Impact of the COVID-19 pandemic on cancer patients in western Pennsylvania: rural-urban disparities.

PURPOSE: Disparities in cancer care persist between patients living in rural versus urban areas. The COVID-19 pandemic may have impacted concerns related to care and personal health differently in rural cancer patients. Using survey data collected from cancer patients in western Pennsylvania, we examined pandemic-related distress, concerns related to cancer care, impact on personal health, and the extent to which these differed by urban-rural residence. METHODS: Patients filled out an initial survey in August-December 2020; a second survey was completed in March 2021. The following patient concerns related to the pandemic were evaluated: threat of COVID-19 to their health, pandemic-related distress, perceptions of cancer care, and vaccine hesitancy. Multivariable logistic regression models were used to examine relationships between these outcomes and urban-rural residence as well as patient-related factors, including anxiety symptoms and social support. RESULTS: The study sample included 1,980 patients, 17% resided in rural areas. COVID-19 represented a major or catastrophic threat to personal health for 39.7% of rural and 49.0% of urban patients (p = 0.0017). Patients with high general anxiety were 10-times more likely to experience pandemic-related distress (p < 0.001). In the follow-up survey (n = 983), vaccine hesitancy was twice as prevalent among rural patients compared to urban (p = 0.012). CONCLUSIONS: The extent to which perceptions of the threat of COVD-19 to personal health and vaccine hesitancy exacerbates rural-urban disparities in cancer care and prognosis warrants further study. Cancer patients may be vulnerable to heightened anxiety and distress triggered by the pandemic.

Re-scaling and small area estimation of behavioral risk survey guided by social vulnerability data.

BACKGROUND: Local governments and other public health entities often need population health measures at the county or subcounty level for activities such as resource allocation and targeting public health interventions, among others. Information collected via national surveys alone cannot fill these needs. We propose a novel, two-step method for rescaling health survey data and creating small area estimates (SAEs) of smoking rates using a Behavioral Risk Factor Surveillance System survey administered in 2015 to participants living in Allegheny County, Pennsylvania, USA. METHODS: The first step consisted of a spatial microsimulation to rescale location of survey respondents from zip codes to tracts based on census population distributions by age, sex, race, and education. The rescaling allowed us, in the second step, to utilize available census tract-specific ancillary data on social vulnerability for small area estimation of local health risk using an area-level version of a logistic linear mixed model. To demonstrate this new two-step algorithm, we estimated the ever-smoking rate for the census tracts of Allegheny County. RESULTS: The ever-smoking rate was above 70% for two census tracts to the southeast of the city of Pittsburgh. Several tracts in the southern and eastern sections of Pittsburgh also had relatively high (> 65%) ever-smoking rates. CONCLUSIONS: These SAEs may be used in local public health efforts to target interventions and educational resources aimed at reducing cigarette smoking. Further, our new two-step methodology may be extended to small area estimation for other locations and health outcomes.

Examining ACCURE's Nurse Navigation Through an Antiracist Lens: Transparency and Accountability in Cancer Care.

There are persistent disparities in the delivery of cancer treatment, with Black patients receiving fewer of the recommended cancer treatment cycles than their White counterparts on average. To enhance racial equity in cancer care, innovative methods that apply antiracist principles to health promotion interventions are needed. The parent study for the current analysis, the Accountability for Cancer Care through Undoing Racism and Equity (ACCURE) intervention, was a system-change intervention that successfully eliminated the Black-White disparity in cancer treatment completion among patients with early-stage breast and lung cancer. The intervention included specially trained nurse navigators who leveraged real-time data to follow-up with patients during their treatment journeys. Community and academic research partners conducted thematic analysis on all clinical notes (n = 3,251) written by ACCURE navigators after each contact with patients in the specialized navigation arm (n = 162). Analysis was informed by transparency and accountability, principles adapted from the antiracist resource Undoing Racism and determined as barriers to treatment completion through prior research that informed ACCURE. We identified six themes in the navigator notes that demonstrated enhanced accountability of the care system to patient needs. Underlying these themes was a process of enhanced data transparency that allowed navigators to provide tailored patient support. Themes include (1) patient-centered advocacy, (2) addressing system barriers to care, (3) connection to resources, (4) re-engaging patients after lapsed treatment, (5) addressing symptoms and side effects, and (6) emotional support. Future interventions should incorporate transparency and accountability mechanisms and examine the impact on racial equity in cancer care.

