Physical Activity and Breast Cancer Prevention Among Chinese American Women: A Qualitative Descriptive Study.

Physical inactivity is a modifiable behavioral risk factor for breast cancer. Chinese American women have an increased breast cancer incidence and a low prevalence of meeting physical activity (PA) recommendations, yet little is known about their knowledge and experience regarding PA and breast cancer prevention. Given the significant cultural differences between Eastern and Western societies, effective interventions to promote PA among Chinese American women require understanding their knowledge levels regarding PA in breast cancer prevention and their PA experiences through a cultural lens. This qualitative descriptive study used virtual semi-structured individual interviews to explore Chinese American women's knowledge and perception of PA, their understanding of the role of PA in breast cancer prevention, and influence of culture and acculturation on PA experience. Twenty-one Chinese American women residing in eight states were interviewed. Using thematic analysis, four themes emerged: A limited appreciation of the preventability of breast cancer, variability in PA perception, Chinese culture norms and lifestyles influencing PA behavior, and the influence of the process of acculturation on PA behavior. Chinese American women had a limited understanding of PA in breast cancer prevention. Chinese culture, lifestyles, and traditional Chinese medicine positively and negatively influence Chinese American women's PA behaviors. When exposed to American culture, Chinese American women tended to adopt new PA behaviors, including increasing leisure-time PA while decreasing occupation- and transportation-related PA. Interventions to increase PA and reduce breast cancer risk among Chinese American women should address cultural factors and acculturation along with education and behavioral change strategies.

Sociodemographic, health-related, and acculturation determinants of physical activity participation among Asian American women.

The purpose of this study was to assess Asian American (AsAm) women's physical activity (PA) and identify predictors (sociodemographic, health-related, and acculturation) of leisure, transportation, and work PA (LPA, TPA, and WPA; respectively). We used data from 1605 AsAm women in the 2011-2018 National Health and Nutrition Examination Survey. PA was self-reported as minutes of weekly LPA, TPA, and WPA. Multivariable logistic regression was performed to build models for meeting the recommendation of ≥150 min of weekly moderate-vigorous intensity PA for each PA domain. About 34% of AsAms met the aerobic PA recommendation through LPA, 16% through WPA, and 15% through TPA. However, less than half of AsAm women met the aerobic PA recommendation through work, transportation, or leisure PA. For the work domain, odds of meeting the aerobic PA recommendation were lower for those who were older (p <.001), had lower body mass index (p =.011), or were non-English speaking (p <.001). For the transportation domain, odds of meeting the aerobic PA recommendation were higher in those who were older (p =.008), were single (p =.017), had lower systolic blood pressure (p =.009), or were living in the US for <15 years (p =.034). For the leisure domain, odds of meeting the aerobic PA recommendation were higher in those with higher education (p <.001), were single (p =.016), had better perceived health status (p-value <0.001), or were US-born (p <.001). Sociodemographics, health-related, and acculturation factors influenced PA differently for each domain. Findings from this study can inform approaches to increase PA across different domains.

Implementation During a Pandemic: Findings, Successes, and Lessons Learned from Community Grantees.

Funding communities through mini-grant programs builds community capacity by fostering leadership among community members, developing expertise in implementing evidence-based practices, and increasing trust in partnerships. The South Carolina Cancer Prevention and Control Research Network (SC-CPCRN) implemented the Community Health Intervention Program (CHIP) mini-grants initiative to address cancer-related health disparities among high-risk populations in rural areas of the state. One community-based organization and one faith-based organization were funded during the most recent call for proposals. The organizations implemented National Cancer Institute evidence-based strategies and programs focused on health and cancer screenings and physical activity and promotion of walking trails. Despite the potential for the COVID-19 pandemic to serve as a major barrier to implementation, grantees successfully recruited and engaged community members in evidence-based activities. These initiatives added material benefits to their local communities, including promotion of walking outdoors where it is less likely to contract the virus when socially distanced and provision of COVID-19 testing and vaccines along with other health and cancer screenings. Future mini-grants programs will benefit from learning from current grantees' flexibility in program implementation during a pandemic as well as their intentional approach to modifying program aspects as needed.

Acceptability of the Mantram Repetition Program to Reduce Stress in Adolescent Survivors of Pediatric Cancer or Brain Tumors.

