Patient recommendations for reducing long-lasting economic burden after breast cancer.

BACKGROUND: In the United States, patients who have breast cancer experience significant economic burden compared with those who have other types of cancers. Cancer-related economic burden is exacerbated by adverse treatment effects. Strategies to resolve the economic burden caused by breast cancer and its adverse treatment effects have stemmed from the perspectives of health care providers, oncology navigators, and other subject-matter experts. For the current study, patient-driven recommendations were elicited to reduce economic burden after 1) breast cancer and 2) breast cancer-related lymphedema, which is a common, persistent adverse effect of breast cancer. METHODS: Qualitative interviews were conducted with 40 long-term breast cancer survivors who were residents of Pennsylvania or New Jersey in 2015 and were enrolled in a 6-month observational study. Purposive sampling ensured equal representation by age, socioeconomic position, and lymphedema diagnosis. Semistructured interviews addressed economic challenges, supports used, and patient recommendations for reducing financial challenges. Interviews were coded, and representative quotes from the patient recommendations were analyzed and reported to illustrate key findings. RESULTS: Of 40 interviewees (mean age, 64 years; mean time since diagnosis, 12 years), 27 offered recommendations to reduce the economic burden caused by cancer and its adverse treatment effects. Nine recommendations emerged across 4 major themes: expanding affordable insurance and insurance-covered items, especially for lymphedema treatment (among the 60% who reported lymphedema); supportive domestic help; financial assistance from diagnosis through treatment; and employment-preserving policies. CONCLUSIONS: The current study yielded 9 actionable, patient-driven recommendations-changes to insurance, supportive services, financial assistance, and protective policies-to reduce breast cancer-related economic burden. These recommendations should be tested through policy and programmatic interventions.

Marketing the HIV test to MSM: ethnic differences in preferred venues and sources.

Lack of awareness of HIV status is associated with an increased likelihood of HIV transmission. We surveyed 633 men who have sex with men (MSM) from diverse ethnic groups recruited from a variety of community venues in a U.S. Midwestern city with rising HIV infection rates. Our first aim was to describe patterns of sexual risk, annual HIV testing frequency, and venues where information about HIV and HIV testing could be disseminated to inner-city MSM. Our second aim was to identify preferred sources to receive information about HIV testing and determine whether these preferences differed by ethnic background. Results indicated that despite similar proportions of high-sexual risk behaviors, compared with African American and Latino MSM, smaller proportions of non-Hispanic White MSM had received an HIV test in the last 12 months. Despite ethnic differences in health care access, a physician's office was the most common HIV testing site. Overall, a majority conveyed a preference to see advertisements in mainstream media outlets. However, when preferences were stratified by ethnicity, African American MSM were the least likely to prefer receiving information from mainstream media and conveyed a stronger preference to receive information from authority figures than non-Hispanic White and Hispanic MSM.

Can Community Health Workers Increase Palliative Care Use for African American Patients? A Pilot Study.

PURPOSE: African American patients with cancer underutilize advance care planning (ACP) and palliative care (PC). This feasibility study investigated whether community health workers (CHWs) could improve ACP and PC utilization for African American patients with advanced cancer. METHODS: African American patients diagnosed with an advanced solid organ cancer (stage IV or stage III disease with a palliative performance score < 60%) were enrolled. Patients completed baseline surveys that assessed symptom burden and distress at baseline and 3 months post-CHW intervention. The CHW intervention consisted of a comprehensive assessment of multiple PC domains and social determinants of health. CHWs provided tailored support and education on the basis of iterative assessment of patient needs. Intervention feasibility was determined by patient and caregiver retention rate above 50% at 3 months. RESULTS: Over a 12-month period, 24 patients were screened, of which 21 were deemed eligible. Twelve patients participated in the study. Patient retention was high at 3 months (75%) and 6 months (66%). Following the CHW intervention, symptom assessment as measured by Edmonton Symptom Assessment System improved from 33.8 at baseline to 18.8 (P = .03). Psychological distress improved from 5.5 to 4.7 (P = .36), and depressive symptoms from 42.2 to 33.6 (P = .09), although this was not significant. ACP documentation improved from 25% at baseline to 75% at study completion. Sixty-seven percentage of patients were referred to PC, with 100% of three decedents using hospice. CONCLUSION: Utilization of CHWs to address PC domains and social determinants of health is feasible. Although study enrollment was identified as a potential barrier, most recruited patients were retained on study.

