A Scoping Review of Cancer Interventions with Arab Americans

This scoping review provides an overview of cancer interventions implemented with Arab Americans across the cancer control continuum, including an examination of outcomes and implementation processes. The search strategy included database searching and reviewing reference lists and forward citations to identify articles describing interventions with Arab adults living in the US, with no restrictions on date of publication or research methodology. The review included 23 papers describing 12 unique cancer interventions. Most interventions focused on individual-level determinants of breast and cervical cancer screening; used non-quasi-experimental research designs to evaluate intervention effectiveness; and demonstrated improvements in short-term cancer screening knowledge. Implementation processes were less commonly described. Most interventions were culturally and linguistically tailored to communities of focus; were delivered in educational sessions in community settings; engaged with the community mostly for recruitment and implementation; and were funded by foundation grants. Suggestions for research and intervention development are discussed.

Patient Navigation Can Improve Breast Cancer Outcomes among African American Women in Chicago: Insights from a Modeling Study

African American (AA) women experience much greater mortality due to breast cancer (BC) than non-Latino Whites (NLW). Clinical patient navigation is an evidence-based strategy used by healthcare institutions to improve AA women's breast cancer outcomes. While empirical research has demonstrated the potential effect of navigation interventions for individuals, the population-level impact of navigation on screening, diagnostic completion, and stage at diagnosis has not been assessed. An agent-based model (ABM), representing 50-74-year-old AA women and parameterized with locally sourced data from Chicago, is developed to simulate screening mammography, diagnostic resolution, and stage at diagnosis of cancer. The ABM simulated three counterfactual scenarios: (1) a control setting without any navigation that represents the "standard of care"; (2) a clinical navigation scenario, where agents receive navigation from hospital-affiliated staff; and (3) a setting with network navigation, where agents receive clinical navigation and/or social network navigation (i.e., receiving support from clinically navigated agents for breast cancer care). In the control setting, the mean population-level screening mammography rate was 46.3% (95% CI: 46.2%, 46.4%), the diagnostic completion rate was 80.2% (95% CI: 79.9%, 80.5%), and the mean early cancer diagnosis rate was 65.9% (95% CI: 65.1%, 66.7%). Simulation results suggest that network navigation may lead up to a 13% increase in screening completion rate, 7.8% increase in diagnostic resolution rate, and a 4.9% increase in early-stage diagnoses at the population-level. Results suggest that systems science methods can be useful in the adoption of clinical and network navigation policies to reduce breast cancer disparities.

An Examination of Culturally Relevant Health Messages in African-American Churches

This quantitative study examined the presence of culturally relevant health messages for African-Americans based on a preexisting dataset from 21 African-American churches in South Carolina (USA). Content analysis served as the primary methodological approach to code printed media messages based on their cultural relevance among African-Americans (Cohen's kappa = .74). Within the dataset (n = 2166), 477 (22%) items were identified as culturally relevant. A low prevalence of culturally relevant messages was found across the three message topics, two media types, and one media source. Due to the limited presence of culturally relevant messages, researchers should collaborate with African-American churches to design health promotion messages.

