The Effectiveness of Smartphone App-Based Interventions for Assisting Smoking Cessation: Systematic Review and Meta-analysis.

BACKGROUND: Smoking is a leading cause of premature death globally. Quitting smoking reduces the risk of all-cause mortality by 11%-34%. Smartphone app-based smoking cessation (SASC) interventions have been developed and are widely used. However, the evidence for the effectiveness of smartphone-based interventions for smoking cessation is currently equivocal. OBJECTIVE: The purpose of this study was to synthesize the evidence for the effectiveness of smartphone app-based interventions for smoking cessation. METHODS: We conducted a systematic review and meta-analysis of the effectiveness of smartphone interventions for smoking cessation based on the Cochrane methodology. An electronic literature search was performed using the Cochrane Library, Web of Science, PubMed, Embase, PsycINFO, China National Knowledge Infrastructure, and Wanfang databases to identify published papers in English or Chinese (there was no time limit regarding the publication date). The outcome was the smoking abstinence rate, which was either a 7-day point prevalence abstinence rate or a continuous abstinence rate. RESULTS: A total of 9 randomized controlled trials involving 12,967 adults were selected for the final analysis. The selected studies from 6 countries (the United States, Spain, France, Switzerland, Canada, and Japan) were included in the meta-analysis between 2018 and 2022. Pooled effect sizes (across all follow-up time points) revealed no difference between the smartphone app group and the comparators (standard care, SMS text messaging intervention, web-based intervention, smoking cessation counseling, or apps as placebos without real function; odds ratio [OR] 1.25, 95% CI 0.99-1.56, P=.06, I2=73.6%). Based on the subanalyses, 6 trials comparing smartphone app interventions to comparator interventions reported no significant differences in effectiveness (OR 1.03, 95% CI 0.85-1.26, P=.74, I2=57.1%). However, the 3 trials that evaluated the combination of smartphone interventions combined with pharmacotherapy compared to pharmacotherapy alone found higher smoking abstinence rates in the combined intervention (OR 1.79, 95% CI 1.38-2.33, P=.74, I2=7.4%). All SASC interventions with higher levels of adherence were significantly more effective (OR 1.48, 95% CI 1.20-1.84, P<.001, I2=24.5%). CONCLUSIONS: This systematic review and meta-analysis did not support the effectiveness of delivering smartphone-based interventions alone to achieve higher smoking abstinence rates. However, the efficacy of smartphone-based interventions increased when combined with pharmacotherapy-based smoking cessation approaches. TRIAL REGISTRATION: PROSPERO CRD42021267615; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=267615.

Engagement in Health Care From the Perspective of Older Adults.

Patient engagement is essential for improving health outcomes and lowering health care costs. The use of patient portals is becoming increasingly important for patient health care engagement. A convenience sample of 100 community-dwelling older adults completed a battery of surveys to explore the use of patient portals as an engagement tool. Criterion sampling was used to select a subset of 23 participants from the initial telephone survey to participate in one of four focus groups based on prior experience with a patient health portal (yes or no) and level of health literacy (low or high). Two core concepts and corresponding themes emerged: Patient Engagement Behaviors included the themes of managing health care, collaborating with providers, relying on family support, being proactive, advocating for health care, and seeking information. Patient-Provider Interactions included the themes of providers coordinate care, providers they can trust, two-way communication with providers, providers know them well, and providers give essential health information. Findings revealed a synergistic relationship among Patient Engagement Behaviors, Patient-Provider Interactions, and family support that can be strengthened in combination to promote the health care engagement capacity of older adults. [Research in Gerontological Nursing, 14(3), 138-149.].

Considerations for assessing physical function and physical activity in clinical trials during the COVID-19 pandemic.

The coronavirus disease-2019 (COVID-19) pandemic has changed the conduct of clinical trials. For studies with physical function and physical activity outcomes that require in-person participation, thoughtful approaches in transitioning to the remote research environment are critical. Here, we share our experiences in transitioning from in-person to remote assessments of physical function and activity during the pandemic and highlight key considerations for success. Details on the development of the remote assessment protocol, integration of a two-way video platform, and implementation of remote assessments are addressed. In particular, procedural challenges and considerations in transitioning and conducting remote assessments will be discussed in terms of efforts to maintain participant safety, maximize study efficiency, and sustain trial integrity. Plans for triangulation and analysis are also discussed. Although the role of telehealth platforms and research activities in remote settings are still growing, our experiences suggest that adopting remote assessment strategies are useful and convenient in assessing study outcomes during, and possibly even beyond, the current pandemic. Trial register and number: ClinicalTrials.gov [NCT03728257].

