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Odebunmi OO, Spees LP, Biddell CB, Yemeke T, Yanguela J, Higgins C, Gilkey M, Ozawa S, Wheeler SB. Benefits, challenges, and strategies related to using presumptive recommendations for HPV vaccination: A qualitative study with rural and non-rural-serving primary care professionals. Hum Vaccin Immunother 2024; 20:2347018. [PMID: 38708779 PMCID: PMC11085946 DOI: 10.1080/21645515.2024.2347018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/22/2024] [Indexed: 05/07/2024] Open
Abstract
HPV vaccination coverage remains far below the national target of 80% among US adolescents, particularly in rural areas, which have vaccine uptake rates that are 10% points lower than non-rural areas on average. Primary care professionals (PCPs) can increase coverage by using presumptive recommendations to introduce HPV vaccination in a way that assumes parents want to vaccinate. Through semi-structured interviews, we explored PCPs' experiences and perceptions of using presumptive recommendations in rural- and non-rural-serving primary care clinics in North Carolina. Thematic analysis revealed that most PCPs in rural and non-rural contexts used presumptive recommendations and felt the strategy was an effective and concise way to introduce the topic of HPV vaccination to parents. At the same time, some PCPs raised concerns about presumptive recommendations potentially straining relationships with certain parents, including those who had previously declined HPV vaccine or who distrust medical authority due to their past experiences with the healthcare system. PCPs dealt with these challenges by using a more open-ended approach when introducing HPV vaccination to parents. In conclusion, our findings suggest that PCPs in both rural and non-rural settings see value in using presumptive recommendations to introduce HPV vaccination, but to adequately address concerns and ensure increased HPV vaccine uptake, PCPs can use simple and culturally sensitive language to ensure fully informed consent and to maintain parental trust. And to further strengthen HPV vaccine discussions, PCPs can utilize other effective HPV communication techniques, like the Announcement Approach, in discussing HPV vaccinations with hesitant parents.
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Affiliation(s)
- Olufeyisayo O. Odebunmi
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lisa P. Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitlin B. Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Tatenda Yemeke
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Juan Yanguela
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Colleen Higgins
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Melissa Gilkey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sachiko Ozawa
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Spencer JC, Spees LP, Biddell CB, Odebunmi OO, Ilyasova AA, Yanguela J, Lich KH, Mills SD, Higgins CR, Ozawa S, Wheeler SB. Inclusion of marginalized populations in HPV vaccine modeling: A systematic review. Prev Med 2024; 182:107941. [PMID: 38522627 DOI: 10.1016/j.ypmed.2024.107941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/26/2024] [Accepted: 03/21/2024] [Indexed: 03/26/2024]
Abstract
OBJECTIVE Models simulating the potential impacts of Human Papillomavirus (HPV) vaccine have been used globally to guide vaccination policies and programs. We sought to understand how and why marginalized populations have been incorporated into HPV vaccine simulation models. METHODS We conducted a systematic search of PubMed, CINAHL, Scopus, and Embase to identify studies using simulation models of HPV vaccination incorporating one or more marginalized population through stratification or subgroup analysis. We extracted data on study characteristics and described these overall and by included marginalized groups. RESULTS We identified 36 studies that met inclusion criteria, which modeled vaccination in 21 countries. Models included men who have sex with men (MSM; k = 16), stratification by HIV status (k = 9), race/ethnicity (k = 6), poverty (k = 5), rurality (k = 4), and female sex workers (k = 1). When evaluating for a marginalized group (k = 10), HPV vaccination was generally found to be cost-effective, including for MSM, individuals living with HIV, and rural populations. In studies evaluating equity in cancer prevention (k = 9), HPV vaccination generally advanced equity, but this was sensitive to differences in HPV vaccine uptake and use of absolute or relative measures of inequities. Only one study assessed the impact of an intervention promoting HPV vaccine uptake. DISCUSSION Incorporating marginalized populations into decision models can provide valuable insights to guide decision making and improve equity in cancer prevention. More research is needed to understand the equity impact of HPV vaccination on cancer outcomes among marginalized groups. Research should emphasize implementation - including identifying and evaluating specific interventions to increase HPV vaccine uptake.
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Affiliation(s)
- Jennifer C Spencer
- Department of Population Health, Dell Medical School, University of Texas at Austin, Austin, TX, United States of America.
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Olufeyisayo O Odebunmi
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Anna A Ilyasova
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Juan Yanguela
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Sarah D Mills
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Colleen R Higgins
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Sachiko Ozawa
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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Biddell CB, Spees LP, Trogdon JG, Kent EE, Rosenstein DL, Angove RS, Rogers CD, Wheeler SB. Economic Evaluation of a Nonmedical Financial Assistance Program on Missed Treatment Appointments Among Adults With Cancer. J Clin Oncol 2024; 42:300-311. [PMID: 37897261 PMCID: PMC10824376 DOI: 10.1200/jco.23.00993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/29/2023] [Accepted: 09/18/2023] [Indexed: 10/30/2023] Open
Abstract
PURPOSE We retrospectively evaluated the clinical and economic impact of a program providing nonmedical financial assistance on missed treatment appointments among patients receiving cancer treatment at a large, Southeastern public hospital system. MATERIALS AND METHODS We used patient electronic health records, program records, and cancer registry data to examine the impact of the program on rates of missed (or no-show) radiation therapy and infusion chemotherapy/immunotherapy appointments in the 180 days after treatment initiation. We used propensity weighting to estimate the effect of the program, stratified by treatment appointment type (radiation therapy, infusion chemotherapy/immunotherapy). We developed a decision tree-based economic model to conduct a cost-consequence analysis from the health system perspective in a hypothetical cohort over a 6-month time horizon. RESULTS Of 1,347 patients receiving radiation therapy between 2015 and 2019, 53% (n = 715) had ≥1 no-shows and 28% (n = 378) received program assistance. Receipt of any assistance was associated with a 2.1 percentage point (95% CI, 0.6 to 3.5) decrease in the proportion of no-shows, corresponding to a 51% decrease in the overall mean no-show proportion. Under the current funding model, the program is estimated to save the health system $153 in US dollars per missed appointment averted, relative to not providing nonmedical financial assistance. Of the 1,641 patients receiving infusion chemotherapy/immunotherapy, 33% (n = 541) received program assistance, and only 14% (n = 223) had ≥1 no-shows. The financial assistance program did not have a significant effect on no-show proportions among infusion visits. CONCLUSION This study used a novel approach to retrospectively evaluate a nonmedical financial assistance program for patients undergoing active cancer treatment. Findings support investment in programs that address patients' nonmedical financial needs, particularly for those undergoing intensive radiation therapy.
