Racial discrimination, knowledge, and health outcomes: The mediating role of hepatitis B-related stigma among patients with chronic hepatitis B.

It is well described in current literature that Hepatitis B virus (HBV) affects Asian Americans more than any other racial group in the United States and that there is a stigma attached to this condition. The effects of stigma can be lasting, penetrating physiologically and psychologically, yet few studies have focused on the consequences of this phenomenon. The purpose of this study was to examine the mediating role of stigma in the effect of racial discrimination and knowledge (of HBV sequelae) on health status of Korean Americans with chronic hepatitis B (CHB). Three hundred sixty-five CHB patients were recruited and enrolled from two clinics in Philadelphia and Los Angeles. Depressive symptoms were measured using the Patient Health Question-9 (PHQ-9), physical health via self-rated health survey and stigma via hepatitis B quality of life (HBQOL)-stigma survey. Perceived racial discrimination and knowledge of CHB sequelae were independent variables. The cohort had an average age of 60.1 years (range 19-84, SD 10.7), 56% were male and 94% were born in South Korea. Mediational analysis found that stigma was a significant mediator between both racial discrimination (indirect effect = .037, Bootstrap 95% CI = [.010-.064]) and sequelae knowledge (indirect effect = .097, Bootstrap 95% CI = [.018-.176]) and depressive symptoms. Stigma also had a direct effect on depressive symptoms (ß = .136, p < .01) and self-rated health (ß = .018, p < .05). In addition, age, gender, education and employment were related to health outcomes. The findings of this study indicate that HBV-related stigma is an important mediator of mental health outcomes in this population. Future studies should identify other psychosocial factors to develop effective intervention programs to reduce stigma and improve quality of life among CHB patients.

Patient and Health Care Professional Perspectives on Addressing Obesity in ESKD.

RATIONALE & OBJECTIVE: Obesity is common among patients with end-stage kidney disease (ESKD) and is a pervasive barrier to kidney transplantation. Patient perspectives about barriers to weight loss and patient and health care professionals' viewpoints about optimal obesity management in ESKD are needed. STUDY DESIGN: Qualitative study using a descriptive phenomenological approach to understand ESKD patients' lived experiences with obesity and weight loss and patients' and health professionals' perceptions about optimal obesity care for ESKD patients. SETTING & PARTICIPANTS: Between October 2020 and December 2021, we conducted 90-minute semistructured interviews with 40 ESKD patients with obesity (body mass index [BMI] ≥30kg/m2) and 60-minute interviews with 20 ESKD health care professionals. ANALYTICAL APPROACH: Deductive and inductive thematic analysis of interviews. RESULTS: Among patients with ESKD, the median age was 55 (IQR, 46-63) years, median BMI was 39.5 (IQR, 35.3-41.6) kg/m2, and median dialysis vintage was 5 (IQR, 3-8) years; 58% were female, and 46% were non-Hispanic White. Among health care professionals, 50% were renal dietitians, 20% were nephrologists, and the remainder were transplant professionals (surgeons, nephrologists, and dietitians). ESKD patients described unique weight loss challenges, including (1) conflicting tenets of "kidney-friendly" versus popular diets, (2) fatigue due to dialysis that affects dietary choices, and (3) perceived pressure and unrealistic expectations from health professionals to lose weight for kidney transplantation. Professionals and patients described a lack of transparent and honest communication about obesity and unclear roles and responsibilities for obesity counseling. LIMITATIONS: Lack of caregiver perspectives and potential lack of transferability to overall dialysis population given overrepresentation of patients with severe obesity and previous weight loss surgery. CONCLUSIONS: Obesity interventions for ESKD patients should be tailored to meet the unique challenges reported by patients with ESKD. Clarifying ESKD health professionals' roles and responsibilities for obesity care would help to ensure that patients have consistent and effective support to manage obesity. PLAIN-LANGUAGE SUMMARY: Adults with coexisting obesity and end-stage kidney disease (ESKD) are often required to lose weight for kidney transplantation. Yet there is little knowledge about barriers to healthy weight loss in this population. In this study, we conducted interviews with 40 ESKD patients with coexisting obesity and 20 ESKD health care professionals to learn about opportunities to improve obesity-related health care in ESKD. Patients reported that fatigue and dialysis affected dietary choices, and fluid and food restrictions hampered weight loss. Professionals described a lack of training, comfort, and time to address obesity. Patients and professionals reported a lack of open communication about obesity management. Improving obesity-related education and clinical communication should be prioritized to improve care for patients with ESKD and obesity.

