Smoking Status, Nicotine Medication, Vaccination, and COVID-19 Hospital Outcomes: Findings from the COVID EHR Cohort at the University of Wisconsin (CEC-UW) Study.

INTRODUCTION: Available evidence is mixed concerning associations between smoking status and COVID-19 clinical outcomes. Effects of nicotine replacement therapy (NRT) and vaccination status on COVID-19 outcomes in smokers are unknown. METHODS: Electronic health record data from 104 590 COVID-19 patients hospitalized February 1, 2020 to September 30, 2021 in 21 U.S. health systems were analyzed to assess associations of smoking status, in-hospital NRT prescription, and vaccination status with in-hospital death and ICU admission. RESULTS: Current (n = 7764) and never smokers (n = 57 454) did not differ on outcomes after adjustment for age, sex, race, ethnicity, insurance, body mass index, and comorbidities. Former (vs never) smokers (n = 33 101) had higher adjusted odds of death (aOR, 1.11; 95% CI, 1.06-1.17) and ICU admission (aOR, 1.07; 95% CI, 1.04-1.11). Among current smokers, NRT prescription was associated with reduced mortality (aOR, 0.64; 95% CI, 0.50-0.82). Vaccination effects were significantly moderated by smoking status; vaccination was more strongly associated with reduced mortality among current (aOR, 0.29; 95% CI, 0.16-0.66) and former smokers (aOR, 0.47; 95% CI, 0.39-0.57) than for never smokers (aOR, 0.67; 95% CI, 0.57, 0.79). Vaccination was associated with reduced ICU admission more strongly among former (aOR, 0.74; 95% CI, 0.66-0.83) than never smokers (aOR, 0.87; 95% CI, 0.79-0.97). CONCLUSIONS: Former but not current smokers hospitalized with COVID-19 are at higher risk for severe outcomes. SARS-CoV-2 vaccination is associated with better hospital outcomes in COVID-19 patients, especially current and former smokers. NRT during COVID-19 hospitalization may reduce mortality for current smokers. IMPLICATIONS: Prior findings regarding associations between smoking and severe COVID-19 disease outcomes have been inconsistent. This large cohort study suggests potential beneficial effects of nicotine replacement therapy on COVID-19 outcomes in current smokers and outsized benefits of SARS-CoV-2 vaccination in current and former smokers. Such findings may influence clinical practice and prevention efforts and motivate additional research that explores mechanisms for these effects.

TrueNTH Sexual Recovery Intervention for couples coping with prostate cancer: Randomized controlled trial results.

BACKGROUND: Despite significant sexual dysfunction and distress after localized prostate cancer treatment, patients typically receive only physiologic erectile dysfunction management. The authors performed a randomized controlled trial of an online intervention supporting couples' posttreatment recovery of sexual intimacy. METHODS: Patients treated with surgery, radiation, or combined radiation and androgen deprivation therapy who had partners were recruited and randomized to an online intervention or a control group. The intervention, tailored to treatment type and sexual orientation, comprised 6 modules addressing expectations for sexual and emotional sequelae of treatment, rehabilitation, and guidance toward sexual intimacy recovery. Couples, recruited from 6 sites nationally, completed validated measures at the baseline and 3 and 6 months after treatment. Primary outcome group differences were assessed with t tests for individual outcomes. RESULTS: Among 142 randomized couples, 105 patients (mostly surgery) and 87 partners completed the 6-month survey; this reflected challenges with recruitment and attrition. There were no differences between the intervention and control arms in Patient-Reported Outcomes Measurement Information System Global Satisfaction With Sex Life scores 6 months after treatment (the primary outcome). Three months after treatment, intervention patients and partners reported more engagement in penetrative and nonpenetrative sexual activities than controls. More than 73% of the intervention participants reported high or moderate satisfaction with module content; more than 85% would recommend the intervention to other couples. CONCLUSIONS: Online psychosexual support for couples can help couples to connect and experience sexual pleasure early after treatment despite patients' sexual dysfunction. Participants' high endorsement of the intervention reflects the importance of sexual health support to couples after prostate cancer treatment. LAY SUMMARY: This study tested a web-based program supporting couples' sexual recovery of sexual intimacy after prostate cancer treatment. One hundred forty-two couples were recruited and randomly assigned to the program (n = 60) or to a control group (n = 82). The program did not result in improvements in participants' satisfaction with their sex life 6 months after treatment, but couples in the intervention group engaged in sexual activity sooner after treatment than couples in the control group. Couples evaluated the program positively and would recommend it to others facing prostate cancer treatment.