Abstract PO-087: Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors

Background: Increasing attention is being paid to understanding and addressing the financial consequences of cancer and cancer treatment; however, in addition to the direct and indirect costs of cancer care, survivors with few financial resources also face social needs such as food insecurity and housing instability. On average, young adults have fewer financial resources than older adults, placing them at risk for adverse financial outcomes due to cancer, including unmet social needs. The purpose of this study is to estimate associations between young adult age at diagnosis and prevalence of social needs among African American cancer survivors. Methods: We utilized data from 3,241 participants in the Detroit Research on Cancer Survivors (ROCS) cohort. African American adults were invited to participate if they were between the ages of 20-79 at diagnosis with breast, colorectal, lung, or prostate cancer since January 1, 2013; or diagnosed with endometrial cancer (ages 20-79) or any other cancer (ages 20-49) since January 1, 2016. Cases were identified through the Metropolitan Detroit Cancer Surveillance System, a population-based cancer registry. Participants self-reported several forms of unmet social needs, including food insecurity, recent utility shut-offs, housing instability, inability to get medical care due to lack of transportation, and whether they generally felt safe in their neighborhood. Modified Poisson models estimated prevalence ratios (PR) and 95% confidence intervals (CI) for social needs by age at diagnosis (20-39 vs. 65+) and tests for trend by 4-level age (20-39, 40-54, 55-64, 65+), controlling for demographic, socioeconomic, and cancer-related factors. Results: Overall, 32% of ROCS participants reported experiencing social needs, and prevalence was inversely associated with age at diagnosis such that 48% of survivors diagnosed as young adults reported any social needs compared with 22% of those diagnosed as older adults (PRadjusted: 2.3, 95% CI: 1.8-2.9; ptrend<0.001). Associations between young adult age at diagnosis and social needs were particularly high for utility shutoffs (PRadjusted: 4.7, 95% CI: 2.8-7.8) and food insecurity (PRadjusted: 3.4, 95% CI: 2.3-4.9) compared with those diagnosed as older adults. Young adults also reported substantially higher prevalence of not feeling safe in their neighborhood (PRadjusted: 2.8, 95% CI: 1.7, 4.6), housing instability (PRadjusted: 2.7, 95% CI: 1.7-4.5), and going without medical care due to lack of transportation (PRadjusted: 2.0, 95% CI: 1.2-3.3). There was an inverse association with age and all social needs examined (all ptrend<0.001). Conclusions: Each unmet social need considered was at least twice as common among African American cancer survivors diagnosed as young adults compared with those diagnosed when they were 65 or older. Young adults often have fewer financial resources compared older adults and should be prioritized in the development of interventions aimed at improving financial outcomes among cancer survivors.

Citation Format: Theresa A. Hastert, Julie J Ruterbusch, Jean A. McDougall, Jamaica R.M. Robinson, Shaila M. Strayhorn, Andrew Abdallah, Gowri Chandrashekar, Ann G. Schwartz. Diagnosis in young adulthood as a risk factor for unmet social needs among African American cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-087.

Healthcare Predictors of Information Dissemination About Genetic Risks

Objectives

Despite the benefits of genetic counseling and testing (GCT), utilization is particularly low among African American (AA) women who exhibit breast cancer features that are common in BRCA-associated cancer. Underutilization is especially problematic for AA women who are more likely to die from breast cancer than women from any other race or ethnicity. Due to medical mistrust, fear, and stigma that can be associated with genetic services among racial/ethnic minorities, reliance on trusted social networks may be an impactful strategy to increase dissemination of knowledge about hereditary cancer risk. Informed by the social cognitive theory, the purpose of this study is to determine: 1) which AA patients diagnosed with breast cancer and with identified hereditary risk are sharing information about hereditary risk with their networks; 2) the nature of the information dissemination; and 3) if personal GCT experiences is associated with dissemination of information about hereditary risk.

Methods

Among consented participants (n = 100) that completed an interview administered using a 202-item questionnaire consisting of open- and closed-ended questions, 62 patients were identified to be at higher risk for breast cancer. Descriptive statistics, bivariable chi-square, Pearson’s exact tests, and regression analyses were conducted to examine differences in characteristics between high-risk participants who disseminated hereditary risk information and participants who did not.

Results

Among high-risk participants, 25 (40%) indicated they had disseminated information about hereditary risk to at least one member in their family/friend network and 37 (60%) had not. Receipt of both provider recommendations and receipt of GCT services was associated with greater odds of disseminating information about hereditary risk with networks, OR = 4.53, 95%CI [1.33, 15.50], p = .02.

Conclusion

Interventions that increase self-efficacy gained through additional personalized knowledge and experience gained through provider recommendations and by undergoing GCT may facilitate information dissemination among social/familial networks.

