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We assessed the psychosocial influences on college males' human papillomavirus (HPV) vaccine patient-provider communication and their uptake of one or more HPV vaccine doses.We conducted a cross-sectional survey with college males attending one large southwestern university. We used logistic regressions to explore the relationships between psychosocial and demographic variables on patient-provider communication and HPV vaccine uptake.Patient-provider communication had the most significant influence on HPV vaccine uptake. However, most college males reported never discussing the HPV vaccine with their healthcare providers. HPV vaccine awareness, perceived subjective norms to vaccinate, and behavioral control to talk to healthcare providers about the vaccine significantly influenced college males' patient-provider communication and vaccine uptake.HPV vaccine awareness, perceived behavioral control to communicate about the vaccine, and subjective norms to vaccinate are all addressable factors that influence HPV vaccine communication and uptake. Future intervention work should specifically target these factors for college men.

Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (Orthopedics . 2022;45(3):139–144.]

BACKGROUND Mindfulness meditation apps are associated with significant health benefits, yet many new app subscribers have low engagement and are unlikely to attain these benefits. OBJECTIVE The purpose of this study was to determine which individual characteristics predict app usage during the first eight weeks after newly subscribing to a meditation app. METHODS New subscribers to the Calm app completed a baseline survey and objective app usage data were collected over their first eight weeks. The baseline survey measured demographics, personality traits, intrinsic motivation for meditation, and symptoms of stress, anxiety, and depression. Regression models were used to assess the relationship between these self-reported characteristics and five app engagement outcomes: 1) days with any app session, 2) average daily minutes including all app session types, 3) an indicator for completing any meditation session, 4) days with any meditation sessions, and 5) average daily minutes of meditation. RESULTS We enrolled 304 participants who were primarily women (79%), White (82%), and had a mental health diagnosis (77%). Intrinsic motivation for meditation was the strongest predictor of app use over the first eight weeks and was associated with 3.63 greater odds of completing any meditation session (95% CI 2.10,6.27; P < 0.01), more days with meditation sessions (1.75 IRR, 95% CI 1.46,2.11; P < 0.01), and 0.32 more average daily meditation minutes (95% CI 0.14,0.49; P < 0.01). Among the individual components of the Intrinsic Motivation Inventory, “feeling pressure to meditate” was associated with fewer days of meditation (0.73 IRR, 95% CI 0.56,0.96; P =.004) and 0.47 fewer minutes of meditation (95% CI -0.74,-0.20; P CONCLUSIONS High intrinsic motivation for meditation was the strongest predictor of meditation app use among new subscribers’ first eight weeks, with a particularly strong negative relationship when motivation came from feeling pressure to use the app. These results suggest that pressure is a harmful source of motivation for meditation, and that future behavioral interventions should attempt to reduce sources of pressure to meditate in order to better maintain meditation performance. CLINICALTRIAL This trial was not preregistered

Potent lifestyle interventions to increase moderate-to-vigorous physical activity are urgently needed for population-level chronic disease prevention. This trial tested the independent and joint effects of a mobile health system automating adaptive goal setting and immediate financial reinforcement for increasing daily walking among insufficiently active adults.Participants were randomized into a 2 (adaptive versus static goal setting) X 2 (immediate versus delayed financial incentive timing) condition factorial trial to increase walking.Participants (N=512 adults) were recruited between 2016 and 2018 and were 64.5% female, aged 18-60 years, 18.8% Hispanic, 6.1% African American, and 83% White.Principles of reinforcement and behavioral economics directed intervention design.Participants wore accelerometers daily (133,876 day-level observations) that remotely measured moderate-to-vigorous physical activity bout minutes of ≥3 minutes/day for 1 year. Primary outcomes were between-condition differences in (1) engaging ≥1 bout of moderate-to-vigorous physical activity on each day and (2) on days with ≥1 bout, daily total moderate-to-vigorous physical activity minutes.Mixed-effects hurdle models tested treatment group X phase (time) interactions using an intent-to-treat approach in 2021. Engaging in any ambulatory moderate-to-vigorous physical activity was greater for Adaptive than for Static Goal groups (OR=2.34, 95% CI=2.10, 2.60 vs OR=1.66, 95% CI=1.50, 1.84; p0.001) and for Immediate than for Static Reinforcement groups (OR=2.16 95% CI=1.94, 2.40 vs OR=1.77, 95% CI=1.59, 1.97; p0.01). The Immediate Reinforcement group increased by 16.54 moderate-to-vigorous physical activity minutes/day, whereas the Delayed Reinforcement group increased by 9.91 minutes/day (p0.001). The combined Adaptive Goals + Immediate Reinforcement group increased by 16.52 moderate-to-vigorous physical activity minutes/day, significantly more than that of either Delayed Reinforcement group.This study offers automated and scalable-behavior change strategies for increasing walking among adults most at-risk for chronic diseases attributed to sedentary lifestyles.This study is registered at www.clinicaltrials.gov (ClinicalTrials.gov Identifier: NCT02717663).

Supplemental Digital Content is Available in the Text., Introduction: Recent studies project thousands of additional AIDS-related deaths because of COVID-19–related disruptions in HIV care. However, the extent to which disruptions in care have materialized since the start of the pandemic is not well understood. Methods: We use electronic health records to investigate how the pandemic has affected clinic visits, patients' antiretroviral therapy (ART) supply, and viral suppression for a cohort of 14,632 HIV clients from a large HIV clinic in Kampala, Uganda. We complement this with an analysis of electronically measured longitudinal ART adherence data from a subcohort of 324 clients. Results: Clinic visits decreased by more than 50% after a national lockdown started. The risk of patients running out of ART on a given day increased from 5% before the lockdown to 25% 3 months later (Relative Risk Ratio of 5.11, 95% confidence interval: 4.99 to 5.24) and remained higher than prelockdown 6 months later at 13% (Relative Risk Ratio of 2.60; 95% confidence interval: 2.52 to 2.70). There was no statistically significant change in electronically measured adherence or viral suppression. Conclusion: We document substantial gaps in HIV care after the start of the COVID-19 pandemic in Uganda. This suggests that measures to improve access should be explored as the pandemic persists. However, ART adherence was unaffected for the subcohort for whom we measured electronic adherence. This suggests that some clients may have stockpiles of ART tablets from previous prescriptions that allowed them to keep taking their medication even when they could not visit the clinic for ART refills.

