Associations between Medicaid enrollment and diagnosis stage and survival among pediatric cancer patients.

BACKGROUND: Medicaid-associated disparities in childhood and adolescent (pediatric) cancer diagnosis stage and survival have been reported. However, a key limitation of prior studies is the assessment of health insurance at a single time point. To evaluate Medicaid-associated disparities more robustly, we used Surveillance, Epidemiology, and End Results (SEER)-Medicaid linked data to examine diagnosis stage and survival disparities in those (i) Medicaid-enrolled and (ii) with discontinuous and continuous Medicaid enrollment. METHODS: SEER-Medicaid linked data from 2006 to 2013 were obtained on cases diagnosed from 0 to 19 years. Medicaid enrollment was classified as enrolled versus not enrolled, with further classifications as continuous when enrolled 6 months before through 6 months after diagnosis, and discontinuous when not enrolled continuously for this period. We used multinomial logistic and Cox proportional hazards regression models to determine associations between enrollment measures, diagnosis stage, and cancer death adjusted for covariates. RESULTS: Among 21,502 cases, a higher odds of distant stage diagnoses were observed in association with Medicaid enrollment (odds ratio [OR] = 1.56, 95% confidence interval [CI]: 1.48-1.65), with the highest odds for discontinuous enrollment (OR = 2.0, 95% CI: 1.86-2.15). Among 30,654 cases, any Medicaid enrollment, continuous enrollment, and discontinuous enrollment were associated with 1.68 (95% CI: 1.35-2.10), 1.66 (95% CI: 1.35-2.05), and 1.89 (95% CI: 1.54-2.33) times higher hazards of cancer death versus no enrollment, respectively. CONCLUSIONS: Medicaid enrollment, particularly discontinuous enrollment, is associated with a higher  distant stage diagnosis odds and risk of death. This study supports the critical need for consistent health insurance coverage in children and adolescents.

Intention to vaccinate children for COVID-19: A segmentation analysis among Medicaid parents in Florida.

COVID-19 vaccines have been granted emergency use authorization for children ages 5 years and older. To understand how racially and ethnically diverse parents of young children enrolled in Medicaid feel about a prospective COVID-19 vaccine for their children, we administered an online survey that included both close-ended and open-ended items to a statewide sample in Florida (n = 1951). We used quantitative responses to conduct a statistical audience segmentation analysis that identified five distinct sub-groups that varied widely in the likelihood that they would get a COVID-19 vaccine for their child. Qualitative responses were used to illustrate differences between the groups. The youngest Black and White mothers were least likely to vaccinate their child (24%), followed by Black and White mothers in their early 30s (36%), younger Hispanic and mixed-race or other race parents (45%), older mothers (48%) and older fathers (71%). Unique challenges to building vaccine confidence emerged for each group. The youngest Black and White mothers were more likely to report their lives being worse during the COVID-19 pandemic, were far more negative and less positive about a COVID-19 vaccine, and were more concerned about paying bills than preventing COVID-19. Younger Hispanic and mixed-race parents were less negative, but more likely to use emotional language (e.g., scared, nervous, worried) talking about a COVID-19 vaccine, and more likely to report that protecting their child's health was their top concern. Recommendations are made for applying the insights gained in outreach and education efforts.

Examining Psychosocial Correlates of a Home Smoking Ban Among Low-income Smokers: Analysis of Social Support, Unmet Social Needs, Perceived Stress, and Depressive Symptoms.

Home smoking bans reduce exposure to second-hand smoke. Understanding how psychosocial factors are related to having a home smoking ban may lead to better interventions for populations less likely to have home smoking bans, including low-income smokers. In this study, we used baseline data from 1,944 participants in a randomized trial of low-income smokers in Missouri to explore psychosocial correlates of a total home smoking ban. Using logistic regression, we examined associations between psychosocial variables (social support, unmet social needs [e.g., food, housing], perceived stress, and depressive symptoms) and a total home smoking ban. 72% of participants were female, and 58% were Black/African American; 26% reported a home smoking ban. In unadjusted and adjusted models, greater social support was associated with greater likelihood of a home smoking ban. Stress was negatively associated with a ban in adjusted models only. The fact that most participants did not have a home smoking ban highlights the need for further intervention in this population. Results suggest links between social support and having a home smoking ban, although effect sizes were small. Smoke-free home interventions that increase social connectedness or leverage existing support may be especially effective. Tobacco control planners may also consider partnering with agencies addressing social isolation.

Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health.

There has been an explosion of interest in addressing social needs in health care settings. Some efforts, such as screening patients for social needs and connecting them to needed social services, are already in widespread practice. These and other major investments from the health care sector hint at the potential for new multisector collaborations to address social determinants of health and individual social needs. This article discusses the rapidly growing body of research describing the links between social needs and health and the impact of social needs interventions on health improvement, utilization, and costs. We also identify gaps in the knowledge base and implementation challenges to be overcome. We conclude that complementary partnerships among the health care, public health, and social services sectors can build on current momentum to strengthen social safety net policies, modernize social services, and reshape resource allocation to address social determinants of health.

Cervical cancer risk and screening among women seeking assistance with basic needs.

BACKGROUND: In the United States, more than half of cervical cancers occur in women who are inadequately screened. Interventions to improve access to cervical cancer preventive care is critical to reduce health inequities. OBJECTIVE: This study aimed to evaluate the need for cervical cancer screening among women seeking assistance with basic needs and to assess best approaches to facilitate Papanicolaou test referral. STUDY DESIGN: This study is a secondary analysis of a randomized controlled trial of low-income female callers to 2-1-1 Missouri, a helpline for local health and social services. The need for cervical cancer screening was assessed. Callers were randomized to 1 of 3 arms, each providing a Papanicolaou test referral: verbal referral only, verbal referral and tailored print reminder, or verbal referral and navigator. The primary outcome was contacting a Papanicolaou test referral 1 month following intervention. Student t tests or Mann-Whitney U tests were used to analyze significant differences in continuous variables, whereas Fisher exact or χ2 tests were used for categorical variables. We stratified by number of unmet basic needs (0-1 vs ≥2) and compared success of contacting a Papanicolaou test referral among study groups (verbal referral vs tailored reminder vs navigator) using the Fisher exact test and χ2 test, respectively. Multivariate logistic regression was used to assess risk factors for nonadherence for Papanicolaou test at baseline and at 1 month follow-up, adjusting for race and ethnicity, age, insurance status, self-rated health, smoking, and study group. RESULTS: Among 932 female callers, 250 (26.8%) needed cervical cancer screening. The frequency of unmet basic needs was high, the most common being lack of money for unexpected expenses (91.2%) and necessities, such as food, shelter, and clothing (73.2%). Among those needing a Papanicolaou test, 211 women received screening referrals. Women in the navigator group (21 of 71, 29.6%) reported higher rates of contacting a Papanicolaou test referral than those exposed to verbal referral only (11/73, 15.1%) or verbal referral and tailored print reminder (9/67, 13.4%) (P=.03). Among 176 women with ≥2 unmet needs who received a Papanicolaou test referral, the provision of a navigator remained associated with contacting the referral (navigator [33.9%] vs verbal referral [17.2%] vs tailored reminder [10.2%]; P=.005). Assignment to the navigator group (adjusted odds ratio, 3.4; 95% confidence interval, 1.4-8.5) and nonwhite race (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.8) were independent predictors of contacting a Papanicolaou test referral. CONCLUSION: Low-income women seeking assistance with basic needs often lack cervical cancer screening. Health navigators triple the likelihood that women will make contact with Papanicolaou test services, but most 2-1-1 callers still fail to schedule Papanicolaou testing despite assistance from navigators. Interventions beyond health navigators are needed to reduce cervical cancer disparities.

Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation.

INTRODUCTION: Given homes are now a primary source of secondhand smoke (SHS) exposure in the United States, research-tested interventions that promote smoke-free homes should be evaluated in real-world settings to build the evidence base for dissemination. This study describes outcome evaluation results from a dissemination and implementation study of a research-tested program to increase smoke-free home rules through US 2-1-1 helplines. METHODS: Five 2-1-1 organizations, chosen through a competitive application process, were awarded grants of up to $70 000. 2-1-1 staff recruited participants, delivered the intervention, and evaluated the program. 2-1-1 clients who were recruited into the program allowed smoking in the home, lived in households with both a smoker and a nonsmoker or child, spoke English, and were at least 18 years old. Self-reported outcomes were assessed using a pre-post design, with follow-up at 2 months post baseline. RESULTS: A total of 2345 households (335-605 per 2-1-1 center) were enrolled by 2-1-1 staff. Most participants were female (82%) and smokers (76%), and half were African American (54%). Overall, 40.1% (n = 940) reported creating a full household smoking ban. Among the nonsmoking adults reached at follow-up (n = 389), days of SHS exposure in the past week decreased from 4.9 (SD = 2.52) to 1.2 (SD = 2.20). Among the 1148 smokers reached for follow-up, 211 people quit, an absolute reduction in smoking of 18.4% (p < .0001), with no differences by gender. CONCLUSIONS: Among those reached for 2-month follow-up, the proportion who reported establishing a smoke-free home was comparable to or higher than smoke-free home rates in the prior controlled research studies. IMPLICATIONS: Dissemination of this brief research-tested intervention via a national grants program with support from university staff to five 2-1-1 centers increased home smoking bans, decreased SHS exposure, and increased cessation rates. Although the program delivery capacity demonstrated by these competitively selected 2-1-1s may not generalize to the broader 2-1-1 network in the United States, or social service agencies outside of the United States, partnering with 2-1-1s may be a promising avenue for large-scale dissemination of this smoke-free homes program and other public health programs to low socioeconomic status populations in the United States.

