5 years, 32% aged 5 to 9 years, and 51% aged 10 to 17 years at the time of maternal death. In follow-up interviews, families' concerns for children's education and childcare were reported to be exacerbated by the financial expenses associated with cancer treatment. CONCLUSIONS AND RELEVANCE: This study provides evidence that the number of maternal orphans due to breast cancer exceeds the number of breast cancer deaths among women in sub-Saharan Africa. The intergenerational consequences associated with cancer deaths in sub-Saharan Africa appear to be large and support the need for continued action to improve survival

Geospatial barriers to healthcare access for breast cancer diagnosis in sub-Saharan African settings: The African Breast Cancer-Disparities in Outcomes Cohort Study.

We examined the geospatial dimension of delays to diagnosis of breast cancer in a prospective study of 1541 women newly diagnosed in the African Breast Cancer-Disparities in Outcomes (ABC-DO) Study. Women were recruited at cancer treatment facilities in Namibia, Nigeria, Uganda and Zambia. The baseline interview included information used to generate the geospatial features: urban/rural residence, travel mode to treatment facility and straight-line distances from home to first-care provider and to diagnostic/treatment facility, categorized into country/ethnicity (population)-specific quartiles. These factors were investigated in relation to delay in diagnosis (≥3 months since first symptom) and late stage at diagnosis (TNM: III, IV) using logistic regression, adjusted for population group and sociodemographic characteristics. The median (interquartile range) distances to first provider and diagnostic and treatment facilities were 5 (1-37), 17 (3-105) and 62 (5-289) km, respectively. The majority had a delay in diagnosis (74%) and diagnosis at late stage (64%). Distance to first provider was not associated with delay in diagnosis or late stage at diagnosis. Rural residence was associated with delay, but the association did not persist after adjustment for sociodemographic characteristics. Distance to the diagnostic/treatment facility was associated with delay (highest vs lowest quartile: odds ratio (OR) = 1.56, 95% confidence interval (CI) = 1.08-2.27) and late stage (overall: OR = 1.47, CI = 1.05-2.06; without Nigerian hospitals where mostly local residents were treated: OR = 1.73, CI = 1.18-2.54). These findings underscore the need for measures addressing the geospatial barriers to early diagnosis in sub-Saharan African settings, including providing transport or travel allowance and decentralizing diagnostic services

Preexisting morbidity profile of women newly diagnosed with breast cancer in sub-Saharan Africa: African Breast Cancer-Disparities in Outcomes study.

The presence of preexisting morbidities poses a challenge to cancer patient care. There is little information on the profile and prevalence of multi-morbidities in breast cancer patients across middle income countries (MIC) to lower income countries (LIC) in sub-Saharan Africa (SSA). The African Breast Cancer-Disparities in Outcomes (ABC-DO) breast cancer cohort spans upper MICs South Africa and Namibia, lower MICs Zambia and Nigeria and LIC Uganda. At cancer diagnosis, seven morbidities were assessed: obesity, hypertension, diabetes, asthma/chronic obstructive pulmonary disease, heart disease, tuberculosis and HIV. Logistic regression models were used to assess determinants of morbidities and the influence of morbidities on advanced stage (stage III/IV) breast cancer diagnosis. Among 2189 women, morbidity prevalence was the highest for obesity (35%, country-specific range 15-57%), hypertension (32%, 15-51%) and HIV (16%, 2-26%) then for diabetes (7%, 4%-10%), asthma (4%, 2%-10%), tuberculosis (4%, 0%-8%) and heart disease (3%, 1%-7%). Obesity and hypertension were more common in upper MICs and in higher socioeconomic groups. Overall, 27% of women had at least two preexisting morbidities. Older women were more likely to have obesity (odds ratio: 1.09 per 10 years, 95% CI 1.01-1.18), hypertension (1.98, 1.81-2.17), diabetes (1.51, 1.32-1.74) and heart disease (1.69, 1.37-2.09) and were less likely to be HIV positive (0.64, 0.58-0.71). Multi-morbidity was not associated with stage at diagnosis, with the exception of earlier stage in obese and hypertensive women. Breast cancer patients in higher income countries and higher social groups in SSA face the additional burden of preexisting non-communicable diseases, particularly obesity and hypertension, exacerbated by HIV in Southern/Eastern Africa

Disparities in breast cancer survival between women with and without HIV across sub-Saharan Africa (ABC-DO): a prospective, cohort study.

BACKGROUND: Studies have shown increased mortality among women living with HIV diagnosed with breast cancer compared with HIV-negative women with breast cancer. We aimed to examine how this HIV differential varies by patient or breast tumour characteristics. METHODS: The African Breast Cancer-Disparities in Outcomes (ABC-DO) study is a prospective cohort of women (aged ≥18 years) with incident breast cancer recruited consecutively at diagnosis (2014-17) from hospitals in Namibia, Nigeria, South Africa, Uganda, and Zambia. Detailed clinical and epidemiological data, including self-reported or tested HIV status, were collected at baseline. Participants were actively followed up via telephone calls every 3 months. The primary outcome was all-cause mortality, assessed in all women who had at least one updated vital status after baseline interview. Using Cox regression, we examined differences in overall survival by HIV status in the cohort, and across country and patient subgroups, adjusted for age, tumour grade, and tumour stage at cancer diagnosis. FINDINGS: Between Sept 8, 2014, and Dec 31, 2017, we recruited 2154 women with primary breast cancer, 519 of whom were excluded due to their countries having small numbers of women with HIV for comparison. Among the remaining 1635 women, 313 (19%) were living with HIV, 1184 (72%) were HIV negative, and 138 (9%) had unknown HIV status. At breast cancer diagnosis, women with HIV were younger and had lower body-mass index (BMI) than their HIV-negative counterparts, but had similar tumour stage, grade, and receptor subtypes. At the end of the follow-up (Jan 1, 2019), a higher proportion of women with HIV (137 [44%] of 313) had died than had HIV-negative women (432 [37%] of 1184). Crude 3-year survival was 9% lower for women with HIV (46% [95% CI 40-53]) than for HIV-negative women (55% [52-59]; hazard ratio (HR) 1·41 [1·15-1·74]). The HIV survival differential did not differ by age, BMI, tumour subtype, or tumour grade, but was stronger in women with non-metastatic disease (3-year survival 52% HIV-positive vs 63% HIV-negative women, adjusted HR 1·65 [1·30-2·10]), whereas women with metastatic cancer had low survival, regardless of HIV status. INTERPRETATION: The larger survival deficit among women with HIV with non-metastatic breast cancer calls for a better understanding of the reasons underlying this differential (eg, biological mechanisms, health behaviours, detrimental HIV-breast cancer treatment interactions, or higher HIV background mortality) to inform strategies for reducing mortality among this patient group. FUNDING: Susan G Komen, International Agency for Research on Cancer, National Cancer Institute, and UK-Commonwealth Scholarships