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Background As the field of D&I (dissemination and implementation) science grows to meet the need for more effective and timely applications of research findings in routine practice, the demand for formalized training programs has increased concurrently. The Mentored Training for Dissemination and Implementation Research in Cancer (MT-DIRC) Program aims to build capacity in the cancer control D&I research workforce, especially among early career researchers. This paper outlines the various components of the program and reports results of systematic evaluations to ascertain its effectiveness. Methods Essential features of the program include selection of early career fellows or more experienced investigators with a focus relevant to cancer control transitioning to a D&I research focus, a 5-day intensive training institute, ongoing peer and senior mentoring, mentored planning and work on a D&I research proposal or project, limited pilot funding, and training and ongoing improvement activities for mentors. The core faculty and staff members of the MT-DIRC program gathered baseline and ongoing evaluation data regarding D&I skill acquisition and mentoring competency through participant surveys and analyzed it by iterative collective reflection. Results A majority (79%) of fellows are female, assistant professors (55%); 59% are in allied health disciplines, and 48% focus on cancer prevention research. Forty-three D&I research competencies were assessed; all improved from baseline to 6 and 18 months. These effects were apparent across beginner, intermediate, and advanced initial D&I competency levels and across the competency domains. Mentoring competency was rated very highly by the fellows––higher than rated by the mentors themselves. The importance of different mentoring activities, as rated by the fellows, was generally congruent with their satisfaction with the activities, with the exception of relatively greater satisfaction with the degree of emotional support and relatively lower satisfaction for skill building and opportunity initially. Conclusions These first years of MT-DIRC demonstrated the program’s ability to attract, engage, and improve fellows’ competencies and skills and implement a multicomponent mentoring program that was well received. This account of the program can serve as a basis for potential replication and evolution of this model in training future D&I science researchers. Electronic supplementary material The online version of this article (10.1186/s13012-018-0711-3) contains supplementary material, which is available to authorized users.

Objective The aims of this feasibility study of an adapted lifestyle intervention for adults with lung cancer were to (1) determine rates of enrollment, attrition, and completion of 5 nurse-patient contacts; (2) examine demographic characteristics of those more likely to enroll into the program; (3) determine acceptability of the intervention; and (4) identify patient preferences for the format of supplemental educational intervention materials. Methods This study used a single-arm, pretest and posttest design. Feasibility was defined as ≥20% enrollment and a completion rate of 70% for 5 nurse-patient contact sessions. Acceptability was defined as 80% of patients recommending the program to others. Data was collected through electronic data bases and phone interviews. Descriptive statistics, Fisher's exact test and Wilcoxon rank sum test were used for analyses. Results Of 147 eligible patients, 42 (28.6%) enrolled and of these, 32 (76.2%) started the intervention and 27 (N = 27/32; 84.4%; 95% CI, 67.2%-94.7%) completed the intervention. Patients who were younger were more likely to enroll in the study (P = .04) whereas there were no significant differences by gender (P = .35). Twenty-three of the 24 (95.8%) participants' contacted posttest recommended the intervention for others. Nearly equal numbers of participants chose the website (n = 16, 50%) vs print (n = 14, 44%). Conclusion The intervention was feasible and acceptable in patients with lung cancer. Recruitment rates were higher and completion rates were similar as compared to previous home-based lifestyle interventions for patients with other types of cancer. Strategies to enhance recruitment of older adults are important for future research.

Since fall 2015, the University of Virginia’s (UVA) Engineering Student Council (ESC) has partnered with the nonprofit Virginia Science Olympiad (VASO) organization to host a Science Olympiad (SciOly) state tournament in Charlottesville, Virginia, each spring. This annual tournament brings over 2,000 middle and high school students, teachers, and parents to the UVA campus, and teams of 15–17 people from roughly 90 schools across Virginia participate in 46 different events (23 middle school, Division B; 23 high school, Division C) relating to the science, technology, engineering, and mathematics (STEM) fields throughout the day-long competition. The national SciOly organization sets the events and rules to comply with national education standards, and the VASO board coordinates the teams and tournaments within the state. By collaborating with VASO, UVA ESC was able to plan a large-scale SciOly tournament at UVA in approximately 10 mo with the support of the UVA School of Engineering and Applied Science. Since this event was planned and executed solely by undergraduates in cooperation with the nonprofit organization, there were institutional hurdles that were overcome through the months of planning. The Virginia SciOly state tournament has continued to be held at UVA with the support and cooperation of the UVA ESC and VASO, and bringing this tournament to UVA has allowed for increased excitement for participating K–12 students and a mitigated burden to the VASO organizers in planning the state competition. This paper aims to provide a resource for other universities to support STEM activities in K–12 outreach organizations, like SciOly, in the future.

Background This paper reports core competencies for dissemination and implementation (D&I) grant application writing and provides tips for writing a successful proposal. Methods Two related phases were used to collect the data: a card sorting process among D&I researchers and an expert review among a smaller set of researchers. Card sorting was completed by 123 respondents. In the second phase, a series of grant application writing tips were developed based on the combined 170 years of grant review experience of the writing team. Results The card sorting resulted in 12 core competencies for DI (b) significance that frames and justifies the importance of a DI (c) innovation that articulates novel products and new knowledge; and (d) approach that uses a relevant D&I model, addresses measurement and the D&I context, and includes an analysis plan well-tied to the aims and measures. Conclusions Writing a successful D&I grant application is a skill that can be learned with experience and attention to the core competencies articulated in this paper.

Importance The use of electronic cigarettes (e-cigarettes) has rapidly increased among youth and young adults, but knowledge gaps exist on the potential health effects of using recently introduced pod-based e-cigarettes. Objective To conduct a systematic review of recent peer-reviewed scientific literature on pod-based e-cigarettes. Evidence Review A search of online databases, including PubMed, Web of Science, Embase, and EBSCO HOST, was conducted to identify pod-based e-cigarette–associated articles from June 2015 (the time when JUUL [JUUL Labs] was introduced) to June 2019. We included English-language articles that presented primary data on pod-based e-cigarettes. Findings Pod-based e-cigarettes represent a substantial evolution in design by increasing the efficient delivery of nicotine. While these products may contain less harmful constituents than other types of e-cigarettes and cigarettes, there is no evidence that the levels found are safe among youth. There is evidence for higher nicotine dependence associated with their use. Pod-based e-cigarette brands, compared with other e-cigarette brands, have targeted youth and young adults with social media marketing. There was less discussion about the use of these products as smoking cessation devices or their health risks on social media. The social acceptability and favorable perceptions of pod-based e-cigarettes may underlie the use of these products. Conclusions and Relevance The appeal and dependence potential of pod-based e-cigarettes for youth emphasize the need for stronger regulations on product design, social media, marketing channels, and youth access together with health communications that emphasize the risks of nicotine dependence.

Behavioral medicine has made significant contributions to our understanding of how to prevent disease and improve health. However, social and environmental factors continue to have a major influence on health in ways that will be difficult to combat on a population level without concerted efforts to scale interventions and translate the evidence into public health policies. Now is also the right time to increase our efforts to produce policy relevant research and partnerships that will maximize the chances that our evidence is taken to scale in ways that can influence population health broadly, and perhaps contribute to the reduction of the recalcitrant health disparities that plague virtually every area of behavioral medicine focus. As a field we must take an active role in policy translation, learning from the public policy and political science disciplines, and our own pioneers in policy translation. This article discusses importance of accelerating evidence translation to policy, and suggests several factors that could enhance our translation efforts, including embracing policy translation as a key goal in behavioral medicine, increasing our understanding in variability of evidence-based policy adoption across and within states, improving our understanding of how to most effectively communicate our findings to policy makers, conducting research that is responsive to policy makers’ needs, and considering the important role of local policy partnerships.

