Social Media and mHealth Technology for Cancer Screening: Systematic Review and Meta-analysis

Comparative efficacy of telehealth interventions on promoting cancer screening: A network meta-analysis of randomized controlled trials

BACKGROUND

Cancer screening is a pivotal method for reducing mortality from disease, but the screening coverage is still lower than expected. Telehealth interventions demonstrated significant benefits in cancer care, yet there is currently no consensus on their impact on facilitating cancer screening or on the most effective remote technology.

DESIGN

A network meta-analysis was conducted to detect the impact of telehealth interventions on cancer screening and to identify the most effective teletechnologies.

METHODS

Six English databases were searched from inception until July 2023 to yield relevant randomized controlled trials (RCTs). Two individual authors completed the literature selection, data extraction, and methodological evaluations using the Cochrane Risk of Bias tool. Traditional pairwise analysis and network meta-analysis were performed to identify the overall effects and compare different teletechnologies.

RESULTS

Thirty-four eligible RCTs involving 131,644 participants were enrolled. Overall, telehealth interventions showed statistically significant effects on the improvement of cancer screening. Subgroup analyses revealed that telehealth interventions were most effective for breast and cervical cancer screening, and rural populations also experienced benefits, but there was no improvement in screening for older adults. The network meta-analysis indicated that mobile applications, video plus telephone, and text message plus telephone were associated with more obvious improvements in screening than other teletechnologies.

CONCLUSION

Our study identified that telehealth interventions were effective for the completion of cancer screening and clarified the exact impact of telehealth on different cancer types, ages, and rural populations. Mobile applications, video plus telephone, and text message plus telephone are the three forms of teletechnologies most likely to improve cancer screening. More well-designed RCTs involving direct comparisons of different teletechnologies are needed in the future.

CLINICAL RELEVANCE

Telehealth interventions should be encouraged to facilitate cancer screening, and the selection of the optimal teletechnology based on the characteristics of the population is also necessary.

What young women (aged 24-29 years) in Australia think about self-collection for cervical screening: a brief report

Background In mid-2022 Australia's National Cervical Screening Program made self-collection of a vaginal sample an option for screening for young women or people with a cervix aged 25 to 29 years for the first time. This study explored what young women thought about, and wanted to know about, self-collection, and what their future screening preferences are. Methods Young women (n =21), aged 24-29years, were recruited through social media. Semi-structured interviews explored screening history, screening preferences and thoughts about self-collection. Data were analysed using an a priori coding framework informed by the Theoretical Framework of Acceptability. Results Young women valued the addition of self-collection to the national cervical screening program, believing it to be less invasive and more convenient. However, they also valued the choice to opt for a clinician-collected specimen if preferred. Conclusions Self-collection is a valuable addition to the National Cervical Screening Program. This study suggests that continued efforts are needed to raise awareness of its availability, and improve understanding about its accuracy, the ease of collection, that you still need to engage with a primary healthcare service to access it and that you can still opt for a clinician-collected test.

Using electronic health records to evaluate the adherence to cervical cancer prevention guidelines: A cross-sectional study

OBJECTIVE

The fight against cervical cancer requires effective screening together with optimal and on-time treatment along the care continuum. We examined the impact of cervical cancer testing and treatment guidelines on testing practices, and follow-up adherence to guidelines.

METHODS

Data from Estonian electronic health records and healthcare provision claims for 50,702 women was used. The annual rates of PAP tests, HPV tests and colposcopies during two guideline periods (2nd version 2012-2014 vs 3rd version 2016-2019) were compared. To assess the adherence to guidelines, the subjects were classified as adherent, over- or undertested based on the timing of the appropriate follow-up test.

RESULTS

The number of PAP tests decreased and HPV tests increased during the 3rd guideline period (p < 0.01). During the 3rd guideline period, among 21-29-year-old women, the adherence to guidelines ranged from 38.7% (44.4…50.1) for ASC-US to 73.4% (62.6…84.3) for HSIL and among 30-59-year-old from 49.0% (45.9…52.2) for ASC-US to 65.7% (58.8…72.7) for ASCH. The highest rate of undertested women was for ASC-US (21-29y: 25.7%; 30-59y: 21.9%). The rates of over-tested women remained below 12% for all cervical pathologies observed. There were 55.2% (95% CI 49.7…60.8) of 21-24-year-olds and 57.1% (95% CI 53.6…60.6) of 25-29-year-old women who received HPV test not adherent to guidelines.

CONCLUSIONS

Our findings highlighted some shortcomings in guideline adherence, especially among women under 30. The insights gained from this study help to improve the quality of care and, thus, reduce cervical cancer incidence and mortality.

Codesign and Launch of 'On the Ball': An Inclusive Community-Based 'Testicular Awareness' Campaign

INTRODUCTION

Increased awareness of testicular diseases can lead to early diagnosis. Evidence suggests that men's awareness of testicular diseases is low, with many expressing their willingness to delay help-seeking for symptoms of concern. The risk of testicular diseases is higher in gender and sexual minority groups. In this study, we discuss the codesign, refinement and launch of 'On the Ball', an inclusive community-based 'testicular awareness' campaign.

METHODS

The World Café participatory research methodology was used. Individuals from Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, policymakers, media/marketing experts and graphic designers were recruited. Participants were handed a brief for 'On the Ball', which was designed based on feedback from a previous World Café workshop. They were assigned to three tables. Participants rotated tables at random for three 20-min rounds of conversations. Each table had a facilitator who focussed on one element of the campaign brief. Data were collected using audio recorders and in writing and were analysed thematically.

RESULTS

Thirteen individuals participated in the workshop. The following themes emerged from the data: (i) campaign identity, (ii) campaign delivery and (iii) campaign impact. Participants recommended enhancements to the campaign logo, slogan, social media posts and poster. They suggested delivering the campaign online via social media and offline using various print and broadcast media. Participants recommended targeting areas with a large number of men such as workplaces. To help measure the impact of the campaign, participants proposed capturing social media analytics and tracking statistics relating to testicular diseases. Recommendations were used to refine the 'On the Ball' campaign and launch it in a university. In total, 411 students engaged with the various elements of the campaign during the soft launch.

CONCLUSIONS

'On the Ball' campaign visuals ought to be inclusive. Online and offline campaign delivery is warranted to reach out to a wider cohort. Campaign impact can be captured using social media analytics as well as measuring clinical outcomes relating to testicular diseases. Future research is needed to implement the campaign online and offline, explore its impact and evaluate its feasibility, acceptability, cost and effect on promoting testicular awareness.