"Keep Your Chin Up, and Keep Eating": Perceptions of Barriers and Facilitators to Healthful Dietary Behaviors Among Individuals With Gastrointestinal Cancer and Caregivers.

BACKGROUND: This study explored perceptions of barriers and facilitators to healthful dietary behaviors among patients with gastrointestinal (GI) cancer and their caregivers, including caregiver preparedness, patient and caregiver self-efficacy for symptom management, and other environmental, social, and familial factors that may serve as barriers and facilitators to healthful eating. METHODS: Using a concurrent mixed methods cross-sectional study design, individuals with GI cancer receiving outpatient chemotherapy and their caregivers completed surveys, dietary assessments, and interviews. Caregiving preparedness, self-efficacy for symptom management, and dietary intake were assessed using validated instruments. Dietary quality was measured using the Healthy Eating Index (HEI)-2020. In-depth interviews explored barriers and facilitators to healthful eating, symptom management, and caregiver preparedness. RESULTS: Twenty-seven patient-caregiver dyads completed study activities (N = 54). Dietary quality scores ranged from 26 to 81, with a median score of 43 for patients and 42 for caregivers. Thematic analysis identified three barriers to healthful eating: caregiver self-efficacy and preparedness, caregiver needs are neglected, and nutrition as a source of conflict. Overall self-efficacy scores (Mdn, [IQR]) were 69.1 (45.0) for caregivers and 75.6 (34.1) for patients. Caregiver preparedness score was 2.99 ± .87; problem areas were identified, including addressing emotional needs, fluctuating eating habits, advanced disease progression and making care activities pleasant. Despite the challenges, three main facilitators were identified: increased awareness and value of nutrition, influential others, and positive coping. CONCLUSION: Our findings suggest the importance of developing interventions that increase nutrition-related preparedness among caregivers and self-efficacy for managing treatment side effects. Future research should continue to explore the relationship between positive coping and dietary behaviors. While engaging patients and caregivers together during dietary interventions is a promising modality, strategies for maintaining personal nutrition-related goals when facing contrasting priorities between patients and caregivers should be addressed.

Public Librarian Perceptions of Assisting Immigrant Patrons: Results from a Multi-State Survey.

Public libraries in the United States (U.S.) are important sources of health information. Immigrants comprise a large portion of the U.S. population, and research suggests that public libraries help immigrants adjust to life in a new country. Public libraries help immigrants access information directly related to health and provide programs that have indirect impacts on health outcomes, including learning a new language and forging social ties. The purpose of this paper was to examine perspectives from librarians related to interactions with immigrant patrons and how their library supports them in this role. Public librarians (n = 205) from two selected U.S. states completed an online survey focusing on how comfortable they were in helping immigrants with inquiries related to health and the role of the public library in supporting librarians in this endeavor. Respondents generally reported high levels of comfort interacting with immigrants, although there was limited interaction on potentially sensitive topics (i.e., immigration, health). Library staff perceived that libraries overall were not effective in meeting the needs of immigrant populations and that librarians were infrequently offered professional training related to cultural competency and diversity. The findings echo previous studies that demonstrate the need for professional development to ensure that librarians are aware of library resources available to assist immigrant patrons. Findings from this study suggest opportunities for public health professionals and public librarians to collaborate to ensure the provision of reliable resources, health information, and referrals to community-based services.

How Public Libraries Help Immigrants Adjust to Life in a New Country: A Review of the Literature.

