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Politi MC, Grant RL, George NP, Barker AR, James AS, Kuroki LM, McBride TD, Liu J, Goodwin CM. Improving Cancer Patients' Insurance Choices (I Can PIC): A Randomized Trial of a Personalized Health Insurance Decision Aid. Oncologist 2020; 25:609-619. [PMID: 32108976 DOI: 10.1634/theoncologist.2019-0703] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 01/17/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Many cancer survivors struggle to choose a health insurance plan that meets their needs because of high costs, limited health insurance literacy, and lack of decision support. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. MATERIALS AND METHODS Eligible individuals (18-64 years, diagnosed with cancer for ≤5 years, English-speaking, not Medicaid or Medicare eligible) were randomized to I Can PIC or an attention control health insurance worksheet. Primary outcomes included health insurance knowledge, decisional conflict, and decision self-efficacy after completing I Can PIC or the control. Secondary outcomes included knowledge, decisional conflict, decision self-efficacy, health insurance literacy, financial toxicity, and delayed care at a 3-6-month follow-up. RESULTS A total of 263 of 335 eligible participants (79%) consented and were randomized; 206 (73%) completed the initial survey (106 in I Can PIC; 100 in the control), and 180 (87%) completed a 3-6 month follow-up. After viewing I Can PIC or the control, health insurance knowledge and a health insurance literacy item assessing confidence understanding health insurance were higher in the I Can PIC group. At follow-up, the I Can PIC group retained higher knowledge than the control; confidence understanding health insurance was not reassessed. There were no significant differences between groups in other outcomes. Results did not change when controlling for health literacy and employment. Both groups reported having limited health insurance options. CONCLUSION I Can PIC can improve cancer survivors' health insurance knowledge and confidence using health insurance. System-level interventions are needed to lower financial toxicity and help patients manage care costs. IMPLICATIONS FOR PRACTICE Inadequate health insurance compromises cancer treatment and impacts overall and cancer-specific mortality. Uninsured or underinsured survivors report fewer recommended cancer screenings and may delay or avoid needed follow-up cancer care because of costs. Even those with adequate insurance report difficulty managing care costs. Health insurance decision support and resources to help manage care costs are thus paramount to cancer survivors' health and care management. We developed a web-based decision aid, Improving Cancer Patients' Insurance Choices (I Can PIC), and evaluated it in a randomized trial. I Can PIC provides health insurance information, supports patients through managing care costs, offers a list of financial and emotional support resources, and provides a personalized cost estimate of annual health care expenses across plan types.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Rachel L Grant
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Nerissa P George
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Abigail R Barker
- Brown School and Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Aimee S James
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Lindsay M Kuroki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Timothy D McBride
- Brown School and Center for Health Economics and Policy, Institute for Public Health, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Courtney M Goodwin
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
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Tipirneni R, Politi MC, Kullgren JT, Kieffer EC, Goold SD, Scherer AM. Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost. JAMA Netw Open 2018; 1:e184796. [PMID: 30646372 PMCID: PMC6324372 DOI: 10.1001/jamanetworkopen.2018.4796] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Navigating health insurance and health care choices requires considerable health insurance literacy. Although recommended preventive services are exempt from out-of-pocket costs under the Affordable Care Act, many people may remain unaware of this provision and its effect on their required payment. Little is known about the association between individuals' health insurance literacy and their use of preventive or nonpreventive health care services. OBJECTIVE To assess the association between health insurance literacy and self-reported avoidance of health care services owing to cost. DESIGN, SETTING, AND PARTICIPANTS In this survey study, a US national, geographically diverse, nonprobability sample of 506 US residents aged 18 years or older with current health insurance coverage was recruited to participate in an online survey between February 22 and 23, 2016. MAIN OUTCOMES AND MEASURES The validated 21-item Health Insurance Literacy Measure (HILM) assessed individuals' self-rated confidence in selecting and using health insurance (score range, 0-84, with higher scores indicating greater levels of health insurance literacy). Dependent variables included delayed or foregone preventive and nonpreventive services in the past 12 months owing to perceived costs, and preventive and nonpreventive use of services. Covariates included age, sex, race/ethnicity, income, educational level, high-deductible health insurance plan, health literacy, numeracy, and chronic health conditions. Analyses included descriptive statistics and bivariate and multivariable logistic regression. RESULTS A total of 506 of 511 participants who began the survey completed it (participation rate, 99.0%). Of the 506 participants, 339 (67.0%) were younger than 35 years (mean [SD] age, 34 [10.4] years), 228 (45.1%) were women, 406 of 504 who reported race (80.6%) were white, and 245 (48.4%) attended college for 4 or more years. A total of 228 participants (45.1%) had 1 or more chronic health condition, 361 of 500 (72.2%) who responded to the survey item had seen a physician in the outpatient setting in the past 12 months, and 446 of the 501 (89.0%) who responded to the survey item had their health insurance plan for 12 or more months. One hundred fifty respondents (29.6%) reported having delayed or foregone care because of cost. The mean (SD) HILM score was 63.5 (12.3). In multivariable logistic regression, each 12-point increase in HILM score was associated with a lower likelihood of both delayed or foregone preventive care (adjusted odds ratio [aOR], 0.61; 95% CI, 0.48-0.78) and delayed or foregone nonpreventive care (aOR, 0.71; 95% CI, 0.55-0.91). CONCLUSIONS AND RELEVANCE This study's findings suggest that lower health insurance literacy may be associated with greater avoidance of both preventive and nonpreventive services. It appears that to improve appropriate use of recommended health care services, including preventive health services, clinicians, health plans, and policymakers may need to communicate health insurance concepts in accessible ways regardless of individuals' health insurance literacy. Plain language communication may be able to improve patients' understanding of services exempt from out-of-pocket costs.
