A sequential multiple assignment randomized trial of symptom management for cancer survivors during treatment and their informal caregivers.

CONTEXT: Many cancer survivors and their informal caregivers experience multiple symptoms during the survivor's treatment. OBJECTIVE: Test relative effectiveness and optimal sequencing of two evidence-based interventions for symptom management. METHODS: In this sequential multiple assignment randomized trial (SMART), survivors of solid tumors with elevated depression or anxiety and their caregivers as dyads were initially randomized after baseline assessment in a 3:1 ratio to the Symptom Management and Survivorship Handbook (SMSH, N = 277 dyads) intervention or SMSH plus 8 weeks of telephone interpersonal counseling (TIPC, N = 97 dyads). After 4 weeks, survivors who were not responding (no improvement or worsening score on depression and/or anxiety item) to SMSH only and their caregivers were re-randomized to continue with SMSH alone (N = 44 dyads) to give it more time or to SMSH + TIPC (N = 44 dyads). Mixed effects and generalized linear models compared severity of depression, anxiety, and a summed index of 16 other symptoms over weeks 1-13 and week 17 between randomized groups and among three dynamic treatment regimes (DTRs). Dyads received SMSH only for 12 weeks (DTR1); SMSH for 12 weeks with 8 weeks of TIPC added from week 1 (DTR2); and SMSH for 4 weeks followed by the combined SMSH + TIPC for 8 weeks if no response at 4 weeks (DTR3). RESULTS: Survivors randomized initially to SMSH alone had significantly lower anxiety over weeks 1-13 compared to those randomized to the combined SMSH + TIPC. In comparing DTRs, survivor's anxiety was significantly lower at week 13 for DTR1 compared to DTR2 with no other main effects for survivors or caregivers. Exploratory moderation analyses indicated a potential benefit of adding TIPC for caregivers of non-responders with elevated baseline symptoms. CONCLUSION: SMSH + TIPC did not result in better symptom outcomes at week 17 than SMSH alone. Lower intensity SMSH may improve depression and anxiety symptoms for most survivors and their caregivers. TRIAL REGISTRATION: Clinicaltrails.gov ID number, NCT03743415; approved and posted on 11/16/2018.

Adapting a dyadic exercise program to be culturally relevant for Hispanic men with prostate cancer using community engagement studio: a brief report.

Background: Cancer disparities exist for Hispanic men with prostate cancer and their caregivers that could be reduced through exercise. Exercising Together© is a six-month, evidence-based dyadic resistance training program that promotes teamwork between prostate cancer survivors and their spouses to improve physical, mental, and relational health outcomes. The purpose of this study was to elicit feedback and recommendations from stakeholders on the Exercising Together© intervention to inform the cultural adaptation of this program for Hispanic men with prostate cancer. Methods: We conducted a virtual Community Engagement Studio (V-CES) with community expert stakeholders representing the Hispanic and cancer care communities in Southern Arizona. The V-CES process included orientation, presentation of the research, guided discussion, and evaluation. The V-CES was audio recorded, transcribed, and rapidly analyzed to identify actionable feedback and contextual adaptations. Results: Nine stakeholders (6/9 male; 5/9 Hispanic) completed all V-CES activities. Through stakeholder engagement and feedback from the V-CES, adaptations to the original Exercising Together© intervention included: (1) inclusion of the cancer survivor's identified caregiver, who may not be a spouse; (2) availability in English and Spanish; (3) shortening the intervention to 3 months; (4) remote delivery of the intervention; and (5) incorporation of low burden procedures. Conclusion: Findings from our V-CES informed the adaptation of a culturally relevant dyadic progressive resistance training program for Hispanic men with prostate cancer and their caregivers.

Predictors of persistence of post-chemotherapy symptoms among survivors of solid tumor cancers.

