Cancer communication and informatics research across the cancer continuum

Does health literacy affect older people's avoidance of medical care? The sense of medical care policy alienation and perceptions of control

We aimed to clarify whether health literacy (HL)  impacts medical care avoidance through an underexplored mediator: a sense of policy alienation towards medical care policy for residents (SPA-M). A moderated mediation model with control perception as a moderator was used to analyze the inner relationship between HL and SPA-M. A cross-sectional survey of 470 people ≥ 60 years old, revealed a significant negative association between HL and medical care avoidance intention, which bootstrapped moderated mediation analysis confirmed is partially mediated by SPA-M. When older people's control perception was high, HL had a significant negative impact on medical care avoidance intention through SPA-M; for low control perception, the effect was insignificant. This study elucidates HL's impact of HL on medical care avoidance, highlighting control perception's relevance to medical care policymaking for older people.

The Impact of 4 Risk Communication Interventions on Cancer Screening Preferences and Knowledge

PURPOSE

The US Preventive Services Task Force has changed their screening recommendations, encouraging informed patient choice and shared decision making as a result of emerging evidence. We aimed to compare the impact of a didactic intervention, a descriptive harms intervention, a narrative intervention, and a new risk communication strategy titled Aiding Risk Information learning through Simulated Experience (ARISE) on preferences for a hypothetical beneficial cancer screening test (one that reduces the chance of cancer death or extends life) versus a hypothetical screening test with no proven physical benefits.

METHOD

A total of 3386 men and women aged 40 to 70 completed an online survey about prostate or breast cancer screening. Participants were randomly assigned to either an unbeneficial test condition (0 lives saved due to screening) or a beneficial test condition (1 life saved due to screening). Participants then reviewed 4 informational interventions about either breast (women) or prostate (men) cancer screening. First, participants were provided didactic information alongside an explicit recommendation. This was followed by a descriptive harms intervention in which the possible harms of overdetection were explained. Participants then viewed 2 additional interventions: a narrative and ARISE (an intervention in which participants learned about probabilities by viewing simulated outcomes). The order of these last 2 interventions was randomized. Preference for being screened with the test and knowledge about the test were measured.

RESULTS

With each successive intervention, preferences for screening tests decreased an equivalent amount for both a beneficial and unbeneficial test. Knowledge about the screening tests was largely unimpacted by the interventions.

CONCLUSIONS

Presenting detailed risk and benefit information, narratives, and ARISE reduced preferences for screening regardless of the net public benefit of screening.

Digital health in oncology in Africa: A scoping review and cross-sectional survey

BACKGROUND

Low- and middle-income countries, especially in Africa, face a growing cancer burden. Adoption of digital health solutions has the potential to improve cancer care delivery and research in these countries. However, the extent of implementation and the impact of digital health interventions across the cancer continuum in Africa have not been studied.

AIMS

To describe the current landscape of digital health interventions in oncology in Africa.

METHODS

We conducted a scoping literature review and supplemented this with a survey. Following the PRISMA for Scoping Reviews guidelines, we searched literature in PubMed and Embase for keywords and synonyms for cancer, digital health, and African countries, and abstracted data using a structured form. For the survey, participants were delegates of the 2019 conference of the African Organization for Research and Training in Cancer.

