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Conceptual model of financial hardship.
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Risk of cancer increases with age; and socioeconomic factors have been shown to be relevant for (predictive of) cancer risk-related behaviors and cancer early detection and screening. Yet, much of this research has relied on traditional measures of socioeconomic status (SES) to assess socioeconomic circumstances, which limits our understanding of t...
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Context 1
... research also showed that financial hardship and/or financial distress experienced over time is detrimental to the health/well-being of older adults. To build on this previous research effort, we propose the material-psychosocial-behavioral conceptual model of financial hardship to sort and characterize the many terms used to describe financial hardship among older adults; we suggest that the conceptual model in Figure 1 can better guide cancer prevention researchers and practitioners to conceptualize and operationalize the aspects of socioeconomic circumstances that are influencing cancer risk-related behaviors among older adults. Though this discussion is introducing a conceptual model of financial hardship for cancer prevention research efforts among older adults, this model can be applied in defining and measuring financial hardship for cancer prevention research in any adult population. ...
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Background
Colorectal cancer (CRC) screening, such as fecal occult blood test (FOBT), is an effective way to prevent CRC, one of the most common cancers worldwide. However, studies found that South Asian ethnic minorities tend not to utilize CRC screening, whose importance on CRC prevention shall be educated among those from ethnic minorities, espe...
Citations
... 3 Financial toxicity is conceptualized as the combined impact from material hardship, psychological distress, and coping behaviors that an individual patient and their family experience in response to these costs. 4,5 For AYAs, identified by the National Cancer Institute as a vulnerable population experiencing cancer health disparities, 6 financial toxicity results from the direct and indirect costs of cancer care, as well as from interrupted education, exclusion from the workforce, and developmental disruption in achieving or maintaining independence. 7,8 Compared to older cancer survivors, AYAs experience disproportionately higher rates of financial toxicity and unemployment, associated with poorer overall survival and bankruptcy. ...
... The interview guide was developed by our study team in consultation with key stakeholders, including an AYA cancer survivor, caregiver advocate, and clinicians with experience caring for AYA patients (Data S1). 35 The interview guide drew on published frameworks of financial toxicity and burden 5,36,37 to allow for open-ended responses from participants regarding how they may or may not have experienced the direct and indirect financial costs of cancer care (i.e., material hardship), how they and their family felt about these costs (i.e., psychological response), and how they adapted or managed these costs (i.e., coping behaviors). The interviewers were trained to probe in depth throughout the session to explore acceptable screening processes to identify financial difficulties and to assess what resources or interventions the AYA and caregiver perceived might reduce financial burdens or address unmet needs. ...
... Our team considered this theme a confirmation of financial toxicity, encompassing the concrete hardships, the psychological impact, and the response of the patient and family to financial stressors. 5 ...
Purpose
We qualitatively explored the unique needs and preferences for financial toxicity screening and interventions to address financial toxicity among adolescents and emerging adults (younger AYAs: 15–25 years) with cancer and their caregivers.
Methods
We recruited English‐ or Spanish‐speaking younger AYAs who were treated for cancer within the past 2 years and their caregivers. Semi‐structured interviews were conducted to explore preferences for screening and interventional study development to address financial toxicity. The data were coded using conventional content analysis. Codes were reviewed with the study team, and interviews continued until saturation was reached; codes were consolidated into categories and themes during consensus discussions.
Results
We interviewed 17 participants; nine were younger AYAs. Seven of the 17 preferred to speak Spanish. We identified three cross‐cutting themes: burden , support , and routine, consistent, and clear . The burden came in the form of unexpected costs such as transportation to appointments, as well as emotional burdens such as AYAs worrying about how much their family sacrificed for their care or caregivers worrying about the AYA's physical and financial future. Support, in the form of familial, community, healthcare institution, and insurance, was critical to mitigating the effects of financial toxicity in this population. Participants emphasized the importance of meeting individual financial needs by routinely and consistently asking about financial factors and providing clear guidance to navigate these needs.
Conclusion
Younger AYAs and their caregivers experience significant financial challenges and unmet health‐related social needs during cancer treatment and often rely on key supports to alleviate these unmet needs. When developing interventions to mitigate financial toxicity, clinicians and health systems should prioritize clear, consistent, and tailorable approaches to support younger AYA cancer survivors and their families.