Public library programs and services offer opportunities to help immigrants navigate daily life in unfamiliar surroundings and a new language. For example, language classes address the social determinants of health as they encourage social participation and community ties and help develop friendships. The purpose of this research was to conduct a narrative literature review to understand how immigrants use public libraries and how public library services influence the social determinants of health for immigrant populations. Keyword searches were conducted on five databases to identify research papers that met the inclusion criteria: empirical studies published in English between 2000 and 2020 related to immigrants' use of public libraries. Thirty-one articles were included in the analysis. Thematic coding identified cross-cutting themes within the sample using the framework of the social-ecological model. Immigrants commonly use public libraries for programs (e.g., language learning), collections (e.g., borrowing books), and services (e.g., asking librarians questions). Immigrant patrons often reported satisfaction with library programs, services, and collections in the language of the host country. A frequent criticism was the relevance and accessibility of collections in their heritage language. In addition, library staff demographics often did not reflect those of immigrant patrons. Health-enhancing benefits associated with library use included increased confidence and self-esteem, cultural integration and preservation, trust and relationships (e.g., making friends), community awareness and engagement, and political integration. Future research and practice areas include collaboration between public health and library professionals to develop library programming that maximizes health and well-being among immigrants.

'It's common sense that an individual must eat': Advocating for food justice with people with psychiatric disabilities through photovoice.

BACKGROUND: People with SMI have often been excluded in advocacy efforts focused on physical health, health care and health and social policy. OBJECTIVE: Following a Photovoice project focused on barriers to healthy eating and physical activity in urban neighbourhoods, participant-researchers were invited to present their insights in community advocacy settings. The purpose of this study was to explore the feasibility and participant-researchers' experience of these community advocacy activities. DESIGN: We held four focus groups with the eight participant-researchers after each community advocacy activity to explore their experience with public speaking, presenting their experiences and advocating. SETTING AND PARTICIPANTS: People with serious mental illness who were overweight/obese living in supportive housing. ANALYSIS APPROACH: Qualitative analysis of the focus group transcripts, using a modified grounded theory approach followed by structured coding focused on empowerment, participation and non-discrimination. RESULTS: Participant-researchers gave three oral presentations of their photographs at a variety of community-based programmes and settings and participated in a rally to advocate for SNAP benefits. Two themes emerged from analysis: (a) Empowerment (the level of choice, influence and control that users of mental health services can exercise over events in their lives) and (b) Barriers to Empowerment (obstacles to participation and well-being). CONCLUSIONS: This evaluation strengthens the evidence that it is feasible for participant-researchers in Photovoice projects to engage in robust advocacy activities, such as presentations and discussions with local policymakers. During focus groups, participant-researchers demonstrated realistic optimism towards their roles as change agents and influencers in spite of acknowledged systemic barriers.

Approaches to Obesity Management in Dialysis Settings: Renal Dietitian Perspectives.

OBJECTIVES: Over 40% of individuals in the United States with end-stage kidney disease have obesity. Little is known about renal dietitian perspectives on obesity management in the setting of dialysis dependence. DESIGN AND METHODS: An online 21-item survey was distributed to 118 renal dietitians via individual outreach and a professional organization e-mail listserv. Four themes were explored: the burden of obesity among dialysis patients, concepts of healthy weight loss, weight loss approaches, and challenges of obesity management in dialysis settings. Respondents were asked to rank approaches and biomarkers for obesity management from 0 (least important or not used) to 100 (most important). Free text fields were provided in each category for additional comments. RESULTS: Thirty-one renal dietitians responded to the survey (26% response rate). The majority of respondents (90%) indicated that access to kidney transplantation was the main reason that dialysis patients with obesity desired weight loss. Calorie restriction was rated as the most common weight loss approach, and dry weight as the most important weight loss biomarker. Nearly 40% of respondents do not alter their nutritional approach when dialysis patients with obesity are losing weight, and 42% of respondents do not monitor changes in waist circumference. Exercise, diet counseling, and stress management were variably prioritized as weight loss management strategies. Barriers to obesity management in dialysis settings included lack of time, lack of training in weight loss counseling, and gaps in current renal nutritional guidelines. CONCLUSION: Despite the high prevalence of obesity among individuals with end-stage kidney disease, the results of this survey suggest that current approaches to obesity management in dialysis settings are highly variable. Many renal dietitians lack time to counsel patients on healthy weight loss strategies. Nutritional guidelines are also needed to support people with dialysis dependence and obesity who desire or require weight loss.

