Demographics and Social Factors Associated With Persistent Nonuse of Video Appointments at a Multisite Health Care Institution: Cross-Sectional Study

BACKGROUND

During the COVID-19 outbreak, video appointments became a popular method for health care delivery, particularly in the early stages of the pandemic. Although Mayo Clinic aimed to reduce face-to-face (F2F) appointments to prevent the spread of the virus, some patients continued seeing their health care providers in person. In the later stages of the pandemic, many patients became comfortable with video appointments, even if they were initially hesitant. However, a subset of patients continued to avoid video appointments. It is not yet clear what sociodemographic factors may be associated with this group of patients.

OBJECTIVE

This cross-sectional study aimed to examine demographic and social determinant of health (SDoH) factors associated with persistent nonusers of video appointments among a sample of patients within a multistate health care organization. We also explored patient beliefs about the use of video for health care appointments.

METHODS

We conducted a 1-time cross-sectional paper survey, mailed between July and December 2022, of patients matching the eligibility criteria: (1) aged ≥18 years as of April 2020, (2) Mayo Clinic Midwest, Florida, or Arizona patient, (3) did not use video appointment services during April-December 2020 but attended F2F appointments in the departments of primary care and psychiatry/psychology. The survey asked patients, "Have you ever had a video appointment with a healthcare provider?" "Yes" respondents were defined as "users" (adapted to video appointments), and "no" respondents were defined as "persistent nonusers" of video appointments. We analyzed demographics, SDoH, and patient beliefs toward video appointments in 2 groups: persistent nonusers of video appointments and users. We used chi-square and 2-tailed t tests for analysis.

RESULTS

Our findings indicate that patients who were older, lived in rural areas, sought care at Mayo Clinic Midwest, and did not have access to the patient portal system were likely to be persistent nonusers of video appointments. Only 1 SDoH factor (not having a disability, handicap, or chronic disease) was associated with persistent nonuse of video appointments. Persistent nonusers of video appointments held personal beliefs such as discomfort with video communication, difficulty interpreting nonverbal cues, and personal preference for F2F appointments over video.

CONCLUSIONS

Our study identified demographic (older age and rural residence), sociodemographic factors (not having a disability, handicap, or chronic disease), and personal beliefs associated with patients' decisions to choose between video versus F2F appointments for health care delivery. Health care institutions should assess patients' negative attitudes toward technology prior to introducing them to digital health care services. Failing to do so may result in its restricted usage, negative patient experience, and wasted resources. For patients who hold negative beliefs about technology but are willing to learn, a "digital health coordinator" could be assigned to assist with various digital health solutions.

Implementing a Metabolism-Informed Approach for Smoking Cessation in an Alaska Tribal Health System: Study Protocol for a Single-Arm Implementation Pilot Trial

Background

Individualized treatment for commercial tobacco smoking cessation, such as through the utilization of the nicotine metabolite ratio (NMR), offers substantial clinical benefit. NMR is a metabolism-informed biomarker that can be used to guide medication selection. NMR testing is particularly promising for tobacco cessation efforts in populations with high rates of smoking, such as some Alaska Native and American Indian (AN/AI) communities. To date, no prior study has evaluated the implementation of NMR-guided tobacco cessation with AN/AI populations.

Methods

The present "QUIT" protocol is a two-phase study that will occur at Southcentral Foundation (SCF), an Alaska Native-owned health system, serving 70,000 AN/AI people, based in Anchorage, Alaska. In Phase one, qualitative interviews with customer-owners (patients), providers and administrators (n = 36) and a 10-participant beta-test will be used to refine a strategy to implement NMR testing in the health system. Phase two will involve a single-arm pilot trial (n = 50) and qualitative interviews throughout data collection (n = 48) to evaluate the implementation strategy and explore the real-world acceptability and feasibility of NMR testing to guide tobacco cessation with AN/AI populations.

Discussion

This study utilizes a community-based participatory approach to refine and implement a nicotine metabolism-informed smoking cessation program in a Tribal healthcare setting. The process and findings from this study will reflect the importance of customer-owner choice and honor the lived experience involved in quitting commercial tobacco. Pilot study data will inform the effect and sample sizes required for a future pragmatic trial of NMR-guided smoking cessation.

A Christian Faith-Based Facebook Intervention for Smoking Cessation in Rural Communities (FAITH-CORE): Protocol for a Community Participatory Development Study

BACKGROUND

Tobacco smoking remains the leading cause of preventable morbidity and mortality in the United States, with significant rural-urban disparities. Adults who live in rural areas of the United States have among the highest tobacco smoking rates in the nation and experience a higher prevalence of smoking-related deaths and deaths due to chronic diseases for which smoking is a causal risk factor. Barriers to accessing tobacco use cessation treatments are a major contributing factor to these disparities. Adults living in rural areas experience difficulty accessing tobacco cessation services due to geographical challenges, lack of insurance coverage, and lack of health care providers who treat tobacco use disorders. The use of digital technology could be a practical answer to these barriers.

OBJECTIVE

This report describes a protocol for a study whose main objectives are to develop and beta test an innovative intervention that uses a private, moderated Facebook group platform to deliver peer support and faith-based cessation messaging to enhance the reach and uptake of existing evidence-based smoking cessation treatment (EBCT) resources (eg, state quitline coaching programs) for rural adults who smoke.

METHODS

We will use the Integrated Theory of Health Behavior Change, surface or deep structure frameworks to guide intervention development, and the community-based participatory research (CBPR) approach to identify and engage with community stakeholders. The initial content library of moderator postings (videos and text or image postings) will be developed using existing EBCT material from the Centers for Disease Control and Prevention Tips from Former Smokers Campaign. The content library will feature topics related to quitting smoking, such as coping with cravings and withdrawal and using EBCTs with faith-based message integration (eg, Bible quotes). A community advisory board and a community engagement studio will provide feedback to refine the content library. We will also conduct a beta test of the intervention with 15 rural adults who smoke to assess the recruitment feasibility and preliminary intervention uptake such as engagement, ease of use, usefulness, and satisfaction to further refine the intervention based on participant feedback.

RESULTS

The result of this study will create an intervention prototype that will be used for a future randomized controlled trial.

CONCLUSIONS

Our CBPR project will create a prototype of a Facebook-delivered faith-based messaging and peer support intervention that may assist rural adults who smoke to use EBCT. This study is crucial in establishing a self-sufficient smoking cessation program for the rural community. The project is unique in using a moderated social media platform providing peer support and culturally relevant faith-based content to encourage adult people who smoke to seek treatment and quit smoking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/52398.

Longitudinal factors associated with increased alcohol consumption in adults during the COVID-19 pandemic

Background: Alcohol is the most abused substance among adults in the United States. The COVID-19 pandemic impacted patterns of alcohol use, but data are conflicting, and previous studies are largely limited to cross-sectional analyses.Objective: This study aimed to longitudinally assess sociodemographic and psychological correlates of changes in three patterns of alcohol use (number of alcoholic drinks, drinking regularity, and binge drinking) during COVID-19.Methods: We studied changes in self-reported drinking behaviors in 222,195 Mayo Clinic patients over 21 years of age (58.1% female and 41.9% male) between April 1, 2019, and March 30, 2021. Logistic regression models were used to estimate associations between patient characteristics and change in alcohol consumption.Results: Sociodemographically younger age, White race, having a college degree, and living in a rural area were associated with increased alcohol use regularity (all p < .05). Younger age, male, White, high-school education or less, living in a more deprived neighborhood, smoking, and living in a rural area were associated with increases in number of alcohol drinks (all p ≤ .04) and binge drinking (all p ≤ .01). Increased anxiety scores were associated with increased number of drinks, while depression severity was associated with both increased drinking regularity and increased number of drinks (all p ≤ .02) independent of sociodemographic characteristics.Conclusion: Our study showed that both sociodemographic and psychological characteristics were associated with increased alcohol consumption patterns during the COVID-19 pandemic. Our study highlights specific target groups previously not described in the literature for alcohol interventions based on sociodemographic and psychological characteristics.

Association of socio-demographic characteristics with alcohol use initiation among never users during the COVID-19 pandemic: a longitudinal study

BACKGROUND

In this longitudinal cohort study, we examined the socio-demographic and psychological predictors of alcohol use initiation during the COVID-19 pandemic in a sample of never alcohol users aged ≥21 prior to COVID-19.

METHODS

Our study population consisted of 56 930 patients aged ≥21, as of 30 March 2019 were collected from a pre-COVID period of 1 year before 31 March 2020, and during-COVID, a period between 1 April 2020 and 30 March 2021. Univariable and multivariable logistic regression models were utilized to examine the roles of socio-demographic variables (gender, age, education, Area Deprivation Index and rural residence) changes in anxiety and depression severity as predictors of alcohol use initiation.