PATIENT OR PUBLIC CONTRIBUTION

The 'On the Ball' campaign was codesigned and refined with members of Lesbian, Gay, Bisexual, Transgender and Queer+ friendly organisations, testicular cancer survivors, health policymakers, media and marketing experts and graphic designers using the World Café participatory research methodology.

Design and evaluation of a colon cancer mobile application

BACKGROUND

Colorectal cancer (CRC) is the third leading cause of cancer and the second cause of cancer-related deaths in the world. Despite the infrastructure and the availability of organized screening programs, participation in their screening programs is less than the set goals. Considering the importance of informing the society about the prevention and early detection of colorectal cancer symptoms and the positive impact of mobile health technologies, the present research was conducted with the aim of designing and evaluating a colon cancer mobile application.

METHODS

The present research was conducted in two phases: software design and evaluation. In the first phase, the software was prepared using the cascade method. First, all the educational content related to colorectal cancer was collected through an expert panel with the participation of 10 specialists. Then the software was evaluated with alpha and beta testing, and the initial version was approved by users in terms of simplicity and usability. In the second phase, a parallel clinical randomized trial study was conducted with the aim of investigating the effect of a colon cancer mobile application on the early detection of colorectal cancer. In this stage, 204 volunteers participated; inclusion criteria were age 18-85 years, owning a smartphone and the ability to read and write. Participants were randomized into control and intervention groups. The intervention group was educated with the colon cancer application for education about colorectal cancer, and the control group was educated with a pamphlet. After education, both groups were screened for colorectal cancer symptoms, and the results were compared.

RESULTS

In the software evaluation phase, the application was used by 204 users. In this stage, 84 (41.2%) women and 120 (58.8%) men, with an average (Standard Deviation) age of 47.53 (13.68) participated. Participants were randomized in two groups, 103 people with an average (Standard Deviation) age of 47.62 (14.65) in intervention group and 101 people with an average (Standard Deviation) age of 47.44 (12.70) in control group. There were no significant differences between the demographic characteristics of age, gender, marriage, occupation, instruction level, digestive disease history, cancer history, cancer risk factors, and family history of cancer between the two groups (P > 0.05). The Mann-Whitney U test indicated that there is a significant difference between the two groups of participants in self-assessment, willingness to do the screening, and the results of the assessment of colorectal cancer (P < 0.05).

CONCLUSION

The results of the research indicated the positive impact of the Colon Cancer Application on the abilities of the users of self-assessment of colon cancer. Therefore, based on the findings, it can be concluded that the use of the colon cancer mobile application is effective for colon cancer prevention and self-care.

TRIAL REGISTRATION

This study was registered in the Iranian Registry of Clinical Trials ( https://irct.behdasht.gov.ir ) on 13/2/2024, with the IRCT ID: IRCT20210131050189N9.

Development of a cancer risk model and mobile health application to inform the public about cancer risks and risk factors

OBJECTIVE

To develop and evaluate a mobile health application, the Cancer Risk Calculator (CRC), aimed at improving public health literacy by providing personalized information on cancer risks and preventive measures.

MATERIALS AND METHODS

The CRC was developed through a comprehensive process involving the identification of necessary content, integration of average cancer risks using data from reliable sources, creation of a novel risk model emphasizing modifiable factors, and the application's development for easy access. The application covers 38 cancer types, 18 subtypes, and approximately 790 risk factors, utilizing data from the Surveillance, Epidemiology, and End Results Program and scientific literature.

RESULTS

CRC offers users personalized risk assessments across a broad range of cancers, emphasizing modifiable risk factors to encourage preventive behaviors. It distinguishes itself by covering more cancer types and risk factors than existing tools, with preliminary user feedback indicating its utility in promoting health literacy and lifestyle changes.

DISCUSSION

The CRC application stands out as an innovative tool in health informatics, significantly enhancing public understanding of cancer risks. Its development underscores the potential of digital health technologies to bolster preventive healthcare strategies through improved health literacy.

CONCLUSION

The Cancer Risk Calculator is a pivotal development in mobile health technology, offering comprehensive and personalized insights into cancer risks and prevention. It serves as a valuable resource for public health education, facilitating informed decisions and lifestyle modifications for cancer prevention.

Noteworthy impacts of COVID-19 pandemic on cancer screening: A systematic review

The sudden onset of the coronavirus disease 2019 (COVID-19) in January 2020 has affected essential global health services. Cancer-screening services that can reduce cancer mortality are strongly affected. However, the specific role of COVID-19 in cancer screening is not fully understood. This study aimed to assess the efficiency of global cancer screening programs before and during the COVID-19 pandemic and to promote potential cancer-screening strategies for the next pandemic. Electronic searches in PubMed, Embase, and Web of Science, and manual searches were performed between January 1, 2020 and March 1, 2023. Cohort studies that reported the number of participants who underwent cancer screening before and during the COVID-19 pandemic were included. The methodological quality of the included studies was assessed using the Newcastle-Ottawa Scale. Differences in cancer-screening rates were estimated using the incidence rate ratio (IRR). Fifty-five cohort studies were included in this meta-analysis. The screening rates of colorectal cancer using invasive screening methods (Pooled IRR = 0.52, 95% CI: 0.42 to 0.65, p < 0.01), cervical cancer (Pooled IRR = 0.56, 95% CI: 0.47 to 0.67, p < 0.01), breast cancer (Pooled IRR = 0.57, 95% CI: 0.49 to 0.66, p < 0.01) and prostate cancer (Pooled IRR = 0.71, 95% CI: 0.56 to 0.90, p < 0.01) during the COVID-19 pandemic were significantly lower than those before the COVID-19 pandemic. The screening rates of lung cancer (Pooled IRR = 0.77, 95% CI: 0.58 to 1.03, p = 0.08) and colorectal cancer using noninvasive screening methods (Pooled IRR = 0.74, 95% CI: 0.50 to 1.09, p = 0.13) were reduced with no statistical differences. The subgroup analyses revealed that the reduction in cancer-screening rates varied across economies. Our results suggest that the COVID-19 pandemic has had a noteworthy impact on colorectal, cervical, breast, and prostate cancer screening. Developing innovative cancer-screening technologies is important to promote the efficiency of cancer-screening services in the post-COVID-19 era and prepare for the next pandemic.