A mixed-methods approach was used to explore the acceptability of the Mantram Repetition Program (MRP) to reduce stress in adolescents with a history of pediatric cancer or brain tumor. Five male participants diagnosed at ages 1-14 years and currently, ages 13-18 years, completed assessments of stress, anxiety, and sleep disturbance and were interviewed about the acceptability of a mantram repetition intervention. Adolescent survivors reported low to moderate levels of stress, anxiety, and sleep disturbance. Data indicate that the MRP is acceptable among adolescent survivors of pediatric cancer and brain tumors, and face-to-face intervention delivery is preferred.

Acculturation, Physical Activity, and Metabolic Syndrome in Asian American Adults.

INTRODUCTION: Asian Americans (AsAms) have a high prevalence of metabolic syndrome (MetS) and are one of the least physically active racial groups in America. The purpose of this study was to examine the relationship between MetS and moderate-to-vigorous physical activity (MVPA) among AsAm adults and whether acculturation modifies this relationship. METHOD: Data were from 2,259 AsAms participating in the 2011-2016 National Health and Nutrition Examination Survey. Physical activity (PA) was self-reported as minutes of weekly MVPA. Acculturation included nativity, length of residency in America, and language preference. The International Diabetes Federation criteria was used to determine the presence of MetS. RESULTS: About 64.4% of AsAms did not meet the PA recommendation (MVPA ≥150 min/week). The prevalence of MetS was 39.2%. The odds of having MetS were greater among AsAms who did not meet MVPA recommendations compared with those who did meet MVPA recommendations (odds ratio [OR] = 1.5, 95% confidence interval [CI] = [1.11, 2.07]). When stratified by acculturation, this association remained statistically significant in the groups who immigrated to America more than 15 years ago and who spoke English only. CONCLUSION: MVPA reduces MetS risk in AsAm adults, especially among more acculturated AsAms. Culturally adapted programs are warranted to promote PA and adequate knowledge of disease prevention in this population.

Perceptions of Endocrine Therapy in African-American Breast Cancer Survivors: Mixed Methods Study.

BACKGROUND: Although the incidence of breast cancer is lower in African-American women than in White women, African-American women have a decreased survival rate. The difference in survival rate may stem from poor endocrine therapy adherence, which increases breast cancer recurrence. Therefore, accessible and culturally sensitive interventions to increase endocrine therapy adherence are necessary. OBJECTIVE: The purpose of this concurrent convergent mixed methods study was to provide further data to guide the development of the proposed culturally sensitive mHealth app, STORY+ for African-American women with breast cancer. METHODS: We recruited 20 African-American women diagnosed with estrogen-positive breast cancer and currently prescribed endocrine therapy. We used a concurrent convergent data collection method to (1) assess the use of smartphones and computers related to health care and (2) identify foundational aspects to support endocrine therapy adherence for incorporation in a mobile health app. RESULTS: Overwhelmingly, the participants preferred using smartphones to using computers for health care. Communicating with health care providers and pharmacies was the most frequent health care use of smartphones, followed by exercise tracking, and accessing the patient portal. We identified 4 aspects of adherence to endocrine therapy and smartphone use for incorporation in app development. The factors that emerged from the integrated qualitative and quantitative data were (1) willingness to use, (2) side effects, (3) social connection, and (4) beliefs about endocrine therapy. CONCLUSIONS: Further research is needed to develop a culturally sensitive app for African-American women with breast cancer to improve adherence to endocrine therapy. Our work strongly suggests that this population would use the app to connect with other African-American breast cancer survivors and manage endocrine therapy.

Interventions to Improve Adherence to Tyrosine Kinase Inhibitors in Chronic Myeloid Leukemia: A Systematic Review.