RESULTS

The literature review identified 57 articles describing 40 digital health interventions or solutions from 17 African countries, while the survey included 111 respondents from 18 African countries, and these reported 25 different digital health systems. Six articles (10.5%) reported randomized controlled trials. The other 51 articles (89.5%) were descriptive or quasi-experimental studies. The interventions mostly targeted cancer prevention (28 articles, 49.1%) or diagnosis and treatment (23 articles, 40.4%). Four articles (7.0%) targeted survivorship and end of life, and the rest were cross-cutting. Cervical cancer was the most targeted cancer (25 articles, 43.9%). Regarding WHO classification of digital interventions, most were for providers (35 articles, 61.4%) or clients (13, 22.8%), while the others were for data services or cut across these categories. The interventions were mostly isolated pilots using basic technologies such as SMS and telephone calls for notifying patients of their appointments or results, or for cancer awareness; image capture apps for cervical cancer screening, and tele-conferencing for tele-pathology and mentorship. Generally positive results were reported, but evaluation focused on structure and process measures such as ease of use, infrastructure requirements, and acceptability of intervention; or general benefits e.g. supporting training and mentorship of providers, communication among providers and clients, and improving data collection and management. No studies evaluated individualized clinical outcomes, and there were no interventions in literature for health system managers although the systems identified in the survey had such functionality, e.g. inventory management. The survey also indicated that none of the digital health systems had all the functionalities for a comprehensive EHR, and major barriers for digital health were initial and ongoing costs, resistance from clinical staff, and lack of fit between the EHR and the clinical workflows.

CONCLUSION

Digital health interventions in oncology in Africa are at early maturity stages but promising. Barriers such as funding, fit between digital health tools and clinical workflows, and inertia towards technology, shall need to be addressed to allow for advancement of digital health solutions to support all parts of the cancer continuum. Future research should investigate the impact of digital health solutions on long-term cancer outcomes such as cancer mortality, morbidity and quality of life.

Riding the Wave of Digital Transformation in Behavioral Medicine

BACKGROUND

Digital technologies provide a platform for accelerating science and broadening impact in behavioral medicine.

PURPOSE

The objective of this invited keynote presentation or paper is to offer a blueprint for navigating the rapidly changing waters of digital health.

METHODS

A strategic literature review on digital health technologies in behavioral medicine was combined with a review of relevant policy initiatives to yield insights on: (a) knowledge building, (b) collaboration, and (c) public health stewardship.

RESULTS

Digital platforms offer unprecedented leverage for accelerating science, facilitating collaboration, and advancing public health. Early successes in behavioral medicine demonstrated how digital platforms could extend the reach of theory-based behavioral therapeutics through increases in efficiency and scale. As medical investments in health information technology increased, the field of behavioral informatics emerged as the collaborative glue binding behavioral theory into a new generation of patient-facing applications, clinical decision support tools, evidence-based communication programs, and population health management strategies. As a leader within the interstitial space between medicine, psychology, and engineering, the Society of Behavioral Medicine is in a distinct position to exert influence on the ways in which our science is utilized to eliminate health disparities; improve support for patients, caregivers, and communities; to promote general health and well-being; and to offer relief when confronted with psychological pain or addiction.

CONCLUSION

Riding the wave of digital transformation has less to do with mastering the complexities of the latest technologies and more to do with adhering closely to established principles for navigating a rapidly changing information environment.

Presenting treatment options in breast cancer consultations: Advice and consent in Italian medical care

Variety, complexity and uncertainty in the therapy outcomes of cancer illness make the treatment recommendation (TR) in oncology a "monumentally difficult task". Previous studies have distinguished unilateral and bilateral formats of treatment recommendations, accordingly to whether, or to what extent, the patient's perspective is included in the consideration of therapeutic options. Others have also shown how the oncologists' presentation of therapeutic options varied accordingly to the severity of the diagnosis and the availability of alternatives. Yet, no study has systemically dentified and compared components of treatment recommendation in oncology on a common set of patients and clinicians. This paper analyzes how different options in breast cancer treatments - radiotherapy, hormone therapy and chemotherapy - are presented and discussed in a set of 12 first post-surgical breast cancer visits carried out by two oncologists of high experience and seniority in two Italian hospitals. Treatment recommendation sequences involving these three option types were analyzed using the methods of conversation analysis. They were also coded for the mention of side effects and treatment burden, and for whether consent to the recommendation was invited, or expressed by the patient. Results show that radiotherapy is presented as presupposed as an extension of surgery and is not further discussed, and hormone therapy is delivered as good news and as not implying any health or lifestyle burdens. Treatment burdens were raised in the much more extensive discussions of chemotherapy, which were also accompanied by a higher chance that the patient was asked for consent to therapy. Implications are drawn as regards the extent to which clinical practice meets theory in communication protocols available in oncology, and how to consider the doctor-patient partnership and the concept of shared decision-making in such an encounter.

