"It was kind of a nightmare, it really was:" financial toxicity among rural women cancer survivors

PURPOSE

The purpose of this study was to examine how rural women cancer survivors experience and manage financial toxicity.

METHODS

A qualitative descriptive design was used to explore experiences of financial toxicity among rural women who received cancer treatment. We conducted qualitative interviews with 36 socioeconomically diverse rural women cancer survivors.

RESULTS

Participants were categorized into three groups: (1) survivors who struggled to afford basic living expenses but did not take on medical debt; (2) survivors who took on medical debt but were able to meet their basic needs; and (3) survivors who reported no financial toxicity. The groups differed by financial and job security and insurance type. We describe each group and, for the first two groups, the strategies they used to manage financial toxicity.

CONCLUSIONS

Financial toxicity related to cancer treatment is experienced differently by rural women cancer survivors depending on financial and job security and insurance type. Financial assistance and navigation programs should be tailored to support rural patients experiencing different forms of financial toxicity.

IMPLICATIONS FOR CANCER SURVIVORS

Rural cancer survivors with financial security and private insurance may benefit from policies aimed at limiting patient cost-sharing and financial navigation to help patients understand and maximize their insurance benefits. Rural cancer survivors who are financially and/or job insecure and have public insurance may benefit from financial navigation services tailored to rural patients that can assist with living expenses and social needs.

Non-use and inadequate use of cervical cancer screening among a representative sample of women in the United States

Introduction

Women's adherence to the United States (U.S.) Preventive Services Task Force guidelines for cervical cancer screening was determined by examining predisposing, enabling, and needs factors from Andersen's Behavioral Model of Health Services Use conceptual framework.

Methods

The outcome was operationalized as cervical cancer screening use, non-use, and inadequate-use. Multinomial logistic regression was conducted on data from the 2019 National Health Interview Survey of 7,331 eligible women aged 21-65.

Results

Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Non-Users than those aged 21-29. Hispanic, Asian, and American Indian/Alaska Native (AIAN) women were more likely to be Non-Users than White women. More educated women were less likely to be Non-Users. Foreign-born women <10 years in the U.S. were more likely to be Non-Users than U.S.-born women. Women with financial hardship were less likely to be Non-Users. Poorer women and uninsured women were more likely to be Non-Users. Women with children in their household were less likely to be Non-Users than those without children. Women who had a well-visit in the past year were less likely to be Non-Users. Women with a history of human papillomavirus (HPV) vaccination were less likely to be Non-Users. Compared with women who used cervical cancer screening services, women aged 30-65 were less likely to be Inadequate-Users. AIAN women were more likely to be Inadequate-Users. Women of other races were less likely to be Inadequate-Users. Employed women were less likely to be Inadequate-Users. Uninsured women were more likely to be Inadequate-Users. Women who had a well-visit within a year were less likely to be Inadequate-Users. Women with past HPV vaccination were more likely to be Inadequate-Users. Smokers were less likely to be Inadequate-Users.

Discussion

Predisposing, enabling, and needs factors are differently associated with non-use and inadequate use of cervical cancer screening. Understanding factors associated with the use, non-use, and inadequate use of cervical cancer screening is crucial to avoid or curb unnecessary tests, increased costs to both society and individuals, and the ill-allocation of limited resources.

Barriers, facilitators, and priority needs related to cancer prevention, control, and research in rural, persistent poverty areas

PURPOSE

The purpose of this study was to identify the barriers, facilitators, and priority needs related to cancer prevention, control, and research in persistent poverty areas.

METHODS

We conducted three focus groups with 17 providers and staff of primary care clinics serving persistent poverty areas throughout the state of Arkansas.

RESULTS

We identified multiple barriers, facilitators, and priority needs related to cancer prevention and control at primary care clinics serving persistent poverty areas. Barriers included transportation, medical costs, limited providers and service availability, and patient fear/discomfort with cancer topics. Facilitators identified were cancer navigators and community health events/services, and priority needs included patient education, comprehensive workflows, improved communication, and integration of cancer navigators into healthcare teams. Barriers to cancer-related research were lack of provider/staff time, patient uncertainty/skepticism, patient health literacy, and provider skepticism/concerns regarding patient burden. Research facilitators included better informing providers/staff about research studies and leveraging navigators as a bridge between clinic and patients.

