Investigating psychological mechanisms linking pain severity to depression symptoms in women cancer survivors at a cancer center with a rural catchment area.

PURPOSE: Women cancer survivors, especially those in rural areas, with high levels of depression may be acutely susceptible to pain due to the ways they think, feel, and behave. The current study seeks to elucidate the relationship between symptoms of depression and pain severity in women cancer survivors, by examining the putative mediators involved in this relationship, specifically their self-efficacy for managing their health, how overwhelmed they were from life's responsibilities, and relational burden. METHODS: Self-report data were collected from 183 cancer survivors of breast, cervical, ovarian, or endometrial/uterine cancer, who were between 6 months and 3 years post-active therapy. RESULTS: Women cancer survivors with higher (vs. lower) symptoms of depression had more severe pain. Individual mediation analyses revealed that survivors with higher levels of depression felt more overwhelmed by life's responsibilities and had lower self-efficacy about managing their health, which was associated with greater pain severity. When all mediators were simultaneously entered into the same model, feeling overwhelmed by life's responsibilities significantly mediated the link between survivors' symptoms of depression and their pain severity. CONCLUSIONS: The relationship between symptoms of depression and pain severity in women cancer survivors may be attributed in part to their self-efficacy and feeling overwhelmed by life's responsibilities. Early and frequent assessment of psychosocial factors involved in pain severity for women cancer survivors may be important for managing their pain throughout the phases of cancer survivorship.

Associations between context and affect within the daily lives of cancer caregivers.

PURPOSE: This study used ecological momentary assessment (EMA) to test the association between activity, location, and social company contexts with cancer caregivers' in-the-moment affect to identify precisely when and where to deliver psychological interventions for caregivers. METHODS: Current cancer caregivers (N = 25) received 8 EMA prompts per day for 7 consecutive days. At each prompt, caregivers reported their current positive affect and negative affect, as well as what they were doing, where they were located, and who they were with. Multilevel logistic regressions tested the associations between caregivers' contexts with their own person-mean-centered state (concurrent momentary level) and trait (overall weekly average) positive or negative affect. RESULTS: Caregivers reported lower state negative affect, as well as higher state positive affect, when socializing (ps < .001), when at a public location (ps < .03), and when around their friends, family, spouse/partner, or care recipient (i.e., person with cancer, ps < .02), relative to when not endorsing the context. Caregivers also reported lower state negative affect when eating/drinking or engaging in leisure (ps < .01; but no parallel effects for state positive affect). Caregivers reported higher state negative affect while working, when at their workplace, or when around work colleagues (ps < .001) and lower state positive affect when at home or alone (ps < .03). CONCLUSIONS: Results suggest the pertinence of a behavioral activation framework to mitigate the emotional strain of caregiving. Interventions that facilitate caregivers' ability to socialize with a range of friends and family, including their loved one with cancer, outside of the home may have the strongest positive emotional impact.

Effects of an internet-delivered insomnia intervention for older adults: A secondary analysis on symptoms of depression and anxiety.

OBJECTIVE: To test whether an Internet-delivered cognitive behavioral therapy for insomnia (CBT-I) program for older adults attenuates symptoms of depression and anxiety. METHODS: Adults aged ≥ 55 with insomnia were randomized to SHUTi-OASIS (Sleep Healthy Using the Internet for Older Adult Sufferers of Insomnia and Sleeplessness; N = 207) or Patient Education (PE; N = 104). Depression and anxiety were assessed (HADS-D and HADS-A, respectively) at baseline, post-assessment, and 6- and 12-month follow-ups. RESULTS: Multilevel modeling of HADS-D showed a condition by time interaction (F[3,779] = 3.23, p = .02): SHUTi-OASIS participants reported lower symptoms than PE at post-assessment. There was no such interaction effect for HADS-A (F[3,779] = 2.12, p = .10). Generalized linear modeling showed no moderation of effects by baseline symptom severity. CONCLUSIONS: Participants randomized to Internet-delivered CBT-I showed stable depression and anxiety across time, while control participants' depressive symptoms briefly increased. CBT-I may help prevent development or worsening of psychological distress among older adults with insomnia. TRIAL REGISTRATION: [Registered at ClinicalTrials.gov; identifier removed for anonymity].