Abstract PO-062: An exploration of patient navigation on various outcomes of African American breast cancer survivors

Introduction: Patient navigation (PN) programs are used throughout the cancer continuum to address barriers faced by African American women and other vulnerable populations. Research has suggested PN can be effective in improving screening and diagnostic care uptake; however, less research has examined its effects post-diagnosis. Although effective for its short-term outcomes (e.g., receipt of screening; care decisions; stage at diagnosis), PN may be limited in its long-term effects during survivorship (e.g., quality of life). Therefore, the objective of this study was to assess the effect of PN on four outcomes of African American breast cancer survivors (BCS): shared decision making (SDM) when undergoing diagnostic care; receipt of an early stage diagnosis; and, current quality of life. Methods: This study was a secondary analysis of the OASIS (Offering African American Survivors Increased Support) study, which followed African American BCS who obtained care at a Chicago-based hospital during or after the Patient Navigation in Medically Underserved Areas (PNMUA) study. Navigated women experienced largely phone- based navigation through screening, diagnostic care, and treatment. Eligibility criteria included: African American race; 18+ years old; receipt of breast healthcare in the study hospital during or after PN trial was implemented; and, receipt of a breast cancer diagnosis. We conducted multivariate logistic (SDM, early stage diagnosis) and linear regression models (quality of life measured with current mental and physical well-being using SF-12 scale) that were adjusted by age, socioeconomic status (income, education, insurance status) and year of diagnosis. Results: The average age of our sample was 66.28 (SD = 9.54). Approximately 26% of the sample had ≤ 12 years of education; 35% were married; 49% had an annual household income of ≤$50,000; and 64% had private insurance. Navigated women had greater odds of reporting shared decision making with their providers during diagnostic visits, non-nav: 26% vs. nav: 44%, OR = 3.48, 95%CI [1.08, 11.15], p = 0.04. There were no differences, however, between navigated and non-navigated women regarding odds of an early stage diagnosis and current quality of life (ps = 0.62-0.94). Conclusion: Navigated women’s greater propensity to engage in SDM compared with non-navigated women aligns with past research and suggests PN is effective for changing patients’ behaviors when actively engaged with navigators. However, we did not find that PN was associated with stage at diagnosis. Further, the absence of an association on current mental and physical well-being suggests that PN may have limited long-term effects. Limitations include use of self-report data and a small, convenience-based sample. Further research should assess how patient navigation can be adapted to have more sustained effects in the long term.

Citation Format: Agnieszka M. Mynarska, Shaila M. Strayhorn, Tynetta Hill-Muhammad, Nyahne Q. Bergeron, Desmona C. Strahan, Stephanie L. Jara, Nancy Rayas, Anita Rong, Misael Villegas, Dana Villines, Karriem S. Watson, Aditya Khanna, Yamilé Molina. An exploration of patient navigation on various outcomes of African American breast cancer survivors [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-062.

Social needs and health-related quality of life among African American cancer survivors: Results from the Detroit Research on Cancer Survivors study

BACKGROUND

Social needs may affect cancer survivors' health-related quality of life (HRQOL) above and beyond sociodemographic and cancer-related factors. The purpose of this study was to estimate associations between social needs and HRQOL.

METHODS

Results included data from 1754 participants in the Detroit Research on Cancer Survivors cohort, a population-based study of African American survivors of breast, colorectal, lung, and prostate cancer. Social needs included items related to food insecurity, utility shutoffs, housing instability, not getting health care because of cost or a lack of transportation, and perceptions of neighborhood safety. HRQOL was measured with the validated Functional Assessment of Cancer Therapy-General (FACT-G). Linear regression models controlled for demographic, socioeconomic, and cancer-related factors.

RESULTS

More than one-third of the survivors (36.3%) reported social needs including 17.1% of survivors reported 2 or more. The prevalence of social needs ranged from 14.8% for food insecurity to 8.9% for utility shutoffs. FACT-G score differences associated with social needs were -12.2 (95% confidence interval [CI] to -15.2 to -9.3) for not getting care because of a lack of transportation, -11.3 (95% CI, -14.2 to -8.4) for housing instability, -10.1 (95% CI, -12.7 to -7.4) for food insecurity, -9.8 (95% CI, -12.7 to -6.9) for feeling unsafe in the neighborhood, -8.6 (95% CI, -11.7 to -5.4) for utility shutoffs, and -6.7 (95% CI, -9.2 to -4.1) for not getting care because of cost.