'It's like you don't have a roadmap really': using an antiracism framework to analyze patients' encounters in the cancer system.

Background: Cancer patients can experience healthcare system-related challenges during the course of their treatment. Yet, little is known about how these challenges might affect the quality and completion of cancer treatment for all patients, and particularly for patients of color. Accountability for Cancer Care through Undoing Racism and Equity is a multi-component, community-based participatory research intervention to reduce Black-White cancer care disparities. This formative work aimed to understand patients' cancer center experiences, explore racial differences in experiences, and inform systems-level interventions.Methods: Twenty-seven breast and lung cancer patients at two cancer centers participated in focus groups, grouped by race and cancer type. Participants were asked about what they found empowering and disempowering regarding their cancer care experiences. The community-guided analysis used a racial equity approach to identify racial differences in care experiences.Results: For Black and White patients, fear, uncertainty, and incomplete knowledge were disempowering; trust in providers and a sense of control were empowering. Although participants denied differential treatment due to race, analysis revealed implicit Black-White differences in care.Conclusions: Most of the challenges participants faced were related to lack of transparency, such that improvements in communication, particularly two-way communication could greatly improve patients' interaction with the system. Pathways for accountability can also be built into a system that allows patients to find solutions for their problems with the system itself. Participants' insights suggest the need for patient-centered, systems-level interventions to improve care experiences and reduce disparities.

Sex differences in the impact of Affordable Care Act Medicaid expansion on colorectal cancer screening.

Access to care varies by sex such that interactions with insurance status result in mixed patterns of preventive services utilization. We examined sex-specific effects of ACA Medicaid expansions on receipt of CRC screening. We used Behavioral Risk Factor Surveillance System data (2008-2016) for adults aged 50-64 years with household income ≤138% of federal poverty level to examine self-reported lifetime use of guideline-recommended CRC screening services overall and by screening modality. We employed difference-in-difference models comparing changes in CRC screening in 20 Medicaid expansion states before and after the ACA to changes in 18 states that did not expand Medicaid during our study period. We divided the expansion period into implementation (2014) and post-expansion (2016) periods to account for possible lagged effects. We observed time-varying effects of Medicaid expansion that revealed relative increases in CRC screening occurring during the post-expansion period. Heterogeneous effects by sex and by screening modality were also observed: there was a significant relative increase of 16.2 percentage points (95% CI [2.2, 30.2]; p-value = 0.023) in lifetime colonoscopy use among women in expansion states relative to non-expansion states in the post-expansion period. There were no significant effects of Medicaid expansion among men. Health insurance expansion had a lagged but significant effect on CRC screening among low-income non-elderly women in Medicaid expansion states, but no effect for men. The observed increase in CRC screening among women suggests that barriers to CRC screening may differ by sex, and tailored interventions to increase CRC screening improve outcomes.

The role of patient-physician relationship on health-related quality of life and pain in cancer patients.

PURPOSE: Health-related quality of life (HRQOL) and pain are important supportive cancer care outcomes. The patient-provider relationship, a modifiable care experience, has been linked to healthcare outcomes; however, less is known about associations between patient-provider relationship and supportive care outcomes in cancer patients. We examined the role of multiple aspects of the patient-provider relationship in explaining patterns of HRQOL and pain among breast and lung cancer patients. METHODS: Our analysis included 283 breast and lung cancer patients from two cancer centers. Clinical data and survey data on patient sociodemographic factors, physical and mental HRQOL, pain, and patient-physician relationship (i.e., doctor's respectfulness, time spent with doctors, patient involvement in decision-making, satisfaction with care, and following doctor's advice/treatment plan) were collected at baseline and during treatment. We estimated adjusted modified Poisson regression models to assess associations between patient-physician relationship factors and physical and mental HRQOL and pain. RESULTS: Compared with patients reporting suboptimal respect from doctors, patients reporting optimal respect were less likely to report below average physical HRQOL (adjusted risk ratio (ARR), 0.73; 95%CI, 0.62-0.86), below average mental HRQOL (ARR, 0.71; 95%CI, 0.54-0.93), and moderate-to-severe pain (ARR, 0.53; 95%CI, 0.35-0.79). Patients reporting optimal involvement in care decision-making and patients who reported following their doctor's advice/treatment plan were less likely to report below average mental HRQOL than their respective counterparts (ARR, 0.64; 95%CI, 0.50-0.83; ARR, 0.65; 95%CI, 0.48-0.86). CONCLUSION: Multiple patient-physician relationship factors account for variations in HRQOL and pain in cancer patients. These findings provide insight into potential targets for improving the patient-provider relationship and supportive cancer care outcomes.

