Financial navigation: Staff perspectives on patients' financial burden of cancer care.

PURPOSE: To describe perceptions of financial navigation staff concerning patients' cancer-related financial burden. METHODS: This qualitative descriptive study used a semi-structured interview guide to examine perceptions of financial navigation staff concerning patients' cancer-related financial burden. Staff who provided financial navigation support services to cancer patients were interviewed from different types of cancer programs across seven states representing rural, micropolitan, and urban settings. Interviews lasted approximately one hour, were audio recorded, and transcribed. Transcripts were double coded for thematic analysis. RESULTS: Thirty-five staff from 29 cancer centers were interviewed. The first theme involved communication issues related to patient and financial navigation staff expectations, timing and the sensitive nature of financial discussions. The second theme involved the multi-faceted impact of financial burden on patients, including stress, difficulty adhering to treatments, and challenges meeting basic, non-medical needs. CONCLUSIONS AND IMPLICATIONS FOR CANCER SURVIVORS: Cancer-related financial burden has a profound impact on cancer survivors' health and non-health outcomes. Discussions regarding cancer-related costs between cancer survivors and healthcare team members could help to normalize conversations and mitigate the multi-faceted determinants and effects of cancer-related financial burden. As treatment may span months and years and unexpected costs arise, having this discussion regularly and systematically is needed.

How cancer programs identify and address the financial burdens of rural cancer patients.

PURPOSE: Financial toxicity is associated with negative patient outcomes, and rural populations are disproportionately affected by the high costs of cancer care compared to urban populations. Our objective was to (1) understand cancer programs' perceptions of rural-urban differences in cancer patients' experiences of financial hardship, (2) evaluate the resources available to cancer patients across the rural-urban continuum, and (3) determine how rural and urban health care teams assess and address financial distress in cancer patients. METHODS: Seven research teams within the Cancer Prevention and Research Control Network conducted semi-structured interviews with cancer program staff who have a role in connecting cancer patients with financial assistance services in both rural and urban counties. Interviews were audio-recorded and transcribed. We identified themes using descriptive content and thematic analysis. RESULTS: We interviewed 35 staffs across 29 cancer care programs in seven states, with roughly half of respondents from programs in rural counties. Participants identified differences in rural and urban patients' experiences of financial hardship related to distance required to travel for treatment, underinsurance, and low socioeconomic status. Insufficient staffing was an identified barrier to addressing rural and urban patients' financial concerns. CONCLUSIONS: Improved financial navigation services could mitigate the effects of financial toxicity experienced by cancer patients, particularly rural patients, throughout treatment and survivorship. Future research is needed to improve how cancer programs assess financial hardship in patients and to expand financial navigation services to better serve rural cancer patients.

Influences on HPV vaccination across levels of the social ecological model: perspectives from state level stakeholders.

Nationally, human papillomavirus (HPV) vaccination rates fall short of the Healthy People 2020 goal of 80% completion. Although strategies to increase these rates exist, low rates persist. We used concept mapping with state-level stakeholders to better understand barriers and facilitators to HPV vaccination. Concept mapping is a participatory research process in which respondents brainstorm ideas to a prompt and then sort ideas into piles. We present results of the brainstorming phase. We recruited participants identified by researchers' professional connections (n = 134) via e-mail invitations from five states (Iowa, South Dakota, Minnesota, Oregon, and Washington) working in adolescent health, sexual health, cancer prevention and control, or immunization. Using Concept Systems' online software we solicited participants' beliefs about what factors have the greatest influence on HPV vaccination rates in their states. From the original sample 58.2% (n = 78) of participants completed the brainstorming activity and generated 372 statements, our team removed duplicates and edited statements for clarity, which resulted in 172 statements. We coded statements using the Social Ecological Model (SEM) to understand at what level factors affecting HPV vaccination are occurring. There were 53 statements at the individual level, 22 at the interpersonal level, 21 in community, 51 in organizational, and 25 in policy. Our results suggest that a tiered approach, utilizing multi-level interventions instead of focusing on only one level may have the most benefit. Moreover, the policy-level influences identified by participants may be difficult to modify, thus efforts should focus on implementing evidence-based interventions to have the most meaningful impact.