"I Saw it Incidentally but Frequently": Exploring the Effects of Online Health Information Scanning on Lung Cancer Screening Behaviors Among Chinese Smokers

In China, lung cancer is the most common cancer with high mortality. While prior research suggests that health information scanning influences cancer screening within the general population, a deeper exploration of the underlying mechanisms is imperative. This study specifically targets smokers, aiming to investigate whether online health information scanning can effectively encourage lung cancer screening and elucidate the mechanisms driving this association. Data were extracted from a Chinese national survey conducted between January and September 2023, exclusively involving current smokers (N = 992). A moderated mediation model was employed to examine a cognitive-affective sequential chain of mediation through risk perceptions and cancer worry. Results showed that 99.1% of Chinese smokers reported online health information scanning, which possessed significant influence. Online health information scanning was positively associated with effective lung cancer screening among smokers directly (OR = 1.927, p < .01) and indirectly (OR = .065, p < .001). The perceived threat of smoking and cancer worry served as the cognitive and affective mediating mechanisms. Furthermore, a moderating effect of eHealth literacy was observed (OR = 6.292, p < .05). Smokers with higher eHealth literacy are more inclined to undergo effective lung cancer screening. Based on these findings, public health sectors should leverage online platforms to disseminate tailored cancer screening education and implement initiatives to enhance public eHealth literacy.

A Web-Based and Mobile Intervention Program Using a Spaced Education Approach for Workplace Mental Health Literacy: Cluster Randomized Controlled Trial

Background

Workplace mental health is an important global health concern.

objectives

This unblinded, phase-III, wait-listed cluster randomized controlled trial aimed to examine the effectiveness of a mobile health (mHealth) psychoeducation program using a spaced education approach on mental health literacy (MHL) in the workplace. The main interest of this paper was the immediate and 3-month medium-term effect of the program on the MHL of workers. The purposely built mHealth platform was also evaluated as a health-related app.

Methods

The mHealth platform was designed using the principle of spaced education as a psychoeducation intervention program, with various modules of web-based and mobile materials presented to the participant in a progressive manner. Short quizzes at the end of each module ensured adequate learning, and successful completion qualified the learner to progress to the next level. The trial recruited 456 employees of specific industries with high levels of work-related stress. Participants who were nested in different offices or units were allocated into the intervention and wait-listed control groups using a block randomization process, with the office or unit as the cluster. A separate sample of 70 individual raters were used for the evaluation of the mHealth platform. The Australian National MHL and Stigma Survey and the Mobile Apps Rating Scale were completed through a web-based self-reported survey to assess MHL and evaluate the app. The trial and follow-up data were analyzed by a generalized linear latent and mixed model with adjustments for the clustering effect of work sites and repeated measures.

Results

Of the 456 participants in the trial, 236 (51.8%) responded to the follow-up survey. Most MHL outcomes obtained significant results immediately after the intervention and across time. After adjusting for the clustering effect, the postintervention weighted mean scores were significantly higher in the intervention group than the control group for correct recognition of a mental health problem, help seeking, and stigmatization by 0.2 (SE 0.1; P=.003), 0.9 (SE 0.2; P<.001), and 1.8 (SE 0.4; P<.001), respectively. After adjusting for the clustering effect, significant differences across time were found in help-seeking intention (P=.01), stigmatization (P<.001), and social distancing (P<.001). The evaluation of the mHealth program resulted in average scores of the 4 major domains ranging from 3.8 to 4.2, with engagement having the lowest score.

Conclusions

The mHealth psychoeducation intervention program using this platform had immediate and 3-month medium-term effects of retaining and improving MHL. The platform was evaluated to have satisfactory performance in terms of functionality, aesthetics, information content, and utility in enhancing MHL. It is anticipated that ongoing development in digital health will provide great benefits in improving the mental health of the global population.

Sexual experiences and information needs among patients with prostate cancer: a qualitative study

Background

Less is known about the sexual life and information seeking of Chinese patients with prostate cancer (PCa) after androgen deprivation therapy (ADT) treatment.

Aim

To identify the experiences of sex and information needs among Chinese patients with PCa after ADT treatment.

Methods

This qualitative study included 15 Chinese patients with PCa in urology inpatient wards, selected via a purposive sampling method. Semistructured interviews were conducted face-to-face or by telephone regarding sexual experiences and information needs after ADT treatment.

Outcomes

Themes and subthemes were assessed among patients with PCa.

Results

Two themes and 5 subthemes emerged from the interview data. The first theme was "altered sexual life and attitude" with 3 subthemes: (1) undesirable sexual function and altered sexuality, (2) sexual attitudes and sociocultural cognition, and (3) behavior adjustment and intimacy. The second theme was "scarce information sources" with 2 subthemes: (1) uncertainty and lack of information support and (2) barriers to access sexual information.

Clinical Implications

The present findings suggest that the following may help patients with PCa manage treatment and develop appropriate sexual attitudes: a tailored sexual health education program, well-equipped consultations rooms, and information delivery innovations.

Strengths and Limitations

Strengths of this study included adding unique evidence among patients with PCa within an Asian context to reveal the understudied topic of sexual health and information needs after ADT treatment. This study was limited in being representative of all Chinese patients with PCa, with different marital statuses, treatment therapies, sexual orientations, and barriers of information seeking.

Conclusion

Sexual life and attitude among patients with PCa were affected by their sociocultural cognition and ADT treatment, and most patients received insufficient information and sexual health education from health care providers.

Best Practices for Developing a Diabetes mHealth App

The widespread use of smartphones in the United States has led to a surge in mHealth apps designed to support people with various health issues. Yet the effectiveness and long-term impacts of these apps still need to be determined. This article presents a case study of the development of MyT1DHero, an mHealth app for people with type 1 diabetes, to identify best practices for app development. We propose four essential best practices based on the insights gained from this case study: incorporating theoretical frameworks, prioritizing user feedback, engaging key stakeholders, and establishing a robust data-collection foundation. These findings have practical implications for researchers and developers seeking to create effective mHealth interventions. Furthermore, we suggest future research directions to advance the development and implementation of innovative health technologies.