Improving the delivery of team-based survivorship care after primary breast cancer treatment through a multi-level intervention: a pilot randomized controlled trial.

PURPOSE: We developed and tested a multi-level intervention, ConnectedCancerCare (CCC), which includes a tailored website and appointment reminder system for women with early-stage breast cancer and a provider summary letter sent to their medical oncologist and primary care provider to improve the delivery of team-based survivorship care. METHODS: We conducted a pilot randomized controlled trial to establish the feasibility and acceptability of CCC. Women diagnosed with stages 0-II breast cancer within one year of completing primary treatment were randomized to CCC (intervention) or a static online survivorship care plan (control). Participants completed baseline and 3-month follow-up surveys online. Post-trial interviews with 5 PCPs, 6 oncology providers, and 8 intervention patients were conducted. RESULTS: Of the 160 eligible women invited to participate, 66 completed the baseline survey and were randomized (41%) and 54 completed a follow-up survey (83%). Participants in the intervention arm found the CCC content to be acceptable, with 82% reporting it was easy to use and 86% reporting they would recommend it to other patients. Women randomized to CCC (vs. control) more often reported scheduling a PCP follow-up visit (64% vs. 42%), communicating with their PCP about provider roles (67% vs. 18%), and higher mean team-based cancer care knowledge scores (3.7 vs. 3.4). CONCLUSION: Deploying CCC in medical oncology practices was feasible, and the intervention content was acceptable. CCC shows promise for improving patient knowledge and patient-provider communication about provider roles in team-based cancer care and encouraging patients to engage with their PCP early in the survivorship period.

Effects of self-transcendence on neural responses to persuasive messages and health behavior change.

Self-transcendence refers to a shift in mindset from focusing on self-interests to the well-being of others. We offer an integrative neural model of self-transcendence in the context of persuasive messaging by examining the mechanisms of self-transcendence in promoting receptivity to health messages and behavior change. Specifically, we posited that focusing on values and activities that transcend the self can allow people to see that their self-worth is not tied to a specific behavior in question, and in turn become more receptive to subsequent, otherwise threatening health information. To test whether inducing self-transcendent mindsets before message delivery would help overcome defensiveness and increase receptivity, we used two priming tasks, affirmation and compassion, to elicit a transcendent mindset among 220 sedentary adults. As preregistered, those who completed a self-transcendence task before health message exposure, compared with controls, showed greater increases in objectively logged levels of physical activity throughout the following month. In the brain, self-transcendence tasks up-regulated activity in a region of the ventromedial prefrontal cortex, chosen for its role in positive valuation and reward processing. During subsequent health message exposure, self-transcendence priming was associated with increased activity in subregions of the ventromedial prefrontal cortex, implicated in self-related processing and positive valuation, which predicted later decreases in sedentary behavior. The present findings suggest that having a positive self-transcendent mindset can increase behavior change, in part by increasing neural receptivity to health messaging.

Relationship Between Coronavirus-Related eHealth Literacy and COVID-19 Knowledge, Attitudes, and Practices among US Adults: Web-Based Survey Study.

BACKGROUND: During a global pandemic, it is critical that the public is able to rapidly acquire new and accurate health information. The internet is a major source of health information. eHealth literacy is the ability of individuals to find, assess, and use health information available on the internet. OBJECTIVE: The goals of this study were to assess coronavirus-related eHealth literacy and examine the relationship between eHealth literacy and COVID-19-related knowledge, attitudes, and practices (KAPs). METHODS: We conducted a web-based survey of a representative sample of 1074 US adults. We adapted the 8-item eHealth Literacy Scale to develop the Coronavirus-Related eHealth Literacy Scale (CoV-eHEALS) to measure COVID-19-related knowledge, conspiracy beliefs, and adherence to protective behaviors (eg, wearing facial masks and social distancing). Our analyses identified sociodemographic associations with the participants' CoV-eHEALS scores and an association between the CoV-eHEALS measure and COVID-19 KAPs. RESULTS: The internal consistency of the adapted CoV-eHEALS measure was high (Cronbach α=.92). The mean score for the CoV-eHEALS was 29.0 (SD 6.1). A total of 29% (306/1074) of the survey participants were classified as having low coronavirus-related eHealth literacy (CoV-eHEALS score <26). Independent associations were found between CoV-eHEALS scores and ethnicity (standardized ß=-.083, P=.016 for Black participants) and education level (standardized ß=-.151, P=.001 for participants with high-school education or lower). Controlling for demographic characteristics, CoV-eHEALS scores demonstrated positive independent associations with knowledge (standardized ß=.168, P<.001) and adherence to protective behaviors (standardized ß=.241, P<.001) and a negative association with conspiracy beliefs (standardized ß=-.082, P=.009). CONCLUSIONS: This study provides an estimate of coronavirus-related eHealth literacy among US adults. Our findings suggest that a substantial proportion of US adults have low coronavirus-related eHealth literacy and are thus at a greater risk of lower and less-protective COVID-19 KAPs. These findings highlight the need to assess and address eHealth literacy as part of COVID-19 control efforts. Potential strategies include improving the quality of health information about COVID-19 available on the internet, assisting or simplifying web-based search for information about COVID-19, and training to improve general or coronavirus-specific search skills.