Prevention and early detection is critical for reducing the population cancer burden. Two approaches have been used: Population approaches change social norms (e.g., smoking bans) or impose incentives (e.g., cigarette taxes); high-risk strategies intervene upon individuals with elevated cancer risk (e.g., smoking cessation). Knowledge about carcinogenesis mechanisms, extreme exposures, and inherited susceptibility provides opportunities to develop precision prevention and early-detection (PPED) strategies. PPED aims to understand the basis of risk, identify groups that optimally benefit from interventions, characterize heterogeneity in intervention responses, optimize intervention timing, and minimize toxicities. We propose a framework around which PPED strategies can be developed. Currently available cancer prevention and early-detection approaches have the potential to reduce a large proportion of the cancer burden in the population. However, even if fully implemented, existing methods cannot fully eliminate the cancer burden. New PPED approaches that exploit the growing knowledge of molecular and biological cancer mechanisms should be developed and implemented. Cancer Discov; 8(7); 803–11. ©2018 AACR.

On 5 and 6 December 2017, the National Institutes of Health (NIH) convened the Pathways to Prevention Workshop: Methods for Evaluating Natural Experiments in Obesity to identify the status of methods for assessing natural experiments to reduce obesity, areas in which these methods could be improved, and research needs for advancing the field. This article considers findings from a systematic evidence review on methods for evaluating natural experiments in obesity, workshop presentations by experts and stakeholders, and public comment. Research gaps are identified, and recommendations related to 4 key issues are provided. Recommendations on population-based data sources and data integration include maximizing use and sharing of existing surveillance and research databases and ensuring significant effort to integrate and link databases. Recommendations on measurement include use of standardized and validated measures of obesity-related outcomes and exposures, systematic measurement of co-benefits and unintended consequences, and expanded use of validated technologies for measurement. Study design recommendations include improving guidance, documentation, and communication about methods used; increasing use of designs that minimize bias in natural experiments; and more carefully selecting control groups. Cross-cutting recommendations target activities that the NIH and other funders might undertake to improve the rigor of natural experiments in obesity, including training and collaboration on modeling and causal inference, promoting the importance of community engagement in the conduct of natural experiments, ensuring maintenance of relevant surveillance systems, and supporting extended follow-up assessments for exemplar natural experiments. To combat the significant public health threat posed by obesity, researchers should continue to take advantage of natural experiments. The recommendations in this report aim to strengthen evidence from such studies.

Cancer survivors are a rapidly growing population and an important target for tobacco treatment interventions. Continued smoking after the diagnosis of cancer is associated with a higher risk of cancer recurrence and mortality. Systematic tobacco cessation programs are effective. This study surveyed American College of Surgeons Commission on Cancer (CoC) programs in the Northeast region of the USA regarding their tobacco control programs. Seventy percent of cancer survivors are treated within CoC programs. The purpose of this study was to describe the extent of implementation of tobacco treatment and determine the organizational delivery of tobacco treatment as measured by the presence of goals to address smoking, leadership support, and integration of tobacco treatment guidelines into care delivery. Data were collected by a survey. The Assessment of Chronic Illness Care questionnaire was used to collect data on implementation of tobacco treatment services. Descriptive statistics were used to analyze the data. Most programs (78.6%) had an electronic health record and of these 68% captured smoking status. Implementation of tobacco treatment was not optimal for identifying smokers, providing patients with community linkages or self-care cessation support. Implementation of decision aides for pharmacotherapy and reassessment of smoking status were the least developed areas. Moreover, the organizational delivery for tobacco treatment was less than optimal. Many cancer programs have not implemented systems to deliver optimal tobacco treatment. Efforts should be made to help cancer programs develop sustainable system-wide programs that address the urgent need to deliver tobacco treatment to all cancer survivors.

Given the growing emphasis on dissemination and implementation as a means to increase the efficiency of the research enterprise, public policy, and the services with which we work, refining methods that facilitate translation and implementation are imperative. Bringing the dissemination and implementation research community to common understanding of answers to our overarching questions is a necessary step. Then we can more consistently answer the questions: How will we gather this information on effective interventions to form the evidence base? Will interventions be applicable to our setting? What methods should we use to decide what to disseminate or implement? Which strategies will give us the greatest impact on population health? What outcomes should be tracked to know if we are making progress? How long will it take to show progress, or when will it be observed? The methods outlined in this book will help in answering these and other important questions.

There is substantial variability in the implementation of evidence-based interventions across the United States, which leads to inconsistent access to evidence-based prevention and treatment strategies at a population level. Increased dissemination and implementation of evidence-based interventions could result in significant public health gains. While the availability of evidence-based interventions is increasing, study of implementation, adaptation, and dissemination has only recently gained attention in public health. To date, insufficient attention has been given to the issue of fidelity. Consideration of fidelity is necessary to balance the need for internal and external validity across the research continuum. There is also a need for a more robust literature to increase knowledge about factors that influence fidelity, strategies for maximizing fidelity, methods for measuring and analyzing fidelity, and examining sources of variability in implementation fidelity.

BACKGROUND: Afterschool interventions have been found to improve the nutritional quality of snacks served. However, there is limited evidence on how these interventions affect children’s snacking behaviors. OBJECTIVE: To determine the impact of an afterschool intervention focused at the school district, site, family, and child levels on dietary consumption of foods and beverages served at snack. DESIGN: Secondary analysis of a group-randomized controlled trial. PARTICIPANTS/SETTING: Data were collected from 400 children at 20 Boston, MA afterschool sites before (fall 2010) and after (spring 2011) intervention implementation. INTERVENTION: The Out-of-School Nutrition and Physical Activity intervention aimed to promote fruits, vegetables, whole grains, and water, while limiting sugary drinks and trans fats. Researchers worked with district foodservice staff to change snack foods and beverages. Teams of afterschool staff participated in three three-hour learning collaborative sessions to build skills and created action plans for changing site practices. The intervention included family and child nutrition education. MAIN OUTCOME MEASURES: Research assistants observed dietary snack consumption using a validated measure on two days per site at baseline and follow-up. STATISTICAL ANALYSES PERFORMED: This study used multivariable regression models, accounting for clustering of observations, to assess the intervention effect, and conducted post-hoc stratified analyses by foodservice type. RESULTS: Children in intervention sites had greater decreases in consumption of juice (−0.61 ounces/snack, 95% CI −1.11 – −0.12), beverage calories (−29.0 kcal/snack, 95% CI −40.1 – −17.9), foods with trans fats (−0.12 servings/snack, 95% CI −0.19 – −0.04), total calories (−47.8 kcal/snack, 95% CI −68.3 – −27.3) and increases in consumption of whole grains (0.10 servings/snack, 95% CI 0.02–0.18) compared to controls. In post hoc analyses, sites with on-site foodservice had significant improvements for all outcomes (p

As a nation, we underinvest in prevention and fail to implement strategies that ensure all population groups equitably share in the return on investment in prevention research and the benefits of prevention effectiveness. There is significant evidence indicating that by applying knowledge that we already have to reduce tobacco, inactivity, and obesity (known modifiable causes of cancer), we can prevent more than 50% of cancers. Vaccination against HPV, aspirin and selective estrogen receptor modulators, and screening programs further reduce risk. Evidence-based prevention strategies are inconsistently implemented across the United States. Substantial variation across States indicates that there is much room for improvement in implementation of prevention. Implementation science applies innovative approaches to identifying, understanding, and developing strategies for overcoming barriers to the adoption, adaptation, integration, scale-up, and sustainability of evidence-based interventions, tools, policies, and guidelines that will prevent cancer through application of evidence-based interventions. When we get implementation of prevention programs right and at scale, we achieve substantial population benefits. Although many efforts are underway to maximize our knowledge about the causes and treatments of cancer, we can achieve reductions in the cancer burden right now by doing what we already know. The time to start is now. Cancer Prev Res; 11(4); 171–84. ©2018 AACR.