RESULTS

Age, gender, race, ethnicity, education and rural status were significant predictors in multivariable analysis. A subgroup analysis showed neither anxiety nor depression had a significant association with alcohol use initiation.

CONCLUSION

Women, younger individuals, those living in a rural area and people who smoke cigarettes were more likely to initiate alcohol use during the pandemic. Our study has public health and clinical implications such as the need for targeted alcohol use screening and intervention for vulnerable individuals.

Mobile Health Intervention to Promote Hypertension Self-Management among African Americans Receiving Care at a Community Health Center: Formative Evaluation of the FAITH! Hypertension App

BACKGROUND

African Americans (AAs) are at a higher risk of premature death from cardiovascular diseases compared to White Americans, with disproportionate attributable risk from uncontrolled hypertension. These health disparities are rooted in structural racism with resultant adverse social determinants of health (SDOH) including limited access to quality healthcare. Given their high usage among AAs, mobile technologies, including smartphones, show promise in increasing access to reliable health information. Thus, culturally tailored mobile health (mHealth) interventions may promote hypertension self-management among this population.

OBJECTIVE

This formative study assessed the feasibility of integrating an innovative mHealth intervention into clinical and community settings to improve blood pressure (BP) control among AAs.

METHODS

A mixed methods study of AA patients with uncontrolled hypertension was implemented over two consecutive phases. In Phase 1, patients and clinicians from two federally qualified health centers (FQHCs) in the Minneapolis-St. Paul, Minnesota metropolitan area provided input through a focus group series to refine an existing culturally tailored mHealth app (FAITH! [Fostering African-American Improvement in Total Health!] App) to promote hypertension self-management among AA patients with uncontrolled hypertension. Phase 2 was a single-arm pre-post intervention pilot study to assess feasibility and patient satisfaction. Patients receiving care at an FQHC participated in a 10-week intervention utilizing the refined FAITH! Hypertension App synchronized with a wireless BP monitor and support from a community health worker (CHW) to address SDOH-related social needs. The multimedia app consisted of a 10-module educational series focused on hypertension and cardiovascular risk factors with interactive self-assessments, medication/BP self-monitoring and social networking. Primary outcomes were feasibility (app engagement/satisfaction) and preliminary efficacy (change in BP) at immediate post-intervention.

RESULTS

In Phase 1, 13 AA patients (69% age ≥50, 77% female) and 16 clinicians (69% age ≥50, 88% female, 63% AA) participated in focus groups. Based on their feedback, app modifications included addition of: BP/medications-tracking, BP self-care task reminders, and culturally sensitive contexts. In Phase 2, 16 AA patients were enrolled (mean age 52.6 years [SD 12.3], 75% female). Of the 16, 38% completed at least half of 10 education modules. Seven of the 16 completed the post-intervention assessment. These patients rated the intervention a 9 (out of 10) as helpful in hypertension self-management. Qualitative data revealed that these patients viewed the app as user-friendly, engaging, and informative, and CHWs were perceived as providing accountability and support. Of the 7 patients, mean systolic and diastolic BPs decreased by 6.4 mmHg (p=.15) and 2.8 mmHg (p=.78) at immediate post-intervention, respectively.

CONCLUSIONS

A culturally tailored mHealth app, with reinforcement by CHW support, may improve hypertension self-management among under-resourced AAs receiving care at FQHCs. A future randomized efficacy trial of the intervention is warranted.

CLINICALTRIAL

Registration: ClinicalTrials.gov Identifier: NCT03777709.

Abstract P396: A Culturally Tailored Mobile Health Lifestyle Intervention Improves Cardiovascular Health Among African Americans With Preexisting Risk Factors

Background: African-American (AA) adults have a higher prevalence of cardiovascular (CV) risk factors, leading to higher CV disease mortality than White adults. Prior findings of our mobile health (mHealth) lifestyle intervention (FAITH! App) demonstrated efficacy in promoting ideal cardiovascular health (CVH) in AAs.

Hypothesis: We hypothesized that the intervention group with preexisting CV risk factors would have a greater increase in LS7 scores than the control group with the same risk factors following use of the FAITH! App.

Methods: A cluster randomized controlled trial was conducted among AAs from 16 churches in Minnesota. The intervention included culturally relevant, LS7-focused education modules, diet/physical activity self-monitoring and a group sharing board. A subgroup of participants with ≥1 diagnosis of overweight/obesity, hyperlipidemia, hypertension (HTN) or diabetes was examined. The primary outcome was change in LS7 score—a measure of CVH ranging from poor to ideal (range 0-14 points)—at 6 months post-intervention.

Results: Forty-nine participants (75.5% female) were included in the intervention (n=20; mean age [SD]: 58.8 [9.5]) or control (n=29, mean age [SD]: 52.5 [10.7]) groups (Table 1). There was no significant difference in the CV risk factor prevalence between the two groups. There was a greater increase in LS7 score in the intervention vs. control group across all CV risk factors, with significant differences among those with overweight/obesity (1.77, p<.0001) and with 2+ or 3+ CV risk factors (1.00, p=.03; 1.09, p=.04). Compared to the control group, the increase in the percentage of participants with ideal LS7 scores in the intervention group was higher among those with overweight/obesity, HTN, diabetes and 3+ CV risk factors.

Conclusions: Our culturally tailored mHealth lifestyle intervention was associated with notable increases in LS7 scores among AAs with preexisting CV risk factors, suggesting its efficacy in improving CVH among this population.

Incidence of Respiratory Syncytial Virus Infection in Older Adults Before and During the COVID-19 Pandemic

Importance

Little is known about the burden and outcomes of respiratory syncytial virus (RSV)-positive acute respiratory infection (ARI) in community-dwelling older adults.

Objective

To assess the incidence of RSV-positive ARI before and during the COVID-19 pandemic, and to assess outcomes for RSV-positive ARI in older adults.

Design, Setting, and Participants

This was a community-based cohort study of adults residing in southeast Minnesota that followed up with 2325 adults aged 50 years or older for 2 RSV seasons (2019-2021) to assess the incidence of RSV-positive ARI. The study assessed outcomes at 2 to 4 weeks, 6 to 7 months, and 12 to 13 months after RSV-positive ARI.

Exposure

RSV-positive and -negative ARI.

Main Outcomes and Measures

RSV status was the main study outcome. Incidence and attack rates of RSV-positive ARI were calculated during each RSV season, including before (October 2019 to April 2020) and during (October 2020 to April 2021) COVID-19 pandemic, and further calculated during non-RSV season (May to September 2021) for assessing impact of COVID-19. The self-reported quality of life (QOL) by Short-Form Health Survey-36 (SF-36) and physical functional measures (eg, 6-minute walk and spirometry) at each time point was assessed.

Results

In this study of 2325 participants, the median (range) age of study participants was 67 (50-98) years, 1380 (59%) were female, and 2240 (96%) were non-Hispanic White individuals. The prepandemic incidence rate of RSV-positive ARI was 48.6 (95% CI, 36.9-62.9) per 1000 person-years with a 2.50% (95% CI, 1.90%-3.21%) attack rate. No RSV-positive ARI case was identified during the COVID-19 pandemic RSV season. Incidence of 10.2 (95% CI, 4.1-21.1) per 1000 person-years and attack rate of 0.42%; (95% CI, 0.17%-0.86%) were observed during the summer of 2021. Based on prepandemic RSV season results, participants with RSV-positive ARI (vs matched RSV-negative ARI) reported significantly lower QOL adjusted mean difference (limitations due to physical health, -16.7 [95% CI, -31.8 to -1.8]; fatigue, -8.4 [95% CI, -14.3 to -2.4]; and difficulty in social functioning, -11.9 [95% CI, -19.8 to -4.0] within 2 to 4 weeks after RSV-positive ARI [ie, short-term outcome]). Compared with participants with RSV-negative ARI, those with RSV-positive ARI also had lower QOL (fatigue: -4.0 [95% CI, -8.5 to -1.3]; difficulty in social functioning, -5.8 [95% CI, -10.3 to -1.3]; and limitation due to emotional problem, -7.0 [95% CI, -12.7 to -1.3] at 6 to 7 months after RSV-positive ARI [intermediate-term outcome]; fatigue, -4.4 [95% CI, -7.3 to -1.5]; difficulty in social functioning, -5.2 [95% CI, -8.7 to -1.7] and limitation due to emotional problem, -5.7 [95% CI, -10.7 to -0.6] at 12-13 months after RSV-positive ARI [ie, long-term outcomes]) independent of age, sex, race and/or ethnicity, socioeconomic status, and high-risk comorbidities.

Conclusions and Relevance

In this cohort study, the burden of RSV-positive ARI in older adults during the pre-COVID-19 period was substantial. After a reduction of RSV-positive ARI incidence from October 2020 to April 2021, RSV-positive ARI re-emerged during the summer of 2021. RSV-positive ARI was associated with significant long-term lower QOL beyond the short-term lower QOL in older adults.

Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift

INTRODUCTION

To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities.

AIMS AND METHODS

In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020.

RESULTS

Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process.

CONCLUSIONS

Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity.

IMPLICATIONS

Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Patient Portal Messaging for Asynchronous Virtual Care During the COVID-19 Pandemic: Retrospective Analysis

BACKGROUND

During the COVID-19 pandemic, patient portals and their message platforms allowed remote access to health care. Utilization patterns in patient messaging during the COVID-19 crisis have not been studied thoroughly. In this work, we propose characterizing patients and their use of asynchronous virtual care for COVID-19 via a retrospective analysis of patient portal messages.

OBJECTIVE

This study aimed to perform a retrospective analysis of portal messages to probe asynchronous patient responses to the COVID-19 crisis.

METHODS

We collected over 2 million patient-generated messages (PGMs) at Mayo Clinic during February 1 to August 31, 2020. We analyzed descriptive statistics on PGMs related to COVID-19 and incorporated patients' sociodemographic factors into the analysis. We analyzed the PGMs on COVID-19 in terms of COVID-19-related care (eg, COVID-19 symptom self-assessment and COVID-19 tests and results) and other health issues (eg, appointment cancellation, anxiety, and depression).

RESULTS

The majority of PGMs on COVID-19 pertained to COVID-19 symptom self-assessment (42.50%) and COVID-19 tests and results (30.84%). The PGMs related to COVID-19 symptom self-assessment and COVID-19 test results had dynamic patterns and peaks similar to the newly confirmed cases in the United States and in Minnesota. The trend of PGMs related to COVID-19 care plans paralleled trends in newly hospitalized cases and deaths. After an initial peak in March, the PGMs on issues such as appointment cancellations and anxiety regarding COVID-19 displayed a declining trend. The majority of message senders were 30-64 years old, married, female, White, or urban residents. This majority was an even higher proportion among patients who sent portal messages on COVID-19.

CONCLUSIONS

During the COVID-19 pandemic, patients increased portal messaging utilization to address health care issues about COVID-19 (in particular, symptom self-assessment and tests and results). Trends in message usage closely followed national trends in new cases and hospitalizations. There is a wide disparity for minority and rural populations in the use of PGMs for addressing the COVID-19 crisis.

Longitudinal Correlates of Increased Alcohol Use Among Adolescents and Young Adults During the COVID-19 Pandemic

AIMS

The objective of this study is to longitudinally assess sociodemographic and psychological correlates of increased alcohol use during the coronavirus disease of 2019 (COVID-19) period among adolescents and young adults.

METHODS

Pre-COVID period is defined as the 1-year period on or before 31 March 2020, and during-COVID period is defined as the period from 1st April 2020 to 30 March 2021. Univariable logistic regression models are used to evaluate the association of demographic characteristics, Area Deprivation Index (ADI), rurality, changes in Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder (GAD-7) scale severity, and the risk of increased alcohol consumption (binge drinking, number of drinks and drinking regularity) from pre-COVID to during-COVID period.

RESULTS AND CONCLUSION

Our study found that worsened anxiety symptoms, older age, being in college and current cigarette smoking status were associated with increased alcohol use among youth during the pandemic year. Socioeconomic position (measured by ADI) and rural status were not found to be associated with increased alcohol use among adolescents and young adults.

Role of Geographic Risk Factors in COVID-19 Epidemiology: Longitudinal Geospatial Analysis

Objective

To perform a geospatial and temporal trend analysis for coronavirus disease 2019 (COVID-19) in a Midwest community to identify and characterize hot spots for COVID-19.

Participants and Methods

We conducted a population-based longitudinal surveillance assessing the semimonthly geospatial trends of the prevalence of test confirmed COVID-19 cases in Olmsted County, Minnesota, from March 11, 2020, through October 31, 2020. As urban areas accounted for 84% of the population and 86% of all COVID-19 cases in Olmsted County, MN, we determined hot spots for COVID-19 in urban areas (Rochester and other small cities) of Olmsted County, MN, during the study period by using kernel density analysis with a half-mile bandwidth.

Results

As of October 31, 2020, a total of 37,141 individuals (30%) were tested at least once, of whom 2433 (7%) tested positive. Testing rates among race groups were similar: 29% (black), 30% (Hispanic), 25% (Asian), and 31% (white). Ten urban hot spots accounted for 590 cases at 220 addresses (2.68 cases per address) as compared with 1843 cases at 1292 addresses in areas outside hot spots (1.43 cases per address). Overall, 12% of the population residing in hot spots accounted for 24% of all COVID-19 cases. Hot spots were concentrated in neighborhoods with low-income apartments and mobile home communities. People living in hot spots tended to be minorities and from a lower socioeconomic background.

Conclusion

Geographic and residential risk factors might considerably account for the overall burden of COVID-19 and its associated racial/ethnic and socioeconomic disparities. Results could geospatially guide community outreach efforts (eg, testing/tracing and vaccine rollout) for populations at risk for COVID-19.

Lay health worker as interventionist training: reflective writing in US family health promotion practice

Lay health worker-led health promotion interventions are well received within racial and ethnic minority communities. Increasing numbers of trained lay health workers will be needed to meet global health goals. The purpose of this process evaluation was to gain insights about how lay health worker as interventionists used theory-based approaches within a nutrition and physical activity health behavior change intervention in a clinical trial enrolling immigrant and refugee families. Data were comprised of ongoing reflective writing statements from four health workers about their implementation of the intervention. Using content analysis three themes emerged: (i) encouraging setting of small, family focused and relevant goals, (ii) being flexible in content delivery and (iii) being personally transformed (i.e. gained a sense of meaning from their experience). Lay health worker interventionist reflections on practice revealed they delivered the intervention within the primacy of the family partnering relationship by attending to unique family needs, and adjusting educational content and goal setting accordingly. Our results provide guidance for training and process evaluation of lay health worker intervention delivery in ethnically and racially diverse populations. Incorporating real-time reflection upon what was learned about skills of facilitating family motivation and family confidence enhanced affective learning and may be useful in future research studies and health promotion practice. The processes identified including setting small goals, flexibility and personal transformation could be considered in future lay health worker-delivered health promotion interventions.

Influence of gender and peer tobacco use on tobacco use intentions after a period of involuntary tobacco abstinence among U.S. Air Force trainees

This study examined gender, prior tobacco use, and social-environmental factors as predictors of intentions to use tobacco (cigarette smoking and/or smokeless tobacco [ST]) after a forced period of abstinence among U.S. Air Force (USAF) trainees. Trainees completed 8½ weeks of basic military training (BMT), then 4 weeks of Technical Training; both required abstinence from tobacco. A cross-sectional survey of 13,514 USAF trainees (73% male, 90% age 18–24, 43% prior tobacco use) was conducted at the beginning of the 4-week Technical Training period. Overall, 17% of the sample reported future tobacco use intentions. Intentions for future tobacco use were less prevalent among non-tobacco users before BMT (1%) than those reporting any tobacco use (37%). From a multivariable logistic regression model predicting intentions to use any tobacco after Technical Training, significant two-way interaction effects were detected between gender, and tobacco use prior to BMT (p = 0.0001), and number of close friends who smoked cigarettes (p = 0.018), and number of close friends who used ST (p = 0.029). Among non-tobacco users before BMT, females were more than twice as likely as males to report tobacco intentions (Odds Ratio = 2.2, Bonferroni corrected 95% CI: 1.14.4, p = 0.011); no gender differences were detected among tobacco users. For females, but not males, having more friends who smoked was associated with greater likelihood of tobacco intentions (Bonferroni corrected p ≤ 0.05). In contrast, for males, but not females, having more friends using ST was associated with greater likelihood of tobacco intentions (Bonferroni corrected p < 0.05). In this sample of USAF trainees, the study provides novel findings on how males and females are influenced differently by their prior tobacco use and peers' tobacco use in predicting tobacco intentions. Prevention efforts focused on uptake and resumption of tobacco use, along with gender-specific strategies, may be warranted.

•

Prior tobacco use predicts tobacco use intentions among U.S. Air Force trainees.

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Male and female trainees are influenced differently by their peers' tobacco use.

•

Gender-specific strategies targeting social norms about tobacco may be warranted.

Urine 4-(methylnitrosamino)-1-(3) pyridyl-1-butanol and cotinine in Alaska native postpartum women and neonates comparing smokers and smokeless tobacco users

OBJECTIVE

Foetuses and neonates of women who use tobacco are exposed to nicotine and tobacco-derived carcinogens. We determined the relationship between urine biomarkers of tobacco toxicant exposure postpartum and in the neonates of Alaska Native (AN) women, comparing smokers and smokeless tobacco (ST) users, including iqmik, a homemade ST product.