Novel Predictors of COVID-19 Protective Behaviors Among US Adults: Cross-sectional Survey.

BACKGROUND: A central component of the public health strategy to control the COVID-19 pandemic involves encouraging mask wearing and social distancing to protect individuals from acquiring and transmitting the virus. OBJECTIVE: This study aims to understand the psychological factors that drive adoption or rejection of these protective behaviors, which can inform public health interventions to control the pandemic. METHODS: We conducted an online survey of a representative sample of 1074 US adults and assessed three novel potential predictors of COVID-19 behaviors: trait reactance, COVID-19 conspiracy beliefs, and COVID-19 apocalypse beliefs. Key outcomes (dependent variables) included an index of COVID-19 protective behaviors, the number of trips taken from the home, and COVID-19 knowledge. RESULTS: In bivariate analyses, all three predictors were significantly correlated in the hypothesized direction with the three COVID-19 outcomes. Specifically, each predictor was negatively (P<.01) correlated with the COVID-19 protective behaviors index and COVID-19 knowledge score, and positively correlated with trips taken from home per week (more of which was considered higher risk). COVID-19 protective behaviors and COVID-19 knowledge were significantly lower in the top median compared to the bottom median for all three predictors. In general, these findings remained significant after adjusting for all novel predictors plus age, gender, income, education, race, political party, and religiosity. Self-identified Republicans (vs other political affiliations) reported the highest values for each of the novel predictors. CONCLUSIONS: This study can inform the development of health communication interventions to encourage the adoption of COVID-19 protective behaviors. Interestingly, we found that higher scores of all three novel predictors were associated with lower COVID-19 knowledge, suggesting that lack of an accurate understanding of the virus may be driving some of these attitudes; although, it is also possible that these attributes may interfere with one's willingness or ability to seek and absorb accurate health information. These individuals may be particularly immune to accepting new information and yielding their beliefs. Health communication professionals may apply lessons learned from countering similar beliefs around climate change and vaccine hesitancy. Messages designed for individuals prone to reactance may be more effective if they minimize controlling language and emphasize the individual's independence in adopting these behavioral recommendations. Messaging for those who possess conspiracy beliefs should similarly not assume that providing evidence contrary to these beliefs will alone alter behavior. Other communication techniques such as rolling with resistance, a strategy used in motivational interviewing, may be helpful. Messaging for those with apocalyptic beliefs may require using religious leaders as the message source and using scripture that would support the adoption of COVID-19 protection behaviors.

Neural Mechanisms of Emotion Regulation Moderate the Predictive Value of Affective and Value-Related Brain Responses to Persuasive Messages.

Emotionally evocative messages can be an effective way to change behavior, but the neural pathways that translate messages into effects on individuals and populations are not fully understood. We used a human functional neuroimaging approach to ask how affect-, value-, and regulation-related brain systems interact to predict effects of graphic anti-smoking messages for individual smokers (both males and females) and within a population-level messaging campaign. Results indicated that increased activity in the amygdala, a region involved in affective reactivity, predicted both personal quit intentions and population-level information-seeking and this was mediated by activity in ventromedial prefrontal cortex (vmPFC), a region involved in computing an integrative value signal. Further, the predictive value of these regions was moderated by expression of a meta-analytically defined brain pattern indexing emotion regulation. That is, amygdala and vmPFC activity strongly tracked with population behavior only when participants showed low recruitment of this brain pattern, which consists of regions involved in goal-driven regulation of affective responses. Overall, these findings suggest that affective and value-related brain responses can predict the success of persuasive messages and that neural mechanisms of emotion regulation can shape these responses, moderating the extent to which they track with population-level message impact.SIGNIFICANCE STATEMENT People and organizations often appeal to our emotions to persuade us, but how these appeals engage the brain to drive behavior is not fully understood. We present an fMRI-based model that integrates affect-, control-, and value-related brain responses to predict the impact of graphic anti-smoking stimuli within a small group of smokers and a larger-scale public messaging campaign. This model indicated that amygdala activity predicted the impact of the anti-smoking messages, but that this relationship was mediated by ventromedial prefrontal cortex and moderated by expression of a distributed brain pattern associated with regulating emotion. These results suggest that neural mechanisms of emotion regulation can shape the extent to which affect and value-related brain responses track with population behavioral effects.