Introduction. Social support is important for behavior change, and it may be particularly important for the complexities of changing multiple risk behaviors (MRB). Research is needed to determine if participants in an MRB intervention can be encouraged to activate their social network to aid their change efforts. Methods. Healthy Directions 2, a cluster-randomized controlled trial of an intervention conducted in two urban health centers, targeted five behaviors (physical activity, fruit and vegetable intake, red meat consumption, multivitamin use, and smoking). The self-guided intervention emphasized changing MRB simultaneously, focused on self-monitoring and action planning, and encouraged participants to seek support from social network members. An MRB score was calculated for each participant, with one point being assigned for each behavioral recommendation that was not met. Analyses were conducted to identify demographic and social contextual factors (e.g., interpersonal, neighborhood, and organizational resources) associated with seeking support and to determine if type and frequency of offered support were associated with changes in MRB score. Results. Half (49.6%) of participants identified a support person. Interpersonal resources were the only contextual factor that predicted engagement of a support person. Compared to individuals who did not seek support, those who identified one support person had 61% greater reduction in MRB score, and participants identifying multiple support persons had 100% greater reduction. Conclusion. Engagement of one’s social network leads to significantly greater change across multiple risk behaviors. Future research should explore strategies to address support need for individuals with limited interpersonal resources.

National data suggest that children are not consuming enough water. Experimental evidence has linked increased water consumption to obesity prevention, and the National AfterSchool Association has named serving water as ones of its standards for healthy eating and physical activity in out-of-school time settings. From fall 2010 to spring 2011, twenty Boston afterschool program sites participated in the Out-of-School Nutrition and Physical Activity (OSNAP) initiative, a group-randomized trial investigating nutrition and physical activity policies and practices that promote child health. Researchers used data from OSNAP to study the key factors that influence the implementation of practices that promote water intake. Aspects of the organizational capacity of the afterschool programs, characteristics of the providers, and the community context were hypothesized to impact changes in children's water consumption. This chapter demonstrates the effectiveness of an afterschool intervention on increases in children's water consumption. It also outlines the substantial influence that implementation factors can have on the effectiveness of an obesity prevention intervention, highlighting the importance of understanding how interventions are delivered in real-world settings.

Background: Black men exhibit a high prevalence of vitamin D deficiency as well as a higher incidence of prostate cancer and higher mortality rates from prostate cancer than Whites. There are few data about the effect of vitamin D3 (cholecalciferol) supplementation on prostate-specific antigen (PSA) in healthy Black men. Methods: During three winters from 2007 to 2010, 105 Black men (median age, 48.9 years) of Boston, MA were randomized into a four-arm, double-blind trial for 3 months of placebo, 1,000, 2,000, or 4,000 U of vitamin D3. At baseline and 3 months, free and total PSA was measured. Results: With vitamin D supplementation, no significant differences in free and total PSA were observed; free PSA, −0.0004 ng/mL (P = 0.94) and total PSA, −0.004 ng/mL (P = 0.92) for each additional 1,000 U/d of vitamin D3. Conclusion: Within an unselected population of healthy Black men without a cancer diagnosis, we found no effect of vitamin D supplementation on free or total PSA. Impact: These findings support prior findings of no change in PSA with vitamin D supplementation and emphasize the need for new methods to assess the influence of vitamin D supplementation on prostate cancer prevention. Cancer Epidemiol Biomarkers Prev; 23(9); 1944–7. ©2014 AACR.

To evaluate the effectiveness of the Healthy Directions 2 (HD2) intervention in the primary care setting.HD2 was a cluster randomized trial (conducted 3/09-11/11). The primary sampling unit was provider (n=33), with secondary sampling of patients within provider (n=2440). Study arms included: 1) usual care (UC); 2) HD2--a patient self-guided intervention targeting 5 risk behaviors; and 3) HD2 plus 2 brief telephone coaching calls (HD2+CC). The outcome measure was the proportion of participants with a lower multiple risk behavior (MRB) score by follow-up.At baseline, only 4% of the participants met all behavioral recommendations. Both HD2 and HD2+CC led to improvements in MRB score, relative to UC, with no differences between the two HD2 conditions. Twenty-eight percent of the UC participants had improved MRB scores at 6 months, vs. 39% and 43% in HD2 and HD2+CC, respectively (ps≤.001); results were similar at 18 months (p≤.05). The incremental cost of one risk factor reduction in MRB score was $310 for HD2 and $450 for HD2+CC.Self-guided and coached intervention conditions had equivalent levels of effect in reducing multiple chronic disease risk factors, were relatively low cost, and thus are potentially useful for routine implementation in similar health settings.

Background: Association studies have suggested that lower circulating 25-hydroxyvitamin D [25(OH)D] in African Americans may partially underlie higher rates of cardiovascular disease and cancer in this population. Nonetheless, the relation between vitamin D supplementation and 25(OH)D concentrations in African Americans remains undefined. Objective: Our primary objective was to determine the doseresponse relation between vitamin D and plasma 25(OH)D. Design: A total of 328 African Americans in Boston, MA, were enrolled over 3 winters from 2007 to 2010 and randomly assigned to receive a placebo or 1000, 2000, or 4000 IU vitamin D3/d for 3 mo. Subjects completed sociodemographic and dietary questionnaires, and plasma samples were drawn at baseline and 3 and 6 mo. Results: Median plasma 25(OH)D concentrations at baseline were 15.1, 16.2, 13.9, and 15.7 ng/mL for subjects randomly assigned to receive the placebo or 1000, 2000, or 4000 IU/d, respectively (P = 0.63). The median plasma 25(OH)D concentration at 3 mo differed significantly between supplementation arms at 13.7, 29.7, 34.8, and 45.9 ng/mL, respectively (P , 0.001). An estimated 1640 IU vitamin D3/d was needed to raise the plasma 25(OH)D concentration to $20 ng/mL in $97.5% of participants, whe reas ad ose of 4000 IU/d was needed to achieve concentrations $33 ng/mL in $80% of subjects. No significant hypercalcemia was seen in a subset of participants. Conclusions: Within African Americans, an estimated 1640 IU vitamin D3/d was required to achieve concentrations of plasma 25(OH)D recommended by the Institute of Medicine, whereas 4000 IU/d was needed to reach concentrations predicted to reduce cancer and cardiovascular disease risk in prospective observational studies. These results may be helpful for informing future trials of disease prevention. This trial was registered at clinicaltrials.gov as NCT00585637. Am J Clin Nutr 2014;99:587‐98.