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Affiliation(s)
- Renuka Tipirneni
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Jeffrey T. Kullgren
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
| | - Edith C. Kieffer
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- School of Social Work, University of Michigan, Ann Arbor
| | - Susan D. Goold
- Institute for Healthcare Policy & Innovation, University of Michigan, Ann Arbor
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Aaron M. Scherer
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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Zhao J, Mir N, Ackermann N, Kaphingst KA, Politi MC. Dissemination of a Web-Based Tool for Supporting Health Insurance Plan Decisions (Show Me Health Plans): Cross-Sectional Observational Study. J Med Internet Res 2018; 20:e209. [PMID: 29925498 PMCID: PMC6031902 DOI: 10.2196/jmir.9829] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/30/2018] [Accepted: 05/12/2018] [Indexed: 11/13/2022] Open
Abstract
Background The rate of uninsured people has decreased dramatically since the Affordable Care Act was passed. To make an informed decision, consumers need assistance to understand the advantages and disadvantages of health insurance plans. The Show Me Health Plans Web-based decision support tool was developed to improve the quality of health insurance selection. In response to the promising effectiveness of Show Me Health Plans in a randomized controlled trial (RCT) and the growing need for Web-based health insurance decision support, the study team used expert recommendations for dissemination and implementation, engaged external stakeholders, and made the Show Me Health Plans tool available to the public. Objective The purpose of this study was to implement the public dissemination of the Show Me Health Plans tool in the state of Missouri and to evaluate its impact compared to the RCT. Methods This study used a cross-sectional observational design. Dissemination phase users were compared with users in the RCT study across the same outcome measures. Time spent using the Show Me Health Plans tool, knowledge, importance rating of 9 health insurance features, and intended plan choice match with algorithm predictions were examined. Results During the dissemination phase (November 2016 to January 2017), 10,180 individuals visited the SMHP website, and the 1069 users who stayed on the tool for more than one second were included in our analyses. Dissemination phase users were more likely to live outside St. Louis City or County (P<.001), were less likely to be below the federal poverty level (P<.001), and had a higher income (P=.03). Overall, Show Me Health Plans users from St. Louis City or County spent more time on the Show Me Health Plans tool than those from other Missouri counties (P=.04); this association was not observed in the RCT. Total time spent on the tool was not correlated with knowledge scores, which were associated with lower poverty levels (P=.009). The users from the RCT phase were more likely to select an insurance plan that matched the tool’s recommendations (P<.001) compared with the dissemination phase users. Conclusions The study suggests that a higher income population may be more likely to seek information and online help when making a health insurance plan decision. We found that Show Me Health Plans users in the dissemination phase were more selective in the information they reviewed. This study illustrates one way of disseminating and implementing an empirically tested Web-based decision aid tool. Distributing Web-based tools is feasible and may attract a large number of potential users, educate them on basic health insurance information, and make recommendations based on personal information and preference. However, using Web-based tools may differ according to the demographics of the general public compared to research study participants.