Maternal Obesity, Birth Size, and Risk of Childhood Cancer Development.

Infants and children are particularly vulnerable to in utero and early-life exposures. Thus, a mother's exposures before and during pregnancy could have important consequences for her child's health, including cancer development. We examined whether birth certificate-derived maternal anthropometric characteristics were associated with increased risk of subsequent childhood cancer development, accounting for established maternal and infant risk factors. Pennsylvania birth and cancer registry files were linked by the state Department of Health, yielding a virtual cohort of births and childhood cancers from 2003 through 2016. The analysis included 1,827,875 infants (13,785,309 person-years at risk), with 2,352 children diagnosed with any cancer and 747 with leukemia before age 14 years. Children born to mothers with a body mass index (weight (kg)/height (m)2) of ≥40 had a 57% (95% confidence interval: 12, 120) higher leukemia risk. Newborn size of ≥30% higher than expected was associated with 2.2-fold and 1.8-fold hazard ratios for total childhood cancer and leukemia, respectively, relative to those with expected size. Being <30% below expected size also increased the overall cancer risk (P for curvilinearity < 0.0001). Newborn size did not mediate the association between maternal obesity and childhood cancer. The results suggest a significant role of early-life exposure to maternal obesity- and fetal growth-related factors in childhood cancer development.

The Nine Habits of successful comprehensive cancer control coalitions.

The nine habits of successful comprehensive cancer control coalitions (Nine Habits) is a guide that outlines the key elements of successful comprehensive cancer control (CCC) coalitions. The guide was developed under the auspices of the Comprehensive Cancer Control National Partnership (CCCNP) and is based on evaluation including a literature review, qualitative and quantitative data collection from high-performing comprehensive cancer control coalitions. Comprehensive cancer control coalitions are made up of key stakeholders who come together to create a shared vision and shared plans to fight cancer, improve health outcomes, and reduce the burden from cancer. The CCCNP produced this guide to help coalitions maintain the health of their coalition efforts by providing tools to examine the key elements of successful coalitions, including leadership, membership, organizational structure, shared resources, and efforts in planning and communications. This paper provides information on how the guide was used by two states to rebuild their coalition and ultimately improve their efforts in improving health outcomes and reducing cancer burden. Lastly, the paper outlines future efforts to continue to support CCC coalitions in their work.

Racial differences in symptom management experiences during breast cancer treatment.

PURPOSE: Racial disparities in cancer treatment-related symptom burden are well documented and linked to worse treatment outcomes. Yet, little is known about racial differences in patients' treatment-related symptom management experiences. Such understanding can help identify modifiable drivers of symptom burden inequities. As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, we examined racial differences in symptom management experiences among Black and White breast cancer survivors (BCS). METHODS: We conducted six focus groups (n = 3 Black BCS groups; n = 3 White BCS groups) with 22 stages I-IV BCS at two cancer centers. Focus groups were audio-recorded and transcribed verbatim. Based on key community-based participatory research principles, our community/academic/medical partner team facilitated focus groups and conducted qualitative analyses. RESULTS: All BCS described positive symptom management experiences, including clinician attentiveness to symptom concerns and clinician recommendations for pre-emptively managing symptoms. Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians' failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS often described dissatisfaction regarding inadequate information on symptom origins and clinicians' failure to offer reassurance. CONCLUSIONS: This study elucidates opportunities for future research aimed at improving equity for cancer treatment-related symptom management. For Black women, warnings about anticipated symptoms and treatment for ongoing symptoms were particular areas of concern. Routine symptom assessment for all women, as well as clinicians' management of symptoms for racially diverse cancer patients, need to be more thoroughly studied and addressed.

The Experience of KAI MAHI, an Employment Initiative for People with an Experience of Mental Illness, as Told by Zarna, Zeus, Lulu, Mary, Paul, and Hemi.