CONCLUSION

Our results inform opportunities to adapt and implement evidence-based interventions to improve cancer prevention, control, and research in persistent poverty areas. To improve cancer prevention and control, we recommend locally-informed strategies to mitigate patient barriers, improved patient education efforts, standardized patient navigation workflows, improved integration of cancer navigators into care teams, and leveraging community health events. Dedicated staff time for research, coordination of research and clinical activities, and educating providers/staff about research studies could improve cancer-related research activities in persistent poverty areas.

Facilitators and barriers to employment for rural women cancer survivors

PURPOSE

Limited research exists on the employment experiences of rural women cancer survivors, yet this population may face unique barriers to employment following a cancer diagnosis. This study aims to identify facilitators and barriers to employment for rural women cancer survivors.

METHODS

We used a qualitative descriptive design to examine facilitators and barriers to employment for rural women cancer survivors. We conducted interviews with 33 rural women with cancer histories.

RESULTS

Facilitators of employment included paid time off, flexible work arrangements, and supportive workplace social networks, while barriers to employment included compromised immunity, long-term treatment effects, stigma and discrimination, and limited rural job markets. Rural women with secure employment histories generally experienced facilitators of employment, while rural women with insecure (e.g., temporary, informal, non-standard) employment histories generally faced barriers to retaining jobs and finding employment.

CONCLUSIONS

Formal and informal workplace support helped rural women retain their jobs during and following cancer treatment, especially those with secure employment. However, women with insecure employment histories generally faced multiple barriers to retaining and finding employment. More inclusive policies to support workers facing disabling illnesses, such as paid medical leave, are needed to ensure cancer survivors can maintain employment and/or financial security during and following their cancer treatment.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors with secure employment may benefit from formal and informal workplace support in retaining their employment. Those with insecure employment histories may benefit from access to job placement services and inclusive policies protecting employment for all workers experiencing disabling illness.

Factors associated with breast cancer screening services use among women in the United States: An application of the Andersen's Behavioral Model of Health Services Use

This study applied Andersen's Behavioral Model of Health Services Use to examine predisposing, enabling, and need factors associated with adherence to the United States Preventive Services Task Force (USPSTF) guidelines for breast cancer screening (BCS). Multivariable logistic regression was used to determine factors of BCS services utilization among 5484 women aged 50-74 from the 2019 National Health Interview Survey. Predisposing factors significantly associated with use of BCS services were: being a Black (odds-ratios [OR]:1.49; 95% confidence interval [CI]:1.14-1.95) or a Hispanic woman (OR:2.25; CI:1.62-3.12); being married/partnered (OR:1.32, CI:1.12-1.55); having more than a bachelor's degree (OR: 1.62; CI:1.14-2.30); and living in rural areas (OR:0.72; CI:0.59-0.92). Enabling factors were: poverty level [≤138% federal poverty level (FPL) (OR:0.74; CI:0.56-0.97), >138-250% FPL (OR:0.77; CI:0.61-0.97), and > 250-400% FPL (OR:0.77; CI:0.63-0.94)]; being uninsured (OR:0.29; CI:0.21-0.40); having a usual source of care at a physician office (OR:7.27; CI:4.99-10.57) or other healthcare facilities (OR:4.12; CI:2.68-6.33); and previous breast examination by a healthcare professional (OR:2.10; CI:1.68-2.64). Need factors were: having fair/poor health (OR:0.76; CI:0.59-0.97) and being underweight (OR:0.46; CI:0.30-0.71). Disparities in BCS services utilization by Black and Hispanic women have been reduced. Disparities still exist for uninsured and financially restrained women living in rural areas. Addressing disparities in BCS uptake and improving adherence to USPSTF guidelines may require revamping policies that address disparities in enabling resources, such as health insurance, income, and health care access.