CONTEXT: Late or residual symptoms diminish quality of life for many cancer survivors after completion of treatment. OBJECTIVES: Examine risk factors associated with persisting symptom burden after chemotherapy and the lack of symptom improvement over time. METHODS: Survivors who completed curative-intent chemotherapy within two years for solid tumors were enrolled into a symptom management trial. There were 375 survivors with two or more comorbid conditions or one comorbid condition and elevated depressive symptoms (pre-defined risk factors in the trial design) who received interventions and 71 survivors without these risk factors who did not receive interventions. For all survivors, symptoms were assessed at intake, 4, and 13 weeks and categorized as mild, moderate, or severe based on the interference with daily life. The probabilities of moderate or severe symptoms and symptom improvement were analyzed using generalized mixed-effects models in relation to comorbidity, depressive symptoms, age, sex, race/ethnicity, employment, time since chemotherapy completion, and physical function. Multiple symptoms were treated as nested within the survivor. RESULTS: Moderate or severe symptoms at baseline and the lack of improvement over time were associated with younger age and lower physical function over and above a greater number of comorbidities and elevated severity of depressive symptoms. CONCLUSION: Risk factors identified in this research (younger age, lower physical function, greater comorbidity, and higher depressive symptoms) can be used to allocate resources for post-treatment symptom management for cancer survivors in order to relieve symptoms that do not necessarily resolve with time.

Loneliness, Spirituality, and Health-Related Quality of Life in Hispanic English-Speaking Cancer Caregivers: A Qualitative Approach.

Hispanic caregivers experiencing higher caregiving burden than their non-Hispanic cohorts, due in part to contextual factors, such as barriers to accessing health care, challenging employment environments, low education and income, immigration issues, and minority stress. Spirituality may serve as a coping strategy for Hispanic caregivers that influences health-related quality of life (HRQoL), possibly by modifying loneliness associated with caregiving. We explored these concepts using semi-structured interviews (N = 10 Hispanic caregivers). Participants shared perceptions of loneliness, spirituality, and how these factors related to HRQoL. Five themes emerged: caregiver experience, coping strategies, loneliness, religion and spirituality to gain strength. Findings suggested that spirituality and religion improved HRQoL partially by reducing loneliness. Future programs to improve HRQoL in Hispanic English-speaking cancer caregivers should address spirituality.

SELF-CONCEPT development of school-aged children with congenital upper limb differences: A mixed-methods study.

BACKGROUND: School-aged children enter an essential phase of psychosocial development in which they begin to form their self-concept. Having a negative self-concept has a direct relationship on the gradual evolution of a child's personality which can influence academic and career success, peer interactions and relationships, generativity and life satisfaction and meaning. There is limited research examining self-concept in children with congenital upper limb differences. OBJECTIVES: Describe self-concept in school-aged children with congenital upper limb differences (CULD). METHODS: In this convergent mixed methods study, we used the Piers Harris Children's Self-Concept Scale (PHCSCS) and modified photovoice methodology to explore self-concept in school aged children with CULD. The quantitative results from the PHCSCS were merged with the qualitative findings from the 63 photographs and 63 written descriptions provided by nine children. RESULTS: Mean self-concept was 51.22 (±10.43). Mean domain scores: behavioral adjustment 52 (±8.19), freedom from anxiety 48.56 (±10.42), happiness and satisfaction 49.44 (±10.73), intellectual and school status 54.78 (±10.31), and social acceptance 49.89 (±8.64). Nine participants described five themes of self-concept: emotions, sense of accomplishments, positive view of oneself and one's physical body, hobbies, and a sense of connection. Children defined their self-concept through expressions of self-efficacy, self-image, and social identity. IMPLICATIONS: Results created a more comprehensive description of self-concept, and expanded understanding of the social identity of school-aged children with congenital upper limb difference. Future research is needed to examine the relationships between self-efficacy, self-image, and social identity to develop interventions promoting healthy self-concept development.

Social determinants of health, psychological distress, and caregiver burden among informal cancer caregivers of cancer survivors during treatment.

