Longitudinal Moderated Mediation Analysis in Parallel Process Latent Growth Curve Modeling in Intervention Studies

Digitizing Survivorship Care Plans Through the POST-Treatment Health Outcomes of Cancer Survivors (POSTHOC) Mobile App: Protocol for a Phase II Randomized Controlled Trial

BACKGROUND

Survivorship care plans (SCPs) are provided at the completion of cancer treatment to aid in the transition from active treatment to long-term survivorship. They describe the details of a patient's diagnosis and treatment and offer recommendations for follow-up appointments, referrals, and healthy behaviors. The plans are currently paper-based and become outdated as soon as a patient's health status changes. There is a need to digitize these plans to improve their accessibility, modifiability, and longevity. With current technology, SCPs can be linked to mobile devices and activity trackers so that patients can track health behaviors and compare them to their clinical goals, taking charge of their own health.

OBJECTIVE

A mobile app, POSTHOC (POST-Treatment Health Outcomes of Cancer Survivors), that digitizes the SCP was developed, with goals of integrating it with wearable technologies and electronic medical records. Herein, we are conducting a randomized controlled trial that evaluates the POSTHOC app versus the traditional SCP on total symptom burden in the early posttreatment period.

METHODS

We will recruit 54 patients who have recently completed curative therapy for cancer (any type) in person and remotely. They will be randomized 2:1, POSTHOC:usual care (unblinded). Those randomized to the POSTHOC group will receive their SCP via the app and will choose to focus on nutrition or exercise for the duration of the study based on their individual plan and personal preferences. Those randomized to the control group will get a paper-based plan. At baseline, 6 weeks, and 12 weeks, we will evaluate patient-reported outcomes, including total symptom burden (web-based questionnaire), diet (24-hour Automated Self-Administered [ASA24]), and physical activity (Fitbit Charge 6 [Google LLC]). We will also collect quantitative and qualitative feedback on the usability of the app from those in the POSTHOC arm to improve the app for future implementation studies, with a specific focus on patient-provider communication. For feasibility, we will calculate the percentage of patients who used the POSTHOC app at least 3 times per week. We will use linear mixed models to evaluate the effects of the POSTHOC app versus those of usual care on other outcomes at weeks 6 and 12.

RESULTS

This trial is open to accrual in the University of Maryland Medical System as of March 2024, and as of July 3, 2024, a total of 20 participants have consented.

CONCLUSIONS

This study is among the first to digitize the SCP in a mobile app and test the effects of a mobile health-delivered behavioral health intervention on symptom burden in cancer survivors. Our results will provide evidence about the effects of health self-management on symptoms. This knowledge will be integral to larger randomized controlled studies, integration with the electronic medical record, and nationwide implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05499663; https://clinicaltrials.gov/ct2/show/NCT05499663.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/59222.

Distress tolerance as a mediator of mindfulness-based intervention for anxiety and depression: Evidence from two randomized controlled trials

Objective

We aimed to investigate whether distress tolerance mediated the effects of mindfulness-based intervention (MBI) on anxiety and depression with two randomized controlled studies.

Method

In Study 1, 374 participants with at least moderate emotional distress were randomized to an intervention group (N = 174) and a waitlist control group (N = 173). Mindfulness, distress tolerance, anxiety, and depression were measured at the pre-test, week 3, week 5, and post-test. In Study 2, 170 participants with emotional disorders were randomized to an intervention group (N = 86) and a control group (N = 84). The same variables were assessed at pre-test, weekly during the intervention, and post-test.

Results

In both studies, linear mixed effect models showed that compared to the control group, mindfulness, distress tolerance, anxiety, and depression significantly improved in the intervention group. Parallel process latent growth curve models showed that changes in distress tolerance mediated the effects of the MBI on changes in anxiety and depression. Random-intercept cross-lagged panel models found that distress tolerance temporally preceded depression, but not anxiety.

Conclusions

Distress tolerance is a potential mechanism underlying MBIs. Interventions targeting distress tolerance could be embedded in MBIs to enhance the intervention effects for emotional distress.

Dietary Composition, Meal Timing, and Cancer-Related Fatigue: Insights From the Women's Healthy Eating and Living Study

BACKGROUND

Cancer-related fatigue is difficult to treat, and dietary interventions are promising yet underused.

OBJECTIVE

We explored associations between dietary patterns and fatigue, and the effect of a dietary intervention versus control on fatigue using Women's Healthy Eating and Living study data, plus mediators and moderators of the intervention effect.

METHODS

The Women's Healthy Eating and Living study was a randomized controlled trial among early-stage breast cancer survivors. The 4-year intervention encouraged fruits, vegetables, fiber, and 15% to 20% calories from fat. Fatigue outcomes included a 9-item energy scale and a single-item tiredness question. Dietary quality was estimated using a modified Healthy Eating Index (24-hour dietary recall) and serum carotenoid concentrations. Nutrient timing was obtained from 4-day food logs.

RESULTS

Among 2914 total participants, lower body mass index was associated with less tiredness and more energy at baseline (P < .001 for both). Earlier start and end times for daily eating windows were associated with less tiredness (P = .014 and P = .027, respectively) and greater energy (P = .006 and P = .102, respectively). The intervention did not lead to improvements in fatigue on average (P > .125). However, the intervention was more effective for participants who were younger, had fewer comorbidities, and did not have radiation treatment. Mediators included increases in serum carotenoids, increases in the modified Healthy Eating Index, and weight loss/maintenance.

CONCLUSION

Diet quality and earlier eating windows were associated with less fatigue.