There is a growing body of evidence endorsing the use of supported employment models for people with an experience of mental illness. However current literature and research regarding the perspective of people with experience of mental illness, as well as alternate models of employment support, is sparse. This study has captured the stories of employment of people with experience of mental illness who participated in KAI MAHI, a group based employment program. Findings identified key components of KAI MAHI, consistent with their overall experiences of employment, which were influential in assisting them to find and sustain employment. These included the opportunity for self-determination, a sense of self-efficacy, and respectful relationships.

Pathways to diagnosis: a qualitative study of the experiences and emotional reactions of parents of children diagnosed with type 1 diabetes.

OBJECTIVE: The aim of this study was to explore from parents' perspectives the circumstances and events which led to their child being diagnosed with type 1 diabetes (T1D). The objective was to understand reasons for delays in seeking treatment and parents' emotional reactions to diagnosis so others can be better informed and supported in future. METHODS: In-depth interviews with 54 parents of children (aged ≤12 yr) with T1D were conducted. Data analysis used an inductive, thematic approach. RESULTS: Parents described a 'prompt' and a 'delayed' pathway to their child being diagnosed. Parents who considered the diagnosis to be 'prompt' reported how they, or other people, had recognized their child had developed symptoms of T1D which resulted in a rapid presentation to health care professionals. In contrast, parents who perceived their child's diagnosis to be 'delayed' did not recognize signs of T1D and attributed their child's deteriorating health to other conditions, being out of routines and/or their stage of development. These parents often only sought medical help when symptoms became extreme. All parents were distressed by their child's diagnosis; however, parents in the 'delayed' pathway expressed unresolved feelings of guilt, particularly when their child was diagnosed with diabetic ketoacidosis. DISCUSSION: Parents' and other people's knowledge about T1D can affect the duration between onset of their child's symptoms and diagnosis. Campaigns to raise awareness should ensure that parents are made aware of symptoms and that T1D can develop during childhood. Health care professionals could discuss with parents the events preceding their child's diagnosis to better determine their emotional support needs.

Knowledge and prevention practices before breast cancer diagnosis in a cross-sectional study among survivors: impact on patients' involvement in the decision making process.

Disparities exist in breast cancer knowledge and education, which tend to influence symptom interpretation and decision to seek screening/care. The present project describes a cohort of women's experiences, knowledge, and health behavior prior to and after a diagnosis of breast cancer. It also studies how knowledge and demographic factors are associated with level of involvement participants had in the treatment of their breast cancer. Women >18 years who have been diagnosed and treated for breast cancer within 10 years were recruited in Pittsburgh, PA, through the Healthy People Cohort Registry, a database of volunteers from the community, and Brooklyn, NY, through the American Cancer Society breast cancer survivor database. Subsequent to institutional ethics approval, a questionnaire was administered by mail and through an electronic interactive format. The study included 124 breast cancer survivors, one-quarter of whom were of African ancestry. Roughly half of the women indicated that their overall knowledge of breast cancer was limited before diagnosis; no significant association between overall knowledge before diagnosis and stage at diagnosis or an active role of the patient in treatment choices was observed. Two-third of the women reported using personal research on internet, books, and other media to increase knowledge on breast cancer after diagnosis; the improvement of knowledge was associated with an active role in therapy choice. White women's self report of breast cancer knowledge prior to diagnosis was higher than that of women of African origin (p = 0.03); the latter experienced more delays in getting results about the diagnosis (p = 0.002), in starting treatment (p = 0.03), and in having treatment available at local facilities (p = 0.007) than white women. White women were more likely to improve their knowledge through their own research (p = 0.08) and through the contribution of their physician (p = 0.06) than women of African origin.There is still a need for addressing breast cancer knowledge among black women, and improvement in physician emotional support and in their contribution to the patient's knowledge is necessary. These efforts may have a positive impact on breast cancer knowledge among black women in the US.

New Zealand occupational therapists' views on evidence-based practice: a replicated survey of attitudes, confidence and behaviours.