BACKGROUND: Lack of adherence to tyrosine kinase inhibitors (TKIs) is a significant problem resulting in incomplete cytogenetic response and increased mortality in patients with chronic myeloid leukemia (CML). Few studies have been conducted on interventions to improve adherence. The authors conducted a systematic review to explore studies that examined the impact of strategies to improve TKI adherence among individuals with CML. METHODS: The first 2 authors completed a systematic literature review according to the guidelines in Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). Studies (n=2633) conducted between 1980 and 2019 were identified through 3 databases and examined for inclusion/exclusion criteria. RESULTS: Fourteen studies were identified which met the eligibility criteria. The studies only examined adherence to imatinib, dasatinib, or nilotinib. Ten of the 14 used large data sets (commercial health insurance plans or Surveillance Epidemiology and End Results [SEER] data) for analysis. The majority of the studies used a cohort design. Adherence was defined and measured in a variety of ways with most studies using 80% or higher as adequate adherence. Strategies not focused on health care costs used a multidisciplinary team approach. CONCLUSION: Development of evidence to improve treatment adherence to TKIs for CML have relied on large data sets rather than prospective trials. Current studies lack patient focused interventions.

The Experience of Chemotherapy Teaching and Readability of Chemotherapy Educational Materials for Women with Breast Cancer.

Chemotherapy is one of the most common forms of treatment for women with breast cancer. While chemotherapy is often effective, managing side effects can be challenging. Chemotherapy education is critical in assisting patients to manage side effects and to improve the treatment experience. However, materials are often not thoroughly assessed for readability and format which could be problematic for patients learning self-care while in treatment. We used a mixed-method design to illuminate chemotherapy teaching and focused on readability and format of education materials. We scored the materials using three readability assessments: (1) Flesch Reading Ease (FRE), (2) Flesch-Kincaid (F-K), and (3) a Simple Measure of Gobbledygook (SMOG). We evaluated the format of the materials using Suitability Assessment of Materials (SAM) guidelines. Lastly, we used thematic analysis to describe the experience of 37 women with breast cancer undergoing chemotherapy education. The mean readability of the materials ranged from "difficult" to "fairly difficult" based on the FRE scoring, and the material was written on a 9th- to 13th-grade reading level. Most of the materials scored as "adequate" using SAM guidelines but lacked incorporation of graphics or illustrations. The thematic analysis revealed three major findings: (1) finding control in learning, (2) receiving unexpected support, and (3) learning in unforeseen ways. Nurses need to supplement chemotherapy education materials with individualized teaching to ensure comprehension. Additionally, nurses and website developers may want to consider implementing culturally appropriate information and use videos to combat challenging readability.

Forgiveness and Health Outcomes in Cancer Survivorship: A Scoping Review.

BACKGROUND: Religious and spiritual beliefs including forgiveness are an important aspect of cancer survivorship; however, the relationship between forgiveness and health is not well understood. OBJECTIVE: The aim of this study was to conduct a scoping review that examines and maps the current research regarding relationships between forgiveness and health outcomes in individuals with cancer. METHODS: We searched 5 electronic databases using key search terms related to forgiveness and cancer. Using a scoping review framework, we synthesized the existing literature regarding forgiveness and health among individuals with cancer and examined forgiveness as a process for coping with cancer. RESULTS: We located 277 articles for review; 24 met inclusion criteria. Forgiveness in interpersonal relationships emerged more often as forgiveness coping than other types of forgiveness. Most studies reported a positive association between forgiveness and mental health. Fewer studies were available regarding relationships between forgiveness and physical health, and findings were mixed. CONCLUSIONS: Forgiveness in interpersonal relationships is a spiritual concern for individuals with cancer. Addressing forgiveness needs may promote mental health in cancer survivors. More empirical evidence is needed to understand the role of forgiveness in physical health in individuals with cancer. IMPLICATIONS FOR PRACTICE: Acknowledging forgiveness beliefs is a psychosocial-spiritual intervention that nurses can provide to support mental health in individuals with cancer. The potential role of forgiveness in physical health for individuals with cancer requires further study.

A Patient-Centered Asthma Management Communication Intervention for Rural Latino Children: Protocol for a Waiting-List Randomized Controlled Trial.

