Dyad and group-based interventions in physical activity, diet, and weight loss: a systematic review of the evidence.

Studies show that interpersonal relations impact behavior change. Yet, a comprehensive review of their efficacy remains unclear. This systematic review examines the efficacy of dyadic and group-based studies that intervened on primary endpoints: diet, PA, and weight loss in adults and their networks. We searched five databases for eligible articles published from 1980 to present. Final inclusion and risk of bias were independently determined and agreed upon by two of the paper's co-authors. Nine dyads and twelve group-based studies were eligible. Of the studies, 36% (4/11) of PA studies, 60% (3/5) of diet studies and 57% (8/14) of studies with weight loss as primary outcomes, reported significant findings. Compared to dyadic interventions, a greater proportion of group-based interventions demonstrated efficacy in PA gain and weight loss as outcomes. Approximately 43% of studies demonstrated low to moderate methodological quality. This systematic review synthesized the evidence of dyadic and group studies that intervened on PA, diet, and weight in adults from the same network. Moderately-high risk of bias and lack of diverse representation restricts inferences around efficacy. High-quality rigorous research is needed to understand the efficacy of dyadic and group-based interventions in addressing these co-occurring endpoints of interest.

Health Literacy Interventions in Cancer: a Systematic Review.

Approximately one-third of adults in the United States (U.S.) have limited health literacy. Those with limited health literacy often have difficultly navigating the health care environment, including navigating care across the cancer continuum (e.g., prevention, screening, diagnosis, treatment). Evidence-based interventions to assist adults with limited health literacy improve health outcomes; however, little is known about health literacy interventions in the context of cancer and their impact on cancer-specific health outcomes. The purpose of this review was to identify and characterize the literature on health literacy interventions across the cancer care continuum. Specifically, our aim was to review the strength of evidence, outcomes assessed, and intervention modalities within the existing literature reporting health literacy interventions in cancer. Our search yielded 1036 records (prevention/screening n = 174; diagnosis/treatment n = 862). Following deduplication and review for inclusion criteria, we analyzed 87 records of intervention studies reporting health literacy outcomes, including 45 pilot studies (prevention/screening n = 24; diagnosis/treatment n = 21) and 42 randomized controlled trials or quasi-experimental trials (prevention/screening n = 31; diagnosis/treatment n = 11). This literature included 36 unique interventions (prevention/screening n = 28; diagnosis/treatment n = 8), mostly in the formative stages of intervention development, with few assessments of evidence-based interventions. These gaps in the literature necessitate further research in the development and implementation of evidence-based health literacy interventions to improve cancer outcomes.

Motivation for physical activity and the moderating effect of cancer diagnosis: A nationally representative cross-sectional study.

The aim of this study was to investigate associations between types of motivation for physical activity and self-reported weekly aerobic moderate-to-vigorous physical activity (MVPA) in the 2012 and 2014 waves of the nationally representative Health Information National Trends Survey 4 (n = 7307). We further explored differential associations between MVPA and types of motivation for physical activity by cancer survivor status. We found that those who were more motivated by "getting enjoyment from exercise" reported 26.4% more MVPA (+49.8 min/week) than those who were less motivated by this factor, adjusting for covariates (p = 0.025). Conversely, those who were more motivated by "concern over the way you look" reported 22.1% less MVPA (-55.5 min/week) than those who were less motivated by this factor, adjusting for covariates (p = 0.002). We found no evidence for a relationship between motivation from either "pressure from others" or "feeling guilty when you skip exercising" and MVPA. We identified a significant interaction for "feeling guilty when you skip exercising" and cancer survivor status, adjusting for covariates (p = 0.034). Cancer survivors who reported being more motivated by "feeling guilty when you skip exercising" reported 36.2% less MVPA (-71.75 min/week) than those who were less motivated by this factor; there was no statistically reliable difference in those without a history of cancer. Findings are concordant with previous literature highlighting the primacy of enjoyment for physical activity adherence. There is a need for further inquiry into guilt-related motivation for physical activity among cancer survivors, as it may have a unique, negative impact in this population.

Response to an exercise intervention after endometrial cancer: differences between obese and non-obese survivors.