BackgroundTo understand the state of tobacco control efforts across Africa, a first-ever survey was implemented to assess the nature and activities of tobacco control stakeholders across the African continent.MethodsA survey in English, Arabic, and French was made available to individuals and organizations to assess the types and scope of tobacco control efforts and experience with tobacco control programs based on FCTC articles/MPOWER components.ResultsThere were 219 respondents from 32 African and 6 non-African countries. Research and advocacy were the most reported activities, and several organizations emerged as network nodes for connecting tobacco control efforts across multiple African countries. The most common FCTC articles/MPOWER components worked on were (W) warning about the dangers of tobacco (58%), (M) monitor tobacco use and policies (49%), and (P) protection against secondhand smoke exposure (47%). Significant between-country differences were also found on some FCTC articles/MPOWER components: (1) (R) price and tax measures [Articles 6 and 15] (F=1.57, p=0.048), (2) industry interference [Article 5.3] (F=1.62, p=0.038), and (3) economically viable alternatives to tobacco growing [Article 17] (F=1.94, p=0.007).DiscussionThis study found a broad and robust tobacco control network across Africa, with multiple organizations serving those networks and having overlapping collaborations. There is considerable variability in tobacco control priorities and networking, and multiple barriers were identified to expanding the network and to fostering increased tobacco control efforts. The results point to important directions for increasing collaboration across FCTC articles/MPOWER components to improve tobacco control efforts; potential research opportunities, including an analysis of tobacco industry activities, an exploration of ways to help people quit tobacco, and approaches to elevate the cost of tobacco; and a solid tobacco control network foundation on which to build. However, exploring creative approaches to increase research most relevant to specific countries and their cultural characteristics is essential.

BACKGROUND Mobile health (mHealth) apps can promote physical activity; however, the pragmatic nature (ie, how well research translates into real-world settings) of these studies is unknown. The impact of study design choices, for example, intervention duration, on intervention effect sizes is also understudied. OBJECTIVE This review and meta-analysis aims to describe the pragmatic nature of recent mHealth interventions for promoting physical activity and examine the associations between study effect size and pragmatic study design choices. METHODS The PubMed, Scopus, Web of Science, and PsycINFO databases were searched until April 2020. Studies were eligible if they incorporated apps as the primary intervention, were conducted in health promotion or preventive care settings, included a device-based physical activity outcome, and used randomized study designs. Studies were assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) and Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) frameworks. Study effect sizes were summarized using random effect models, and meta-regression was used to examine treatment effect heterogeneity by study characteristics. RESULTS Overall, 3555 participants were included across 22 interventions, with sample sizes ranging from 27 to 833 (mean 161.6, SD 193.9, median 93) participants. The study populations’ mean age ranged from 10.6 to 61.5 (mean 39.6, SD 6.5) years, and the proportion of males included across all studies was 42.8% (1521/3555). Additionally, intervention lengths varied from 2 weeks to 6 months (mean 60.9, SD 34.9 days). The primary app- or device-based physical activity outcome differed among interventions: most interventions (17/22, 77%) used activity monitors or fitness trackers, whereas the rest (5/22, 23%) used app-based accelerometry measures. Data reporting across the RE-AIM framework was low (5.64/31, 18%) and varied within specific dimensions (Reach=44%; Effectiveness=52%; Adoption=3%; Implementation=10%; Maintenance=12.4%). PRECIS-2 results indicated that most study designs (14/22, 63%) were equally explanatory and pragmatic, with an overall PRECIS-2 score across all interventions of 2.93/5 (SD 0.54). The most pragmatic dimension was flexibility (adherence), with an average score of 3.73 (SD 0.92), whereas follow-up, organization, and flexibility (delivery) appeared more explanatory with means of 2.18 (SD 0.75), 2.36 (SD 1.07), and 2.41 (SD 0.72), respectively. An overall positive treatment effect was observed (Cohen d=0.29, 95% CI 0.13-0.46). Meta-regression analyses revealed that more pragmatic studies (−0.81, 95% CI −1.36 to −0.25) were associated with smaller increases in physical activity. Treatment effect sizes were homogenous across study duration, participants’ age and gender, and RE-AIM scores. CONCLUSIONS App-based mHealth physical activity studies continue to underreport several key study characteristics and have limited pragmatic use and generalizability. In addition, more pragmatic interventions observe smaller treatment effects, whereas study duration appears to be unrelated to the effect size. Future app-based studies should more comprehensively report real-world applicability, and more pragmatic approaches are needed for maximal population health impacts. CLINICALTRIAL PROSPERO CRD42020169102; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=169102

