Patient-reported observations on medical procedure timeliness (PROMPT) in breast cancer: a qualitative study.

PURPOSE: Timeliness of care is an important healthcare outcome measure. The objective of this study was to explore patient perspectives on the timeliness of breast cancer diagnosis and treatment at accredited breast cancer centers. METHODS: In this qualitative study, 1 hour virtual interviews were conducted with participants 18-75 years old who were diagnosed and treated for stage 0-III breast cancer at a National Accreditation Program for Breast Centers facility from 2018 to 2022. Thematic analysis was used to identify key themes of participant experiences. RESULTS: Twenty-eight participants were interviewed. Two thematic domains were identified: etiologies of expedited or delayed care and the impact of delayed or expedited care on patients. Within these domains, multiple themes emerged. For etiologies of expedited or delayed care, participants discussed (1) the effect of scheduling appointments, (2) the COVID-19 pandemic, (3) dissatisfaction with the timeline for various parts of the diagnostic workup, and (4) delays related to patient factors, including socioeconomic status. For the impact of expedited or delayed care, patients discussed (1) the emotional and mental impact of waiting, (2) the importance of communication and clear expectations, and (3) the impact of electronic health portals. Patients desired each care interval (e.g., the time from mammogram to breast biopsy) to be approximately 7 days, with longer intervals sometimes preferred prior to surgery. CONCLUSION: These patient interviews identify areas of delay and provide patient-centered, actionable items to improve the timeliness of breast cancer care.

Protocol for a cluster-randomized trial of a school-based skin cancer preventive intervention for adolescents.

BACKGROUND: Adolescents infrequently use sun protection and engage in intentional tanning more frequently compared to other age groups, leading to increased ultraviolet radiation (UVR) exposure that heightens skin cancer risk across the lifespan. High schools are therefore an ideal setting for offering skin cancer preventive interventions. Yet, there are limited UVR protection interventions for high school students, especially those that are personalized, tested using randomized designs, and include long-term outcome assessment to determine the durability of intervention effects. METHOD: The Sun-safe Habits Intervention and Education (SHINE) cluster-randomized trial will test a novel, personalized intervention that targets high school adolescents' sun protection and tanning behaviors, and tracks their outcomes for up to one year following intervention. Enrolled high schools will be randomized to receive either the personalized SHINE intervention, which includes facial UVR photographs and sun protection action planning, or standard education using publicly available materials. Students in both conditions will receive information about skin cancer, sun protection, and skin self-examination. Outcome variables will include students' sun protection and tanning behaviors and sunburn occurrence. Potential moderators (e.g., race/ethnicity) and mediators (e.g., self-efficacy) will also be assessed and tested. CONCLUSIONS: This trial examines the efficacy of a personalized intervention targeting sun protection and tanning of high school students. The project will lead to new scientific understanding of the theoretical mechanisms underlying outcomes and moderators of the intervention effects, which will inform future intervention tailoring to meet the needs of vulnerable subgroups.

Moderating influences on parents' fatalistic beliefs about cancer and their association with sun safety behaviors among children of melanoma survivors: Implications for treatment.

The purpose of this study is to examine the association between parents' fatalism about melanoma and their children's sun protection, and the potential moderating role of parent-child communication. In this observational study of N = 69 melanoma-surviving parents of children ages 8-17, parents reported on their own melanoma fatalism, as well as their children's sun safety behaviors and parent-child discussion about sun safety. Parent gender, family history of melanoma, and frequency of parent-child discussions moderated the relationship between parents' fatalism and children's sun safety behaviors. Among mothers and parents with a family history of melanoma, high fatalism was associated with lower child sunscreen use, especially when discussions were less frequent. Melanoma surviving parents' fatalistic beliefs about cancer indirectly influence their children's health behavior and are a risk factor for unsafe sun behavior. Attending to parent gender, family history, and their communications about protective behaviors as co-factors of this risk could inform future intervention targeting.

The Family Lifestyles, Actions and Risk Education (FLARE) study: Protocol for a randomized controlled trial of a sun protection intervention for children of melanoma survivors.