BACKGROUND/AIM: Evidence-based practice is internationally recognised as an essential component of contemporary occupational therapy, and as being critical to the future of the profession. However, its uptake by therapists has been modest with barriers such as therapists attitudes, skills and organisational support frequently cited. This study explored New Zealand therapists' perceptions of their behaviours, skills and attitudes regarding evidence-based practice. METHOD: A survey comprising open and closed questions was emailed to all therapists holding practicing certificates who had consented to be contacted about research (n = 1587) with 30% (n = 473) of surveys returned. Therapists' evidence-based practice attitudes, skills and behaviours were examined using descriptive statistics. Relationships between therapists' perceptions of evidence-based practice and demographic characteristics of therapists were explored using Chi-square analysis. Text responses were analysed using content analysis. RESULTS: New Zealand therapists have a positive attitude towards evidence-based practice (84%), but report moderate reference to research literature (56%) during clinical decision-making and moderate (66%) to low (35%) levels of confidence in research-related skills. Therapists with training in evidence-based practice had higher levels of confidence, perceived research as more relevant to practice and reported less barriers to implementing evidence-based practice than other therapists. A perception that evidence-based practice is separate to clinical reasoning was widely held. CONCLUSION: New Zealand therapists' evidence-based practice behaviours, skills and attitudes are largely consistent with international comparisons. However, if New Zealand therapists are to enact the ideal of being 'evidence-based' then accessible training in evidence-based practice-related skills is indicated and should include education of what evidence-based practice means.

Impact of the 2020 New Zealand COVID-19 lockdown on participants in a community-based, peer-led fall prevention program.

OBJECTIVES: To explore the impacts of the 2020 New Zealand COVID-19 lockdown on peer-led Steady as You Go (SAYGO) fall prevention exercise classes and members, and to develop recommendations for mitigating impacts during future lockdowns. METHODS: Semi-structured phone interviews were conducted with 20 SAYGO program participants and managers following the first COVID-19 lockdown in New Zealand. Interviews were audio-recorded, transcribed verbatim and analysed using the General Inductive Approach. RESULTS: Participants were between 67 and 88 years of age, predominantly female (90%) and NZ European (80%), with one participant identifying as NZ Maori. Three themes were constructed from the analysis: Personal Function and Well-Being, Class Functioning and Logistics, and Future Strategies for Classes During Prospective Lockdowns. Participants used a range of strategies to stay connected with each other and continue the SAYGO exercises at home. Most participants and peer-leaders reported that they maintained physical function during lockdown, although some had feelings of psychological distress and social isolation. Contact systems and resource distribution varied substantially between groups. Classes resumed post-lockdown with only minor modifications and slightly decreased attendance. CONCLUSIONS: Overall, members of this peer-led model of fall prevention classes demonstrated resilience during the COVID-19 lockdown, despite some challenges. We propose three recommendations to address the challenges of maintaining existing peer-led exercise classes in the context of prospective lockdowns: (1) develop a comprehensive contact detail register and plans for each group; (2) delivery of modified exercise classes remotely over lockdown; and (3) implementation of a nationwide IT education and resource program for older adults.

Examining Rural-Urban Differences in Fatalism and Information Overload: Data from 12 NCI-Designated Cancer Centers.

BACKGROUND: Rural populations experience a disproportionate cancer burden relative to urban populations. One possibility is that rural populations are more likely to hold counterproductive cancer beliefs such as fatalism and information overload that undermine prevention and screening behaviors. METHODS: Between 2016 and 2020, 12 U.S. cancer centers surveyed adults in their service areas using online and in-person survey instruments. Participants (N = 10,362) were designated as rural (n = 3,821) or urban (n = 6,541). All participants were 18 and older (M = 56.97, SD = 16.55), predominately non-Hispanic White (81%), and female (57%). Participants completed three items measuring cancer fatalism ("It seems like everything causes cancer," "There's not much you can do to lower your chances of getting cancer," and "When I think about cancer, I automatically think about death") and one item measuring cancer information overload ("There are so many different recommendations about preventing cancer, it's hard to know which ones to follow"). RESULTS: Compared with urban residents, rural residents were more likely to believe that (i) everything causes cancer (OR = 1.29; 95% CI, 1.17-1.43); (ii) prevention is not possible (OR = 1.34; 95% CI, 1.19-1.51); and (iii) there are too many different recommendations about cancer prevention (OR = 1.26; 95% CI, 1.13-1.41), and cancer is always fatal (OR = 1.21; 95% CI, 1.11-1.33). CONCLUSIONS: Compared with their urban counterparts, rural populations exhibited higher levels of cancer fatalism and cancer information overload. IMPACT: Future interventions targeting rural populations should account for higher levels of fatalism and information overload.