Feasibility of ecological momentary assessment to study depressive symptoms among cancer caregivers.

OBJECTIVE: Ecological momentary assessment (EMA) may help with the development of more targeted interventions for caregivers' depression, yet the use of this method has been limited among cancer caregivers. This study aimed to demonstrate the feasibility of EMA among cancer caregivers and the use of EMA data to understand affective correlates of caregiver depressive symptoms. METHODS: Caregivers (N = 25) completed a depressive symptom assessment (Patient Health Questionnaire-8) and then received eight EMA survey prompts per day for 7 days. EMA surveys assessed affect on the orthogonal dimensions of valence and arousal. Participants completed feedback surveys regarding the EMA protocol at the conclusion of the week-long study. RESULTS: Of 32 caregivers approached, 25 enrolled and participated (78%), which exceeded the a priori feasibility cutoff of 55%. The prompt completion rate (59%, or 762 of 1,286 issued) did not exceed the a priori cutoff of 65%, although completion was not related to caregivers' age, employment status, physical health quality of life, caregiving stress, or depressive symptoms or the patients' care needs (ps > 0.22). Caregivers' feedback about their study experience was generally positive. Mixed-effects location scale modeling showed caregivers' higher depressive symptoms were related to overall higher reported negative affect and lower positive affect, but not to affective variability. CONCLUSIONS: Findings from this feasibility study refute potential concerns that an EMA design is too burdensome for distressed caregivers. Clinically, findings suggest the potential importance of not only strategies to reduce overall levels of negative affect, but also to increase opportunities for positive affect.

Recruiting breast cancer patients for mHealth research: Obstacles to clinic-based recruitment for a mobile phone app intervention study.

BACKGROUND: Nearly half of newly diagnosed breast cancer patients will report clinically significant symptoms of depression and/or anxiety within the first year of diagnosis. Research on the trajectory of distress in cancer patients suggests that targeting patients early in the diagnostic pathway could be particularly impactful. Given the recent rise of smartphone adoption, apps are a convenient and accessible platform from which to deliver mental health support; however, little research has examined their potential impact among newly diagnosed cancer patients. One reason is likely due to the obstacles associated with in-clinic recruitment of newly diagnosed cancer patients for mHealth pilot studies. METHODS: This article draws from our experiences of a recently completed pilot study to test a suite of mental health apps in newly diagnosed breast cancer patients. Recruitment strategies included in-clinic pamphlets, flyers, and direct communication with clinicians. Surgical oncologists and research staff members approached eligible patients after a medical appointment. Research team members met with patients to provide informed consent and review the study schedule. RESULTS: Four domains of in-clinic recruitment challenges emerged: (a) coordination with clinic staff, (b) perceived burden among breast cancer patients, (c) limitations regarding the adoption and use of technology, and (d) availability of resources. Potential solutions are provided for each challenge. CONCLUSION: Recruitment of newly diagnosed cancer patients is a major challenge to conducting mobile intervention studies for researchers on a pilot-study budget. To realize the impact of mobile interventions for the most vulnerable cancer patient populations, health researchers must address barriers to in-clinic recruitment to provide vital preliminary data in proposals of large-scale research projects.

Do treatment effects of a web-based cognitive behavioral therapy for insomnia intervention differ for users with and without pain interference? A secondary data analysis.

Cognitive-behavioral therapy for insomnia (CBT-I) shows treatment benefits among individuals with pain interference; however, effects of Internet-delivered CBT-I for this population are unknown. This secondary analysis used randomized clinical trial data from adults assigned to Internet-delivered CBT-I to compare changes in sleep by pre-intervention pain interference. Participants (N = 151) completed the Insomnia Severity Index (ISI) and sleep diaries [sleep onset latency (SOL); wake after sleep onset (WASO)] at baseline, post-assessment, 6- and 12-month follow-ups. Linear mixed-effects models showed no differences between pain interference groups (no, some, moderate/severe) for changes from baseline to any follow-up timepoint for ISI (p = .72) or WASO (p = .88). There was a small difference in SOL between those reporting some versus no or moderate/severe pain interference (p = .04). Predominantly comparable and sustained treatment benefits for both those with and without pain interference suggest that Internet-delivered CBT-I is promising for delivering accessible care to individuals with comorbid pain and insomnia.