OBJECTIVE: This study compared three ethnic/racial groups of informal cancer caregivers on social determinants of health and tested social determinants of health as predictors of psychological distress and caregiver burden. METHODS: This study was a secondary analysis of baseline data of a sequential multiple assignment randomized trial (SMART) testing symptom management interventions with caregiver-survivor dyads. Caregivers completed baseline measures of social determinants of health (SDoH), functional limitations, psychological distress, and caregiver burden. Hispanic, non-Hispanic White, and non-Hispanic other races caregivers were compared on these variables. Multivariate tests of associations between SDoH and caregiver burden and psychological distress were conducted in structural equation modeling with caregiver burden and psychological distress as latent variables. RESULTS: Hispanic caregivers reported significantly higher caregiver burden, specifically for finances, family, and schedules. Caregiver burden was significantly predicted by having income barely or not meeting needs, being female, socially isolated, married, Hispanic, and having poor physical functioning. Significant predictors of caregivers' psychological distress: being female, being socially isolated, and having poor physical functioning. CONCLUSION: Hispanic caregivers experience significant challenges associated with caregiver burden, especially if they are female, socially isolated, and have poor physical functioning. Assessment of these SDoH is important in caregiver health to provide supportive care during caregiving. CLINICAL TRIAL REGISTRATION NUMBER: NCT03743415 www.clinicaltrials.gov.

Social isolation and social connectedness among young adult cancer survivors: A systematic review.

BACKGROUND: Social isolation and connectedness are social determinants of health that have demonstrated effects on cancer-related outcomes. These constructs have been systematically evaluated among pediatric and older adult cancer populations. In this review, the authors evaluated the prevalence, correlates, and psychosocial implications of social isolation and connectedness among young adult (YA) cancer survivors aged 18-39 years. METHODS: Peer-reviewed articles published in English before June 2021 were identified from database searches and included articles' reference lists according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included articles described studies that assessed social isolation and/or connectedness among YA cancer survivors. RESULTS: In total, 5094 unique records were identified; 4143 were excluded after title/abstract screening, and 907 were excluded after full-text review. Forty-four articles were included. Few studies used validated measures or directly assessed social isolation or connectedness. Social isolation was similarly prevalent among YAs and older cancer survivors and noncancer populations. Demographic, clinical, and behavioral risk and protective factors for social isolation were identified. Social isolation was related to worse psychological well-being, whereas social connectedness was often, but not always, related to better psychological well-being. CONCLUSIONS: This growing literature underscores the relevance of social isolation and connectedness as important health determinants among YA cancer survivors. The identified risk and protective factors can identify YAs who especially may benefit from screening for social isolation. Future studies are needed that directly, reliably, and validly evaluate social isolation and connectedness to inform the development of interventions to decrease isolation and increase connectedness.

Depression among Underserved Rural and Urban Caregivers of Latinas with Breast Cancer.

Among Latino/as, informal caregiving duties are often deemed a family responsibility. Understanding psychological outcomes tied to caregivers of Latina breast cancer survivors is important to identify the impacts of cancer. Secondary analysis of baseline data collected in a randomized clinical trial (RCT) from 230 Latina breast cancer survivor-caregiver dyads. Characteristics of caregivers residing in rural/underserved and urban areas were compared using t- or chi-square tests. General linear models were used to analyze depressive symptoms in relation to residence, survivor-caregiver relationship, acculturation, obligation, reciprocity, and comorbidities. Urban residence was significantly associated with higher levels of depression controlling for survivor-caregiver relationship acculturation, obligation, reciprocity, and comorbidities. Mother caregivers had significantly higher levels of depression than other caregivers. Depression among Latino/a caregiver's providing care to an adult child is an important consideration as Latino/as are less likely to seek out/have access to mental health services than other groups.

A Sequential Multiple Assignment Randomized Trial of Symptom Management After Chemotherapy.