METHODS

AN women, including 36 smokers, 9 commercial ST and 16 iqmik users their neonates participated. Urine from the woman at the time of delivery and her neonate's first urine were analysed for cotinine, the major metabolite of nicotine, and 4-(methylnitrosamino)-1-(3) pyridyl-1-butanol (NNAL), a tobacco-specific carcinogen biomarker.

RESULTS

Maternal urine cotinine and neonatal urine cotinine were strongly correlated in all tobacco use groups (r from 0.83 to 0.9, p < 0.002). Correlations between maternal cotinine and neonatal NNAL were moderately strong for cigarettes and commercial smokeless but weaker for iqmik users (r 0.73, 0.6 and 0.36, respectively).

CONCLUSION

Correlations between maternal and neonatal biomarkers of tobacco toxicant exposure vary, dependent on tobacco product use.

SIGNIFICANCE

This study provides novel data on biomarkers of tobacco exposure among postpartum AN women and their neonates. The results could be useful to guide future epidemiological studies of health risks associated with use of various tobacco products during pregnancy.

Linking Podcasts With Social Media to Promote Community Health and Medical Research: Feasibility Study

Background

Linking podcasts with social media is a strategy to promote and disseminate health and health research information to the community without constraints of time, weather, and geography.

Objective

To describe the process of creating a podcast library and promoting it on social media as a strategy for disseminating health and biomedical research topics to the community.

Methods

We used a community and patient engagement in research approach for developing a process to use podcasts for dissemination of health and health research information. We have reported the aspects of audience reach, impressions, and engagement on social media through the number of downloads, shares, and reactions posted on SoundCloud, Twitter, and Facebook, among others.

Results

In collaboration with our local community partner, we produced 45 podcasts focused on topics selected from a community health needs assessment with input from health researchers. Episodes lasted about 22 minutes and presented health-related projects, community events, and community resources, with most featured guests from Olmsted County (24/45, 53%). Health research was the most frequently discussed topic. Between February 2016 and June 2017, episodes were played 1843 times on SoundCloud and reached 1702 users on our Facebook page.

Conclusions

This study demonstrated the process and feasibility of creating a content library of podcasts for disseminating health- and research-related information. Further examination is needed to determine the best methods to develop a sustainable social media plan that will further enhance dissemination (audience reach), knowledge acquisition, and communication of health topics.

Racial disparities in bipolar disorder treatment and research: a call to action

OBJECTIVES

Health disparities between individuals of African and European ancestry are well documented. The disparities in bipolar disorder may be driven by racial bias superimposed on established factors contributing to misdiagnosis, including: evolving empirically based diagnostic criteria (International Classification of Diseases [ICD], Research Diagnostic Criteria [RDC] and Diagnostic and Statistical Manual [DSM]), multiple symptom domains (i.e. mania, depression and psychosis), and multimodal medical and additional psychiatric comorbidity.

METHODS

For this paper, we reviewed the phenomenological differences between bipolar individuals of African and European ancestry in the context of diagnostic criteria and clinical factors that may contribute to a potential racial bias.

RESULTS

Published data show that bipolar persons of African ancestry, compared with bipolar persons of non-African ancestry, are more often misdiagnosed with a disease other than bipolar disorder (i.e. schizophrenia). Additionally, studies show that there are disparities in recruiting patients of African ancestry to participate in important genomic studies. This gap in biological research in this underrepresented minority may represent a missed opportunity to address potential racial differences in the risk and course of bipolar illness.

CONCLUSION

A concerted effort by the research community to increase inclusion of diverse persons in studies of bipolar disorder through community engagement may facilitate fully addressing these diagnostic and treatment disparities in bipolar individuals of African ancestry.

mHealth Intervention Promoting Cardiovascular Health Among African-Americans: Recruitment and Baseline Characteristics of a Pilot Study

Background

Mobile health (mHealth) interventions are promising avenues to promote cardiovascular (CV) health among African-Americans (AAs) and culturally tailored technology-based interventions are emerging for this population.

Objective

The objectives of this study were to use a community-based participatory research (CBPR) approach to recruit AAs into a pilot intervention study of an innovative mHealth CV health promotion program and to characterize technology use patterns and eHealth literacy (EHL).

Methods

Community partners from five predominately AA churches in southeast Minnesota collaborated with our academic institution to recruit AA congregants into the pilot study. Field notes as well as communications between the study team and community partners were used to design the recruitment strategy and its implementation with a goal of enrolling 50 participants. At its core, the recruitment strategy included community kickoff events to detail the state-of-the-art nature of the mHealth intervention components, the utility of CV health assessments (physical examination, laboratory studies and surveys) and the participants’ role in advancing our understanding of the efficacy of mHealth interventions among racial/ethnic minority groups. Detailed recruitment data were documented throughout the study. A self-administered, electronic survey measured sociodemographics, technology use and EHL (eHEALS scale).

Results

A total of 50 participants (70% women) from five AA churches were recruited over a one-month period. The majority (>90%) of participants reported using some form of mobile technology with all utilizing these technologies within their homes. Greater than half (60% [30/50]) reported being “very comfortable” with mobile technologies. Overall, participants had high EHL (84.8% [39/46] with eHEALS score ≥26) with no differences by sex.

Conclusions

This study illustrates the feasibility and success of a CBPR approach in recruiting AAs into mHealth intervention research and contributes to the growing body of evidence that AAs have high EHL, are high-users of mobile technologies, and thus are likely to be receptive to mHealth interventions.

Perceived risks and reasons to smoke cigarettes during pregnancy among Alaska native women

OBJECTIVE

The purpose of this study was to explore perceptions of the risks of smoking and reasons Alaska Native women give for smoking during pregnancy.

DESIGN

A total of 118 women (54 smokers, 64 non-smokers) enrolled in a biomarker study and completed a baseline interview asking about their concerns regarding tobacco use while pregnant and reasons why pregnant women might smoke during pregnancy. Responses were collapsed into six categories of perceived risks of smoking and eight categories of reasons to smoke during pregnancy.

RESULTS

The majority of both pregnant non-smokers and smokers (72.6% and 60.4%) agreed that smoking during pregnancy could negatively impact the health of their baby. However, non-smokers were more likely than smokers (77.4% vs. 58.5%) to view smoking during pregnancy as a risk factor for the baby's development (p = .029). Both non-smokers and smokers identified addiction as a reason for smoking during pregnancy (82.8% and 63%); however, non-smokers were more likely than smokers to state this was a reason for use (p = .015). Seventy-three percent of the entire sample reported a reason to smoke in pregnancy was to help manage negative affect.

CONCLUSION

Results from this work may be helpful in advancing research by identifying targets for intervention specific to Alaska Native women receiving prenatal care in Anchorage, Alaska.

A majority rule approach for region-of-interest-guided streamline fiber tractography

Hand-drawn gray matter regions of interest (ROI) are often used to guide the estimation of white matter tractography, obtained from diffusion-weighted magnetic resonance imaging (DWI), in healthy and in patient populations. However, such ROIs are vulnerable to rater bias of the individual segmenting the ROIs, scan variability, and individual differences in neuroanatomy. In this report, a "majority rule" approach is introduced for ROI segmentation used to guide streamline tractography in white matter structures. DWI of one healthy participant was acquired in ten separate sessions using a 3 T scanner over the course of a month. Four raters identified ROIs within the left hemisphere [Cerebral Peduncle (CPED); Internal Capsule (IC); Hand Portion of the Motor Cortex, or Hand Bump, (HB)] using a group-established standard operating procedure for ROI definition to guide the estimation of streamline tracts within the corticospinal tract (CST). Each rater traced the ROIs twice for each scan session. The overlap of each rater's two ROIs was used to define a representative ROI for each rater. These ROIs were combined to create a "majority rules" ROI, in which the rule requires that each voxel is selected by at least three of four raters. Reproducibility for ROIs and CST segmentations were analyzed with the Dice Similarity Coefficient (DSC). Intra-rater reliability for each ROI was high (DSCs ≥ 0.83). Inter-rater reliability was moderate to adequate (DSC range 0.54-0.75; lowest for IC). Using intersected majority rules ROIs, the resulting CST showed improved overlap (DSC = 0.82) in the estimated streamline tracks for the ten sessions. Despite high intra-rater reliability, there was lower inter-rater reliability consistent with the expectation of rater bias. Employing the majority rules method improved reliability in the overlap of the CST.

Executive function fails to predict smoking outcomes in a clinical trial to motivate smokers to quit

BACKGROUND

Executive function (EF) is considered an important mediator of health outcomes. It is hypothesized that those with better EF are more likely to succeed in turning their intentions into actual health behaviors. Prior studies indicate EF is associated with smoking cessation. Experimental and longitudinal studies, however, have yielded mixed results. Few studies have examined whether EF predicts post-treatment smoking behavior. Fewer still have done so prospectively in a large trial. We sought to determine if EF predicts quit attempts and cessation among community smokers in a large randomized trial evaluating the efficacy of motivational interventions for encouraging cessation.