Predictors of Patient Portal Use Among Community-Dwelling Older Adults.

Older adults lag behind their younger counterparts in the use of patient portals, which may limit their ability to engage in health care. A better understanding of the factors associated with portal use among older adults is needed. We examined the proportion of 100 community-dwelling older adults who reported using a portal, the associations between sociobehavioral factors and portal use, and modeled predictors of portal use. Of the 52% who reported using a portal, 28% used the portal on their own, and 24% received assistance from others or had others access the portal on their behalf. After controlling for confounders, only marital status was significantly associated with any portal use. Marital status and patient activation were significantly associated with independent portal use. Further exploration is warranted to identify additional factors and the possible mechanisms underlying portal use by older adults. [Research in Gerontological Nursing, 14(1), 33-42.].

The Impact of Urban Zen Integrative Therapy on Symptoms and Health-Related Quality of Life for Patients with Pulmonary Hypertension.

Background: Patients with pulmonary hypertension (PH) experience distressing symptoms that can undermine quality of life (QoL) and treatment adherence. Complementary health approaches are known to help manage symptoms of chronic conditions and may have therapeutic benefits in PH. Objective: To explore the impact of Urban Zen Integrative Therapy (UZIT) on PH-related symptoms. Design: A within-subjects, pre-/post-intervention, repeated-measures design. Subjects/Setting: Community-dwelling adults with PH received weekly UZIT sessions in an outpatient setting. Measurements: Participants (n = 14) rated symptoms before and after each session and before and after the six-week UZIT program. Mixed-effects modeling with repeated measures was used to estimate differences in mean symptom scores before and after individual sessions. Cohen's d effect sizes were used to evaluate the impact of the UZIT program on symptoms. Results: Mean scores for pain (F(1, 105) = 19.99, p < 0.001), anxiety (F(1, 96) = 24.64, p < 0.001), fatigue (F(1, 120) = 15.68, p < 0.001), and dyspnea (F(1, 68) = 16.69, p < 0.001) were significantly reduced after UZIT sessions. Effects were moderate to large for symptom severity (d = 0.59-1.32) and moderate for symptom burden (d = 0.56) and fatigue (d = 0.62), and small for QoL (d = 0.33) after the six-week UZIT program. Conclusions: Individualized UZIT sessions were associated with reductions in symptom severity for pain, anxiety, fatigue, and dyspnea. The six-week UZIT program was associated with improvements in symptom burden, activity limitation, and QoL. ClinicalTrial.gov no.: NCT03194438.

Intervention fidelity monitoring of Urban Zen Integrative Therapy (UZIT) for persons with pulmonary hypertension.

BACKGROUND: Systematic and consistent dose delivery is critical in intervention research. Few studies testing complementary health approach (CHA) interventions describe intervention fidelity monitoring (IFM) and measurement. OBJECTIVE: To describe methodological processes in establishing and measuring consistent dose, delivery, and duration of a multi-component CHA intervention. METHODS: Adults with pulmonary hypertension received six weekly, 1-hour Urban Zen Integrative Therapy (UZIT) sessions. A total of 78 sessions were delivered and 33% of these sessions were audited. Intervention dose (time allocated to each component), intervention consistency (protocol adherence audits), and intervention delivery (performance and sequence of components) were captured using remote video observation and review of the recorded video. IFM audits were performed at the beginning (n = 16), middle (n = 5), and end (n = 5) of the study. RESULTS: UZIT interventionists adhered to the intervention protocol (99.3%) throughout the study period. Interventionists delivered UZIT components within the prescribed timeframe: 1) Beginning: gentle body movement (18.9 ± 5.8 min.), restorative pose with guided body awareness meditation (21.3 ± 2.7 min.), and Reiki (22.8 ± 3.1 min.); 2) Middle: gentle body movement (15.9 ± 1.5 min.), pose/body awareness meditation (30.1 ± 6.5 min.), and Reiki (30.1 ± 7.0 min.); 3) End: gentle body movement (18.1 ± 3.6 min.), pose/body awareness meditation (35.3 ± 6.4 min.), and Reiki (34.5 ± 7.0 min.). Essential oil inhalation was delivered during UZIT sessions 100% of the time. Interventionists adhered to treatment delivery behaviors throughout the study period: beginning (98.86%), middle (100%), and end (100%). DISCUSSION: In this pilot study, we demonstrated that the dose, consistency, and delivery of multi-component CHA therapy can be standardized and monitored to ensure intervention fidelity.