CONTEXT: Many cancer survivors experience a lingering symptom burden after chemotherapy. OBJECTIVES: In this sequential multiple assignment randomized trial, we tested optimal sequencing of two evidence-based interventions for symptom management. METHODS: Survivors of solid tumors (N = 451) were interviewed at baseline and stratified as high or low need for symptom management based on comorbidity and depressive symptoms. High need survivors were randomized initially to the 12-week Symptom Management and Survivorship Handbook (SMSH, N = 282) or 12-week SMSH with eight weeks of Telephone Interpersonal Counseling (TIPC, N = 93) added during weeks one to eight. After four weeks of the SMSH alone, non-responders on depression were re-randomized to continue with SMSH alone (N = 30) or add TIPC (N = 31). Severity of depression and summed severity index of 17 other symptoms over weeks one to13 were compared between randomized groups and among three dynamic treatment regimes (DTRs): 1) SMSH for 12 weeks; 2) SMSH for 12 weeks with eight weeks of TIPC from week one; 3) SMSH for four weeks followed by SMSH+TIPC for eight weeks if no response to the SMSH alone on depression at week four. RESULTS: There were no main effects for randomized arms or DTRs, but there was a significant interaction of trial arm with baseline depression favoring SMSH alone during weeks one to four in the first randomization and SMSH+TIPC in the second randomization. CONCLUSION: The SMSH may represent a simple effective option for symptom management, adding TIPC only when there is no response to SMSH alone for people with elevated depression and multiple co-morbidities.

Social Determinants of Health and Symptom Burden During Cancer Treatment.

BACKGROUND: Cancer survivors (defined as individuals from diagnosis to the end of life) in treatment experience multiple physical and psychological symptoms (e.g., fatigue, pain, depression, anxiety, disturbed sleep) that influence their well-being and treatment outcomes. Underrepresented cancer survivors may disproportionately experience greater symptom burden (number of symptoms, symptom severity, depression, anxiety). OBJECTIVES: The aim of this study was to examine the relationships of social determinants of health, including age, ethnicity, education, income and whether income meets the survivor's needs, neighborhood (rural vs. urban), access to healthcare (e.g., insurance), and social isolation, with symptom burden in cancer survivors. METHODS: This secondary analysis included baseline data from 400 cancer survivors of solid tumor cancers undergoing chemotherapy or targeted therapy who participated in a larger randomized trial of symptom management interventions. Symptom burden was measured by the Center for Epidemiological Studies-Depression scale for depression and Patient-Reported Outcomes Measurement Information System scores for anxiety and social isolation, summed severity index of 16 symptoms from the General Symptom Distress Scale, and the total number of symptoms. Self-reported comorbid conditions were measured using the Bayliss tool. General linear models were used to relate symptom measures (one at a time) to age, number of comorbid conditions, level of education, marital status, income meeting needs, and size of metropolitan neighborhood. Additional covariates included site of cancer, its treatment, and whether the cancer was metastatic. RESULTS: Non-Hispanic White survivors ( n = 191) were older and had more comorbid conditions, a higher proportion of metastatic cancers, and higher levels of education and income compared with Hispanic survivors ( n = 168) and non-Hispanic survivors of other races ( n = 41). Compared with the other two groups, Hispanic survivors had the lowest rate of health insurance availability, and non-Hispanic survivors of other races had the lowest social isolation. Age, number of comorbid conditions, and social isolation were significantly associated with number of symptoms, symptom severity, and depression. Age and social isolation were associated with anxiety. In addition, the symptom severity of non-Hispanic White survivors was lower than that of Hispanic survivors and non-Hispanic survivors of other races. DISCUSSION: These findings highlight the health disparities in symptom burden experienced among cancer survivors when considering their social determinants of health. Assessing these may help clinicians address health disparities in cancer care.

Lesbian Gay Bisexual Transgender and Queer Health-Care Experiences in a Military Population.