OBJECTIVE: The objective of this paper is to describe baseline differences between obese and non-obese endometrial cancer survivor in anthropometrics, exercise behavior, fitness, heart rate and blood pressure, and quality of life, and to analyze whether the effect of a home-based exercise intervention on these outcomes differed for obese and non-obese participants. METHODS: One hundred post-treatment Stage I-IIIa endometrial cancer survivors participated in a single arm 6month study in which they received a home-based exercise intervention. Cardiorespiratory fitness, anthropometrics, and exercise behavior were measured every two months, and quality of life (QOL) and psychological distress were measured at baseline and 6months. RESULTS: Adjusting for potential confounders, at baseline obese survivors had poorer cardiorespiratory fitness (p=.002), higher systolic blood pressure (p=.018), and lower physical functioning (p<.001) and ratings of general health (p=.002), and more pain (p=.037) and somatization (.002). Significant improvements were seen in exercise behavior, resting heart rate, systolic blood pressure, and multiple QOL domains over the course of the intervention. Obese survivors had less improvement in exercise behavior and cardiorespiratory fitness than non-obese survivors, but there were no differences with regard to improvements in QOL and stress. CONCLUSIONS: Home based exercise interventions are beneficial to endometrial cancer survivors, including those whose BMI is in the obese range. While obese survivors have lower levels of physical activity and fitness, they experienced similar activity, fitness, quality of life and mental health benefits. Exercise should be encouraged in endometrial cancer survivors, including those who are obese.

Health behaviors and depressive symptoms in testicular cancer survivors.

OBJECTIVES: Testicular cancer has one of the highest 5-year survival rates of all cancer sites. The survival period is marked by an increased risk of secondary cancer and cardiovascular events owing to treatment-related toxicities. The purposes of this cross-sectional study were to determine the prevalence of health behaviors and depressive symptoms and to assess the relationship between depression and health behaviors in survivors of testicular cancer. METHODS: A total of 162 survivors of testicular cancer 2 to 10 years after their diagnosis completed a one-time telephone interview. The interview included a battery of questions from the Behavioral Risk Factor Surveillance System assessing health behaviors (smoking, physical activity, cholesterol screening, colorectal cancer screening, alcohol consumption, and fruit and vegetable intake) and the Centers for Epidemiological Studies-Depression (CES-D) questionnaire assessing depressive symptoms. RESULTS: The interviews revealed a low prevalence of positive health behaviors among survivors of testicular cancer. The percentage (17.5%) of survivors of testicular cancer who scored above the cutoff on the CES-D was greater than that (11%) of large-scale population-based estimates in men aged 19 to 44 years. Smoking was significantly related to depression. Depressive symptoms (CES-D score) differed significantly depending on smoking status (current smokers, mean = 15.2; former smokers, mean = 6.2, P <0.001; and never smokers, mean = 8.7, P <0.001). CONCLUSIONS: Given the increased risk of cancer and treatment-related morbidities of these survivors, the findings of this study suggest that healthcare professionals should encourage survivors of testicular cancer to engage in positive health behaviors and check for depressive symptoms.

A pilot study for a screening trial of cervical fluorescence spectroscopy.

Fluorescence spectroscopy is a promising technology for detection of epithelial precancers and cancers. In preparation for a multicenter phase II screening trial, a pilot trial was conducted to test data collection and patient examination procedures, use data forms, time procedures, and identify problems with preliminary data analysis. Women 18 years of age and older underwent a questionnaire, a complete history, and a physical examination, including a pan-colposcopy of the lower genital tract. A fiber-optic probe measured fluorescence excitation-emission matrices at 1-3 cervical sites for 58 women. The data collection procedures, data forms, and procedure times worked well, although collection times for all the clinical data take an average of 28 min. The clinical team followed procedures well, and the data could be retrieved from the database at all sites. The multivariate analysis algorithm correctly identified squamous normal tissue 99% of the time and columnar normal tissue only 7%. The assessment of ploidy from monolayer samples was not accurate in this small sample. The study was successful as a pilot trial. We learned who participated, who withdrew, how often abnormalities were present, and that algorithms that have worked extremely well in previous studies do not work as well when a few study parameters are changed. The current algorithm for diagnosis identified squamous normal tissue very accurately and did less well for columnar normal tissue. Inflammation may be an explanation for this phenomenon. Fluorescence spectroscopy is a promising technology for the detection of epithelial precancers and cancers. The screening trial of fluorescence and reflectance spectroscopy was successful.