BACKGROUND: Children of parents who had melanoma are more likely to develop skin cancer themselves owing to shared familial risks. The prevention of sunburns and promotion of sun-protective behaviors are essential to control cancer among these children. The Family Lifestyles, Actions and Risk Education (FLARE) intervention will be delivered as part of a randomized controlled trial to support parent-child collaboration to improve sun safety outcomes among children of melanoma survivors. METHODS: FLARE is a two-arm randomized controlled trial design that will recruit dyads comprised of a parent who is a melanoma survivor and their child (aged 8-17 years). Dyads will be randomized to receive FLARE or standard skin cancer prevention education, which both entail 3 telehealth sessions with an interventionist. FLARE is guided by Social-Cognitive and Protection Motivation theories to target child sun protection behaviors through parent and child perceived risk for melanoma, problem-solving skills, and development of a family skin protection action plan to promote positive modeling of sun protection behaviors. At multiple assessments through one-year post-baseline, parents and children complete surveys to assess frequency of reported child sunburns, child sun protection behaviors and melanin-induced surface skin color change, and potential mediators of intervention effects (e.g., parent-child modeling). CONCLUSION: The FLARE trial addresses the need for melanoma preventive interventions for children with familial risk for the disease. If efficacious, FLARE could help to mitigate familial risk for melanoma among these children by teaching practices which, if enacted, decrease sunburn occurrence and improve children's use of well-established sun protection strategies.

Common Data Element Collection in Underserved School Communities: Challenges and Recommendations.

OBJECTIVES: To provide recommendations for future common data element (CDE) development and collection that increases community partnership, harmonizes data interpretation, and continues to reduce barriers of mistrust between researchers and underserved communities. METHODS: We conducted a cross-sectional qualitative and quantitative evaluation of mandatory CDE collection among Rapid Acceleration of Diagnostics-Underserved Populations Return to School project teams with various priority populations and geographic locations in the United States to: (1) compare racial and ethnic representativeness of participants completing CDE questions relative to participants enrolled in project-level testing initiatives and (2) identify the amount of missing CDE data by CDE domain. Additionally, we conducted analyses stratified by aim-level variables characterizing CDE collection strategies. RESULTS: There were 15 study aims reported across the 13 participating Return to School projects, of which 7 (47%) were structured so that CDEs were fully uncoupled from the testing initiative, 4 (27%) were fully coupled, and 4 (27%) were partially coupled. In 9 (60%) study aims, participant incentives were provided in the form of monetary compensation. Most project teams modified CDE questions (8/13; 62%) to fit their population. Across all 13 projects, there was minimal variation in the racial and ethnic distribution of CDE survey participants from those who participated in testing; however, fully uncoupling CDE questions from testing increased the proportion of Black and Hispanic individuals participating in both initiatives. CONCLUSIONS: Collaboration with underrepresented populations from the early study design process may improve interest and participation in CDE collection efforts.

Preliminary Reach of an Information Technology Approach to Support COVID-19 Testing in Schools.

OBJECTIVES: SCALE-UP Counts tests population health management interventions to promote coronavirus disease 2019 (COVID-19) testing in kindergarten through 12th-grade schools that serve populations that have been historically marginalized. METHODS: Within 6 participating schools, we identified 3506 unique parents/guardians who served as the primary contact for at least 1 student. Participants were randomized to text messaging (TM), text messaging + health navigation (HN) (TM + HN), or usual care. Bidirectional texts provided COVID-19 symptom screening, along with guidance on obtaining and using tests as appropriate. If parents/guardians in the TM + HN group were advised to test their child but either did not test or did not respond to texts, they were called by a trained health navigator to address barriers. RESULTS: Participating schools served a student population that was 32.9% non-white and 15.4% Hispanic, with 49.6% of students eligible to receive free lunches. Overall, 98.8% of parents/guardians had a valid cell phone, of which 3.8% opted out. Among the 2323 parents/guardians included in the intervention, 79.6% (n = 1849) were randomized to receive TM, and 19.1% (n = 354) engaged with TM (ie, responded to at least 1 message). Within the TM + HN group (40.1%, n = 932), 1.3% (n = 12) qualified for HN at least once, of which 41.7% (n = 5) talked to a health navigator. CONCLUSIONS: TM and HN are feasible ways to reach parents/guardians of kindergarten through 12th-grade students to provide COVID-19 screening messages. Strategies to improve engagement may strengthen the impact of the intervention.