Implementation of Evidence-Based Practice for Benign Paroxysmal Positional Vertigo in the Emergency Department: A Stepped-Wedge Randomized Trial.

STUDY OBJECTIVE: We evaluated a strategy to increase use of the test (Dix-Hallpike's test [DHT]) and treatment (canalith repositioning maneuver [CRM]) for benign paroxysmal positional vertigo in emergency department (ED) dizziness visits. METHODS: We conducted a stepped-wedge randomized trial in 6 EDs. The population was visits with dizziness as a principal reason for the visit. The intervention included educational sessions and decision aid materials. Outcomes were DHT or CRM documentation (primary), head computed tomography (CT) use, length of stay, admission, and 90-day stroke events. The analysis was multilevel logistic regression with intervention, month, and hospital as fixed effects and provider as a random effect. We assessed fidelity with monitoring intervention use and semistructured interviews. RESULTS: We identified 7,635 dizziness visits during 18 months. The DHT or CRM was documented in 1.5% of control visits (45/3,077; 95% confidence interval 1% to 1.9%) and 3.5% of intervention visits (159/4,558; 95% confidence interval 3% to 4%; difference 2%, 95% confidence interval 1.3% to 2.7%). Head CT use was lower in intervention visits compared with control visits (44.0% [1,352/3,077] versus 36.9% [1,682/4,558]). No differences were observed in admission or 90-day subsequent stroke risk. In fidelity evaluations, providers who used the materials typically reported positive clinical experiences but provider engagement was low at facilities without an emergency medicine residency program. CONCLUSION: These findings provide evidence that an implementation strategy of a benign paroxysmal positional vertigo-focused approach to ED dizziness visits can be successful and safe in promoting evidence-based care. Absolute rates of DHT and CRM use, however, were still low, which relates in part to our broad inclusion criteria for dizziness visits.

Feasibility of a Smartphone-Based Tobacco Treatment for HIV-Infected Smokers.

BACKGROUND: Cigarette smoking is common among persons living with HIV (PLWH) in the United States. It is the leading cause of mortality in this group, and efforts to promote cessation have been largely unsuccessful. METHODS: From 2015 to 2017, we performed a randomized controlled trial of Positively Smoke Free-Mobile (PSF-M) versus standard care. PSF-M is a mobile Web site that offers a 42-day text message-based quit-smoking program with smartphone features including quit-day selection/calendar, educational/motivational videos, and HELP button for cravings. RESULTS: One hundred individuals enrolled, 48 were randomized to PSF-M (mean age = 45 years, 54% male, 81% black, 31% Latino) and 52 to the standard care condition. All participants were offered a 3-month supply of nicotine patches. Participants randomized to the mobile intervention visited the PSF-M home page a mean of 83 times, viewed 5.6/8 videos, logged in on 13 of 42 possible days, and received 131 texts. Among them, 77% tapped HELP for cravings, and craving response options were used by the following proportions: phone-a-friend, 58%; play-a-game, 29%; play-a-song, 4%. Older age and nonblack race were both associated with higher levels of engagement with the site. Of participants, 61% rated PSF-M very or extremely helpful, and 98% would recommend PSF-M to PLWH family or friends. Abstinence at 3 months, quit attempts, and daily cigarette intake all favored PSF-M over standard care but did not achieve statistical significance in our pilot sample. CONCLUSIONS: Smartphone-based tobacco treatment for PLWH was feasible and achieved moderate-high rates of engagement and satisfaction in a middle-aged, ethnic or racial minority group in the poorest urban community in the United States. IMPLICATIONS: Cigarette smoking has emerged as the leading killer of PLWH. Behavioral interventions have achieved only limited success in promoting cessation in this population. In this study, we explore the feasibility and preliminary efficacy of a multimodal, Web-based, quit-smoking intervention delivered to PLWH smokers via their smartphones.

Knowledge regarding and patterns of genetic testing in patients newly diagnosed with breast cancer participating in the iCanDecide trial.

