Kuang-Yi Wen, Ph.D. - US grants

Project Summary/Abstract An estimated 40% of women who smoke quit during their pregnancy, however, up to 80% of these women relapse in the postpartum period, despite the health risks for themselves and their children. Relapse prevention in the postpartum period offers a unique opportunity to capitalize on a positive behavioral change. Yet, the design of effective smoking interventions for postpartum relapse prevention is challenging, due in large part to the competing needs and stressors in this population, especially among low income women. New, innovative intervention delivery models are needed to provide high levels of social support for ongoing behavioral change, while simultaneously addressing the new demands associated with young babies. Twitter, one of the most popular microblogging social media platforms that facilitate an instant mode of communication via tweets (short texts), seems especially promising for delivering smoking cessation interventions among underserved populations. Guided by the Cognitive-Social Health Information Processing (C-SHIP) framework, as well as by health communication best practices, the proposed study will develop and test an evidence- based, cognitive-behavioral twitter-enabled system-generated and participant-driven intervention (Tweet2commit) designed to reduce postpartum smoking relapse among low-income minority women who have quit immediately before or during their pregnancies. The Tweet2commit will be developed through a systematic formative evaluation process that includes literature and evidence-based content review, followed by an iterative cycling of text drafting, health literacy evaluation of texts, review by targeted focus group and pre-test through usability testing. The overarching goal of Tweet2commit is to provide evidence-based information and cognitive-behavioral coping strategies, as well as to harness the potential of peer-mediated social interaction, for supporting smoking abstinence. The intervention will consist of: 1) system-generated tweets targeting C-SHIP-based relapse factors and 2) user-generated tweets: participants will be asked to tweet when commenting on the system-generated tweets or when experiencing needs for coping with lapse or relapse so their peer can respond accordingly. We will also use a combination of best practice strategies to engage online participation and peer-support exchange. A pilot RCT will be conducted to explore the efficacy of the Tweet2commit intervention on reducing postpartum relapse rates, compared to a Usual Care control. A mixed-methods approach including the analysis of objective Twitter usage data will be conducted to measure participant?s engagement and satisfaction as well as perceived barriers. The proposed research will be the first randomized controlled study that leverages the potential of Twitter for disseminating evidence-based smoking cessation strategies and harnessing the participatory nature of tweeting for live interactive mobile support groups among underserved postpartum women. The approach is innovative, evidence-based, highly transportable for wide scale dissemination, and can readily be applied to other substance abuse contexts.

PROJECT SUMMARY/ABSTRACT Substantial evidence reports that adjuvant hormone therapy (AHT) decrease breast cancer (BCa) recurrence and mortality, however, rates of adherence to AHT have reported to be as low as 25%, which can lead to poor survival outcomes. Side effects from AHT can negatively affect HRQOL and are one of the most commonly cited reasons for nonadherence to AHT. Patients also reported a range of barriers to AHT adherence, including: at the cognitive level, women report negative beliefs about the efficacy of AHT, low cancer recurrence fears, and a lack of behavioral cues to prevent unintentionally missing doses. At the affective level, barriers include distress about side effects and high concerns regarding the impact of its long-term use. At the interpersonal level, low family support and poor communication with providers have been associated with AHT nonadherence. However, little is known about effective AHT adherence-promoting interventions. Guided by our team?s Cognitive-Social Health Information Processing Model and health communication best practices, an evidence-based mobile text messaging intervention (Txt2Adhere) was iteratively developed with patient- centered input and clinical and behavioral evaluation. The goal of Txt2Adhere is to address 1) cognitive barriers by increasing knowledge about AHT, reinforcing AHT benefits, and providing skills for medication uptake; 2) affective barriers by normalizing feelings and providing self-management skills to manage distress and symptoms; and 3) interpersonal barriers by enhancing women?s communication skills with families and providers. In a pilot study, Txt2Adhere participants reported significantly higher adherence to AHT at 2 months, compared with a UC group. The proposed study innovatively builds on the success of our pilot study by: 1) expanding the intervention period to six months; 2) following participants for 1 year; 3) adding a wireless smart pill bottle component; and 4) including a larger sample. For the phase 1 of the proposed study, focus groups and a behavioral scientific advisory panel review will be conducted to finalize the refinement and enhancement of Txt2Adhere. During phase 2, we will evaluate the efficacy of Txt2Adhere on a diverse group of BCa patients (N=300) in comparison with a UC group, recruited from Fox Chase Cancer Center and Temple University Hospital. A total of four assessments will be conducted: baseline, 3-months, 6-months, and 12-months (6- months post-intervention) follow-ups. Outcome and process variables include assessment of AHT adherence rate (measured by AdhereTech smart pill bottles), symptom distress, theory-based variables, intervention participant satisfaction with and usage of the intervention. We hypothesize that Txt2Adhere participants will report significantly higher levels of AHT adherence rates and lower levels of symptom distress than the UC group. We will determine if the reduction in cognitive-affective barriers mediates the effects of the intervention. We will explore if being minority, younger or older moderate the effects of the intervention. The study is significant because Txt2Adhere has the potential to reduce persistent AHT nonadherence among BCa women.