ABTRACTThis study aimed to understand the experiences of lesbian, gay, bisexual, transgender, and queer of former military service members. Data for this analysis was collected from the two open-ended survey questions as part of a larger online survey. The analysis was performed using the web-based data analysis application Dedoose. Eighty-eight qualitative responses were used. Analysis of the responses revealed five main themes: (1) identity, (2) negative experiences, (3) impact of experiences, (4) policy, and (5) positive experiences. These findings can influence future military research by focusing on the effects of the Don't Ask Don't Tell policy, negative and positive experiences, and the impact of those experiences.

Social and Cultural Factors, Self-efficacy, and Health in Latino Cancer Caregivers.

BACKGROUND: Latino cancer caregivers are at risk of physical, mental, and emotional health issues. Sociocultural factors such as informational support, Anglo orientation, and spiritual practice may compound or protect against these risks. OBJECTIVE: The purpose of this research project was to examine self-efficacy as a mediator between sociocultural factors and health outcomes in Latino cancer caregivers. METHODS: This is a secondary analysis of baseline caregiver data from an experimental study testing two psychoeducational interventions in Latina individuals with breast cancer and their caregivers. Caregivers (N = 233) completed items assessing self-efficacy, informational support, Anglo orientation, spiritual practice, depression, and global health. Caregiver data were analyzed using hierarchical linear regression and mediation analysis. RESULTS: Spiritual well-being was not significantly associated with health outcomes or self-efficacy. In regression analysis, both informational support ( b = 0.32; 95% confidence interval [CI], 0.20 to 0.45; P < .001) and Anglo orientation ( b = 0.15; 95% CI, 0.11 to 2.48; P < .05) were significant predictors of global health, but informational support ( b = -0.43; 95% CI, -0.55 to -0.30; P < .001) was the only significant predictor of depression. There were indirect relationships through self-efficacy for symptom management for both informational support and Anglo orientation and health outcomes. CONCLUSIONS: Informational support and Anglo orientation were significantly related to health outcomes directly and indirectly through self-efficacy in Latino cancer caregivers. IMPLICATIONS FOR PRACTICE: Informational support through the health system and community, when provided with attention to culture and Spanish language translation, can increase Latino cancer caregivers' self-efficacy to care for themselves and improve health outcomes.

Use of scheduled and unscheduled health services by cancer survivors and their caregivers.

PURPOSE: The purpose was to determine predictors of scheduled and unscheduled health services use by cancer survivors undergoing treatment and their informal caregivers. METHODS: English- or Spanish-speaking adult cancer survivors undergoing chemotherapy or targeted therapy for a solid tumor cancer identified a caregiver (N = 380 dyads). Health services use over 2 months was self-reported by survivors and caregivers. Logistic regression models were used to relate the likelihood of service use (hospitalizations, emergency department [ED] or urgent care visits, primary care, specialty care) to social determinants of health (age, sex, ethnicity, level of education, availability of health insurance), and number of comorbid conditions. Co-habitation with the other member of the dyad and other member's health services use were considered as additional explanatory variables. RESULTS: Number of comorbid conditions was predictive of the likelihood of scheduled health services use, both primary care and specialty care among caregivers, and primary care among survivors. Greater probability of specialty care use was associated with a higher level of education among survivors. Younger age and availability of health insurance were associated with greater unscheduled health services use (hospitalizations among survivors and urgent care or ED visits among caregivers). Unscheduled health services use of one member of the dyad was predictive of use by the other. CONCLUSIONS: These findings inform efforts to optimize health care use by encouraging greater use of scheduled and less use of unscheduled health services. These educational efforts need to be directed especially at younger survivors and caregivers.

The Online Cancer Nutrition Misinformation: A framework of behavior change based on exposure to cancer nutrition misinformation.