The Model of Gamification Principles for Digital Health Interventions: Evaluation of Validity and Potential Utility.

BACKGROUND: Although gamification continues to be a popular approach to increase engagement, motivation, and adherence to behavioral interventions, empirical studies have rarely focused on this topic. There is a need to empirically evaluate gamification models to increase the understanding of how to integrate gamification into interventions. OBJECTIVE: The model of gamification principles for digital health interventions proposes a set of five independent yet interrelated gamification principles. This study aimed to examine the validity and reliability of this model to inform its use in Web- and mobile-based apps. METHODS: A total of 17 digital health interventions were selected from a curated website of mobile- and Web-based apps (PsyberGuide), which makes independent and unbiased ratings on various metrics. A total of 133 independent raters trained in gamification evaluation techniques were instructed to evaluate the apps and rate the degree to which gamification principles are present. Multiple ratings (n≥20) were collected for each of the five gamification principles within each app. Existing measures, including the PsyberGuide credibility score, mobile app rating scale (MARS), and the app store rating of each app were collected, and their relationship with the gamification principle scores was investigated. RESULTS: Apps varied widely in the degree of gamification implemented (ie, the mean gamification rating ranged from 0.17≤m≤4.65 out of 5). Inter-rater reliability of gamification scores for each app was acceptable (κ≥0.5). There was no significant correlation between any of the five gamification principles and the PsyberGuide credibility score (P≥.49 in all cases). Three gamification principles (supporting player archetypes, feedback, and visibility) were significantly correlated with the MARS score, whereas three principles (meaningful purpose, meaningful choice, and supporting player archetypes) were significantly correlated with the app store rating. One gamification principle was statistically significant with both the MARS and the app store rating (supporting player archetypes). CONCLUSIONS: Overall, the results support the validity and potential utility of the model of gamification principles for digital health interventions. As expected, there was some overlap between several gamification principles and existing app measures (eg, MARS). However, the results indicate that the gamification principles are not redundant with existing measures and highlight the potential utility of a 5-factor gamification model structure in digital behavioral health interventions. These gamification principles may be used to improve user experience and enhance engagement with digital health programs.

Developing a Process for the Analysis of User Journeys and the Prediction of Dropout in Digital Health Interventions: Machine Learning Approach.

BACKGROUND: User dropout is a widespread concern in the delivery and evaluation of digital (ie, web and mobile apps) health interventions. Researchers have yet to fully realize the potential of the large amount of data generated by these technology-based programs. Of particular interest is the ability to predict who will drop out of an intervention. This may be possible through the analysis of user journey data-self-reported as well as system-generated data-produced by the path (or journey) an individual takes to navigate through a digital health intervention. OBJECTIVE: The purpose of this study is to provide a step-by-step process for the analysis of user journey data and eventually to predict dropout in the context of digital health interventions. The process is applied to data from an internet-based intervention for insomnia as a way to illustrate its use. The completion of the program is contingent upon completing 7 sequential cores, which include an initial tutorial core. Dropout is defined as not completing the seventh core. METHODS: Steps of user journey analysis, including data transformation, feature engineering, and statistical model analysis and evaluation, are presented. Dropouts were predicted based on data from 151 participants from a fully automated web-based program (Sleep Healthy Using the Internet) that delivers cognitive behavioral therapy for insomnia. Logistic regression with L1 and L2 regularization, support vector machines, and boosted decision trees were used and evaluated based on their predictive performance. Relevant features from the data are reported that predict user dropout. RESULTS: Accuracy of predicting dropout (area under the curve [AUC] values) varied depending on the program core and the machine learning technique. After model evaluation, boosted decision trees achieved AUC values ranging between 0.6 and 0.9. Additional handcrafted features, including time to complete certain steps of the intervention, time to get out of bed, and days since the last interaction with the system, contributed to the prediction performance. CONCLUSIONS: The results support the feasibility and potential of analyzing user journey data to predict dropout. Theory-driven handcrafted features increased the prediction performance. The ability to predict dropout at an individual level could be used to enhance decision making for researchers and clinicians as well as inform dynamic intervention regimens.