BACKGROUND: Rural Latino children with asthma suffer high rates of uncontrolled asthma symptoms, emergency department visits, and repeat hospitalizations. This vulnerable population must negotiate micro- and macrolevel challenges that impact asthma management, including language barriers, primary care access, parental time off from work, insurance coverage, distance from specialty sites, and documentation status. There are few proven interventions that address asthma management embedded within this unique context. OBJECTIVE: Using a bio-ecological approach, we will determine the feasibility of a patient-centered collaborative program between rural Latino children with asthma and their families, school-based nursing programs, and primary care providers, facilitated by the use of a smartphone-based mobile app with a Spanish-language interface. We hypothesize that improving communication through a collaborative, patient-centered intervention will improve asthma management, empower the patient and family, decrease outcome disparities, and decrease direct and indirect costs. METHODS: The specific aims of this study include the following: (1) Aim 1: produce and validate a Spanish translation of an existing asthma management app and evaluate its usability with Latino parents of children with asthma, (2) Aim 2: develop and evaluate a triadic, patient-centered asthma intervention preliminary protocol, facilitated by the bilingual mobile app validated in Aim 1, and (3) Aim 3: investigate the feasibility of the patient-centered asthma intervention from Aim 2 using a waiting-list randomized controlled trial (RCT) to investigate the effects of the intervention on school days missed and medication adherence. RESULTS: Mobile app translation, initial usability testing, and app software refinement were completed in 2019. Analysis is in progress. Preliminary protocol testing is underway; we anticipate that the waiting-list RCT, using the refined protocol developed in Aim 2, will commence in fall 2020. CONCLUSIONS: Tailored, technology-based solutions have the potential to successfully address issues affecting asthma management, including communication barriers, accessibility issues, medication adherence, and suboptimal technological interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04633018; https://www.clinicaltrials.gov/ct2/show/NCT04633018. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18977.

Improving Adherence to Adjuvant Hormonal Therapy Among Disadvantaged Women Diagnosed with Breast Cancer in South Carolina: Proposal for a Multimethod Study.

BACKGROUND: Current clinical guidelines recommend that hormone receptor-positive breast cancer survivors take adjuvant hormonal therapy (AHT) for 5 to 10 years, following the end of definitive treatment. However, fewer than half of patients adhere to the guidelines, and suboptimal adherence to AHT is associated with an increased risk of breast cancer mortality. Research has extensively documented sociodemographic and disease-specific factors associated with adherence to AHT, but very little evidence exists on behavioral factors (eg, knowledge, patient-provider communication) that can be modified and targeted by interventions. OBJECTIVE: The goal of this study is to develop and test a theory-based, multilevel intervention to improve adherence to AHT among breast cancer survivors from racially and socioeconomically disadvantaged backgrounds (eg, Medicaid-insured). The specific aims are to (1) explore multilevel (eg, patient, health care system) factors that influence adherence to AHT; (2) develop a theory-based, multilevel intervention to improve adherence to AHT; and (3) pilot test and evaluate the intervention developed in Aim 2. METHODS: For Aim 1, we will recruit breast cancer survivors and health care professionals to participate in semistructured interviews to gain their perspectives about barriers and facilitators to AHT use. We will conduct a directed content analysis of the Aim 1 qualitative interview data. For Aim 2, we will integrate Aim 1 findings and current literature into the design of a multilevel intervention using an Intervention Mapping approach. For Aim 3, we will recruit Medicaid-insured breast cancer survivors to assess the feasibility of the pilot intervention. RESULTS: From May 2016 to July 2018, we completed interviews with 19 breast cancer survivors and 23 health care professionals in South Carolina. We will conduct a directed content analysis of the qualitative interview data. Results from this analysis will be used, in combination with current literature, to design (Aim 2) and pilot test a theory-based multilevel intervention (Aim 3) in Summer 2021. Results of the pilot are expected for Fall 2021. CONCLUSIONS: This study will provide a deeper understanding of how to improve adherence to AHT, using a novel and multilevel approach, among socioeconomically disadvantaged breast cancer survivors who often experience disproportionate breast cancer mortality. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/17742.

Factors influencing chemotherapy knowledge in women with breast cancer.