BACKGROUND: The current study reports rates of knowledge regarding the probability of a BRCA1 and/or S pathogenic variant and genetic testing in patients with breast cancer, collected as part of a randomized controlled trial of a tailored, comprehensive, and interactive decision tool (iCanDecide). METHODS: A total of 537 patients newly diagnosed with early-stage breast cancer were enrolled at the time of their first visit in 22 surgical practices, and were surveyed 5 weeks (496 patients; Response Rate [RR], 92%) after enrollment after treatment decision making. Primary outcomes included knowledge regarding the probability of carrying a BRCA1 and/or BRCA2 pathogenic variant and genetic testing after diagnosis. RESULTS: Overall knowledge regarding the probability of having a BRCA1 and/or BRCA2 pathogenic variant was low (29.8%). Significantly more patients in the intervention group compared with the control group had knowledge regarding the probability of a BRCA1 and/or BRCA2 pathogenic variant (35.8% vs 24.4%; P <.006). In multivariable logistic regression, the intervention arm remained significantly associated with knowledge regarding the probability of having a BRCA1 and/or BRCA2 pathogenic variant (odds ratio, 1.79; 95% confidence interval, 1.18-2.70). CONCLUSIONS: The results of the current study suggest that although knowledge concerning the probability of having a BRCA1 and/or BRCA2 pathogenic variant remains low in this patient population, the interactive decision tool improved rates compared with a static Web site. As interest in genetic testing continues to rise, so will the need to integrate tools into the treatment decision process to improve informed decision making.

Self-affirmation alters the brain's response to health messages and subsequent behavior change.

Health communications can be an effective way to increase positive health behaviors and decrease negative health behaviors; however, those at highest risk are often most defensive and least open to such messages. For example, increasing physical activity among sedentary individuals affects a wide range of important mental and physical health outcomes, but has proven a challenging task. Affirming core values (i.e., self-affirmation) before message exposure is a psychological technique that can increase the effectiveness of a wide range of interventions in health and other domains; however, the neural mechanisms of affirmation's effects have not been studied. We used functional magnetic resonance imaging (fMRI) to examine neural processes associated with affirmation effects during exposure to potentially threatening health messages. We focused on an a priori defined region of interest (ROI) in ventromedial prefrontal cortex (VMPFC), a brain region selected for its association with self-related processing and positive valuation. Consistent with our hypotheses, those in the self-affirmation condition produced more activity in VMPFC during exposure to health messages and went on to increase their objectively measured activity levels more. These findings suggest that affirmation of core values may exert its effects by allowing at-risk individuals to see the self-relevance and value in otherwise-threatening messages.

Decision-support networks of women newly diagnosed with breast cancer.

BACKGROUND: Little is known about the size and characteristics of the decision-support networks of women newly diagnosed with breast cancer and whether their involvement improves breast cancer treatment decisions. METHODS: A population-based sample of patients newly diagnosed with breast cancer in 2014 and 2015, as reported to the Georgia and Los Angeles Surveillance, Epidemiology, and End Results registries, were surveyed approximately 7 months after diagnosis (N = 2502; response rate, 68%). Network size was estimated by asking women to list up to 3 of the most important decision-support persons (DSPs) who helped them with locoregional therapy decisions. Decision deliberation was measured using 4 items assessing the degree to which patients thought through the decision, with higher scores reflecting more deliberative breast cancer treatment decisions. The size of the network (range, 0-3 or more) was compared across patient-level characteristics, and adjusted mean deliberation scores were estimated across levels of network size using multivariable linear regression. RESULTS: Of the 2502 women included in this analysis, 51% reported having 3 or more DSPs, 20% reported 2, 18% reported 1, and 11% reported not having any DSPs. Married/partnered women, those younger than 45 years, and black women all were more likely to report larger network sizes (all P < .001). Larger support networks were associated with more deliberative surgical treatment decisions (P < .001). CONCLUSIONS: Most women engaged multiple DSPs in their treatment decision making, and involving more DSPs was associated with more deliberative treatment decisions. Future initiatives to improve treatment decision making among women with breast cancer should acknowledge and engage informal DSPs. Cancer 2017;123:3895-903. © 2017 American Cancer Society.

The impact of doctor-patient communication on patients' perceptions of their risk of breast cancer recurrence.

