Publications by authors named "Nicole M Alberts"

30 Publications

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Prevalence and predictors of cancer-related worry and associations with health behaviors in adult survivors of childhood cancer.

Cancer 2021 Apr 12. Epub 2021 Apr 12.

Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: Cancer-related worry (CRW) is common among cancer survivors; however, little is known about factors associated with CRW or its impact on health behaviors in adult survivors of childhood cancer.

Methods: Survivors in the St. Jude Lifetime Cohort Study (n = 3211; 51% male; mean age, 31.2 years [SD, 8.4 years]; mean time after diagnosis, 22.8 years [SD, 8.3 years]) underwent medical evaluations and completed ratings of CRW, psychological symptoms, and health behaviors. Multivariable modified Poisson regression models examined associations between CRW and treatment exposures, chronic health conditions, psychological symptoms, and health behaviors.

Results: Sixty-four percent of survivors (95% confidence interval [CI], 62.6-65.9) reported worry about subsequent malignancy, 45% (95% CI, 43.5-46.9) reported worry about physical problems related to cancer, and 33% (95% CI, 31.2-34.4) reported worry about relapse. Multiple psychological symptoms, treatment exposures, and chronic conditions significantly increased the risk of CRW. Survivors reporting CRW were at increased risk for substance use, inadequate physical activity, and increased health care utilization after adjustments for chronic conditions. For example, with adjustments for chronic conditions, those who endorsed CRW were more likely to have ≥5 cancer-related physician visits, ≥5 physician visits related to cancer, and ≥5 calls to a physician's office in the previous 2 years in comparison with survivors who were not worried. CRW was also associated with an increased risk of current tobacco use, past marijuana use, and current marijuana use.

Conclusions: A substantial proportion of adult survivors of childhood cancer reported CRW associated with increased health care utilization. CRW may serve as an intervention target to promote well-being and adaptive health behaviors.
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http://dx.doi.org/10.1002/cncr.33563DOI Listing
April 2021

Change in Pain Status and Subsequent Opioid and Marijuana Use Among Long-Term Adult Survivors of Childhood Cancer.

JNCI Cancer Spectr 2020 Dec 20;4(6):pkaa070. Epub 2020 Aug 20.

Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.

We evaluated pain status change and associations with subsequent opioid/marijuana use among 1208 adult survivors of childhood cancer. Pain status and opioid/marijuana were self-reported at baseline and follow-up evaluation (mean interval = 4.2 years). Over time, 18.7% of survivors endorsed persistent/increasing significant pain; 4.8% and 9.0% reported having used opioids and marijuana at follow-up. Persistent/increased (vs none/decreased) pain, persistent/increased (vs none/decreased) anxiety, and lack of health insurance increased odds of subsequent opioid use by 7.69-fold (95% confidence interval [CI] = 3.71 to 15.95), 2.55-fold (95% CI = 1.04 to 6.24), and 2.50-fold (95% CI = 1.07 to 5.82), respectively. Persistent/increased (vs none/decreased) depression increased odds of subsequent marijuana use by 2.64-fold (95% CI = 1.10 to 6.33).
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http://dx.doi.org/10.1093/jncics/pkaa070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771010PMC
December 2020

Pain and functional outcomes in adult survivors of childhood cancer: A report from the St. Jude Lifetime Cohort study.

Cancer 2020 Dec 28. Epub 2020 Dec 28.

Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: Although survivors of childhood cancer are at risk of chronic pain, the impact of pain on daily functioning is not well understood.

Methods: A total of 2836 survivors (mean age, 32.2 years [SD, 8.5 years]; mean time since diagnosis, 23.7 years [SD, 8.2 years]) and 343 noncancer community controls (mean age, 35.5 years [SD, 10.2 years]) underwent comprehensive medical, neurocognitive, and physical performance assessments, and completed measures of pain, health-related quality of life (HRQOL), and social functioning. Multinomial logistic regression models, using odds ratios and 95% confidence intervals (95% CIs), examined associations between diagnosis, treatment exposures, chronic health conditions, and pain. Relative risks (RRs) between pain and neurocognition, physical performance, social functioning, and HRQOL were examined using modified Poisson regression.