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Affiliation(s)
- Caitlin B. Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Lisa P. Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Justin G. Trogdon
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Erin E. Kent
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Donald L. Rosenstein
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- Department of Psychiatry, UNC School of Medicine, Chapel Hill, NC
| | | | | | - Stephanie B. Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill (UNC), Chapel Hill, NC
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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Semprini JT, Biddell CB, Eberth JM, Charlton ME, Nash SH, Yeager KA, Evans D, Madhivanan P, Brandt HM, Askelson NM, Seaman AT, Zahnd WE. Measuring and addressing health equity: an assessment of cancer center designation requirements. Cancer Causes Control 2023; 34:23-33. [PMID: 36939948 PMCID: PMC10512189 DOI: 10.1007/s10552-023-01680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/27/2023] [Indexed: 03/21/2023]
Abstract
PURPOSE By requiring specific measures, cancer endorsements (e.g., accreditations, designations, certifications) promote high-quality cancer care. While 'quality' is the defining feature, less is known about how these endorsements consider equity. Given the inequities in access to high-quality cancer care, we assessed the extent to which equity structures, processes, and outcomes were required for cancer center endorsements. METHODS We performed a content analysis of medical oncology, radiation oncology, surgical oncology, and research hospital endorsements from the American Society of Clinical Oncology (ASCO), American Society of Radiation Oncology (ASTRO), American College of Surgeons Commission on Cancer (CoC), and the National Cancer Institute (NCI), respectively. We analyzed requirements for equity-focused content and compared how each endorsing body included equity as a requirement along three axes: structures, processes, and outcomes. RESULTS ASCO guidelines centered on processes assessing financial, health literacy, and psychosocial barriers to care. ASTRO guidelines related to language needs and processes to address financial barriers. CoC equity-related guidelines focused on processes addressing financial and psychosocial concerns of survivors, and hospital-identified barriers to care. NCI guidelines considered equity related to cancer disparities research, inclusion of diverse groups in outreach and clinical trials, and diversification of investigators. None of the guidelines explicitly required measures of equitable care delivery or outcomes beyond clinical trial enrollment. CONCLUSION Overall, equity requirements were limited. Leveraging the influence and infrastructure of cancer quality endorsements could enhance progress toward achieving cancer care equity. We recommend that endorsing organizations 1) require cancer centers to implement processes for measuring and tracking health equity outcomes and 2) engage diverse community stakeholders to develop strategies for addressing discrimination.
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Affiliation(s)
- Jason T Semprini
- Department of Health Management and Policy, College of Public Health, University of Iowa, 145 N. Riverside Dr. N277, Iowa City, IA, 52240, USA.
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jan M Eberth
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Mary E Charlton
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Sarah H Nash
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Donoria Evans
- National Partnerships and Innovations, American Cancer Society, Decatur, GA, USA
| | - Purnima Madhivanan
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona. Tucson, Tuscon, AZ, USA
| | - Heather M Brandt
- St. Jude Children's Research Hospital and St. Jude Comprehensive Cancer Center, Memphis, TN, USA
| | - Natoshia M Askelson
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Aaron T Seaman
- Department of Community and Behavioral Health, College of Public Health, University of Iowa, Iowa City, IA, USA
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Whitney E Zahnd
- Department of Health Management and Policy, College of Public Health, University of Iowa, 145 N. Riverside Dr. N277, Iowa City, IA, 52240, USA
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Waters AR, Biddell CB, Killela M, Kasow KA, Page K, Wheeler SB, Drier SW, Kelly MS, Robles J, Spees LP. Financial burden and recommended multilevel solutions among caregivers of pediatric hematopoietic stem cell transplant recipients. Pediatr Blood Cancer 2023; 70:e30700. [PMID: 37776093 PMCID: PMC10615841 DOI: 10.1002/pbc.30700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The healthcare costs of patients who receive hematopoietic stem cell transplantation (HSCT) are substantial. At the same time, the increasing use of pediatric HSCT leaves more caregivers of pediatric HSCT recipients at risk for financial burden-an understudied area of research. METHODS Financial burden experienced by caregivers of recipients who received autologous or allogeneic transplants was assessed using an explanatory mixed-methods design including a one-time survey and semi-structured interviews. Financial burden was assessed through an adapted COmprehensive Score for financial Toxicity (COST) as well as questions about the types of out-of-pocket costs and cost-coping behaviors. Chi-squared or Fisher's exact tests were used to assess differences in costs incurred and coping behaviors by financial toxicity and financial toxicity by demographic factors. Interviews were audio recorded, transcribed, and analyzed using directed content analysis. RESULTS Of 99 survey participants, 64% experienced high financial toxicity (COST ≤ $ \le \;$ 22). Caregivers with high financial toxicity were more likely to report costs related to transportation and diet. High financial toxicity was associated with nearly all cost-coping behaviors (e.g., borrowed money). High financial toxicity was also associated with increased use of hospital financial support and transportation assistance. Qualitative analysis resulted in four categories that were integrated with quantitative findings: (1) care-related out-of-pocket costs incurred, (2) cost-coping behaviors, (3) financial support resources used, and (4) multilevel recommendations for reducing financial burden. CONCLUSIONS Considering the substantial, long-term financial burden among pediatric HSCT patients and their caregivers, this population would benefit from adapted and tailored financial burden interventions.
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Affiliation(s)
- Austin R Waters
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - Mary Killela
- School of Nursing, UNC-CH, Chapel Hill, North Carolina, USA
| | - Kimberly A Kasow
- Department of Pediatrics, UNC-CH, Chapel Hill, North Carolina, USA
| | - Kristin Page
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
| | - Sarah W Drier
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
| | - Matthew S Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joanna Robles
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
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Petermann VM, Biddell CB, Planey AM, Spees LP, Rosenstein DL, Manning M, Gellin M, Padilla N, Samuel-Ryals CA, Birken SA, Reeder-Hayes K, Deal AM, Cabarrus K, Bell RA, Strom C, Young TH, King S, Leutner B, Vestal D, Wheeler SB. Assessing the pre-implementation context for financial navigation in rural and non-rural oncology clinics. Front Health Serv 2023; 3:1148887. [PMID: 37941608 PMCID: PMC10627810 DOI: 10.3389/frhs.2023.1148887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 09/25/2023] [Indexed: 11/10/2023]
Abstract
Background Financial navigation (FN) is an evidence-based intervention designed to address financial toxicity for cancer patients. FN's success depends on organizations' readiness to implement and other factors that may hinder or support implementation. Tailored implementation strategies can support practice change but must be matched to the implementation context. We assessed perceptions of readiness and perceived barriers and facilitators to successful implementation among staff at nine cancer care organizations (5 rural, 4 non-rural) recruited to participate in the scale-up of a FN intervention. To understand differences in the pre-implementation context and inform modifications to implementation strategies, we compared findings between rural and non-rural organizations. Methods We conducted surveys (n = 78) and in-depth interviews (n = 73) with staff at each organization. We assessed perceptions of readiness using the Organizational Readiness for Implementing Change (ORIC) scale. In-depth interviews elicited perceived barriers and facilitators to implementing FN in each context. We used descriptive statistics to analyze ORIC results and deductive thematic analysis, employing a codebook guided by the Consolidated Framework for Implementation Research (CFIR), to synthesize themes in barriers and facilitators across sites, and by rurality. Results Results from the ORIC scale indicated strong perceptions of organizational readiness across all sites. Staff from rural areas reported greater confidence in their ability to manage the politics of change (87% rural, 76% non-rural) and in their organization's ability to support staff adjusting to the change (96% rural, 75% non-rural). Staff at both rural and non-rural sites highlighted factors reflective of the Intervention Characteristics (relative advantage) and Implementation Climate (compatibility and tension for change) domains as facilitators. Although few barriers to implementation were reported, differences arose between rural and non-rural sites in these perceived barriers, with non-rural staff more often raising concerns about resistance to change and compatibility with existing work processes and rural staff more often raising concerns about competing time demands and limited resources. Conclusions Staff across both rural and non-rural settings identified few, but different, barriers to implementing a novel FN intervention that they perceived as important and responsive to patients' needs. These findings can inform how strategies are tailored to support FN in diverse oncology practices.