Feasibility and Acceptability of an Interactive Cancer-Communication Video Program Using African American Breast Cancer Survivor Stories.

To examine the feasibility and acceptability of an interactive video program of African American breast cancer survivor stories, we explored story reactions among African American women with newly diagnosed breast cancer and associations between patient factors and intervention use. During a randomized controlled trial, patients in the intervention arm completed a baseline/pre-intervention interview, received the video intervention, and completed a post-intervention 1-month follow-up interview. Additional video exposures and post-exposure interviews occurred at 6- and 12-month follow-ups. Multivariable linear mixed-effects models examined interview and clinical data in association with changes in minutes and actions using the program. After Exposure1, 104 of 108 patients allocated to the intervention reported moderate-to-high levels of positive emotional reactions to stories and identification with storytellers. Exposure1 mean usage was high (139 minutes) but declined over time (p <.0001). Patients receiving surgery plus radiation logged about 50 more minutes and actions over 12-month follow-up than patients receiving surgery only (p <.05); patients reporting greater trust in storytellers logged 18.6 fewer actions over time (p =.04). Patients' topical interests evolved, with patients watching more follow-up care and survivorship videos at Exposure3. The intervention was feasible and evaluated favorably. New videos might satisfy patients' changing interests.

Perceptions of Health Coaching for Behavior Change Among Medicaid and Commercially Insured Adults.

Use of health coaching to help individuals make and sustain changes in health behavior and disease management is increasing, and early evidence about its effects is promising. However, few studies assess participants' preferences and expectations about health coaches, the use of the term health coach, and the coaching relationship. To help inform the design of future health coaching programs, we conducted qualitative interviews with 50 U.S. adults (25 with Medicaid, 25 commercially insured) to assess their (1) sources of health information; (2) familiarity with, preferences for, and associations with 32 terms that could describe "someone who uses experience and one-on-one communication to help others change behaviors to improve their health;" and (3) perceptions of how well different terms apply across different health behaviors and for nonhealth concerns (e.g., financial, career). Results showed wide variability in preferences for different coaching terms and mental models of coaching that differed by insurance type. Commercially insured participants made a distinction between experts and supporters as different categories of coaches. Medicaid participants associated coach with sports and viewed the term as less professional. All participants preferred terms such as advisor and specialist, and all wanted content experts who could also appreciate the broader context of their life.

Implementing an Evidence-based Tobacco Control Program at Five 2-1-1 Call Centers: An Evaluation Using the Consolidated Framework for Implementation Research.