Acceptance and Use of Mobile Technology for Health Self-Monitoring in Lung Transplant Recipients during the First Year Post-Transplantation.

OBJECTIVES: To describe lung transplant recipients (LTRs') acceptance and use of mobile technology for health self-monitoring during the first year post-transplantation, and explore correlates of the use of technology in the 0 to 2, >2 to ≤6, >6 to ≤12, and 0 to 12 months. METHODS: Secondary analysis of data from 96 LTR assigned to use Pocket PATH(®), a smartphone application, for daily health self-monitoring in a randomized controlled trial. Use of Pocket PATH was categorized as low, moderate, and high use. Proportional odds models for ordinal logistic regression were employed to explore correlates of use of technology. RESULTS: LTR reported high acceptance of Pocket PATH at baseline. However, acceptance was not associated with actual use over the 12 months (p=0.45~0.96). Actual use decreased across time intervals (p<0.001). Increased self-care agency was associated with the increased odds of higher use in women (p=0.03) and those less satisfied with technology training (p=0.02) in the first 2 months. Higher use from >2 to ≤6 months was associated with greater satisfaction with technology training (OR=3.37, p=0.01) and shorter length of hospital stay (OR=0.98, p=0.02). Higher use from >6 to ≤12 months was associated with older age (OR=1.05, p=0.02), lower psychological distress (OR=0.43, p=0.02), and better physical functioning (OR=1.09, p=0.01). Higher use over 12 months was also associated with older age (OR=1.05, p=0.007), better physical functioning (OR=1.13, p=0.001), and greater satisfaction with technology training (OR=3.05, p=0.02). CONCLUSIONS: Correlates were different for short- and long-term use of mobile technology for health self-monitoring in the first year post-transplantation. It is important to follow up with LTR with longer hospital stay, poor physical functioning, and psychological distress, providing ongoing education to improve their long-term use of technology for health self-monitoring.

Patterns and Predictors of Sleep Quality Within the First Year After Lung Transplantation.

CONTEXT: Sleep quality affects health and self-management in chronic illness. Limited research has examined patterns and predictors of sleep quality and its impact on self-management and health-related quality of life (HRQOL) among lung transplant recipients (LTRs). OBJECTIVE: The aims of this study were to identify the patterns, predictors, and impact of poor sleep quality on self-management behaviors and HRQOL the first year after lung transplantation. METHODS: Secondary analysis of 75 LTRs who participated in a randomized controlled trial. Pittsburgh Sleep Quality Index (PSQI) was administered at baseline, 2, 6, and 12 months after transplant; 12-month PSQI was dichotomized categorizing good versus poor sleepers. Predictors were measured at the time of transplant; self-management and HRQOL were measured at 12 months. Logistic regression identified predictors of poor sleep. Correlations examined poor sleep quality, self-management behaviors, and HRQOL. RESULTS: Sleep quality was relatively stable during the first year, and 24 of the 75 (32%) of the sample met criteria for poor sleep quality at 12 months. The only multivariate predictor of poor sleep was female gender (odds ratio = 3.421; P = .026); the mental component of HRQOL was the only outcome associated with poor sleep (r = -.348; P < .01). CONCLUSION: Nearly one-third of LTRs reported persistent poor sleep through year 1. More females reported poor sleep quality, and sleep quality was inversely related to mental HRQOL by 12 months. Knowledge of these relationships may help identify LTRs at the greatest risk for poor sleep and guide strategies to promote sleep and optimize HRQOL.

Delivering an in-Home Exercise Program via Telerehabilitation: A Pilot Study of Lung Transplant Go (LTGO).