HPV vaccine, Twitter, and gay, bisexual and other men who have sex with men.

This study aimed to quantify human papillomavirus (HPV) vaccine Twitter messaging addressing gay, bisexual and other men who have sex with men (GB+MSM) and describes messaging by vaccine sentiment (attitudes towards vaccine) and characteristics (topic of messaging). Between August 2014 and July 2015, we collected 193 379 HPV-related tweets and classified them by vaccine sentiment and characteristics. We analysed a subsample of tweets containing the terms 'gay', 'bisexual' and 'MSM' (N = 2306), and analysed distributions of sentiment and characteristics using chi-square. HPV-related tweets containing GB+MSM terms occupied 1% of our sample. The subsample had a largely positive vaccine sentiment. However, a proportion of 'gay' and 'bisexual' tweets did not mention the vaccine, and a proportion of 'gay' and 'MSM' tweets had a negative sentiment. Topics varied by GB+MSM term-HPV risk messaging was prevalent in 'bisexual' (25%) tweets, and HPV transmission through sex/promiscuity messaging was prevalent in 'gay' (18%) tweets. Prevention/protection messaging was prevalent only in 'MSM' tweets (49%). Although HPV vaccine sentiment was positive in GB+MSM messaging, we identified deficits in the volume of GB+MSM messaging, a lack of focus on vaccination, and a proportion of negative tweets. While HPV vaccine promotion has historically focused on heterosexual HPV transmission, there are opportunities to shape vaccine uptake in GB+MSM through public health agenda setting using social media messaging that increases knowledge and minimizes HPV vaccine stigma. Social media-based HPV vaccine promotion should also address the identities of those at risk to bolster vaccine uptake and reduce the risk of HPV-attributable cancers.

Mental illness and bipolar disorder on Twitter: implications for stigma and social support.

Background: Mental illness (MI), and particularly, bipolar disorder (BD), are highly stigmatized. However, it is unknown if this stigma is also represented on social media.Aims: Characterize Twitter-based stigma and social support messaging ("tweets") about mental health/illness (MH)/MI and BD and determine which tweets garnered retweets.Methods: We collected tweets about MH/MI and BD during a three-month period and analyzed tweets from dates with the most tweets ("spikes"), an indicator of topic interest. A sample was manually content analyzed, and the remainder were classified using machine learning (logistic regression) by topic, stigma, and social support messaging. We compared stigma and support toward MH/MI versus BD and used logistic regression to quantify tweet features associated with retweets, to assess tweet reach.Results: Of the 1,270,902 tweets analyzed, 94.7% discussed MH/MI and 5.3% discussed BD. Spikes coincided with a celebrity's death and a MH awareness campaign. Although the sample contained more support than stigma messaging, BD tweets contained more stigma and less support than MH/MI tweets. However, stigma messaging was infrequently retweeted, and users often retweeted personal MH experiences.Conclusions: These findings demonstrate opportunities for social media advocacy to reduce stigma and increase displays of social support towards people living with BD.

A "Swiss paradox" in the United States? Level of spatial aggregation changes the association between income inequality and morbidity for older Americans.

