Childhood cancer survivors often have complex health needs that require medical surveillance, requiring them
to navigate the complexities of the health care system. Despite the Affordable Care Act’s expansion of
insurance, many childhood cancer survivors continue to experience underinsurance and barriers to care.
Adequate health insurance literacy is a key skill for survivors to obtain and utilize health insurance and to
prevent high out-of-pocket costs or unmet health care needs. Interventions are critically needed to support
childhood cancer survivors in addressing issues of insurance, but to date no intervention has been developed
to improve childhood survivors’ health insurance literacy. Guided by Andersen and Aday’s Behavioral Model of
Health Services Use, we developed a patient navigation intervention and health insurance booklet, targeted for
survivors. We conducted a pilot randomized trial comparing intervention, Health Insurance Navigation Tools
(HINT-S), delivered synchronously via Zoom, to enhanced usual care (EUC; digital health insurance booklet
only) among 82 survivors in the Childhood Cancer Survivor Study (CCSS) cohort. HINT-S incorporates a
strong psychoeducational component, with 4 45-minute sessions designed to improve survivors’ conceptual
knowledge of health insurance and cost. Preliminary results support its feasibility, acceptability, and preliminary
efficacy. In response to RFA-CA-20-027, we propose a Type 1 hybrid effectiveness-implementation trial to test
HINT-S vs. EUC to promote health insurance literacy, as well as improving downstream financial hardship and
health care. We will randomize 520 survivors from the CCSS cohort to: HINT-S, HINT-A (4 prerecorded,
asynchronous navigator sessions, which has the potential to be cost-effective and scalable), and EUC. All
study activities, including recruitment, data collection, and navigation, will be conducted virtually, via the CCSS
mHealth platform and patient portal. We will investigate whether HINT-S improves health insurance literacy
over EUC at 6 months (primary outcome) and explore the relative difference in effect size and cost of HINT-S
compared to HINT-A. We will explore moderators (e.g., sociodemographics, insurance status, state Medicaid
expansion status, cancer and health history, and baseline literacy) of the intervention effects. The association
of health insurance literacy with longer-term outcomes, such as financial hardship (worry, unmet healthcare
needs, and financial consequences of medical costs), decreases in out-of-pocket-costs, and improvements in
healthcare utilization at 18 months will be investigated. Implementation evaluation will assess the intervention’s
reach, engagement, acceptability, fidelity, and sustainability (including cost). This study is innovative for the 1)
comparison of digital intervention delivery, 2) focus on health insurance literacy, and 3) access to a national
sample of long-term childhood cancer survivors. Digitally-delivered interventions that address health insurance
literacy can lead to national sustainable improvements in childhood survivors’ health care costs and care.