Results: Approximately 18% of survivors (95% CI, 16.1%-18.9%) versus 8% of controls (95% CI, 5.0%-10.9%) reported moderate to very severe pain with moderate to extreme daily interference (P < .001). Severe and life-threatening chronic health conditions were associated with an increased likelihood of pain with interference (odds ratio, 2.03; 95% CI, 1.62-2.54). Pain with daily interference was found to be associated with an increased risk of impaired neurocognition (attention: RR, 1.88 [95% CI, 1.46-2.41]; and memory: RR, 1.65 [95% CI, 1.25-2.17]), physical functioning (aerobic capacity: RR, 2.29 [95% CI, 1.84-2.84]; and mobility: RR, 1.71 [95% CI, 1.42-2.06]), social functioning (inability to hold a job and/or attend school: RR, 4.46 [95% CI, 3.45-5.76]; and assistance with routine and/or personal care needs: RR, 5.64 [95% CI, 3.92-8.10]), and HRQOL (physical: RR, 6.34 [95% CI, 5.04-7.98]; and emotional: RR, 2.83 [95% CI, 2.28-3.50]).

Conclusions: Survivors of childhood cancer are at risk of pain and associated functional impairments. Survivors should be screened routinely for pain and interventions targeting pain interference are needed.
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http://dx.doi.org/10.1002/cncr.33303DOI Listing
December 2020

Empirically Derived Profiles of Health-Related Quality of Life in Youth and Young Adults with Sickle Cell Disease.

J Pediatr Psychol 2021 Mar;46(3):293-303

Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN.

Objective: Determining how the health-related quality of life (HRQOL) is impacted by living with Sickle Cell Disease (SCD) can inform psychosocial interventions. The purpose of the present study is to determine if demographic and treatment variables predict membership into empirically derived subgroups of HRQOL among youth and young adults with SCD.

Methods: Three hundred and seven youth and young adults with SCD (mean 17.63 years ± 3.74 years, 50.5% female) completed the Pediatric Quality of Life InventoryTM Sickle Cell Disease Module. Latent profile analysis examined subgroups/classes of HRQOL and relationships with demographic and treatment variables.

Results: Three distinct classes emerged: High HRQOL (34% of the sample), Moderate HRQOL (44% of the sample), and Low HRQOL (22% of the sample). Being female was associated with increased odds of being in the moderate or low groups. Living with more severe SCD (genotypes HbSS and HbSβ0 thalassemia) was associated with increased odds of being in the Low HRQOL group. Treatment with chronic red blood cell transfusion therapy was associated with increased odds of being in the High HRQOL group. Older age predicted a small increase in the odds of being in the Low versus High HRQOL group.

Conclusions: The present study adds to the literature on HRQOL in SCD by exploring person-centered, empirically derived groups of HRQOL. Identification of demographic and treatment factors that predict membership into those groups within a large sample assists in tailoring needed psychosocial interventions for youth with SCD.
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http://dx.doi.org/10.1093/jpepsy/jsaa104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977438PMC
March 2021

Wearable Respiratory Monitoring and Feedback for Chronic Pain in Adult Survivors of Childhood Cancer: A Feasibility Randomized Controlled Trial From the Childhood Cancer Survivor Study.

JCO Clin Cancer Inform 2020 11;4:1014-1026

St Jude Children's Research Hospital, Memphis, TN.

Purpose: Approximately 40% of childhood cancer survivors experience chronic pain, with many also reporting pain-related disability. Given associations established in the general population among respiration, anxiety, and pain, continuous tracking and feedback of respiration may help survivors manage pain.

Methods: A feasibility, nonblinded, randomized controlled trial (RCT) comparing wearable respiratory monitoring with a control group examined feasibility, acceptability, and preliminary efficacy among survivors of childhood cancer with chronic pain who were ≥ 18 years of age, able to speak and read English, lived in the United States, and had access to a smartphone and the Internet. The primary outcomes were pain interference, pain severity, anxiety, negative affect, and perceived stress. The intervention group (n = 32) received a wearable respiratory monitor, used the device, and completed an in-application breathing exercise daily for 30 days. The control group (n = 33) received psychoeducation after completion of the study.

Results: Almost all participants in the intervention group (n = 31 of 32) and control group (n = 32 of 33) completed the study. Of those who completed the intervention, 90.3% wore the device for ≥ 50% of the trial. Posttreatment improvement for negative affect (Cohen = 0.59; 95% CI, 0.09 to 1.10) was significantly greater in the intervention group compared with the control group. A follow-up study (n = 24) examined acceptability and feasibility of a second-generation device among those who completed the RCT. Most survivors (81.0%) wore the device daily during the trial and 85.7% reported satisfaction with the device and the application.