... Medical financial hardship was categorized into 3 domains: material conditions, psychological responses, and coping behaviors. This framework provides a multidimensional measure of medical financial hardship by capturing material conditions resulting from increased health-care expenses and reduced income (eg, difficulties in paying medical bills), psychological responses to treatment and care cost (eg, financial worry and distress), and consequent health-care-seeking behaviors (eg, delaying or forgoing care because of cost) (1, 31,32). This approach has been adopted in previous studies, particularly in survey studies, with the benefit of summarizing information from multiple measures within the same domain of hardship (26,33). ...
Background
Young adult cancer survivors face medical financial hardships that may lead to delaying or forgoing medical care. This study describes the medical financial difficulties young adult cancer survivors in the United States experience in the post–Patient Protection and Affordable Care Act period.
Method
We identified 1009 cancer survivors aged 18 to 39 years from the National Health Interview Survey (2015-2022) and matched 963 (95%) cancer survivors to 2733 control individuals using nearest-neighbor matching. We used conditional logistic regression to examine the association between cancer history and medical financial hardship and to assess whether this association varied by age, sex, race and ethnicity, and region of residence.
Results
Compared with those who did not have a history of cancer, young adult cancer survivors were more likely to report material financial hardship (22.8% vs 15.2%; odds ratio = 1.65, 95% confidence interval = 1.50 to 1.81) and behavior-related financial hardship (34.3% vs 24.4%; odds ratio = 1.62, 95% confidence interval = 1.49 to 1.76) but not psychological financial hardship (52.6% vs 50.9%; odds ratio = 1.07, 95% confidence interval = 0.99 to 1.16). Young adult cancer survivors who were Hispanic or lived in the Midwest and South were more likely to report psychological financial hardship than their counterparts.
Conclusions
We found that young adult cancer survivors were more likely to experience material and behavior-related financial hardship than young adults without a history of cancer. We also identified specific subgroups of young adult cancer survivors that may benefit from targeted policies and interventions to alleviate medical financial hardship.
... Yet, there is no agreed-upon definition or measure of financial hardship across research fields. However, cancer researchers recently developed a three-domain conceptual model to help sort the many terms used to capture the financial hardship experience in the context of cancer survivorship [24][25][26]. The three-domain conceptual model is characterized by: 1) a material domain that captures the lack of financial resources, 2) a psychological domain that captures how people feel about their lack of financial resources, and 3) a behavioral domain that captures how people manage (or adjust) their financial resources or the purposeful efforts that people use to economize to meet their financial obligations. ...
... Financial hardship was assessed using 11 indicators in the baseline survey. The authors sorted these items into the material, psychological, and behavioral domains previously described in the cancer prevention and survivorship research [24]. ...
... The material domain includes indicators related to the lack of financial resources [24]. Three indicators were used as the measures of the material domain of financial hardship: 1) income to poverty line ratio, adjusted for the total household size (3 = < 300%, 2 = ≥ 300% but less than 600%, 1 = ≥ 600%), 2) health insurance coverage (no = 1 or yes = 0), and 3) public/government financial assistance, based on whether the household received public or government assistance in the last calendar year (yes = 1, or no = 0), such as supplemental security income, social security disability insurance, food stamps, Temporary Assistance for Needy Family (TANF), and unemployment benefits. ...
Background
Measures of financial hardship have been suggested to supplement traditional indicators of socioeconomic status (SES) to elucidate household economic well-being. This study formally tested the construct validity of financial hardship and examined its association with markers of inflammation.
Methods
This study utilized data from the Midlife Development in the United States Refresher Study (MIDUS-R; Age = 23-76, 53.7% female, 71% white). Participants were divided into exploratory factor analysis (EFA; completed SAQs only; N = 2,243) and confirmatory factor analysis sample (CFA; completed SAQs and biomarker assessment; N = 863). Analysis was divided into three steps. First, exploratory factor analysis (EFA) is used to examine if the three-domain factor (material, psychological, and behavioral) is the best fitting model for financial hardship measures. Second, we conducted CFA to test the hypothesized three-factor measurement model of financial hardship. Third, we tested the association between domains and the general latent factor of financial hardship and inflammation (interleukin 6/IL6, c-reactive protein/CRP, and fibrinogen).
Results
Results from EFA supported the three-domain model of financial hardship. The hypothesized three-domain measurement model fits well in a different sample within MIDUS-R. In the models adjusted for age and sex, higher material hardship was associated with elevated IL6, CRP, and fibrinogen, while higher behavioral hardship was associated with higher CRP. The association between the material domain and IL6 remained significant after adding body mass index, education, and race as additional covariates. The second-order financial hardship measurement model was associated with IL6, CRP, and fibrinogen, adjusted for age, sex, BMI, education, and race.