METHODS

Participants (N=255) completed a baseline assessment that included a cognitive battery to assess EF (Oral Trail Making Test B, Stroop, Controlled Oral Word Association Test). Participants were then randomized to 4 sessions of Motivational Interviewing or Health Education or one session of Brief Advice to quit. Quit attempts and cessation were assessed at weeks 12 and 26.

RESULTS

In regression analyses, none of the EF measures were statistically significant predictors of quit attempts or cessation (all ps>0.20).

CONCLUSIONS

Our data did not support models of health behavior that emphasize EF as a mediator of health outcomes. Methodological shortcomings weaken the existing support for an association between EF and smoking behavior. We suggest methodological improvements that could help move this potentially important area of research forward.

Smoking in Pregnancy Among Indigenous Women in High-Income Countries: A Narrative Review

INTRODUCTION

Pregnant women in socioeconomically disadvantaged circumstances, such as Indigenous women, have a high prevalence of smoking. Tobacco smoking is the most significant reversible risk factor for the health of Indigenous pregnant women and their babies.

METHODS

As researchers working in this specialized area, we conducted a narrative review of the literature on smoking among Indigenous pregnant women in the United States, Canada, New Zealand, and Australia. We summarize prevalence and factors influencing tobacco use, interventions, and evidence gaps for tobacco control and smoking cessation. Recommendations are made for future interventions, policy changes, and much-needed research.

RESULTS

Common themes emerging across the four countries reveal opportunities for cross-cultural collaborative studies and trials. These include the social-normative use of tobacco as barriers to quitting in pregnancy and the need for evaluations of interventions at the family and community level. Socioeconomic disparities underscore the importance of enhancing the implementation and reach of strategies to prevent and reduce prenatal tobacco smoking among Indigenous women. Elders and community health care providers as role models for nontobacco use could be explored. Qualitative work is needed to understand the barriers and opportunities, such as cultural strengths supporting quitting tobacco to develop more effective approaches.

CONCLUSIONS

Although a high-priority group, there remains a dearth of research on Indigenous women's smoking in pregnancy. Studies have assessed knowledge and attitudes to smoking in pregnancy, and small feasibility studies and a few empirical trials have been conducted. Recommendations for promising culturally appropriate cessation interventions have been made. Larger trials are warranted.

IMPLICATIONS

Strategies to support quitting among pregnant Indigenous women need to be multifactorial and take account of the social determinants of smoking including historical antecedents, community norms, cultural strengths, and recognition of individual and community needs. Cross-country research collaborations have the potential to leverage funding, share expertise, and strengthen approaches to tackle an important and poorly attended health disparity that has a profound impact on the entire life course for Indigenous peoples.

Abstract 020: Stress and Achievement of Cardiovascular Health Metrics: The American Heart Association Life’s Simple 7 TM in African-Americans of the Jackson Heart Study

Background: Cardiovascular disease (CVD) remains the leading cause of death for African-American (AA) adults. There is a low prevalence of ideal cardiovascular health (CVH) (as defined by the American Heart Association’s Life’s Simple 7 TM (LS7)), especially diet, physical activity and obesity among AAs placing them at a disproportionately high risk for CVD. The identification of psychosocial stress that may influence ideal CVH could assist in the development of more effective behavior change interventions among AAs.

Objectives: The aim of this study is to examine the associations of multidimensional stressors (chronic stress, minor stressors, and major life events - MLEs) with the LS7 components (classified as poor, intermediate and ideal) in AAs. We hypothesize that stress is negatively associated with the likelihood of achievement of intermediate/ideal levels of the LS7 components and LS7 composite score after adjusting for traditional socio-demographic factors.

Methods: Using the Jackson Heart Study (JHS), a cohort of AAs based in Jackson, Mississippi (n=4383), we conducted a cross-sectional analysis of the association of stress measures with LS7 components (smoking, diet, physical activity, body mass index, blood pressure, total cholesterol and glucose). This association was measured using logistic regression which assessed the odds ratios (OR, 95% confidence interval (CI)) of the achievement of intermediate/ideal levels of CVH with progressive adjustment for demographic, socioeconomic, behavioral and biomedical factors. A composite LS7 score was calculated [range 0-14; categorized as 0 to 6 (poor), 7 to 8 (intermediate) and 9 to 14 (ideal)]. We also constructed a cumulative stress score as a summation of tertiles of each stress measure (range 3-9).

Results: Fewer participants achieved intermediate or ideal CVH for the LS7 components including diet (39%), physical activity (51%) and BMI (47%). Higher chronic stress and minor stressors scores were associated a decreased likelihood of achievement of ideal/intermediate levels for smoking [OR 0.80; 95% CI 0.73-0.88 and OR 0.84; 95% CI 0.75-0.94, respectively). Higher MLE scores were associated decreased likelihood of achievement of ideal/intermediate levels for smoking (OR 0.84; 95% CI 0.76-0.92) and glucose (OR 0.90; 95% CI 0.82-0.98). Those with higher minor stressors and MLE scores were less likely to achieve intermediate or ideal LS7 composite score categories (OR 0.89; 95% CI 0.81-0.97 and OR 0.91; 95% CI 0.84-0.98, respectively). There was no statistically significant association between LS7 composite scores and cumulative stress scores.

Conclusions: Our results suggest that key stress measures may contribute adversely to CVH among AAs. These findings provide support for future lifestyle interventions which integrate a focus on alleviating stressors in this high risk population to improve CVH.

Preventing cardiovascular disease: Participant perspectives of the FAITH! Program

Striking cardiovascular health disparities exist among African-Americans in Minnesota compared to Whites; however, community-based interventions to address cardiovascular disease risk are lacking. This study explored participant perceptions of a culturally tailored, cardiovascular disease prevention program developed using a community-based participatory research process. Research participation perceptions, program benefits, and program satisfaction/acceptability were analyzed using a mixed-methods approach. Overall, acceptability was high. Findings highlight the favorable inclusion of African-Americans (research perception), knowledge gained about healthy lifestyle practices (benefits), and quality of the curriculum/speakers (satisfaction). Community-based participatory research may be useful in fostering the acceptability of behavior change interventions among marginalized African-American communities.

High tobacco use prevalence with significant regional and sex differences in smokeless tobacco use among Western Alaska Native people: the WATCH study

Tobacco use prevalence among Alaska Native (AN) people living in Alaska is greater than the general population prevalence statewide and nationally. Better understanding of regional tobacco use is needed to improve cessation efforts and reduce prevalence. Using self-reported baseline data from the Western Alaska Tribal Collaborative for Health study, we describe tobacco use patterns among AN people in two western Alaska regions. Data were stratified by age group and sex. Dual- and multi-product use in the Yukon-Kuskokwim (Y-K) region was stratified by concurrent vs sequential use. Overall, 87% of the cohort reported having used tobacco. In Norton Sound, cigarette (98%) was the predominant tobacco type. In Y-K 71% smoked, 76% used smokeless tobacco (ST), with 47% reporting use of both products. ST use in Y-K consisted of commercial ST and homemade iqmik. Y-K women reported more ST product use, while men reported more cigarette use. Among dual- and multi-product users, the majority reported concurrent use, with no significant differences between men and women. Distinct regional differences include high smoking prevalence in Norton Sound and frequent use of smoking and ST products in Y-K. Findings support modification of cessation programmes to address regional variations in tobacco use patterns.

Recruiting unmotivated smokers into a smoking induction trial

Little is known about effective methods to recruit unmotivated smokers into cessation induction trials, the reasons unmotivated smokers agree to participate, and the impact of those reasons on study outcomes. A mixed-method approach was used to examine recruitment data from a randomized controlled cessation induction trial that enrolled 255 adult smokers with low motivation to quit. Over 15 months, 33% of smokers who inquired about the study were enrolled. Common recruitment methods included word-of-mouth, print advertisements and clinic referrals. Frequently mentioned reasons for participating included to: gain financial incentives (44.7%), learn about research or help others quit (43%), learn about smoking and risks (40%) and help with future quits (i.e. Quit Assistance, 23.9%). Separate regression models predicting study outcomes at 26 weeks indicated that smokers who said they participated for Quit Assistance reported higher motivation to quit (B 1.26) and were more likely to have made a quit attempt (OR 2.03) compared to those not mentioning this reason, when baseline characteristics were controlled. Understanding reasons for unmotivated smokers' interest in treatment can help practitioners and researchers design effective strategies to engage this population.

A Randomized Trial of Motivational Interviewing: Cessation Induction Among Smokers With Low Desire to Quit

INTRODUCTION

Despite limitations in evidence, the current Clinical Practice Guideline advocates Motivational Interviewing for smokers not ready to quit. This study evaluated the efficacy of Motivational Interviewing for inducing cessation-related behaviors among smokers with low motivation to quit.

DESIGN

Randomized clinical trial.