Medical Financial Hardship and Food Security among Cancer Survivors in the United States

BACKGROUND

Some cancer survivors experience medical financial hardship, which may reduce their food security. The purpose of this study was to explore whether medical financial hardship is related to food security among cancer survivors.

METHODS

The study was based on cross-sectional data from the 2020 National Health Interview Survey. We used ordinal logistic regression to examine the relationship between material, psychological, and behavioral medical financial hardships and household food security (i.e., high, marginal, low, or very low) among individuals ages ≥18 years who reported a cancer diagnosis from a health professional (N = 4,130).

RESULTS

The majority of the sample reported high household food security (88.5%), with 4.8% reporting marginal, 3.6% reporting low, and 3.1% reporting very low household food security. In the adjusted model, the odds of being in a lower food security category were higher for cancer survivors who had problems paying or were unable to pay their medical bills compared with those who did not [OR, 1.73; 95% confidence interval (CI), 1.06-2.82, P = 0.027], who were very worried about paying their medical bills compared with those who were not at all worried (OR, 2.88; 95% CI, 1.64-5.07; P < 0.001), and who delayed medical care due to cost compared with those who did not (OR, 2.56; 95% CI, 1.29-5.09; P = 0.007).

CONCLUSIONS

Food insecurity is rare among cancer survivors. However, medical financial hardship is associated with an increased risk of lower household food security among cancer survivors.

IMPACT

A minority of cancer survivors experience medical financial hardship and food insecurity; social needs screenings should be conducted.

Understanding Vaccination Among Hesitant Adopters of the COVID-19 Vaccine Using the Increasing Vaccination Model

The coronavirus disease (COVID-19) was the third leading cause of death in 2021 in the United States and has led to historic declines in life expectancy for Americans. While vaccination is an effective mitigation strategy for COVID-19, vaccine hesitancy remains a major barrier to individual and population-level protection. An emerging literature on hesitant adopters of COVID-19 vaccines highlights co-occurrence of hesitancy and vaccine uptake as an understudied phenomenon, with the potential to provide insight into factors that lead hesitant individuals to become vaccinated despite their hesitancy. We use qualitative interviews among hesitant adopters in Arkansas to examine vaccine hesitancy among this understudied group. Drawing on the Increasing Vaccination Model, we find that the most frequently reported motivations of hesitant adopters were within the domain of social processes, pointing to a critical focal point for targeted health communications intervening in this domain (e.g. social norms, social networks, and altruistic behavior). We find that recommendations from health care workers (HCWs) other than physicians/providers may serve as an effective influence to vaccinate. We also demonstrate negative effects of low provider and HCW confidence and weak recommendations on motivations to vaccinate among individuals expressing vaccine hesitancy. Additionally, we find individual information-seeking behaviors among hesitant adopters bolstered confidence in the efficacy of the COVID-19 vaccine. Based on these findings, clear, accessible, and authoritative health communication has a role in combatting the COVID-19 misinformation/disinformation infodemic.

Hesitant but vaccinated: assessing COVID-19 vaccine hesitancy among the recently vaccinated

We administered a survey during the fifteen-minute wait time after the COVID-19 vaccine was given (N = 1475) to examine attitudes towards COVID-19 vaccines among adults who were vaccinated in Arkansas between April 22nd and July 6th, 2021. We found 60% of those who had just been vaccinated reported some level of hesitancy, including 10% who reported being "very hesitant." Hesitancy was not evenly distributed across sociodemographic groups (age, sex, race/ethnicity, and education) and was associated with whether a non-English language is spoken in the home, health care coverage, and flu vaccination over the past five years in bivariate analysis. Generalized ordered logistic regression results reveal associations between the log-ordered odds of COVID-19 vaccine hesitancy and age, sex, race/ethnicity, health care coverage, health literacy, and flu vaccination over the past five years. Surprisingly, a prior COVID-19 diagnosis was not significantly associated with COVID-19 vaccine hesitancy. These results can inform health care and communication strategies. Further attention to "hesitant adopters" can provide insights into the process of overcoming vaccine hesitancy that are critical to vaccine uptake.

