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Background Cancer-related financial hardship is an increasingly recognized concern for patients, families, and caregivers. Many Native American (NA) patients are at increased risk for cancer-related financial hardship due to high prevalence of low income, medical comorbidity, and lack of private health insurance. However, financial hardship screening (FHS) implementation for NA patients with cancer has not been reported. The objective of this study is to explore facilitators and barriers to FHS implementation for NA patients. Methods We conducted key informant interviews with NA patients with cancer and with clinical staff at an academic cancer center. Included patients had a confirmed diagnosis of cancer and were referred to the cancer center through the Indian Health Service, Tribal health program, or Urban Indian health program. Interviews included questions regarding current financial hardship, experiences in discussing financial hardship with the cancer care and primary care teams, and acceptability of completing a financial hardship screening tool at the cancer center. Clinical staff included physicians, advanced practice providers, and social workers. Interviews focused on confidence, comfort, and experience in discussing financial hardship with patients. Recorded interviews were transcribed and thematically analyzed using MAXQDA® software. Results We interviewed seven patients and four clinical staff. Themes from the interviews included: 1) existing resources and support services; 2) challenges, gaps in services, and barriers to care; 3) nuances of NA cancer care; and 4) opportunities for improved care and resources. Patients identified financial challenges to receiving cancer care including transportation, lodging, food insecurity, and utility expenses. Patients were willing to complete a FHS tool, but indicated this tool should be short and not intrusive of the patient’s financial information. Clinical staff described discomfort in discussing financial hardship with patients, primarily due to a lack of training and knowledge about resources to support patients. Having designated staff familiar with I/T/U systems was helpful, but perspectives differed regarding who should administer FHS. Conclusions We identified facilitators and barriers to implementing FHS for NA patients with cancer at both the patient and clinician levels. Findings suggest clear organizational structures and processes are needed for financial hardship to be addressed effectively.

Background The American Cancer Society discourages the dual use of electronic cigarettes (ECs) and cigarettes because such use has not resulted in reduced exposures to the harmful effects of smoking. American Indian (AI) people have the highest prevalence of smoking and of EC use in the United States, but very little is known about dual EC and cigarette use in AI communities. Methods In 2016, 375 adult AI in Oklahoma who smoked cigarettes completed a survey about EC use (vaping). We describe vaping patterns, nicotine dependence, and reasons for EC use among the subset of 44 (12%) current dual EC users. To differentiate habitual EC users from occasional or merely curious users, we defined dual use as using ECs on some days or every day in the past 30 days. Results About one-third of dual users vaped ten or more times daily. About two-thirds used a tank product. Eleven percent used ECs without nicotine and another 9% were unsure of the nicotine content. A minority (40%) enjoyed vaping more than smoking, and most (76%) would smoke first on days they did both. Thirty-one percent vaped within 5 min of waking and another 24% within 30 min. Although the two-item heaviness of use index did not differ significantly between smoking and vaping, the ten-item Penn State Dependence Index (PSDI) suggested greater dependence on smoking than vaping (11.02 vs. 6.42, respectively; p  < .0001). The most common reasons for vaping were to reduce smoking (79%), enjoyment of flavors (78%), and ability to vape where smoking is not allowed (73%). Perceptions of less harm to others (69%) or to self were the next most common (65%). Fewer than half used ECs to reduce stress, for affordability, or because others used them. Conclusions Nearly 20% of dual users used ECs either without nicotine or without knowing if the product contained nicotine. The PSDI indicated greater dependence on smoking than vaping. Reasons for vaping were nearly equal between smoking reduction and enjoying flavors. Understanding patterns of dual use will inform future efforts to address nicotine dependence for AI communities with high prevalence of smoking.

Background Oklahoma’s cumulative COVID-19 incidence is higher in rural than urban counties and higher than the overall US incidence. Furthermore, fewer Oklahomans have received at least one COVID-19 vaccine compared to the US average. Our goal is to conduct a randomized controlled trial using the multiphase optimization strategy (MOST) to test multiple educational interventions to improve uptake of COVID-19 vaccination among underserved populations in Oklahoma. Methods Our study uses the preparation and optimization phases of the MOST framework. We conduct focus groups among community partners and community members previously involved in hosting COVID-19 testing events to inform intervention design (preparation). In a randomized clinical trial, we test three interventions to improve vaccination uptake: (1) process improvement (text messages); (2) barrier elicitation and reduction (electronic survey with tailored questions/prompts); and (2) teachable moment messaging (motivational interviewing) in a three-factor fully crossed factorial design (optimization). Discussion Because of Oklahoma’s higher COVID-19 impact and lower vaccine uptake, identifying community-driven interventions is critical to address vaccine hesitancy. The MOST framework provides an innovative and timely opportunity to efficiently evaluate multiple educational interventions in a single study. Trial Registration ClinicalTrials.gov: NCT05236270, First Posted: February 11, 2022, Last Update Posted: August 31, 2022.

