QUEER, SICK, AND POOR: FINANCIAL HARDSHIP AMONG LGBTQ+ CANCER SURVIVORS AND CAREGIVERS

Significance: Lesbian, gay, bisexual, transgender and other sexual and gender minority (LGBTQ+) populations make up a substantial proportion of the United States (US) population—over 23 million individuals. LGBTQ+ populations throughout the US face identity-related stigma, ranging from interpersonal to structural, that leads to a variety of physical, mental, and economic health disparities. At the same time, the rising costs of cancer care puts over half of cancer survivors at risk of financial hardship and the subsequent outcomes—poor quality of life and reduced access to care. Emerging research suggests that LGBTQ+ cancer survivors and caregivers may experience worse financial hardship in comparison to non-LGBTQ+ counterparts, driven by existing economic inequities and multi-level anti-LGBTQ+ stigma. However, inequity in financial burden has not been estimated using national datasets, nor, has an intersectional lens been taken to interrogate the diversity of the LGBTQ+ population. Innovation: Employing multiple national datasets with sexual orientation and gender identity data (SOGI) data (Aims 1 and 2) as well as an explanatory sequential mixed-methods design with in-depth qualitative interviews (Aim 3) this dissertation provided a novel opportunity to provide national findings among LGBTQ+ cancer survivors paired with in-depth experiences of LGBTQ+ cancer caregivers. Integration of cancer-related financial hardship frameworks and the theory of intersectionality is not only responsive to national calls to center health equity (NOT-HS-21-014), but it also allows, for the first time, comprehensive and robust estimates to be generated for LGBTQ+ cancer survivors of diverse identities. Aims: Aim 1 used multivariable logit regression to estimate inequities in material, behavioral, and psychological financial hardship between LGB (e.g., lesbian, gay, bisexual) and non-LGB cancer survivors in the National Health Interview Survey. Aim 2 employed intersectional analyses to estimate inequity in behavioral financial hardship across identities and ages between LGBTQ+ and non-LGBTQ+ cancer survivors in the All of Us Research Program dataset. Aim 3 used an explanatory sequential mixed-methods design including in-depth qualitative interview building on an existing federally funded parent grant study. Aim 3 analyses described the lived experience of financial burden among LGBTQ+ cancer caregivers as well as provided multi-level LGBTQ+ specific recommendations. Study Impact: This study employs multiple data sources that each provide unique and important context to LGBTQ+ inequities in financial hardship. Affordability is crucial to access to care, thus understanding the between and within LGBTQ+ community variation in financial hardship promotes equity in health services delivery. Overall, the purpose of this study was to estimate inequity, identify modifiable factors, and elicit LGBTQ+ recommendations to improve the provision of cancer health services to LGBTQ+ populations.