Conclusion: The results of this pilot study support the acceptability and feasibility of wearable respiratory monitoring among survivors of childhood cancer. Larger randomized trials are needed to assess efficacy and maintenance of this intervention for chronic pain.
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http://dx.doi.org/10.1200/CCI.20.00070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713517PMC
November 2020

Pain in long-term survivors of childhood cancer: A systematic review of the current state of knowledge and a call to action from the Children's Oncology Group.

Cancer 2020 Jan 28;127(1):35-44. Epub 2020 Oct 28.

Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, Tennessee.

Survivors of childhood cancer may be at risk of experiencing pain, and a systematic review would advance our understanding of pain in this population. The objective of this study was to describe: 1) the prevalence of pain in survivors of childhood cancer, 2) methods of pain measurement, 3) associations between pain and biopsychosocial factors, and 4) recommendations for future research. Data sources for the study were articles published from January 1990 to August 2019 identified in the PubMed, PsycINFO, EMBASE, and Web of Science data bases. Eligible studies included: 1) original research, 2) quantitative assessments of pain, 3) articles published in English, 4) cancers diagnosed between birth and age 21 years, 5) survivors at 5 years from diagnosis and/or at 2 years after therapy completion, and 6) a sample size >20. Seventy-three articles were included in the final review. Risk of bias was considered using the Cochrane risk of bias tool. The quality of evidence was evaluated according to Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria. Common measures of pain were items created by the authors for the purpose of the study (45.2%) or health-related quality-of-life/health status questionnaires (42.5%). Pain was present in from 4.3% to 75% of survivors across studies. Three studies investigated chronic pain according the definition in the International Classification of Diseases. The findings indicated that survivors of childhood cancer are at higher risk of experiencing pain compared with controls. Fatigue was consistently associated with pain, females reported more pain than males, and other factors related to pain will require stronger evidence. Theoretically grounded, multidimensional measurements of pain are absent from the literature.
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http://dx.doi.org/10.1002/cncr.33289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7875461PMC
January 2020

Pain in Youth With Sickle Cell Disease: A Report From the Sickle Cell Clinical Research and Intervention Program.

Clin J Pain 2021 Jan;37(1):43-50

Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta.

Objectives: Pain is prevalent among youth with sickle cell disease (SCD). However, previous research has been limited by small sample sizes and lacked examinations of developmental differences in pain, which are critical to minimizing the development of chronic pain as youth transition into adulthood. The primary aim of the current study was to compare pain and pain interference across 4 developmental groups in a large sample of youth with SCD. The secondary aim was to identify risk factors for greater pain and pain interference.

Materials And Methods: Utilizing a cross-sectional study design, the expression and predictors of pain and pain interference were compared across 4 developmental stages: toddlers/preschoolers (2 to 4 y), school-aged children (5 to 7 y), preadolescents (8 to 12 y), and adolescents (13 to 18 y). Participants included 386 youth with SCD and their caregivers.

Results: Caregiver-reported pain and pain interference and youth-reported pain interference increased across developmental groups and plateaued approaching adolescence (multivariate analyses of variance P=0.002 for pain and P<0.001 for pain interference). Elevated fatigue, anxiety, and perceived difficulties with pain management were the most robust predictors of higher youth- and caregiver-reported pain (βs ranging from 0.15 to 0.68; P<0.001) and pain interference (βs ranging from 0.18 to 0.64; P<0.001).

Discussion: Disease and treatment-related variables were not associated with pain. Self-reported pain was elevated in older versus younger developmental groups and was largely linked to anxiety, fatigue, and perceptions of pain management, thus highlighting the modifiable nature of factors influencing pain among youth with SCD.
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http://dx.doi.org/10.1097/AJP.0000000000000889DOI Listing
January 2021

Pain in Youth With Sickle Cell Disease: A Report From the Sickle Cell Clinical Research and Intervention Program.

Clin J Pain 2021 Jan;37(1):43-50

Aflac Cancer and Blood Disorders Center, Children's Healthcare of Atlanta.

Objectives: Pain is prevalent among youth with sickle cell disease (SCD). However, previous research has been limited by small sample sizes and lacked examinations of developmental differences in pain, which are critical to minimizing the development of chronic pain as youth transition into adulthood. The primary aim of the current study was to compare pain and pain interference across 4 developmental groups in a large sample of youth with SCD. The secondary aim was to identify risk factors for greater pain and pain interference.