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Affiliation(s)
- Victoria M. Petermann
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B. Biddell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Arrianna Marie Planey
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa P. Spees
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Donald L. Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michelle Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mindy Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Neda Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cleo A. Samuel-Ryals
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A. Birken
- Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, United States
| | - Katherine Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Allison M. Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kendrel Cabarrus
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Ronny A. Bell
- Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, United States
| | - Carla Strom
- Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC, United States
- Wake Forest Baptist Comprehensive Cancer Center, Wake Forest University, Winston-Salem, NC, United States
| | - Tiffany H. Young
- Buddy Kemp Support Center, Novant Health Cancer Institute, Charlotte, NC, United States
| | - Sherry King
- Carteret Health Care Cancer Center, Carteret, NC, United States
| | - Brian Leutner
- Pardee UNC Health Care, Hendersonville, NC, United States
| | - Derek Vestal
- UNC Lenoir Health Care, Kinston, NC, United States
| | - Stephanie B. Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Johnson K, Biddell CB, Gora Combs K, Wiesman J, Valdes Lupi M, Hassmiller Lich K. Local Health Department Values and Organizational Authorities Guiding Cross-Sector Work During COVID-19. Health Promot Pract 2023:15248399231192989. [PMID: 37649378 DOI: 10.1177/15248399231192989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
OBJECTIVE The COVID-19 pandemic highlighted the role that local health departments (LHDs) have in cross sector can address alone, including the work of value alignment and the strategic use of organizational authorities. The practices by which LHDs used their authorities to conduct cross-sector work during the pandemic need exploration. METHOD We conducted semi-structured interviews with 19 public health leaders from metropolitan LHDs across the United States. Our interview guide assessed the values that LHD leadership prioritized in their cross-sector work as well as the range of organizational authorities they leveraged to influence external decision-making in other sectors. RESULTS We found that LHDs approached cross-sector work by leaning on diverse values and authorities, each with unique implications for their work. The LHDs emphasized their approach to value alignment on a sector-by-sector basis, strategically using diverse organizational authorities-economic, political, moral, scientific, and logistical. While each authority and value we assessed was present across all interviewees, how each shaped action varied. Internally, LHDs emphasized certain authorities more than others to the degree that they more closely aligned with prioritized core values. CONCLUSION Our findings highlight the ongoing need for LHD leadership to improve their ability to effectively communicate public health values and the unique authorities by which health-supporting work can be facilitated, including how this message must be adapted, depending on the specific sectors with which the LHD needs to partner and the governance arrangement in which the LHD is situated.
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Affiliation(s)
- Karl Johnson
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitlin B Biddell
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - John Wiesman
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Reeder-Hayes KE, Biddell CB, Manning ML, Rosenstein DL, Samuel-Ryals CA, Spencer JC, Smith S, Deal A, Gellin M, Wheeler SB. Knowledge, Attitudes, and Resources of Frontline Oncology Support Personnel Regarding Financial Burden in Patients With Cancer. JCO Oncol Pract 2023; 19:654-661. [PMID: 37294912 DOI: 10.1200/op.22.00631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 12/16/2022] [Accepted: 03/03/2023] [Indexed: 06/11/2023] Open
Abstract
PURPOSE Financial navigation services support patients with cancer and address the direct and indirect financial burden of cancer diagnosis and treatment. These services are commonly delivered through a variety of frontline oncology support personnel (FOSP) including navigators, social workers, supportive care providers, and other clinic staff, but the perspective of FOSPs is largely absent from current literature on financial burden in oncology. We surveyed a national sample of FOSPs to understand their perspectives on patient financial burden, resource availability, and barriers and facilitators to assisting patients with cancer-related financial burden. METHODS We used Qualtrics online survey software and recruited participants using multiple professional society and interest group mailing lists. Categorical responses were described using frequencies, distributions of numeric survey responses were described using the median and IQR, and two open-ended survey questions were categorized thematically using a priori themes, allowing additional emergent themes. RESULTS Two hundred fourteen FOSPs completed this national survey. Respondents reported a high awareness of patient financial burden and felt comfortable speaking to patients about financial concerns. Patient assistance resources were commonly available, but only 15% described resources as sufficient for the observed needs. A substantial portion of respondents reported moral distress related to this lack of resources. CONCLUSION FOSPs, who already have requisite knowledge and comfort in discussing patient financial needs, are a critical resource for mitigating cancer-related financial burden. Interventions should leverage this resource but prioritize transparency and efficiency to reduce the administrative and emotional toll on the FOSP workforce and reduce the risk of burnout.
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Affiliation(s)
- Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Michelle L Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Donald L Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cleo A Samuel-Ryals
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Current Address: Flatiron Health, New York, NY
| | - Jennifer C Spencer
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Current Address: Department of Population Health, Dell Medical School, The University of Texas at Austin, Austin, TX
| | | | - Allison Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Mindy Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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9
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Spees LP, Biddell CB, Smith JS, Marais ACD, Hudgens MG, Sanusi B, Jackson S, Brewer NT, Wheeler SB. Cost-effectiveness of Human Papillomavirus Self-collection Intervention on Cervical Cancer Screening Uptake among Underscreened U.S. Persons with a Cervix. Cancer Epidemiol Biomarkers Prev 2023; 32:1097-1106. [PMID: 37204419 PMCID: PMC10524653 DOI: 10.1158/1055-9965.epi-22-1267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 02/05/2023] [Accepted: 05/11/2023] [Indexed: 05/20/2023] Open
Abstract
BACKGROUND We evaluate the cost-effectiveness of human papillomavirus (HPV) self-collection (followed by scheduling assistance for those who were HPV+ or inconclusive) compared with scheduling assistance only and usual care among underscreened persons with a cervix (PWAC). METHODS A decision tree analysis was used to estimate the incremental cost-effectiveness ratios (ICER), or the cost per additional PWAC screened, from the Medicaid/state and clinic perspectives. A hypothetical cohort represented 90,807 low-income, underscreened individuals. Costs and health outcomes were derived from the MyBodyMyTest-3 randomized trial except the usual care health outcomes were derived from literature. We performed probabilistic sensitivity analyses (PSA) to evaluate model uncertainty. RESULTS Screening uptake was highest in the self-collection alternative (n = 65,721), followed by the scheduling assistance alternative (n = 34,003) and usual care (n = 18,161). The self-collection alternative costs less and was more effective than the scheduling assistance alternative from the Medicaid/state perspective. Comparing the self-collection alternative with usual care, the ICERs were $284 per additional PWAC screened from the Medicaid/state perspective and $298 per additional PWAC screened from the clinic perspective. PSAs demonstrated that the self-collection alternative was cost-effective compared with usual care at a willingness-to-pay threshold of $300 per additional PWAC screened in 66% of simulations from the Medicaid/state perspective and 58% of simulations from the clinic perspective. CONCLUSIONS Compared with usual care and scheduling assistance, mailing HPV self-collection kits to underscreened individuals appears to be cost-effective in increasing screening uptake. IMPACT This is the first analysis to demonstrate the cost-effectiveness of mailed self-collection in the United States.