We evaluated the feasibility, safety, system usability, and intervention acceptability of Lung Transplant Go (LTGO), an 8-week in-home exercise intervention for lung transplant recipients using a telerehabilitation platform, and described changes in physical function and physical activity from baseline to post-intervention. The intervention was delivered to lung transplant recipients in their home via the Versatile and Integrated System for TeleRehabilitation (VISYTER). The intervention focused on aerobic and strengthening exercises tailored to baseline physical function. Participants improved walk distance (6-minute walk distance), balance (Berg Balance Scale), lower body strength (30-second chair stand test) and steps walked (SenseWear Armband®). No adverse events were reported. Participants rated the program highly positively in regard to the technology and intervention. The telerehabilitation exercise program was feasible, safe, and acceptable. Our findings provide preliminary support for the LTGO intervention to improve physical function and promote physical activity in lung transplant recipients.

Predictors and influence of goal orientation on self-management and health-related quality of life after lung transplant.

Context-Lung transplant recipients are encouraged to perform self-management behaviors to maximize health outcomes; however, performance is often less than ideal. Goal orientation is known to influence achievement of academic goals, but the influence of goal orientation on performance of self-management is unknown. Objectives-To identify characteristics at transplant that are predictive of higher goal orientation and examine relationships between Goal Orientation Index (GOI) subscores (Acting, Planning, Reflecting), self-management behaviors (adhering, self-monitoring, and communicating critical changes), and health-related quality of life (HRQOL) at 1 year after transplant. Design-A descriptive, secondary analysis of data from 33 lung transplant recipients who were assessed at transplant and followed for 1 year as part of a clinical trial. GOI subscores were dichotomized at the median to categorize recipients with high and low goal orientation. Logistic regression was used to identify predictors of higher GOI subscores. Correlations between higher GOI subscores, self-management, and HRQOL were examined. Results-Lung transplant recipients reported relatively high mean GOI subscores (Acting, Planning, and Reflecting) and the 3 subscores were correlated (r=0.31-0.86). Self-care agency was the only significant predictor (P=.04) of higher GOI (Reflecting). Lung transplant recipients with higher Planning and Reflecting subscores were more likely to adhere (r = 0.36 and 0.46, respectively). Recipients with higher GOI subscores reported significantly better mental HRQOL (r = 0.42-0.36). Recipients with higher GOI Planning or Acting subscores reported significantly less anxiety (r = -0.39-0.46) and fewer depressive symptoms (r = -0.40-0.43). Conclusion-Assessing goal orientation may offer a novel approach for promoting adherence and HRQOL after lung transplant.

Preferences for technology versus human assistance and control over technology in the performance of kitchen and personal care tasks in baby boomers and older adults.

PURPOSE: Quality of Life technology (QoLT) stresses humans and technology as mutually dependent and aware, working together to improve task performance and quality of life. This study examines preferences for technology versus human assistance and control in the context of QoLT. METHOD: Data are from a nationally representative, cross-sectional web-based sample of 416 US baby boomers (45-64) and 114 older adults (65+) on preferences for technology versus human assistance and control in the performance of kitchen and personal care tasks. Multinomial logistic regression and ordinary least squares regression were used to determine predictors of these preferences. RESULTS: Respondents were generally accepting of technology assistance but wanted to maintain control over its' operation. Baby boomers were more likely to prefer technology than older adults, and those with fewer QoLT privacy concerns and who thought they were more likely to need future help were more likely to prefer technology over human assistance and more willing to relinquish control to technology. CONCLUSIONS: Results suggest the need for design of person- and context-aware QoLT systems that are responsive to user desires for level of control over operation of the technology. The predictors of these preferences suggest potentially receptive markets for the targeting of QoLT systems.

Rates and correlates of health maintenance behaviors after living kidney donation.

CONTEXT AND OBJECTIVE: Donating a kidney may provide an opportunity for donors to reevaluate their health maintenance behaviors (eg, regular exercise, smoking cessation, medical checkups). Although the effect of donation on donors' health, quality of life, and financial outcomes has received growing attention, no studies have examined whether donation is related to changes in health maintenance behaviors. The study aims were to (1) describe and compare kidney donors' health maintenance behaviors before and after donation, and (2) determine the correlates of health maintenance behaviors after donation. DESIGN, SETTING, PARTICIPANTS AND MEASURES: We conducted a telephone-interview study with 85 randomly selected laparoscopic kidney donors in a major US transplant center to assess health behaviors before and after donation, postdonation characteristics (eg, quality of life, postsurgical pain), and demographics. RESULTS: Sample demographics included a median age of 48 years; 55% were female, 82% were white, 71% were married, and 52% were college graduates. Few health behaviors changed significantly from before to after donation. Only the rate of medical checkups increased after donation (P< .001). Logistic regression was used to examine the association of demographics and postdonation characteristics with postdonation health maintenance behaviors, after adjusting for predonation behavior. Older age, higher income, less postsurgical pain, and better physical functioning were associated with more exercise after donation. Longer time since donation was associated with a higher prevalence of obesity. CONCLUSIONS: These results may help identify donors who are at greater risk for poor health maintenance behaviors after donation and suggest areas of health behavior that should be the focus of education sessions before donation.