Approaches for end-of-life care in the field of gynecologic oncology: an exploratory study.

We sought to explore the Society of Gynecologic Oncologists (SGO) members' opinions and decisions about end-of-life issues and incurable conditions. A survey was mailed to members of the SGO. Their responses were recorded on a Likert scale and entered into a database. The survey explored opinions, experiences, and decisions in managing terminally ill gynecologic oncology patients. Of 900 surveys, 327 were returned (response rate, 36%). Seventy-three percent were men, 89% were white, and 72% were of Christian denomination. Respondents believed that 97% of patients who are dying realize that they are dying but stated only 40% of these patients initiate conversations about end-of-life issues. In contrast, 92% of respondents stated that they initiate end-of-life discussions with patients. Ninety-two percent of respondents thought that the patients should be allowed to make end-of-life choices independently after the facts are given to them. However, 44% thought that it is important to influence the way information is presented, and 54% believe that the gynecologic oncologist (GO) controls the outcome of end-of-life discussions. Although the physicians' sex, race, religion, and age did not correlate with their treatment decisions, religion did correlate with less fear of death (P = 0.011) and less discomfort when talking with patients about death (P = 0.005). Fifty-four percent of respondents believed that the GO controls the outcome of end-of-life discussions, and 40% believe that their actions prolong the process of dying. Expanding our understanding of what motivates GOs to recommend continued treatment over palliation is important for preserving informed patient-motivated end-of-life decisions.

Health-related quality of life in gynecological oncology: instruments and psychometric properties.

Quality of life is generally recognized as a subjective, multidimensional concept, which places emphasis on the self-perception and subjective experience of the patient compared to the expectation of an individual's current health state. Health-related quality of life, which encompasses the psychological, physical, and social functioning of patients, has evolved over recent decades into an established treatment outcome in cancer clinical trials. Assessing quality of life as a clinical trial outcome enables clinicians to better address concerns of gynecological oncology patients, but selection of appropriate measurement tools is critical. This article reviews the concepts of reliability and validity, and describes three health-related quality of life instruments, their psychometric properties, and their use in gynecological oncology clinical trials and other cancer research.

Reliability and validity of the functional assessment of cancer therapy-ovarian.

PURPOSE: To report the reliability and validity of the Functional Assessment of Cancer Therapy-Ovarian (FACT-O) in a consecutive series of outpatients with epithelial ovarian cancer. PATIENTS AND METHODS: Two hundred thirty-two ovarian cancer patients attending an outpatient gynecologic oncology clinic completed questionnaires at baseline. The patients' FACT-O scores were compared with their performance status, disease stage, treatment status, and other factors hypothesized to be related to quality of life. Patients received a second questionnaire either one week after baseline to assess the instrument's test-retest reliability and/or two months after baseline to evaluate its sensitivity to change in performance status. RESULTS: Internal consistency and test-retest reliability of the FACT-O were adequate. Overall, the scales correlated with other measures as expected; all correlations were in the hypothesized direction. Patients with advanced disease, poor performance status, and who were receiving active treatment had lower scores on physical, functional, and ovarian cancer-specific scales. The total FACT-O and emotional well-being scores were lower for patients with poor performance status and patients in active treatment. The FACT-O total and all subscale scores except emotional well-being were sensitive to decreases in performance status. CONCLUSION: Overall, the FACT-O provides a reliable and valid assessment of the quality of life of women with ovarian cancer, and is appropriate as a brief quality of life assessment in clinical trials and descriptive studies.

Depression, anxiety, and quality of life in patients with epithelial ovarian cancer.

OBJECTIVE: The aims of this study were to evaluate psychological distress and quality of life (QOL) in patients with epithelial ovarian cancer (EOC) and to examine the relationship between these problems and health and demographic variables. METHODS: Of 344 consecutive patients identified, 246 completed questionnaires. Four dimensions of QOL were assessed including physical, functional, emotional, and social/family well-being, as well as concerns specific to ovarian cancer patients. Depression was measured with the Center for Epidemiologic Studies-Depression (CES-D) scale and anxiety was measured by the State Anxiety Subscale of the Spielberger State-Trait Anxiety Inventory. Performance status was evaluated by the Zubrod score. RESULTS: Sixty-five patients (26%) had early stage disease; 181 (74%) had advanced disease. One hundred twenty-one patients (49%) were under active treatment, while 124 (51%) were seen for posttherapy surveillance. Forty-eight (21%) met CES-D cutoff criteria for a clinical evaluation for depression, and 29% scored above the 75th percentile for anxiety. Performance status was related to depression, anxiety, and QOL problems, except in the domain of social well-being. CONCLUSIONS: Clinically significant depression and anxiety may be more prevalent in patients with EOC than previously reported. Future studies of screening for and treating psychological distress are being designed to improve QOL in these women.