IMPLICATIONS FOR PRACTICE

Programs that encourage high diet quality and a morning meal and discourage nighttime eating should be tested for efficacy in reducing cancer-related fatigue in survivorship.

Effects and mechanisms of an online short-term audio-based mindfulness program on positive affect: A randomized controlled trial including exploratory moderator analyses

This study investigated the effects and mechanisms of an online short-term audio-based mindfulness (SAM) intervention program on positive affect and explored how well-being and negative affect influenced these effects and mechanisms. Participants (N = 100) were randomized into an intervention group (n = 50) and a control group (n = 50). Those in the mindfulness group underwent 3 weeks of an online SAM program and completed the online measures four times, while those in the control group completed the measures twice. Participants completed measures including the World Health Organization Well-Being Index, the Freiburg Mindfulness Inventory, and the Positive and Negative Affect Schedule. The effects of measures in both groups were compared. Parallel process latent growth curve modeling analysis was used to explore the longitudinal moderated mediation effects. The results showed that SAM was effective at improving positive affect, mindfulness, well-being, and reducing negative affect. Mindfulness growth speed during the intervention period mediated the relationship between SAM and positive affect improvement speed. The moderation effects of baseline well-being and negative effect on mediation effects were found to be significant. The SAM program was effective for the general public and was more beneficial for those with medium/high well-being and low/medium negative affect.

Pain Catastrophizing and Clinical Outcomes Among Patients Receiving a Novel Cognitive-Behavioral Therapy for Irritable Bowel Syndrome: An Experimental Therapeutics Approach

Irritable bowel syndrome (IBS) is the most common gastrointestinal (GI) condition treated by GI and primary care physicians. Although IBS symptoms (abdominal pain, bowel problems) are generally refractory to medical therapies, consistent research has shown that they improve following cognitive-behavioral therapy (CBT). Notwithstanding empirical support for CBT, there is less research explicating the reasons for why or how it works. Like other pain disorders, the focus on change mechanisms for behavioral pain treatments has focused on pain-specific cognitive-affective processes that modulate pain experience, few of which are more important than pain catastrophizing (PC). The fact that PC changes are seen across treatments of differing theoretical and technical orientation, including CBT, yoga, and physical therapy, suggests that it may be a nonspecific (vs. theory-based) change mechanism akin to therapeutic alliance and treatment expectancy. Therefore, the current study examined change in PC as a concurrent mediator of IBS symptoms severity, global GI symptom improvement, and quality of life among 436 Rome III-diagnosed IBS patients enrolled in a clinical trial undergoing two dosages of CBT versus a nonspecific comparator emphasizing education and support. Results from structural equation modeling parallel process mediation analyses suggest that reduction in PC during treatment are significantly associated with improvement in IBS clinical outcomes through 3-month follow-up. Results from the current study provide evidence that PC may be an important, albeit nonspecific change mechanism, during CBT for IBS. Overall, reducing the emotional unpleasantness of pain through cognitive processes is associated with improved outcomes for IBS.

The Healthy Body Image Intervention and Reduction in Eating Disorder Symptomatology and Muscle Building Supplement Use in High School Students: A Study of Mediating Factors

Background

Mediation analysis is important to test the theoretical framework underpinning an intervention. We therefore aimed to investigate if the healthy body image (HBI) intervention's effect on eating disorder (ED) symptomatology and use of muscle building supplements was mediated by the change in risk and protective factors for ED development and muscle building supplement use.

Methods

This study used data from the HBI intervention: a cluster randomized controlled universal intervention aiming to promote positive body image and embodiment and reduce the risk for ED development including 30 schools in Norway. A total of 1,713 (37% boys) participants were included in the analyses. Conditional latent growth curve analyses were performed to test for indirect effects on ED symptomatology and weekly frequency of protein and creatine supplement use measured at the 12-month follow-up via change in the proposed mediators.

Results

In girls, the reduction in ED symptomatology was mediated by positive changes in protective factors (self-esteem and body image flexibility) and reductions in risk factor scores (perceived media pressure and thin appearance internalization). Comparable changes in protective and risk factors among boys played no mediating role.

Conclusion

Interventions aiming to reduce the risk of ED development in girls may benefit from aiming to enhance self-esteem and body image flexibility and reduce perceived media pressure and thin appearance internalization. Future studies should investigate the casual relationship between muscle building supplement use and risk and protective factors for ED development in both girls and boys.

The Relationship Between Parental Career-Related Factors and Adolescents’ Ambivalence in Career Decision-Making: A Longitudinal Mediation Study

Our current research aimed to investigate the mediating relationship between Parental Career-Related Factors, adolescents’ Career Decision-Making Self-Efficacy, and Ambivalence in Career Decision-Making with a total of 605 students from China. We collected data at three different time points, with a 6-month interval between each time point. Then we applied a Cross-Lagged Panel Model using data from all three waves, and the results showed that a higher level of support in Parental Career-Related Behaviors and Adolescent Parent Career Congruence measured at time 1 positively predicted Career Decision-Making Self-Efficacy at time 2; Career Decision-Making Self-Efficacy at time 2 negatively predicted Ambivalence in Career Decision-Making at time 3; and the indirect effect of support in Parental Career-Related Behaviors and Adolescent Parent Career Congruence on Ambivalence in Career Decision-Making was significant. Therefore, Career Decision-Making Self-Efficacy mediated the relationship between support in Parental Career-Related Behaviors and Ambivalence in Career Decision-Making and between Adolescent Parent Career Congruence and Ambivalence in Career Decision-Making. The implications, limitations, and future direction are discussed.