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Affiliation(s)
- Lisa P. Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Jennifer S. Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Andrea C. Des Marais
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Michael G. Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Busola Sanusi
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Sarah Jackson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Noel T. Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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10
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Escoffery C, Petagna C, Agnone C, Perez S, Saber LB, Ryan G, Dhir M, Sekar S, Yeager KA, Biddell CB, Madhivanan P, Lee S, English AS, Savas L, Daly E, Vu T, Fernandez ME. A systematic review of interventions to promote HPV vaccination globally. BMC Public Health 2023; 23:1262. [PMID: 37386430 PMCID: PMC10308645 DOI: 10.1186/s12889-023-15876-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 05/11/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Despite the human papillomavirus (HPV) vaccine being a safe, effective cancer prevention method, its uptake is suboptimal in the United States (U.S.). Previous research has found a variety of intervention strategies (environmental and behavioral) to increase its uptake. The purpose of the study is to systematically review the literature on interventions that promote HPV vaccination from 2015 to 2020. METHODS We updated a systematic review of interventions to promote HPV vaccine uptake globally. We ran keyword searches in six bibliographic databases. Target audience, design, level of intervention, components and outcomes were abstracted from the full-text articles in Excel databases. RESULTS Of the 79 articles, most were conducted in the U.S. (72.2%) and in clinical (40.5%) or school settings (32.9%), and were directed at a single level (76.3%) of the socio-ecological model. Related to the intervention type, most were informational (n = 25, 31.6%) or patient-targeted decision support (n = 23, 29.1%). About 24% were multi-level interventions, with 16 (88.9%) combining two levels. Twenty-seven (33.8%) reported using theory in intervention development. Of those reporting HPV vaccine outcomes, post-intervention vaccine initiation ranged from 5% to 99.2%, while series completion ranged from 6.8% to 93.0%. Facilitators to implementation were the use of patient navigators and user-friendly resources, while barriers included costs, time to implement and difficulties of integrating interventions into the organizational workflow. CONCLUSIONS There is a strong need to expand the implementation of HPV-vaccine promotion interventions beyond education alone and at a single level of intervention. Development and evaluation of effective strategies and multi-level interventions may increase the uptake of the HPV vaccine among adolescents and young adults.
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Affiliation(s)
- Cam Escoffery
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA.
| | - Courtney Petagna
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA
| | - Christine Agnone
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA
| | - Stephen Perez
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA
| | - Lindsay B Saber
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA
| | - Grace Ryan
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Meena Dhir
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA
| | - Swathi Sekar
- Rollins School of Public Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA, 30322, 404-727-4701, USA
| | - Katherine A Yeager
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Caitlin B Biddell
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, Durham, NC, USA
| | - Purnima Madhivanan
- Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, USA
| | - Stephanie Lee
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Amanda S English
- Institute for Health Disparities, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Lara Savas
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Eliza Daly
- Prevention Research Center, College of Public Health, University of Iowa, Iowa City, IA, USA
| | - Thuy Vu
- Health Promotion Research Center, School of Public Health, University of Washington, Seattle, WA, USA
| | - Maria E Fernandez
- Center for Health Promotion and Prevention Research, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
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11
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Biddell CB, Spees LP, Trogdon JG, Kent EE, Rosenstein DL, Angove RSM, Wheeler SB. Association of patient-reported financial barriers with healthcare utilization among Medicare beneficiaries with a history of cancer. J Cancer Surviv 2023:10.1007/s11764-023-01409-x. [PMID: 37266819 PMCID: PMC10692305 DOI: 10.1007/s11764-023-01409-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/22/2023] [Indexed: 06/03/2023]
Abstract
PURPOSE We examined characteristics associated with financial barriers to healthcare and the association of financial barriers with adverse healthcare events among US adult cancer survivors enrolled in Medicare. METHODS We used nationally representative Medicare Current Beneficiary Survey data (2011-2013, 2015-2017) to identify adults with a history of non-skin cancer. We defined financial barriers as cost-related trouble accessing and/or delayed care in the prior year. Using propensity-weighted multivariable logistic regression, we examined associations between financial barriers and adverse healthcare events (any ED visits, any inpatient hospitalizations). RESULTS Overall, 11.0% of adult Medicare beneficiaries with a history of cancer reported financial barriers in the prior year, with higher burden among beneficiaries < 65 years of age vs. ≥ 65 (32.5% vs. 8.2%, p < 0.0001) and with annual income < $25,000 vs. ≥ $25,000 (18.1% vs. 6.9%, p < 0.0001). In bivariate models, financial barriers were associated with a 7.8 percentage point (95% CI: 1.5-14.0) increase in the probability of ED visits. In propensity-weighted models, this association was not statistically significant. The association between financial barriers and hospitalizations was not significant in the overall population; however, financial barriers were associated with a decreased probability of hospitalization among Black/African American beneficiaries. CONCLUSIONS Despite Medicare coverage, beneficiaries with a history of cancer are at risk for experiencing financial barriers to healthcare. In the overall population, financial barriers were not associated with ED visits or hospitalizations. IMPLICATIONS FOR CANCER SURVIVORS Policies limiting Medicare patient out-of-pocket spending and care models addressing health-related social needs are needed to reduce financial barriers experienced.
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Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA.
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Justin G Trogdon
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Erin E Kent
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
- Department of Psychiatry, UNC School of Medicine, Chapel Hill, NC, USA
| | | | - Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA
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12
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LeBlanc MR, Coles T, Biddell CB, Fiala MA. Measuring Financial Toxicity: A Closer Look. Value Health 2023; 26:953-955. [PMID: 36997116 DOI: 10.1016/j.jval.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 06/04/2023]
Affiliation(s)
- Matthew R LeBlanc
- School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; UNC Lineberger Comprehensive Cancer Center, Chapel Hill, NC, USA.
| | - Theresa Coles
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Caitlin B Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mark A Fiala
- School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
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13
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Biddell CB, Waters AR, Angove RSM, Gallagher KD, Rosenstein DL, Spees LP, Kent EE, Planey AM, Wheeler SB. Facing financial barriers to healthcare: patient-informed adaptation of a conceptual framework for adults with a history of cancer. Front Psychol 2023; 14:1178517. [PMID: 37255517 PMCID: PMC10225523 DOI: 10.3389/fpsyg.2023.1178517] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
Background Cancer-related financial hardship is associated with negative clinical outcomes, which may be partially explained by cost-related delayed or forgone care in response to financial barriers. We sought to understand patient experiences facing financial barriers to medical care following a cancer diagnosis. Methods We conducted virtual, semi-structured interviews in Fall 2022 with 20 adults with a history of cancer who had experienced cancer-related financial hardship in the prior year. We used template analysis within a pragmatic paradigm, combining constructivist and critical realist theoretical perspectives, to analyze interview transcripts and adapt an existing conceptual framework of financial barriers to care. Results The majority of interviewees identified as women (70%), non-Hispanic white (60%), and reported an annual household income of <$48,000 (60%). As interviewees sought to overcome financial barriers, they described substantial frustration at the limitations and complexities of United States health and social care systems, resulting in a reliance on a fragmented, uncertain resource landscape. The administrative burden resulting from bureaucratic systems and the advocacy responsibilities required to navigate them ultimately fell on interviewees and their caregivers. Thus, participants described their ability to overcome financial barriers as being influenced by individual and interpersonal factors, such as social support, comfort asking for help, time, prior experience navigating resources, and physical and mental health. However, participants noted health system organizational factors, such as whether all new patients proactively met with a social worker or financial navigator, as having the potential to lessen the administrative and financial burden experienced. Conclusion We present an adapted conceptual framework outlining multi-level factors influencing patient experiences coping with financial barriers to medical care. In addition to influencing whether a patient ultimately delays or forgoes care due to cost, financial barriers also have the potential to independently affect patient mental, physical, and financial health.