The Personal Health Network Mobile App for Chemotherapy Care Coordination: Qualitative Evaluation of a Randomized Clinical Trial

BACKGROUND

Cancer care coordination addresses the fragmented and inefficient care of individuals with complex care needs. The complexity of care coordination can be aided by innovative technology. Few examples of information technology-enabled care coordination exist beyond the conventional telephone follow-up. For this study, we implemented a custom-designed app, the Personal Health Network (PHN)-a Health Insurance Portability and Accountability Act-compliant social network built around a patient to enable patient-centered health and health care activities in collaboration with clinicians, care team members, caregivers, and others designated by the patient. The app facilitates a care coordination intervention for patients undergoing chemotherapy.

OBJECTIVE

This study aimed to understand patient experiences with PHN technology and assess their perspectives on the usability and usefulness of PHNs with care coordination during chemotherapy.

METHODS

A two-arm randomized clinical trial was conducted to compare the PHN and care coordination with care coordination alone over a 6-month period beginning with the initiation of chemotherapy. A semistructured interview guide was constructed based on a theoretical framework of technology acceptance addressing usefulness, usability, and the context of use of the technology within the participant's life and health care setting. All participants in the intervention arm were interviewed on completion of the study. Interviews were recorded and transcribed verbatim. A summative thematic analysis was completed for the transcribed interviews. Features of the app were also evaluated.

RESULTS

A total of 27 interviews were completed. The resulting themes included the care coordinator as a partner in care, learning while sick, comparison of other technology to make sense of the PHN, communication, learning, usability, and usefulness. Users expressed that the nurse care coordinators were beneficial to them because they helped them stay connected to the care team and answered their questions. They shared that the mobile app gave them access to the health information they were seeking. Users expressed that the mobile app would be more useful if it was fully integrated with the electronic health record.

CONCLUSIONS

The findings highlight the value of care coordination from the perspectives of cancer patients undergoing chemotherapy and the important role of technology, such as the PHN, in enhancing this process by facilitating better communication and access to information regarding their illness.

Use of Mobile Devices to Help Cancer Patients Meet Their Information Needs in Non-Inpatient Settings: Systematic Review

BACKGROUND

The shift from inpatient to outpatient cancer care means that patients are now required to manage their condition at home, away from regular supervision by clinicians. Subsequently, research has consistently reported that many patients with cancer have unmet information needs during their illness. Mobile devices, such as mobile phones and tablet computers, provide an opportunity to deliver information to patients remotely. To date, no systematic reviews have evaluated how mobile devices have been used specifically to help patients meet to their information needs.

OBJECTIVE

A systematic review was conducted to identify studies that describe the use of mobile interventions to enable patients with cancer meet their cancer-related information needs in non-inpatient settings, and to describe the effects and feasibility of these interventions.

METHODS

MEDLINE, Embase, and PsycINFO databases were searched up until January 2017. Search terms related to "mobile devices," "information needs," and "cancer" were used. There were no restrictions on study type in order to be as inclusive as possible. Study participants were patients with cancer undergoing treatment. Interventions had to be delivered by a mobile or handheld device, attempt to meet patients' cancer-related information needs, and be for use in non-inpatient settings. Critical Appraisal Skills Programme checklists were used to assess the methodological quality of included studies. A narrative synthesis was performed and findings were organized by common themes found across studies.

RESULTS

The initial search yielded 1020 results. We included 23 articles describing 20 studies. Interventions aimed to improve the monitoring and management of treatment-related symptoms (17/20, 85%), directly increase patients' knowledge related to their condition (2/20, 10%), and improve communication of symptoms to clinicians in consultations (1/20, 5%). Studies focused on adult (17/20; age range 24-87 years) and adolescent (3/20; age range 8-18 years) patients. Sample sizes ranged from 4-125, with 13 studies having 25 participants or fewer. Most studies were conducted in the United Kingdom (12/20, 52%) or United States (7/20, 30%). Of the 23 articles included, 12 were of medium quality, 9 of poor quality, and 2 of good quality. Overall, interventions were reported to be acceptable and perceived as useful and easy to use. Few technical problems were encountered. Adherence was generally consistent and high (periods ranged from 5 days to 6 months). However, there was considerable variation in use of intervention components within and between studies. Reported benefits of the interventions included improved symptom management, patient empowerment, and improved clinician-patient communication, although mixed findings were reported for patients' health-related quality of life and anxiety.