The majority of cancer diagnoses and morbidity occurs in patients age 65 and over. This age group has increased incidence of by multiple co-morbid conditions, geriatric syndromes, dependence in instrumental activities and activities of daily living, and polypharmacy reflecting the heterogeneity of aging and influence the treatment outcomes for older adults. Clinical guidelines recommend the routine use of a Comprehensive Geriatric Assessment (CGA) for older cancer patients with the potentials to identify and optimize nononcologic issues and alter chemotherapy decision and improve treatment tolerance. However, a CGA is time intensive and it is not feasible for every older adult with cancer to be seen by a geriatrician given the shortage of geriatricians. G8, an eight-item questionnaire, has been recommended as a brief screening tool which is usually administered by a health care provider with good sensitivity to identify patients who are most likely to be benefit from a CGA. However, the implementation of the G8 in routine oncology clinical practice has mixed results with sub optimal uptake due to clinical and system barriers. To fill the void, we propose using a patient- mediated implementation approach, specifically adopting the Chatbot technology to delivering a structured set of G8 screening questions that can simulate the content experienced by real-life conversation such as with a health care provider. Our proposed Chatbot application, JeffSeniorChat, will facilitate G8 screening with supportive and educational content to explain the purpose and benefit of the G8 tool, each question with examples and probes to help with recall, and next steps after the G8 assessment is completed and how the results might impact their cancer treatments. Guided by the Health Belief Model, health communication best practices and our preliminary formative work, JeffSeniorChat will be iteratively developed and refined through a rapid prototyping process using patient-stakeholder inputs and plain-language evidence-based content and usability testing to finalize the intervention. We will examine the feasibility and acceptability of the JeffSeniorChat intervention targeting G8 self-assessment completion and CGA attendance in 150 older adult with cancer. Overall G8 score will be automatically calculated by the JeffSeniorChat backend algorithm and patients with G8 scores ? 14 will be prompted to schedule a CGA at Jefferson?s Senior Adult Oncology Center. Feasibility will be determined by pre-specified enrollment and G8 completion rate. Acceptability will be measured by participant reported intervention credibility and satisfaction. Among patients with G8 scores ? 14 referred to a CGA, exploratory outcomes will examine CGA attendance compliance, predictive value of the JeffSeniorChat collected G8 score with the final frailty designation determined by the CGA, and perceived barriers among CGA non-adherent patients via follow-up interviews. Streamlining G8-triage process to a CGA through the Chatbot-enabled patient self-reported assessment and intervention should improve clinical efficiency and improve CGA attendance rate, ultimately optimizing treatment selection and outcomes.