Application of the 'online assessment + FOBT at home' to improve participation and the efficacy of opportunistic screening for colorectal cancer: a retrospective cohort study

BACKGROUND

Colorectal cancer (CRC) screening faces two major challenges: insufficient screening coverage and poor adherence. A smartphone applet named "Early Screening Assistant (ESA)" was developed to create an online risk-assessment and fecal occult blood test (FOBT) at home. This retrospective study was designed to evaluate whether the new CRC screening strategy can improve the colonoscopy participation rate (PR) and lesion detection rate (DR).

METHODS

In total, 6194 individuals who accepted normal health examinations and CRC screening based on the ESA from June 2020 to May 2022 were assigned to the ESA group. Accordingly, 7923 inhabitants who only accepted normal health examinations were assigned to the control group. The colonoscopy PR and neoplastic lesion DR were then compared between the two groups.

RESULTS

Overall, a higher proportion of subjects in the ESA group (285 of 6194 [4.6%]) completed colonoscopy than in the control group (126 of 7923, [1.6%]), p < 0.01). The neoplastic lesion DR also significantly increased in the ESA group (76 of 6194 [1.22%]) compared with the control group (15 of 7923 [0.19%]) (p < 0.01). The adjusted diagnostic sensitivity and specificity of the "Online assessment + FOBT at home" were 41.5% and 62.6% for neoplastic lesions, respectively.

CONCLUSIONS

This retrospective cohort study confirmed that the new CRC screening strategy based on the "Online assessment + FOBT at home" can improve colonoscopy participation and the neoplastic lesion detection rate and may represent a promising screening strategy for CRC.

TRIAL REGISTRATION

This study was registered in China Clinical Trial Registry ( https://www.chictr.org.cn ) on 29/09/2022.

REGISTRATION NUMBER

ChiCTR2200064186.

Gaps in Adhering to Pap Testing Recommendations and Related Barriers in a Sample of Young Adults in the US

Given ongoing gaps in adherence to Pap testing recommendations, this study examined: 1) adherence to Pap test screening recommendations; and 2) barriers to Pap test screening among those who were nonadherent, using constructs from the Andersen model. We analyzed Spring 2022 survey data among 541 US young adults who reported having a cervix (n = 541; mean age = 27.73, 42.1% heterosexual, 57.9% sexual minority, 86.0% woman, 3.7% transgender man, 68.2% White, 31.8% racial/ethnic minority). Multivariable logistic regression examined sociodemographic correlates of nonadherence to Pap testing recommendations (i.e., no Pap testing in the past 3 years). Among those who were nonadherent, barriers to Pap testing were assessed. 68.6% (n = 371) were defined as adherent and 31.4% (n = 170) nonadherent. Multivariable regression findings indicated significant differences by race/ethnicity such that Asians (vs. Whites) were more likely to be nonadherent (OR = 2.41, CI = 1.11, 3.70, p = .021); no other differences in relation to race/ethnicity or sexual/gender identity were found. The most commonly reported barriers were: "I have not gotten around to it" (42.9%), "getting a Pap test is just not a priority for me" (30.6%), "fear/worry" (28.2%), "dislike/don't like having procedures done" (27.1%), "my healthcare provider has never mentioned it" (21.2%), "haven't had sex so I don't consider myself at high risk" (20.6%), and "COVID-19 pandemic prevented me" (15.3%). Pap testing is underutilized among young adults in the US, particularly Asians. Multilevel interventions must address barriers within the healthcare system (e.g., provider recommendation), external environment (e.g., societal factors), and individual realm (e.g., perceptions).

Enhancing head and neck tumor management with artificial intelligence: Integration and perspectives

Head and neck tumors (HNTs) constitute a multifaceted ensemble of pathologies that primarily involve regions such as the oral cavity, pharynx, and nasal cavity. The intricate anatomical structure of these regions poses considerable challenges to efficacious treatment strategies. Despite the availability of myriad treatment modalities, the overall therapeutic efficacy for HNTs continues to remain subdued. In recent years, the deployment of artificial intelligence (AI) in healthcare practices has garnered noteworthy attention. AI modalities, inclusive of machine learning (ML), neural networks (NNs), and deep learning (DL), when amalgamated into the holistic management of HNTs, promise to augment the precision, safety, and efficacy of treatment regimens. The integration of AI within HNT management is intricately intertwined with domains such as medical imaging, bioinformatics, and medical robotics. This article intends to scrutinize the cutting-edge advancements and prospective applications of AI in the realm of HNTs, elucidating AI's indispensable role in prevention, diagnosis, treatment, prognostication, research, and inter-sectoral integration. The overarching objective is to stimulate scholarly discourse and invigorate insights among medical practitioners and researchers to propel further exploration, thereby facilitating superior therapeutic alternatives for patients.

Right Information, Right Patient, Right Time: Utilizing the MyCareCompass Platform to Deliver Patient Education in the Oncology Setting

Patient education is an important part of cancer care as it increases patient activation and informed decision-making, reduces anxiety, and improves outcomes. However, challenges to providing appropriate education to patients exist on both the health provider and patient side of the equation, e.g., time constraints and health literacy issues. Digital health education is a fast-growing field of interest that has been shown to improve health outcomes, increase effectiveness of medical treatments and education, lower medical costs, and enhance both clinical diagnosis and research opportunities by streamlining data collection, sharing, and analysis. In 2019, Fox Chase Cancer Center was selected by ARCHES, an established patient education software company, to pilot its award-winning digital patient engagement system MyCareCompass. During the pilot, patients scheduled for port insertions were sent electronic messages inviting them to review various online educational materials related to their procedure and subsequent concerns. The invitations and resources were seamlessly integrated into the scheduling system and timed to arrive when patients would most need them. There was high usage of the port-related materials and patients reported a high level of satisfaction with the delivery system and the information. This automated process of delivering high-quality and relevant patient education was able to be implemented smoothly with IT involvement, had a positive impact on patients without adding any extra burden to the care team, and highlighted opportunities to integrate these types of interventions into routine care.

Video Interventions for Reducing Health Inequity in Cancer Screening Programmes: a Systematic Review

BACKGROUND

Health equity can lead to disparities in cancer screening, treatment, and mortality. This systematic review aims to identify and describe interventions that used video or DVD formats to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates compared to usual care conditions.

METHODS

We searched PubMed, Web of Science, Embase, and Cochrane databases for randomized control trials (RCTs) published until 18/01/2023 that compared intervention versus usual care control groups, with the percentage of cancer screening uptake during follow-up as an outcome. The risk of Bias was assessed with the Cochrane Collaboration tool.