BACKGROUND The intensive data typically collected by mobile health (mHealth) apps allows factors associated with persistent use to be investigated, which is an important objective given users’ well-known struggles with sustaining healthy behavior. OBJECTIVE Data from a commercial meditation app (n=14,879; 899,071 total app uses) were analyzed to assess the validity of commonly given habit formation advice to meditate at the same time every day, preferably in the morning. METHODS First, the change in probability of meditating in 4 nonoverlapping time windows (morning, midday, evening, and late night) on a given day over the first 180 days after creating a meditation app account was calculated via generalized additive mixed models. Second, users’ time of day preferences were calculated as the percentage of all meditation sessions that occurred within each of the 4 time windows. Additionally, the temporal consistency of daily meditation behavior was calculated as the entropy of the timing of app usage sessions. Linear regression was used to examine the effect of time of day preference and temporal consistency on two outcomes: (1) short-term engagement, defined as the number of meditation sessions completed within the sixth and seventh month of a user’s account, and (2) long-term use, defined as the days until a user’s last observed meditation session. RESULTS Large reductions in the probability of meditation at any time of day were seen over the first 180 days after creating an account, but this effect was smallest for morning meditation sessions (63.4% reduction vs reductions ranging from 67.8% to 74.5% for other times). A greater proportion of meditation in the morning was also significantly associated with better short-term engagement (regression coefficient B=2.76, PB=50.6, PB=–2.06, PB=–51.7, P=.001). Significant relationships were not found for midday sessions (any outcome) or for evening sessions when examining long-term use. Additionally, temporal consistency in the performance of morning meditation sessions was associated with better short-term engagement (B=–1.64, PB=55.8, P CONCLUSIONS Meditating in the morning was associated with higher rates of maintaining a meditation practice with the app. This is consistent with findings from other studies that have hypothesized that the strength of existing morning routines and circadian rhythms may make the morning an ideal time to build new habits. In the long term, less temporal consistency in meditation sessions was associated with more persistent app use, suggesting there are benefits from maintaining flexibility in behavior performance. These findings improve our understanding of how to promote enduring healthy lifestyles and can inform the design of mHealth strategies for maintaining behavior changes.

BACKGROUND Nonadherence to antiretroviral therapy (ART) among people living with HIV (PLHIV) is a crucial barrier to attaining viral suppression globally. Existing behavioral interventions have successfully increased ART adherence, but typically show only short-term impact that dissipates after the interventions are withdrawn. The purpose of this study is to test the feasibility and acceptability of a novel behavioral intervention that uses text messages and behavioral economics (BE)-based incentives to support the anchoring of daily ART pill-taking behavior to an existing routine in order to improve long-term ART adherence. OBJECTIVE To test the feasibility, acceptability, and preliminary efficacy of a novel intervention that utilizes text messages and conditional incentives to support ART initiators in establishing pill-taking habits. METHODS A sample of 150 participants 18 years and older who have initiated ART in the preceding three months will be recruited at Mildmay Uganda in Kampala, Uganda. All participants will be educated on the anchoring strategy and will choose an existing routine to pair with their daily ART adherence from a set of three suggested routines: getting dressed in the morning, eating breakfast, or eating dinner. Participants will then be randomized to either receive usual care (C = 50) or one of the two interventions delivered over three months: daily text message reminders to follow their chosen anchoring plan (Messages group; T1 = 50) or daily text messages and incentives conditional on taking their ART medication around the time of their chosen anchor (Incentives group; T2 = 50). Long-term ART adherence will be evaluated for six months post intervention, and survey assessments will be conducted at baseline, month 3, and month 9. The outcomes include feasibility and acceptability measures, as well as intervention efficacy outcomes defined by 1) electronically measured mean medication adherence during the intervention and 2) during the six months post intervention, along with 3) a measure of routine ART adherence based on taking medications around the time of participants’ anchor during the intervention and 4) during the six months post intervention. RESULTS This pilot RCT was funded by the National Institutes of Mental Health in the United States (R34MH122331), and approved by the RAND Human’s Subjects Protection Committee (2020-N0632), Mildmay Uganda Research Ethics Committee (MUREC) (0701-2021), as well as the Uganda National Council for Science and Technology (HS128ES). As of February 18, 2022, recruitment was completed. CONCLUSIONS This study is the first to employ BE-based interventions in combination with the anchoring strategy to improve long-term ART adherence among treatment initiators. The results of this pilot RCT will help to refine this combined intervention approach for testing at scale, and will broaden our understanding of the habit formation process. CLINICALTRIAL Clinicaltrials.gov, NCT05131165. Retrospectively registered on 12 November 2021.

BACKGROUND Chronic (ie, long-term) elevated stress is associated with a number of mental and physical health conditions. Mindfulness meditation mobile apps are a promising tool for stress self-management that can overcome several barriers associated with in-person interventions; however, to date, poor app-based intervention adherence has limited the efficacy of these mobile health tools. Anchoring, or pairing, a new behavior with an existing routine has been shown to effectively establish habits that are maintained over time, but this strategy typically only works for those with high initial motivation and has yet to be tested for maintaining meditation with a mobile app. OBJECTIVE This study will test novel combinations of behavioral economics–based incentives with the anchoring strategy for establishing and maintaining adherence to an effective dose of meditation with a mobile app. METHODS This 16-week study will use a 5-arm, parallel, partially blinded (participants only), randomized controlled design. We will implement a fractional factorial study design that varies the use of self-monitoring messages and financial incentives to support participants’ use of their personalized anchoring strategy for maintaining adherence to a ≥10 minute-per-day meditation prescription during an 8-week intervention period, followed by an 8-week postintervention observation period. Specifically, we will vary the use of self-monitoring messages of either the target behavior (ie, meditation tracking) or the outcome associated with the target behavior (ie, mood symptom tracking). We will also vary the use of financial incentives conditional on either meditation at any time of day or meditation performed at approximately the same time of day as participants’ personalized anchors. RESULTS Continuous meditation app use data will be used to measure weekly meditation adherence over the 16-week study period as a binary variable equal to 1 if participants complete ≥10 minutes of meditation for ≥4 days per week and 0 otherwise. We will measure weekly anchoring plan adherence as a binary variable equal to 1 if participants complete ≥10 minutes of meditation within +1 or −1 hour of the timing of their chosen anchor on ≥4 days per week and 0 otherwise. In addition to these primary measures of meditation and anchoring plan adherence, we will also assess the secondary measures of stress, anxiety, posttraumatic stress disorder, sleep disturbance, and meditation app habit strength at baseline, week 8, and week 16. CONCLUSIONS This study will fill an important gap in the mobile health literature by testing novel intervention approaches for establishing and maintaining adherence to app-based mindfulness meditation. If successful, this study will identify an accessible and scalable stress self-management intervention that can help combat stress in the United States. CLINICALTRIAL ClinicalTrials.gov NCT05217602; https://clinicaltrials.gov/ct2/show/NCT05217602 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/39930

