SUMR Research Presentation

1. Natalie J. Bradford University of Illinois at Urbana/Champaign College of Applied Health Sciences SUMR Research Presentation

2. Research Projects • Understanding Health & Unhealthy Relationships: Perspectives of Young Adult African American Women - Talking about Relationships • Mentor: Anne Teitelman, PhD, CRNP (PI) • Access to Outpatient Care at Cancer Centers for Newly Diagnosed Patients who are Uninsured or have Medicaid • Mentor: Keerthi Gogineni, M.D (Co-Investigator) and Katrina Armstrong, M.D., M.S.C.E (PI)

3. TALKING ABOUT RELATIONSHIPS Theory • Theory of Reasoned Action & Theory of Planned Behavior: • Individual motivational factors & intentions are the best predictors of one’s behavior Factors: • Attitudes • cultural norms • perceived control when performing certain actions

4. TALKING ABOUT RELATIONSHIPS Purpose • Learn more about how young women view healthy and unhealthy relationships including different types of relationships on risk for HIV and sexually transmitted infections (STIs) • Develop a program to prevent HIV and promote healthy relationships for adolescent girls 14 to 17 years of age Outcome measures: • condom use • multiple sex partners

5. TALKING ABOUT RELATIONSHIPS Population of interest • African American young women (ages 14-17) • Been in serious relationship with a male partner • History of abusive relationship with a male partner

6. TALKING ABOUT RELATIONSHIPS Study Design • Screening interview • Focus Group Survey • Focus Groups • Transcribe & code • New survey

7. TALKING ABOUT RELATIONSHIPS My Contribution • Media • Television shows, music, & music videos • Identify messages about teen dating violence/abuse, healthy and unhealthy relationships ,and safe sex in the media • Use media to address certain topics & issues in a culturally appropriate way • Help initiate discussions in focus groups and in the intervention

8. TALKING ABOUT RELATIONSHIPS Background • Only about 1 in 10 of the programs on television that include sexual content mentions the possible consequences or the need to use contraceptives or protection against STDs. • When asked where they have learned the most about sex, younger adolescents (13 - 15 years old) rank the mass media fourth behind parents, friends, and schools. Older adolescents (16 - 17 years old) put friends first, then parents, and then the media. • Of the few experimental studies on the relationship between exposure to sexual media content and its effects it is suggested that the media do have an impact by reinforcing a relatively consistent set of sexual and relationship norms.

9. TALKING ABOUT RELATIONSHIPS Sample Selection • Music • 2008 end of the year charts • Billboard Hot 100 • BET Notarized Top 100 videos • MTV’s Bigger than the Sound Top Songs of 2008 • Television • shows geared toward teenagers or with messages about unhealthy and healthy relationships • Images • Internet searches for images included in dating violence awareness programs & safe sex campaigns Limitations • No 2009 end of the year charts • Lack of video clips accessible online

10. TALKING ABOUT RELATIONSHIPS Analysis/Coding • Use codes from focus group • Use questions from focus group • Code in 3 different formats

11. TALKING ABOUT RELATIONSHIPS Format 1: for songs whose overall theme didn’t relate to unhealthy & healthy relationships, but had lyrics relevant to the topic Limiting Yourself to no more than one partner (Multiple Sex Partners)

12. TALKING ABOUT RELATIONSHIPS Format 2: for songs whose overall theme related to healthy and unhealthy relationships and or had a music video that related to healthy and unhealthy relationships Song/artist: Rain on Me/Ashanti Analysis: Verbal, emotional, and physical abuse – In the video Ashanti is a singer whose recent rise to fame has caused her boyfriend to become jealous, controlling, and abusive. The video starts with her boyfriend yelling at her about not spending enough time with him. The verbal argument turns violent as the boyfriend hits the singer. The lyrics of the song indicate that the singer is not only being hurt physically, but is “internally dying.” Video link:http://www.youtube.com/watch?v=yRkbENHLSuI Lyrics: (Verse 1) I’m lookin’ in the mirror at this woman down and out. She’s internally dyin’ and knew this was not what love’s about. I-I-I don’t wanna be this woman the second time around, ‘Cause I’m wakin’ up screamin’, no longer believing That I’m gonna be around, yeah. (Bridge) Over and over I tried (you know), And over and over you lied (ohh-hoo-ohh-ohh), And over and over I cried, yeah (over, yeah, yeah), And over and over I tried (yeah, yeah, yeah), And over and over you lied (you lied), And over and over I cried, yeah. I don’t know why… …….