Introduction: The Smoke-Free Homes (SFH) Program is an evidence-based intervention offered within 2-1-1 information and referral call centers to promote smoke-free homes in low-income populations. We used the Consolidated Framework for Implementation Research to conduct a mixed-methods analysis of facilitators and barriers to scaling up SFH to five 2-1-1 sites in the United States. Methods: Data were collected from staff in 2015-2016 via online surveys administered before (N = 120) and after SFH training (N = 101) and after SFH implementation (N = 79). Semi-structured telephone interviews were conducted in 2016 with 25 staff to examine attitudes towards SFH, ways local context affected implementation, and unintended benefits and consequences of implementing SFH. Results: Post-implementation, 79% of respondents reported that SFH was consistent with their 2-1-1's mission, 70% thought it led to more smoke-free homes in their population, 62% thought it was easy to adapt, and 56% thought participants were satisfied. Composite measures of perceived appropriateness of SFH for 2-1-1 callers and staff positivity toward SFH were significantly lower post-implementation than pre-implementation. In interviews, staff said SFH fit with their 2-1-1's mission but expressed concerns about intervention sustainability, time and resources needed for delivery, and how SFH fit into their workflow. Conclusions: Sites' SFH implementation experiences were affected both by demands of intervention delivery and by SFH's perceived effectiveness and fit with organizational mission. Future implementation of SFH and other tobacco control programs should address identified barriers by securing ongoing funding, providing dedicated staff time, and ensuring programs fit with staff workflow. Implications: Smoke-free home policies reduce exposure to secondhand smoke. Partnering with social service agencies offers a promising way to scale up evidence-based smoke-free home interventions among low-income populations. We found that the SFH intervention was acceptable and feasible among multiple 2-1-1 delivery sites. There were also significant challenges to implementation, including site workflow, desire to adapt the intervention, time needed for intervention delivery, and financial sustainability. Addressing such challenges will aid future efforts to scale up evidence-based tobacco control interventions to social service agencies such as 2-1-1.

Basic needs, stress and the effects of tailored health communication in vulnerable populations.

This study examined whether unmet basic needs (food, housing, personal and neighborhood safety, money for necessities) and perceived stress affect recall of and response to a tailored print intervention one month later. Participants (N = 372) were adults who had called 2-1-1 Missouri between June 2010 and June 2012. A series of path analyses using Mplus were conducted to explore the relationships among basic needs, perceived stress, number of health referrals received in a tailored intervention, recalling the intervention and contacting a health referral. Participants were mainly women (85%) and African-American (59%) with a mean age of 42.2 years (SD = 13.3; range 19-86); 41% had annual household income <$10 000. Unmet basic needs were positively associated with increased levels of perceived stress, which, in turn, were negatively associated with recalling the intervention and calling any of the health referrals provided. Tailored printed interventions may be less effective in populations with acute unmet basic needs. More broadly, the effectiveness of minimal contact behavioral interventions might be enhanced by simultaneous efforts to address unmet basic needs.

The context of collecting family health history: examining definitions of family and family communication about health among African American women.

Public health initiatives encourage the public to discuss and record family health history information, which can inform prevention and screening for a variety of conditions. Most research on family health history discussion and collection, however, has predominantly involved White participants and has not considered lay definitions of family or family communication patterns about health. This qualitative study of 32 African American women-16 with a history of cancer-analyzed participants' definitions of family, family communication about health, and collection of family health history information. Family was defined by biological relatedness, social ties, interactions, and proximity. Several participants noted using different definitions of family for different purposes (e.g., biomedical vs. social). Health discussions took place between and within generations and were influenced by structural relationships (e.g., sister) and characteristics of family members (e.g., trustworthiness). Participants described managing tensions between sharing health information and protecting privacy, especially related to generational differences in sharing information, fear of familial conflict or gossip, and denial (sometimes described as refusal to "own" or "claim" a disease). Few participants reported that anyone in their family kept formal family health history records. Results suggest family health history initiatives should address family tensions and communication patterns that affect discussion and collection of family health history information.

Behavioral economics: "nudging" underserved populations to be screened for cancer.

Persistent disparities in cancer screening by race/ethnicity and socioeconomic status require innovative prevention tools and techniques. Behavioral economics provides tools to potentially reduce disparities by informing strategies and systems to increase prevention of breast, cervical, and colorectal cancers. With an emphasis on the predictable, but sometimes flawed, mental shortcuts (heuristics) people use to make decisions, behavioral economics offers insights that practitioners can use to enhance evidence-based cancer screening interventions that rely on judgments about the probability of developing and detecting cancer, decisions about competing screening options, and the optimal presentation of complex choices (choice architecture). In the area of judgment, we describe ways practitioners can use the availability and representativeness of heuristics and the tendency toward unrealistic optimism to increase perceptions of risk and highlight benefits of screening. We describe how several behavioral economic principles involved in decision-making can influence screening attitudes, including how framing and context effects can be manipulated to highlight personally salient features of cancer screening tests. Finally, we offer suggestions about ways practitioners can apply principles related to choice architecture to health care systems in which cancer screening takes place. These recommendations include the use of incentives to increase screening, introduction of default options, appropriate feedback throughout the decision-making and behavior completion process, and clear presentation of complex choices, particularly in the context of colorectal cancer screening. We conclude by noting gaps in knowledge and propose future research questions to guide this promising area of research and practice.