RESULTS

After screening 4201 abstracts, 192 full texts were assessed for eligibility and 18 were included that focused on colorectal (n = 9), cervical (n = 5), breast (n = 5), and prostate (n = 1) cancer screening. All were based in the USA except one and most focused on ethnicity/race, while some included low-income populations. Most of the video interventions used to increase cervical cancer screening reported positive results. Studies aimed at increasing mammography uptake were mostly effective only in specific groups of participants, such as low-income or less-educated African American women. Results for colorectal cancer screening were conflicting. Videos that were culturally tailored or used emotive format were generally more effective than information-only videos.

CONCLUSIONS

Video interventions to increase cancer screening among populations with low screening uptake show some positive effects, though results are mixed. Interventions that use individual and cultural tailoring of the educational material should be further developed and investigated outside of the USA.

Usability and Satisfaction Testing of Game-Based Learning Avatar-Navigated Mobile (GLAm), an App for Cervical Cancer Screening: Mixed Methods Study

BACKGROUND

Barriers to cervical cancer screening in young adults include a lack of knowledge and negative perceptions of testing. Evidence shows that mobile technology reduces these barriers; thus, we developed a web app, Game-based Learning Avatar-navigated mobile (GLAm), to educate and motivate cervical cancer screening using the Fogg Behavioral Model as a theoretic guide. Users create avatars to navigate the app, answer short quizzes with education about cervical cancer and screening, watch videos of the screening process, and earn digital trophies.

OBJECTIVE

We tested ease of use, usefulness, and satisfaction with the GLAm app among young adults.

METHODS

This mixed methods study comprised a qualitative think-aloud play interview session and a quantitative survey study. Participants were cervical cancer screening-eligible US residents aged 21 to 29 years recruited through social media. Qualitative study participants explored the app in a think-aloud play session conducted through videoconference. Data were analyzed using directed content analysis to identify themes of ease of use, usefulness, and content satisfaction. Qualitative study participants and additional participants then used the app independently for 1 week and completed a web-based survey (the quantitative study). Ease of use, usefulness, and satisfaction were assessed using the validated Technology Acceptance Model and Computer System Usability Questionnaire adapted to use of an app. Mean (SD) scores (range 1-7) are presented.

RESULTS

A total of 23 individuals participated in one or both study components. The mean age was 25.6 years. A majority were cisgender women (21/23, 91%) and White (18/23, 78%), and 83% (19/23) had at least some secondary education. Nine participants completed the think-aloud play session. Direct content analysis showed desire for content that is concise, eases anxiety around screenings, and uses game features (avatars and rewards). Twenty-three individuals completed the quantitative survey study. Mean scores showed the app was perceived to be easy to use (mean score 6.17, SD 0.27) and moderately useful to increase cervical cancer screening knowledge and uptake (mean score 4.94, SD 0.27). Participants were highly satisfied with the app (mean score 6.21, SD 1.20).

CONCLUSIONS

Survey results showed participants were satisfied with the app format and found it easy to use. The app was perceived to be moderately useful to inform and motivate cervical cancer screening; notably, the screening reminder function was not tested in this study. Qualitative study results demonstrated the app's ability to ease anxiety about screening through demonstration of the screening process, and brevity of app components was favored. Interpretation of results is limited by the predominantly cisgender, White, and educated study population; additional testing in populations which historically have lower cervical cancer screening uptake is needed. A modified version of the app is undergoing efficacy testing in a randomized clinical trial.

Digital technology for health shows disparities in cancer prevention between digital health technology users and the general population in Romania

Introduction

Digital health services and technology are rapidly developing following the COVID-19 pandemic. This study aimed to reveal the differences between users of digital health technology (DHT) and the general population with regard to cancer prevention.

Materials and Methods

This was an observational study on a conventional sample of 270 DHT users with completed data, performed in September 2021.

Results

A significant difference was observed in the proportion of DHT users and the general population reporting the screening test results, which was 2-6 times higher in the DHT group. Digital technologies applied to the "self-care" model were more suitable for internet-literate populations.

Discussion

Including digital technologies in a self-care model may be more suitable for internet-literate individuals. Thus, in a preventative health organizational framework, DHT should be integrated and used at the primary care level in the general population to improve disparities in the preventative health domain.

The Role of Social Media and Breast Cancer: How Does It Impact Patients?

Introduction

Patients are increasingly turning to other sources for their health information. Social media has become mainstream, and the easy access to online communities, health professionals, and shared experiences of other patients has made social media a place where many patients turn to.

Methods

In this qualitative report, 2 patients who have had breast cancer describe the reasons why they use social media, what they perceive the advantages and disadvantages are, and what the impact of social media has been through their cancer treatment and beyond.

Results

The reasons why patients turn to social media are varied. These can include information gathering, peer support, shared experiences, and advocacy. There appear to be advantages and disadvantages; however, overall, the impact seems to be a positive one when used judiciously.

Discussion

It is clear that social media has a role to play in healthcare, whether by providing meaningful social connections, delivery of information, or psychological support. Healthcare professionals perhaps should consider the importance of social media in their practice.

Digital health and telehealth in cancer care: a scoping review of reviews

The COVID-19 pandemic necessitated remote cancer care delivery via the internet and telephone, rapidly accelerating an already growing care delivery model and associated research. This scoping review of reviews characterised the peer-reviewed literature reviews on digital health and telehealth interventions in cancer published from database inception up to May 1, 2022, from PubMed, Cumulated Index to Nursing and Allied Health Literature, PsycINFO, Cochrane Reviews, and Web of Science. Eligible reviews conducted a systematic literature search. Data were extracted in duplicate via a pre-defined online survey. Following screening, 134 reviews met the eligibility criteria. 77 of those reviews were published since 2020. 128 reviews summarised interventions intended for patients, 18 addressed family caregivers, and five addressed health-care providers. 56 reviews did not target a specific phase of the cancer continuum, whereas 48 reviews tended to address the active treatment phase. 29 reviews included a meta-analysis, with results showing positive effects on quality of life, psychological outcomes, and screening behaviours. 83 reviews did not report intervention implementation outcomes but when reported, 36 reported acceptability, 32 feasibility, and 29 fidelity outcomes. Several notable gaps were identified in these literature reviews on digital health and telehealth in cancer care. No reviews specifically addressed older adults, bereavement, or sustainability of interventions and only two reviews focused on comparing telehealth to in-person interventions. Addressing these gaps with rigorous systematic reviews might help guide continued innovation in remote cancer care, particularly for older adults and bereaved families, and integrate and sustain these interventions within oncology.