13. TALKING ABOUT RELATIONSHIPS Format 3: for television shows TV Show: Degrassi: The Next Generation Episode: Never Gonna Give You Up (season 3 episode 10) Video link: http://www.megavideo.com/?v=LYWLVAAU (10:57…16:39…18:39) Analysis: Terri has a new boyfriend named Rick. Things seem great, but Terri has low self esteem and Rick is controlling and becomes abusive. Rick tries to dictate Terri’s actions, but when Terri doesn’t comply Rick gets angry. His temper leads him to yelling, grabbing and pushing Terri. Terri’s friends suspect she is being abused by Rick, but Terri insists that she is not. This shows the beginning stages of dating violence when there is mostly verbal abuse and only mild physical abuse.

14. TALKING ABOUT RELATIONSHIPS Images • ALDO FIGHTS AIDS/YOUTH AIDS CAMPAIGN • Campaign to break the silence about youth HIV/AIDS • Red Flag Campaign • Campaign in Virginia to promote awareness and prevention of dating violence • DECLARE YOURSELF • campaign to empower and encourage every eligible 18-29 year-old in America to register and vote • message and campaign images addressing are extremely relevant for awareness about healthy relationships. This campaign uses images in that suggest that silence and a lack of communication can have a harmful impact. This is especially true in relationships where dating violence is apparent. • STRAPPED 4 LIFE • Rap artist Lil Wayne has teamed up with Strapped Condoms to start a campaign promoting condom use and safe sex.

22. “Females ages 16-24 are more vulnerable to intimate partner violence than any other age group – at a rate almost triple the national average.”

23. “The occurrence of dating violence is associated with unhealthy sexual behaviors that can lead to unintended pregnancy, STDs and HIV infections.”

24. “Only 33% of teens who were in an abusive relationship ever told anyone about the abuse.” Only You Can Silence Yourself…

25. …Make Them Hear You

26. “You need to get informed, not infected and don’t forget, stay strapped baby!” -Lil Wayne

27. TALKING ABOUT RELATIONSHIPS Conclusion • Sex is a common topic, but safe sex awareness isn’t • Focus on multiple partners • Associated w/risky sexual behavior • Focus on money/material possessions used to attract and control girls • Control is often a predecessor to dating violence • Talk more about emotional and verbal abuse than physical abuse • Verbal & emotional abuse are more difficult to recognize • Lack of communication • Allows abusive relationships to escalate

28. TALKING ABOUT RELATIONSHIPS References • Brown, J. D., Mass Media Influences on Sexuality • Montano, D., Kasprzyk, D. (1988). Theory of Reasoned Action, Theory of Planned Behavior, and the Integrated Behavioral Model. In Glanz, K., Barbara, R. K., Viswanath, K. (Ed.), Health Behavior and Health Education: Theory, Research, and Practice (pp. 67-96). San Francisco, CA: Jossey-Bass . • U.S. Department of Justice, Bureau of Justice Statistics, Special Report: Intimate Partner Violence and Age of Victim, 1993-99 (Oct. 2001, rev. 11/28/01). • (Silverman JG, Raj A, Mucci L, Hathaway J. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. Journal of the American Medical Association 2001; 286(5):5729.) • http://www.theredflagcampaign.org/ • Liz Claiborne Inc., Conducted by Teenage Research Unlimited, (February 2005). • http://www.strappedcondoms.com/ • http://www.declareyourself.com/ • http://www.aldoshoes.com/_static/webupload/websiteDocuments/100000/AFA-press-release_EN.pdf

29. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Background • Patients who have no insurance or Medicaid have difficulty accessing outpatient specialty services and are more likely to have poor cancer related outcomes. • Studies suggest that patients have better outcomes when treated in specialized centers. • Similar studies have been done examining access to care in the context of making new primary care, psychiatric, and dermatologic appointments. • Currently there are no studies evaluating barriers to access for new outpatient oncology appointments for Medicaid and uninsured patients at cancer centers.

30. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Background • National Cancer Institute-designated Cancer Center (NCI) • Nonprofit institution with peer-reviewed cancer research funded by the P30 Cancer Center Support Grant that provides state-of-the-art cancer research, discoveries, and clinical care • Centers for Medicare and Medicaid Services (CMS) • Reimburses hospitals that care for Medicare and Medicaid patients • Disproportionate Share Hospitals (DSH) • Hospitals that are eligible for adjusted reimbursements due to the higher proportion of patients with Medicare and Medicaid cared for at such institutions. • Metropolitan Statistical Area (MSA) • contains a core urban area with a population of 50,000 or more and includes any adjacent counties that have a high degree of social and economic integration with the urban core.

31. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Purpose • Assess disparities in access to care at cancer centers for uninsured or Medicaid patients • Examine potential barriers newly diagnosed cancer patients with no insurance or Medicaid encounter when attempting to schedule an appointment at a cancer center • Measure access

32. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Defining access Is an appointment made? • If yes… • When is the appointment? • Out of pocket cost? • If no… • Reason • alternative sources of care • Time spent on phone • Number of attempts

33. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Sample Selection CMS hospital list • NCI-designated centers • Teaching hospitals • Hospitals with extreme DSH percentage Enrich for Top 50 MSA Top 25 MSA 3 centers within each MSA

34. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Specific Aim 1: To explore the association between outcomes of a newly diagnosed patient’s request for an initial outpatient visit at a cancer center and the patient’s insurance status and type of cancer diagnosis • H1a: • Patients who are uninsured or have Medicaid are less likely to get an appointment • H1b: • Patients with a cancer diagnosis requiring more specialized care are more likely to get an appointment regardless of insurance status • H1c: • Patients who are uninsured or have Medicaid are more likely to get an appointment at a cancer center affiliated with a hospital that has a higher Disproportionate Share Hospital (DSH) percentage or academic affiliation

35. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Specific Aim 2: To describe patient-specific and center-specific variables associated with outcomes of requests for an initial outpatient visit at a cancer center for a patient newly diagnosed with cancer who is uninsured or has Medicaid • patient-specific variables • center specific variables • outcome variables

36. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Methodology • Call hospital for number to their outpatient cancer center • NCI centers’ numbers online • Script/simulated patient profile/data entry sheet • 6 scenarios

37. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Revisions to script • IRB approval • Waiver of informed consent • Minimal risk/harm to subjects • Cancer center • list of hospitals confidential • Staff • identity confidential • Real patients • if appointment scheduled for simulated patient, call back the same day to cancel • Pilot calls • Need doctor referral • Flow of script

38. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Actual calls • 3 cancer centers from each of the top 25 MSA’s • Used same centers for each scenario • 3 scenarios • Liver cancer: private insurance, Medicaid, uninsured • Maximum of 3 attempts per center • One scenario per week

42. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Analysis • H1a: Patients who are uninsured or have Medicaid are less likely to get an appointment • supported • H1b: Patients with a cancer diagnosis requiring more specialized care are more likely to get an appointment regardless of insurance status • need to compare w/colon cancer scenarios • H1c: Patients who are uninsured or have Medicaid are more likely to get an appointment at a cancer center affiliated with a hospital that has a higher Disproportionate Share Hospital (DSH) percentage or academic affiliation • Need more detailed data and analysis

43. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS Conclusion • Private insurance • need referral • Uninsured • required to speak with financial counselor • center didn’t accept self-paying patients, • required/encouraged patient to apply for financial medical assistance through the state • Many centers only provide radiation or infusion therapy • Being put on hold • Many centers close for lunch • Possible flaws in design

44. ACCESS TO OUTPATIENT CARE AT CANCER CENTERS References • Access to specialty care and medical services in community health centers. Cooks NL, et al. Health Affairs. 2007 Sep-Oct; 26(5): 1459-68 • Expanding the definition of Access: it isn’t just about health insurance. Hall AG et al. Journal of Health Care for the Poor and Underserved 19 (2008): 625-638 • Referrals without access: for psychiatric referrals, wait for the beep. Rhodes KV et al. Annals of Emergency Medicine. 2008. In Press. • Do cancer centers designated by the National Cancer Institute have better surgical outcomes? Birkmeyer NJ et al. Cancer. 2005; 103:435-441. • Do specialists do it better? The impact of specialization on the processes and outcomes of care for cancer patients. Grilli R et al. Annals of Oncology. 1998;365-374. • Web site of the Commission on Cancer. http://www.facs.org/cancer. • Waiting times to see a dermatologist are perceived as too long by dermatologists: implications for the dermatology workforce. Suneja T et al. Archives of Dermatology. 2001 Oct;137(10):1295-301. • http://www.census.gov/population/www/metroareas/metroarea.html