Rationale and design of the SenseWhy project: A passive sensing and ecological momentary assessment study on characteristics of overeating episodes.

Objectives: Overeating interventions and research often focus on single determinants and use subjective or nonpersonalized measures. We aim to (1) identify automatically detectable features that predict overeating and (2) build clusters of eating episodes that identify theoretically meaningful and clinically known problematic overeating behaviors (e.g., stress eating), as well as new phenotypes based on social and psychological features. Method: Up to 60 adults with obesity in the Chicagoland area will be recruited for a 14-day free-living observational study. Participants will complete ecological momentary assessments and wear 3 sensors designed to capture features of overeating episodes (e.g., chews) that can be visually confirmed. Participants will also complete daily dietitian-administered 24-hour recalls of all food and beverages consumed. Analysis: Overeating is defined as caloric consumption exceeding 1 standard deviation of an individual's mean consumption per eating episode. To identify features that predict overeating, we will apply 2 complementary machine learning methods: correlation-based feature selection and wrapper-based feature selection. We will then generate clusters of overeating types and assess how they align with clinically meaningful overeating phenotypes. Conclusions: This study will be the first to assess characteristics of eating episodes in situ over a multiweek period with visual confirmation of eating behaviors. An additional strength of this study is the assessment of predictors of problematic eating during periods when individuals are not on a structured diet and/or engaged in a weight loss intervention. Our assessment of overeating episodes in real-world settings is likely to yield new insights regarding determinants of overeating that may translate into novel interventions.

Objectively-Assessed Ultraviolet Radiation Exposure and Sunburn Occurrence.

Ultraviolet radiation (UVR) exposure is the primary modifiable risk factor for melanoma. Wearable UVR sensors provide a means of quantifying UVR exposure objectively and with a lower burden than self-report measures used in most research. The purpose of this study was to evaluate the relationship between detected UVR exposure and reported sunburn occurrence. In this study, a UVR monitoring device was worn by 97 parent-child dyads during waking hours for 14 days to measure instantaneous and accumulated UVR exposure. The results showed that the participants' total UVR exposure was associated with reported sunburn after adjusting for Fitzpatrick skin type and geographic location. It was observed that one standard erythemal dose (SED) increase in the participants' daily total UVR exposure was associated with reported sunburn (an odds ratio (OR) of 1.26 with a 95% CI of 1.13 and 1.41, and p < 0.001 for parents and an OR of 1.28 with a 95% CI of 1.12 and 1.47, and p < 0.001 for children). A one-SED increase in the participants' UVR exposure from 10 am to 4 pm was also associated with reported sunburn (an OR of 1.31 with a 95% CI of 1.15 and 1.49, and p < 0.001 for parents and an OR of 1.33 with a 95% CI of 1.12 and 1.59, and p = 0.001 for children). We found that elevated UVR exposure recordings measured by the UVR sensor were associated with reported sunburn occurrence. Future directions for wearable UVR sensors may include their use as an intervention tool to support in-the-moment sunburn prevention.

Development of an Implementation Facilitation Strategy to Link Mental Health Screening and eHealth Intervention for Clients in Ryan White-Funded Clinics in Chicago.