Because rates of skin cancer are greater among adult survivors of childhood cancer who received radiation therapy than among the general population, the National Cancer Institute recommends skin self-examinations and annual physician examination. There has been no comprehensive assessment of survivors' adherence to the skin cancer screening guidelines associated with skin self-examination (SSE) and physician whole-body skin examination (PSE). We conducted a cross-sectional survey of radiation-treated, adult 5-year survivors of childhood cancer, diagnosed between 1970 and 1986, in the Childhood Cancer Survivor Study cohort. Multivariate multinomial logit regression investigated the association between demographic, cancer diagnosis, patient activation, cancer treatment characteristics, and skin cancer screening practice. Among 728 survivors, 13.1% reported performing SSE in the prior 2 months plus receiving PSE in the prior 12 months, and 16.4% and 11.0% reported performing only an SSE or a PSE, respectively; 59.5% of survivors reported having had neither. Participants at the highest patient activation score were most likely to report SSE plus PSE compared with neither (adjusted relative risk ratio = 4.16, 95% confidence interval = 1.34-12.85). Most adult survivors of childhood cancer who had radiation therapy do not practice strategies that promote early detection of skin cancer. Interventions designed to activate survivors to increase their participation in screening are needed.

Purpose: Young women with breast cancer suffer distress both at the time of diagnosis and afterwards. This study aimed to elucidate which issues are most disturbing to this population and which might be amenable to intervention. Methods: English-speaking women treated or involved in research at the Dana-Farber Cancer Institute for stage I-III breast cancer while aged 18-42 years were invited to participate in one of four focus groups. A trained moderator led each 90-minute audio-recorded group using a semi-structured interview guide. All transcripts were coded using thematic content analysis with NVivo software. Results: Thirty-six women participated. Three major themes emerged from the analyses of these focus groups' data: (1) participants felt different from older breast cancer patients with regard to relationships, fertility, menopausal symptoms, treatment side effects, and work/finances; (2) participants faced unique challenges transitioning into the survivorship phase of care; and (3) participants desired assistance, including connections with other young patients, help navigating the healthcare system, educational materials, and lists of appropriate counselors. Conclusion: Young women with breast cancer have unmet needs for psychosocial support, education, and symptom management, and can identify potential support that may help meet these needs.

BACKGROUND The U.S. Preventive Services Task Force has released new guidelines on obesity, urging primary care physicians to provide obese patients with intensive, multi-component behavioral interventions. However, there are few studies of weight loss in real world nonacademic primary care, and even fewer in largely racial/ethnic minority, low-income samples.

The objective of the study was to assess the effectiveness of group counseling, using a problem-solving therapy approach, on reducing depressive symptoms and increasing prenatal disclosure rates of HIV status among HIV-positive pregnant women living in Dar es Salaam, Tanzania. A randomized controlled trial was performed comparing a six-week structured nurse-midwife facilitated psychosocial support group with the standard of care. Sixty percent of women in the intervention group were depressed post-intervention, versus 73% in the control group [Relative Risk (RR) = 0.82, 95% confidence interval (CI): 0.67-1.01, p=0.066]. HIV disclosure rates did not differ across the two study arms. However, among those women who disclosed, there was a significantly higher level of overall personal satisfaction with the response to disclosure from family and friends among women in the treatment (88%) compared to the control group (62%; p=0.004). The results indicate reductions in the level of depressive symptoms comparable with major depressive disorder (MDD) for HIV-positive pregnant women participating in a group counseling intervention. Although the psychosocial group counseling did not significantly increase disclosure rates, an improvement in the level of personal satisfaction resulting from disclosure was associated with the intervention. This suggests that the counseling sessions have likely reduced the burden of depression and helped clients better manage partner reactions to disclosure. Public agencies and non-governmental organizations working in Tanzania and similar settings should consider offering structured psychosocial support groups to HIV-positive pregnant women to prevent poor mental health outcomes, promote early childhood development, and potentially impact HIV-related disease outcomes in the long term.

Learning Objectives Identify predictors of excessive risk perception in women with a distant history of DCIS. Explain the importance of educating women with a history of DCIS about reasonable assessments of their risk for future breast cancer. Introduction. Previous research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk for future breast cancer at the time of diagnosis and soon thereafter. This study aims to evaluate risk perceptions after 5 years. Patients and Methods. In a longitudinal cohort study, we mailed long-term follow-up surveys to 315 women who had previously responded to a survey 18 months after they were diagnosed with DCIS, excluding those who had experienced recurrence and those not treated at our institution. We evaluated risk perceptions with items used previously in the cohort. Results. One hundred ninety-three women (61%) responded. The median time since diagnosis was 5.9 years. We excluded 12 because of recurrence. Of the 181 remaining, 32% perceived at least a moderate 5-year risk for developing DCIS again, 43% perceived at least a moderate lifetime risk for developing DCIS again, 27% perceived at least a moderate 5-year risk for invasive breast cancer, 38% perceived at least a moderate lifetime risk for invasive breast cancer, and 24% perceived at least a moderate risk for DCIS spreading to other body parts. In a multivariate model, worse financial status and higher perceived risk in the previous survey were the only predictors of at least a moderate perception of risk for DCIS spreading. Conclusion. Women with a history of DCIS continue to harbor inaccurate perceptions of their risk for future breast cancer events even 5 years after diagnosis.

This study assessed the prevalence of smoking restrictions among households of survivors of childhood and young adult cancer who smoke. It also examined the relationship between home smoking restrictions and motivation to quit smoking, as well as other smoking, psychosocial, and environmental factors.Participants included 374 smokers who were childhood or young adult cancer survivors (between the ages of 18 and 55 years) recruited from five cancer centers to participate in a randomized smoking cessation trial. Survivors completed baseline measures about the smoking restrictions in their households, their smoking behavior, and related psychological and environmental factors, which are the focus of the current manuscript.Almost 54% of survivors reported that smoking was prohibited in their households. Living with a nonsmoking partner, having a strict smoking policy at work, and not being nicotine dependent all increased the likelihood of having a total home smoking ban. Participants who were older, smoked more cigarettes per day over the prior week, and received prior chemotherapy were less likely to reside in households that adopted total bans.Findings suggest that socio-environmental factors and current smoking behaviors are associated with complete smoking restrictions in the homes of survivors. These factors should be considered when communicating with survivors about the importance of establishing strict smoking policies in their private residences.

Background Shared decision making (SDM) is a widely recommended yet unproven strategy for increasing colorectal cancer (CRC) screening uptake. Previous trials of decision aids to increase SDM and CRC screening uptake have yielded mixed results. Purpose To assess the impact of decision aid–assisted SDM on CRC screening uptake. Design RCT. Setting/participants The study was conducted at an urban, academic safety-net hospital and community health center between 2005 and 2010. Participants were asymptomatic, average-risk patients aged 50–75 years due for CRC screening. Intervention Study participants ( n =825) were randomized to one of two intervention arms (decision aid plus personalized risk assessment or decision aid alone) or control arm. The interventions took place just prior to a routine office visit with their primary care providers. Main outcome measures The primary outcome was completion of a CRC screening test within 12 months of the study visit. Logistic regression was used to identify predictors of test completion and mediators of the intervention effect. Analysis was completed in 2011. Results Patients in the decision-aid group were more likely to complete a screening test than control patients (43.1% vs 34.8%, p =0.046) within 12 months of the study visit; conversely, test uptake for the decision aid and decision aid plus personalized risk assessment arms was similar (43.1% vs 37.1%, p =0.15). Assignment to the decision-aid arm (AOR=1.48, 95% CI=1.04, 2.10), black race (AOR=1.52, 95% CI=1.12, 2.06) and a preference for a patient-dominant decision-making approach (AOR=1.55, 95% CI=1.02, 2.35) were independent determinants of test completion. Activation of the screening discussion and enhanced screening intentions mediated the intervention effect. Conclusions Decision aid–assisted SDM has a modest impact on CRC screening uptake. A decision aid plus personalized risk assessment tool is no more effective than a decision aid alone. Trial registration This study is registered at www.clinicaltrials.gov NCT00251862.