Examining the relationship between changes in personality and depression in older adult cancer survivors.

Objectives: Despite widespread agreement that personality traits change across the lifespan into older adulthood, the association between changes in personality and depression among older adult cancer survivors is unknown. It was hypothesized that older adults with (vs. without) a past cancer diagnosis would experience an increase in neuroticism, and decreases in conscientiousness, agreeableness, openness, and extraversion, and that changes in these traits would mediate the relationship between receiving a cancer diagnosis and change in depression. Two hypotheses were tested in a cancer survivor sample. First, that increased chronic stressors and decreased physical health would mediate the link between personality change and increased depression. Second, that personality change would mediate the link between changes in chronic stressors/health and increased depression.Method: Secondary data analysis utilizing three waves of data from the Health and Retirement Study. Data was compiled from 5,217 participants, among whom 707 received a cancer diagnosis.Results: Older adults with (vs. without) a cancer diagnosis decreased in conscientiousness, which was associated with increased depression. Among cancer survivors, worsening chronic stressors/health mediated many pathways between personality change and an increased depression. Increased neuroticism mediated the link between worsening health/chronic stressors and increased depression.Conclusion: With the exception of conscientiousness, changes in personality did not mediate the link between cancer survivor status and depression. Among older adult cancer survivors, changes in personality traits may increase depression through worsening physical health and chronic stressors, potentially informing targeted interventions. Interventions that target increased neuroticism may be particularly useful in older adult cancer survivors.

Relationships between trait emotion dysregulation and emotional experiences in daily life: an experience sampling study.

Few studies have examined how trait emotion dysregulation relates to momentary affective experiences and the emotion regulation (ER) strategies people use in daily life. In the current study, 112 college students completed a trait measure of emotion dysregulation and completed experience sampling and end-of-day surveys over a two- to three-week period, asking about their emotional experiences and ER strategy use. Participants completed a total of 3798 experience sampling (in-the-moment) and 995 nightly diary surveys. We examined the top 40% of each participant's reported instances of negative affect (to capture times when emotions more likely need regulation). Results indicated that a higher level of trait emotion dysregulation was associated with the following in-the-moment responses: (a) higher level of negative affect; (b) greater desire to change emotions; (c) more attempts to regulate emotion; (d) higher relative endorsements of avoidant (e.g. thought suppression) versus engagement (e.g. acceptance) ER strategy use; and (e) lower perceived effectiveness of ER. Further, individuals with a higher (vs. lower) level of trait emotion dysregulation were less able to identify emotions over the course of the day. Findings demonstrate how trait emotion dysregulation may predict emotional experiences and ER in daily life.

Examining the feasibility, acceptability, and potential utility of mobile distress screening in adult cancer patients.

OBJECTIVE: A common method of distress monitoring in cancer patients relies on static and retrospective data collected in-person at the time of a health care provider appointment. Relatively little work has examined the potential usefulness of mobile distress monitoring using cancer patients' smartphones. The current study deployed longitudinal distress monitoring using secure text messaging. METHODS: In an observational study, a total of 52 cancer patients receiving active cancer treatment (Mage  = 58, 62% female) received a text message once a week for 4 weeks. Text messages contained a secure link to complete online the Patient Health Questionnaire-4 (PHQ-4), a commonly used distress screener. RESULTS: Cancer patients completed a distress screener 75% of the time they received a text message. On average, it took less than a minute to complete each mobile distress screener. Geolocation data indicated that cancer patients completed distress screeners across a range of locations. Analyses of model fit of distress scores indicated significant heterogeneity in variability of distress scores over time and across cancer patients (AIC = 630.5). Quantitative feedback from cancer patients at the end of the study indicated high ease of use, ease of learning, and satisfaction of completing mobile distress screeners. CONCLUSIONS: These findings support the use of secure text messaging to monitor longitudinal, out of clinic, distress in cancer patients. Findings also highlight the importance of mobile-based approaches to distress screening in order to maximize opportunities to intervene.