Although a preponderance of research indicates that increased income inequality negatively impacts population health, several international studies found that a greater income inequality was associated with better population health when measured on a fine geographic level of aggregation. This finding is known as a "Swiss paradox". To date, no studies have examined variability in the associations between income inequality and health outcomes by spatial aggregation level in the US. Therefore, this study examined associations between income inequality (Gini index, GI) and population health by geographic level using a large, nationally representative dataset of older adults. We geographically linked respondents' county data from the 2012 Behavioral Risk Factor Surveillance System to 2012 American Community Survey data. Using generalized linear models, we estimated the association between GI decile on the state and county levels and five population health outcomes (diabetes, obesity, smoking, sedentary lifestyle and self-rated health), accounting for confounders and complex sampling. Although state-level GI was not significantly associated with obesity rates (b = - 0.245, 95% CI - 0.497, 0.008), there was a significant, negative association between county-level GI and obesity rates (b = - 0.416, 95% CI - 0.629, - 0.202). State-level GI also associated with an increased diabetes rate (b = 0.304, 95% CI 0.063, 0.546), but the association was not significant for county-level GI and diabetes rate (b = - 0.101, 95% CI - 0.305, 0.104). Associations between both county-level GI and state-level GI and current smoking status were also not significant. These findings show the associations between income inequality and health vary by spatial aggregation level and challenge the preponderance of evidence suggesting that income inequality is consistently associated with worse health. Further research is needed to understand the nuances behind these observed associations to design informed policies and programs designed to reduce socioeconomic health inequities among older adults.

"Then you raise them with Shirchoy or cookies": Understanding influences on delayed dietary diversity among children in Tajikistan.

Dietary diversity is a key component of infant and young child feeding (IYCF) as well as adult health. In Tajikistan, a predominantly rural, former Soviet country in Central Asia, we conducted formative research to identify barriers to dietary diversity and strategies for nutrition behaviour change. In Spring, 2016, mixed-methods data collection took place across 13 villages in all five regions, collecting collaborative mapping; structured assessments of stores and markets; home visits for dietary recalls; food storage, preparation, and meal observations; focus groups with pregnant women, mothers of young children, fathers, and mothers-in-law; and in-depth expert interviews with local nutrition and health influentials. Overall, maternal diet was adequate in terms of diversity (only 13% reported <5/10 food groups in the past 24 hr); however, only 42% of index children 6-24 months met WHO guidelines for diversity, and only 34% met minimum acceptable diet criteria. In addition to issues of poverty and food scarcity, qualitative data reveal many behavioural barriers to timely introduction of diverse complementary foods. Women's strategies focused on gradual introduction of household diet components, without regard for diversity or nutrition. Foods such as meat were seen as costly and thus inappropriate for IYCF, and food taboos (i.e., fresh vegetables) further reduced diversity. Infant food preparation methods such as grinding were seen as impractical, and many foods were withheld until children develop teeth. Possible nutrition education strategies include point-of-purchase campaigns to improve availability and appeal of IYCF-friendly foods, as well as influencing other key household members through mosques, schools, and health care providers.

A Prostate Cancer Composite Score to Identify High Burden Neighborhoods.

This study presents a novel geo-based metric to identify neighborhoods with high burdens of prostate cancer, and compares this metric to other methods to prioritize neighborhoods for prostate cancer interventions. We geocoded prostate cancer patient data (n = 10,750) from the Pennsylvania cancer registry from 2005 to 2014 by Philadelphia census tract (CT) to create standardized incidence ratios (SIRs), mortality ratios (SMRs), and mean prostate cancer aggressiveness. We created a prostate cancer composite (PCa composite) variable to describe CTs by mean-centering and standard deviation-scaling the SMR, SIR, and mean aggressiveness variables and summing them. We mapped CTs with the 25 highest PCa composite scores and compared these neighborhoods to CTs with the 25 highest percent African American residents and the 25 lowest median household incomes. The mean PCa composite score among the 25 highest CTs was 4.65. Only seven CTs in Philadelphia had both one of the highest PCa composite scores and the highest percent African American residents. Only five CTs had both the highest PCa composites and the lowest median incomes. Mean PCa composite scores among CTs with the highest percent African American residents and lowest median incomes were 2.08 and 1.19, respectively. The PCa composite score is an accurate metric for prioritizing neighborhoods based on burden. If neighborhoods were prioritized based on percent African American or median income, priority neighborhoods would have been very different and not based on PCa burden. These methods can be utilized by public health decision-makers when tasked to prioritize and select neighborhoods for cancer interventions.