CONCLUSIONS

The current review highlighted that mobile interventions for patients with cancer are only meeting treatment or symptom-related information needs. There were no interventions designed to meet patients' full range of cancer-related information needs, from information on psychological support to how to manage finances during cancer, and the long-term effects of treatment. More comprehensive interventions are required for patients to meet their information needs when managing their condition in non-inpatient settings. Controlled evaluations are needed to further determine the effectiveness of these types of intervention.

Do Experts Understand Performance Measures? A Mixed-Methods Study of Infection Preventionists

OBJECTIVE Central line-associated bloodstream infection (CLABSI) is associated with significant morbidity and mortality. Despite a nationwide decline in CLABSI rates, individual hospital success in preventing CLABSI is variable. Difficulty in interpreting and applying complex CLABSI metrics may explain this problem. Therefore, we assessed expert interpretation of CLABSI quality data.

DESIGN

Cross-sectional survey PARTICIPANTS. Members of the Society for Healthcare Epidemiology of America (SHEA) Research Network (SRN) METHODS. We administered a 10-item test of CLABSI data comprehension. The primary outcome was percent correct of attempted questions pertaining to the CLABSI data. We also assessed expert perceptions of CLABSI reporting. RESULTS The response rate was 51% (n=67).Among experts, the average proportion of correct responses was 73% (95% confidence interval [CI], 69%-77%). Expert performance on unadjusted data was significantly better than risk-adjusted data (86% [95% CI, 81%-90%] vs 65% [95% CI, 60%-70%]; P<.001). Using a scale of 1 to 100 (0, never reliable; 100, always reliable), experts rated the reliability of CLABSI data as 61. Perceived reliability showed a significant inverse relationship with performance (r=-0.28; P=.03), and as interpretation of data improved, perceptions regarding reliability of those data decreased. Experts identified concerns regarding understanding and applying CLABSI definitions as barriers to care. CONCLUSIONS Significant variability in the interpretation of CLABSI data exists among experts. This finding is likely related to data complexity, particularly with respect to risk-adjusted data. Improvements appear necessary in data sharing and public policy efforts to account for this complexity. Infect Control Hosp Epidemiol 2018;39:71-76.

Lung Cancer Messages on Twitter: Content Analysis and Evaluation

PURPOSE

The aim of this project was to describe and evaluate the levels of lung cancer communication across the cancer prevention and control continuum for content posted to Twitter during a 10-day period (September 30 to October 9) in 2016.

METHODS

Descriptive and inferential statistics were used to identify relationships between tweet characteristics in lung cancer communication on Twitter and user-level data. Overall, 3,000 tweets published between September 30 and October 9 were assessed by a team of three coders. Lung cancer-specific tweets by user type (individuals, media, and organizations) were examined to identify content and structural message features. The study also assessed differences by user type in the use of hashtags, directed messages, health topic focus, and lung cancer-specific focus across the cancer control continuum.

RESULTS

Across the universe of lung cancer tweets, the majority of tweets focused on treatment and the use of pharmaceutical and research interventions, followed by awareness and prevention and risk topics. Among all lung cancer tweets, messages were most consistently tweeted by individual users, and personal behavioral mobilizing cues to action were rare.

CONCLUSIONS

Lung cancer advocates, as well as patient and medical advocacy organizations, with an interest in expanding the reach and effectiveness of social media efforts should monitor the topical nature of public tweets across the cancer continuum and consider integrating cues to action as a strategy to increase engagement and behavioral activation pertaining to lung cancer reduction efforts.