OBJECTIVE: To estimate novel measures of generalist physicians’ network connectedness to HIV specialists and their associations with two dimensions of HIV quality of care. DATA SOURCES: Medicare and Medicaid claims and the American Medical Association Masterfile data on people living with HIV (PLWH) and the physicians providing their HIV care in California between 2007 and 2010. STUDY DESIGN: I construct regional patient‐sharing physician networks from the shared treatment of PLWH and calculate (a) measures of network connectedness to all physician types and (b) specialty‐weighted measures to describe connectedness to HIV specialists. Two HIV quality of care outcomes are then evaluated: medication quality (prescribing antiretroviral drugs from at least two drug classes) and monitoring quality (at least two annual HIV virus monitoring scans). Linear probability models estimate the associations between network statistics and the two dimensions of HIV quality of care, and a policy simulation demonstrates the importance of these statistical relationships. These analyses include 16 124 PLWH, 3240 generalists, and 1031 HIV specialists. DATA COLLECTION/EXTRACTION METHODS: PLWH are identified from claims for patients with any indication of HIV using an existing algorithm from the literature. PRINCIPAL FINDINGS: Generalists’ network connectedness to HIV specialists is positively related with their own HIV medication quality; one additional HIV specialist connection is associated with a 1.46 percentage point (SE 0.42, P

ObjectiveDescribe the landscape of tobacco-related topics, funders and institutional networks in Africa.Data sourcesWe searched PubMed, Embase and African Index Medicus for published articles from January 1996 to August 2018 in any language.Study selectionTwo researchers independently reviewed titles and abstracts for a focus on nicotine or tobacco product(s) and describe data or recommendations specific to Africa. Ultimately, 818 articles were identified.Data extractionThree independent coders conducted qualitative analyses of articles and extracted funders, study populations, countries of research focus, research topics, tobacco products, study design and data source. A bibliometric analysis estimated coauthorship networks between the countries of authors’ primary institutional affiliation.Data synthesisAll 54 African countries were represented in two or more articles. The coauthorship network included 2714 unique authors representing 90 countries. Most articles employed a cross-sectional study design with primary data collection, focused on cigarettes and studied use behaviour. Few articles examined tobacco farming or interventions for cessation or prevention. The most frequently cited funder was the US National Institutes of Health (27.2%). A range of coauthorship patterns existed between African institutions with some coauthoring with one institution while others coauthored with 761 institutions in other African countries.ConclusionsThe literature review identified the need for implementation research for tobacco control interventions and policies, economic and development impacts of tobacco use research, and tobacco industry and tobacco production and farming research. Numbers of research collaborations between institutions in Africa vary, suggesting the need for regional institutional capacity building.

In the US, individuals between ages 18 and 26 have the highest incidence of new human papillomavirus (HPV) infections, the most common sexually transmitted infection worldwide. HPV infection can cause genital warts, and persistent infection with cancerous strains can develop into multiple types of cancers. In 2011, the Centers for Disease Control and Prevention recommended that both men and women receive the vaccine. However, young adult men, including college-aged men, have been slow to initiate and complete the vaccine series. Our cross-sectional study, guided by the Theory of Planned Behavior, explores college men’s vaccination uptake and series completion behaviors and their intentions to vaccinate. Using logistic regression, we examined how students’ attitudes, perceived behavioral control, and subjective norms impacted their HPV vaccine–related behaviors and intentions. Subjective norms, followed by perceived behavioral control to communicate with a provider about the HPV vaccine, had the largest impact on students’ HPV vaccine uptake and completion behaviors and intentions to vaccinate. Both subjective norms and positive attitudes about the vaccine impacted students’ intentions to vaccinate against HPV. Based on these findings, we make various recommendations including campus interventions and policies that could increase HPV vaccine uptake and completion behaviors among college men.

Background Many HIV-positive patients do not appropriately adhere to their antiretroviral medication (ART). This leads to higher viral loads and greater probability of HIV transmission. Present bias—a tendency to give in to short-term temptations at the expense of long-term outcomes—is a potential driver of low adherence. In this study we test a novel intervention rooted in behavioral economics that is designed to overcome present bias and increase ART adherence. Methods/design We will enroll 330 HIV-positive patients at Mildmay Hospital in Kampala, Uganda, into a 2-year randomized controlled trial. Participants will be randomized to one of three groups. The first intervention group (T1, n = 110) will be eligible for small lottery prizes based on timely clinic visits and demonstration of viral suppression. Group 2 (T2, n = 110) will be eligible for the same lottery prizes conditional on high adherence measured by a medication event management system (MEMS) cap. The control group (n = 110) will receive the usual standard of care. Adherence will be measured continuously throughout the intervention period and for 12 months post-intervention to evaluate effect persistence. Surveys will be conducted at baseline and then every 6 months. Viral loads will be measured annually. Primary outcomes are whether the viral load is detectable and MEMS-measured adherence. Secondary outcomes are the log-transformed viral load as a continuous measure and a binary measure for whether the person took at least 90% of their ART pills. Discussion Our study is one of the first to investigate the effectiveness of lottery incentives for improving ART adherence, and in addition, it compares the relative efficacy of using electronically measured adherence versus viral load to determine lottery eligibility. MEMS caps are relatively costly, whereas viral load testing is now part of routine clinical care in Uganda. BEST will test whether directly incentivizing viral suppression (which can be implemented using readily available clinic data) is as effective as incentivizing electronically measured adherence. Cost-effectiveness analyses of the two implementation modes will also be performed. Trial registration ClinicalTrials.gov, NCT03494777. Registered on 11 April 2018.

