Purpose We report the validation of an instrument to measure mistrust of health care organizations and examine the relationship between mistrust and health care service underutilization. Methods We conducted a telephone survey of a random sample of households in Baltimore City, MD. We surveyed 401 persons and followed up with 327 persons (81.5 percent) 3 weeks after the baseline interview. We conducted tests of the validity and reliability of the Medical Mistrust Index (MMI) and then conducted multivariate modeling to examine the relationship between mistrust and five measures of underutilization of health services. Results Using principle components analysis, we reduced the 17-item MMI to 7 items with a single dimension. Test–retest reliability was moderately strong, ranging from Pearson correlation of 0.346–0.697. In multivariate modeling, the MMI was predictive of four of five measures of underutilization of health services: failure to take medical advice (b = 1.56, p<.01), failure to keep a follow-up appointment (b = 1.11, p = .01), postponing receiving needed care (b = 0.939, p = .01), and failure to fill a prescription (b = 1.48, p = .002). MMI was not significantly associated with failure to get needed medical care (b = 0.815, p = .06). Conclusions The MMI is a robust predictor of underutilization of health services. Greater attention should be devoted to building greater trust among patients.

Black women in the US have both a higher percentage of late-stage diagnoses as well as the highest rates of mortality from breast cancer when compared to women of other ethnic subgroups. Additionally, Black women have the second highest prevalence of cervical cancer. Many reports evaluating the cancer outcomes of Black women combine data on African born immigrants and US born Blacks. This categorization ignores subtle yet important cultural differences between the two groups, which may ultimately affect breast and cervical cancer screening practices. Therefore, this study investigated knowledge and awareness levels of breast and cervical cancer screening practices among female African born immigrants to the US residing in the Washington D.C. metropolitan area. Data were collected from 38 participants through key informant interviews, focus group sessions and a socio-demographic questionnaire over a three-month study period. Results suggest that fatalism, stigma and privacy are among the major factors that affect the decision to seek preventative screening measures for breast and cervical cancer among this population. Additionally, the study implies that cervical cancer awareness is significantly lower among this population when compared to breast cancer. This study highlights differences between women of African descent residing in the US and the need for continued research to increase understanding of the manner in which immigrant status affects health-seeking behavior. This information is critical for researchers, physicians and public health educators aiming to design culturally appropriate interventions to effectively reduce the prevalence of breast and cervical cancer among female African immigrants living in the US.

Genetic counseling and testing for hereditary breast cancer have the potential benefit of early detection and early interventions in African American women. However, African American women have low use of these services compared to White women. We conducted two focus groups with African American women diagnosed with breast cancer (affected group, n=13) and women with at least one first-degree relative with breast/ovarian cancer (unaffected group, n= 8). A content analysis approach was employed to analyze interview data. Breast cancer survivors had more knowledge about genetic counseling and testing than participants who were unaffected with cancer. However, knowledge about genetic counseling was limited in both groups. Barriers to pursuing genetic counseling and testing included poor understanding of the genetic counseling and testing process, fear of carrying the mutation, concerns about discrimination, and cost. Motivators to participate in genetic counseling and testing included desire to help family members, insurance coverage, and potential of benefiting the larger African American community. Education efforts are needed to increase genetic counseling and testing awareness in the African American community.

Characteristics associated with breast and cervical screening adherence differs among Black, Latina, and Arab underserved women. Interventions to improve screening should be tailored for racial/ethnic groups with particular attention to competing survival priorities, health literacy risks factors, and provider recommendations.