Primary care provider interventions for addressing cancer screening participation with marginalised patients: a scoping review protocol

INTRODUCTION

Cancer screening is an integral component of primary care, and providers can play a key role in facilitating screening. While much work has focused on patient interventions, there has been less attention on primary care provider (PCP) interventions. In addition, marginalised patients experience disparities in cancer screening which are likely to worsen if not addressed. The objective of this scoping review is to report on the range, extent and nature of PCP interventions that maximise cancer screening participation among marginalised patients. Our review will target cancers where there is strong evidence to support screening, including lung, cervical, breast and colorectal cancers.

METHODS AND ANALYSIS

This is a scoping review conducted in accordance with the framework by Levac et al. Comprehensive searches will be conducted by a health sciences librarian using Ovid MEDLINE, Ovid Embase, Scopus, CINAHL Complete and the Cochrane Central Register of Controlled Trials. We will include peer-reviewed English language literature published from 1 January 2000 to 31 March 2022 that describes PCP interventions to maximise cancer screening participation for breast, cervical, lung and colorectal cancers. Two independent reviewers will screen all articles and identify eligible studies for inclusion in two stages: title and abstract, then full text. A third reviewer will resolve any discrepancies. Charted data will be synthesised through a narrative synthesis using a piloted data extraction form informed by the Template for Intervention Description and Replication checklist.

ETHICS AND DISSEMINATION

Since this is a synthesis of digitally published literature, no ethics approval is needed for this work. We will target appropriate primary care or cancer screening journals and conference presentations to publish and disseminate the results of this scoping review. The results will also be used to inform an ongoing research study developing PCP interventions for addressing cancer screening with marginalised patients.

The Role of Social Media in Breast Cancer Care and Survivorship: A Narrative Review

Background

Female breast cancer (BC) is the most diagnosed cancer and the leading cause of malignancy-related death worldwide. With the widespread utilisation of the Internet, social media has presented an invaluable yet underemployed tool in the context of BC medical information dissemination, support hub formation, and patient empowerment.

Summary

In this narrative review, we explore the untapped potential of social media in this context, caveats, and future directions that may aid in formulating a new era of patient led, in addition to patient-centred care.

Key Messages

Social media represents a powerful tool with significant potential to enable the seeking and sharing of BC-related information, and enhance patient education, communication, engagement, and empowerment. However, its use is associated with a number of limitations, including confidentiality and addiction issues, excessive and inaccurate information, and a possibility of jeopardising the patient-doctor relationship. Further research is needed to shed more light on this topic.

Realfood and Cancer: Analysis of the Reliability and Quality of YouTube Content

This study analyzes the quality and reliability of videos related to nutrition and cancer on YouTube.

STUDY DESIGN

An observational, retrospective, cross-sectional, time-limited study analyzing activity on the social network YouTube was proposed.

METHODS

The information from the videos was extracted through an API search tool, using the NodeXL software. The criteria to select the videos on YouTube were the keywords "real food", "realfood", and "cancer" and the hashtags #realfood and #cancer were present, videos in English and videos available on 1 December 2022.

RESULTS

The DISCERN value in the total number of videos viewed was 2.25 (±0.88) points, indicating low reliability. The videos uploaded by HRU represented only 20.8%. Videos suggesting that the use of foods defined as "real food" could cure cancer without the intervention of any other treatment accounted for 12.5%. Videos that provided external links to scientific/technical evidence verifying the information represented only 13.89% of the total number of videos. Of these videos, 70% corresponded to HRU. The DISCERN value for videos from HRU users was 3.05 (0.88), a value that reflects a good reliability of videos from these users.

CONCLUSIONS

This study provides information on the content and quality of the videos that we can find on YouTube. We found videos of non-health users who do not base their content on any scientific evidence, with the danger that this entails for the population, but it also highlights that the videos published by HRU have greater reliability and quality, being better perceived by the population, so it is important to encourage healthcare professionals and health institutions to share verified information on YouTube.

mHealth Technology as a Help Tool during Breast Cancer Treatment: A Content Focus Group

PURPOSE

To assess the usability and preferences of the contents of mHealth software developed for breast cancer patients as a tool to obtain patient-reported outcomes (PROMs), improve the patient's knowledge about the disease and its side effects, increase adherence to treatment, and facilitate communication with the doctor.

INTERVENTION

an mHealth tool called the Xemio app provides side effect tracking, social calendars, and a personalized and trusted disease information platform to deliver evidence-based advice and education for breast cancer patients.

METHOD

A qualitative research study using semi-structured focus groups was conducted and evaluated. This involved a group interview and a cognitive walking test using Android devices, with the participation of breast cancer survivors.

RESULTS

The ability to track side effects and the availability of reliable content were the main benefits of using the application. The ease of use and the method of interaction were the primary concerns; however, all participants agreed that the application would be beneficial to users. Finally, participants expressed their expectations of being informed by their healthcare providers about the launch of the Xemio app.

CONCLUSION

Participants perceived the need for reliable health information and its benefits through an mHealth app. Therefore, applications for breast cancer patients must be designed with accessibility as a key consideration.

A systematic review of the available literature on the use of social media in brain tumor

Purpose

The use of social media is one of the new technological options that has been recommended as a potential new strategy for delivering high-quality, high-value cancer prevention and management services. Despite the increasing use of social media, little research has been done on the use of social media in brain tumors. Therefore, this systematic review aims to provide a comprehensive review of the use of social media in brain tumor research.

Design/methodology/approach

A systematic search was performed in PubMed, Scopus and Web of Science from inception to August 1, 2022. English full-text articles evaluating social media use, benefit or content in brain tumor were considered.

Findings

Sixteen documents satisfied the inclusion criteria and were included in the final analysis. Most of the included studies (n = 11/16) were conducted and published by researchers in the USA. In terms of social media platform, most studies focused on Twitter (8/16, 50%) and YouTube (8/16, 50%), followed by Facebook (6/16, 37.5%) and Instagram (4/16, 25%). Most studies (n = 7/12) analyzed the content of brain tumor information provided on social media, followed by patients’ use of social media (n = 3/12) and the quality of information on social media (n = 3/12). The other three articles also examined patient recruitment, crowdfunding and caregiver use of social media.