"Life is hard": How the COVID-19 pandemic affected daily stressors of women

The COVID-19 pandemic radically and rapidly altered Americans' daily life as they navigated quarantines, school closings, job insecurity, and disrupted social activities. The COVID-19 pandemic has disproportionately affected women who have reported higher levels of stress, anxiety, and depression related to the pandemic compared to men. The study explored how the COVID-19 pandemic affected daily stressors of women. Qualitative and quantitative data were collected simultaneously using an online questionnaire from female participants (N = 531) who were 18 years of age or older and residing, employed, or accessing health care in Arkansas. A qualitative descriptive approach was used to summarize and synthesize participants' experiences and perceptions. Qualitative data allowed respondents to describe their lived experiences of how the COVID-19 pandemic affected them from their perspective. Four primary themes related to participants' experiences of stress related to the COVID-19 outbreak are reported: 1) employment and expenses, 2) social distancing, 3) caregiving, and 4) emotional/mental health. Several subthemes emerged within primary themes. The study documented respondents' lived experiences and how COVID-19 stress increased anxiety, depression, fear, and frustration. These findings contribute important nuances about women's experiences of stress caused by COVID-19 and can inform future health policies to address women's health post-pandemic and in future health crises. This study makes a significant contribution to the literature as the first article that uses qualitative methods to document sources of COVID-19 pandemic stress for women in their own words.

Factors influencing COVID-19 vaccine decision-making among hesitant adopters in the United States

Increasing COVID-19 vaccine uptake is crucial to managing the endemic. In this qualitative study, we examine factors influencing the decision-making process of COVID-19 hesitant adopters - those who reported some level of hesitancy and are vaccinated. Using interviews with 49 participants, we documented multiple factors influencing the decision-making process to get the COVID-19 vaccine among a racially and ethnically diverse sample of hesitant adopters in the US. Participants described influences related to sociocultural context and personal and group influences, which affected their decision to get the COVID-19 vaccine despite being hesitant. We find politics, culture, healthcare professionals, employment, vaccine attitudes and beliefs, social networks, and the media influence the decision to get vaccinated. Our findings provide nuanced and in-depth information in their own words. This study expands on prior literature on COVID-19 vaccine hesitancy, especially among hesitant adopters. These findings can inform future interventions and research targeting vaccine-hesitant populations to increase vaccine uptake.

Physical activity and fruit and vegetable consumption during the COVID-19 pandemic for people with type 2 diabetes mellitus

AIMS

To understand the associations between sociodemographic factors, self-rated health, and COVID-19-related changes in physical activity and diet and the reported number of days per week participants engaged in physical activity and consumed fruits and vegetables for people with type 2 diabetes mellitus (T2DM).

METHODS

Respondents from Arkansas primary care clinics completed a survey between October 2020 and January 2021. Multivariable regression determined associations between sociodemographic factors, self-rated health, and COVID-19-related changes in physical activity and diet and the reported number of days per week participants engaged in physical activity and consumed fruits and vegetables.

RESULTS

Respondents exercised for at least 30 min on a mean of 2.09 days and consumed five or more fruit and vegetable servings on a mean of 3.57 days. Males engaged in one additional day of physical activity compared to women. Respondents with a college degree or higher ate 5 or more fruit and vegetable servings on fewer days per week than those with a high school education or less.

CONCLUSIONS

Results reaffirm a need for diabetes education programs and health care providers to provide information on the importance of maintaining physical activity and a healthy diet as part of a self-care plan for T2DM, especially during public health emergencies like the COVID-19 pandemic.