"Taking Up a New Problem": Context and Determinants of Pod-Mod Electronic Cigarette Use Among College Students.

In this article, we explore the context and determinants of pod-mod electronic cigarette (ECIG) use among college students aged 18 to 24 in the United States. We conducted semi-structured interviews with 55 students (M age = 20 years, 56% female, 65% White) on three campuses in the Northwest, Midwest, and Southeast. We performed a thematic analysis. Students described ECIG use by peers, increased ECIG exposure and prevalence in college, and school-related stress as reasons for vaping. Pod-mod features such as convenience, design, easy concealment, and flavors made vaping more appealing. Negative aspects of vaping included addiction, cost, and possible health consequences. Most viewed vaping as a college behavior and intended to quit after graduation. Our results show that the college environment plays a major role in young adult ECIG use. These findings can inform the development of targeted interventions to prevent and control uptake of ECIGs by young adults.

Exploring Opportunities to Leverage Pharmacists in Rural Areas to Promote Administration of Human Papillomavirus Vaccine.

Rural pharmacists have been identified as potential partners, along with health care providers, schools, and public health agencies, in administering and promoting the human papillomavirus (HPV) vaccine. We sought to understand the role of pharmacists in this work. We interviewed 11 pharmacists working at independently owned pharmacies in Iowa to explore their perspectives on HPV vaccine administration and promotion. Most pharmacists agreed that HPV vaccination was within their professional scope. They identified factors that facilitate vaccine administration (eg, accessibility of pharmacies). They also reported personal barriers (eg, lack of information, concerns about safety) and organizational barriers (eg, time and staff capacity). Future work should focus on alleviating barriers and building on strengths to improve vaccination rates and ultimately prevent HPV-related cancers.

Intersectoral cooperation to increase HPV vaccine coverage: an innovative collaboration between Managed Care Organizations and state-level stakeholders.

In order to reduce disparities in human papillomavirus (HPV) vaccine coverage, intersectoral approaches are needed to reach vulnerable populations, including Medicaid enrollees. This manuscript describes a collaboration between Medicaid Managed Care Organizations (MCOs), the American Cancer Society, and a state health department in a Midwestern state to address HPV vaccination. Qualitative interviews (n = 11) were conducted via telephone with key stakeholders from the three participating organizations using an interview guide designed to capture the process of developing the partnership and implementing the HPV-focused project. Interviews were transcribed and coded using thematic analysis. Interviewees described motivation to participate, including shared goals, and facilitators, like pooled resources. They cited barriers, such as time and legal challenges. Overall, interviewees reported that they believed this project is replicable. Conducting this project revealed the importance of shared vision, effective communication, and the complementary resources and experiences contributed by each organization. Valuable lessons were learned about reaching the Medicaid population and groundwork was laid for future efforts to serve vulnerable populations and reduce health disparities. This work has significant implications for other organizations seeking to partner with large nonprofits, state health departments, MCOs, or others, and the lessons learned from this project could be translated to other groups working to improve vaccination rates in their communities.

Understanding the processes that Federally Qualified Health Centers use to select and implement colorectal cancer screening interventions: a qualitative study.