Purpose To explore feasibility of using a Nurse Cancer Care Coordinator (CCC) to synthesize cancer survivorship care data, assess degree of cancer-related distress, and coordinate care for American Indian (AI) patients seen in a tribal primary care clinic. Methods A CCC from one of Choctaw Nation’s primary care facility collected data on American Indian adults who had completed cancer treatment within the preceding five-years. Measures included demographics, cancer type, treatment and potential adverse effects, schedule of follow-up visits, behavioral risk assessment, global distress and checklist of distress sources, and length of time and frequency of attempts to complete data collection. Results None of the participants had ever received a survivorship care plan (SCP). A total of 15 oncology providers were contacted to gather SCP and Distress Thermometer (DT) information on the 23 participants. Time to complete the SCP ranged from 30 to 120 min, with an average of 62 min per participant. The baseline DT score was 4.4 out of 10 and the average number of problems reported was 5.0. The top five challenges experienced by participants were fatigue (57%), pain (57%), worry (48%), tingling in hands/feet (33%), and sleep (33%). Conclusions A Nurse CCC embedded within a tribal clinic organized clinically relevant survivorship care information, but this was a labor-intensive undertaking. Further work is needed to determine if risk stratification could be used to identify subsets of patients who would most benefit from this intervention. Implications for cancer survivors : Enhancement of Primary Care and Oncology communication may improve survivor care and health outcomes.

Despite high cancer-related mortality, health systems serving American Indian and Alaska Native populations offer only primary care. The University of Oklahoma is bridging the gap with oncology services.

Purpose Native American (NA) patients with cancer are at increased risk of financial hardship due to lack of private health insurance coverage, medical comorbidities, and higher poverty rates. We aimed to implement and evaluate a pilot financial hardship screening (FHS) program among NA patients with cancer. Methods In 2022, we piloted the implementation of FHS among adult NA patients with cancer referred by NA-specific health facilities to an NCI-designated cancer center using the COmprehensive Score for financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) tool. We dichotomized COST-FACIT scores as mild/no hardship (26–44) and moderate/severe hardship (≤ 25). To evaluate the implementation, we conducted interviews with patients and clinical staff who participated in the screening process. We thematically analyzed interview transcriptions using inductive and deductive coding to identify themes. Results Of 42 patients completing FHS, 76.2% reported moderate/severe hardship. Ten patients and four clinical staff (1 physician, 3 NA navigation staff) completed interviews. We identified three themes: (1) FHS perceptions and intervention experiences, (2) FHS efficacy and opportunities for expansion, and (3) nuances for NA patients and patient-related factors. Patients expressed positive experiences with FHS, including identifying financial challenges, but preferences regarding timing varied. Staff reported logistic and sustainability challenges in implementing FHS. However, clinic staff reported positive experiences with the tool, interactions with patients, and the resulting supportive care referrals. Conclusion Implementation of FHS for NA patients with cancer was well received by patients and staff and was perceived by both groups as facilitating efforts to address financial hardship. Measures to improve staffing and sustainability are needed to enable broader implementation.

Background: Racial and ethnic disparities in health care have been well documented, but poorly explained. Objective: To examine the effect of access barriers, including English fluency, on racial and ethnic disparities in health care. Research Design: Cross-sectional analysis of the Community Tracking Survey (1996-1997). Subjects: Adults 18 to 64 years with private or Medicaid health insurance. Measures: Independent variables included race, ethnicity, and English fluency. Dependent variables included having had a physician or mental health visit, influenza vaccination, or mammogram during the past year. Results: The health care use pattern for English-speaking Hispanic patients was not significantly different than for non-Hispanic white patients in the crude or multivariate models. In contrast, Spanish-speaking Hispanic patients were significantly less likely than non-Hispanic white patients to have had a physician visit (RR, 0.77; 95% CI, 0.72-0.83), mental health visit (RR, 0.50; 95% CI, 0.32-0.76), or influenza vaccination (RR, 0.30; 95% CI, 0.15-0.52). After adjustment for predisposing, need, and enabling factors, Spanish-speaking Hispanic patients showed significantly lower use than non-Hispanic white patients across all four measures. Black patients had a significantly lower crude relative risk of having received an influenza vaccination (RR, 0.73; 95% CI, 0.58-0.87). Adjustment for additional factors had little impact on this effect, but resulted in black patients being significantly less likely than non-Hispanic white patients to have had a visit with a mental health professional (RR, 0.46; 95% CI, 0.37-0.55). Conclusions: Among insured nonelderly adults, there are appreciable disparities in health-care use by race and Hispanic ethnicity. Ethnic disparities in care are largely explained by differences in English fluency, but racial disparities in care are not explained by commonly used access factors.