Social Anxiety and Friendship Quality over Time.

High social anxiety in adults is associated with self-report of impaired friendship quality, but not necessarily with impairment reported by friends. Further, prospective prediction of social anxiety and friendship quality over time has not been tested among adults. We therefore examined friendship quality and social anxiety prospectively in 126 young adults (67 primary participants and 59 friends, aged 17-22 years); the primary participants were screened to be extreme groups to increase power and relevance to clinical samples (i.e., they were recruited based on having very high or very low social interaction anxiety). The prospective relationships between friendship quality and social anxiety were then tested using an Actor-Partner Interdependence Model. Friendship quality prospectively predicted social anxiety over time within each individual in the friendship, such that higher friendship quality at Time 1 predicted lower social anxiety approximately 6 months later at Time 2. Social anxiety did not predict friendship quality. Although the results support the view that social anxiety and friendship quality have an important causal relationship, the results run counter to the assumption that high social anxiety causes poor friendship quality. Interventions to increase friendship quality merit further consideration.

Using written narratives in public health practice: a creative writing perspective.

Narratives have become an increasingly common health communication tool in recent years. Vivid, engaging writing can help audiences identify with storytellers and understand health messages, but few public health practitioners are trained to create such stories. A transdisciplinary perspective, informed by both creative writing advice and evidence-based public health practices, can help public health professionals use stories more effectively in their work. This article provides techniques for creating written narratives that communicate health information for chronic disease prevention. We guide public health professionals through the process of soliciting, writing, and revising such stories, and we discuss challenges and potential solutions.

Screening for Health-Related Social Needs and Financial Toxicity Among Patients With Cancer Treated With Radiation Therapy: Findings From a Quality Improvement Project.

INTRODUCTION: Financial toxicity is common among patients with cancer, as are co-occurring health-related social risks (HRSRs). There is limited evidence to support best practices in screening for HRSRs and financial toxicity in the cancer context. This analysis sought to understand variations of identified needs based on treatment course using data from a large screening program. METHODS: This 2022 to 2023 screening quality improvement program included four services (breast, gastrointestinal, gynecologic, thoracic) at an urban comprehensive cancer center. The Comprehensive Score for Financial Toxicity measured financial toxicity. Patients completed an HRSR checklist documenting food, housing, medication, or transportation insecurity and financial borrowing practices. Differences were evaluated by treatment course (radiation therapy [RT] versus other treatment and RT plus chemotherapy versus other treatment). RESULTS: Screening surveys were sent to 70,983 unique patients; 38,249 completed a screening survey (54% response rate). Of responders, 4% (n = 1,686) underwent RT in the 120 days before their survey, and 3% (n = 1,033) received RT in combination with chemotherapy. Overall, patients receiving RT had lower unadjusted Comprehensive Score for Financial Toxicity scores, indicating worse financial toxicity. The proportion of patients receiving RT reporting unmet transportation (15% versus 12%, P < .001) and food (13% versus 11%, P = .02) needs was significantly higher than for patients not receiving RT. More patients receiving RT borrowed money than did patients not receiving RT (17% versus 15%, P = .02). In multivariable models, RT (alone or in combination) was associated with worse financial toxicity and transportation difficulties. CONCLUSIONS: Screening for financial toxicity and HRSR is possible at a large cancer center. Patients receiving RT have higher transportation insecurity and worse financial toxicity compared with those receiving other treatments. Tailored intervention throughout the treatment trajectory is essential.

What Do Medicaid Members Want From Their Health Plan? Insights From a Qualitative Study to Improve Engagement in Case Management.

PURPOSE OF STUDY: Managed care organizations (MCOs) provide case management services to address unmet health and social needs among their members. Few studies have examined factors influencing members' decision to participate in these programs. The purpose of the present study was to describe the life circumstances of Medicaid members offered case management, what they wanted from their MCO, and their perceptions of case management and barriers to participation. Results will inform practice to raise the awareness, engagement, and impact of case management programs. PRIMARY PRACTICE SETTINGS: Case management offered through a Midwestern Medicaid MCO. METHODOLOGY AND SAMPLE: Adult members who had been offered case management services in the 6 months preceding the study were eligible for the study. Fifteen people from each strata were recruited: members who engaged with case management, declined it, or declined it initially but later engaged (N = 45). Participants completed a qualitative interview by phone and a brief health survey online. RESULTS: Across strata, only 22 participants recalled engagement with case management. Members described a variety of life challenges (e.g., chronic health conditions, caregiver responsibilities, and limited finances) and services they desired from their MCO (e.g., stipends for over-the-counter health expenses, improved transportation services, and caregiver assistance). Participants identified direct communication, emotional support, and referrals for resources as benefits of case management.