How badly will I feel if you don't like me?: Social anxiety and predictions of future affect.

The current study investigated whether high and low socially anxious individuals would show differences in affective forecasting accuracy (i.e., the prediction of emotional states in response to future events) to positive versus negative social evaluation. High (n=94) and low (n=98) socially anxious participants gave a speech and were randomly assigned to receive a positive or negative evaluation. For affective forecasts made proximally (moments before the speech), those low in social anxiety overpredicted their affect to a greater extent to a negative evaluation versus a positive evaluation. In contrast, those high in social anxiety overpredicted their affect to positive and negative evaluations comparably, and failed to adjust their prediction for a future hypothetical negative evaluation - in effect, not learning from their prior forecasting error. Results suggest that affective forecasting biases deserve further study as a maintaining factor for social anxiety symptoms.

Using Mobile Sensing to Test Clinical Models of Depression, Social Anxiety, State Affect, and Social Isolation Among College Students.

BACKGROUND: Research in psychology demonstrates a strong link between state affect (moment-to-moment experiences of positive or negative emotionality) and trait affect (eg, relatively enduring depression and social anxiety symptoms), and a tendency to withdraw (eg, spending time at home). However, existing work is based almost exclusively on static, self-reported descriptions of emotions and behavior that limit generalizability. Despite adoption of increasingly sophisticated research designs and technology (eg, mobile sensing using a global positioning system [GPS]), little research has integrated these seemingly disparate forms of data to improve understanding of how emotional experiences in everyday life are associated with time spent at home, and whether this is influenced by depression or social anxiety symptoms. OBJECTIVE: We hypothesized that more time spent at home would be associated with more negative and less positive affect. METHODS: We recruited 72 undergraduate participants from a southeast university in the United States. We assessed depression and social anxiety symptoms using self-report instruments at baseline. An app (Sensus) installed on participants' personal mobile phones repeatedly collected in situ self-reported state affect and GPS location data for up to 2 weeks. Time spent at home was a proxy for social isolation. RESULTS: We tested separate models examining the relations between state affect and time spent at home, with levels of depression and social anxiety as moderators. Models differed only in the temporal links examined. One model focused on associations between changes in affect and time spent at home within short, 4-hour time windows. The other 3 models focused on associations between mean-level affect within a day and time spent at home (1) the same day, (2) the following day, and (3) the previous day. Overall, we obtained many of the expected main effects (although there were some null effects), in which higher social anxiety was associated with more time or greater likelihood of spending time at home, and more negative or less positive affect was linked to longer homestay. Interactions indicated that, among individuals higher in social anxiety, higher negative affect and lower positive affect within a day was associated with greater likelihood of spending time at home the following day. CONCLUSIONS: Results demonstrate the feasibility and utility of modeling the relationship between affect and homestay using fine-grained GPS data. Although these findings must be replicated in a larger study and with clinical samples, they suggest that integrating repeated state affect assessments in situ with continuous GPS data can increase understanding of how actual homestay is related to affect in everyday life and to symptoms of anxiety and depression.

The relation between depression and appreciation: The role of perceptions of emotional utility in an experimental test of causality.

The present research examined the potential role of perceived utility of appreciation in depressive symptoms. In a between-subjects design, participants were induced to increase their experience of appreciation or their perceived usefulness of appreciation. Self-reported perceptions of emotional utility, actual experience of emotion, as well as depression scores gathered from semi-structured interviews, were obtained at baseline and post-induction. As predicted, although participants in both groups evidenced lower levels of depressive symptoms at post-induction than at baseline, there was a greater decrease among participants in the appreciation-utility condition than among those in the appreciation-experience condition. Further, perceived utility of appreciation was an important mediator in moderated mediation models.

Examining the contextual and temporal stability of perceptions of emotional utility.

The present research examined the degree to which perceptions of emotional utility are stable across contexts and over time. Self-reported perceptions of emotional utility and actual experience of emotion were measured in two samples of college students. In Study 1, participants were presented with two different types of goals (independent vs. interdependent) and were asked to rate the degree to which they found different types of emotions (e.g., appreciation, pride) useful in each context. In Study 2, participants completed daily online questionnaires in which they responded to questions assessing perceptions of emotional utility and actual affect in relation to personal goals. As predicted, across both samples, perceived utility of specific types of emotions was found to be associated with specific types of goals. Importantly, perceived utility of emotion was also found to be a relatively stable individual difference variable, even after taking into account the actual experience of emotion.