CONCLUSIONS

Social needs were common in this cohort of African American cancer survivors and were associated with clinically significant differences in HRQOL. Clinical oncology care and survivorship care planning may present opportunities to screen for and address social needs to mitigate their impact on survivors' HRQOL.

Strategies for Designing Clergy and Spouse Obesity-Related Programs

PURPOSE

Clergy have influence on the health of congregations and communities yet struggle with health behaviors. Interventions tailored to their occupation-specific demands and unique needs may provide a solution. Qualitative methods were used to identify opportunities and resources for the development of an effective obesity-related program for clergy.

APPROACH

Ninety-minute focus groups were held with clergy (3 groups) and spouses (3 separate groups). Discussion explored: Program target(s); Opportunities and barriers that influence diet, physical activity, and stress-reduction practices; Empowering and culturally relevant health promotion strategies.

SETTING

All study activities took place in Memphis, TN.

PARTICIPANTS

Eighteen clergy and fourteen spouses participated. All clergy were male, all spouses were female.

METHOD

Previous research with clergy informed the interview guide and the PEN-3 framework aided in organizing the coding of clergy and spouse focus groups. Focus groups were audio recorded and transcripts analyzed using NVivo® 12.

RESULTS

Themes included: 1) Intervention targets-clergy, spouses, congregations; 2) Opportunities and barriers-making time, establishing boundaries, church traditions, individuals who support and hinder behavior change; 3) Intervention strategies-tools for healthy eating, goal setting, camaraderie, combining face-to-face with eHealth modalities.

CONCLUSION

The relationship between clergy, spouse, and congregation make it important for obesity-related programs to target the unique needs of both clergy and spouses. Strategies should focus on healthy eating and personal connections no matter the modality used.

Assessing the relationship between patient-provider communication quality and quality of life among rural cancer survivors

PURPOSE

We explored relationships between patient-provider communication quality (PPCQ) and three quality of life (QOL) domains among self-identified rural cancer survivors: social well-being, functional well-being, and physical well-being. We hypothesized that high PPCQ would be associated with greater social and functional well-being, but be less associated with physical well-being, due to different theoretical mechanisms.

METHODS

All data were derived from the 2017-2018 Illinois Rural Cancer Assessment (IRCA). To measure PPCQ and QOL domains, we respectively used a dichotomous measure from the Medical Expenditure Panel Survey's Experience Cancer care tool (high, low/medium) and continuous measures from the Functional Assessment of Cancer Therapy-General (FACT-G).

RESULTS

Our sample of 139 participants was largely female, non-Hispanic White, married, and economically advantaged. After adjusting for demographic and clinical variables, patients who reported high PPCQ exhibited greater social well-being (Std. β = 0.20, 95% CI: 0.03, 0.35, p = 0.02) and functional well-being (Std. β = 0.20, 95% CI: 0.05, 0.35, p = 0.03) than patients with low/medium PPCQ. No association was observed between PPCQ and physical well-being (Std. β = 0.06, 95% CI: - 2.51, 0.21, p = 0.41). Sensitivity analyses found similar, albeit attenuated, patterns.

CONCLUSION

Our findings aligned with our hypotheses. Future researchers should explore potential mechanisms underlying these differential associations. Specifically, PPCQ may be associated with social and functional well-being through interpersonal mechanisms, but may not be as associated with physical well-being due to multiple contextual factor rural survivors disproportionately face (e.g., limited healthcare access, economic hardship) and stronger associations with clinical factors.