SETTING/PARTICIPANTS

Two-hundred fifty-five daily smokers reporting low desire to quit smoking were recruited from an urban community during 2010-2011 and randomly assigned to Motivational Interviewing, health education, or brief advice using a 2:2:1 allocation. Data were analyzed from 2012 to 2014.

INTERVENTION

Four sessions of Motivational Interviewing utilized a patient-centered communication style that explored patients' own reasons for change. Four sessions of health education provided education related to smoking cessation while excluding elements characteristic of Motivational Interviewing. A single session of brief advice consisted of brief, personalized advice to quit.

MAIN OUTCOMES MEASURES

Self-reported quit attempts; smoking abstinence (biochemically verified); use of cessation pharmacotherapies; motivation; and confidence to quit were assessed at baseline and 3- and 6-month follow-ups.

RESULTS

Unexpectedly, no significant differences emerged between groups in the proportion who made a quit attempt by 6-month follow-up (Motivational Interviewing, 52.0%; health education, 60.8%; brief advice, 45.1%; p=0.157). Health education had significantly higher biochemically verified abstinence rates at 6 months (7.8%) than brief advice (0.0%) (8% risk difference, 95% CI=3%, 13%, p=0.003), with the Motivational Interviewing group falling in between (2.9% abstinent, 3% risk difference, 95% CI=0%, 6%, p=0.079). Both Motivational Interviewing and health education groups showed greater increases in cessation medication use, motivation, and confidence to quit relative to brief advice (all p<0.05), and health education showed greater increases in motivation relative to Motivational Interviewing (Cohen's d=0.36, 95% CI=0.12, 0.60).

CONCLUSIONS

Although Motivational Interviewing was generally more efficacious than brief advice in inducing cessation behaviors, health education appeared the most efficacious. These results highlight the need to identify the contexts in which Motivational Interviewing may be most efficacious and question recommendations to use Motivational Interviewing rather than other less complex cessation induction interventions.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01188018.

An investigation of the colorectal cancer experience and receptivity to family-based cancer prevention programs

PURPOSE

Cancer is a shared family experience and may provide a "teachable moment" to motivate at-risk family members to adopt cancer prevention and health promotion behaviors. This study explored how a diagnosis of colorectal cancer (CRC) is experienced by family members and may be used to develop a family-based CRC prevention program. Preferences regarding content, timing, and modes of program delivery were examined. Social cognitive theory provided the conceptual framework for the study.

METHODS

This study employed mixed methodology (semi-structured interviews and self-report questionnaires). Participants included 73 adults (21 patients, 52 family members) from 23 families (two patients were deceased prior to being interviewed). Most patients (n = 14; 67 %) were interviewed 1-5 years post-diagnosis. Individual interviews were audio-recorded, transcribed, and content analyzed.

RESULTS

For many, a CRC diagnosis was described as a shared family experience. Family members supported each other's efforts to prevent CRC through screening, exercising, and maintaining a healthy diet. Teachable moments for introducing a family-based program included the time of the patient's initial cancer surgery and post-chemotherapy. Reported willingness to participate in a family-based program was associated with risk perception, self-efficacy, outcome expectancies, and the social/community context in which the program would be embedded. Program preferences included cancer screening, diet/nutrition, weight management, stress reduction, and exercise. Challenges included geographic dispersion, variation in education levels, generational differences, and scheduling.

CONCLUSIONS

CRC patients and family members are receptive to family-based programs. Feasibility concerns, which may be mitigated but not eliminated with technological advances, must be addressed for successful family-based programs.

SNPs in PTGS2 and LTA predict pain and quality of life in long term lung cancer survivors

PURPOSE

Lung cancer survivors report the lowest quality of life relative to other cancer survivors. Pain is one of the most devastating, persistent, and incapacitating symptoms for lung cancer survivors. Prevalence rates vary with 80-100% of survivors experiencing cancer pain and healthcare costs are five times higher in cancer survivors with uncontrolled pain. Cancer pain often has a considerable impact on quality of life among cancer patients and cancer survivors. Therefore, early identification, and treatment is important. Although recent studies have suggested a relationship between single nucleotide polymorphisms (SNPs) in several cytokine and inflammation genes with cancer prognosis, associations with cancer pain are not clear. Therefore, the primary aim of this study was to identify SNPs related to pain in lung cancer survivors.

PATIENTS AND METHODS

Participants were enrolled in the Mayo Clinic Lung Cancer Cohort upon diagnosis of their lung cancer. 1149 Caucasian lung cancer survivors (440 surviving <3 years; 354 surviving 3-5 years; and 355 surviving >5 years) completed study questionnaires and had blood DNA samples available. Ten SNPS from PTGS2 and LTA genes were selected based on the serum-based studies in the literature. Outcomes included pain, and quality of life as measured by the SF-8.

RESULTS

Of the 10 SNPs evaluated in LTA and PTGS2 genes, 3 were associated with pain severity (rs5277; rs1799964), social function (rs5277) and mental health (rs5275). These results suggested both specificity and consistency of these inflammatory gene SNPs in predicting pain severity in lung cancer survivors.

CONCLUSION

These results provide support for genetic predisposition to pain severity and may aid in identification of lung cancer survivors at high risk for morbidity and poor QOL.

Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial

Background

Although the current Clinical Practice Guideline recommend Motivational Interviewing for use with smokers not ready to quit, the strength of evidence for its use is rated as not optimal. The purpose of the present study is to address key methodological limitations of previous studies by ensuring fidelity in the delivery of the Motivational Interviewing intervention, using an attention-matched control condition, and focusing on unmotivated smokers whom meta-analyses have indicated may benefit most from Motivational Interviewing. It is hypothesized that MI will be more effective at inducing quit attempts and smoking cessation at 6-month follow-up than brief advice to quit and an intensity-matched health education condition.

Methods/Design

A sample of adult community resident smokers (N = 255) who report low motivation and readiness to quit are being randomized using a 2:2:1 treatment allocation to Motivational Interviewing, Health Education, or Brief Advice. Over 6 months, participants in Motivational Interviewing and Health Education receive 4 individual counseling sessions and participants in Brief Advice receive one brief in-person individual session at baseline. Rigorous monitoring and independent verification of fidelity will assure the counseling approaches are distinct and delivered as planned. Participants complete surveys at baseline, week 12 and 6-month follow-up to assess demographics, smoking characteristics, and smoking outcomes. Participants who decide to quit are provided with a self-help guide to quitting, help with a quit plan, and free pharmacotherapy. The primary outcome is self-report of one or more quit attempts lasting at least 24 hours between randomization and 6-month follow-up. The secondary outcome is biochemically confirmed 7-day point prevalence cessation at 6-month follow-up. Hypothesized mediators of the presumed treatment effect on quit attempts are greater perceived autonomy support and autonomous motivation. Use of pharmacotherapy is a hypothesized mediator of Motivational Interviewing’s effect on cessation.

Discussion

This trial will provide the most rigorous evaluation to date of Motivational Interviewing’s efficacy for encouraging unmotivated smokers to make a quit attempt. It will also provide effect-size estimates of MI’s impact on smoking cessation to inform future clinical trials and inform the Clinical Practice Guideline.

Trial registration

ClinicalTrials.gov NCT01188018

Relationship between cytokine gene single nucleotide polymorphisms and symptom burden and quality of life in lung cancer survivors

BACKGROUND

Previous research has demonstrated that many lung cancer survivors report difficulties with symptom control and experience a poor quality of life (QOL). Although recent studies have suggested a relationship of single nucleotide polymorphisms (SNPs) in several cytokine genes with cancer susceptibility and prognosis, associations with symptom burden and QOL have not been examined. The current study was conducted to identify SNPs related to symptom burden and QOL outcomes in lung cancer survivors.

METHODS

All participants were enrolled in the Mayo Clinic Lung Cancer Cohort following diagnosis of lung cancer. A total of 1149 Caucasian lung cancer survivors completed questionnaires and had genetic samples available. The main outcome measures were symptom burden as measured by the Lung Cancer Symptom Scale and health-related QOL as measured by the Short-Form General Health Survey.

RESULTS

Twenty-one SNPs in cytokine genes were associated with symptom burden and QOL outcomes. Our results suggested both specificity and consistency of cytokine gene SNPs in predicting outcomes.

CONCLUSIONS

These results provide support for genetic predisposition to QOL and symptom burden and may aid in identification of lung cancer survivors at high risk for symptom management and QOL difficulties.