BACKGROUND: Chemotherapy knowledge is linked to managing side effects, reducing exposure to potential infection, and adjusting lifestyle behaviors while going through treatment. However, no research exists regarding the influence of patients' personal attributes on chemotherapy knowledge. Aim The aim of this study was to describe the relationships of health literacy and demographics on chemotherapy knowledge among women with breast cancer undergoing treatment. METHOD: We used a descriptive, exploratory design with convenience sampling of women with breast cancer receiving intravenous chemotherapy who completed one mandatory education session. Participants completed a demographic questionnaire and three instruments: 1) Rapid Estimate of Adult Literacy - Short Form (REALM-SF); 2) Shortened Test of Functional Health Literacy in Adults (S-TOFHLA); and 3) Leuven Questionnaire on Patient Knowledge of Chemotherapy (L-PaKC). We used univariate linear regression and ANOVA to identify how health literacy and demographics influenced chemotherapy knowledge. RESULTS: The REALM-SF (p = .022) and S-TOFHLA (p = .023) scores were significantly associated with chemotherapy knowledge. Chemotherapy knowledge scores were affected by marital status (p = .018) and income (p < .001) where married women had significantly higher chemotherapy knowledge scores (M = 92.6, SD = 6.6) than women who were divorced (M = 83.3, SD = 16.7) with a knowledge score difference of -9.3 between the groups (p = .02). Comparisons showed significant differences of chemotherapy knowledge between women with differing income levels. CONCLUSIONS: This study highlights the relevance of considering patients' health literacy and personal attributes such as marital status and income when teaching about chemotherapy.

Use of a Paper Checklist to Increase Clinician Adherence to Mammography Screening Guidelines.

OBJECTIVE: To increase clinician adherence to mammography screening guidelines. DESIGN: Quality improvement initiative. SETTING/LOCAL PROBLEM: At a nurse practitioner-led primary care practice, a chart audit of adherence to American Cancer Society mammography screening guidelines indicated a 12% adherence rate for clinicians writing mammography orders. PARTICIPANTS: Nurse practitioners providing care to women ages 40 years and older. INTERVENTION/MEASUREMENTS: The intervention was a screening checklist that was completed by the woman at registration and given to the clinician during the examination. The pre- and postintervention measurement was the percentage of mammogram orders. A Fisher exact test was used to examine changes from pre- to postintervention rates of adherence. RESULTS: After the intervention, the percentage of women for whom a mammogram was recommended and ordered was 69.6%, compared to 12% from the original chart audit. This change was statistically significant (p = .01). CONCLUSION: Clinicians must find efficient approaches to improve processes within their practice settings to ensure that preventive care recommendations are made during visits. Although the screening checklist was deemed useful, improvement in adherence rates is still needed, and a paperless system should be initiated.

A Smartphone App for Self-Management of Heart Failure in Older African Americans: Feasibility and Usability Study.

BACKGROUND: Mobile health (mHealth) apps are dramatically changing how patients and providers manage and monitor chronic health conditions, especially in the area of self-monitoring. African Americans have higher mortality rates from heart failure than other racial groups in the United States. Therefore, self-management of heart failure may improve health outcomes for African American patients. OBJECTIVE: The aim of the present study was to determine the feasibility of using an mHealth app, and explore the outcomes of quality of life, including self-care maintenance, management, and confidence, among African American patients managing their condition after discharge with a diagnosis of heart failure. METHODS: Prior to development of the app, we conducted qualitative interviews with 7 African American patients diagnosed with heart failure, 3 African American patients diagnosed with cardiovascular disease, and 6 health care providers (cardiologists, nurse practitioners, and a geriatrician) who worked with heart failure patients. In addition, we asked 6 hospital chaplains to provide positive spiritual messages for the patients, since spirituality is an important coping method for many African Americans. These formative data were then used for creating a prototype of the app, named Healthy Heart. Specifically, the Healthy Heart app incorporated the following evidence-based features to promote self-management: one-way messages, journaling (ie, weight and symptoms), graphical display of data, and customized feedback (ie, clinical decision support) based on daily or weekly weight. The educational messages about heart failure self-management were derived from the teaching materials provided to the patients diagnosed with heart failure, and included information on diet, sleep, stress, and medication adherence. The information was condensed and simplified to be appropriate for text messages and to meet health literacy standards. Other messages were derived from interviews conducted during the formative stage of app development, including interviews with African American chaplains. Usability testing was conducted over a series of meetings between nurses, social workers, and computer engineers. A pilot one-group pretest-posttest design was employed with participants using the mHealth app for 4 weeks. Descriptive statistics were computed for each of the demographic variables, overall and subscales for Health Related Quality of Life Scale 14 (HQOL14) and subscales for the Self-Care of Heart Failure Index (SCHFI) Version 6 using frequencies for categorical measures and means with standard deviations for continuous measures. Baseline and postintervention comparisons were computed using the Fisher exact test for overall health and paired t tests for HQOL14 and SCHFI questionnaire subscales. RESULTS: A total of 12 African American participants (7 men, 5 women; aged 51-69 years) diagnosed with heart failure were recruited for the study. There was no significant increase in quality of life (P=.15), but clinically relevant changes in self-care maintenance, management, and confidence were observed. CONCLUSIONS: An mHealth app to assist with the self-management of heart failure is feasible in patients with low literacy, low health literacy, and limited smartphone experience. Based on the clinically relevant changes observed in this feasibility study of the Healthy Heart app, further research should explore effectiveness in this vulnerable population.