Abstract D025: “Place it in God’s hands”: Exploring the influence of sources of social support and religious coping practices of African American breast cancer survivors

Background: Religious coping (i.e. religious practices or beliefs that help an individual adapt to a stressful situation) has been shown to help African American breast cancer survivors obtain a better quality of life as well as find purpose from their cancer experience. Both prayer and church attendance are believed to be the most common religious coping practices among African American breast cancer survivors. However, relatively little is known about: 1) the relative commonness of religious coping practices; and, 2) which sources of social support (i.e. church members, clergy leaders, family, and friends) may also influence religious coping among survivors. Objective(s): To assess the prevalence of religious coping mechanisms and the sources of social support who influence African American breast cancer survivors. Methods: The current study was a secondary analysis of the OASIS (Offering African American Survivors Increased Support) study. Participants were eligible for this study if they identified as being an African American female adult and were diagnosed between 2011-2014 within a local hospital in Chicago, IL. Eligible participants answered a modified version of the Church-based Social Support Scale and responded to open-ended questions related to their social support experiences by members of their social network. Results: A total of 33 participants completed the questionnaire at the time of data analysis. Weekly religious service attendance was highly prevalent among study participants post-diagnosis (n=12, 36.4%). Approximately eighteen percent of survivors (n=6) reported praying throughout their breast cancer journey. No participants reported receiving prayer from their church members or clergy leaders. However, nine participants (27.3%) expressed that a family member and/or a friend offered to pray for them throughout their cancer experience. Conclusion: There was a relatively high prevalence of church attendance. Family and friends appeared to be the more common source of influence in the form of religious coping through prayer. Future researchers should consider partnering with both family and friends when conducting faith-based and religious-based interventions to improve quality of life among African American breast cancer survivors.

Citation Format: Shaila M. Strayhorn, Nyahne Q Bergeron, Desmona Strahan, Aditya Khanna, Kariem Watson, Dana Villines, Yamilé Molina. “Place it in God’s hands”: Exploring the influence of sources of social support and religious coping practices of African American breast cancer survivors [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D025.

Abstract A077: Examining the relationship between various informal sources of social support and the physical well-being among cancer survivors

Cancer survivors have previously reported lower quality of life scores compared to non-cancer survivors. More specifically, the quality of life domain of physical well-being has previously been shown to be significantly worse among cancer survivors compared to non-cancer survivors. Previous studies have observed that specific sources of informal social support (i.e., support from family and friends) can improve a cancer survivor's physical well-being. However, no studies to date have assessed if support from fictive kin (or individuals who are not related by marriage or blood but are considered to be an extension of the family) and church members may also play a role on the physical well-being of cancer survivors. The purpose of this study was to examine the association between four informal sources of social support (i.e., family, friends, fictive kin, and church members) and the physical well-being among cancer survivors. Findings were based on data collected from the National Survey of American Life (NSAL) dataset. Physical well-being was measured using the following item from the NSAL dataset: “How would you rate your overall physical health at the present time?” A total of 238 cancer survivors (n=70 non-Hispanic whites, n=36 Caribbean Blacks, n=132 African Americans) comprised the study sample. Multiple imputation analyses were conducted within SAS to assess the associations between the informal sources of social support and the physical well-being among cancer survivors. All multiple imputation analyses were controlled for gender, age, race, household income, years of education, marital status, employment status, length of time residing in the U.S, and insurance coverage. Neither friends (β= -0.07, SE=0.09, p=0.42) nor fictive kin (β=0.06, SE=0.13, p=0.66) were significantly associated with the physical well-being of cancer survivors. Support from family was marginally associated with physical well-being (β=0.16, SE=0.08, p=0.05). A positive association was observed between support from church members and physical well-being (β=0.22, SE=0.09, p=0.01). Findings from this study suggest that support from church members can play an important role on the physical well-being of cancer survivors. Researchers of future health promotion interventions should consider collaborating with churches as a means of improving the physical well-being among cancer survivors.

Citation Format: Shaila M. Strayhorn. Examining the relationship between various informal sources of social support and the physical well-being among cancer survivors [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr A077.