PURPOSE: Doctor-patient communication is the primary way for women diagnosed with breast cancer to learn about their risk of distant recurrence. Yet little is known about how doctors approach these discussions. METHODS: A weighted random sample of newly diagnosed early-stage breast cancer patients identified through SEER registries of Los Angeles and Georgia (2013-2015) was sent surveys about ~2 months after surgery (Phase 2, N = 3930, RR 68%). We assessed patient perceptions of doctor communication of risk of recurrence (i.e., amount, approach, inquiry about worry). Clinically determined 10-year risk of distant recurrence was established for low and intermediate invasive cancer patients. Women's perceived risk of distant recurrence (0-100%) was categorized into subgroups: overestimation, reasonably accurate, and zero risk. Understanding of risk and patient factors (e.g. health literacy, numeracy, and anxiety/worry) on physician communication outcomes was evaluated in multivariable regression models (analytic sample for substudy = 1295). RESULTS: About 33% of women reported that doctors discussed risk of recurrence as "quite a bit" or "a lot," while 14% said "not at all." Over half of women reported that doctors used words and numbers to describe risk, while 24% used only words. Overestimators (OR .50, CI 0.31-0.81) or those who perceived zero risk (OR .46, CI 0.29-0.72) more often said that their doctor did not discuss risk. Patients with low numeracy reported less discussion. Over 60% reported that their doctor almost never inquired about worry. CONCLUSIONS: Effective doctor-patient communication is critical to patient understanding of risk of recurrence. Efforts to enhance physicians' ability to engage in individualized communication around risk are needed.

Learning to live with nephrotic syndrome: experiences of adult patients and parents of children with nephrotic syndrome.

Background: People living with nephrotic syndrome (NS) need to develop an in-depth understanding of their condition in order to participate in treatment decisions, develop self-management skills and integrate illness into daily life. However, the learning needs of adult patients and parents of children with NS are unknown. We therefore explored patient and parent perspectives on learning needs related to NS as part of a larger study to develop a shared learning tool for NS. Methods: Qualitative data were collected using semistructured focus groups and individual interviews with adult patients (n = 22) and parents of children with NS (n = 25). Results: The complexity of NS and its treatment made decision making challenging, as patients/parents often had to assimilate information about a condition that is poorly understood. Specific informational needs related to understanding the diagnosis and treatment approaches as well as learning to manage NS were identified. Difficulty in getting accurate information often made learning challenging. The importance of learning to monitor their condition, including understanding triggers that might precipitate a relapse, was highlighted, underscoring the need for individualized approaches to ensure unique learning needs are addressed. Conclusions: Our findings reveal some of the unique concerns of people with NS given its uncertain course and the limited information available specific to NS. These results suggest the need for shared communication between the patient/parents and providers to elicit the patient's/parents' understanding of NS and to support them in meeting their unique learning needs.

Sexual Health Concerns Among Cancer Survivors: Testing a Novel Information-Need Measure Among Breast and Prostate Cancer Patients.

While it is recognized that cancer treatment can contribute to problems in sexual function, much less is currently known about the specific sexual health concerns and information needs of cancer survivors. This study tested a new instrument to measure cancer survivors' sexual health concerns and needs for sexual information after cancer treatment. The Information on Sexual Health: Your Needs after Cancer (InSYNC), developed by a multidisciplinary team of experts, is a novel 12-item questionnaire to measure sexual health concerns and information needs of cancer survivors. We tested the measure with a sample of breast and prostate cancer survivors. A convenience sample of 114 cancer survivors (58 breast, 56 prostate) was enrolled. Results of the InSYNC questionnaire showed high levels of sexual concern among cancer survivors. Areas of concern differed by cancer type. Prostate cancer survivors were most concerned about being able to satisfy their partners (57 %) while breast cancer survivors were most concerned with changes in how their bodies worked sexually (46 %). Approximately 35 % of all cancer survivors wanted more information about sexual health. Sexual health concerns and unmet information needs are common among breast and prostate cancer survivors, varying in some aspects by type of cancer. Routine screening for sexual health concerns should be included in comprehensive cancer survivorship care to appropriately address health care needs. The InSYNC questionnaire is one tool that may help clinicians identify concerns facing their patients.

What couples say about their recovery of sexual intimacy after prostatectomy: toward the development of a conceptual model of couples' sexual recovery after surgery for prostate cancer.