BACKGROUND: Patients with cancer and caregivers increasingly use the internet to find health and lifestyle information, yet online recipes, diet, and nutrition content are unregulated and may be confusing or even misleading. We describe cancer-related nutrition and meal planning information from Pinterest. METHODS: In June 2020, we searched Pinterest using "cancer recipe" and "recipe for cancer" at 3 times daily for 2 weeks. Duplicates were removed for a final sample of n = 103 pins. Each pin was coded for 58 variables including descriptives, cancer claims (eg, treatment, prevention, and cure), and nutrition claims (eg, "turmeric cures cancer"). We summarized each variable to describe the content of cancer nutrition claims on Pinterest and examined associations between claim types and contextual factors, including the use of academic citations, disclaimers, and personal anecdotes. RESULTS: Pinners had on average 116,767 followers (range, 0-1.5 million). Almost half of content sites were for profit (48.5%) and 34% were selling a product. Health claims were common, with content that purported to prevent (41.8%), treat (27.2%), or cure (10.7%) cancer. Vague phrases such as "anti-cancer," "cancer-fighting," or "cancer-busting" were also used. The inclusion of validity indicators including academic citations, disclaimers, and personal anecdotes varied significantly by the types of claims made. Together, these analyses informed the development of a conceptual framework of cancer-related nutrition misinformation. CONCLUSIONS: There are clear financial incentives for the promotion of cancer nutrition information online. More research is needed to understand how exposure to nutrition information can influence patient/caregiver behavior and downstream clinical and psychosocial outcomes.

Family caregivers of those with cancer: quality of life outcomes from a sequential multiple assignment randomized trial.

PURPOSE: To conduct a secondary analysis focused on health-related quality of life (HRQOL) among caregivers engaged in a 12-week complementary therapy sequential multiple assignment randomized trial (SMART) of reflexology and/or meditative practices (MP), to manage cancer patients' symptoms. METHODS: In this SMART, patient-caregiver dyads were initially randomized to 4 weeks of caregiver-delivered reflexology for the patient (N = 150), MP with the patient (N = 150), or control (N = 47). After 4 weeks, dyads with patients not improving on fatigue (non-responders, n = 69 to reflexology and n = 57 to MP) were re-randomized to continue the same therapy or add the other therapy for an additional 4 weeks. Week-12 caregiver HRQOL was measured using the Patient Reported Outcomes Measurement Information System (PROMIS) Profile-29 and the Caregiver Reaction Assessment Tool (CRAT) for caregiver burden; scores were analyzed using general linear models. RESULTS: In the comparison of 4 adaptive intervention sequences: reflexology for 8 weeks, reflexology for 4 weeks followed by MP for 4 weeks if no response to reflexology, MP for 8 weeks, and MP for 4 weeks followed by reflexology for 4 weeks if no response to MP, there were no differences in PROMIS-29 scores. However, CRAT domains of impact on schedule, family support, and finances worsened when adding reflexology after the first 4 weeks of MP. The CRAT domain of health worsened by adding either intervention compared to continuing the same one. CONCLUSIONS: Clinicians should be aware that caregiver engagement in more than one complementary therapy may increase caregiver burden in some domains but not affect other HRQOL domains. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02759146.

Optimizing a Behavioral Sleep Intervention for Gynecologic Cancer Survivors: Study Design and Protocol.