Evaluation of a peer-led falls prevention program for older adults.

OBJECTIVE: To evaluate measures of strength and balance and falls incidence in participants attending fall prevention exercise classes taught by volunteer peer leaders, paid professional (Age Concern Otago group), or a comparison class (comparison group). DESIGN: Quasi-experimental evaluation with 12-month follow-up. SETTING: Community. PARTICIPANTS: Older adults with increased fall risk (N=118; mean age, 75.5 y; age range, 65-94 y), with 23% drop out at 12 months. INTERVENTION: Peer-led group (n=52) and Age Concern Otago (n=41) weekly 1-hour strength and balance classes adapted from a home-based nurse/physical therapist-administered program and comparison group (n=25) 1-hour weekly seated exercise classes. MAIN OUTCOME MEASURES: Timed Up and Go test, 30-second chair stand, functional reach, step touch, Single Leg Stand, and balance confidence at baseline, 10 weeks, and 6 and 12 months. Falls diaries collected monthly for 12 months. Continued exercise participation questionnaire at 6 and 12 months. RESULTS: At baseline, the peer-led group achieved normative standards on most tests and performed significantly better than the Age Concern Otago and comparison groups (overall P<.05). The Age Concern Otago group reached normative standards on most tests at 10 weeks. Functional improvements were similar in the peer-led group and Age Concern Otago groups from 10 weeks to 12 months, and all functional measures were significantly greater than in the comparison group (overall P<.02). Poisson regression showed a tendency for a 27% decrease in falls for the peer-led group compared with the comparison group (incidence rate ratio [IRR], .73; 95% confidence interval, .48-1.1; P=.07). Continued participation in strength and balance classes at 12 months was greater in the peer-led group and Age Concern Otago groups compared with the comparison group. CONCLUSIONS: This peer-led model maintained measures of strength and balance and was superior to seated exercise. People in the Age Concern Otago group chose to continue these classes over other activities, whereas the comparison group had discontinued exercise classes by 12 months. Peer-led classes may decrease the fall incidence, although larger studies are needed to confirm this finding.

Identifying student opinion leaders to lead e-cigarette interventions: protocol for a randomized controlled pragmatic trial.

BACKGROUND: After the US Surgeon General declared youth electronic cigarette (e-cigarette) use an epidemic in 2018, the number of youth e-cigarette users continued to surge, growing from 3.8 million in 2018 to over 5 million 2019. Youth who use e-cigarettes are at a substantially higher risk of transitioning to traditional cigarettes, becoming regular cigarette smokers, and increasing their risk of developing tobacco-related cancer. A majority of youth are misinformed about e-cigarettes, often believing they are not harmful or contain no nicotine. Middle school students using e-cigarettes have been affected by its normalization leading to influence by their peers. However, social and group dynamics can be leveraged for a school-based peer-led intervention to identify and recruit student leaders to be anti-e-cigarette champions to prevent e-cigarette initiation. This study outlines a project to use social network analysis to identify student opinion-leaders in schools and train them to conduct anti-e-cigarette programming to their peers. METHODS: In the 2019-2020 academic school year, 6th grade students from nine schools in the Pittsburgh area were recruited. A randomized controlled trial (RCT) was conducted with three arms-expert, elected peer-leader, and random peer-leader-for e-cigarette programming. Sixth grade students in each school completed a network survey that assessed the friendship networks in each class. Students also completed pre-intervention and post-intervention surveys about their intention-to-use, knowledge, and attitudes towards e-cigarettes. Within each peer-led arm, social network analysis was conducted to identify peer-nominated opinion leaders. An e-cigarette prevention program was administered by (1) an adult content-expert, (2) a peer-nominated opinion leader to assigned students, or (3) a peer-nominated opinion leader to random students. DISCUSSION: This study is the first to evaluate the feasibility of leveraging social network analysis to identify 6th grade opinion leaders to lead a school-based e-cigarette intervention. TRIAL REGISTRATION: ClinicalTrials.gov NCT04083469 . Registered on September 10, 2019.

Implementation of a cluster randomized controlled trial: Identifying student peer leaders to lead E-cigarette interventions.