"I am hesitant to visit the doctor unless absolutely necessary": A qualitative study of delayed care, avoidance of care, and telehealth experiences during the COVID-19 pandemic

The COVID-19 pandemic has disrupted the health care system, resulting in decreased health care utilization. During the pandemic, some patients chose to postpone clinic visits or avoid them altogether while health care providers concurrently scaled back their services. As a result, health care has shifted to a greater reliance on telehealth and virtual care. This study uses a qualitative descriptive design, focused on providing summaries of participant experiences of health care and telehealth utilization during the COVID-19 pandemic. Three primary themes emerged during analysis: delayed health care, avoidance of care, and experiences of telehealth. Sub-themes of delayed health care included care delays and scheduling difficulties. Participants reported avoidance of health care due to fear of COVID-19 infection, as well as general changes to care-seeking behaviors. Participants also reported positive experiences with telehealth, with some respondents noting limitations of telehealth systems, such as limitations on procedures and patient-centered monitoring of chronic illness. Our findings support studies that have found both health care delays and changes in health care utilization patterns during the pandemic. Most importantly, this study expands the literature concerning links between fear of COVID-19 and altered care-seeking behaviors, which is the first study to do so focusing on these concerns in the participants' own words. Finally, while telehealth is promising in preserving continuity of care during pandemics, long-term integration into the health care system is not without challenges, and this study provides insights into how patients experienced telehealth during COVID-19 in their own words. Data collection, survey design, and research priorities for this study were based on input from ongoing community partnerships.

COVID-19 Death Exposure among Adults in the United States

As of May 17, 2022, more than a million deaths due to COVID-19 have been recorded in the US. For each COVID-19 death, there are an estimated nine bereaved family members and an unknown number of bereaved friends. This study aimed to assess the correlates of self-reported COVID-19 death exposure (i.e., loss of a close friend or family member) among US adults using online survey data (n = 1,869) collected between September 17, 2021 and October 3, 2021. One in four US adults in this national sample reported the loss of a close friend or family member due to COVID-19. The odds of losing a close friend or family member due to COVID-19 death were greater for those age 60 or older, all minoritized racial/ethnic groups except for Asian American respondents, married/coupled respondents, those who had foregone care due to cost in the past year, and those who reported a COVID-19 infection.

Assessment of Colorectal Cancer Screening Disparities in U.S. Men and Women Using a Demographically Representative Sample

Timely receipt of colorectal cancer (CRC) screening can reduce morbidity and mortality. This is the first known study to adopt Andersen's model of health services use to identify factors associated with CRC screening among US adults. The data from National Health Interview Survey from 2019 was utilized to conduct the analyses. Multivariable logistic regression was used to separately analyze data from 7,503 age-eligible women and 6,486 age-eligible men. We found similar CRC screening levels among men (57.7%) and women (57.6%). Factors associated with higher screening odds in women were older age, married/cohabitating with a partner, Black race, >bachelor's degree, having a usual source of care, and personal cancer history. Factors associated with lower odds for women were American Indian/Alaska Native race, living in the US for ≤10 years, ≤138% federal poverty level (FPL), uninsured or having Medicare, and in fair/poor health. For men, factors associated with higher screening odds were older age, homosexuality, married/cohabitating with a partner, Black race, >high school/general educational development education, having military insurance, having a usual source of care, and personal cancer history. Factors associated with lower odds for men were being a foreign-born US resident, living in the South or Midwest, ≤138% FPL, and being uninsured or having other insurance. Despite lower screening rates in the past, Black adults show a significantly higher likelihood of CRC screening than White adults; yet, screening disparities remain in certain other groups. CRC screening efforts should continue to target groups with lower screening rates to eliminate screening disparities.

Pandemic-Amplified Material Hardship and Community-Led Support among Marshallese Diasporic Communities in the United States

This article explores the experiences of Marshallese diasporic migrants in the United States (U.S.) during the COVID-19 pandemic in relation to material hardship and community-led relief efforts. Focus groups with 53 Marshallese migrants in three states revealed that material hardship, including food and housing insecurity, inadequate healthcare, and difficulty paying bills, intensified among their communities during the pandemic. In response, Marshallese community-based groups provided relief to their fellow community members, including food, cash assistance, and personal protective equipment. The findings fit a pattern of intensified hardship and community-led relief among marginalized communities in the U.S. during the COVID-19 pandemic.