Conclusion
Explicating the socioeconomic environment to include indicators of financial hardship can help researchers better understand the pathway between SES and the inflammation process, which may help elucidate pathways between SES and age-related chronic diseases associated with inflammation.
... Interviews and instrument administration were conducted in Spanish by bilingual members of the study team. Sessions were audio-recorded and transcribed verbatim and analyzed in English using a deductive approach based on the existing conceptual model of FT delineating major subdomains of FT: material, psychological, and behavioral (Altice et al., 2017;Tucker-Seeley and Thorpe, 2019). Two independent coders (GM and GS) analyzed the data. ...
Background
Financial toxicity (FT) reflects multi-dimensional personal economic hardships borne by cancer patients. It is unknown whether measures of FT—to date derived largely from English-speakers—adequately capture economic experiences and financial hardships of medically underserved low English proficiency US Hispanic cancer patients. We piloted a Spanish language FT instrument in this population.
Methods
We piloted a Spanish version of the Economic Strain and Resilience in Cancer (ENRICh) FT measure using qualitative cognitive interviews and surveys in un-/under-insured or medically underserved, low English proficiency, Spanish-speaking Hispanics (UN-Spanish, n = 23) receiving ambulatory oncology care at a public healthcare safety net hospital in the Houston metropolitan area. Exploratory analyses compared ENRICh FT scores amongst the UN-Spanish group to: (1) un-/under-insured English-speaking Hispanics (UN-English, n = 23) from the same public facility and (2) insured English-speaking Hispanics (INS-English, n = 31) from an academic comprehensive cancer center. Multivariable logistic models compared the outcome of severe FT (score > 6).
Results
UN-Spanish Hispanic participants reported high acceptability of the instrument (only 0% responded that the instrument was “very difficult to answer” and 4% that it was “very difficult to understand the questions”; 8% responded that it was “very difficult to remember resources used” and 8% that it was “very difficult to remember the burdens experienced”; and 4% responded that it was “very uncomfortable to respond”). Internal consistency of the FT measure was high (Cronbach’s α = 0.906). In qualitative responses, UN-Spanish Hispanics frequently identified a total lack of credit, savings, or income and food insecurity as aspects contributing to FT. UN-Spanish and UN-English Hispanic patients were younger, had lower education and income, resided in socioeconomically deprived neighborhoods and had more advanced cancer vs. INS-English Hispanics. There was a higher likelihood of severe FT in UN-Spanish (OR = 2.73, 95% CI 0.77–9.70; p = 0.12) and UN-English (OR = 4.13, 95% CI 1.13–15.12; p = 0.03) vs. INS-English Hispanics. A higher likelihood of severely depleted FT coping resources occurred in UN-Spanish (OR = 4.00, 95% CI 1.07–14.92; p = 0.04) and UN-English (OR = 5.73, 95% CI 1.49–22.1; p = 0.01) vs. INS-English. The likelihood of FT did not differ between UN-Spanish and UN-English in both models (p = 0.59 and p = 0.62 respectively).
Conclusion
In medically underserved, uninsured Hispanic patients with cancer, comprehensive Spanish-language FT assessment in low English proficiency participants was feasible, acceptable, and internally consistent. Future studies employing tailored FT assessment and intervention should encompass the key privations and hardships in this population.
... The subtheme 'household health expenditure ratio' was mentioned as the total OOP expenditure as percentage of household income in one included model [2]. Available savings and assets were also mentioned in the a priori concept 'material resources' and included in models [2,32,43]. We added the term 'household' to clarify the focus on household unit of this sub-theme. ...
... In addition, 'financial coping behavior' is also closely linked to 'financial coping ability' themes, as is shown in the work of Tucker-Seeley and Thorpe (2019) [43] as a bidirectional relationship. There were also observations by authors from another study [37] that further illustrated this relationship. ...
Background:
Multiple studies have indicated a socioeconomic impact of cancer and cancer care on patients and their families. Existing instruments designed to measure this impact lack consensus in their conceptualization of the issue. Further, various terminologies have been used in the literature (e.g., financial burden, financial hardship, financial stress) without clear definitions and consistent conceptual background. Based on a targeted review of existing models addressing the socioeconomic impact of cancer, our goal was to develop a comprehensive framework from a European perspective.