Racial and Geographic Disparities in Endocrine Therapy Adherence Among Younger Breast Cancer Survivors.

OBJECTIVES: African American (AA) women with breast cancer (BrCA) have higher mortality than any other race. Differential mortality has been attributed to nonadherence to endocrine therapy (ET). ET can lower the risk of dying by one third; yet 50% to 75% of all women are nonadherent to ET. Despite the wealth of research examining adherence to ET, understanding which groups of women at risk for poor adherence is not well established. The aim of this investigation was to describe ET adherence by race and geographic location among a cohort of younger BrCA survivors. MATERIALS AND METHODS: Cancer registry records were linked to administrative data from Medicaid and a private insurance plan in South Carolina. Inclusion criteria included: European American (EA) or AA race, 3 years of continuous enrollment in the insurance plan after diagnosis, and BrCA diagnosis between 2002 and 2010. Adherence was measured by computing a medication possession ratio (MPR) based upon refill service dates and the number of pills dispensed. Adjusted least squared means were calculated by racial and geographic group using analysis of covariance methods. RESULTS: The average MPR for EA women was significantly higher at 96% compared with 92% for AA women (P<0.01). After adjustment for years on hormone therapy, age, and number of pharmacies utilized, rural AA women had an average MPR of 90% compared with 95% for EA women (P<0.01). CONCLUSIONS: AA women residing in rural areas demonstrate significantly lower adherence compared with their EA counterparts. Interventions are needed to improve adherence that may ameliorate AA mortality disparities.

What makes a good health 'app'? Identifying the strengths and limitations of existing mobile application evaluation tools.

Research using mHealth apps has the potential to positively impact health care management and outcomes. However, choosing an appropriate mHealth app may be challenging for the health researcher. The author team used existing evaluation tools, checklists, and guidelines to assess selected mHealth apps to identify strengths, challenges, and potential gaps within existing evaluation tools. They identified specific evaluation tool components, questions, and items most effective in examining app content, usability, and features, including literacy demand and cultural appropriateness; technical information; practical aspects of app functionality; and evolving capabilities of mobile medical apps. Challenges included the subjective nature of the results, time required to complete the evaluation, lack of emphasis on evidence-based content, and inadequate tool flexibility. Health researchers considering the integration of mobile apps into research will benefit from evaluation tools that assess both evidence-based content and the ability of the mobile app to securely integrate with other digital technologies involved in patient care. Next steps will include the involvement of health care providers and professionals, including nurses a wide range of expertise, to develop an mHealth evaluation tool that focuses on identifying quality, evidence-based mobile apps into patient outcomes research.

Moderators of the effect of psychosocial interventions on fatigue in women with breast cancer and men with prostate cancer: Individual patient data meta-analyses.