Self-conscious emotions in worry and generalized anxiety disorder.

OBJECTIVES: Current theories regarding worry and generalized anxiety disorder (GAD) highlight the potential avoidance functions of worry, and it has been suggested that worry functions to avoid self-conscious emotions in particular. Therefore, the present study examined the roles of proneness and aversion to self-conscious emotions in worry and GAD. DESIGN: Cross-sectional data from two samples were collected: (1) a sample of 726 undergraduates, and (2) a selected sample of 51 community members, 37.3% of whom met DSM-IV criteria for GAD. Zero-order correlations and hierarchical multiple regression analyses were used to examine associations of self-conscious emotion constructs to worry and GAD. METHOD: Proneness to guilt and shame (propensities for experiencing guilt and shame, respectively) were assessed via the Test of Self-Conscious Affect-3. Aversion to guilt and shame (perceptions of guilt and shame, respectively, as especially painful, undesirable emotions) were assessed using the Guilt Aversion Assessment and Shame-Aversive Reactions Questionnaire, respectively. Worry was assessed using the Penn State Worry Questionnaire, and GAD was assessed via the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. RESULTS: Correlations indicated positive associations between self-conscious emotion constructs and worry/GAD. However, in the selected community sample, regression analyses indicated that only shame aversion was positively associated with worry/GAD, over and above all other self-conscious emotion constructs and depression. CONCLUSIONS: Results suggest a prominent role for an intolerance for shame in worry and GAD, which is broadly consistent with psychological models of worry. Future directions for research and clinical implications are discussed. PRACTITIONER POINTS: Positive clinical implications: Evidence supporting the theorized importance of self-conscious emotions in worry and GAD. Specifically highlights the need to address intolerance for shame in treatment. Limitations: Small sample size in Study 2. Use of cross-sectional data.

Family Cancer Caregiver Use of and Benefit from an Internet-delivered Insomnia Intervention: Results from a Single-Group Feasibility Trial.

Background: Cancer caregivers are more likely to report clinically significant symptoms of insomnia than cancer patients and the general population, yet research has been limited regarding cognitive-behavioral therapy for insomnia (CBT-I) among this population. Methods: To better understand cancer caregivers' engagement with and benefit from CBT-I, cancer caregivers were enrolled in a nonrandomized pilot feasibility trial of an evidence-based Internet-delivered insomnia program. Thirteen caregivers completed mixed-methods assessments prior to receiving the insomnia program and after the nine-week intervention period. Results: Compared to the five caregivers who did not complete any intervention Cores, the eight caregivers who completed at least one of the intervention Cores tended to report more sleep impairment (insomnia symptom severity; minutes of sleep onset latency and wake after sleep onset), less physical and emotional strain from caregiving, and less maladaptive sleep beliefs at the baseline assessment. These caregivers who used the program also showed large improvements in their insomnia symptoms. Caregivers' qualitative feedback about their experience with the program identified potential areas that might be modified to improve caregivers' engagement with and benefit from Internet-delivered insomnia programs. Conclusions: Findings suggest that family cancer caregivers can use and benefit from a fully-automated Internet-delivered CBT-I program, even without caregiving-specific tailoring. Further rigorous research is needed to better understand whether and how program modifications may allow more caregivers to initiate and engage with this program.

Evaluating the impact of patients' psychological and physical problems on their interest in participating in research at a cancer center with a rural catchment area.