Method:
A 'best-fit' framework synthesis was applied. First, we systematically identified existing models to generate a priori concepts. Second, we systematically identified relevant European qualitative studies and coded their results against these a priori concepts. Inclusion and exclusion criteria were predefined and applied thoroughly in these processes. Thematic analysis and team discussions were applied to finalize the (sub)themes in our proposed conceptual framework. Third, we examined model structures and quotes from qualitative studies to explore relationships among (sub)themes. This process was repeated until no further change in (sub)themes and their relationships emerged.
Result:
Eighteen studies containing conceptual models and seven qualitative studies were identified. Eight concepts and 20 sub-concepts were derived from the included models. After coding the included qualitative studies against the a priori concepts and following discussions among team members, seven themes and 15 sub-themes were included in our proposed conceptual framework. Based on the identified relationships, we categorized themes into four groups: causes, intermediate consequences, outcomes and risk factors.
Conclusion:
We propose a Socioeconomic Impact Framework based on a targeted review and synthesis of existing models in the field and adapted to the European perspective. Our work contributes as an input to a European consensus project on socioeconomic impact research by an Organization European Cancer Institute (OECI) Task Force.
... © 2023 by American Society of Clinical Oncology BACKGROUND Financial toxicity is a prevalent and devastating effect of cancer care 1 affecting up to 75% of adults with cancer. 2 Financial toxicity is conceptualized into three domains: material hardship, psychological distress, and coping behaviors because of the costs of cancer care. 3,4 Patients who experience financial toxicity report poorer health-related quality of life and higher likelihood of filing for bankruptcy. [5][6][7] Most patients with cancer are at risk of experiencing financial toxicity during and after treatment; however, patients who are younger, who report lower household income, and who experience changes in or lack of employment are at increased risk. ...
Purpose:
Implementation of routine financial screening is a critical step toward mitigating financial toxicity. We evaluated the feasibility, sustainability, and acceptability of systematic financial screening in the outpatient breast oncology clinic at a large, urban cancer center.
Methods:
We developed and implemented a stakeholder-informed process to systematically screen for financial hardship and worry. A 2-item assessment in English or Spanish was administered to patients through the electronic medical record portal or using paper forms. We evaluated completion rates and mode of completion. Through feedback from patients, clinicians, and staff, we identified strategies to improve completion rates and acceptability.
Results:
From March, 2021, to February, 2022, 3,500 patients were seen in the breast oncology clinic. Of them, 39% (n = 1,349) responded to the screening items, either by paper or portal, 12% (n = 437) preferred not to answer, and the remaining 49% (n = 1,714) did not have data in their electronic health record, meaning they were not offered screening or did not complete the paper forms. Young adults (18-39 years) were more likely to respond compared with patients 70 years or older (61% v 30%, P < .01). English-preferring patients were more likely to complete the screening compared with those who preferred Spanish (46% v 28%, P < .01). Non-Hispanic White patients were more likely to respond compared with Non-Hispanic Black patients and with Hispanic patients (46% v 39% v 32%, P < .01). Strategies to improve completion rates included partnering with staff to facilitate paper form administration, optimizing patient engagement with the portal, and clearly communicating the purpose of the screening.
Conclusion:
Systematic financial screening is feasible, and electronic data capture facilitates successful implementation. However, inclusive procedures that address language and technology preferences are needed to optimize screening.
... Yet, there is no agreed-upon de nition or measure of nancial hardship across research elds. However, cancer researchers recently developed a three-domain conceptual model to help sort the many terms used to capture the nancial hardship experience in the context of cancer survivorship [24][25][26]. The three-domain conceptual model is characterized by: 1) a material domain that captures the lack of nancial resources, 2) a psychological domain that captures how people feel about their lack of nancial resources, and 3) a behavioral domain that captures how people manage (or adjust) their nancial resources or the purposeful efforts that people use to economize to meet their nancial obligations. ...
... Most of the MIDUS Refresher participants who completed the phone interview (73%) also completed selfadministered questionnaires (SAQs psychological, and behavioral domains previously described in the cancer prevention and survivorship research [24]. ...
... To further explicate socioeconomic correlates of systemic in ammation, this study investigated the association between material, psychological, and behavioral indicators of nancial hardship and three markers of in ammation among participants who completed the biomarker assessment in the MIDUS Refresher Study (2013-2016). We conceptualized nancial hardship as a three-domain model including material, psychological, and behavioral components [24]. We tested the construct validity of this conceptualization by investigating whether the items measuring nancial hardship in the MIDUS Refresher Study were indeed capturing these three domains. ...