E-cigarette use has been increasing among middle school students. Intervention programs to prevent e-cigarette initiation administered by authority figures are met with more resistance from youth compared to peer-led programs. Therefore, this study aimed to assess the feasibility, acceptability, and implementation process of using social network analysis (SNA) to identify student peer leaders in schools and train them to deliver e-cigarette prevention programming to their peers. Nine schools were recruited to participate in the study during the 2019-2020 school year. Schools were assigned to one of three conditions: (1) expert; (2) peer-random (selected peer-leaders would teach to random students); and (3) peer-fixed (selected peer-leaders would teach to assigned students based on nominations). Study participation varied by day due to school attendance, with 686 participants at baseline and 608 at posttest. Almost all students who did not complete the study resulted from the interruption of schools being closed due to COVID-19. Implementation issues fell into three categories: (1) scheduling, (2) day-of logistics, and (3) student group dynamics. Overall, the results showed positive satisfaction among teachers, who unanimously found the program appropriate for the grade-level and that peer-leaders worked well within their groups. Peer-led students-both random and assigned-reported having more fun and willing to tell friends to try the program compared to expert-led students. This study demonstrated the feasibility of implementing a peer-led e-cigarette prevention program for 6th grade students, using SNA to provide intervention rigidity and validity.

Differences in Breast and Colorectal Cancer Screening Adherence Among Women Residing in Urban and Rural Communities in the United States.

Importance: Screening for breast and colorectal cancer has resulted in reductions in mortality; however, questions remain regarding how these interventions are being diffused to all segments of the population. If an intervention is less amenable to diffusion, it could be associated with disparities in mortality rates, especially in rural vs urban areas. Objectives: To compare the prevalence of breast and colorectal cancer screening adherence and to identify factors associated with screening adherence among women residing in rural vs urban areas in the United States. Design, Setting, and Participants: This population-based cross-sectional study of women aged 50 to 75 years in 11 states was conducted from 2017 to 2020. Main Outcomes and Measures: Adherence to cancer screening based on the US Preventative Services Task Force guidelines. For breast cancer screening, women who had mammograms in the past 2 years were considered adherent. For colorectal cancer screening, women who had (1) a stool test in the past year, (2) a colonoscopy in the past 10 years, or (3) a sigmoidoscopy in the past 5 years were considered adherent. Rural status was coded using Rural Urban Continuum Codes, and other variables were assessed to identify factors associated with screening. Results: The overall sample of 2897 women included 1090 (38.4%) rural residents; 2393 (83.5%) non-Hispanic White women; 263 (9.2%) non-Hispanic Black women; 68 (2.4%) Hispanic women; 1629 women (56.2%) aged 50 to 64 years; and 712 women (24.8%) with a high school education or less. Women residing in urban areas were significantly more likely to be adherent to colorectal cancer screening compared with women residing in rural areas (1429 [82%] vs 848 [78%]; P = .01), whereas the groups were equally likely to be adherent to breast cancer screening (1347 [81%] vs 830 [81%]; P = .78). Multivariable mixed-effects logistic regression analyses confirmed that rural residence was associated with lower odds of being adherent to colorectal cancer screening (odds ratio [OR], 0.81; 95% CI, 0.66-0.99, P = .047). Non-Hispanic Black race was associated with adherence to breast cancer screening guidelines (OR, 2.85; 95% CI, 1.78-4.56; P < .001) but not colorectal cancer screening guidelines. Conclusions and Relevance: In this cross-sectional study, women residing in rural areas were less likely to be adherent to colorectal cancer screening guidelines but were similarly adherent to breast cancer screening. This suggests that colorectal cancer screening, a more recent intervention, may not be as available in rural areas as breast cancer screening, ie, colorectal screening has lower amenability.

Life satisfaction in chronic pain patients: the stress-buffering role of the centrality of religion.

Chronic pain (CP) is a stressful condition that severely impacts individuals' lives. Researchers have begun to explore the role of religion for CP patients, but the literature is scarce, especially for West European populations. Drawing from the transactional theory of stress, this study examined the associations between the religious meaning system and the life satisfaction for a group of CP patients who were members of a Flemish patients' association. To take into account the religious landscape of West European countries, the centrality of one's religious meaning system, rather than religious content, was the focus. Results from the questionnaires completed by 207 patients suggest that the centrality of a meaning system is an important factor in the promotion of life satisfaction for this group, above and beyond the influence of several control variables. Furthermore, the centrality of the religious meaning system moderated or buffered the detrimental influence of pain severity on life satisfaction.