"Thanks for Letting Us All Share Your Mammogram Experience Virtually": Developing a Web-Based Hub for Breast Cancer Screening

Background

The decision around whether to attend breast cancer screening can often involve making sense of confusing and contradictory information on its risks and benefits. The Word of Mouth Mammogram e-Network (WoMMeN) project was established to create a Web-based resource to support decision making regarding breast cancer screening. This paper presents data from our user-centered approach in engaging stakeholders (both health professionals and service users) in the design of this Web-based resource. Our novel approach involved creating a user design group within Facebook to allow them access to ongoing discussion between researchers, radiographers, and existing and potential service users.

Objective

This study had two objectives. The first was to examine the utility of an online user design group for generating insight for the creation of Web-based health resources. We sought to explore the advantages and limitations of this approach. The second objective was to analyze what women want from a Web-based resource for breast cancer screening.

Methods

We recruited a user design group on Facebook and conducted a survey within the group, asking questions about design considerations for a Web-based breast cancer screening hub. Although the membership of the Facebook group varied over time, there were 71 members in the Facebook group at the end point of analysis. We next conducted a framework analysis on 70 threads from Facebook and a thematic analysis on the 23 survey responses. We focused additionally on how the themes were discussed by the different stakeholders within the context of the design group.

Results

Two major themes were found across both the Facebook discussion and the survey data: (1) the power of information and (2) the hub as a place for communication and support. Information was considered as empowering but also recognized as threatening. Communication and the sharing of experiences were deemed important, but there was also recognition of potential miscommunication within online discussion. Health professionals and service users expressed the same broad concerns, but there were subtle differences in their opinions. Importantly, the themes were triangulated between the Facebook discussions and the survey data, supporting the validity of an online user design group.

Conclusions

Online user design groups afford a useful method for understanding stakeholder needs. In contrast to focus groups, they afford access to users from diverse geographical locations and traverse time constraints, allowing more follow-ups to responses. The use of Facebook provides a familiar and naturalistic setting for discussion. Although we acknowledge the limitations in the sample, this approach has allowed us to understand the views of stakeholders in the user-centered design of the WoMMeN hub for breast cancer screening.

Visualizing risks in cancer communication: A systematic review of computer-supported visual aids

OBJECTIVE

Health websites are becoming important sources for cancer information. Lay users, patients and carers seek support for critical decisions, but they are prone to common biases when quantitative information is presented. Graphical representations of risk data can facilitate comprehension, and interactive visualizations are popular. This review summarizes the evidence on computer-supported graphs that present risk data and their effects on various measures.

METHODS

The systematic literature search was conducted in several databases, including MEDLINE, EMBASE and CINAHL. Only studies with a controlled design were included. Relevant publications were carefully selected and critically appraised by two reviewers.

RESULTS

Thirteen studies were included. Ten studies evaluated static graphs and three dynamic formats. Most decision scenarios were hypothetical. Static graphs could improve accuracy, comprehension, and behavioural intention. But the results were heterogeneous and inconsistent among the studies. Dynamic formats were not superior or even impaired performance compared to static formats.

CONCLUSIONS

Static graphs show promising but inconsistent results, while research on dynamic visualizations is scarce and must be interpreted cautiously due to methodical limitations.

PRACTICE IMPLICATIONS

Well-designed and context-specific static graphs can support web-based cancer risk communication in particular populations. The application of dynamic formats cannot be recommended and needs further research.

Graphic Narratives and Cancer Prevention: A Case Study of an American Cancer Society Comic Book

As the interest in graphic medicine grows, health communicators have started engaging readers with compelling visual and textual accounts of health and illness, including via comic books. One context where comics have shown promise is cancer communication. This brief report presents an early example of graphic medicine developed by the American Cancer Society. "Ladies … Wouldn't It Be Better to Know?" is a comic book produced in the 1960s to provide the public with lay information about the Pap test for cervical cancer prevention and detection. An analysis of a key narrative attribute, plot development, illustrates the central role that perceived barriers played in this midcentury public health message, a component that remains a consideration of cancer communication design today. This case study of an early graphic narrative identifies promising cancer message features that can be used to address and refute barriers to cervical cancer screening and connects contemporary research with historical efforts in public health communication.