BACKGROUND: To reduce the impact of depression on people living with HIV, we are implementing a clinic-based behavioral health screener and referral to Optimizing Resilience and Coping with HIV through Internet Delivery, an evidenced-based intervention. We used the Consolidated Framework for Implementation Research to identify contextual barriers and facilitators in advance of implementation. SETTING: Sixteen Chicagoland area Ryan White Medical Case Management sites. METHODS: We conducted a sequential mixed-methods study with medical case managers and supervisors. Participants completed an online survey assessing Consolidated Framework for Implementation Research domains, scored on a 1 (strongly disagree) to 5 (strongly agree) scale. Survey results informed a purposive sampling frame and interview protocol. Interviews were analyzed by rapid qualitative analysis. RESULTS: On average, survey respondents (n = 58) slightly agreed with positive views of team culture, learning climate, and implementation readiness (mean = 3.80-3.87). Potential barriers included intervention complexity (mean = 3.47), needed human resources (mean = 2.71-3.33), and only slight agreement with relative advantage over existing screening/referral systems (mean = 3.09-3.71). Qualitative results (n = 15) identified low advantage for clinics with robust behavioral health systems but strong advantage in clinics without these services. Respondents identified system-wide training and monitoring strategies to facilitate implementation. CONCLUSIONS: Ryan White Medical Case Management sites are a generally favorable context for the implementation of the interventions. As illustrated in an implementation research logic model, barriers will be addressed through deploying strategies proposed to impact clinic- and individual-level outcomes, including electronic prompts (reduce complexity), training on Optimizing Resilience and Coping with HIV through Internet Delivery as a complement to other behavioral health services (increase relative advantage), and feedback during implementation (strengthen rewards/incentives).

Interactive Beliefs about Genes and Behavior Predict Improved Sun Protection Following Melanoma Genetic Counseling.

BACKGROUND: Little is known about how members of cancer-prone families think about genetic determinism and whether personal behavior can amplify or counter genetic risk for disease. PURPOSE: Understanding how people think about the impact of personal behavior on disease risk may inform communications about genetic risks and their management. METHODS: We assessed three sets of beliefs about the impact of behavior on genetic risk-interactive (unhealthful behaviors can amplify genetic risk), subtractive (healthful behaviors can reduce genetic risk), and deterministic (genes primarily determine health outcomes)-among 114 unaffected members of melanoma-prone families receiving genetic counseling (51.6% men, average age = 35.3). We examined whether these beliefs predicted changes in perceived control, motivation to manage melanoma risk, and sun-protection behavior one year later. RESULTS: Participants strongly endorsed interactive and subtractive beliefs, but not deterministic beliefs. These beliefs generally did not change, even among those who received positive CDKN2A/p16 genetic test results conferring up to 76% lifetime melanoma risk. Controlling for age, sex, education, skin type, and genetic test result, interactive beliefs predicted sustained increases in perceptions of personal control, motivation to reduce sun exposure, use of multiple sun-protection methods, and reduction in objectively assessed tanning at the wrist one year following genetic counseling. Subtractive beliefs predicted increased personal control, motivation to manage risk, and sunscreen use, while deterministic beliefs were generally unrelated to outcomes. CONCLUSIONS: Among people at highly elevated hereditary cancer risk, beliefs that unhealthful behaviors can amplify genetic risk seem to be especially motivating of behavioral risk-reduction efforts.

Food Handling Concerns and Practices at Home during the COVID-19 Pandemic by Food Security Status.

ABSTRACT: There is limited examination about coronavirus disease 19 (COVID-19)-related food handling concerns and practices that cause chemical or microbial contamination and illness, particularly among those with food insecurity. We investigated consumer food handling concerns and practices during the COVID-19 pandemic and whether they differed by food insecurity status. An online survey was distributed among Chicago, IL, residents between 15 July and 21 August 2020 (n = 437). Independent t tests and Fisher's exact tests were used to identify differences in food handling concerns and practices between those with and without food insecurity (alpha = 0.05). Survey items included questions about food handling practices that were considered safe or neutral (i.e., washing hands and produce with water, sanitizing food packaging) and unsafe (i.e., using cleaning agents to wash foods, leaving perishable foods outside) by using 5-point Likert-style scales or categorical responses (i.e., yes, no). Participant responses fell between "slightly" and "somewhat" concerned about contracting COVID-19 from food and food packaging (mean ± standard error [SE]: 2.7 ± 0.1). Although participants reported washing their hands before eating and before preparing foods at least "most of the time" (mean ± SE: 4.4 ± 0.0 and 4.5 ± 0.0, respectively), only one-third engaged in unsafe practices. The majority of participants (68%) indicated that they altered food handling practices due to the COVID-19 pandemic and received information about food safety from social media (61%). When investigating differences in concerns and practices by food insecurity status, food insecure participants were more concerned about COVID-19 foodborne transmission for all food items (all P < 0.001) and more frequently performed unsafe food handling practices than those with food security (all P < 0.001). Results from this study suggest more investigation is needed to understand barriers to safe food handling knowledge and practices, particularly among those with food insecurity.