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Affiliation(s)
- Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Austin R. Waters
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Rebekah S. M. Angove
- Patient Insight Institute, Patient Advocate Foundation, Hampton, VA, United States
| | | | - Donald L. Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States
| | - Lisa P. Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Erin E. Kent
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Arrianna Marie Planey
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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14
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Spees LP, Biddell CB, Angove RSM, Gallagher KD, Anderson E, Christenbury A, Rocque G, Wheeler SB. Barriers to COVID-19 vaccine uptake among resource-limited adults diagnosed with chronic illness. Front Public Health 2023; 11:1046515. [PMID: 36844843 PMCID: PMC9948023 DOI: 10.3389/fpubh.2023.1046515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/20/2023] [Indexed: 02/11/2023] Open
Abstract
Background Despite the use of interventions (e.g., monetary incentives, educational campaigns, on-site workplace vaccination) to increase COVID-19 vaccination, differences in uptake persist by poverty level, insurance status, geography, race, and ethnicity, suggesting that these interventions may not be adequately addressing the barriers faced by these populations. Among a sample of resource-limited individuals with chronic illnesses, we (1) described the prevalence of different types of barriers to the COVID-19 vaccination and (2) identified associations between patients' sociodemographic characteristics and barriers to vaccination. Methods We surveyed a national sample of patients with chronic illness and demonstrated healthcare affordability and/or access challenges about barriers to COVID-19 vaccination in July 2021. We categorized participant responses into cost, transportation, informational, and attitudinal barrier domains and assessed the prevalence of each domain, both overall and by self-reported vaccination status. Using logistic regression models, we examined unadjusted and adjusted associations between respondent characteristics (sociodemographic, geographic, and healthcare access) and self-reported barriers to vaccination. Results Of 1,342 respondents in the analytic sample, 20% (264/1,342) reported informational barriers and 9% (126/1,342) reported attitudinal barriers to COVID-19 vaccination. Transportation and cost barriers were reported much less commonly, by only 1.1% (15/1,342) and 0.7% (10/1,342) of the sample, respectively. Controlling for all other characteristics, respondents with either a specialist as their usual source of care or no usual source of care had an 8.4 (95% CI: 1.7-15.1) and 18.1 (95% CI: 4.3-32.0) percentage point higher predicted probability, respectively, of reporting informational barriers to care. Compared to females, males had an 8.4% point (95% CI: 5.5-11.4) lower predicted probability of reporting attitudinal barriers. Only attitudinal barriers were associated with COVID-19 vaccine uptake. Conclusion Among a sample of adults with chronic illnesses who had received financial assistance and case management services from a national non-profit, informational and attitudinal barriers were more commonly reported than logistical or structural access barriers (i.e., transportation and cost barriers). Interventions should target attitudinal barriers among patients with chronic illness, who may have particular concerns about the interaction of the vaccine with ongoing medical care. Additionally, interventions targeting informational barriers are particularly needed among individuals without a usual source of care.
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Affiliation(s)
- Lisa P. Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | - Eric Anderson
- Patient Advocate Foundation, Hampton, VA, United States
| | | | - Gabrielle Rocque
- Division of Hematology and Oncology, Department of Medicine, University of Alabama-Birmingham, Birmingham, AL, United States
| | - Stephanie B. Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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15
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Johnson K, Biddell CB, Hecht HK, Lich KH, Swann J, Delamater P, Mayorga M, Ivy J, Smith RL, Patel MD. Organizational decision‐making during COVID‐19: A qualitative analysis of the organizational decision‐making system in the United States during COVID‐19. Contingencies & Crisis Mgmt 2022. [DOI: 10.1111/1468-5973.12437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Karl Johnson
- Department of Health Policy and Management, Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Hillary K. Hecht
- Department of Health Policy and Management, Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Kristen H. Lich
- Department of Health Policy and Management, Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Julie Swann
- Department of Industrial and Systems Engineering North Carolina State University Raleigh North Carolina USA
| | - Paul Delamater
- Department of Geography University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Maria Mayorga
- Department of Industrial and Systems Engineering North Carolina State University Raleigh North Carolina USA
| | - Julie Ivy
- Department of Industrial and Systems Engineering North Carolina State University Raleigh North Carolina USA
| | - Raymond L. Smith
- Department of Engineering, College of Engineering and Technology East Carolina University Greenville North Carolina USA
| | - Mehul D. Patel
- Department of Emergency Medicine, School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
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16
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Wheeler SB, Biddell CB, Manning ML, Gellin MS, Padilla NR, Spees LP, Rogers CD, Rodriguez-O'Donnell J, Samuel-Ryals C, Birken SA, Reeder-Hayes KE, Petermann VM, Deal AM, Rosenstein DL. Lessening the Impact of Financial Toxicity (LIFT): a protocol for a multi-site, single-arm trial examining the effect of financial navigation on financial toxicity in adult patients with cancer in rural and non-rural settings. Trials 2022; 23:839. [PMID: 36192802 PMCID: PMC9527389 DOI: 10.1186/s13063-022-06745-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 09/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Almost half of the patients with cancer report cancer-related financial hardship, termed "financial toxicity" (FT), which affects health-related quality of life, care retention, and, in extreme cases, mortality. This increasingly prevalent hardship warrants urgent intervention. Financial navigation (FN) targets FT by systematically identifying patients at high risk, assessing eligibility for existing resources, clarifying treatment cost expectations, and working with patients and caregivers to develop a plan to cope with cancer costs. This trial seeks to (1) identify FN implementation determinants and implementation outcomes, and (2) evaluate the effectiveness of FN in improving patient outcomes. METHODS The Lessening the Impact of Financial Toxicity (LIFT) study is a multi-site Phase 2 clinical trial. We use a pre-/post- single-arm intervention to examine the effect of FN on FT in adults with cancer. The LIFT trial is being conducted at nine oncology care settings across North Carolina in the United States. Sites vary in geography (five rural, four non-rural), size (21-974 inpatient beds), and ownership structure (governmental, non-profit). The study will enroll 780 patients total over approximately 2 years. Eligible patients must be 18 years or older, have a confirmed cancer diagnosis (any type) within the past 5 years or be living with advanced disease, and screen positive for cancer-related financial distress. LIFT will be delivered by full- or part-time financial navigators and consists of 3 components: (1) systematic FT screening identification and comprehensive intake assessment; (2) connecting patients experiencing FT to financial support resources via trained oncology financial navigators; and (3) ongoing check-ins and electronic tracking of patients' progress and outcomes by financial navigators. We will measure intervention effectiveness by evaluating change in FT (via the validated Comprehensive Score of Financial Toxicity, or COST instrument) (primary outcome), as well as health-related quality of life (PROMIS Global Health Questionnaire), and patient-reported delayed or forgone care due to cost. We also assess patient- and stakeholder-reported implementation and service outcomes post-intervention, including uptake, fidelity, acceptability, cost, patient-centeredness, and timeliness. DISCUSSION This study adds to the growing evidence on FN by evaluating its implementation and effectiveness across diverse oncology care settings. TRIAL REGISTRATION ClinicalTrials.gov NCT04931251. Registered on June 18, 2021.