A Longitudinal Investigation of the Association Between Stroke and Loneliness.

OBJECTIVES: The present research examined associations between stroke and long-term trajectories of loneliness. METHODS: We conducted secondary analyses in 3 large representative panel studies of adults 50 years and older in the United States, Europe, and Israel: the English Longitudinal Study of Aging (ELSA; analytic N = 14,992); the Survey of Health, Aging, and Retirement in Europe (SHARE; analytic N = 103,782); and the Health and Retirement Study (HRS; analytic N = 22,179). Within each sample, we used discontinuous growth curve modeling to estimate loneliness trajectories across adulthood and the impact of stroke on loneliness trajectories. RESULTS: Across all 3 samples, participants who experienced stroke reported higher levels of loneliness relative to participants who did not experience stroke. In ELSA and HRS (but not SHARE), loneliness levels were higher after stroke onset relative to before stroke onset. DISCUSSION: This research adds to a growing body of evidence demonstrating elevated loneliness among stroke survivors and highlights the need for interventions to increase social connectedness after stroke.

"We need a little strength as well": Examining the social context of informal caregivers for Black women with breast cancer.

BACKGROUND: Informal caregivers (e.g., partners, other family members, friends) often provide social support to Black women with breast cancer, and caregivers find both benefits and challenges in their caregiving role. METHODS: In this qualitative study, twenty-four caregivers for Black women with breast cancer participated in focus groups and interviews. Participants responded to a brief close-ended questionnaire as well as semi-structured questions about their experiences as cancer caregivers. Demographic information was collected, and relationship satisfaction was measured by the Relationship Assessment Scale-General scale (RAS-G). Focus groups and interviews were recorded, transcribed verbatim, and coded by two independent coders. Using an iterative, discussion-based process, the study team developed and refined themes. RESULTS: All caregivers described themselves as Black/African American, and the majority identified as female (79%). The mean RAS-G score was 4.5 (SD = 0.5), indicating high levels of relationship satisfaction. Qualitative themes included using a range of strategies to provide emotional support; shifting between roles; needing time and space; and trying to stay strong. Several female caregivers described how the cumulative experiences of providing care for multiple family members and friends could be draining, as could their own experiences in the patient role. CONCLUSIONS: These findings show a complex, multilayered social context that affects both the patient-caregiver relationship and the health and wellbeing of caregivers. Clinicians providing treatment and support for Black women with breast cancer should be mindful of how the health context of the family may affect patient and caregiver outcomes.

Expanding population-level interventions to help more low-income smokers quit: Study protocol for a randomized controlled trial.

BACKGROUND: Low-income Americans have higher rates of smoking and a greater burden of smoking-related disease. In the United States, smokers in every state can access evidence-based telephone counseling through free tobacco quitlines. However, quitlines target smokers who are ready to quit in the next 30 days, which can exclude many low-income smokers. A smoke-free homes intervention may help engage smokers in tobacco control services who are not yet ready to quit. Previous research in low-income populations suggests that receiving a smoke-free homes intervention is associated with higher quit rates. This study tests whether, at a population level, expanding on quitlines to include a smoke-free homes intervention for smokers not ready to quit could engage more low-income smokers and increase long-term cessation rates. METHODS: In a Hybrid Type 2 design, participants are recruited from 211 helplines in 9 states and randomly assigned to standard quitline or quitline plus smoke-free homes intervention arms. Participants in both arms are initially offered quitline services. In the quitline plus smoke-free homes condition, participants who decline the quitline are then offered a smoke-free homes intervention. Participants complete a baseline and follow-up surveys at 3 and 6 months. Those who have not yet quit at the 3-month follow-up are re-offered the interventions, which differ by study arm. The primary study outcome is self-reported 7-day point prevalence abstinence from smoking at 6-month follow-up. CONCLUSION: This real-world cessation trial involving 9 state tobacco quitlines will help inform whether offering smoke-free homes as an alternative intervention could engage more low-income smokers with evidence-based interventions and increase overall cessation rates. This study has been registered at ClinicalTrials.gov (Study Identifier: NCT04311983).

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.