Compared to Oklahoma, 33 states have higher all-cause cancer incidence rates, but only three states have higher all-cause cancer mortality rates. Given this troubling gap between Oklahoma’s cancer incidence and mortality rankings, in-depth examination of cancer incidence, staging, and mortality rates among this state’s high-risk populations is warranted. This study provides in-depth information on overall and cause-specific cancer incidence and mortality for the rural and urban Oklahoma populations classified by Rural-Urban Continuum Codes (RUCC). Data were publicly available and de-identified, accessed through Oklahoma Statistics on Health Available for Everyone (OK2SHARE). Statistical analysis included calculating age-specific rates, age-adjusted rates, and percentages, as well as assessing temporal patterns using average annual percent change with 95 % confidence intervals determined by Joinpoint regression analysis. Urban areas had a higher proportion of female breast cancer cases, while large and small rural areas had higher rates of lung and bronchus cancer. Urban residents were more likely to have private insurance and less likely to have Medicare compared to rural residents. Cancer incidence rates increased with age, and men had higher mortality rates than women. Lung and bronchus cancer was the leading cause of cancer death, with lower rates in urban areas compared to rural areas. Findings demonstrate the need to improve the early detection of cancer among the rural populations of Oklahoma. Additionally, the high mortality rates for most types of cancer experienced by the state’s rural population underscores the need to improve cancer detection and treatment in these locations. •Urban areas had a higher rates of female breast cancer cases compared to urban areas.•Large and small rural areas had higher rates of lung cancer than urban areas.•Urban residents were more likely to report private insurance compared to rural residents.•Urban residents were less likely to report Medicare compared to rural residents.•Urban areas have higher incidence rates than rural areas, but lower mortality rates.

Background: Estimates of the relative contributions of physicians, physician assistants (PAs), and nurse practitioners (NPs) toward rural primary care are needed to inform workforce planning activities aimed at reducing rural primary shortages. Objectives: For each provider group, this study quantifies the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. Methods: A randomly drawn sample of 788 physicians, 601 PAs, and 918 NPs with rural addresses in 13 US states responded to a mailed questionnaire that measured reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Analysis of variance and χ2 testing were used to test for bivariate associations. Multivariate regression was used to model average weekly outpatient volume adjusting for provider sociodemographics and geographical location. Results: Compared with physicians, average weekly outpatient visit quantity was 8% lower for PAs and 25% lower for NPs (P<0.001). After multivariate adjustment, this gap became negligible for PAs (P=0.56) and decreased to 10% for NPs (P<0.001). Compared with PAs and NPs, primary care physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and afterhours call coverage (all P<0.001). Conclusions: Although our findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor impact on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.

Objective: The objective of this study was to assess rural-urban differences in mammography and Papanicolaou (Pap) smear screening. Methods: Data from the Behavioral Risk Factor Surveillance System (1994-2000, 2002, 2004) were used to examine trends in these two tests by rural-urban residence location. Results: In 2004, 70.8 percent of rural and 75.7 percent of urban respondents had received timely mammography; this difference remained significant in adjusted analyses and was greatest for women in remote rural locations. Although overall participation in mammography increased over time, a persistent rural-urban gap was identified. In contrast, in 2004, while 83.1 percent of rural and 86.1 percent of urban respondents had received a timely Pap test, the adjusted difference was not significant and Pap testing did not improve over time. Advanced age and low socioeconomic status were associated with a lack of screening. Conclusions: Over an 11-year interval, mammography screening improved nationally, but women living in rural locations remained less likely than their urban counterparts to receive this test. However, no secular improvement in Pap testing was found, and no significant rural-urban differences were observed. Policy Implications: Interventions to improve breast cancer screening are needed for rural women. Such efforts should target older women and those with low socioeconomic status.