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Affiliation(s)
- Stephanie B Wheeler
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA. .,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Caitlin B Biddell
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michelle L Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mindy S Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Neda R Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cynthia D Rogers
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julia Rodriguez-O'Donnell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Cleo Samuel-Ryals
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah A Birken
- Wake Forest School of Medicine, Winston-Salem, NC, USA.,Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Katherine E Reeder-Hayes
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Victoria M Petermann
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Donald L Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Departments of Psychiatry and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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17
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Biddell CB, Spees LP, Petermann V, Rosenstein DL, Manning M, Gellin M, Padilla N, Samuel-Ryals CA, Birken SA, Reeder-Hayes K, Deal AM, Cabarrus K, Bell RA, Strom C, DeAntonio PA, Young TH, King S, Leutner B, Vestal D, Wheeler SB. Financial Assistance Processes and Mechanisms in Rural and Nonrural Oncology Care Settings. JCO Oncol Pract 2022; 18:e1392-e1406. [PMID: 35549521 PMCID: PMC9509146 DOI: 10.1200/op.21.00894] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/28/2022] [Accepted: 04/06/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Patients with cancer are at heightened risk of experiencing financial hardship. Financial navigation (FN) is an evidence-based approach for identifying and addressing patient and caregiver financial needs. In preparation for the implementation of a multisite FN intervention, we describe existing processes (ie, events and actions) and mechanisms (ie, how events work together) connecting patients to financial assistance, comparing rural and nonrural practices. METHODS We conducted in-depth, semistructured interviews with stakeholders (ie, administrators, providers, and staff) at each of the 10 oncology care sites across a single state (five rural and five nonrural practices). We developed process maps for each site and analyzed stakeholder perspectives using thematic analysis. After reporting findings back to stakeholders, we synthesized themes and process maps across rural and nonrural sites separately. RESULTS Eighty-three stakeholders were interviewed. We identified six core elements of existing financial assistance processes across all sites: distress screening (including financial concerns), referrals, resource connection points, and pharmaceutical, insurance, and community/foundation resources. Processes differed by rurality; however, facilitators and barriers to identifying and addressing patient financial needs were consistent. Open communication between staff, providers, patients, and caregivers was a primary facilitator. Barriers included insufficient staff resources, challenges in routinely identifying needs, inadequate preparation of patients for anticipated medical costs, and limited tracking of resource availability and eligibility. CONCLUSION This study identified a clear need for systematic implementation of oncology FN to equitably address patient and caregiver financial hardship. Results have informed our current efforts to implement a multisite FN intervention, which involves comprehensive financial toxicity screening and systematization of intake and referrals.
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Affiliation(s)
- Caitlin B. Biddell
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Lisa P. Spees
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Victoria Petermann
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina at Chapel Hill, School of Nursing, Chapel Hill, NC
| | - Donald L. Rosenstein
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Michelle Manning
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Mindy Gellin
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Neda Padilla
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Cleo A. Samuel-Ryals
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Sarah A. Birken
- Wake Forest School of Medicine, Winston-Salem, NC
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Katherine Reeder-Hayes
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Division of Oncology, Chapel Hill, NC
| | - Allison M. Deal
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Kendrel Cabarrus
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
| | - Ronny A. Bell
- Wake Forest School of Medicine, Winston-Salem, NC
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | - Carla Strom
- Wake Forest School of Medicine, Winston-Salem, NC
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Tiffany H. Young
- Novant Health Cancer Institute, Buddy Kemp Support Center, Charlotte, NC
| | - Sherry King
- Carteret Health Care Cancer Center, Morehead City, NC
| | | | | | - Stephanie B. Wheeler
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Department of Health Policy and Management, Chapel Hill, NC
- University of North Carolina at Chapel Hill, Lineberger Comprehensive Cancer Center, Chapel Hill, NC
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18
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Biddell CB, Johnson KT, Patel MD, Smith RL, Hecht HK, Swann JL, Mayorga ME, Hassmiller Lich K. Cross-sector decision landscape in response to COVID-19: A qualitative network mapping analysis of North Carolina decision-makers. Front Public Health 2022; 10:906602. [PMID: 36052008 PMCID: PMC9424900 DOI: 10.3389/fpubh.2022.906602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/29/2022] [Indexed: 01/22/2023] Open
Abstract
Introduction The COVID-19 pandemic response has demonstrated the interconnectedness of individuals, organizations, and other entities jointly contributing to the production of community health. This response has involved stakeholders from numerous sectors who have been faced with new decisions, objectives, and constraints. We examined the cross-sector organizational decision landscape that formed in response to the COVID-19 pandemic in North Carolina. Methods We conducted virtual semi-structured interviews with 44 organizational decision-makers representing nine sectors in North Carolina between October 2020 and January 2021 to understand the decision-making landscape within the first year of the COVID-19 pandemic. In line with a complexity/systems thinking lens, we defined the decision landscape as including decision-maker roles, key decisions, and interrelationships involved in producing community health. We used network mapping and conventional content analysis to analyze transcribed interviews, identifying relationships between stakeholders and synthesizing key themes. Results Decision-maker roles were characterized by underlying tensions between balancing organizational mission with employee/community health and navigating organizational vs. individual responsibility for reducing transmission. Decision-makers' roles informed their perspectives and goals, which influenced decision outcomes. Key decisions fell into several broad categories, including how to translate public health guidance into practice; when to institute, and subsequently loosen, public health restrictions; and how to address downstream social and economic impacts of public health restrictions. Lastly, given limited and changing information, as well as limited resources and expertise, the COVID-19 response required cross-sector collaboration, which was commonly coordinated by local health departments who had the most connections of all organization types in the resulting network map. Conclusions By documenting the local, cross-sector decision landscape that formed in response to COVID-19, we illuminate the impacts different organizations may have on information/misinformation, prevention behaviors, and, ultimately, health. Public health researchers and practitioners must understand, and work within, this complex decision landscape when responding to COVID-19 and future community health challenges.
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Affiliation(s)
- Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States,*Correspondence: Caitlin B. Biddell
| | - Karl T. Johnson
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mehul D. Patel
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Raymond L. Smith
- Department of Engineering, East Carolina University, Greenville, NC, United States
| | - Hillary K. Hecht
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Julie L. Swann
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, United States
| | - Maria E. Mayorga
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, NC, United States
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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19
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Johnson K, Biddell CB, Hassmiller Lich K, Swann J, Delamater P, Mayorga M, Ivy J, Smith RL, Patel MD. Use of Modeling to Inform Decision Making in North Carolina during the COVID-19 Pandemic: A Qualitative Study. MDM Policy Pract 2022; 7:23814683221116362. [PMID: 35923388 PMCID: PMC9340948 DOI: 10.1177/23814683221116362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 07/05/2022] [Indexed: 11/17/2022] Open
Abstract
Background. The COVID-19 pandemic has popularized computer-based decision-support models, which are commonly used to inform decision making amidst complexity. Understanding what organizational decision makers prefer from these models is needed to inform model development during this and future crises. Methods. We recruited and interviewed decision makers from North Carolina across 9 sectors to understand organizational decision-making processes during the first year of the COVID-19 pandemic (N = 44). For this study, we identified and analyzed a subset of responses from interviewees (n = 19) who reported using modeling to inform decision making. We used conventional content analysis to analyze themes from this convenience sample with respect to the source of models and their applications, the value of modeling and recommended applications, and hesitancies toward the use of models. Results. Models were used to compare trends in disease spread across localities, estimate the effects of social distancing policies, and allocate scarce resources, with some interviewees depending on multiple models. Decision makers desired more granular models, capable of projecting disease spread within subpopulations and estimating where local outbreaks could occur, and incorporating a broad set of outcomes, such as social well-being. Hesitancies to the use of modeling included doubts that models could reflect nuances of human behavior, concerns about the quality of data used in models, and the limited amount of modeling specific to the local context. Conclusions. Decision makers perceived modeling as valuable for informing organizational decisions yet described varied ability and willingness to use models for this purpose. These data present an opportunity to educate organizational decision makers on the merits of decision-support modeling and to inform modeling teams on how to build more responsive models that address the needs of organizational decision makers.