Daily burdens of recipients and family caregivers after lung transplant.

CONTEXT: Lung transplant recipients are prescribed a complex medical regimen that is thought to be burdensome and to interfere with daily activities of recipients and family caregivers. Yet empirical studies describing the activities that lung transplant recipients and their family caregivers perform on a typical day and the emotions associated with performing these activities are lacking. OBJECTIVE: To identify the daily activities and burdens after lung transplant. DESIGN: The Day Reconstruction Method and content analysis were used to reconstruct a typical day for lung transplant recipients and their family caregivers. SETTING: The adult cardiothoracic transplant program of The University of Pittsburgh Medical Center. PARTICIPANTS: Twenty-one dyads of lung transplant recipients and their family caregivers. MAIN OUTCOME MEASURES: Variables of interest included lung transplant recipients' and family caregivers' daily activities and associated emotions, sociodemographics, clinical characteristics, and patient-reported outcomes of quality of life, symptoms of depression and anxiety, and functional performance. RESULTS: Participants reported 286 daily activities and 138 associated positive and negative emotions. No activities or emotions were uniquely reported by lung transplant recipients or caregivers, providing evidence of the shared responsibility for caregiving and health maintenance. Most activities reported by caregivers and lung transplant recipients were health-related. Compared with lung transplant recipients, caregivers reported positive emotions more often, yet reported lower overall daily mood. This finding is consistent with results of previous studies indicating that specific caregiving tasks were typically rewarding for caregivers, but overall, care giving takes its toll. CONCLUSION: Findings enhance our understanding of the burdens lung transplant recipients and caregivers face and point to the need for further support for dyads after lung transplant.

Medical adherence in pediatric organ transplantation: what are the next steps?

PURPOSE OF REVIEW: Adherence within pediatric transplantation has gained importance as the complexities of long-term medical management of these patients are identified and knowledge regarding the negative consequences of nonadherence accumulates. We review recent findings to highlight gaps in the literature and make suggestions for future directions. RECENT FINDINGS: Most research has focused on medication nonadherence, and a recent meta-analysis indicates that nonadherence is more prevalent in adolescent transplant recipients than in younger children. Nonadherence to other areas of the regimen (e.g. clinic attendance) may be even more common than medication nonadherence. However, work to date is based primarily on kidney and liver pediatric transplant patients, with a paucity of research on heart, lung and intestinal recipients. Risk factors for nonadherence after pediatric transplantation include poor family and child functioning. Intervention research remains rare. Challenges include the need for clearer definitions of what constitutes clinically significant nonadherence, longitudinal and prospective assessment of a wider range of potential risk factors, and the development and evaluation of interventions to treat or prevent nonadherence. SUMMARY: Adherence research in pediatric transplantation is in its infancy. Significant opportunities exist to advance the field and create standards for effective identification, measurement, and treatment of nonadherence.

Data safety and monitoring for research involving remote health monitoring.

Investigators conducting research involving human subjects are obligated to safeguard the wellbeing of the study participants. Other than requiring investigators to establish procedures for ongoing monitoring and reporting of adverse events, federal regulations do not dictate how human subject safety should be ensured. A variety of data safety monitoring (DSM) procedures may be acceptable depending on the nature, size, and complexity of the study. However, practical guidance for establishing and implementing appropriate DSM plans for such studies are lacking. In this article, we provide a review of the DSM considerations associated with monitoring health remotely and describe the Pocket Personal Assistant for Tracking Health project as an exemplar for how to develop effective DSM plans for research that captures clinical data using remote health-monitoring devices. Protecting the safety and welfare of participants is one of the most important mandates for research involving human subjects. Investigators have an ethical and scientific responsibility to monitor the safety of research participants. Investigators typically fulfill this responsibility by monitoring and reporting adverse events.