Digitally characterizing the dynamics of multiple health behavior change.

OBJECTIVE: We applied the ORBIT model to digitally define dynamic treatment pathways whereby intervention improves multiple risk behaviors. We hypothesized that effective intervention improves the frequency and consistency of targeted health behaviors and that both correlate with automaticity (habit) and self-efficacy (self-regulation). METHOD: Study 1: Via location scale mixed modeling we compared effects when hybrid mobile intervention did versus did not target each behavior in the Make Better Choices 1 (MBC1) trial (n = 204). Participants had all of four risk behaviors: low moderate-vigorous physical activity (MVPA) and fruit and vegetable consumption (FV), and high saturated fat (FAT) and sedentary leisure screen time (SED). Models estimated the mean (location), between-subjects variance, and within-subject variance (scale). RESULTS: Treatment by time interactions showed that location increased for MVPA and FV (Bs = 1.68, .61; ps < .001) and decreased for SED and FAT (Bs = -2.01, -.07; ps < .05) more when treatments targeted the behavior. Within-subject variance modeling revealed group by time interactions for scale (taus = -.19, -.75, -.17, -.11; ps < .001), indicating that all behaviors grew more consistent when targeted. METHOD: Study 2: In the MBC2 trial (n = 212) we examined correlations between location, scale, self-efficacy, and automaticity for the three targeted behaviors. RESULTS: For SED, higher scale (less consistency) but not location correlated with lower self-efficacy (r = -.22, p = .014) and automaticity (r = -.23, p = .013). For FV and MVPA, higher location, but not scale, correlated with higher self-efficacy (rs = .38, .34, ps < .001) and greater automaticity (rs = .46, .42, ps < .001). CONCLUSIONS: Location scale mixed modeling suggests that both habit and self-regulation changes probably accompany acquisition of complex diet and activity behaviors. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Priority of Risk (But Not Perceived Magnitude of Risk) Predicts Improved Sun-Protection Behavior Following Genetic Counseling for Familial Melanoma.

BACKGROUND: Understanding multiple components of risk perceptions is important because perceived risk predicts engagement in prevention behaviors. PURPOSE: To examine how multiple components of risk perceptions (perceived magnitude of and worry about risk, prioritization of the management of one's risk) changed following genetic counseling with or without test reporting, and to examine which of these components prospectively predicted improvements in sun-protection behavior 1 year later. METHODS: A prospective, nonrandomized study design was used. Participants were 114 unaffected members of melanoma-prone families who (i) underwent genetic testing for a CDKN2A/p16 mutation (n = 69) or (ii) were at comparably elevated risk based on family history and underwent genetic counseling but not testing (no-test controls, n = 45). Participants reported risk perception components and sun-protection behavior at baseline, immediately following counseling, and 1 month and 1 year after counseling. RESULTS: Factor analysis indicated three risk components. Carriers reported increased perceived magnitude and priority of risk, but not cancer worry. No-test controls showed no changes in any risk perception. Among noncarriers, priority of risk remained high at all assessments, whereas magnitude of risk and cancer worry decreased. Of the three risk components, greater priority of risk uniquely predicted improved self-reported sun protection 1 year post-counseling. CONCLUSIONS: Priority of risk (i) seems to be a component of risk perceptions distinguishable from magnitude of risk and cancer worry, (ii) may be an important predictor of daily prevention behavior, and (iii) remained elevated 1 year following genetic counseling only for participants who received a positive melanoma genetic test result.