Facilitators to vaccination among hesitant adopters

To end the COVID-19 pandemic, it is essential to increase vaccine coverage in the United States (U.S.). In this study, we examine the facilitators that helped hesitant adopters - those who are both vaccinated and report some degree of hesitancy - overcome barriers to vaccination. Drawing on a sample of 867 hesitant adopters in Arkansas, we find social networks, individual actions, health care organizations and professionals, employers, religious communities and leaders, and the media all play a role in helping the vaccine hesitant overcome barriers to vaccination. Our findings demonstrate vaccine hesitancy and uptake occur simultaneously, and overcoming hesitancy in the U.S. population requires multifaceted strategies from multiple entities. We provide recommendations for overcoming barriers, including hesitancy, based on our findings.

Trusted Sources of COVID-19 Vaccine Information among Hesitant Adopters in the United States

The World Health Organization has identified vaccine hesitancy as a top health concern. Emerging research shows that those who are hesitant may still get vaccinated; however, little is known about those who say they are hesitant but still get vaccinated. Most people have high trust in several sources of COVID-19 information, and trust in certain information sources such as the Centers for Disease Control and Prevention and health care providers was associated with being vaccinated. This study explored trusted information sources among hesitant adopters in the United States with a survey respondents completed while waiting after receiving a COVID-19 vaccine dose. The study included (n = 867) respondents. The majority of respondents were female (60.21%); were between the ages of 18 and 44 years old (71.97%); and were diverse, with most identifying as White (44.54%) or Hispanic/Latinx (32.55%). Hesitant adopters reported multiple trusted sources of COVID-19 vaccine information, which can be grouped into four emergent subthemes: (1) Health care/Medical science, (2) Personal relationships, (3) News and social media, and (4) Individual/Myself. Some respondents expressed a distrust of all sources of COVID-19 vaccine information, despite receiving the vaccine, describing a lack of trust in traditional sources of information such as the mainstream media or government. This study contributes to the literature by documenting trusted sources of COVID-19 vaccine information among hesitant adopters in the United States. Findings provide important insights about respondents' trusted sources of COVID-19 vaccine information that can inform future public health messaging campaigns intended to increase vaccine uptake among hesitant adopters.

Cancer-Related Debt and Mental-Health-Related Quality of Life among Rural Cancer Survivors: Do Family/Friend Informal Caregiver Networks Moderate the Relationship?

Social connectedness generally buffers the effects of stressors on quality of life. Is this the case for cancer-related debt among rural cancer survivors? Drawing on a sample of 135 rural cancer survivors, we leverage family/friend informal caregiver network data to determine if informal cancer caregivers buffer or exacerbate the effect of cancer-related debt on mental-health-related quality of life (MHQOL). Using data from the Illinois Rural Cancer Assessment, a survey of cancer survivors in rural Illinois, we estimate the association between cancer-related debt and MHQOL and whether informal caregiver network size and characteristics moderate this association. Over a quarter of survivors (27%) reported cancer-related debt, and those who did reported worse MHQOL. However, this association only held for survivors who had an informal caregiver network. These findings supplement what is already known about the role of social connectedness in cancer survivors' health outcomes. We offer possible explanations for these findings.

Racial disparities in eligibility for low-dose computed tomography lung cancer screening among older adults with a history of smoking

PURPOSE

Lung cancer early detection screening has been demonstrated to decrease lung cancer mortality among high-risk smokers. This study aimed to examine whether current screening guidelines may disproportionately exclude African American smokers who are at higher overall risk for lung cancer.

METHODS

Data from the 2014 Health and Retirement Study were analyzed. Older African Americans and Whites with a history of smoking were included in the analyses (n = 7,348). Eligibility criteria established by the U.S. Preventive Services Task Force (USPSTF) for LDCT lung cancer screening were used. Multivariate logistic regression analyses were conducted to examine racial differences in eligibility for LDCT lung cancer screening.

RESULTS

Overall, 21.1% of current and 10.5% of former smokers met USPSTF's eligibility criteria for LDCT screening. In multivariate logistic regression analyses, African American smokers were less likely to be eligible for LDCT lung cancer screening compared to Whites (odds ratio = 0.5; p < 0.001).