Research on Skin Cancer-Related Behaviors and Outcomes in the NIH Grant Portfolio, 2000-2014: Skin Cancer Intervention Across the Cancer Control Continuum (SCI-3C)

Importance

The Surgeon General's Call to Action to Prevent Skin Cancer broadly identified research gaps, but specific objectives are needed to further behavioral intervention research.

Objective

To review National Institute of Health (NIH) grants targeting skin cancer-related behaviors and relevant outcomes.

Design, Setting, and Participants

A portfolio analysis of the title, abstract, specific aims, and research plans of identified grant applications from 2000 to 2014 targeting skin cancer-related behaviors or testing behavioral intervention effects on cancer-relevant outcomes along the cancer continuum.

Main Outcomes and Measures

Funding trends were compared along the cancer control continuum, with respect to investigator demographics and use of theory, technology, policy, and changes to environmental surroundings (built environment).

Results

A total of 112 submitted applications met inclusion criteria; of these, 40 (35.7%) were funded, and 31 of the 40 were interventions. Comparing the 40 funded grants with the 72 unfunded grants, the overall success rates did not differ significantly between male (33.3%) and female (37.3%) investigators, nor did the frequency of R01 awards (36.7% and 28.1%, respectively). Among intervention awards, most (24 of 31) addressed prevention. Fewer awards targeted detection alone or in conjunction with prevention (3) or cancer survivorship (4), and no grant addressed emotional sequelae or adherence behavior related to diagnosis or treatment. Fewer than half of funded grants aimed for clinically related targets (eg, sunburn reduction). Use of theory and technology occurred in more than 75% of grants. However, the full capability of proposed technology was infrequently used, and rarely did constructs of the proposed behavior change theory clearly and comprehensively drive the intervention approach. Policy or environmental manipulation was present in all dissemination grants but was rarely used elsewhere, and 19.4% included policy implementation and 25.8% proposed changes in built environment.

Conclusions and Relevance

Grant success rate in skin cancer-related behavioral science compares favorably to the overall NIH grant success rate (approximately 18%), and the success rate of male and female investigators was not statistically different. However, gaps exist in behavioral research addressing all points of the skin cancer control continuum, measuring interventions that hit clinically related targets, and leveraging technology, theory, and environmental manipulation to optimize intervention approach.

Development and psychometric evaluation of the Decisional Engagement Scale (DES-10): A patient-reported psychosocial survey for quality cancer care

In light of recent health care reforms, we have provided an illustrative example of new opportunities available for psychologists to develop patient-reported measures related to health care quality. Patient engagement in health care decision making has been increasingly acknowledged as a vital component of quality cancer care. We developed the 10-item Decisional Engagement Scale (DES-10), a patient-reported measure of engagement in decision making in cancer care that assesses patients' awareness of their diagnosis, sense of empowerment and involvement, and level of information seeking and planning. The National Institutes of Health's ResearchMatch recruitment tool was used to facilitate Internet-mediated data collection from 376 patients with cancer. DES-10 scores demonstrated good internal consistency reliability (α = .80), and the hypothesized unidimensional factor structure fit the data well. The reliability and factor structure were supported across subgroups based on demographic, socioeconomic, and health characteristics. Higher DES-10 scores were associated with better health-related quality of life (r = .31). In concurrent validity analyses controlling for age, socioeconomic status, and health-related quality of life, higher DES-10 scores were associated with higher scores on quality-of-care indices, including greater awareness of one's treatments, greater preferences for shared decision making, and clearer preferences about end-of-life care. A mini-measure, the DES-3, also performed well psychometrically. In conclusion, DES-10 and DES-3 scores showed evidence of reliability and validity, and these brief patient-reported measures can be used by researchers, clinicians, nonprofits, hospitals, insurers, and policymakers interested in evaluating and improving the quality of cancer care. (PsycINFO Database Record