Key Points Question Are there racial and ethnic disparities in patients undergoing prostate magnetic resonance imaging after receiving an elevated prostate-specific antigen test result? Findings In this cohort study of 794 809 commercially insured men from 2011 to 2017 undergoing a prostate-specific antigen test, Black and Hispanic patients were significantly less likely than White patients to undergo prostate magnetic resonance imaging after receiving an elevated test score. Meaning These results suggest that racial and ethnic disparities exist in the use of subsequent prostate magnetic resonance imaging, highlighting a need to better understand and mitigate physician decision-making biases and other potential sources of the disparities in the identification and management of prostate cancer., This cohort study examines disparities based on race and ethnicity in prostate cancer screenings following elevated prostate-specific antigen levels among US men., Importance Prostate cancer screening and diagnosis exhibit known racial and ethnic disparities. Whether these disparities persist in prostate magnetic resonance imaging (MRI) utilization after elevated prostate-specific antigen (PSA) results is poorly understood. Objective To assess potential racial and ethnic disparities in prostate MRI utilization following elevated PSA results. Design, Setting, and Participants This cohort study of 794 809 insured US men was drawn from deidentified medical claims between January 2011 and December 2017 obtained from a commercial claims database. Eligible participants were aged 40 years and older and received a single PSA result and no prior PSA screening or prostate MRI claims. Analysis was performed in January 2021. Main Outcomes and Measures Multivariable logistic regression was used to examine associations between elevated PSA results and follow-up prostate MRI. For patients receiving prostate MRI, multivariable regressions were estimated for the time between PSA and subsequent prostate MRI. PSA thresholds explored included PSA levels above 2.5 ng/mL, 4 ng/mL, and 10 ng/mL. Analyses were stratified by race, ethnicity, and age. Results Of 794 809 participants, 51 500 (6.5%) had PSA levels above 4 ng/mL; of these, 1524 (3.0%) underwent prostate MRI within 180 days. In this sample, mean (SD) age was 59.8 (11.3) years (range 40-89 years); 31 350 (3.9%) were Asian, 75 935 (9.6%) were Black, 107 956 (13.6%) were Hispanic, and 455 214 (57.3%) were White. Compared with White patients, Black patients with PSA levels above 4 ng/mL and 10 ng/mL were 24.1% (odds ratio [OR], 0.78; 95% CI, 0.65-0.89) and 35.0% (OR, 0.65; 95% CI, 0.50-0.85) less likely to undergo subsequent prostate MRI, respectively. Asian patients with PSA levels higher than 4 ng/mL (OR, 0.76; 95% CI, 0.58-0.99) and Hispanic patients with PSA levels above 10 ng/mL (OR, 0.77; 95% CI, 0.59-0.99) were also less likely to undergo subsequent prostate MRI compared with White patients. Black patients between ages 65 and 74 years with PSA above 4 ng/mL and 10 ng/mL were 23.6% (OR, 0.76; 95% CI, 0.64-0.91) and 43.9% (OR, 0.56; 95% CI, 0.35-0.91) less likely to undergo MRI, respectively. Race and ethnicity were not significantly associated with mean time between PSA and MRI. Conclusions and Relevance Among men with elevated PSA results, racial and ethnic disparities were evident in subsequent prostate MRI utilization and were more pronounced at higher PSA thresholds. Further research is needed to better understand and mitigate physician decision-making biases and other potential sources of disparities in prostate cancer diagnosis and management.

BACKGROUND Physical and mental health benefits can be attained from persistent, long-term performance of mindfulness meditation with a mobile meditation app, but in general, few mobile health app users persistently engage at a level necessary to attain the corresponding health benefits. Anchoring or pairing meditation with a mobile app to an existing daily routine can establish an unconsciously initiated meditation routine that may improve meditation persistence. OBJECTIVE The purpose of this study was to test the use of either personalized anchors or fixed anchors for establishing a persistent meditation app routine with the mobile app, Calm. METHODS We conducted a randomized controlled trial and randomly assigned participants to one of 3 study groups: (1) a personalized anchor (PA) group, (2) fixed anchor (FA) group, or (3) control group that did not use the anchoring strategy. All participants received app-delivered reminder messages to meditate for at least 10 minutes a day using the Calm app for an 8-week intervention period, and app usage data continued to be collected for an additional 8-week follow-up period to measure meditation persistence. Baseline, week 8, and week 16 surveys were administered to assess demographics, socioeconomic status, and changes in self-reported habit strength. RESULTS A total of 101 participants across the 3 study groups were included in the final analysis: (1) PA (n=56), (2) FA (n=49), and (3) control group (n=62). Participants were predominantly White (83/101, 82.2%), female (77/101, 76.2%), and college educated (ie, bachelor’s or graduate degree; 82/101, 81.2%). The FA group had a significantly higher average odds of daily meditation during the intervention (1.14 odds ratio [OR]; 95% CI 1.02-1.33; P=.04), and all participants experienced a linear decline in their odds of daily meditation during the 8-week intervention (0.96 OR; 95% CI 0.95-0.96; PP=.03). Additionally, those who more frequently adhered to their anchoring strategy during the intervention typically used anchors that occurred in the morning and showed a significantly smaller decline in their odds of daily meditation during the 8-week follow-up period (1.13 OR; 95% CI 1.02-1.35; P=.007). CONCLUSIONS The FA group had more persistent meditation with the app, but participants in the FA or PA groups who more frequently adhered to their anchoring strategy during the intervention had the most persistent meditation routines, and almost all of these high anchorers used morning anchors. These findings suggest that the anchoring strategy can create persistent meditation routines with a mobile app. However, future studies should combine anchoring with additional intervention tools (eg, incentives) to help more participants successfully establish an anchored meditation routine. CLINICALTRIAL ClinicalTrials.gov NCT04378530; https://clinicaltrials.gov/ct2/show/NCT04378530