Background
Measures of financial hardship have been suggested to supplement traditional measures of socioeconomic status (SES) to elucidate household economic well-being. This study formally tested the construct validity of the financial hardship construct and examined its association with markers of inflammation.
Methods
This study utilized data from 863 respondents from the Midlife Development in the United States Refresher Study (MIDUS-R) who completed the biomarker assessment (ages 25–76, mean age = 50.8; 52% female; 69% non-Hispanic white). Analysis for this study was divided into three steps. First, using exploratory factor analysis (EFA), we examined if the three-domain factor (material, psychological, and behavioral) is the best fitting model for financial hardship measures. Second, we conducted confirmatory factor analysis (CFA) to test the second-order measurement model of financial hardship with a three-factor first-order domain (material, psychological, and behavioral). Finally, we tested the association between the latent factor of financial hardship and interleukin 6 (IL6), c-reactive protein (CRP), and fibrinogen.
Results
Results from EFA supported the three-domain model of financial hardship. The hypothesized second-order measurement model for the three-domain model of financial hardship met the overall goodness-of-fit criteria (χ2 = 35.50, df = 11, RMSEA = 0.05; CFI = 0.99; TLI = 0.98; SRMR = 0.02). Finally, higher financial hardship was significantly associated with IL6 and fibrinogen but not CRP.
Conclusion
Explicating the socioeconomic environment to include indicators of financial hardship can help researchers better understand the pathway between SES and the inflammation process, which may help elucidate pathways between SES and age-related chronic diseases associated with inflammation.
... BMC Health Services Research (2022) 22:832 opportunities) as costs of care contribute to financial toxicity in three domains: (a) psychological responses, specifically, financial distress (worry about money), (b) new or worsened material hardships (food, housing, utility insecurity), and/or (c) detrimental financial coping behaviors (suboptimal treatment adherence that impacts care outcomes, debt non-payment that can lead to bankruptcy) [3][4][5]. Individual characteristics and social determinants of health both may contribute to worse financial distress among parents of children with cancer, similar to adults with cancer [6,7]. For example, financial distress may be affected by gender-based role norms about providing financially for the family or caregiving for ill or elderly family members [4]. ...
Background
The study purpose is to describe trajectories of financial distress for parents of children (ages 1–14.9 years) with newly diagnosed acute lymphoblastic leukemia (ALL). The secondary aim is to identify multilevel factors (child, parent, household, treating institution) that influence change in financial distress over time.
Methods
The study uses a prospective cohort design, repeated measurements, and mixed methods. The settings are Children’s Oncology Group (COG) institutions participating in the National Cancer Institute Community Oncology Research Program (NCORP). Eligible participants are English- and/or Spanish-speaking parents or legal guardians (hereafter “parents”) of index children. Parents are asked to complete a survey during their child’s induction (T1) and maintenance therapy (T2), and near treatment completion (T3). Study surveys include items about (a) the child’s cancer and clinical course, (b) parental socio-economic status, financial distress and financial coping behaviors, and (c) household material hardships. At least 15 parents will be invited to participate in an optional semi-structured interview. NCORP institutions that enroll at least one parent must complete an annual survey about institution resources that could influence parental financial distress.
Discussion
The results will inform future interventions to mitigate financial distress for parents of children diagnosed with ALL and could be instructive beyond this disease group.
Trial registration
This trial was initially registered with the NCI Clinical Trial Reporting Program ID: NCI-2021–03,567 on June 16, 2021. The study can be found on clinicaltrials.gov, Identifier NCT04928599 .
... The interview guide focused on how LGBTQIA+ AYA survivors' cancer, the COVID-19 pandemic, and their LGBTQIA+ identity impacted their financial experiences. The interview guide was modeled to encompass three domains of financial hardship: 1) Materialout of pocket expenses, employment issues, and ability to meet financial needs; 2) Psychologicalstress experienced due to costs and lost income; and 3) Behavioralcoping behaviors engaged in as a response to financial hardship including changes in health service utilization and adherence, as well as changes to nonhealthcare spending (29,30). In this analysis the three domains of financial hardship used in the interviews and the COmprehensive Score for financial Toxicity (COST) was used in the survey. ...