Parent and child perspectives on family interactions related to melanoma risk and prevention after CDKN2A/p16 testing of minor children.

Predispositional genetic testing of children for adult-onset health risks is typically only used when prevention and screening measures have utility during childhood. Little is known about how children and their parents may use predispositional risk information, including whether it changes their interactions around risk-reducing prevention and screening behaviors. The current study examined perspectives on family interactions around skin cancer prevention and control practices through 1 year after test reporting and counseling among children who received melanoma predispositional genetic testing and their parents. Eighteen children (50% carriers, 56% male, mean age = 12.4 years) and 11 parents from 11 families participated in semi-structured interviews 1 month and 1 year after receiving the child's test result. Both parents (73%) and children (50%) reported making changes to family skin cancer prevention and control practices after receiving the test result. Parent- and child-reported discussions about melanoma prevention increased over time (36% parents and 61% children at 1 month, 73% parents and 67% at 1 year). One-quarter (27%) of parents and no children reported having conflicts about sun protection or screening 1 year after test reporting. A majority of parents (63%) reported treating their child differently at the 1-year follow-up, especially among carriers. Predispositional genetic testing for melanoma was associated with reported changes to plans for and discussions about sun protection, and high levels of parent-child collaboration to implement child sun protection. Future work could seek to identify child and parent factors and interactions that predict improved prevention and screening behaviors following pediatric predispositional genetic testing.

CDKN2A testing and genetic counseling promote reductions in objectively measured sun exposure one year later.

PURPOSE: This study investigated whether genetic counseling and test reporting for the highly penetrant CDKN2A melanoma predisposition gene promoted decreases in sun exposure. METHODS: A prospective, nonequivalent control group design compared unaffected participants (N = 128, Mage = 35.24, 52% men) from (1) families known to carry a CDKN2A pathogenic variant, who received counseling about management recommendations and a positive or negative genetic test result and (2) no-test control families known not to carry a CDKN2A pathogenic variant, who received equivalent counseling based on their comparable family history. Changes in daily ultraviolet radiation (UVR) exposure (J/m2), skin pigmentation (melanin index), and sunburns between baseline and one year following counseling were compared among carriers (n = 32), noncarriers (n = 46), and no-test control participants (n = 50). RESULTS: Both carriers and no-test control participants exhibited a decrease one year later in daily UVR dose (B = -0.52, -0.33, p < 0.01). Only carriers exhibited a significant decrease in skin pigmentation at the wrist one year later (B = -0.11, p < 0.001), and both carriers and no-test control participants reported fewer sunburns than noncarriers (p < 0.05). Facial pigmentation did not change for any group. Noncarriers did not change on any measure of UVR exposure. CONCLUSIONS: These findings support the clinical utility of disclosing CDKN2A test results and providing risk management education to high-risk individuals.

Assessing recall of personal sun exposure by integrating UV dosimeter and self-reported data with a network flow framework.

BACKGROUND: Melanoma survivors often do not engage in adequate sun protection, leading to sunburn and increasing their risk of future melanomas. Melanoma survivors do not accurately recall the extent of sun exposure they have received, thus, they may be unaware of their personal UV exposure, and this lack of awareness may contribute towards failure to change behavior. As a means of determining behavioral accuracy of recall of sun exposure, this study compared subjective self-reports of time outdoors to an objective wearable sensor. Analysis of the meaningful discrepancies between the self-report and sensor measures of time outdoors was made possible by using a network flow algorithm to align sun exposure events recorded by both measures. Aligning the two measures provides the opportunity to more accurately evaluate false positive and false negative self-reports of behavior and understand participant tendencies to over- and under-report behavior. METHODS: 39 melanoma survivors wore an ultraviolet light (UV) sensor on their chest while outdoors for 10 consecutive summer days and provided an end-of-day subjective self-report of their behavior while outdoors. A Network Flow Alignment framework was used to align self-report and objective UV sensor data to correct misalignment. The frequency and time of day of under- and over-reporting were identified. FINDINGS: For the 269 days assessed, the proposed framework showed a significant increase in the Jaccard coefficient (i.e. a measure of similarity between self-report and UV sensor data) by 63.64% (p < .001), and significant reduction in false negative minutes by 34.43% (p < .001). Following alignment of the measures, under-reporting of sun exposure time occurred on 51% of the days analyzed and more participants tended to under-report than to over-report sun exposure time. Rates of under-reporting of sun exposure were highest for events that began from 12-1pm, and second-highest from 5-6pm. CONCLUSION: These discrepancies may reflect lack of accurate recall of sun exposure during times of peak sun intensity (10am-2pm) that could ultimately increase the risk of developing melanoma. This research provides technical contributions to the field of wearable computing, activity recognition, and identifies actionable times to improve participants' perception of their sun exposure.