What Drives Health Professionals to Tweet About #HPVvaccine? Identifying Strategies for Effective Communication.

INTRODUCTION: We conducted this study to quantify how health professionals use Twitter to communicate about the human papillomavirus (HPV) vaccine. METHODS: We collected 193,379 tweets from August 2014 through July 2015 that contained key words related to HPV vaccine. We classified all tweets on the basis of user, audience, sentiment, content, and vaccine characteristic to examine 3 groups of tweets: 1) those sent by health professionals, 2) those intended for parents, and 3) those sent by health professionals and intended for parents. For each group, we identified the 7-day period in our sample with the most number of tweets (spikes) to report content. RESULTS: Of the 193,379 tweets, 20,451 tweets were from health professionals; 16,867 tweets were intended for parents; and 1,233 tweets overlapped both groups. The content of each spike varied per group. The largest spike in tweets from health professionals (n = 851) focused on communicating recently published scientific evidence. Most tweets were positive and were about resources and boys. The largest spike in tweets intended for parents (n = 1,043) centered on a national awareness day and were about resources, personal experiences, boys, and girls. The largest spike in tweets from health professionals to parents (n = 89) was in January and centered on an event hosted on Twitter that focused on cervical cancer awareness month. CONCLUSION: Understanding drivers of tweet spikes may help shape future communication and outreach. As more parents use social media to obtain health information, health professionals and organizations can leverage awareness events and personalize messages to maximize potential reach and parent engagement.

Social Norm, Family Communication, and HBV Screening among Asian Americans.

Individuals' behaviors are influenced by those of others in their social environment (i.e., descriptive norms), as well as by how individuals perceive they should behave in that environment (e.g., injunctive norms). Although social norms are thought to play an important role in hepatitis B virus (HBV) screening, limited theoretical or empirical guidance exists on how the underlying process works. In addition, norms are social phenomena that are spread through family discussion about the importance of getting HBV screening. Using the theory of normative social behavior (TNSB), this study examined the roles of injunctive norms (IN), descriptive norms (DN), and family discussion in HBV screening behavior among Asian Americans. Data from a survey of Asian Americans in the Baltimore Washington metropolitan area (N = 877) were used to test underlying theoretical propositions. DN and family discussion emerged as key factors in HBV screening behavior among all Asian Americans. IN were associated with HBV screening among Chinese and Korean Americans, but not for Vietnamese Americans. Family discussion moderated the influence of DN on behavior among Chinese and Vietnamese Americans. However, the main effect of DN on screening behavior was not modified by IN (no interactions between DN and IN). The results indicate that family discussion and social norms are integral in enabling Asian Americans to undergo HBV screening and warrant sensitivity in the design and implementation of a liver cancer prevention program in this high-risk group of Asian Americans.

Prevalence and correlates of local health department activities to address mental health in the United States.

Mental health has been recognized as a public health priority for nearly a century. Little is known, however, about what local health departments (LHDs) do to address the mental health needs of the populations they serve. Using data from the 2013 National Profile of Local Health Departments - a nationally representative survey of LHDs in the United States (N=505) - we characterized LHDs' engagement in eight mental health activities, factors associated with engagement, and estimated the proportion of the U.S. population residing in jurisdictions where these activities were performed. We used Handler's framework of the measurement of public health systems to select variables and examined associations between LHD characteristics and engagement in mental health activities using bivariate analyses and multilevel, multivariate logistic regression. Assessing gaps in access to mental healthcare services (39.3%) and implementing strategies to improve access to mental healthcare services (32.8%) were the most common mental health activities performed. LHDs that provided mental healthcare services were significantly more likely to perform population-based mental illness prevention activities (adjusted odds ratio: 7.1; 95% CI: 5.1, 10.0) and engage in policy/advocacy activities to address mental health (AOR: 3.9; 95% CI: 2.7, 5.6). Our study suggests that many LHDs are engaged in activities to address mental health, ranging from healthcare services to population-based interventions, and that LHDs that provide healthcare services are more likely than others to perform mental health activities. These findings have implications as LHDs reconsider their roles in the era of the Patient Protection and Affordable Care Act and LHD accreditation.