Critical thinking skills in nursing students: comparison of simulation-based performance with metrics.

AIM: This paper is a report of an examination of the relationship between metrics of critical thinking skills and performance in simulated clinical scenarios. BACKGROUND: Paper and pencil assessments are commonly used to assess critical thinking but may not reflect simulated performance. METHODS: In 2007, a convenience sample of 36 nursing students participated in measurement of critical thinking skills and simulation-based performance using videotaped vignettes, high-fidelity human simulation, the California Critical Thinking Disposition Inventory and California Critical Thinking Skills Test. Simulation-based performance was rated as 'meeting' or 'not meeting' overall expectations. Test scores were categorized as strong, average, or weak. RESULTS: Most (75.0%) students did not meet overall performance expectations using videotaped vignettes or high-fidelity human simulation; most difficulty related to problem recognition and reporting findings to the physician. There was no difference between overall performance based on method of assessment (P = 0.277). More students met subcategory expectations for initiating nursing interventions (P ≤ 0.001) using high-fidelity human simulation. The relationship between videotaped vignette performance and critical thinking disposition or skills scores was not statistically significant, except for problem recognition and overall critical thinking skills scores (Cramer's V = 0.444, P = 0.029). There was a statistically significant relationship between overall high-fidelity human simulation performance and overall critical thinking disposition scores (Cramer's V = 0.413, P = 0.047). CONCLUSION: Students' performance reflected difficulty meeting expectations in simulated clinical scenarios. High-fidelity human simulation performance appeared to approximate scores on metrics of critical thinking best. Further research is needed to determine if simulation-based performance correlates with critical thinking skills in the clinical setting.

Meta-analysis of medical regimen adherence outcomes in pediatric solid organ transplantation.

BACKGROUND: Adherence to the medical regimen after pediatric organ transplantation is important for maximizing good clinical outcomes. However, the literature provides inconsistent evidence regarding prevalence and risk factors for nonadherence posttransplant. METHODS: A total of 61 studies (30 kidney, 18 liver, 8 heart, 2 lung/heart-lung, and 3 with mixed recipient samples) were included in a meta-analysis. Average rates of nonadherence to six areas of the regimen, and correlations of potential risk factors with nonadherence, were calculated. RESULTS: Across all types of transplantation, nonadherence to clinic appointments and tests was most prevalent, at 12.9 cases per 100 patients per year (PPY). The immunosuppression nonadherence rate was six cases per 100 PPY. Nonadherence to substance use restrictions, diet, exercise, and other healthcare requirements ranged from 0.6 to 8 cases per 100 PPY. Only the rate of nonadherence to clinic appointments and tests varied by transplant type: heart recipients had the lowest rate (4.6 cases per 100 PPY vs. 12.7-18.8 cases per 100 PPY in other recipients). Older age of the child, family functioning (greater parental distress and lower family cohesion), and the child's psychological status (poorer behavioral functioning and greater distress) were among the psychosocial characteristics significantly correlated with poorer adherence. These correlations were small to modest in size (r=0.12-0.18). CONCLUSIONS: These nonadherence rates provide benchmarks for clinicians to use to estimate patient risk. The identified psychosocial correlates of nonadherence are potential targets for intervention. Future studies should focus on improving the prediction of nonadherence risk and on testing interventions to reduce risk.

The utility of the Purpose-in-Life Test in persons with AIDS.

The purpose of this study was to describe the utility of the Purpose-in-Life Test among persons with AIDS using both Part A (quantitative) and Part B (qualitative). A cross-sectional descriptive design was used with a sample of 74 persons with AIDS from community settings. The Purpose-in-Life Test and a sociodemographic questionnaire were administered. Analytic methods included descriptive and inferential statistics and content analysis. Part A scores indicated that only one third of the participants reported a definite purpose in life; however, results from Part B demonstrated that the majority of participants viewed their life as meaningful and dynamic. Demographic characteristics such as race, income, and education were significantly related to purpose in life. Assessing purpose in life using both Part A and Part B of the Purpose-in-Life Test may assist nurses with a more in-depth understanding of purpose in life and assist persons with AIDS with identifying opportunities for personal growth.