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Affiliation(s)
- Jingsong Zhao
- Huntsman Cancer Institute, Salt Lake City, UT, United States
| | - Nageen Mir
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis, St. Louis, MO, United States
| | - Nicole Ackermann
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis, St. Louis, MO, United States
| | - Kimberly A Kaphingst
- Huntsman Cancer Institute, Salt Lake City, UT, United States.,Department of Communication, University of Utah, Salt Lake City, UT, United States
| | - Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in Saint Louis, St. Louis, MO, United States
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Politi MC, Shacham E, Barker AR, George N, Mir N, Philpott S, Liu JE, Peters E. A Comparison Between Subjective and Objective Methods of Predicting Health Care Expenses to Support Consumers' Health Insurance Plan Choice. MDM Policy Pract 2018; 3:2381468318781093. [PMID: 30288450 PMCID: PMC6124924 DOI: 10.1177/2381468318781093] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 05/14/2018] [Indexed: 11/17/2022] Open
Abstract
Objective. Numerous electronic tools help consumers select health insurance plans based on their estimated health care utilization. However, the best way to personalize these tools is unknown. The purpose of this study was to compare two common methods of personalizing health insurance plan displays: 1) quantitative healthcare utilization predictions using nationally representative Medical Expenditure Panel Survey (MEPS) data and 2) subjective-health status predictions. We also explored their relations to self-reported health care utilization. Methods. Secondary data analysis was conducted with responses from 327 adults under age 65 considering health insurance enrollment in the Affordable Care Act (ACA) marketplace. Participants were asked to report their subjective health, health conditions, and demographic information. MEPS data were used to estimate predicted annual expenditures based on age, gender, and reported health conditions. Self-reported health care utilization was obtained for 120 participants at a 1-year follow-up. Results. MEPS-based predictions and subjective-health status were related (P < 0.0001). However, MEPS-predicted ranges within subjective-health categories were large. Subjective health was a less reliable predictor of expenses among older adults (age × subjective health, P = 0.04). Neither significantly related to subsequent self-reported health care utilization (P = 0.18, P = 0.92, respectively). Conclusions. Because MEPS data are nationally representative, they may approximate utilization better than subjective health, particularly among older adults. However, approximating health care utilization is difficult, especially among newly insured. Findings have implications for health insurance decision support tools that personalize plan displays based on cost estimates.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Enbal Shacham
- College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Abigail R Barker
- Brown School of Social Work, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Nerissa George
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Nageen Mir
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Sydney Philpott
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Jingxia Esther Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Ellen Peters
- Department of Psychology, Ohio State University, Columbus, Ohio
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Politi MC, Kuzemchak MD, Liu J, Barker AR, Peters E, Ubel PA, Kaphingst KA, McBride T, Kreuter MW, Shacham E, Philpott SE. Show Me My Health Plans: Using a Decision Aid to Improve Decisions in the Federal Health Insurance Marketplace. MDM Policy Pract 2016; 1. [PMID: 28804780 PMCID: PMC5550739 DOI: 10.1177/2381468316679998] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Since the Affordable Care Act was passed, more than 12
million individuals have enrolled in the health insurance marketplace. Without
support, many struggle to make an informed plan choice that meets their health
and financial needs. Methods: We designed and evaluated a decision
aid, Show Me My Health Plans (SMHP), that provides education, preference
assessment, and an annual out-of-pocket cost calculator with plan
recommendations produced by a tailored, risk-adjusted algorithm incorporating
age, gender, and health status. We evaluated whether SMHP compared to HealthCare.gov improved health insurance decision quality and
the match between plan choice, needs, and preferences among 328 Missourians
enrolling in the marketplace. Results: Participants who used SMHP
had higher health insurance knowledge (LS-Mean = 78 vs. 62; P < 0.001),
decision self-efficacy (LS-Mean = 83 vs. 75; P < 0.002), confidence in their
choice (LS-Mean = 3.5 vs. 2.9; P < 0.001), and improved health insurance
literacy (odds ratio = 2.52, P < 0.001) compared to participants using
HealthCare.gov. Those using SMHP were 10.3 times more likely to
select a silver- or gold-tier plan (P < 0.0001). Discussion:
SMHP can improve health insurance decision quality and the odds that consumers
select an insurance plan with coverage likely needed to meet their health needs.
This study represents a unique context through which to apply principles of
decision support to improve health insurance choices.
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Affiliation(s)
- Mary C Politi
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Marie D Kuzemchak
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Jingxia Liu
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Abigail R Barker
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Ellen Peters
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Peter A Ubel
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Kimberly A Kaphingst
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Timothy McBride
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Matthew W Kreuter
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Enbal Shacham
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
| | - Sydney E Philpott
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri (MCP, MDK, JL, SEP); Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri (ARB, TM, MWK); Department of Psychology, Ohio State University, Columbus, Ohio (EP); Fuqua School of Business, Sanford School of Public Policy, and School of Medicine, Duke University, Durham, North Carolina (PAU); Department of Communication, University of Utah, Salt Lake City, Utah (KAK); and College for Public Health and Social Justice, Saint Louis University, St. Louis, Missouri (ES)
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