To examine whether a family-based intervention targeting both smoking fathers and nonsmoking mothers in well-child health clinics is effective in increasing fathers' abstinence from cigarette smoking.This parallel 2-arm randomized controlled trial recruited a total of 1158 families with a daily-smoking father, a nonsmoking mother, and a child aged 0-18 months from the 22 maternal and child health centers in Hong Kong. The intervention group received the family-based intervention, including 6 nurse-led individual face-to-face and telephone counseling sessions within 1 month after recruitment and a voluntary face-to-face family counseling session (FCS). The control group received a leaflet, a self-help booklet, and brief quitting advice only. Father-reported 7-day and 6-month abstinence, smoking reduction, quit attempts, mother-reported help and support, and child salivary cotinine level were assessed at 12 months. Generalized estimating equation models were used to compare these outcomes between the 2 study groups.Compared with the control group, the intervention group reported a greater prevalence of 7-day (13.7% vs 8.0%; OR, 1.92; 95% CI, 1.16-3.17; P .01) and 6-month self-reported abstinence (13.4% vs. 7.5%; OR, 2.10; 95% CI, 1.30-3.40; P .01). Within the intervention group, compared with receipt of individual counseling only, participation in the FCS was associated with increases in fathers' self-reported abstinence (20.2% vs 12.3%; P = .02), mothers' help (66.1% vs 43.8%; P .01), and support to the fathers (55.0% vs 45.4%; P .01).The family-based smoking cessation intervention for the families in the well-child healthcare setting was effective in increasing the fathers' self-reported abstinence. Additional participation in the FCS increased mothers' help and support to the fathers.Controlled-trials.com: ISRCTN99111655; Hkuctr.com: HKUCTR-465.

Prompting may promote engagement with behavior change interventions. Prompts can be delivered inexpensively via automated voice response (AVR) reminders or short message service (SMS) text messages. We examined the association between participants' characteristics and preferred reminder modality.Healthy Directions 2 is a cluster randomized controlled trial implemented in Boston, Massachusetts to promote change in multiple behavioral cancer risk factors. At baseline (2009), participants completed a survey assessing socio-demographics, health status, height/weight, and factors associated with technology. One-third of participants randomized to receive the intervention (n=598) were randomized to receive automated reminders, with participants selecting modality.28% (167/598) of participants selected SMS reminders. Controlling for clustering by primary care provider, younger participants (OR=0.97, 95% CI=(0.95, 0.99), p0.01), those most comfortable with computers (very uncomfortable OR=0.54, 95% CI=(0.29, 1.01), p≤0.05: referent group = very comfortable), and those who frequently sent/received text messages (never OR=0.09 CI=(0.04, 0.16) p0.01; 1-3 times/month OR=0.38, 95% CI=(0.15, 0.93) p=0.04: referent group=1-5 times/week) were more likely to choose SMS.Interventions should make both modalities available to ensure that more participants can benefit from prompting. Studies examining the effect of automated reminders may have reduced effectiveness or generalizability if they employ only one modality.

Smoking cessation among cancer patients is critical for improving outcomes. Understanding factors associated with smoking abstinence after the diagnosis of cancer can provide direction to develop and test interventions to enhance cessation rates. The purpose of this study was to identify determinants of smoking outcomes among cancer patients.Standardized questionnaires were used to collect data from 163 smokers or recent-quitters (quit≤6 months) at study entry of which 132 and 121 had data collected at 3 and 6 months. Biochemical verification was conducted with urinary cotinine and carbon monoxide. Descriptive statistics, Cronbach alpha coefficients, Pearson correlations, Fisher's exact test, and multivariable logistic regression were used for analyses.Seven-day-point-prevalence-abstinence (PPA) rates were 90/132 (68%) at 3 months; 46/71 (65%) among lung and 44/61 (72%) among head and neck cancer patients, whereas 7-day-PPA rates were 74/121 (61%) at 6 months; 31/58 (53%) among lung and 43/63 (68%) among head and neck cancer patients. Continuous abstinence rates were 63/89 (71%) at 3 months; 32/45 (71%) among lung and 31/44 (70%) among head and neck cancer patients, whereas continuous abstinence rates were 46/89 (52%) at 6 months; 18/45 (40%) among lung and 28/44 (64%) among head and neck cancer patients. Lower cancer-related, psychological and nicotine withdrawal symptoms were associated with increased 7-D-PPA abstinence rates at 3 and 6 months in univariate models. In multivariable models, however, decreased craving was significantly related with 7-day-PPA at 3 months and decreased craving and increased self-efficacy were associated with 7-D-PPA at 6 months. Decreased craving was the only factor associated with continuous abstinence at 6 months.Smoking outcomes among lung and head and neck cancer patients appear to have remained the same over the last two decades despite the availability of an increased number of pharmacotherapy options to treat tobacco dependence. Decreased craving and increased self-efficacy were the most consistent factors associated with improved smoking outcomes but symptom control may also play a role in optimal management. Use of combined, and/or higher doses of pharmacotherapy along with behavioral interventions that increase self-efficacy and manage symptoms may promote enhanced cessation rates.

Many skin cancer screenings occur in non-traditional community settings, with the beach being an important setting due to beachgoers being at high risk for skin cancer. This study is a secondary analysis of data from a randomized trial of a skin cancer intervention in which participants (n = 312) had a full-body skin examination by a clinician and received a presumptive diagnosis (abnormal finding, no abnormal finding). Participants’ pursuit of follow-up was assessed post-intervention (n = 283). Analyses examined: (1) participant’s recall of screening results, and (2) whether cognitive and behavioral variables were associated with follow-up being as advised. Just 12% of participants (36/312) did not correctly recall the results of their skin examination. One-third (33%, 93/283) of participants’ follow-up was classified as being not as advised (recommend follow-up not pursued, unadvised follow-up pursued). Among participants whose follow-up was not as advised, 71% (66/93) did not seek recommended care. None of the measured behavioral and cognitive variables were significantly associated with recall of screening examination results or whether follow-up was as advised. Research is needed to determine what factors are associated with follow-up being as advised and to develop messages that increase receipt of advised follow-up care.

To identify patterns of Internet use among childhood and young adult cancer survivors who smoke.Baseline assessment data were collected from 2005 to 2008 for the Partnership for Health-2 (PFH-2) study, a web-based smoking cessation intervention for childhood and young adult cancer survivors. Participants were surveyed about their Internet access and use. Sociodemographic, clinical, and psychosocial data also were collected.Internet access and use was widespread among PFH-2 participants. However, older, less-educated, and female survivors reported less frequent Internet use, even when they had access to the Internet at home and/or at work. These associations were significant in multivariable analyses.Although the digital divide is narrowing, Internet use and engagement remains socially patterned. web-based prevention interventions are a promising method of reaching this geographically dispersed, high-risk population, but certain subgroups-particularly older and lower socioeconomic status survivors-might be missed by this approach.

Among adolescents and young adults (AYAs) in the United States, cancer is the leading cause of disease-related death. AYA survivors face numerous short- and long-term health and psychosocial issues, as well as increased risk for behavioral and lifestyle challenges, including poor diet, low physical activity (PA), and substance abuse. Many of these behaviors are modifiable, but gaps in care serve as barriers for AYA survivors.The purpose of this article is to (a) raise awareness of AYAs' increased risk for poor diet, low PA, and substance abuse; (b) examine previous interventions addressing these issues; and (c) provide recommendations for future directions.This article summarizes a workshop coordinated by the Institute of Medicine and the Livestrong Foundation to address AYA survivors' needs and ways to enhance their quality of care.Oncology nurses can promote the inclusion of lifestyle behaviors in survivorship care plans of AYA patients and serve as a valuable resource in improving AYA care on a larger scale. In addition, oncology nurse researchers may offer greater understanding of AYA patients' and survivors' needs and best practices by conducting much-needed research with this understudied population.