Applying Multiple Data Collection Tools to Quantify Human Papillomavirus Vaccine Communication on Twitter.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. There are several vaccines that protect against strains of HPV most associated with cervical and other cancers. Thus, HPV vaccination has become an important component of adolescent preventive health care. As media evolves, more information about HPV vaccination is shifting to social media platforms such as Twitter. Health information consumed on social media may be especially influential for segments of society such as younger populations, as well as ethnic and racial minorities. OBJECTIVE: The objectives of our study were to quantify HPV vaccine communication on Twitter, and to develop a novel methodology to improve the collection and analysis of Twitter data. METHODS: We collected Twitter data using 10 keywords related to HPV vaccination from August 1, 2014 to July 31, 2015. Prospective data collection used the Twitter Search API and retrospective data collection used Twitter Firehose. Using a codebook to characterize tweet sentiment and content, we coded a subsample of tweets by hand to develop classification models to code the entire sample using machine learning procedures. We also documented the words in the 140-character tweet text most associated with each keyword. We used chi-square tests, analysis of variance, and nonparametric equality of medians to test for significant differences in tweet characteristic by sentiment. RESULTS: A total of 193,379 English-language tweets were collected, classified, and analyzed. Associated words varied with each keyword, with more positive and preventive words associated with "HPV vaccine" and more negative words associated with name-brand vaccines. Positive sentiment was the largest type of sentiment in the sample, with 75,393 positive tweets (38.99% of the sample), followed by negative sentiment with 48,940 tweets (25.31% of the sample). Positive and neutral tweets constituted the largest percentage of tweets mentioning prevention or protection (20,425/75,393, 27.09% and 6477/25,110, 25.79%, respectively), compared with only 11.5% of negative tweets (5647/48,940; P<.001). Nearly one-half (22,726/48,940, 46.44%) of negative tweets mentioned side effects, compared with only 17.14% (12,921/75,393) of positive tweets and 15.08% of neutral tweets (3787/25,110; P<.001). CONCLUSIONS: Examining social media to detect health trends, as well as to communicate important health information, is a growing area of research in public health. Understanding the content and implications of conversations that form around HPV vaccination on social media can aid health organizations and health-focused Twitter users in creating a meaningful exchange of ideas and in having a significant impact on vaccine uptake. This area of research is inherently interdisciplinary, and this study supports this movement by applying public health, health communication, and data science approaches to extend methodologies across fields.

Identity reconstruction among older cancer survivors: Age and meaning in the context of a life-altering illness.

This article evaluates how older cancer patients describe cancer survivorship and incorporate the cancer experience into long-term evaluations of health. From a series of 53 qualitative interviews with adults with histories of breast and prostate cancers and non-Hodgkin's lymphoma, we analyzed age-related discussions among those 65 and older (n = 21). Emergent themes revealed the: (1) historical conceptualization of cancer, (2) changed perspective following diagnosis, (3) cancer in the context of a long biography, (4) cancer in the context of the aging body and decline, and (5) meaning of time remaining and quality of life. One important suggestion from our work, relevant to all clinicians regardless of specialty or role, is to incorporate goals for the future into individualized survivor care plans for older survivors.

Capitalizing on the "teachable moment" to promote healthy dietary changes among cancer survivors: the perspectives of health care providers.