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Affiliation(s)
- Karl Johnson
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitlin B. Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julie Swann
- Department of Industrial and Systems Engineering, North Carolina State University, Atlanta, GA, USA
| | - Paul Delamater
- Department of Geography, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria Mayorga
- Department of Industrial and Systems Engineering, North Carolina State University, Atlanta, GA, USA
| | - Julie Ivy
- Department of Industrial and Systems Engineering, North Carolina State University, Atlanta, GA, USA
| | - Raymond L. Smith
- Department of Engineering, College of Engineering and Technology, East Carolina University, Greenville, NC, USA
| | - Mehul D. Patel
- Department of Emergency Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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20
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Wheeler SB, Birken SA, Wagi CR, Manning ML, Gellin M, Padilla N, Rogers C, Rodriguez J, Biddell CB, Strom C, Bell RA, Rosenstein DL. Core functions of a financial navigation intervention: An in-depth assessment of the Lessening the Impact of Financial Toxicity (LIFT) intervention to inform adaptation and scale-up in diverse oncology care settings. Front Health Serv 2022; 2:958831. [PMID: 36925862 PMCID: PMC10012722 DOI: 10.3389/frhs.2022.958831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/21/2022] [Indexed: 11/11/2022]
Abstract
Background Lessening the Impact of Financial Toxicity (LIFT) is an intervention designed to address financial toxicity (FT) and improve cancer care access and outcomes through financial navigation (FN). FN identifies patients at risk for FT, assesses eligibility for financial support, and develops strategies to cope with those costs. LIFT successfully reduced FT and improved care access in a preliminary study among patients with high levels of FT in a single large academic cancer center. Adapting LIFT requires distinguishing between core functions (components that are key to its implementation and effectiveness) and forms (specific activities that carry out core functions). Our objective was to complete the first stage of adaptation, identifying LIFT core functions. Methods We reviewed LIFT's protocol and internal standard-operating procedures. We then conducted 45-90 min in-depth interviews, using Kirk's method of identifying core functions, with key LIFT staff (N = 8), including the principal investigators. Interviews focused on participant roles and intervention implementation. Recorded interviews were transcribed verbatim. Using ATLAS.ti and a codebook based on the Model for Adaptation Design and Impact, we coded interview transcripts. Through thematic analysis, we then identified themes related to LIFT's intervention and implementation core functions. Two report back sessions with interview participants were incorporated to further refine themes. Results Six intervention core functions (i.e., what makes LIFT effective) and five implementation core functions (i.e., what facilitated LIFT's implementation) were identified to be sufficient to reduce FT. Intervention core functions included systematically cataloging knowledge and tracking patient-specific information related to eligibility criteria for FT relief. Repeat contacts between the financial navigator and participant created an ongoing relationship, removing common barriers to accessing resources. Implementation core functions included having engaged sites with the resources and willingness necessary to implement FN. Developing navigators' capabilities to implement LIFT-through training, an established case management system, and connections to peer navigators-were also identified as implementation core functions. Conclusion This study adds to the growing evidence on FN by characterizing intervention and implementation core functions, a critical step toward promoting LIFT's implementation and effectiveness.
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Affiliation(s)
- Stephanie B Wheeler
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sarah A Birken
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States.,Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Cheyenne R Wagi
- Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Michelle L Manning
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Mindy Gellin
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Neda Padilla
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Cindy Rogers
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Julia Rodriguez
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Caitlin B Biddell
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Carla Strom
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Ronny Antonio Bell
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, United States
| | - Donald L Rosenstein
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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21
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Biddell CB, Wheeler SB, Angove RSM, Gallagher KD, Anderson E, Kent EE, Spees LP. Racial and Ethnic Differences in the Financial Consequences of Cancer-Related Employment Disruption. Front Oncol 2021; 11:690454. [PMID: 34395255 PMCID: PMC8361325 DOI: 10.3389/fonc.2021.690454] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 07/16/2021] [Indexed: 01/16/2023] Open
Abstract
Introduction Cancer-related employment disruption contributes to financial toxicity and associated clinical outcomes through income loss and changes in health insurance and may not be uniformly experienced. We examined racial/ethnic differences in the financial consequences of employment disruption. Methods We surveyed a national sample of cancer patients employed at diagnosis who had received assistance from a national nonprofit about the impact of cancer diagnosis and treatment on employment. We used logistic regression models to examine racial/ethnic differences in income loss and changes in health insurance coverage. Results Of 619 cancer patients included, 63% identified as Non-Hispanic/Latinx (NH) White, 18% as NH Black, 9% as Hispanic/Latinx, 5% as other racial/ethnic identities, and 5% unreported. Over 83% reported taking a significant amount of time off from work during cancer diagnosis and treatment, leading to substantial income loss for 64% and changes in insurance coverage for 31%. NH Black respondents had a 10.2 percentage point (95% CI: 4.8 – 19.9) higher probability of experiencing substantial income loss compared to NH White respondents, and Hispanic or Latinx respondents had a 12.4 percentage point (95% CI: 0.3 – 24.5) higher probability compared to NH White respondents, controlling for clinical characteristics (i.e., cancer type, stage and age at diagnosis, and time since diagnosis). Similarly, NH Black respondents had a 9.3 percentage point (95% CI: -0.7 – 19.3) higher probability of experiencing changes in health insurance compared to NH White respondents, and Hispanic or Latinx respondents had a 10.0 percentage point (95% CI: -3.0 – 23.0) higher probability compared to NH White respondents. Discussion Compared with NH White respondents, NH Black and Hispanic/Latinx respondents more commonly reported employment-related income loss and health insurance changes. Given documented racial/ethnic differences in job types, benefit generosity, and employment protections as a result of historic marginalization, policies to reduce employment disruption and its associated financial impact must be developed with a racial equity lens.
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Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | | | | | - Eric Anderson
- Patient Advocate Foundation, Hampton, VA, United States
| | - Erin E Kent
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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22
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Oh NL, Biddell CB, Rhodes BE, Brewer NT. Provider communication and HPV vaccine uptake: A meta-analysis and systematic review. Prev Med 2021; 148:106554. [PMID: 33857561 DOI: 10.1016/j.ypmed.2021.106554] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 04/06/2021] [Accepted: 04/11/2021] [Indexed: 12/13/2022]
Abstract
Provider communication can be critically important to families as they consider HPV vaccination. We sought to characterize the association of provider communication and HPV vaccine uptake, and when communication better motivates vaccination. We searched four databases for studies published between 2006 and 2019. Eligible studies examined health care provider communication (defined as recommendation or discussion) and HPV vaccine uptake (defined as initiation, completion, or follow-through) in the US. Two coders independently identified eligible studies and coded effect sizes and study characteristics. We pooled effect sizes using random-effects meta-analysis. We identified 59 eligible studies of 265,083 patients. Receiving a provider recommendation was associated with higher HPV vaccine initiation (pooled OR = 10.1, 95% CI: 7.6-13.4). HPV vaccine initiation was 24% for patients without and 60% for patients with a provider recommendation. The pooled effect size for provider recommendation and initiation was smaller for probability samples, clinical records, and NIS-Teen (all p < 0.002). Recommendations were equally effective for males and females, for different patient ages, and over time. Provider recommendation was also associated with higher HPV vaccine series completion and follow-through. Provider discussion was similarly associated with higher HPV vaccine initiation (OR = 12.4, 95% CI: 6.3-24.3). In summary, provider communication was robustly associated with HPV vaccination initiation, completion, and follow-through. These findings suggest that US public health efforts to increase HPV vaccine coverage should continue to emphasize provider communication.