Background The COVID-19 pandemic has been declared an international public health emergency, and it may have long-lasting effects on people’s mental health. There is a need to identify effective health behaviors to mitigate the negative mental health impact of COVID-19. Objective The objectives of this study were to (1) examine the regional differences in mental health and COVID-19–related worry, attention to news, and stress, in light of the state-level prevalence of COVID-19 cases; (2) estimate the associations between mental health and COVID-19–related worry, attention to news, and stress and health behavior engagement (ie, physical activity, mindfulness meditation); and (3) explore the mediating effect of health behavior engagement on the associations between mental health and COVID-19–related worry, attention to news, and stress. Methods A cross-sectional survey was distributed to a sample of US adult paying subscribers to the Calm app (data were collected from April 22 to June 3, 2020). The survey assessed COVID-19–related worry, attention to news, and stress; health behavior engagement; and mental health (ie, perceived stress, posttraumatic stress disorder, and anxiety and depression). Statistical analyses were performed using R software. Differences in COVID-19–related worry, attention to news, and stress and mental health by location were assessed using t tests and chi-square tests. Logistic and ordinary least squares models were used to regress mental health and health behavior on COVID-19–related worry, attention to news, and stress; moreover, causal mediation analysis was used to estimate the significance of the mediation effects. Results The median age of the respondents (N=8392) was 47 years (SD 13.8). Participants in the Mid-Atlantic region (New Jersey, New York, and Pennsylvania) reported higher levels of stress, more severe depression symptoms, greater worry about COVID-19, paying more attention to COVID-19–related news, and more stress related to social distancing recommendations than participants living in other regions. The association between worry about COVID-19 and perceived stress was significantly mediated by changes in physical activity (P Conclusions Our findings describe the mental health impact of COVID-19 and outline how continued participation in health behaviors such as physical activity and mindfulness meditation reduce worsening of mental health due to the COVID-19 pandemic. These data have important implications for public health agencies and health organizations to promote the maintenance of health habits to reduce the residual mental health burden of the COVID-19 pandemic.

Incentives are used to improve many health-related behaviors, but evidence is mixed for their effectiveness both during the incentivization period and, even more so, on the persistence of healthier habits after incentives are withdrawn. In this paper, we present the results of a randomized controlled trial that successfully uses incentives to improve medication adherence among HIV-infected patients in Uganda over 20 months, and follows the sample for another 6 months to measure the persistence of these behavioral improvements. Our study contributes to the literature on habit formation by identifying a behavioral strategy that is associated with persistently high medication adherence and independent of observable individual-level characteristics and the receipt of incentives. We reject the prevailing economic theory of habit formation in favor of a psychological definition of habits as reflexive context-behavior associations, and these findings help outline an expanded set of intervention design parameters for better promoting persistent, healthier behaviors.

BACKGROUND Behavioral habits are often initiated by contextual cues that occur at approximately the same time each day; so, it may be possible to identify a reflexive habit based on the temporal similarity of repeated daily behavior. Mobile health tools provide the detailed, longitudinal data necessary for constructing such an indicator of reflexive habits, which can improve our understanding of habit formation and help design more effective mobile health interventions for promoting healthier habits. OBJECTIVE This study aims to use behavioral data from a commercial mindfulness meditation mobile phone app to construct an indicator of reflexive meditation habits based on temporal similarity and estimate the association between temporal similarity and meditation app users’ perceived health benefits. METHODS App-use data from June 2019 to June 2020 were analyzed for 2771 paying subscribers of a meditation mobile phone app, of whom 86.06% (2359/2771) were female, 72.61% (2012/2771) were college educated, 86.29% (2391/2771) were White, and 60.71% (1664/2771) were employed full-time. Participants volunteered to complete a survey assessing their perceived changes in physical and mental health from using the app. Receiver operating characteristic curve analysis was used to evaluate the ability of the temporal similarity measure to predict future behavior, and variable importance statistics from random forest models were used to corroborate these findings. Logistic regression was used to estimate the association between temporal similarity and self-reported physical and mental health benefits. RESULTS The temporal similarity of users’ daily app use before completing the survey, as measured by the dynamic time warping (DTW) distance between app use on consecutive days, significantly predicted app use at 28 days and at 6 months after the survey, even after controlling for users’ demographic and socioeconomic characteristics, total app sessions, duration of app use, and number of days with any app use. In addition, the temporal similarity measure significantly increased in the area under the receiver operating characteristic curve (AUC) for models predicting any future app use in 28 days (AUC=0.868 with DTW and 0.850 without DTW; PP CONCLUSIONS The temporal similarity of the meditation app use was a significant predictor of future behavior, which suggests that this measure can identify reflexive meditation habits. In addition, temporal similarity was associated with greater perceived mental health benefits, which demonstrates that additional mental health benefits may be derived from forming reflexive meditation habits. CLINICALTRIAL

BACKGROUND Mindfulness meditation smartphone apps may improve mental health but lack evidence-based behavioral strategies to encourage their regular use for attaining mental health benefits. In October 2019, the Calm mindfulness meditation app introduced a mood check-in feature, but its effects on participation in meditation have yet to be tested. OBJECTIVE The objective of this study was to investigate how a mood check-in feature impacts meditation behavior in Calm app subscribers. METHODS This was a retrospective longitudinal analysis of mobile app usage data from a random sample of first-time subscribers to the Calm app (n=2600) who joined in summer 2018 or summer 2019. The mood check-in feature allows users to rate their mood using an emoji after completing a meditation session and displays a monthly calendar of their past mood check-ins. Regression analyses were used to compare the rate of change in meditation behavior before and after the introduction of mood check-ins and to estimate how usage of mood check-ins was associated with individuals’ future meditation behavior (ie, intent-to-treat effects). Additional regression models examined the heterogenous effect of mood check-ins between subscribers who were active or inactive users prior to the introduction to mood check-ins (ie, above or below the median number of weeks with any meditation within their cohort). In order to confirm the specific associations between mood check-ins and meditation engagement, we modeled the direct relationship between the use of mood check-ins in previous weeks and subsequent meditation behavior (ie, treatment on the treated effects). RESULTS During the first 9 months of their subscription, the 2019 cohort completed an average of 0.482 more sessions per week (95% CI 0.309 to 0.655) than the 2018 cohort; however, across both cohorts, average weekly meditation declined (–0.033 sessions per week, 95% CI –0.035 to –0.031). Controlled for trends in meditation before mood check-ins and aggregate differences between the 2018 and 2019 samples, the time trend in the number of weekly meditation sessions increased by 0.045 sessions among the 2019 cohort after the introduction of mood check-ins (95% CI 0.039 to 0.052). This increase in meditation was most pronounced among the inactive subscribers (0.063 sessions, 95% CI 0.052 to 0.074). When controlled for past-week meditation, use of mood check-ins during the previous week was positively associated with the likelihood of meditating the following week (odds ratio 1.132, 95% CI 1.059 to 1.211); however, these associations were not sustained beyond 1 week. CONCLUSIONS Using mood check-ins increases meditation participation in Calm app subscribers and may be especially beneficial for inactive subscribers. Mobile apps should consider incorporating mood check-ins to help better engage a wider range of users in app-based meditation, but more research is warranted.