Physicians' perspectives on medication adherence and health promotion among cancer survivors.

BACKGROUND: Cancer survivors face an increased risk of cardiovascular events compared with the general population. Adopting a healthy lifestyle may reduce these risks, and guidelines encourage health-promotion counseling for cancer survivors, but the extent of physician adherence is unclear. METHODS: This mixed-method study surveyed 91 physicians, including 30 primary care physicians (PCPs), 30 oncologists, and 31 specialists (urologists, dermatologists, and gynecologists). Interviews also were conducted with 12 oncologists. RESULTS: Most PCPs (90%) reported recommending health promotion (eg, weight loss, smoking cessation) to at least some cancer survivors, whereas few oncologists (26.7%) and specialists (9.7%) said they ever did so (P < .001). Although most physicians believed that at least 50% of cancer survivors would be adherent to medication regimens to prevent cancer recurrence, they also believed that, if patients were trying to lose weight, they would not remain medication-adherent. In interviews, oncologists expressed fear that providing health-promotion advice would distress or overwhelm patients. Additional health-promotion barriers identified by thematic analysis included: identifying cancer as oncologists' focal concern, time pressure, insufficient behavior change training, and care coordination challenges. Facilitators included perceiving a patient benefit and having health-promotion resources integrated into the cancer care system. CONCLUSIONS: Physicians often do not have the time, expertise, or resources to address health promotion with cancer survivors. Research is needed to evaluate whether health-promotion efforts compromise medical regimen adherence, as physicians' responses suggest.

Toward a precision behavioral medicine approach to addressing high-risk sun exposure: a qualitative analysis.

OBJECTIVES: Precision behavioral medicine techniques integrating wearable ultraviolet radiation (UVR) sensors may help individuals avoid sun exposure that places them at-risk for skin cancer. As a preliminary step in our patient-centered process of developing a just-in-time adaptive intervention, this study evaluated reactions and preferences to UVR sensors among melanoma survivors. MATERIALS AND METHODS: Early stage adult melanoma survivors were recruited for a focus group (n = 11) or 10-day observational study, which included daily wearing a UVR sensor and sun exposure surveys (n = 39). Both the focus group moderator guide and observational study exit interviews included questions on UVR sensing as a potential intervention strategy. These responses were transcribed and coded using an inductive strategy. RESULTS: Most observational study participants (84.6%) said they would find information provided by UVR sensors to be useful to help them learn about how specific conditions (eg, clouds, location) impact sun exposure and provide in-the-moment alerts. Focus group participants expressed enthusiasm for UVR information and identified preferred qualities of a UVR sensor, such as small size and integration with other devices. Participants in both studies indicated concern that UVR feedback may be difficult to interpret and some expressed that a UVR sensor may not be convenient or desirable to wear in daily life. DISCUSSION: Melanoma survivors believe that personalized UVR exposure information could improve their sun protection and want this information delivered in a method that is meaningful and actionable. CONCLUSION: UVR sensing is a promising component of a precision behavioral medicine strategy to reduce skin cancer risk.

Daily Minutes of Unprotected Sun Exposure (MUSE) Inventory: Measure description and comparisons to UVR sensor and sun protection survey data.