INTRODUCTION: Interventions designed to help couples recover sexual intimacy after prostatectomy have not been guided by a comprehensive conceptual model. AIM: We examined a proposed biopsychosocial conceptual model of couples' sexual recovery that included functional, psychological, and relational aspects of sexuality, surgery-related sexual losses, and grief and mourning as recovery process. METHODS: We interviewed 20 couples preoperatively and 3 months postoperatively. between 2010 and 2012. Interviews were analyzed with Analytic Induction qualitative methodology, using NVivo software. Paired t-tests described functional assessment data. Study findings led to a revised conceptual model. MAIN OUTCOME MEASURES: Couples' experiences were assessed through semi-structured interviews; male participants' sexual function was assessed with the Expanded Prostate Cancer Index Composite and female participants' sexual function with the Female Sexual Function Index. RESULTS: Preoperatively, 30% of men had erectile dysfunction (ED) and 84% of partners were postmenopausal. All valued sexual recovery, but worried about cancer spread and surgery side effects. Faith in themselves and their surgeons led 90% of couples to overestimate erectile recovery. Postoperatively, most men had ED and lost confidence. Couples' sexual activity decreased. Couples reported feeling loss and grief: cancer diagnosis was the first loss, followed by surgery-related sexual losses. Couples' engagement in intentional sex, patients' acceptance of erectile aids, and partners' interest in sex aided the recovery of couples' sexual intimacy recovery. Unselfconscious sex, not returning to erectile function baseline, was seen as the end point. Survey findings documented participants' sexual function losses, confirming qualitative findings. CONCLUSIONS: Couples' sexual recovery requires addressing sexual function, feelings about losses, and relationship simultaneously. Perioperative education should emphasize the roles of nerve damage in ED and grief and mourning in sexual recovery.

Exploring the "active ingredients" of an online smoking intervention: a randomized factorial trial.

INTRODUCTION: Research needs to systematically identify which components increase online intervention effectiveness (i.e., active ingredients). This study explores the effects of 4 potentially important design features in an Internet-based, population-level smoking intervention. METHODS: Smokers (n = 1,865) were recruited from a large health care organization, regardless of readiness to quit. Using a full factorial design, participants were randomized to 1 of the 2 levels of each experimental factor (message tone [prescriptive vs. motivational], navigation autonomy [dictated vs. not], e-mail reminders [yes vs. no], and receipt of personally tailored testimonials [yes vs. no]) and provided access to the online intervention. Primary outcomes were self-reported 7-day point-prevalent smoking abstinence and confirmed utilization of adjunct treatment (pharmacotherapy or phone counseling) available through the health plan at 1 year. Outcomes were also assessed at 2 and 6 months and were examined among all enrolled participants (intent-to-treat [ITT]) and all who viewed the intervention (modified ITT). RESULTS: At 1 year, 13.7% were abstinent and 26.0% utilized adjunct treatment. None of the contrasting factor levels differentially influenced abstinence or treatment utilization at 12 months. In the modified ITT sample, smokers receiving testimonials were less likely to use adjunct treatment at 6 months (odds ratio = 0.54, 95% confidence interval = 0.30-0.98, p = .04). CONCLUSIONS: None of the design features enhanced treatment outcome. The negative effect observed for testimonials is provocative, but it should be viewed with caution. This study offers a model for future research testing the "active ingredients" of online interventions.

Exploring the role of the partner in couples' sexual recovery after surgery for prostate cancer.

BACKGROUND: Prostate cancer survivors' post-surgery sexual problems are well documented and long lasting. Partners' distress in this context leads to psychological morbidity which is poorly understood. Given the prevalence of prostate cancer diagnoses in older men, partners' distress represents a public health concern. This study elucidates an important aspect of partners' distress which has hitherto been undocumented. It can lead to further research and health-care provisions that will support couples in prostate cancer survivorship towards improved mental health and health outcomes. PURPOSE: Partner sexual function has been viewed as a factor in men's erectile function recovery after prostatectomy for prostate cancer. However, patients' and partners' perceptions on the role of the partner in couples' sexual recovery has not been studied. We wanted to understand those perceptions and to see whether their perceptions were congruent. METHODS: Men and partners were recruited from a previous study and interviewed separately about the role of the partner. Interview transcripts were analyzed using grounded theory with the help of NVivo software. RESULTS: Ten men and nine partners participated; most were more than 1 year past surgery. Men were 62, and partners were 58 years old on average. Nine men had erectile dysfunction. Six female partners were post-menopausal, and a participating male partner had post-prostatectomy erectile dysfunction. Men and partners agreed that partners provide emotional and logistical support. Both perceived the partner's own sexual interest, not function, as critical to the couple's sexual recovery. Some men felt pressured by partners' initiative, feeling insecure about sexual performance. Men were unaware of partners' sexual needs or needs for support. Partners expressed those needs but were unsure of what kind of support they needed. CONCLUSION: Partners' sexual and support needs during couples' sexual recovery after prostatectomy should be acknowledged and addressed as a legitimate aspect of research and care for men recovering from prostatectomy.

Mi Sleep Coach Mobile App to Address Insomnia Symptoms Among Cancer Survivors: Single-Arm Feasibility Study.