Introduction: The purpose of this paper was to describe pregnant women’s COVID-19 perceptions, mental health and meditation habits compared to non-pregnant women in a sample of meditation mobile app subscribers. Methods: Women completed the “COVID-19 Health and Well-being Survey” which assessed perceptions of COVID-19 (i.e., worry, attention to news, stress from social distancing), perceived stress, post-traumatic stress disorder (PTSD), anxiety and depression, and meditation habits. Propensity scores were used to match the five most similar non-pregnant women to each pregnant woman based on racial minority status, ethnicity, age, household income, education, and residence in a state with a high COVID outbreak rate. Perceptions of COVID-19, mental health, and meditation habits were compared using t-tests and chi-square tests. Results: Of the 6,157 respondents, 50 were pregnant. The sample was mostly White (88.89%) with a mean age of 37.69 (SD=11.20). Pregnant women were more worried about getting COVID-19 than non-pregnant women and felt that they were taking more precautionary measures to prevent infection. Compared to non-pregnant women, pregnant women had less severe symptoms of depression and PTSD. The amount/frequency of meditation declined during the pandemic (t=2.31, p=.02). Pregnant women reported weaker pre-COVID-19 meditation habits, but larger increases in strength of meditation habits during the pandemic. Discussion: The strength of mediation habits may play a role in pregnant women’s mental health during COVID-19. Stronger meditation habits may prevent increases in stress despite increased worry related to getting infected by COVID-19 and may reduce symptoms of depression and PTSD.

BACKGROUND Rural and urban differences in health outcomes and behaviors have been well-documented, with significant rural health disparities frequently highlighted. Mobile health (mHealth) apps, such as meditation apps, are a novel method for improving health and behaviors. These apps may be a critical health promotion strategy during the COVID-19 pandemic and could potentially be used to address rural health disparities. However, limited research has assessed whether meditation app health outcomes are associated with rural and urban residence, and it is unclear whether disparities in health and behaviors between rural and urban populations would persist among meditation app users. OBJECTIVE We aimed to explore associations between rural or urban status, psychological outcomes, and physical activity among users of a mobile meditation app. We further aimed to explore associations between rural or urban status and perceived effects of COVID-19 on stress, mental health, and physical activity, and to explore changes in these outcomes in rural versus urban app users over time. METHODS This study was a secondary analysis of a national survey conducted among subscribers to the meditation app Calm. Eligible participants completed online baseline surveys from April to June 2020, and follow-up surveys from June to September 2020, assessing demographics, psychological outcomes, physical activity, and perceived effects of COVID-19 on stress, mental health, and physical activity. RESULTS Participants (N=8392) were mostly female (7041/8392, 83.9%), non-Hispanic (7855/8392, 93.6%), and White (7704/8392, 91.8%); had high socioeconomic status (income ≥US $100,000: 4389/8392, 52.3%; bachelor’s degree or higher: 7251/8392, 86.4%); and resided in a metropolitan area core (rural-urban commuting area code 1: 7192/8392, 85.7%). Rural or urban status was not associated with baseline stress, depression, anxiety, pre–COVID-19 and current physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Repeated-measures models showed overall decreases in depression, anxiety, and perceived effects of COVID-19 on physical activity from baseline to follow-up, and no significant changes in stress or perceived effects of COVID-19 on stress and mental health over time. Models also showed no significant main effects of rural or urban status, COVID-19 statewide prevalence at baseline, or change in COVID-19 statewide prevalence. CONCLUSIONS We did not find associations between rural or urban status and psychological outcomes (ie, stress, depression, and anxiety), physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Rural or urban status does not appear to drive differences in outcomes among meditation app users, and the use of mHealth apps should continue to be explored as a health promotion strategy in both rural and urban populations. Furthermore, our results did not show negative cumulative effects of COVID-19 on psychological outcomes and physical activity among app users in our sample, the majority of whom were urban, White, female, and of high socioeconomic status. Further research is needed to investigate meditation app use as a health promotion strategy in rural and urban populations.