One in five US adults will be diagnosed with skin cancer. As most skin cancers are attributable to sun exposure, this risk factor is an important target for research and intervention. Most sun exposure measures assess frequency of specific sun-protection behaviors, which does not account for the use of multiple, potentially overlapping sun-protection methods. In contrast, the Daily Minutes of Unprotected Sun Exposure (MUSE) Inventory assesses sun-protection behavior during self-reported activities, providing several useful metrics, including duration of unprotected sun exposure on 17 body sites, combined to yield an overall MUSE score weighted by percent of body exposed. The present study was conducted July-September 2017, in Chicago, IL USA. For 10 days, participants (39 melanoma survivors; Mage = 58.59, 64.5% female) wore an ultraviolet radiation (UVR) sensor and completed the Daily MUSE Inventory each evening. The Sun Habits Survey was completed at the end of the study. Outdoor time reported in the MUSE Inventory significantly predicted outdoor time recorded by UVR sensors, B = 0.53, p < .001. For all sun-protection behaviors except shade, reports from the Daily MUSE Inventory (i.e., percentage of outdoor time a particular strategy was used) correlated with frequency ratings of the same strategy from the Sun Habits Survey (rs = 0.66-0.75, p < .05). In sum, the Daily MUSE Inventory corresponds with sensor and survey data, and provides a novel metric of unprotected sun exposure that will be useful for evaluating overall extent of sun exposure, including exposure on several smaller body sites that are at high risk for skin cancer.

Multicomponent mHealth Intervention for Large, Sustained Change in Multiple Diet and Activity Risk Behaviors: The Make Better Choices 2 Randomized Controlled Trial.

BACKGROUND: Prevalent co-occurring poor diet and physical inactivity convey chronic disease risk to the population. Large magnitude behavior change can improve behaviors to recommended levels, but multiple behavior change interventions produce small, poorly maintained effects. OBJECTIVE: The Make Better Choices 2 trial tested whether a multicomponent intervention integrating mHealth, modest incentives, and remote coaching could sustainably improve diet and activity. METHODS: Between 2012 and 2014, the 9-month randomized controlled trial enrolled 212 Chicago area adults with low fruit and vegetable and high saturated fat intakes, low moderate to vigorous physical activity (MVPA) and high sedentary leisure screen time. Participants were recruited by advertisements to an open-access website, screened, and randomly assigned to either of two active interventions targeting MVPA simultaneously with, or sequentially after other diet and activity targets (N=84 per intervention) or a stress and sleep contact control intervention (N=44). They used a smartphone app and accelerometer to track targeted behaviors and received personalized remote coaching from trained paraprofessionals. Perfect behavioral adherence was rewarded with an incentive of US $5 per week for 12 weeks. Diet and activity behaviors were measured at baseline, 3, 6, and 9 months; primary outcome was 9-month diet and activity composite improvement. RESULTS: Both simultaneous and sequential interventions produced large, sustained improvements exceeding control (P<.001), and brought all diet and activity behaviors to guideline levels. At 9 months, the interventions increased fruits and vegetables by 6.5 servings per day (95% CI 6.1-6.8), increased MVPA by 24.7 minutes per day (95% CI 20.0-29.5), decreased sedentary leisure by 170.5 minutes per day (95% CI -183.5 to -157.5), and decreased saturated fat intake by 3.6% (95% CI -4.1 to -3.1). Retention through 9-month follow-up was 82.1%. Self-monitoring decreased from 96.3% of days at baseline to 72.3% at 3 months, 63.5% at 6 months, and 54.6% at 9 months (P<.001). Neither attrition nor decline in self-monitoring differed across intervention groups. CONCLUSIONS: Multicomponent mHealth diet and activity intervention involving connected coaching and modest initial performance incentives holds potential to reduce chronic disease risk. TRIAL REGISTRATION: ClinicalTrials.gov NCT01249989; https://clinicaltrials.gov/ct2/show/NCT01249989 (Archived by WebCite at https://clinicaltrials.gov/ct2/show/NCT01249989).