A physiology based inverse dynamic analysis of human gait: potential and perspectives

One approach to compute the musculotendon forces that underlie human motion is to combine an inverse dynamic analysis with a static optimisation procedure. Although computationally efficient, this classical inverse approach fails to incorporate constraints imposed by muscle physiology. The present paper reports on a physiological inverse approach (PIA) that combines an inverse dynamic analysis with a dynamic optimisation procedure. This allows the incorporation of a full description of muscle activation and contraction dynamics, without loss of computational efficiency. A comparison of muscle excitations and MT-forces predicted by the classical and the PIA is presented for normal and pathological gait. Inclusion of muscle physiology primarily affects the rate of active muscle force build-up and decay and allows the estimation of passive muscle force. Consequently, it influences the onset and cessation of the predicted muscle excitations as well as the level of co-contraction.

Capacity to increase walking speed is limited by impaired hip and ankle power generation in lower functioning persons post-stroke

It is well known that stroke patients walk with reduced speed, but their potential to increase walking speed can also be impaired and has not been thoroughly investigated. We hypothesized that failure to effectively recruit both hip flexor and ankle plantarflexor muscles of the paretic side limits the potential to increase walking speed in lower functioning hemiparetic subjects. To test this hypothesis, we measured gait kinematics and kinetics of 12 persons with hemiparesis following stroke at self-selected and fast walking conditions. Two groups were identified: (1) lower functioning subjects (n=6) who increased normalized walking speed from 0.52 leg lengths/s (ll/s, SEM: 0.04) to 0.72 ll/s (SEM: 0.03) and (2) higher functioning subjects (n=6) who increased walking speed from 0.88 ll/s (SEM: 0.04) to 1.4 ll/s (SEM 0.03). Changes in spatiotemporal parameters, joint kinematics and kinetics between self-selected and fast walking were compared to control subjects examined at matched walking speeds (0.35 ll/s (SEM: 0.03), 0.63 ll/s (SEM: 0.03), 0.92 ll/s (SEM: 0.04) and 1.4 ll/s (SEM: 0.04)). Similar to speed-matched controls, the higher functioning hemiparetic subjects increased paretic limb hip flexion power and ankle plantarflexion power to increase walking speed. The lower functioning hemiparetic subjects did not increase power generation at the hip or ankle to increase walking speed. This observation suggests that impaired ankle power generation combined with saturation of hip power generation limits the potential to increase walking speed in lower functioning hemiparetic subjects.

Abstract B24: Attitudes of pancreatic cancer family members toward cancer risk and screening

B24

Purpose

Pancreatic cancer (PC) is the fourth leading cause of cancer death in the United States for which no recommended screening guidelines are available. An estimated 34,290 deaths related to PC is expected to occur in 2008 and the 5-year relative survival rate for this cancer is 5% for all stages combined. A person's chance of developing this cancer increases three-fold if a first-degree relative has pancreatic cancer. The purpose of this study was to assess attitudes of unaffected family members in the Mayo Clinic Pancreas Cancer Family study toward PC cancer risk and future screening options. This is the first study to report such attitudes of PC family members.

Subjects and Methods

At-risk family members with two or more relatives affected with pancreas cancer in the kindred and primary care controls completed a survey asking about: perceived PC risk, degree of PC worry/concern, attitude toward cancer screening in general, and intentions regarding PC screening if it were a blood test or endoscopic ultrasound.

Results

386 family members in 109 PC kindreds and 1058 controls completed surveys. Forty-six percent of PC family members reported that it was likely they would develop PC during their lifetime compared to 6% of controls. Forty-one percent of family members reported having thoughts regarding the possibility of getting pancreatic cancer during the past month versus 4.6% of controls. Similarly, 74% of family members reported concern about getting PC as compared to 40.6% of controls. 94% of family members reported they would be likely to undergo a blood-based PC screening test compared to 89.7% of controls. For endoscopic ultrasound, 71% of family members would be likely to undergo screening as compared to 55% of controls. All comparisons were statistically significant.

Conclusion

Compared to controls, PC family members perceive their personal PC risk to be high and report a higher rate of PC-related cancer worry/concern. A high percentage of family members and controls indicate receptivity to PC screening, especially if it were a blood test. If the screening is more invasive (i.e. EUS), interest declines, particularly among controls. This information can help investigators to understand and address potential motivators and barriers to recruitment for future PC studies and indicates that there is a need to develop educational interventions among these families to reduce their actual and perceived pancreatic cancer risk.

Citation Information: Cancer Prev Res 2008;1(7 Suppl):B24.

Natural history of nicotine withdrawal

AIMS

To examine the natural history of nicotine withdrawal and individual differences associated with withdrawal duration and severity.

DESIGN AND SETTING

Prospective study of withdrawal symptoms among smokers who quit for at least 24 hours. Participants used Ecological Momentary Assessment to monitor symptoms in their natural environment using an Electronic Diary (ED).

PARTICIPANTS

A total of 214 cigarette smokers (59% female, 92% Caucasian).

INTERVENTION

All participants received a clinic-based, behavioral, group cessation intervention. Severity and duration of withdrawal was not addressed explicitly in treatment.

MEASUREMENTS

Participants were 'beeped' by the ED approximately five times/day to complete affect assessments (negative affect, arousal, attention disturbance, restlessness), and daily assessments of sleep disturbance (at waking) and of cognitive performance (each evening) for a week prior to quitting and for up to 21 days after quitting. Withdrawal was considered resolved when withdrawal scores returned to baseline levels for at least 2 consecutive days.

FINDINGS

All symptoms returned to baseline levels within 10 days of quitting. All variables except arousal and sleep disturbance showed change over time. No robust predictors of individual differences in withdrawal responses emerged.

CONCLUSIONS

The time-course of withdrawal may be shorter than previously reported. The natural history of nicotine withdrawal may have implications for theories of withdrawal and smoking relapse and for smoking cessation treatment.

Does Unilateral Pedaling Activate a Rhythmic Locomotor Pattern in the Nonpedaling Leg in Post-Stroke Hemiparesis?

Recent investigation in persons with clinically complete spinal cord injury has revealed that locomotor activity in one limb can activate rhythmic locomotor activity in the opposite limb. Although our previous research has demonstrated profound influences of the nonparetic limb on paretic limb motor activity poststroke, the potency of interlimb pathways for increasing recruitment of the paretic limb motor pattern is unknown. This experiment tested whether there is an increased propensity for rhythmic motor activity in one limb (pedaling limb) to induce rhythmic motor activity in the opposite limb (test limb) in persons poststroke. Forty-nine subjects with chronic poststroke hemiparesis and twenty controls pedaled against a constant mechanical load with their pedaling leg while we recorded EMG and pedal forces from the test leg. For the experimental conditions, subjects were instructed to either pedal with their test leg (bilateral pedaling) or rest their test leg while it was either stationary or moved anti-phased (unilateral pedaling). In persons poststroke, unilateral pedaling activated a complete pattern of rhythmic alternating muscle activity in the nonpedaling, test leg. This effect was most clearly demonstrated in the most severely impaired individuals. In most of the control subjects, unilateral pedaling activated some muscles in the nonpedaling leg weakly, if at all. We propose that, ipsilateral excitatory pathways associated with contralateral pedaling in control subjects are increasingly up-regulated in both legs in persons with hemiparesis as a function of increased hemiparetic severity. This enhancement of interlimb pathways may be of functional importance since contralateral pedaling induced a complete motor pattern of similar amplitude to the bilateral pattern in both the paretic and nonparetic leg of the subjects with severe hemiparesis.

Interlimb Influences on Paretic Leg Function in Poststroke Hemiparesis

After stroke, paretic leg motor impairment is typically viewed as a unilateral control deficit. However, much of the neural circuitry controlling normal leg function is organized bilaterally to produce coordinated, task-specific activity in the two legs. Thus, as a result of contralesional neural control processes, paretic leg motor pattern generation may be substantially influenced by the nonparetic leg sensorimotor state during bilateral lower limb tasks. Accordingly, we investigated whether different paretic leg motor patterns are observed during mechanically equivalent bilateral and unilateral tasks and, if so, whether nonparetic leg participation improved or exacerbated paretic leg coordination deficits. A pedaling apparatus that mechanically decoupled the legs was used to present subjects with increasingly complex bi- and unilateral motor tasks: isometric force generation, discrete movement, and pedaling. Bilateral electromyographic and pedal force data were collected from 21 persons with chronic poststroke hemiparesis and 11 similarly aged controls. During isometric force generation and discrete movements, nonparetic leg influences on paretic leg coordination were similar and not markedly different from interlimb influences in controls. In bilateral pedaling, however, interlimb influences differed from controls such that paretic leg coordination deficits were exacerbated. During pedaling movements, the suppression of interlimb influences similar to those observed in isometric and discrete movement may occur in controls but may be disrupted in hemiparesis. We suggest that the coupling of pattern generation between the two legs may result in greater, albeit more impaired, paretic leg motor output during bilateral pedaling than during unilateral pedaling.

Ethnic variation in socioenvironmental factors that influence adolescent smoking

PURPOSE

To compare black, Hispanic and white adolescent smokers on socioenvironmental factors associated with smoking.