Colorectal cancer (CRC) screening is highly effective at reducing cancer-related morbidity and mortality, yet screening rates remain suboptimal. Evidence-based interventions can increase screening rates, particularly when they target multiple levels (e.g., patients, providers, health care systems). However, effective interventions remain underutilized. Thus, there is a pressing need to build capacity to select and implement multilevel CRC screening interventions. We report on formative research aimed at understanding how Federally Qualified Health Center (FQHC) staff select and implement CRC screening interventions, which will inform development of capacity-building strategies. We report the qualitative findings from a study that used a mixed methods design, starting with a quantitative survey followed by a qualitative study. In-depth interviews were conducted with 28 staff from 14 FQHCs in 8 states. The Consolidated Framework for Implementation Research (CFIR) guided interview questions and data analysis. Related to the CFIR process domain, few respondents described conducting formal assessments of factors contributing to low screening rates prior to planning their interventions. Many described engaging champions, implementation leaders, and external change agents. Few described a systematic approach to executing implementation plans beyond conducting plan-do-study-act cycles. Reflection and evaluation consisted primarily of reviewing Uniform Data System performance measures. Findings also include themes related to factors influencing these implementation processes. Although FQHCs are implementing CRC screening interventions, they are not actively targeting the multilevel factors influencing their CRC screening rates. Our findings on gaps in FQHCs' implementation processes will inform development of strategies to build capacity to select and implement multilevel CRC screening interventions.

Patient navigator reported patient barriers and delivered activities in two large federally-funded cancer screening programs.

Few data are available on patient navigators (PNs) across diverse roles and organizational settings that could inform optimization of patient navigation models for cancer prevention. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) and the Colorectal Cancer and Control Program (CRCCP) are two federally-funded screening programs that support clinical- and community-based PNs who serve low-income and un- or underinsured populations across the United States. An online survey assessing PN characteristics, delivered activities, and patient barriers to screening was completed by 437 of 1002 identified PNs (44%). Responding PNs were racially and ethnically diverse, had varied professional backgrounds and practice-settings, worked with diverse populations, and were located within rural and urban/suburban locations across the U.S. More PNs reported working to promote screening for breast/cervical cancers (BCC, 94%) compared to colorectal cancer (CRC, 39%). BCC and CRC PNs reported similar frequencies of individual- (e.g., knowledge, motivation, fear) and community-level patient barriers (e.g., beliefs about healthcare and screening). Despite reporting significant patient structural barriers (e.g., transportation, work and clinic hours), most BCC and CRC PNs delivered individual-level navigation activities (e.g., education, appointment reminders). PN training to identify and champion timely and patient-centered adjustments to organizational policies, practices, and norms of the NBCCEDP, CRCCP, and partner organizations may be beneficial. More research is needed to determine whether multilevel interventions that support this approach could reduce structural barriers and increase screening and diagnostic follow-up among the marginalized communities served by these two important cancer-screening programs.

Feasibility of a Coordinated Human Papillomavirus (HPV) Vaccination Program between a Medical Clinic and a Community Pharmacy.

Human papillomavirus (HPV) vaccination coverage could be enhanced by community pharmacies working with medical clinics to coordinate completion of the HPV vaccination series. The objective for this study was to assess the feasibility of a coordinated model of HPV vaccine delivery in which a clinic gives the first dose and refers patients to a partnering community pharmacy to receive subsequent doses. A medical clinic-community pharmacy team was established in a Midwestern state to develop and operate a coordinated care model for HPV vaccinations. Under the coordinated model, the clinic identified patients needing HPV vaccination(s), administered the first dose and described the option to complete the vaccination series at the pharmacy. Interested patients then had an information sheet faxed and electronic prescriptions sent to the pharmacy. The pharmacy contacted the patients to schedule administration of 2nd and 3rd doses of the HPV vaccine. Over a 12-month period, 51 patients were referred to the pharmacy by the clinic. Of these, 23 patients received a total of 25 vaccinations. Clinic and pharmacy personnel mostly rated the coordinated program favorably. An initial study of a coordinated HPV vaccination program between a medical clinic and a community pharmacy supported patients getting HPV vaccinations.

A multi-site case study of community-clinical linkages for promoting HPV vaccination.