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Affiliation(s)
- N Loren Oh
- University of North Carolina School of Medicine, United States of America; Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, United States of America
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, United States of America
| | - Blythe E Rhodes
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, United States of America
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina, United States of America.
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23
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Biddell CB, Spees LP, Smith JS, Brewer NT, Des Marais AC, Sanusi BO, Hudgens MG, Barclay L, Jackson S, Kent EE, Wheeler SB. Perceived Financial Barriers to Cervical Cancer Screening and Associated Cost Burden Among Low-Income, Under-Screened Women. J Womens Health (Larchmt) 2021; 30:1243-1252. [PMID: 33851854 DOI: 10.1089/jwh.2020.8807] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Despite screening's effectiveness in reducing cervical cancer incidence and mortality, disparities in cervical cancer screening uptake remain, with lower rates documented among uninsured and low-income individuals. We examined perceived financial barriers to, and the perceived cost burden of, cervical cancer screening. Materials and Methods: We surveyed 702 low-income, uninsured or publicly insured women ages 25-64 years in North Carolina, U.S., who were not up to date on cervical cancer screening according to national guidelines. Participants were asked about perceived financial barriers to screening and how much they perceived screening would cost. We used multivariable logistic regression to assess the sociodemographic predictors of perceived financial barriers. Results: Seventy-two percent of participants perceived financial barriers to screening. Screening appointment costs (71%) and follow-up/future treatment costs (44%) were most commonly reported, followed by lost pay due to time missed from work (6%) and transportation costs (5%). In multivariable analysis, being uninsured (vs. publicly insured), younger (25-34 vs. 50-64 years), White (vs. Black), and not reporting income data were associated with perceiving screening costs and future treatment costs as barriers to screening. Participants reported wide-ranging estimates of the perceived out-of-pocket cost of screening ($0-$1300), with a median expected cost of $245. Conclusions: The majority of our sample of low-income women perceived substantial financial barriers to screening, particularly related to screening appointment costs and potential follow-up/future treatment costs. Providing greater cost transparency and access to financial assistance may reduce perceived financial barriers to screening, potentially increasing screening uptake among this underserved population. Clinicaltrials.gov registration number NCT02651883.
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Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jennifer S Smith
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Health Behavior and Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Andrea C Des Marais
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Busola O Sanusi
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Michael G Hudgens
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Lynn Barclay
- American Sexual Health Association, Research Triangle Park, North Carolina, USA
| | - Sarah Jackson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Erin E Kent
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
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24
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Biddell CB, Spees LP, Mayer DK, Wheeler SB, Trogdon JG, Rotter J, Birken SA. Developing personalized survivorship care pathways in the United States: Existing resources and remaining challenges. Cancer 2020; 127:997-1004. [PMID: 33259060 DOI: 10.1002/cncr.33355] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/27/2020] [Accepted: 11/12/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Deborah K Mayer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.,School of Nursing, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | | | - Sarah A Birken
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina
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25
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Wheeler SB, Spees L, Biddell CB, Rotter J, Trogdon JG, Birken SA, Mayer D. Development of a personalized follow-up care algorithm for Medicare breast cancer survivors. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.29_suppl.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
204 Background: The rapidly growing number of cancer survivors in the US have substantial healthcare needs requiring surveillance and care for the late and long-term effects of cancer treatment and comorbidities. Lacking a clear system of care, experts recommend a personalized approach to survivorship care. The objective of this study was to test a clinical prediction algorithm to distinguish low-complexity breast cancer survivors who may be suited to self-manage their survivorship care and be followed by their primary care provider (PCP) from survivors who require specialty care. Methods: We used the Surveillance and Epidemiology End Results (SEER) registry – Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data to identify women diagnosed with stage 0-3 breast cancer between 2003 and 2011. Cross-validated random forest machine learning models separately estimated survivors’ independent risk of all-cause death, cancer-specific death, recurrence, or severe late effects within 3 years following treatment completion. The absence of these outcomes identified survivors as potentially eligible for self-management and PCP care. Predictors included measures of baseline health status and health care utilization, patient socio-demographic characteristics, cancer characteristics, and financial burden. Results: Among the 4,516 survivors in the primary cohort, 82% were white, and the mean (SD) age was 75.1 (7.8) years. Almost 50% were diagnosed with Stage I breast cancer, followed by 25.2% with Stage 2, 19.3% with Stage 0, and 5.6% with Stage III. Within the 3-year follow-up period, 372 (8.2%) survivors died (111 or 2.5% from cancer), 665 (14.7%) experienced recurrence, and 488 (10.8%) were hospitalized due to severe late effects. Predicting all-cause death resulted in 91.9% out-of-sample accuracy, a 37.6% improvement over an uninformed model. Important predictors across outcomes included age, geographic region, diagnosis year, financial burden, comorbidities, and cancer stage. Conclusions: Survivors requiring specialty care are characterized by higher comorbidity, lower educational attainment, and advanced age, suggesting that, in addition to cancer characteristics, personalized care pathways developed in response to our findings must account for social and contextual factors as well.
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Affiliation(s)
| | - Lisa Spees
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | | | - Sarah A. Birken
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Deborah Mayer
- The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Biddell CB, O'Leary MC, Wheeler SB, Spees LP. Variation in Cervical Cancer Screening Preferences among Medically Underserved Individuals in the United States: A Systematic Review. Cancer Epidemiol Biomarkers Prev 2020; 29:1535-1548. [PMID: 32457182 DOI: 10.1158/1055-9965.epi-20-0306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/16/2020] [Accepted: 05/19/2020] [Indexed: 11/16/2022] Open
Abstract
Underutilization of effective screening is one driver of disparities in cervical cancer incidence and mortality. Consideration of patient preferences could help to improve screening rates in populations facing substantial barriers to preventive care. We conducted a systematic review of the literature on cervical cancer screening preferences among medically underserved patients in the United States. We searched six electronic databases (PubMed, Web of Science, EMBASE, Scopus, CINAHL, and PsycINFO) for articles published through February 2019 (Prospero ID: CRD42019125431). Among the 43 articles included, 23 reported screening modality preferences, 11 reported preferences related to provider demographics and attributes, six reported screening scheduling and results delivery preferences, and nine reported preferences related to health education and communication. This review demonstrates the wide variety of medically underserved patient preferences related to cervical cancer screening. It also draws attention to two key preference trends that emerged despite heterogeneity in study design, populations, and preference assessment. Consistent preferences for human papillomavirus self-testing over traditional Pap testing highlight a key potential mechanism for increasing cervical cancer screening uptake among medically underserved populations. In addition, preferences for gender- and language-concordant providers underscore the need for continued efforts toward expanding diversity among medical professionals.
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Affiliation(s)
- Caitlin B Biddell
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Meghan C O'Leary
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Stephanie B Wheeler
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Center for Health Promotion & Disease Prevention, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lisa P Spees
- Department of Health Policy & Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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