PURPOSE: Although cancer is often thought of as a teachable moment, many cancer survivors do not adhere to behavioral recommendations that might improve their health. This study explored health care providers' perspectives on the importance and feasibility of addressing behavior change, specifically healthy diet, with cancer survivors. METHODS: In-depth interviews were conducted with 33 health care providers who care for posttreatment survivors of breast cancer, prostate cancer, and non-Hodgkin's lymphoma. Interviews were analyzed thematically. RESULTS: Health care providers emphasized the strength of evidence linking diet/obesity to recurrence in their assessment of the importance of promoting dietary change among their survivor patients. Cancer specialists (e.g., oncologists, surgeons) generally brought up dietary change with patients if they considered the evidence to be strong. In contrast, primary care providers viewed health promotion as important for all patients and reported treating cancer survivor patients the same as others when it came to making dietary recommendations. There was a lack of consensus among providers on the best timing to bring up behavior change. Providers described specific subgroups of patients who they saw as more motivated to make behavior changes and patient barriers to making dietary changes. CONCLUSIONS: Health care providers can play an important role in promoting healthy diet among cancer survivors. As the evidence base around diet and cancer recurrence/prognosis grows, it is important that this information is communicated to providers. Strategies such as incorporating behavior change messages into survivor care plans may help standardize recommendations to survivors.

The association of area-level social class and tobacco use with adverse breast cancer characteristics among white and black women: evidence from Maryland, 1992-2003.

BACKGROUND: In breast cancer, worse disease characteristics are associated with fewer social resources and black race. However, it is unknown whether social gradients have similar impact across race, and whether behaviors, including tobacco use, may explain a portion of the social gradient. METHODS: We modeled relationships between area-level social class, tobacco spending and tumor characteristics, using 50,062 white and black cases diagnosed from 1992-2003 in Maryland, a racially and economically diverse state on the east coast of the United States. Multi-level models estimated the effect of area-level social class and tobacco consumption on tumor grade, size, and stage at diagnosis. RESULTS: Adjusting for race, age and year of diagnosis, higher social class was associated with lower risk for tumors with histological grade 3 or 4 (O.R. 0.96, 95% C.I. 0.94,0.99), those diagnosed at SEER stage 2 or later (O.R. 0.89, 95% C.I. 0.86, 0.91), and tumor size >2 cm (O.R. 0.87, 95% C.I. 0.84, 0.90). Higher tobacco spending was associated with higher risk for higher grade (O.R. 1.01, 1.00, 1.03) and larger tumors (O.R. 1.03, 95% C.I. 1.01, 1.06), but was not statistically significantly related to later stage (O.R. 1.00, 95% C.I. 0.98, 1.02). Social class was less protective for black women, but tobacco effects were not race-specific. CONCLUSIONS: Results suggest that in one U.S. geographic area, there is a differential protection from social class for black and white women, supporting use of intersectionality theory in breast cancer disparities investigations. Area-level tobacco consumption may capture cases' direct use and second hand smoke exposure, but also may identify neighborhoods with excess cancer-related behavioral or environmental exposures, beyond those measured by social class. Given the growing global burden of both tobacco addiction and aggressive breast cancer, similar investigations across diverse geographic areas are warranted.

Exploring important influences on the healthfulness of prostate cancer survivors' diets.

A cancer diagnosis is often conceptualized as a teachable moment when individuals might be motivated to make lifestyle changes. Many prostate cancer survivors, however, do not adhere to dietary guidelines. In this article, we explore how cancer affected prostate cancer survivors' diets and identify important influences on diet. Twenty prostate cancer survivors completed three 24-hour dietary recalls and an in-depth dietary interview. We analyzed interviews using a constant comparison approach, and dietary recall data quantitatively to assess quality and qualitatively to identify food choice patterns. Most men reported not making dietary changes following their cancer diagnosis but did express an interest in healthy eating, primarily to facilitate weight loss. Men portrayed barriers to healthy eating that often outweighed their motivation to eat healthy. Public health programs should consider alternative ways of framing healthy eating programs for prostate cancer survivors that might be more effective than a cancer-specific focus.