Human papillomavirus (HPV) vaccination rates in the U.S. are suboptimal, requiring innovative partnerships between community and clinical entities to remedy this issue. A rigorous evaluation of HPV-related community-clinical linkages (CCLs) was conducted to understand their components, processes, and outcomes to increase HPV vaccination. Cancer Prevention and Control Research Network (CPCRN) investigators explored CCLs in their communities employing an iterative, case study approach. Information describing nine CCLs on HPV vaccination was collected from representatives from the community organization and clinical setting. Thematic content analysis was used to analyze and interpret data. Five CCLs included a federally qualified health center as the clinical partner, and five included a non-profit organization as the community partner. Five reflected clinically focused integration wherein engagement occurs in the community but vaccine delivery and follow-up occur in the clinical setting. The main impetus was the need to improve HPV vaccination and a community's strong interest in preventing cancer. Noted critical components were a designated person to support the CCL and funding. Results will guide HPV vaccination promotion, education, and intervention efforts. CCLs provide an opportunity to study the adaption, integration, and enhancement of evidence-based approaches to increase HPV vaccination.

Implementation Challenges and Opportunities Related to HPV Vaccination Quality Improvement in Primary Care Clinics in a Rural State.

Efforts to understand low human papillomavirus vaccine coverage led us to explore quality improvement (QI) decision-making programs and processes to increase vaccine uptake. These QI programs often include interventions recommended by the AFIX (Assessment Feedback Incentives eXchange) Program that supports Vaccines for Children (VFC) clinics. However, little is known about decision-making around intervention selection or extent of implementation. In collaboration with the state public health department in the rural Midwestern, investigators developed a survey to explore vaccine-related QI in VFC clinics. The survey was distributed via email to all VFC clinics (n = 605); results presented are from the primary care clinics (n = 115). Respondents (VFC liaisons) reported decisions about vaccine QI were made by multiple actors within their own clinics (45.1%), by a clinic manager in charge of multiple clinics (33.0%) and/or at a centralized administrative office (35.2%). Additionally, the majority of respondents considered external actors, like insurance companies (52.7%) or Medicaid/Medicare (50.5%), important to the decision-making process. Most commonly implemented interventions focused on provider knowledge and patient education. Least commonly implemented interventions required systematic changes, such as reminder/recall and follow-up after missed appointments. This preliminary research indicates there are multiple points of decision-making within clinics and health care systems, and therefore change agents at all points need to be involved. The most commonly implemented interventions focus on providers and patients, with an emphasis on education. Interventions requiring system-level changes and use of electronic health records are less common and more attention should be directed towards such interventions.

Bracing in Ponseti Clubfoot Treatment: Improving Parental Adherence Through an Innovative Health Education Intervention.

Clubfoot is the most common musculoskeletal birth defect, characterized by abnormal tendon and muscle development, leading to abnormal bone alignment of the feet. The Ponseti method is considered the gold standard in clubfoot treatment, and consists of a series of plaster castings, followed by 4 years of brace use. The most common cause of clubfoot relapse is nonadherence with the bracing protocol by the child's caretakers. The purpose of this study was to design, implement, and evaluate an educational bracing program for parents of children with clubfoot in an effort to improve bracing adherence. The educational bracing program for parents of children with clubfoot was designed with incorporation of findings from previous research, adult teaching methodology, and parental feedback. An educational brochure and a practice doll were created for use in educational sessions with parents during routine treatment visits. Two educational sessions were conducted with a health educator, employing identical questionnaires to assess changes in parental knowledge and skills upon completion of the program. Thirty parents completed the educational bracing program, and the majority reported increased knowledge and self-efficacy regarding the bracing protocol of the Ponseti method. In addition, the health practitioners who conducted the educational sessions witnessed an improved ability of all parents to apply the brace as directed, and to recognize and correct improper fit. Completion of the educational program by the parents resulted in immediate improvements in knowledge and skills related to clubfoot bracing. Given that noncompliance to the bracing protocol is the most common cause of clubfoot relapse, these immediate effects of the educational program are promising not only because they encourage proper brace use, but because these immediate improvements have the potential to reduce future rates of clubfoot relapse.