CONCLUSION

African American smokers were less likely to meet established lung cancer screening eligibility criteria compared to Whites. Current lung cancer screening criteria may not adequately capture African Americans at risk and may widen the health disparities in African Americans. Further longitudinal studies are needed to evaluate the efficacy of current lung cancer screening guideline.

Abstract C22: Cancer-related financial burden, employment, and health among rural cancer survivors

Purpose: A growing body of literature has begun to document rural-urban disparities among cancer survivors. Rural survivors report worse mental health, health behaviors (e.g., smoking, physical activity), and self-rated health relative to urban counterparts. There is a need to determine modifiable determinants of these disparities, including work. Only one study of which we are aware has explored financial determinants of health: Weaver and colleagues found rural survivors were more likely to report not being able to work because of health-related reasons than urban counterparts. Little, however, is known about cancer-related financial burden during (e.g., filing for bankruptcy) and after treatment (e.g., not returning to work).

Objective: This study seeks to: 1) characterize cancer-related financial burden and employment among rural survivors and 2) examine how these factors pertain to their self-rated health.

Methods: We drew from an ongoing larger study that is characterizing the health needs of 600 rural cancer survivors and caregivers of cancer patients throughout Illinois State. Participants were recruited via non-probability based sampling methods, including physical flyers placed in rural community organizations (e.g., churches, hair salons, support groups), public health departments, clinics, hospitals, and cancer centers as well as at cancer-related events (e.g., Relay for Life); word of mouth; and electronic flyers distributed via websites, listservs, and social media. Interested participants contacted staff via the study website or phone number. To be eligible for the study, individuals self-reported: 1) being 18 years or older, 2) identifying as a survivor and/or caregiver, and 3) living in a rural part of Illinois State. After screening and providing informed consent, participants completed surveys by mail, phone, or website. Participants received $15 for their time and effort.

Results: Since February, we have recruited 72 current survivors, 84% of whom completed the survey online and 27% of whom also self-reported having been caregivers of cancer patients during their lifetime. Our sample was largely female, married, and non-Latino White (NLW). Survivors in the sample are well-educated overall, with 52% holding a bachelor's degree or above. The median annual household income (AHI) was $50,001 to $75,000, with 40% reporting an AHI of more than $75,000. Approximately 26% of respondents indicated cancer-related financial burden. With regard to work, 52% indicated cancer-related work stoppage, 18% indicated they did not return to work, and 40% indicated a reduced workload during treatment. Cancer-related financial burden was associated with family income, in that work stoppage was associated with lower annual household income (B = -0.32, 95% CI [-0.14, -1.35], p = .02). Finally, we examined how cancer-related financial burdens and employment factors were associated with rural residents' self-rated health. Cancer-related employment factors were associated with self-rated health, in that returning to work at a different job (as opposed to the same job) was associated with lower self-rated health (B = -.49, 95% CI [-.34, -.06], p = .008).

Discussion: Our study suggests that work may be an important determinant of rural-urban disparities among cancer survivors. Specifically, financial burden and work difficulties were fairly prevalent among our sample. Returning to work at a different job was significantly associated with lower self-rated health. Limitations include small sample size, generalizability, and an inability to make causal inferences. Our next steps will be to further explore how these work-related factors pertain to specific health behaviors, mental health, and physical health outcomes among survivors and caregivers.

Citation Format: Emily Hallgren, Leslie R. Carnahan, Kristine Zimmermann, Yamile Molina. Cancer-related financial burden, employment, and health among rural cancer survivors [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C22.

The More Things Change, the More They Stay the Same: A Study to Evaluate Compliance With Inclusion and Assessment of Women and Minorities in Randomized Controlled Trials

PURPOSE

The National Institutes of Health (NIH) Revitalization Act of 1993 requires NIH-funded clinical trials to include women and minorities as participants and assess outcomes by sex and race or ethnicity. The objective of this study was to investigate current levels of compliance with these guidelines for inclusion, analysis, and reporting in NIH-funded randomized controlled trials (RCTs) and compare the results with those from 2009 and 2004, which the authors reported previously.