Understanding factors that promote or prevent adherence to recommended health behaviors is essential for developing effective health programs, particularly among lower income populations who carry a disproportionate burden of disease. We conducted in-depth qualitative interviews ( n = 64) with low-income Black and Latina women who shared the experience of requiring diagnostic follow-up after having a screening mammography with abnormal findings. We found that in addition to holding negative and fatalistic cancer-related beliefs, the social context of these women was largely defined by multiple challenges and major life stressors, factors that may interfere with their ability to attain health. Factors commonly mentioned included competing health issues, economic hardship, demanding caretaking responsibilities and relationships, insurance-related challenges, distrust of health care providers, and inflexible work policies. Black women also reported discrimination and medical mistrust, whereas Latinas experienced difficulties associated with immigration and social isolation. These results suggest that effective health interventions not only address change among individuals but must also change health care systems and social policies in order to reduce health disparities.

OBJECTIVES: To examine adherence rates for multiple cancer screening tests, which will inform prevention efforts in community health centers (CHCs). METHODS: We report on the prevalence of screening for multiple cancers (cervical, breast, colorectal) among 43,000 patients who are predominantly Hispanic, in four CHC sites that share an integrated electronic medical record. RESULTS: Among the 20,057 patients eligible for at least one test, 43% of the population was current on all screening targets; 15,887 additional screening tests were needed among 11,526 individuals. CONCLUSIONS: Expanding use of health information technology in community health centers provides an opportunity to create an electronic infrastructure for addressing multiple screening needs from a patient-centered perspective.

People of lower-socioeconomic position (SEP) and most racial/ethnic minorities face significant communication challenges which may negatively impact their health. Previous research has shown that these groups rely heavily on interpersonal sources to share and receive health information; however, little is known about these lay sources. The purpose of this paper is to apply the concept of a market maven to the public health sector with the aims of identifying determinants of high health information mavenism among low-SEP and racial/ethnic minority groups and to assess the information they may be sharing based on their own health beliefs. Data for this study were drawn from the baseline survey (n = 325) of a US randomized control intervention study aimed at eliciting an understanding of Internet-related challenges among lower-SEP and minority individuals. Regression models were estimated to distinguish significant determinants of health information mavenism among the sample. Similarly, bivariate and logistic multivariable models were estimated to determine the association between health information mavenism and accurate health beliefs relating to diet, physical activity and smoking. The data illustrate that having a larger social network, being female and being older were important factors associated with higher mavenism scores. Additionally being a moderate consumer of general media as well as fewer years in the US and lower language acculturation were significant predictors of higher mavenism scores. Mavens were more likely than non-mavens to maintain accurate beliefs regarding diet; however, there was no distinction between physical activity and smoking beliefs between mavens and non-mavens. These results offer a unique understanding of health information mavenism which could better leverage word-of-mouth health communication efforts among lower-SEP and minority groups in order to reduce communication inequalities. Moreover, the data indicate that health information mavens may serve as an ideal point of intervention in attempts to modify health beliefs with the goal of reducing health disparities among these populations.

OBJECTIVE: To describe parents' attitudes toward pediatric genetic testing for common, adult-onset health conditions and to identify factors underlying these attitudes. PARTICIPANTS AND METHODS: Parents (n = 219) enrolled in a large, group-practice health plan were offered a “multiplex” genetic test for susceptibility to 8 common, adult-onset health conditions and completed an online survey assessing attitudes and beliefs about the risks and benefits of the test for their child, their willingness to consider having their child tested, and other psychosocial variables. RESULTS: Parents viewed the benefits of pediatric testing to outweigh its risks (positive decisional balance) and were moderately interested in pediatric testing. Variables associated with positive decisional balance included greater interest in knowing about gene-health associations in their child, anticipation of less difficulty understanding their child's genetic health risks, and more positive emotional reactions to learning about their child's decreased health risks (adjusted R2 = 0.33, P < .0001). Similarly, variables associated with greater parental willingness to test were being a mother (versus being a father), greater perceived risk of diseases in their child, greater interest in knowing about gene-health relationships in their child, anticipating less difficulty learning about their child's genetic health risks, anticipating more positive emotional reactions to learning about their child's decreased health risks, and positive decisional balance (adjusted R2 = 0.57, P < .0001). CONCLUSIONS: As genetic susceptibility testing for common, adult-onset health conditions proliferates, pediatricians should anticipate parents' interest in testing children and be prepared to facilitate informed decision making about such testing.

Background There are limited data on the effectiveness of skin cancer prevention education and early detection programs at beaches. Objectives We evaluate 4 strategies for addressing skin cancer prevention in beach settings. Methods This prospective study at 4 beaches included 4 intervention conditions: (1) education only; (2) education plus biometric feedback; (3) education plus dermatologist skin examination; or (4) education plus biometric feedback and dermatologist skin examination. Outcomes included sun protection behaviors, sunburns, and skin self-examinations. Results There was a significant increase in hat wearing, sunscreen use, and a reduction in sunburns in the education plus biometric feedback group (odds ratio = 1.97, 1.94, and 1.07, respectively), and greater improvements in knowing what to look for in skin-self examinations (odds ratio = 1.13); there were no differences in frequency of self-examinations. Skin examinations plus biometric feedback led to greater reductions in sunburns. The dermatologist examinations identified atypical moles in 28% of participants. Limitations Inclusion of only one beach per condition, use of self-report data, and a limited intervention period are limitations. Conclusions Education and biometric feedback may be more effective than education alone for impacting sun protective attitudes and behaviors in beachgoing, high-risk populations.

Social media, and specifically social networking sites (SNSs), are emerging as an important platform for communication and health information exchange. Yet, despite the increase in popularity and use, only a limited number of empirical studies document which segments of the adult population are and are not using social networking sites and with what, if any, affect on health. The purpose of this study is to identify potential communication inequalities in social networking site use among a representative sample of U.S. adults and to examine the association between SNS use and psychological well-being. We analyzed data from the National Cancer Institute's 2007 Health Information National Trends Survey (HINTS). Thirty-five percent of online adults reported SNS use within the past 12 months, and there were no significant differences in SNS use by race/ethnicity or socioeconomic position. Younger age (p = .00) was the most significant predictor of SNS use, while being married (p = .02) and having a history of cancer (p = .02) were associated with a decreased odds of SNS use. SNS use was significantly associated with a 0.80 (p = .00) increment in psychological distress score after controlling for other factors. The absence of inequalities in adult SNS use across race/ethnicity and class offers some support for the continued use of social media to promote public health efforts; however, issues such as the persisting digital divide and potential deleterious effects of SNS use on psychological well-being need to be addressed.