OBJECTIVE: Psychosocial interventions can reduce cancer-related fatigue effectively. However, it is still unclear if intervention effects differ across subgroups of patients. These meta-analyses aimed at evaluating moderator effects of (a) sociodemographic characteristics, (b) clinical characteristics, (c) baseline levels of fatigue and other symptoms, and (d) intervention-related characteristics on the effect of psychosocial interventions on cancer-related fatigue in patients with non-metastatic breast and prostate cancer. METHODS: Data were retrieved from the Predicting OptimaL cAncer RehabIlitation and Supportive care (POLARIS) consortium. Potential moderators were studied with meta-analyses of pooled individual patient data from 14 randomized controlled trials through linear mixed-effects models with interaction tests. The analyses were conducted separately in patients with breast (n = 1091) and prostate cancer (n = 1008). RESULTS: Statistically significant, small overall effects of psychosocial interventions on fatigue were found (breast cancer: ß = -0.19 [95% confidence interval (95%CI) = -0.30; -0.08]; prostate cancer: ß = -0.11 [95%CI = -0.21; -0.00]). In both patient groups, intervention effects did not differ significantly by sociodemographic or clinical characteristics, nor by baseline levels of fatigue or pain. For intervention-related moderators (only tested among women with breast cancer), statistically significant larger effects were found for cognitive behavioral therapy as intervention strategy (ß = -0.27 [95%CI = -0.40; -0.15]), fatigue-specific interventions (ß = -0.48 [95%CI = -0.79; -0.18]), and interventions that only targeted patients with clinically relevant fatigue (ß = -0.85 [95%CI = -1.40; -0.30]). CONCLUSIONS: Our findings did not provide evidence that any selected demographic or clinical characteristic, or baseline levels of fatigue or pain, moderated effects of psychosocial interventions on fatigue. A specific focus on decreasing fatigue seems beneficial for patients with breast cancer with clinically relevant fatigue.

Essential Elements of Song for Grieving Young Adults.

Complications experienced by grieving young adults have developmental, mental, and behavioral components. Music offers opportunities to promote healthy grieving. While song writing has been widely used as an informal therapy for centuries, current researchers are beginning to explore its benefits. There is a noticeable lack of literature regarding the role of music in the grieving process. The aims of this study were to explore the grieving experiences of young adults who had lost a family member or friend, to identify song elements most helpful in promoting healthy grieving, and then to use these findings to compose a piece of music. Fifteen 20- to 23-year-old participants were interviewed about the death of a close friend or family member using a structured interview guide that included questions about their experience with the death and their grief, as well as questions about what song elements might help in grief. These questions included specifics about the song tempo (speed), dynamic (volume), and whether the song should contain lyrics (words). Thematic analysis was used to analyze interviews. Themes derived from the interview that should be relayed in a song included: Grief can include joy and pain together; It will get better; There is value in community; and, It is ok not to be ok For song elements, participants elected a slow tempo, a mixed or soft dynamic, and inclusion of lyrical content. All findings were integrated into a song composition that may help promote healthy grieving.

Mammography Adherence: Creation of a Process Change Plan to Increase Usage Rates.

BACKGROUND: Mammography is the optimal tool to mitigate breast cancer morbidity and mortality; however, in many healthcare settings, mammography adherence rates are decreasing. OBJECTIVES: This nurse-led quality improvement project was conducted to improve patient adherence to annual mammography screening. METHODS: Data collection included clinical information from the electronic health record, chart reviews, tracking documentation used by the clinic's social worker, interviews with staff, observation of the clinical setting, creation of a process flow map to identify barriers, and identification of internal and external resources. Strategies to reduce barriers included communication with staff about problems, a streamlined referral process, a scripted message about mammography, an up-front assessment of financial and social barriers to adherence, and an early referral to resources. FINDINGS: A pre-process change chart audit showed a 22% mammography adherence rate. The post-process change rate was 51%, representing a statistically significant difference in adherence.

Using a Continuing Multimedia Case Study to Develop Critical Thinking and Empathy.

BACKGROUND: Critical thinking and empathy are essential elements in attaining competencies expected of Bachelor of Science in Nursing graduates. Our purpose is to describe the use of a continuing multimedia case study in a large online course, including the pedagogical framework, implementation, and impact on student learning. METHOD: We adapted qualitative analysis strategies to thematically analyze data from course assignments to demonstrate evidence of the development of critical thinking and empathy. RESULTS: Students reported a variety of critical thinking skills acquired through continuous examination of patient problems and completion of case study-based tasks. Students described changes in their emotions and attitudes toward the older adult patient in the case study and the population represented with empathy as the dominant emotion. CONCLUSION: The use of a continuing multimedia case study provided a successful platform for enhancing the learning of didactic content and the development of critical thinking and empathy. [J Nurs Educ. 2019;58(3):169-172.].