BACKGROUND: Cancer patients' participation in research trials is essential to improving their care and treatment. In a large sample of adults recently diagnosed with cancer, the aim of the current study is to investigate the relationship between cancer patients' interest in research and the psychological and physical problems they experience resulting from their cancer diagnosis. METHOD: We analyzed data from 906 cancer patients collected during routine clinical care. Correlational analyses focused on the relationship between patients' psychological and physical problems and their interest in research. Hierarchical binary logistic regression analyses tested whether patients' psychological/physical problems as a block predicted their interest in research, above and beyond their sociodemographic characteristics. RESULTS: Higher levels of patients' anxiety, fear of cancer treatment, difficulty managing emotions, worry, suicidal/homicidal ideation, fatigue, problems related to physical appearance, sleep difficulty, and changes to weight/appetite, were associated with a greater interest in research. Patients' psychological/physical problems, as a block, incrementally predicted their interest in research (Δχ2 = 24.34, df = 14, p = .04, Δr2=0.05), though none of the individual psychological/physical problems were found to be significant predictors. A higher level of education was significantly positively associated with an increased likelihood of being interested in research (OR = 1.26, 95%CI = 1.09, 1.46, p = .001). CONCLUSION: Cancer patients' problems stemming from their diagnosis can be important factors in their decision to participate in research. Depending on the needs of the trial in question, researchers may want to account for patients' level of symptom burden in deciding who to approach for enrollment in a research trial.

Retention and engagement of rural caregivers of adolescents in a short message service intervention to reduce sugar-sweetened beverage intake.

Objective: This study investigates a 6-month short message service (SMS) intervention to reduce adolescent sugar-sweetened beverage (SSB) intake. The objectives are to describe caregiver retention and SMS engagement as well as explore differences by caregiver characteristics. Methods: Caregivers completed a baseline survey then messages were sent two times per week. Message types included the following: SSB intake assessments, educational information, infographic URLs, and strategies. Engagement was measured through interaction with these messages and included: assessment completion, reminders needed, number of strategies chosen, and URLs clicked. Results: Caregivers (n = 357) had an average baseline SSB intake of 23.9 (SD = 26.8) oz/day. Of those, 89% were retained. Caregivers with a greater income and education were retained at a higher rate. Average engagement included: 4.1 (SD = 1.3) of 5 assessments completed with few reminders needed [4.1 (SD = 3.7) of 14 possible], 3.2 (SD = 1.1) of 4 strategies selected, and 1.2 (SD = 1.6) of 5 URLs clicked. Overall, average engagement was relatively high, even where disparities were found. Demographic characteristics that were statistically related to lower engagement included younger age, lower income, lower educational attainment, single caregivers, lower health literacy. Furthermore, caregivers with a reduced intention to change SSB behaviors completed fewer assessments and needed more reminders. Higher baseline SSB intake was associated with lower engagement across all indicators except URL clicks. Conclusions: Results can be used to develop targeted retention and engagement strategies (e.g., just-in-time and/or adaptive interventions) in rural SMS interventions for identified demographic subsets. Trial registration: Clincialtrials.gov: NCT03740113.

Outcomes of a Caregiver-Focused Short Message Service (SMS) Intervention to Reduce Intake of Sugar-Sweetened Beverages in Rural Caregivers and Adolescents.

This study examined enrollment, retention, engagement, and behavior changes from a caregiver short message service (SMS) component of a larger school-based sugar-sweetened beverage (SSB) reduction intervention. Over 22 weeks, caregivers of seventh graders in 10 Appalachian middle schools received a two-way SMS Baseline Assessment and four monthly follow-up assessments to report their and their child's SSB intake and select a personalized strategy topic. Between assessments, caregivers received two weekly one-way messages: one information or infographic message and one strategy message. Of 1873 caregivers, 542 (29%) enrolled by completing the SMS Baseline Assessment. Three-quarters completed Assessments 2-5, with 84% retained at Assessment 5. Reminders, used to encourage adherence, improved completion by 19-40%, with 18-33% completing after the first two reminders. Most caregivers (72-93%) selected a personalized strategy and an average of 28% viewed infographic messages. Between Baseline and Assessment 5, daily SSB intake frequency significantly (p < 0.01) declined for caregivers (-0.32 (0.03), effect size (ES) = 0.51) and children (-0.26 (0.01), ES = 0.53). Effect sizes increased when limited to participants who consumed SSB twice or more per week (caregivers ES = 0.65, children ES = 0.67). Findings indicate that an SMS-delivered intervention is promising for engaging rural caregivers of middle school students and improving SSB behaviors.