Adjuvant therapy improves breast cancer survival but is underutilized by Black women. Few interventions have addressed this problem. This preliminary report describes the process we used to develop a decision support intervention for Black women eligible for adjuvant therapy. Aims were to use qualitative methods to describe factors that influence Black women’s adjuvant therapy decisions, use these formative data to develop messages for a treatment decision-support intervention, and pilot test the acceptability and utility of the intervention with community members and newly diagnosed women. Thirty-four in-depth interviews were conducted with breast cancer patients in active treatment, survivors and cancer providers to gather qualitative data. Participant ages ranged from 38 to 69 years. A cultural framework was used to analyze the data and to inform intervention messages. Most women relied on their providers for treatment recommendations. Several women reported problems communicating with providers and felt unprepared to ask questions and discuss adjuvant treatment options. Other factors related to treatment experiences were: spiritual coping, collectivism, and sharing breast cancer experiences with other Black survivors. Using these formative data, we developed an intervention that is survivor-based and includes an in-person session which incorporates sharing personal stories, communication skills training and decision support. Intervention materials were reviewed by community members, researchers/clinicians and patients newly diagnosed with breast cancer. Patients reported satisfaction with the intervention and felt better prepared to talk with providers. The intervention will be tested in a randomized trial to enhance decision support and increase use of indicated adjuvant treatment.

Background: Empirical data on the link between stress and cardiovascular (CVD) risk among African-American women is limited. We examined associations of stressful life events and social strain with incident CVD among African-American women and tested for effect modification by resilience. Methods and Results: Our analysis included 10,785 African-American women enrolled in the Women's Health Initiative Observational Study and Clinical Trials cohort. Participants were followed for CVD for up to 23 years (mean, 12.5). Multivariable Cox regression was used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between stressrelated exposures and incident CVD. We included interactions between follow-up time (age) and

Black women are just as likely to have hereditary breast cancer mutations as White women, yet their participation in genetic counseling and testing is substantially lower. This study sought to describe Black women’s awareness and perceptions of BRCA1/2 testing and to identify barriers and motivators to seeking BRCA1/2 services. Fifty intercept interviews were conducted with Black women in public places (a professional women’s basketball game, a grocery store, a faith-based community event, and the waiting area at a breast care clinic) in Washington, DC. More than half of the women (54%) were aware that genetic tests to determine risk for certain breast and ovarian cancers exist, but the majority (88%) had never heard of BRCA1/2 , specifically. After hearing a description of BRCA1/2 genetic markers, 82% stated that they would agree to BRCA1/2 testing if it was offered to them. Perceived advantages of testing included cancer prevention and the ability to share information with family members. Perceived disadvantages included emotional distress associated with identification of the mutation and the potential misuse of results to deny healthcare or employment. Physician recommendation, self-care, and known family history were among the motivators for testing. Women listed possible media and venues for intervention. In spite of low rates of BRCA1/2 testing in the Black community, women in this sample were open to the idea. Interventions that address barriers and include cultural tailoring are necessary.

Macroparasite infections (e.g., helminths) remain a major human health concern. However, assessing transmission dynamics is problematic because the direct observation of macroparasite dispersal among hosts is not possible. We used a novel landscape genetics approach to examine transmission of the human roundworm Ascaris lumbricoides in a small human population in Jiri, Nepal. Unexpectedly, we found significant genetic structuring of parasites, indicating the presence of multiple transmission foci within a small sampling area (∼14 km2). We analyzed several epidemiological variables, and found that transmission is spatially autocorrelated around households and that transmission foci are stable over time despite extensive human movement. These results would not have been obtainable via a traditional epidemiological study based on worm counts alone. Our data refute the assumption that a single host population corresponds to a single parasite transmission unit, an assumption implicit in many classic models of macroparasite transmission. Newer models have shown that the metapopulation-like pattern observed in our data can adversely affect targeted control strategies aimed at community-wide impacts. Furthermore, the observed metapopulation structure and local mating patterns generate an excess of homozygotes that can accelerate the spread of recessive traits such as drug resistance. Our study illustrates how molecular analyses complement traditional epidemiological information in providing a better understanding of parasite transmission. Similar landscape genetic approaches in other macroparasite systems will be warranted if an accurate depiction of the transmission process is to be used to inform effective control strategies.