Background: Research has demonstrated that many women with ductal carcinoma in situ (DCIS) overestimate their risk of future breast cancer events. However, no prior studies have evaluated risk perceptions in long-term follow-up. Methods: As part of a multicenter longitudinal cohort study, we mailed long-term follow-up surveys to 315 of 392 women who had previously responded to a survey 18 months after they were diagnosed with DCIS (33 of the 392 were excluded because they were receiving follow-up care at outside centers, and 44 because of recurrence/death). We evaluated psychosocial distress by Hospitalized Anxiety and Depression Scale (HADS) and Revised Impact of Events Scale (RIES), quality of life (QOL) by Short Form Health Survey (SF-36), and risk perceptions with items used previously in the cohort. Results: One hundred ninety-three women (61%) responded. They were a median age of 53 yrs (range 31-89) and a median of 5.8 yrs from diagnosis (range 4.3-7.0). Twelve were excluded due to report of recurrence. Of the 181 remaining, 32% perceived at least a moderate risk of developing DCIS again within 5 yrs; 43% perceived at least a moderate lifetime risk of developing DCIS again; 27% perceived at least a moderate risk of developing invasive breast cancer within 5 yrs; 38% perceived at least a moderate lifetime risk of developing invasive breast cancer; 24% perceived at least a moderate risk of DCIS spreading to other parts of their bodies. For qualitative responses of ≥ moderate perceived risk, median quantitative risk perception was 10% regarding 5-yr risk of DCIS or invasive cancer, 20% regarding lifetime risk, and 50% pertaining to risk of DCIS spreading. The proportion of women reporting ≥ moderate perceived risk of DCIS spreading remained stable over time (25% at baseline; 26% at 18 mos), but this proportion decreased for other perceptions of risk (e.g., at baseline and 18 mos, 51% and 50% of these same women perceived ≥ moderate risk of developing DCIS again within 5 yrs). In a multivariable model, worse financial status (OR 2.6, 95% CI 1.3-5.3) and higher perceived risk on earlier surveys (OR 24.4, 95% CI 12.7-47.2) were the only predictors of ≥ moderate perception of risk of DCIS spreading to other parts of the body in long-term follow-up. Non-significant covariates included age, race, education, grade of DCIS, comedonecrosis, mastectomy, radiation, marital status, employment status, comorbidity, and HADS and RIES scores. This contrasted with earlier survey data, which demonstrated an association between higher risk perceptions and anxiety by HADS and RIES. In long-term follow-up, only 7% were found to be anxious (HADS Anxiety ≥11) and 0.6% were depressed (HADS Depression ≥11). Median SF-36 scores were 48.9 (range 15.7-58.2) and 47.1 (range 23.6-60.3) for the physical and mental components, respectively, consistent with overall good QOL. Conclusions: Women with a history of DCIS continue to harbor inaccurate perceptions of risk of future breast cancer events even at 6 yrs follow-up. Future research should evaluate how these excessive risk perceptions impact health behaviors. Interventions to improve risk perceptions are warranted. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-15-01.

Purpose. To study informal skill transfer via staff networks as a complement to formal training among afterschool childcare providers implementing a health promotion program. Design. Cross-sectional, sociometric network analysis. Setting. Boston Young Men's Christian Association (YMCA) afterschool programs implementing the iPLAY program. Participants. All 91 staff members at 20 sites were eligible; 80 completed the survey (88% response rate). Measures. At the network level, network density measured system-level connectedness. At the staff level, the independent variable was out degree, the number of individuals to whom respondents noted a program-related connection. The dependent variable was skill gains, the number of key implementation skills gained from the network. Analysis. We mapped the staff program-related social network. We utilized multiple linear regression to estimate the relationship between out degree and skill gains, and we adjusted for clustering of staff in sites. Results. Most staff (77%) reported gaining at least one skill from the network, but only 2% of potential network connections were established. The regression model showed that out degree (i.e., number of program-related contacts) was significantly associated with skill gains (β = .48, p < .01) independent of other variables. Conclusion. Informal skill transfer in staff networks may be a useful complement to formal training for implementation of health promotion programs, but informal skill transfer was likely underutilized in this network. Future research employing longitudinal and/or multisite data should examine these findings in greater detail.

Ductal carcinoma in situ (DCIS) is a noninvasive breast cancer that constitutes between 12% and 15% of breast cancers.1 Although the biological characteristics and treatment options of DCIS have been the subject of growing research over the past several decades, only a small number of studies have examined the psychosocial sequelae of a DCIS diagnosis.2–6 In addition, no research has been conducted to identify socioeconomic subgroups of women who might be vulnerable to psychological morbidity after a DCIS diagnosis. Research on the psychosocial sequelae of a DCIS diagnosis is warranted for several reasons. First of all, DCIS is generally not life-threatening. When treated with standard therapy, the majority of cases will not result in local or systemic recurrence.1,7 Yet, similar to invasive breast cancer, the primary treatment for DCIS is surgery, with 30% of women undergoing mastectomy and 60% undergoing a breast-conserving procedure.1 Consequently, women with DCIS may experience many of the same psychosocial issues as women who are treated for invasive breast cancer, such as anxiety,8–10 depression, sexual problems, and negative body image.9 In fact, the limited research that has directly compared women with DCIS to women with invasive breast cancer has found no difference in their levels of psychological symptoms (ie, difficulty sleeping, anxiety, and depression),2 quality of life, and overall well-being.3 However, women with DCIS may experience fewer physical symptoms, better general health, and a less negative impact on their sex life and interpersonal relationships than women with invasive breast cancer.3 The word carcinoma and the surgical treatments for DCIS suggest a level of disease severity, and the distinction between invasive and noninvasive cancer can be confusing for many patients.4,5 In addition, women report being frustrated by the lack of available information about their DCIS.4,5 A shortage of information may leave women with DCIS unaware of their true breast cancer risk. For example, research suggests that women with DCIS do not differ from women with invasive breast cancer in their perceived risk of local or distant recurrence or distant metastases2 or of dying from their disease.3 Furthermore, between 54% and 61% of women perceived at least a moderate risk for disease recurrence,6,11 and 39% perceived at least a moderate risk for invasive cancer in the next 5 years.6 These risk perceptions are inaccurate, as true risk for local recurrence in the form of DCIS or invasive breast cancer after modern therapy ranges approximately 1% to 7%.12–14 Prior work from our group suggests that distress may contribute to inaccurate risk perceptions. For example, women with elevated DCIS-related intrusive or avoidant thoughts were more likely to overestimate their risk of metastasis, whereas women with elevated anxiety were more likely to overestimate their risk of a DCIS or invasive breast cancer recurrence and of developing invasive breast cancer in their lifetime.6 To effectively address the psychosocial needs of women with DCIS, it is important to consider that the incidence and prevalence of distress after DCIS may not be equal across all women, but instead may vary by socioeconomic status (SES). SES is inversely associated with psychological morbidity after an invasive cancer diagnosis.15–22 In addition, SES dictates access to important resources such as money, knowledge, and social connections/support that could be used to minimize the impact of a major health crisis such as a cancer diagnosis.23–29 Women with low SES may not have the same financial and psychosocial resources to cope with their DCIS; thus, this population may be vulnerable to anxiety and depression after their diagnosis. The extent to which SES affects distress after a DCIS diagnosis has not been previously addressed. The authors conducted a prospective longitudinal observational study to examine the psychosocial impact of a DCIS diagnosis.6 The current paper analyzes a subset of these data to examine whether SES was associated with anxiety and depression in these women. Because social support is inversely associated with distress across populations,30,31 and social support is positively associated with SES,24–28 this paper also explores whether the association between SES and distress was explained by differences in social support (mediation) and whether social support buffered against distress among women with low SES (moderation). We hypothesized that 1) women’s distress (anxiety and depression) would be inversely associated with their SES (education and financial status) at baseline and at the 9-month follow-up; 2) SES would predict a change in distress from baseline to the 9-month follow-up; and 3) social support would mediate and moderate the association between SES and anxiety and depression.