Abstract D024: Evaluating cultural contexts in social support instruments used with African American cancer survivors: A systematic review

Background: Various instruments used to measure social support have emphasized the importance of examining the relationships between this interpersonal-level factor and specific health outcomes among cancer survivors. Through these instruments, an increase in certain factors of social support (i.e. sources of social support, type of social support, etc.) have been shown to improve the quality of life among cancer survivors. Unfortunately, social support instruments were not developed specifically for African American cancer survivors and therefore may not address the cultural contexts of this population. Objective: To conduct a systematic review examining the cultural contexts of social support instruments used with African American cancer survivors. Methods: PubMed, PsychINFO, and EMBASE were utilized to identify full-text quantitative articles that 1) possessed a study sample of at least 50% African American cancer survivors, and 2) referenced or documented the psychometric properties of the social support instrument. Results: We screened 1,161 titles and 113 abstracts. Eleven articles met the eligibility criteria and used nine different social support instruments. Only one of the instruments, the Ways of Coping Questionnaire, was developed with a sample of African American cancer survivors. The remaining instruments were piloted with study samples that were either comprised of racially diverse undergraduates (n=4), married couples (n=1), breast cancer survivors (n=2), or individuals with various chronic illnesses (n=1). The Ways of Coping Questionnaire, was the only instrument that inquired about support from church members and God. Four of the remaining instruments, solely focused on support from other informal sources (i.e. family, friends, significant others). Emotional support was also observed to be the most prevalent type of social support within five of the nine instruments. Conclusion: African American cancer survivors were rarely represented during the development of social support instruments. As a result, the unique experiences and cultural contexts of African American cancer survivors are not adequately assessed by these commonly used social support instruments. Therefore, the science of survivorship, particularly with African American cancer survivors, suffers from the notable gap of cultural contexts when measuring social support. Moreover, additional types of social support (i.e. instrumental social support, belonging social support, and tangible social support), were rarely captured within the instruments despite their influence on the overall quality of life among cancer survivors. Developing an instrument that is initially piloted among African American cancer survivors would generate a better understanding of how different factors of social support may impact the overall quality of life of this population.

Citation Format: Shaila M Strayhorn, Perla Chebli, Catherine Pichardo, Yamilé Molina, Carol J Ferrans, Kimlin T. Ashing. Evaluating cultural contexts in social support instruments used with African American cancer survivors: A systematic review [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr D024.

Comorbidities, treatment-related consequences, and health-related quality of life among rural cancer survivors

PURPOSE

We explored how lifetime comorbidities and treatment-related cancer symptoms were associated with quality of life (QOL) in rural cancer survivors.

METHODS

Survivors (n = 125) who were rural Illinois residents aged 18+ years old were recruited from January 2017 to September 2018. We conducted 4 multivariable regressions with QOL domains as outcomes (social well-being, functional well-being, mental health-MHQOL, physical health-PHQOL); the number of physical and psychological comorbidities (e.g., arthritis, high blood pressure, stroke) and treatment-related cancer symptoms (e.g., worrying, feeling sad, lack of appetite, lack of energy) as predictors; and, cancer-related and demographic factors related to these variables as covariates.

RESULTS

The number of comorbidities and number of treatment-related symptoms were inversely associated with functional well-being (Std β = - 0.36, p < 0.0001 and - 0.18, p = 0.03), and MHQOL (Std β = - 0.30, p = 0.001 and Std β = - 0.25, p = 0.004). Comorbidities were associated inversely with social well-being (Std β = - 0.27, p = .003). Comorbidities and treatment-related symptoms were not associated with PHQOL (p = 0.20-0.24). Sensitivity analyses suggested that psychological comorbidities, treatment-related psychological symptoms, and physical comorbidities were associated with social well-being, functional well-being, and MHQOL.

CONCLUSIONS

Our study highlights the utility of risk-based survivorship care plans to address the negative, additive impact of comorbidities and the treatment-related symptoms to improve the health-related QOL among rural survivors. Future research should assess how contextual factors (e.g., geographic distance to oncologists and other providers) should be incorporated in survivorship care planning and implementation for rural survivors.