Theory-Based Development of an Implementation Intervention Using Community Health Workers to Increase Palliative Care Use.

CONTEXT: Opportunities for the use of palliative care services are missed in African American (AA) communities, despite Level I evidence demonstrating their benefits. OBJECTIVES: Single-institution and stakeholder-engaged study to design an intervention to increase palliative care use in AA communities. METHODS: Two-phased qualitative research design guided by the Behavior Change Wheel and Theoretical Domains Framework models. In Phase 1, focus group sessions were conducted to identify barriers and facilitators of palliative care use and the viability of community health workers (CHWs) as a solution. After applying the Behavior Change Wheel and Theoretical Domains Framework to data gathered from Phase 1, Phase 2 consisted of a stakeholder meeting to select intervention content and prioritize modes of delivery. RESULTS: A total of 15 stakeholders participated in our study. Target behaviors identified were for patients to gain knowledge about benefits of palliative care, physicians to begin palliative care discussions earlier in treatment, and to improve patient-physician interpersonal communication. The intervention was designed to improve patient capability, physician capability, patient motivation, physician motivation, and increase patient opportunities to use palliative care services. Strategies to change patient and physician behaviors were all facilitated by CHWs and included creation and dissemination of brochures about palliative care to patients, empowerment and activation of patients to initiate goals-of-care discussions, outreach to community churches, and expanding patient social support. CONCLUSION: Use of a theory-based approach to facilitate the implementation of a multi-component strategy provided a comprehensive means of identifying relevant barriers and enablers of CHWs as an agent to increase palliative care use in AA communities.

Combat Readiness, Harm Aversion, and Promotion Eligibility: A Qualitative Study of U.S. Servicemembers Views on Tobacco Use and Control in the Military.

INTRODUCTION: More than half a century after the first Surgeon General's Report on Smoking and Tobacco Use, tobacco use remains the leading cause of preventable disease for the U.S. military. Military tobacco use impairs troop readiness, decreases productivity, reduces servicemember physical performance, and leads to chronic illness in veterans. The Department of Defense (DoD) spends considerable effort to maintain a combat ready force, and tobacco use is contradictory to these efforts. U.S. servicemember tobacco use is estimated to cost the federal government more than $6.5 billion annually. The uniqueness of military culture allows for innovative means of tobacco regulation and prevention. Our study examines the U.S. Navy cultural and servicemember perceptions to inform future tobacco control research and policies. MATERIALS AND METHODS: We developed a behavioral model of tobacco use from existing literature. Using this model as a theoretical framework, our study qualitatively examined tobacco use in the active duty Navy population stationed in Okinawa, Japan. Thirty one-on-one interviews were conducted with active duty servicemembers. Sessions were recorded, transcribed, and analyzed in MAXQDA12. RESULTS: Multiple military-specific themes were identified. Themes: (1) tobacco use is a "right," (2) the military may limit active duty servicemembers' rights, (3) tobacco restrictions are justified if they prevent harm to others, (4) tobacco restrictions are not widely enforced, (5) smoke breaks are viewed as a legitimate reason to rest at work, and (6) the benefit of tobacco is as a stimulant. Novel tobacco cessation techniques suggested by our study include: (1) expand the buddy system to create an artificial support network for tobacco cessation and (2) tie promotion eligibility to tobacco use. CONCLUSIONS: This qualitative study identifies military-specific themes from the tobacco user perspective that help to guide research and policy in reducing tobacco use among military servicemembers. Possible interventions suggested by our findings may include replacing tobacco breaks with fitness breaks to relieve workplace stress and support the culture of fitness, expanding the use of pharmacologic stimulants to replace tobacco when used to maintain alertness, and gathering social support for tobacco cessation from non-healthcare unit members. Further study is needed to elucidate the effectiveness of proposed interventions suggested by our findings, with the ultimate aim of policy changes within the military to optimize health and military readiness, while decreasing long-term health effects and costs of tobacco use.