The relationship between organizational characteristics and the adoption of workplace smoking policies.

Organizational-level variables that are hypothesized to influence the level of smoking policy restrictions and the prevalence of smoking control activities were tested in a sample of 1 14 worksites that participated in the Working Well Trial, a national trial of worksite health promotion. Predictors related to more restrictive policies included smaller size, larger percentage of white-collar workers, larger number of complaints about environmental tobacco smoke, less complexity, more formalization, and having a CEO who valued health and employees' well-being. The number of smoking control activities offered in a worksite was predicted by having a larger blue-collar workforce, a higher percentage of female employees, higher levels of workforce stability, and a CEO who valued health and employees' well-being. Efforts to identify predictors of companies' adoption and implementation of workplace-based policies and interventions are an important part of tobacco control efforts and will enhance future intervention and research efforts.

Recruitment and retention of minority women in cancer screening, prevention, and treatment trials.

Researchers are giving greater attention to the recruitment and retention of minority women in clinical studies because of their historical underrepresentation, despite their greater morbidity and mortality for many conditions. Using findings from four studies, this article examines documented barriers to the recruitment and retention of minority women to clinical cancer research and discusses effective recruitment strategies. Among the major barriers to recruitment were lack of awareness, lack of transportation, interference with work/family responsibilities, financial costs, negative side effects, and burdensome procedures. Effective recruitment strategies focused on using culturally targeted mass mailings and media presentations based on acquiring an understanding of the minority community. Recommendations are made for further study and implementation.

Measuring participatory strategies: instrument development for worksite populations.

A participatory strategies approach which involves employees in the planning and delivery of worksite health promotion programs was utilized in the 55 experimental worksites included in the national, NCI-funded Working Well Trial. According to study protocol, Employee Advisory Boards (EABs) were organized in each experimental worksite. This paper describes two substudies designed to develop and measure participatory strategies associated with the EABs in the Working Well Trial. Study 1 determined characteristics of the EABs, developed subscales and assessed the internal consistency of the scales. Study 2 used a confirmatory factor analysis to examine the structure of the developed questionnaire. The four subscales include: Autonomy/Independence, Management Involvement, Institutionalization/Commitment and Others Involvement. Results from Study 1 indicate that the four subscales of the 24-item instrument demonstrated strong internal consistency and three were sensitive enough to register differences by Study Center at the baseline. Study 2 results found that the EAB subscales again demonstrated good internal consistency, structural stability and acceptable sensitivity. An initial validity analysis was performed and yielded results which supported some but not all of the hypothesized associations. Implications for further refinement and application of this new instrument in worksite settings are explored.

Impact of the Working Well Trial on the worksite smoking and nutrition environment.

This article reports the effect of a worksite cancer control intervention on aspects of the physical and social environment related to dietary and smoking behaviors of employees. Data are from 111 intervention and control worksites that participated in the Working Well Trial. Employee surveys and interviews with key organizational informants assessed environmental and normative changes relevant to nutrition and tobacco use. Results indicated significant effects of the intervention on all nutrition outcomes: access to healthy food, nutritional information at work, and social norms regarding dietary choice. Significant benefits were not found for smoking norms or smoking policies. However, changes occurred in both the control and intervention sites on these variables. This first large analysis of environmental and normative effects of a worksite intervention is consistent with the employee behavior change findings for the trial and serves as a model for future analyses of multilevel worksite health promotion programs.

Gender differences in chronic disease risk behaviors through the transition out of high school.