Sleep difficulties, particularly symptoms of insomnia and circadian disruption, are among the primary complaints of gynecologic cancer survivors before, during, and after treatment. Moreover, difficulty sleeping has been linked to poorer health-related quality of life and elevated symptom burden in this population. Although leading behavioral sleep interventions have demonstrated efficacy among cancer survivors, up to 50% of survivors are non-adherent to these treatments, likely because these interventions require labor-intensive behavior and lifestyle changes. Therefore, there is a need for more effective and acceptable approaches to diminish sleep disturbance among cancer survivors. This manuscript describes the methodology of a two-part study guided by the Multiphase Optimization Strategy (MOST) framework to identify a streamlined behavioral sleep intervention for gynecologic cancer survivors. Three candidate intervention components previously shown to decrease sleep disturbance will be evaluated, including sleep restriction, stimulus control, and systematic bright light exposure. Participants will be adult women with a history of non-metastatic gynecologic cancer who have completed primary treatment and who report current poor sleep quality. Fifteen participants will be recruited for Part 1 of the study, which will utilize qualitative methods to identify barriers to and facilitators of intervention adherence. Results will inform changes to the delivery of the candidate intervention components to promote adherence in Part 2, where 80 participants will be recruited and randomized to one of eight conditions reflecting every possible combination of the three candidate intervention components in a full factorial design. Participants will complete assessments at baseline, post-intervention, and 3-months post-intervention. Part 2 results will identify the combination of candidate intervention components that yields the most efficacious yet efficient 6-week intervention for diminishing sleep disturbance. This is the first known study to apply the MOST framework to optimize a behavioral sleep intervention and will yield a resource-efficient treatment to diminish sleep disturbance, improve health-related quality of life, and decrease symptom burden among gynecologic cancer survivors. ClinicalTrials.gov Identifier: NCT05044975.

Exploring the relationship between loneliness, spirituality, and health-related quality of life in Hispanic cancer caregivers.

Caregivers of cancer patients find it challenging to perform their roles and to meet the demands of caregiving. Spirituality has been investigated as a potential coping strategy employed by caregivers, yet spirituality and related practices vary among cultural groups. In this study, we investigated the relationship between spirituality and health-related quality of life (HRQOL) and evaluated mediation effects of loneliness on this relationship. The sample was 234 lower socioeconomic status (SES) Hispanic caregivers of breast cancer survivors using existing data from the Support for Latinas with Breast Cancer and Their Intimate and Family Partners study, funded by the American Cancer Society (Badger, PI). A cross-sectional analysis was conducted at baseline, using self-reported spirituality, loneliness, and HRQOL data collected from 2012 to 2017. The exposures and outcomes were assessed using the Spiritual Well-Being Scale, the Social Isolation-Short Form 8a PROMIS Item Bank v2.0 scale, and the Global Health Scale PROMIS v.1.0/1.1 scale. Descriptive and mediation analyses using the Preacher and Hayes' approach were conducted to estimate the direct effect of spirituality on HRQOL and the indirect effect of spirituality through mediation of loneliness in relation to HRQOL. A positive association between spirituality and HRQOL was found, whereas loneliness was inversely associated with HRQOL (b = - .18, SE = .03, p < .0001). Age did not function as a moderator of the spirituality-HRQOL association in any of the models tested, but in the model testing mediation, loneliness was shown to mediate the association between spirituality and HRQOL (b = - .17, p < .0001). These results suggest that spirituality may be beneficial to HRQOL in caregivers of Hispanic breast cancer survivors, due in part to reduced loneliness among more spiritual caregivers.

Reflexology and meditative practices for symptom management among people with cancer: Results from a sequential multiple assignment randomized trial.

Optimal sequencing of complementary therapies can help improve symptom management through nonpharmacological approaches. A 12-week sequential multiple assignment randomized trial comparing home-based reflexology and meditative practices on severity of fatigue and other symptoms was conducted among patients with cancer and their informal caregivers. Dyads were initially randomized to reflexology (N = 150), meditative practices (N = 150), or control (N = 47). If patient's fatigue did not improve (nonresponse) after 4 weeks of reflexology or meditative practices, the dyad was rerandomized to either add the other therapy or continue with the original therapy for weeks 5-8. Four decision rules (DRs) were compared: (1) Initiating reflexology, and if nonresponse on fatigue after 4 weeks, continue with reflexology for another 4 weeks, thus providing a higher dose; (2) Initiating reflexology, and if nonresponse on fatigue after 4 weeks, add meditative practices for the next 4 weeks; (3) Initiating meditative practices, and if nonresponse on fatigue after 4 weeks, continue meditative practices for another 4 weeks, thus providing a higher dose; and (4) Initiating meditative practices, and if nonresponse on fatigue after 4 weeks, add reflexology for the next 4 weeks. Symptoms were evaluated weekly using the M.D. Anderson Symptom Inventory (MDASI). Clinically, nurses can recommend either therapy since no differences were found among the 4 DRs, with the exception of lower severity for summed MDASI symptoms at week 8 for the use of reflexology only (DR-1) versus DR-2 (sequencing reflexology to meditative practices). Adding the other therapy for nonresponders after 4 weeks may not be warranted.