Practical implications

By identifying the use, benefits and content of social media platforms in different settings, patients, clinicians and policymakers can better benefit from harnessing the power of social media in different ways, leading to improved health-care services.

Originality/value

To the authors knowledge, this is the first study to systematically examine social media use, benefits and content status in brain tumors.

Experiences of Women With Breast Cancer Using Telehealth: A Qualitative Systematic Review

Breast cancer is the most prevalent malignant neoplasm among women. Its treatment comprises different strategies. Telehealth can ensure continuity of care in distant locations. This study aimed to synthesize qualitative evidence of women's experiences with telehealth during the treatment and follow-up of breast cancer. We performed a qualitative systematic review and meta-synthesis. The databases included in the search were: Pubmed, EMBASE, CINAHAL, and Web of Science. The search combined the terms: breast cancer, telemedicine, telehealth, and qualitative study. The studies included were: qualitative design and mixed methods studies with qualitative components. The COREQ Checklist assisted in assessing the quality of included studies and an adaptation of thematic analysis for the qualitative meta-synthesis. We included twelve articles in the review. In the meta-synthesis, 3 themes emerged. (1) Structure: simple design and space to obtain information but in need of adjustments. (2) Usability: about the benefits and limitations of telehealth. (3) Interaction with health professionals. Telehealth is an accepted strategy for the clinical care of women with breast cancer. Patients identified the need for improvements in structure, usability, and interaction. PROTOCOL REGISTRATION: PROSPERO registration number CRD42021228326, registered 06/02/2021.

Comprehending the impact of #Breastcancer, #Breastsurgery and related hashtags on Twitter: A content and social network cross-sectional analysis #Breastcancer#Breastsurgery

BACKGROUND

Early detection along with improved locoregional and systemic therapies have decreased breast cancer mortality and allowed for the clinical implementation of breast conserving surgical options, in turn reducing the clinical and psychosocial impact of mastectomy. To what extend this has been successfully conveyed through social media for breast cancer awareness, has not been previously investigated.

METHODS

This study presents a content and social network cross-sectional descriptive study of Twitter and Google trends data worldwide from platform launch (2006 and 2004 respectively) until May 15th, 2022, in agreement with the STROBE guidelines. Tweets associated with the hashtags #Breastcancer, #Breastsurgery, #Oncoplasticsurgery, #Mastectomy, #Breastreconstruction, #Breastconservingsurgery were licensed and downloaded through the Vincitas and Tweetbinder online platforms. Associated available demographics, namely username, biography, location, date and language of post, were extracted from the Twitter dataset while interest percentage, location and language of search were extracted from the Google trends dataset.

RESULTS

A total of 390111 unique tweets were generated by 127284 unique users, with 2 users engaging with all six hashtags. Original tweets constituted on average 39.1% [Min 30.7% to max 47.2%] of the total. Hashtag frequency increased on Twitter for all six searches during October, the breast-cancer awareness month, but not on Google trends. Cancer survivors engaged much more often with the hashtag #Breastcancer and #Mastectomy, whereas #Breastsurgery, #Oncoplasticsurgery, #Breastconservingsurgery, #Breastreconstruction were mostly used by health professionals.

CONCLUSION

In this large qualitative and quantitative dataset, geo-temporal oscillations on Twitter and Google trends for hashtags relevant with breast cancer provide preliminary insights on information flow and user engagement. Understanding the effective use of social media platforms may provide the niche for disseminating evidence and promoting education on the surgical options of patients with breast cancer.

Evaluation of Usability and User Experience of Oncodoc 's M-Health Application for Early Detection of Cancer

OBJECTIVE

Cancer is a non-communicable disease that accounts for 71% of deaths globally. The prevalence of people living with cancer in Indonesia increased from 1.4/1000 population (2013) to 1.8/1,000 population (2018). This study aims to evaluate usability, user experience, and user feedback on the use of the Oncodoc m-health application.

METHODS

 The research method uses mixed methods with a cross-sectional approach and online survey sampling techniques (677 respondents), in December 2021-January 2022 in Indonesia. The instruments used are the System Usability Scale and User Experience Questionnaire. The variables measured include the characteristics of respondents, usability, user experience, and responses to using applications qualitatively. Quantitative data were analysed descriptively and the User Experience Questionnaire's analysis tool. Qualitative data were analysed thematically.

RESULTS

Evaluation of the usability of Oncodoc's m-health application is in the "acceptable" category (70.88), and the adjective rating is in the "Good" category. Evaluations of the relative quality of user experience are in the "good" and "very good" types. The average user experience scale is (mean; SD): attractiveness (1.80; 0.99), perspicuity (1.82; 1.05), efficiency (1.78; 1.09), dependability (1.56; 1.01), stimulation (1.81; 1.06), and novelty (1.32; 1.10). The findings of this study are 1) the ability to accommodate user needs, 2) usage barriers, and 3) user expectations for the Oncodoc application.

CONCLUSION

Overall, the Oncodoc m-health application is acceptable to users. We recommend developing a cancer early detection application with an approach that refers to user needs for further research.

Improve the cervical cancer prevention behaviors through mobile-based educational intervention based on I-CHANGE model: study protocol for a randomized controlled trial

Background

Applications of mobile technologies (mHealth) have the potential to reduce health inequalities, give patients more control over their health, and improve health care’s cost-effectiveness. The widespread use of mobile phones offers us a new way to prevent cervical cancer. The objective of the study was to design and develop a mobile phone application (app) that aims to conduct a behavioral intervention for women and to evaluate the efficacy of the app-based intervention.

Methods

This study involves 5 phases. In the first phase, understanding women’s perspectives will be identified using a qualitative approach based on the I-Change model. In phase 2, the results from the qualitative approach and requirement prioritization through providing experts’ perspectives will be done. The main outputs of this phase will be resulted in prioritizing the main measurable effective variables of the I-Change model. Phase 3 will be processed for the development and psychometric of an assessment tool regarding selected constructs. In phase 4, the App framework and content development will be performed. In phase 5, a three-armed, parallel-design randomized controlled trial will be conducted on women. Two hundred ten women will be randomly assigned to three groups including two intervention groups and one control group. The intervention groups included the following: (1) a mobile application and (2) a digital book. The data will be evaluated using tools designed and constructed in phase 3 of the study at baseline in 3-month follow-up assessments. The impact of the two interventions on cervical cancer prevention behaviors through mobile-based educational intervention will then be evaluated.