BACKGROUND: Major life transitions (e.g., graduation from high school) are times when many changes occur in a person's social and physical environment. Men and women likely experience aspects of these changes differently. As a result, health-related behaviors likely change at these times with possible differences in these changes by gender. METHODS: Gender differences in the performance of chronic disease risk-related behaviors (fruit, juice, and vegetable intake; physical activity; tobacco and alcohol use; and sexual practices) through the transition out of high school (HS) were assessed in a secondary analysis of a nationally representative sample from the 1992 National Health Interview Survey-Youth Risk Behavior Survey. The survey was completed by 5881 young people aged 14 to 21 years. Regression discontinuity analysis with piecewise regression was performed. RESULTS: Statistically significant gender by transition effects were obtained for exercise/physical activity (decreases at the transition point for males), snuff use (decrease for females in HS), binge drinking and number of days drinking alcohol (increases for males at the transition point), and use of alcohol or drugs before sexual intercourse (decrease for females post HS). Fruit intake decreased for males and females and daily and heavy cigarette smoking increased during the HS years. Effect sizes were small but promising, given that the data set was not designed to test this hypothesis. CONCLUSION: These data offer evidence of differences by gender in chronic disease risk behaviors through the HS transition. Longitudinal studies are needed to assess the true nature of these differences, the tracking of these risk behaviors and their personal, social, and environmental determinants, including gender-specific determinants, that may explain these changes and inform future intervention development.

Ethnic differences in cancer risk behaviors through the transition out of high school.

Differences were assessed by ethnic group in the performance of cancer risk related lifestyle behaviors through the transition out of high school. Data were obtained from a nationally representative probability sample survey, the 1992 National Health Interview Survey-Youth Risk Behavior Survey. A cross-sectional sub-sample included adolescents with an age range from high school freshmen to young adults within four years after high school. Self reported indicators of diet, physical activity, cigarette smoking, smokeless tobacco use, alcohol use, and sexual practices were the primary dependent measures. Cancer risk increased at the transition out of high school through changes in cancer related behaviors. Hispanic-American males experienced somewhat higher risks after the transition for chewing tobacco and snuff. African Americans experienced somewhat higher risks after the transition for physical activity, chewing tobacco, and number of sexual partners. Further research needs to verify these findings with longitudinal designs, assessment of tracking of behaviors through the transition, and of the ecological, social and psychosocial correlates that may explain why these changes occurred.

Worksite health and safety climate: scale development and effects of a health promotion intervention.

BACKGROUND: Environmental influences on health and health behavior have an important place in research on worksite health promotion. We tested the validity and internal consistency of a new measure of organizational health and safety climate that was used in a large randomized trial of a worksite cancer prevention program (the Working Well Trial). The resulting scales then were applied to assess intervention effects. METHODS: This study uses data from a subset of 40 worksites in the Working Well Trial. Employees at 20 natural gas pipeline worksite and 20 rural electrical cooperatives completed a cross-sectional questionnaire at baseline and 3-year follow-up. RESULTS: A factor analysis of this self-report instrument produced a two-factor solution. The resulting health and safety climate scales had good internal consistency (Cronbach's alpha = 0.74 and 0.82, respectively) and concurrent validity. The health climate scale was correlated more highly with organizational measures that were indicative of a supportive health climate than those indicating supportive safety climate, while the reverse was true of the safety climate scale. Changes in health climate were associated with the number of smoking and smokeless tobacco programs offered at the worksites at the time of the 3-year follow-up (r = 0.46 and 0.42, respectively). The scales were not correlated with most employee health behaviors. The health climate scores increased at intervention worksites, compared with scores at control worksites (F[1,36] = 7.57, P = 0.009). CONCLUSIONS: The health and safety climate scales developed for this study provide useful instruments for measuring organizational change related to worksite health promotion activities. The Working Well Intervention resulted in a significant improvement in worksite health climate.

Durability, dissemination, and institutionalization of worksite tobacco control programs: results from the Working Well trial.

Durability, dissemination and institutionalization o f tobacco control activities are reported, based on the Working Well worksite cancer control intervention study (n = 83 worksites). Tobacco control activities increased significantly in intervention worksites as a result of research-supported activities but were not sustained 2 years after the conclusion of the intervention. Intervention sites were more likely than control sites to initiate and maintain structures for institutionalizing programs, such as assigning a committee responsibility for health-promotion programs or providing a budget for health-promoting activities. Dissemination of the program to control worksites had little impact on the level of smoking control activities in control worksites. Although program durability was not a primary aim of this intervention study, these analyses provide an important assessment of program maintenance beyond a funded intervention and underscore the need for additional research to identify effective organizational strategies for institutionalization of worksite health-promotion programs.