Background Rural and urban differences in health outcomes and behaviors have been well-documented, with significant rural health disparities frequently highlighted. Mobile health (mHealth) apps, such as meditation apps, are a novel method for improving health and behaviors. These apps may be a critical health promotion strategy during the COVID-19 pandemic and could potentially be used to address rural health disparities. However, limited research has assessed whether meditation app health outcomes are associated with rural and urban residence, and it is unclear whether disparities in health and behaviors between rural and urban populations would persist among meditation app users. Objective We aimed to explore associations between rural or urban status, psychological outcomes, and physical activity among users of a mobile meditation app. We further aimed to explore associations between rural or urban status and perceived effects of COVID-19 on stress, mental health, and physical activity, and to explore changes in these outcomes in rural versus urban app users over time. Methods This study was a secondary analysis of a national survey conducted among subscribers to the meditation app Calm. Eligible participants completed online baseline surveys from April to June 2020, and follow-up surveys from June to September 2020, assessing demographics, psychological outcomes, physical activity, and perceived effects of COVID-19 on stress, mental health, and physical activity. Results Participants (N=8392) were mostly female (7041/8392, 83.9%), non-Hispanic (7855/8392, 93.6%), and White (7704/8392, 91.8%); had high socioeconomic status (income ≥US $100,000: 4389/8392, 52.3%; bachelor’s degree or higher: 7251/8392, 86.4%); and resided in a metropolitan area core (rural-urban commuting area code 1: 7192/8392, 85.7%). Rural or urban status was not associated with baseline stress, depression, anxiety, pre–COVID-19 and current physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Repeated-measures models showed overall decreases in depression, anxiety, and perceived effects of COVID-19 on physical activity from baseline to follow-up, and no significant changes in stress or perceived effects of COVID-19 on stress and mental health over time. Models also showed no significant main effects of rural or urban status, COVID-19 statewide prevalence at baseline, or change in COVID-19 statewide prevalence. Conclusions We did not find associations between rural or urban status and psychological outcomes (ie, stress, depression, and anxiety), physical activity, or perceived effects of COVID-19 on stress, mental health, and physical activity. Rural or urban status does not appear to drive differences in outcomes among meditation app users, and the use of mHealth apps should continue to be explored as a health promotion strategy in both rural and urban populations. Furthermore, our results did not show negative cumulative effects of COVID-19 on psychological outcomes and physical activity among app users in our sample, the majority of whom were urban, White, female, and of high socioeconomic status. Further research is needed to investigate meditation app use as a health promotion strategy in rural and urban populations.

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has been declared an international public health emergency with potential long-lasting effects on mental health. The purpose of this survey was to examine the regional differences in mental health and perceptions of COVID-19 in light of the state-level prevalence of COVID-19 cases, estimate the associations between perceptions of COVID-19 and health behavior engagement (i.e., physical activity, mindfulness meditation) and mental health, and explore the mediating effect of health behavior engagement on the relationship between perceptions of COVID-19 and mental health.Methods: A cross-sectional survey was distributed to a sample of US adult paying subscribers to the Calm app (data collection April 22 to June 3, 2020). The survey assessed perceptions of COVID-19, health behavior engagement, and mental health (i.e., perceived stress, post-traumatic stress disorder, and anxiety and depression). All statistical analyses were performed using R software. Differences in perceptions of COVID-19 and mental health by location were assessed using t-tests and chi-square tests. Logistic and OLS models regressed mental health and health behavior on COVID-19 perceptions, and Causal Mediation Analysis was used to estimate the significance of mediation effects. Results: Median age (N=8392) was 47 (SD=13.8) years. Mid-Atlantic region participants reported higher levels of stress, more severe depression symptoms, were more worried about COVID-19, paid more attention to COVID-19 news, and had more stress related to social distancing recommendations than participants living in other regions. The relationship between worry about COVID-19 and perceived stress was significantly mediated by changes in physical activity (pConclusions: Our findings describe the mental health impact of COVID-19 and outline how continued participation in health behaviors such as physical activity and mindfulness meditation may buffer against worsening mental health due to the COVID-19 pandemic. These data have important implications for public health agencies and health organizations to promote the maintenance of health habits to reduce the residual mental health burden of the COVID-19 pandemic.

Background Behavioral habits are often initiated by contextual cues that occur at approximately the same time each day; so, it may be possible to identify a reflexive habit based on the temporal similarity of repeated daily behavior. Mobile health tools provide the detailed, longitudinal data necessary for constructing such an indicator of reflexive habits, which can improve our understanding of habit formation and help design more effective mobile health interventions for promoting healthier habits. Objective This study aims to use behavioral data from a commercial mindfulness meditation mobile phone app to construct an indicator of reflexive meditation habits based on temporal similarity and estimate the association between temporal similarity and meditation app users’ perceived health benefits. Methods App-use data from June 2019 to June 2020 were analyzed for 2771 paying subscribers of a meditation mobile phone app, of whom 86.06% (2359/2771) were female, 72.61% (2012/2771) were college educated, 86.29% (2391/2771) were White, and 60.71% (1664/2771) were employed full-time. Participants volunteered to complete a survey assessing their perceived changes in physical and mental health from using the app. Receiver operating characteristic curve analysis was used to evaluate the ability of the temporal similarity measure to predict future behavior, and variable importance statistics from random forest models were used to corroborate these findings. Logistic regression was used to estimate the association between temporal similarity and self-reported physical and mental health benefits. Results The temporal similarity of users’ daily app use before completing the survey, as measured by the dynamic time warping (DTW) distance between app use on consecutive days, significantly predicted app use at 28 days and at 6 months after the survey, even after controlling for users’ demographic and socioeconomic characteristics, total app sessions, duration of app use, and number of days with any app use. In addition, the temporal similarity measure significantly increased in the area under the receiver operating characteristic curve (AUC) for models predicting any future app use in 28 days (AUC=0.868 with DTW and 0.850 without DTW; P Conclusions The temporal similarity of the meditation app use was a significant predictor of future behavior, which suggests that this measure can identify reflexive meditation habits. In addition, temporal similarity was associated with greater perceived mental health benefits, which demonstrates that additional mental health benefits may be derived from forming reflexive meditation habits.

Behavioral economics (BE) has been used to study a number of health behaviors such as smoking and drug use, but there is little knowledge of how these insights relate to HIV prevention and care. We present novel evidence on the prevalence of the common behavioral decision-making errors of present-bias, overoptimism, and information salience among 155 Ugandan HIV patients, and analyze their association with subsequent medication adherence. 36 % of study participants are classified as present-biased, 21 % as overoptimistic, and 34 % as having salient HIV information. Patients displaying present-bias were 13 % points (p = 0.006) less likely to have adherence rates above 90 %, overoptimistic clients were 9 % points (p = 0.04) less likely, and those not having salient HIV information were 17 % points (p < 0.001) less likely. These findings indicate that BE may be used to screen for future adherence problems and to better design and target interventions addressing these behavioral biases and the associated suboptimal adherence.