Discussion

A theory-based health education program using a mobile app to improve cervical cancer-preventive behaviors will be implemented for the first time in Iran. With an effective health mobile-based educational design, it is very important to determine whether Iranian women will be motivated to adhere to preventive behavior related to CC.

Trial registration

Iranian Clinical Trial Register IRCT20181205041861N3. Registered V2.0 on 26 October 2021.

Health care provider's experience and perspective of cervical cancer screening in Singapore: A qualitative study

Background

In Singapore, the current cervical cancer screening (CCS) coverage rate of 48% falls below the national target of 70%. Health care providers (HCPs) play a critical role in promoting CCS uptake. However, there is limited understanding of the perspectives of HCPs regarding CCS. Hence, we aimed to understand the challenges encountered by HCPs delivering CCS in different care settings in the Singapore health system. We also aimed to explore perspectives on newer features of CCS such as self-sampling and HPV genotyping.

Methods

Physicians, nurses, program administrators and laboratory technicians involved with CCS were invited for a one-on-one semi-structured interview conducted over Zoom between May to August 2021. The interviews were transcribed and analyzed using thematic analysis.

Results

Eighteen HCPs from 12 institutions were interviewed. Most participants were women (61.1%) and worked in public health institutions (72.2%). For factors influencing CCS, nine key themes were identified and organized into four categories: (1) patient factors, (2) HCP factors, (3) health system factors and (4) health promotion factors. Key themes commonly highlighted by study participants were related to patients' preferences and acceptance for screening, the processes of delivering CCS, the national priority for cervical cancer and the effectiveness of existing health promotion efforts. Five key themes were identified for CCS innovations. Self-sampling was viewed favorably to increase CCS uptake, while primary HPV screening with HPV partial genotyping had higher sensitivities to detect pre-cancers and cancers compared to cytology. Extended HPV genotyping beyond HPV16/18 could play an important role in CCS with increasing HPV vaccination coverage, as well as in the management of persistent HPV infection.

Conclusion

In Singapore, HCPs face multiple challenges for CCS in practice. Insights from this study are directly relevant to, and useful for developing policies around national CCS programs and treatment guidelines.

Prostate cancer awareness among transgender women after gender-affirming surgery

BACKGROUND

The prostate gland remains unresected during gender-affirming surgery (GAS) for transgender women (TGW), and may develop malignancies in later life. We sought to evaluate prostate cancer awareness (PCA) among post-GAS TGW.

METHODS

The investigators implemented a cross-sectional study and enrolled a sample of Thai post-GAS TGW without medical background. Predictor variables were categorized as demographic, clinical, operative, or postoperative. The outcome variable was PCA (yes/no). Appropriate statistics were computed, and a p-value ≤ 0.05 was considered statistically significant.

RESULTS

The sample consisted of 100 Thai post-GAS TGW (4% bisexual, 12% bachelor [or higher] graduates, 51% service workers, 64% had monthly net income <40,000 TB [or ca. 1050 Euro], 92% operated by plastic surgeons) with a mean age of 26.2 ± 5.4 years (range: 18-45). On bivariate analysis, PCA was significantly associated with educational level (p = 0.007; adjusted odd ratio [OR_adj. ]: 5.85; 95% confidence interval [95% CI]: 1.65-20.69), being operated ≥ 10 years  (p = 0.01; OR_adj. : 0.16; 95% CI: 0.04-0.76), self-recognition of the remaining prostate gland (p = 0.0001; OR_adj. : 0.02; 95% CI: 0-0.12), and emphasis on PCA by the GAS operator (p = 0.01; OR_adj. : 0.07; 95% CI: 0.01-0.63). Multiple linear regression analysis revealed a statistically significant, positive correlation (r = 0.78; p = 0.0001) among these four predictors, and continued to confirm the positive effect on PCA in TGW with high education and realization of the prostate gland (r = 0.56; p = 0.04) or information on PCA by the operator (r = 0.68; p = 0.003).

CONCLUSION

The GSA operator should intensively inform TGW about the remnant prostate and the risk of PC, especially those with low and middle levels of education attained.

Digital technologies in cancer care: a review from the clinician's perspective

Physicians are increasingly utilizing digital health technologies (DHT) such as smartphone applications, network-enabled wearable devices, web-based communication platforms, videoconferencing, chatbots, artificial intelligence and virtual reality to improve access to, and quality of, care. DHT aid in cancer screening, patient education, shared decision-making, promotion of positive health habits, symptom monitoring and intervention, patient-provider communication, provision of psychological support and delivery of effective survivorship care. This narrative review outlines how physicians may utilize digital health to improve or augment their delivery of cancer care. For the full potential of DHT to be realized, experts must develop appropriate solutions to issues surrounding the regulation, liability, quality, security, equity and reimbursement of DHT.

Test Your Health at Home: Comparing Online Screening Tests of Hearing, Cognition, and Cardiovascular Health

PURPOSE

The purpose of this study was to investigate the extent to which validated online screening measures of cognitive impairment, psychosocial well-being, and cardiovascular health are associated with a validated hearing screener in a sample of adults based in the United Kingdom.

METHOD

Sixty-one adults (43 female; M _age = 44.7 years) participated in a cross-sectional study delivered remotely. Participants completed the hearWHO smartphone application, a digits-in-noise hearing screener, and the Modified Telephone Interview for Cognitive Status (TICS-M), a screening tool for cognitive impairment. Psychosocial well-being (social isolation and loneliness) and cardiovascular health were assessed through self-report.

RESULTS

Separate independent analyses of variance, with age, gender, and education as covariates, demonstrated participants who failed the hearWHO screener had poorer scores on the TICS-M, engaged in less physical activity, and reported more sedentary behavior and greater social isolation. Multivariate regression analyses revealed that lower TICS-M scores, having obtained less education, identifying as female, and reporting greater sedentary behavior and social isolation were the strongest predictors of lower hearWHO scores.

CONCLUSIONS

The results from this study suggest that poorer hearing, as measured by the hearWHO screener, is independently associated with having worse cognitive function, more time spent being sedentary, and greater social isolation. Thus, this study demonstrates the potential of online screening measures to identify additional health conditions that confer risk to chronic disease as hearing loss manifests. This could help to inform the development of tailored treatment and support to improve an individual's readiness to seek help for and manage both their general and hearing health.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19251956.