METHOD

The authors identified 782 RCTs published in 14 leading U.S. medical journals in 2015 with a PubMed search. Of those, 142 were the primary report of an NIH-funded RCT, conducted in the United States, and eligible for analysis. The authors reviewed abstract, text, and tables of each eligible study as well as any follow-up published commentary to determine compliance with NIH guidelines.

RESULTS

Thirty-five studies limited enrollment to one sex. The median enrollment of women in the remaining 107 studies was 46%, but 16 (15.0%) enrolled less than 30% women. Twenty-eight of the 107 (26%) reported at least one outcome by sex or explicitly included sex as a covariate in statistical analysis. Of the 142 studies, 19 (13.4%) analyzed or reported outcomes by race or ethnicity. There were no statistically significant changes in inclusion, analysis, or reporting by sex, race, or ethnicity compared with the previous studies.

CONCLUSIONS

NIH policies have not resulted in significant increases in reporting results by sex, race, or ethnicity. The authors recommend strong journal policies to increase compliance with NIH policies.

Health Beliefs of Marshallese Regarding Type 2 Diabetes

OBJECTIVES

The Marshallese population suffers from disproportionate rates of type 2 diabetes. This study identifies the underlying beliefs and perceptions that affect diabetes self-management behavior in the US Marshallese population living in Arkansas.

METHODS

The study employs focus groups with a semi-structured interview guide developed using a community-based participatory research (CBPR) approach and the Health Belief Model. Data were collected from 41 participants; bilingual community co-investigators provided translation as needed.

RESULTS

The results show high-perceived threat, with most participants describing diabetes as inevitable and a death sentence. Participants are generally unaware of the benefits of diabetes self-management behaviors, and the Marshallese population faces significant policy, environmental, and systems barriers to diabetes self-management. The primary cue to action is a diagnosis of diabetes, and there are varying levels of self-efficacy.

CONCLUSIONS

The research grounded in the Health Belief Model provides important contributions that can help advance diabetes self-management efforts within Pacific Islander communities.

Effect of US health policies on health care access for Marshallese migrants

The Republic of the Marshall Islands is a sovereign nation previously under the administrative control of the United States. Since 1986, the Compacts of Free Association (COFA) between the Republic of the Marshall Islands and the United States allows Marshall Islands citizens to freely enter, lawfully reside, and work in the United States, and provides the United States exclusive military control of the region. When the COFA was signed, COFA migrants were eligible for Medicaid and other safety net programs. However, these migrants were excluded from benefits as a consequence of the Personal Responsibility and Work Opportunity Reconciliation Act. Currently, COFA migrants have limited access to health care benefits in the United States, which perpetuates health inequalities.

Protein retention in ion-exchange chromatography: effect of net charge and charge distribution

The charge regulated slab model is used to evaluate the salt dependence of the retention of Staphylococcal nuclease A and its mutants in cation-exchange chromatography. An important feature of this work is that the net charge of the proteins is varied in two different ways: (a) by changing the eluent pH so that the charges are created by protonation and (b) by point mutation at position 116. Since the structure of Staphylococcal nuclease and the mutants are known, the pH dependence of retention data of the different mutants gives detailed insights into the retention mechanism. Experimental results show that the salt dependence of retention is affected more strongly by changes of the eluent pH than by point mutations. This implies that the amino acid in position 116 has only a moderately strong interaction with the stationary phase surface and that a patch on one side of the protein surface is mainly responsible for the electrostatic interaction with the surface.

Prediction of protein retention at gradient elution conditions in ion-exchange chromatography

This work presents a prediction procedure for protein retention in ion-exchange chromatography, where two linear gradient experiments of different length give the protein retention time at other linear gradients. The procedure predicts the retention time of early and late eluting proteins with similar precision and predictions by extrapolation deviate approximately 3% or less from the experimental retention times. By using the ionic strength, this procedure predicts protein retention times obtained with divalent ions in the eluent more accurately than a well-established procedure that uses the protein co-ion concentration.