METHODS

The study uses a cross-sectional design. A needs assessment of 1305 current, former and never adolescent smokers from four ethnically and geographically diverse sites in the United States was conducted in 1999. Two sites were selected because they represented urban cities in the Northeast and Midwest with a high proportion of black and Hispanic residents. Two additional sites were selected to recruit rural and suburban adolescents. From this larger sample, 181 subjects from three focal ethnic groups (white n = 138; black n = 24; Hispanic n = 19) who had smoked at least 100 cigarettes in their lifetime and were current smokers (smoked in the past 30 days) were included. The three ethnic groups were compared on the following variables of interest: peer and family influences on smoking, situational factors associated with smoking, places that were likely sites for smoking and perceptions of friends and family as potential support persons for quitting smoking. All data were analyzed with Chi-square analysis.

RESULTS

Almost all (96%) of the black adolescents lived with another smoker compared to 68% of Hispanic and 60% of whites (p = .004). Black teens were more likely to smoke with family members (50%) than Hispanics (5%) or whites (25%) (p = .003). In addition, 50% of black teens compared to 5% of Hispanics and 12% of white teens, reported smoking to fit in (p < .0001). Black teens in this study emphasized the familial and social pressures of smoking. Higher rates of acceptance of smoking by family members, role modeling by household members, more prevalent beliefs that smoking is a way to achieve belonging, and lack of perceived support for quitting by friends appear to influence cigarette smoking more for black than white or Hispanic youth.

CONCLUSIONS

These preliminary results indicate that familial and household norms play a critical role in influencing cigarette smoking among black teens.

Helping adolescents quit smoking:a needs assessment of current and former teen smokers

This study compared the survey responses of 280 current and former adolescent smokers for what they perceived would be helpful (or what had helped) in quitting smoking. The survey was developed from focus groups and was structured using Prochaska and DiClementes Stages of Change health behavior framework. Results showed that former smokers and current smokers in the preparation stage of change shared beliefs about the importance of interpersonal support, those who were contemplating a quit decision worried about obstacles and internal issues, and current smokers not thinking about quitting focused on external rewards. The findings that significant differences exist based on the adolescent smokers Stage of Change imply that this framework can be appropriately applied to this context.

Methodological issues in measuring treatment outcome in adolescent smoking cessation studies

As the prevalence of adolescent smoking and, notably, regular smoking has increased over the last decade, researchers and practitioners have called for a consideration of treatment programs to promote cessation among adolescents who smoke. The adolescent smoking cessation treatment field is still in its infancy, though. The literature addressing adolescent cessation is rather limited to date, often plagued by methodological problems and characterized by little success. Many basic methodological questions remain for researchers to address before we will be able to answer questions such as which treatment approaches work best for which adolescent smokers. The purpose of this paper is to review briefly what is known about adolescent smoking cessation, to identify some important methodological issues to consider in treatment outcome studies, and to make recommendations to researchers to help provide a common ground for future comparisons of results across studies. We will address the natural history of adolescent smoking cessation, treatment outcomes, validity of self-reports and biochemical validation, and research recommendations.

Adaptations in maximal motor unit discharge rate to strength training in young and older adults

Six young (mean = 23 years) and 6 older (mean = 76 years) adults participated in isometric resistance training 5 days/week for 6 weeks. The task involved isometric fifth finger abduction. Maximal motor unit discharge rates (MUDRs) were obtained from the abductor digiti minimi of each hand at 0, 2, 14, and 42 days of training using a quadrifilar needle electrode and automatic spike recognition software. In agreement with previous findings, maximal MUDR at baseline was significantly lower in older adults (P < 0.001), averaging 51.5 (+/-17.13) HZ in young and 43.3 (+/-14.88) HZ in older adults. In response to resistance training, maximal voluntary force increased 25% in young and 33% in older subjects (P < 0.001). Maximal MUDR increased significantly (11% young, 23% older) on day 2 [F(3,36) = 2.58, P < 0.05], but in older subjects returned to baseline levels thereafter. These adaptations in abductor digiti minimi MUDR suggest a two-part response to strengthening fifth finger abduction: early disinhibition followed by altered MU activation.

An accelerometry-based system for the assessment of balance and postural sway

The aim of this investigation was to develop an inexpensive, efficient system for the clinical assessment of static and dynamic balance and postural sway using accelerometry-based measurements. Subjects consisted of 10 young (range 18-32 years) and 10 older (range 69-86 years) individuals screened for polypharmacy and history of cardiovascular, neurological or orthopedic health conditions. A lightweight uniaxial accelerometer and general-purpose microcomputer were used to obtain measurements of postural sway. Customized software was written to acquire the data and provide a real-time display consisting of amplitude and frequency characteristics of the sway profile. Intraclass reliability coefficients greater than R = 0.75 were obtained in both eyes-open and challenging-standing balance tasks. Preliminary results demonstrate that the instrumentation can be used to discriminate among balance tasks and to differentiate healthy older adults from those with a tendency toward frequent falls. Moreover, the technique described yields a simple-to-administer, inexpensive procedure that can be conducted in the home or another natural environment. Accelerometry also allows for balance training and re-learning, using tasks that might ordinarily pose a balance challenge for the older or frail adult.

Adaptations in motor unit discharge activity with force control training in young and older human adults

Six young (aged 18-22 years) and six older (aged 66-76 years) healthy humans participated in a visually guided isometric force modulation training program designed to improve accurate control of force during ankle dorsiflexion. Isometric force and the discharge activity of motor units (MU) supplying the tibialis anterior muscle were sampled concurrently at the beginning of the study, following 2 weeks of force modulation training and again after a 4 week retention period which followed immediately. The initial maximal voluntary force (MVC) and MU discharge rates were similar between young and older adults at 10-60% MVC while MU discharge rates during maximal effort were significantly reduced in older adults. Following the 2 weeks of force modulation training, both young and older adults demonstrated significant improvements in force accuracy (44% young, 48% older) and significantly reduced MU discharge rates at 30%, 40%, and 60% MVC. Young adults also demonstrated increased MVC force (11%), while older adults demonstrated significantly increased (30%) maximal MU discharge rate. Thus, following 2 weeks of force modulation training, young and older individuals demonstrated similar MU discharge rates at all force levels. The MU discharge rate adaptations were retained after the 4 week retention period. In young adults, improved force accuracy and increased MVC force were accompanied by significantly reduced MU recruitment thresholds. In the older subjects, improved force accuracy was accompanied by an increase in the difference between the recruitment-derecruitment force threshold and significantly reduced antagonist co-contraction. Age-related alterations in force regulation and MU discharge activity cannot be explained solely on the basis of contractile changes in senescent muscle. Rather, reliance on compensatory neuromuscular changes including antagonist muscle co-contraction is suggested.

Maximal motor unit discharge rates in the quadriceps muscles of older weight lifters

Although the existence of "neural factors" is regularly cited as an important contributor to muscular strength, we have little specific knowledge regarding the existence of such neural factors or how they contribute to the expression of muscular force.

PURPOSE

The present investigation sought to assess maximal motor unit discharge rates in older, highly resistance-trained adults to determine whether maximal motor unit discharge rates might be one such neural contributor to maximal strength production.

METHODS

Subjects consisted of seven well-trained older weight lifters (ages 67-79 yr) and five untrained age-matched older adults. While subjects performed 50 and 100% maximal voluntary knee extensor contractions (MVC), recordings from groups of motor units were obtained from the rectus femoris muscle by using an indwelling electrode. Off-line analysis was performed to identify individual motor unit firing occurrences and to compute maximal motor unit discharge rates.

RESULTS

As expected, knee extension strength in the trained weight lifters (367.0 +/- 72.0 N) was significantly greater than that in the control subjects (299.9 +/- 35.9 N; P < 0.05). Motor unit discharge rates were similar in the two subject groups at the 50% MVC force level (P > 0.05), but maximal (100% MVC) motor unit discharge rate in the weight lifters (23.8 +/- 7.71 pps) was significantly greater than that in the age-matched controls (19.1 +/- 6.29 pps; P < 0.05).

CONCLUSION

Motor unit discharge rates may comprise an important neural factor contributing to maximal strength in older adults.

Identification of two novel diurnal genes by screening of a rat brain cDNA library

While the hypothalamus is fundamental for sleep and circadian regulation, the molecular mechanism involved are poorly understood. We have used a differential gene expression technique to identify hypothalamic genes which have altered expression in rat sleep periods. Complex cDNA probes from rat hypothalami removed at Zeitgeber times 4 and 15 were hybridised to rat brain cDNA library girds. From 30 differentially expressed clones, six were further analysed and two were confirmed to exhibit increased expression at Zeitgeber time 4. A Northern blot hybridization of brain, heart, kidney, lung, testis and skin mRNA showed that both clones were brain specific. Therefore, we have identified two novel brain specific diurnally expressed hypothalamic genes. Both genes may have roles in sleep or circadian regulation.