Evidence is lacking regarding effective and sustainable weight loss approaches for use in the primary care setting. We conducted a 12-week randomized controlled trial to evaluate the short-term efficacy of a web-based weight loss intervention among 101 primary care patients with obesity and hypertension. Patients had access to a comprehensive website that used a moderate-intensity weight loss approach designed specifically for web-based implementation. Patients also participated in four (two in-person and two telephonic) counseling sessions with a health coach. Intent-to-treat analysis showed greater weight loss at 3 months (-2.56 kg; 95% CI -3.60, -1.53) among intervention participants (-2.28 +/- 3.21 kg), relative to usual care (0.28 +/- 1.87 kg). Similar findings were observed among intervention completers (-3.05 kg; 95% CI -4.24, -1.85). High rates of participant retention (84%) and website utilization were observed, with the greatest weight loss found among those with a high frequency of website logins (quartile 4 vs. 1: -4.16 kg; 95% CI -1.47, -6.84). The intervention's approach promoted moderate weight loss at 12 weeks, though greater weight loss was observed among those with higher levels of website utilization. Efficacious web-based weight loss interventions can be successfully offered in the primary care setting.

Young women with newly diagnosed breast cancer face substantial challenges including higher risk of disease recurrence and likelihood of harboring a genetic mutation compared with older women. Many young women are also very concerned about their future fertility and this population often feels isolated from other breast cancer survivors due to their age and life stage. Some worry that their doctors are unsure of how to treat them. To address these issues, we developed a comprehensive program at our institution to coordinate and enhance the care, support, and education for young women with breast cancer. The Young and Strong study is a randomized clinical trial (RCT) to evaluate a virtual, exportable, scalable version of this program designed to improve the quality of care and the psychosocial well-being of this vulnerable population. The specific aims of this program are: 1) To develop, pilot, and refine an exportable and sustainable educational and support intervention for young women with breast cancer and their oncology providers (Young Women's Intervention; YWI). 2) To determine the effect of the YWI compared to a contact-time control intervention focused on promoting physical activity (Physical Activity Intervention; PAI) on attention to fertility issues in a RCT: “Young and Strong”. We initially conducted 4 focus groups (n = 36) and 20 key informant interviews, and developed, piloted, and refined the YWI as well as the PAI. Based on this successful work, we launched the Young and Strong study in June 2012 as a cluster-randomized trial at a total of 54 sites (40 community and 14 academic sites across the United States). Randomization is 1:1 between sites, and stratified by practice type (community vs. academic). Each community site will enroll 5-10 participants, each academic site 15 participants. Total recruitment will be 410-610 pts. The primary objective is to evaluate whether YWI, as compared to PAI, is associated with greater attention to fertility issues, assessed via medical record review. In addition, participants will complete assessments at baseline, 3, 6, and 12 months that assess satisfaction with care, psychosocial well-being, physical activity and anthropomorphic changes. Young and Strong activated in June 2012 and all sites have been identified. As of 6/11/2013 the study has been initiated at 53 out of 54 sites, and total of 282 women have enrolled on the study. Eligibility Criteria: 1. Women age 18-45 years at diagnosis 2. Stage I-III invasive breast cancer without known recurrence or metastatic disease 3. Newly-diagnosed (within 3 months of initial diagnosis) 4. Have 1st appt. with a medical oncologist at participating site after the site opens to enrollment 5. Able to read and write in English For further information, contact Ann Partridge, MD, MPH at 888-814-3324. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-4-02.

The primary aim of this paper was to explore whether provider's understanding of patient's social context is associated with screening uptake, independent of provider's recommendation. Baseline data were collected in 2004-2005 from a cluster randomized control trial in 12 low-income housing sites. Participants included 695 low-income, multiethnic adults aged 50 years and over who were primarily insured (97%). Provider's recommendation was significantly associated with current adherence to colorectal cancer (CRC) screening. Provider's understanding of patient's social context, as operationalized by how well participants felt that their provider knew (a) their responsibilities at work, home, or school; (b) their worries about health; and (c) them as a person and their values and beliefs, was also significantly associated with current adherence to screening, independent of provider's recommendation. Participants who reported that their provider knew them well on two or three items were significantly more likely to be current with CRC screening compared to those who reported their provider knew them well on only one or none of the items (odds ratio = 1.56; 95% confidence interval = 1.06, 2.29). Our findings indicate that provider's understanding of patient's social context, independent of provider's recommendation for CRC screening, contributed to adherence to CRC screening in this low-income, multiethnic population.

Background Although discrimination has been identified as a potential determinant of existing racial/ethnic health disparities, no studies have investigated whether racial discrimination contributes to disparities in physical activity. Purpose The primary aim of the current study was to examine the association between interpersonal racial discrimination and physical activity. Methods Baseline data were collected during 2004–2005 among a predominately black and Hispanic sample of adult residents living in 12 low-income–housing sites in Boston MA ( n =1055). Residents reported experiences of lifetime racial discrimination during interviewer-administered surveys and wore a pedometer for 5 days to measure physical activity. For analyses, performed in 2009, linear regression models with a cluster design were conducted to predict physical activity, measured as steps per day. Results Nearly 48% of participants reported ever experiencing racial discrimination, and discrimination was most commonly experienced on the street or in a public setting. No association was found between discrimination and physical activity, when examined in bivariate, multivariable, or race-stratified models. Conclusions The current results indicate that self-reported racial discrimination is not a key determinant of physical activity among residents living in low-income housing. However, additional research is warranted to address current limitations of this study.

As organizations implement novel health promotion programs across multiple sites, they face great challenges related to knowledge management. Staff social networks may be a useful medium for transferring program-related knowledge in multi-site implementation efforts. To study this potential, we focused on the role of extra-team connections (ties between staff members based in different site teams) as potential channels for knowledge sharing. Data come from a cross-sectional study of after-school child-care staff implementing a health promotion program at 20 urban sites of the Young Men's Christian Association of Greater Boston. We conducted a sociometric social network analysis and attempted a census of 91 program staff members. We surveyed 80 individuals, and included 73 coordinators and general staff, who lead and support implementation, respectively, in this study. A multiple linear regression model demonstrated a positive relationship between extra-team connections (beta = 3.41, P0.0001) and skill receipt, a measure of knowledge transfer. We also found that intra-team connections (within-team ties between staff members) were also positively related to skill receipt. Connections between teams appear to support knowledge transfer in this network, but likely require greater active facilitation, perhaps via organizational changes. Further research on extra-team connections and knowledge transfer in low-resource, high turnover environments is needed.

Childhood cancer survivors are at risk for medical and psychosocial late effects as a result of their cancer and its therapy. Promotion of healthy lifestyle behaviors and provision of regular risk-based medical care and surveillance may modify the evolution of these late effects. This manuscript summarizes publications from the Childhood Cancer Survivor Study (CCSS) that have examined health behaviors, risk-based health care, and interventions to promote healthy lifestyle practices. Long-term survivors use tobacco and alcohol and have inactive lifestyles at higher rates than is ideal given their increased risk of cardiac, pulmonary, and metabolic late effects. Nearly 90% of survivors report receiving some form of medical care. However, only 18% report medical visits related to their prior cancer that include discussion or ordering of screening tests or counseling on how to reduce the specific risks arising from their cancer. One low-cost, peer-driven intervention trial has been successful in improving smoking cessation within the CCSS cohort. On the basis of data from CCSS investigations, several trials to promote improved medical surveillance among high-risk groups within the cohort are underway. Despite their long-term risks, many survivors of childhood cancer engage in risky health behaviors and do not receive adequate risk-based medical care.