Background
In the United States, the cost of cancer treatment can lead to severe financial burden for cancer survivors. The economic impacts of the COVID-19 pandemic compound cancer survivors’ financial challenges. Financial burden may be particularly challenging for lesbian, gay, bisexual, transgender, queer, intersex, asexual and other sexual and gender minority (LGBTQIA+) survivors. LGBTQIA+ survivors who are adolescent and young adults (AYA) may face elevated financial burden due to multiple, intersecting identities.
Methods
An explanatory sequential mixed methods design was applied, beginning with a survey of AYA cancer survivors in the Mountain West region of the United States. Survey measures included demographics, COVID-19 impacts, the COmprehensive Score for financial Toxicity (COST), Perceived Stress Scale-4 (PSS-4), and PROMIS anxiety and depression scales. Two-way t-tests were used to analyze differences in outcomes between LGBTQIA+ and non-LGBTQIA+ AYAs. All LGBTQIA+ survey participants were invited to complete an interview, and those who agreed participated in descriptive interviews about financial burden due to cancer, COVID-19, and LGBTQIA+ identity. Interviews were audio recorded, transcribed, and analyzed using Dedoose.
Results
Survey participants (N=325) were LGBTQIA+ (n=29, 8.9%), primarily female (n= 197, 60.6%), non-Hispanic White (n= 267, 82.2%), and received treatment during COVID-19 (n= 174, 54.0%). LGBTQIA+ interview participants (n=9, 100%) identified as a sexual minority and (n=2, 22.2%) identified as a gender minority. Most were non-Hispanic White (n=6, 66.7%) and had received treatment during COVID-19 (n=7, 77.8%). Statistical analyses revealed that LGBTQIA+ AYAs reported significantly worse COST scores than non-LGBTQIA+ AYAs (p=0.002). LGBTQIA+ AYAs also reported significantly higher PSS-4 (p=0.001), PROMIS anxiety (p=0.002) and depression scores (p<0.001) than non-LGBTQIA+ AYAs, reflecting worse mental health outcomes. High costs of cancer treatment and employment disruptions due to COVID-19 contributed to substantial financial stress, which exacerbated existing mental health challenges and introduced new ones.
Conclusions
LGBTQIA+ AYA survivors reported substantial financial burden and psychological distress exacerbated by cancer, the COVID-19 pandemic, and LGBTQIA+ stigma. Given their multiple intersecting identities and potential for marginalization, LGBTQIA+ AYA survivors deserve prioritization in research to reduce financial burden and poor mental health.
... Tucker-Seeley and colleagues developed a conceptual model of FT and emphasised three components of financial burden, namely, the material, psychosocial and behavioural domains. 47 Head developed SWBS based on James Coleman's Theory of Social Class; this scale contains 17 items across 3 domains: human capital, material capital and social capital. 14 30 48 Witte et al's systematic review analysed 352 different questions regarding financial spending and found six domains (financial spending, financial resources, psychosocial affect, support seeking, coping care and coping lifestyle) that can represent reactions to subjective financial distress. ...
Objective
The aim of this systematic review was to summarise the psychometric properties of patient-reported outcome measures (PROMs) measuring financial toxicity (FT) in cancer survivors.
Design
This systematic review was conducted according to the guidance of the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.
Data sources
Comprehensive searches were performed in PubMed, MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, ProQuest and Cochrane Library from database inception to February 2022.
Eligibility criteria for selecting studies
We included studies that reported any PROMs for measuring FT in cancer survivors who were ≥18 years old. FT was defined as perceived subjective financial distress resulting from objective financial burden. Studies that were not validation studies and that used a PROM only as an outcome measurement were excluded.
Data extraction and synthesis
Two reviewers independently extracted data from the included papers. We used the COSMIN criteria to summarise and evaluate the psychometric properties of each study regarding structural validity, internal consistency, reliability, measurement error, hypothesis testing for construct validity, cross-cultural validity/measurement invariance, criterion validity and responsiveness.
Results
A total of 23 articles (21 PROMs) were eligible for inclusion in this study. The findings highlighted that the Comprehensive Score for Financial Toxicity (COST) had an adequate development process and showed better psychometric properties than other PROMs, especially in internal consistency (Cronbach’s α=0.92), reliability (intraclass correlation coefficient=0.80) and hypothesis testing (r=0.42–0.20).
Conclusions
From a psychometric property perspective, the COST could be recommended as the most suitable worldwide available measure for use in research and clinical practice across different contexts. We suggest that PROMs should be selected only after careful consideration of the local socioeconomic context. Future studies are warranted to develop various FT PROMs based on different social and cultural backgrounds and to clarify the theoretical grounds for assessing FT.