BACKGROUND: Rates of sleep disturbance among survivors of cancer are more than 3 times higher than the general population. Causes of sleep disturbance among survivors are many and multifaceted, including anxiety and fear related to cancer diagnosis and treatments. Cognitive behavioral therapy for insomnia (CBT-I) is considered a first-line treatment for insomnia; However, a lack of access to trained professionals and limited insurance coverage for CBT-I services has limited patient access to these effective treatments. Evidence supports digital delivery of CBT-I (dCBT-I), but there is only limited evidence to support its use among survivors of cancer. Broad adoption of smartphone technology provides a new channel to deliver dCBT-I, but no prior studies have evaluated mobile dCBT-I interventions for survivors. To address the need for accessible and efficacious CBT-I for survivors of cancer, the Mi Sleep Coach program was developed to adapt CBT-I for delivery to survivors of cancer as a self-directed mobile health app. OBJECTIVE: This single-arm feasibility study assessed the adherence, attrition, usefulness, and satisfaction of the Mi Sleep Coach app for insomnia. METHODS: A 7-week, single-arm study was conducted, enrolling adult survivors of breast, prostate, or colon cancer reporting sleep disturbances. RESULTS: In total, 30 participants were enrolled, with 100% completing the study and providing data through week 7. Further, 9 out of 10 app features were found to be useful by 80% (n=24) to 93% (n=28) of the 30 participants. Furthermore, 27 (90%) participants were satisfied with the Mi Sleep Coach app and 28 (93%) would recommend the use of the Mi Sleep Coach app for those with insomnia. The Insomnia Severity Index showed a decrease from baseline (18.5, SD 4.6) to week 7 (10.4, SD 4.2) of 8.1 (P<.001; Cohen d=1.5). At baseline, 25 (83%) participants scored in the moderate (n=19; 15-21) or severe (n=6; 22-28) insomnia range. At week 7, a total of 4 (13%) patients scored in the moderate (n=4) or severe (n=0) range. The number of patients taking prescription sleep medications decreased from 7 (23%) at baseline to 1 (3%; P<.001) at week 7. The number of patients taking over-the-counter sleep medications decreased from 14 (47%) at baseline to 9 (30%; P=.03) at week 7. CONCLUSIONS: The Mi Sleep Coach app demonstrated high levels of program adherence and user satisfaction and had large effects on the severity of insomnia among survivors of cancer. The Mi Sleep Coach app is a promising intervention for cancer-related insomnia, and further clinical trials are warranted. If proven to significantly decrease insomnia in survivors of cancer in future randomized controlled clinical trials, this intervention would provide more survivors of cancer with easy access to evidence-based CBT-I treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT04827459; https://clinicaltrials.gov/study/NCT04827459.

"Girls on the Move" intervention protocol for increasing physical activity among low-active underserved urban girls: a group randomized trial.

BACKGROUND: Increasing moderate to vigorous physical activity among urban girls of low socioeconomic status is both a challenge and a public health priority. Physical activity interventions targeting exclusively girls remain limited, and maintenance of moderate to vigorous physical activity during the post-intervention period has been difficult to maintain. The main aim of the 5-year "Girls on the Move" group randomized trial is to evaluate the efficacy of a comprehensive school-based intervention in increasing girls' minutes of moderate to vigorous physical activity and improving cardiovascular fitness, body mass index, and percent body fat immediately post-intervention (after 17 weeks) and at 9-month post-intervention follow-up (9 months after end of intervention). METHODS/DESIGN: A total of 24 urban middle schools in the Midwestern U.S. will be randomized to either receive the intervention or serve as a control (N = 1200 girls). The intervention, based on the Health Promotion Model and Self-Determination Theory, will include: (1) two face-to-face motivational, individually tailored counseling sessions with a registered nurse, one at the beginning and the other at the end of the intervention period; (2) an interactive Internet-based session during which each girl receives individually tailored motivational and feedback messages via iPad at 11 weeks (shortly after midpoint of intervention); and (3) a 90-minute after-school physical activity club. Racially diverse, low-active, 10- to 14-year-old 5th to 8th-grade girls will complete questionnaires and physical measures at baseline and post-intervention (n = 50 per school). Minutes of moderate to vigorous physical activity will be assessed with accelerometers. Cardiovascular fitness will be assessed by estimating VO2 max with PACER (Progressive Aerobic Cardiovascular Endurance Run) scores. Height and weight will be assessed to calculate body mass index. Percent body fat will be estimated with a foot-to-foot bioelectric impedance scale. Linear mixed effects regression analyses will be performed to assess intervention effects. DISCUSSION: This multi-component approach is expected to improve girls' moderate to vigorous physical activity and related physical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT01503333.