Implementation of Un Abrazo Para La FamiliaTM in southern Arizona with extension to survivors and assessment of effects on distress.

Introduction: Un Abrazo Para La FamiliaTM [Embracing the Family] (Abrazo) is a 3-hr psychoeducational intervention designed for low-income informal caregivers who are cosurvivors of cancer. A rehabilitation-informed preventive intervention, Abrazo reflects the importance of family, culture, and socioeconomic background. A pilot study was conducted to inform a larger geographic implementation of Abrazo. The aims were to determine if previous outcomes of increased cancer knowledge and self-efficacy could be replicated and to investigate intervention effects on distress. Method: A pretest-posttest design was used to assess changes in cancer knowledge, self-efficacy, and distress for Abrazo participants. Distress was measured with the American Medical Association's Caregiver Assessment (Epstein-Lubow et al., 2010) and the National Comprehensive Cancer Network Distress Thermometer (Donovan et al., 2014; Forsythe et al., 2013; Fulcher & Gosselin-Acomb, 2007). The Patient Health Questionnaire-4 (PHQ-4) (Kroenke et al., 2009) measured symptoms of anxiety and depression. Results: Both survivors (n = 37) and cosurvivors (n = 103) increased in cancer knowledge and self-efficacy after completing Abrazo. Mean levels of distress and symptoms decreased for cosurvivors, but not for survivors. At study entry, 19% of cosurvivors and 12% of survivors scored ≥6/12 on the PHQ-4, the standard cutoff for clinically significant symptoms. Only 13% of cosurvivors, but 30% of survivors exceeded this threshold at three-month follow-up. Elevated symptoms persisted in 12% of survivors from baseline to follow-up; in 18% of survivors, symptoms rose between baseline and follow-up. Discussion: Increased cancer knowledge and self-efficacy in participants replicates evidence of Abrazo's effectiveness. The result of decreased distress in cosurvivors extends our understanding of Abrazo's effectiveness with this population. The increase in distress in cancer survivors warrants further attention to their intervention needs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Self-efficacy in caregivers of adults diagnosed with cancer: An integrative review.

PURPOSE: Cancer caregivers experience health challenges related to their caregiving role, and self-efficacy can contribute to health outcomes through behavioral, environmental, and personal factors. The purpose of this integrative review was to examine self-efficacy in caregivers of adults diagnosed with cancer, including its association with health factors. METHOD: A systematic search of PubMed, CINAHL, and PsychInfo yielded 560 articles. Following duplicate removal, 232 articles were screened for inclusion criteria with 71 articles remaining for final review. RESULTS: Studies were generally quantitative (n = 67), with predominantly female (n = 55), White (n = 36) caregivers, between the ages of 45-60 (n = 48). Self-efficacy was significantly associated with quality of life, caregiver function, social support, hope, depression, anxiety, and burden as a predictor, mediator, and outcome. Physical health and social determinants of health (social support and financial well-being) were addressed among fewer studies than mental and emotional health outcomes. CONCLUSIONS: Addressing self-efficacy in diverse populations and within physical, mental, and social health contexts will enhance understanding of how self-efficacy impacts caregivers of adults diagnosed with cancer. Nurses and other health care professionals can then effectively address supportive needs of caregivers in the personal, behavioral, and environmental domains.