Materials And Methods: Utilizing a cross-sectional study design, the expression and predictors of pain and pain interference were compared across 4 developmental stages: toddlers/preschoolers (2 to 4 y), school-aged children (5 to 7 y), preadolescents (8 to 12 y), and adolescents (13 to 18 y). Participants included 386 youth with SCD and their caregivers.

Results: Caregiver-reported pain and pain interference and youth-reported pain interference increased across developmental groups and plateaued approaching adolescence (multivariate analyses of variance P=0.002 for pain and P<0.001 for pain interference). Elevated fatigue, anxiety, and perceived difficulties with pain management were the most robust predictors of higher youth- and caregiver-reported pain (βs ranging from 0.15 to 0.68; P<0.001) and pain interference (βs ranging from 0.18 to 0.64; P<0.001).

Discussion: Disease and treatment-related variables were not associated with pain. Self-reported pain was elevated in older versus younger developmental groups and was largely linked to anxiety, fatigue, and perceptions of pain management, thus highlighting the modifiable nature of factors influencing pain among youth with SCD.
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http://dx.doi.org/10.1097/AJP.0000000000000889DOI Listing
January 2021

Development of the InCharge Health Mobile App to Improve Adherence to Hydroxyurea in Patients With Sickle Cell Disease: User-Centered Design Approach.

JMIR Mhealth Uhealth 2020 05 8;8(5):e14884. Epub 2020 May 8.

Department of Hematology, St Jude Children's Research Hospital, Memphis, TN, United States.

Background: Sickle cell disease (SCD) is an inherited blood disorder causing acute complications and chronic progressive end organ damage. SCD is associated with significant morbidity, early mortality, impaired health-related quality of life, and increased acute health care utilization. Hydroxyurea is a US Food and Drug Administration-approved medication that reduces disease complications, acute health care utilization, and costs. However, adherence to hydroxyurea is suboptimal. Mobile health (mHealth) interventions have the potential to improve hydroxyurea adherence, but few examples exist that are specific to the SCD population.

Objective: This study aimed to design a mHealth intervention for individuals with SCD to improve adherence to hydroxyurea, using a user-centered design that was informed by specific barriers to hydroxyurea adherence and utilization in this population.

Methods: This study consisted of 4 phases. In phase 1, individuals with SCD and health care providers participated in an optimization digital workshop. In phase 2, patients completed surveys pertaining to their interest in mHealth use, barriers and facilitators to hydroxyurea use, and health literacy. Phases 3 and 4 involved semistructured interviews and focus groups, respectively, and used the Health Belief Model (HBM) as the framework to investigate drivers of poor hydroxyurea adherence and to inform the development of an app prototype. In addition, in phase 4, we have incorporated the patients' feedback on the preliminary app prototype and its features.

Results: Barriers to hydroxyurea adherence were consistent with the literature and included forgetfulness and several specific thoughts and emotions associated with hydroxyurea use (eg, fear of side effects, depression, stigma, and hopelessness). In addition, more than half of the participants reported potentially low health literacy. Preferred patient app features included 7 key components, namely (1) medication reminders and tracker, (2) disease education, (3) communication, (4) personalization, (5) motivation, (6) support during pain episodes, and (7) social support. Utilizing a user-centered design approach, data obtained from patients and providers were translated into features within the app, mapping to components of the HBM and the specific drivers of hydroxyurea adherence and matching the literacy level of the population, resulting in the development of a novel mobile app called InCharge Health.

Conclusions: The InCharge Health app is an mHealth intervention developed with substantial input from users and by mapping the HBM as the framework that guided the choice for its components. InCharge Health is a customized product for the SCD population aimed at optimizing medication adherence, with the end goal of improving quality of life and health outcomes among patients with SCD. The efficacy and implementation of the InCharge Health app as an mHealth intervention to promote hydroxyurea adherence will be tested in a future stepped-wedge multicenter trial for adolescents and adults with SCD.
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http://dx.doi.org/10.2196/14884DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245000PMC
May 2020

The Physical and Psychological Experience of Rowing the North Atlantic Solo and Unassisted.

Wilderness Environ Med 2020 Jun 27;31(2):144-150. Epub 2020 Mar 27.

Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor, MI.

Introduction: The present study followed an individual's successful, record-setting, solo, unsupported row across the North Atlantic Ocean to gain an understanding of the physical and psychological experience of this extreme endurance feat.

Methods: The participant was a 37-y-old male endurance athlete. Over the course of his nearly 39-d row, he provided daily ratings of effort, physical symptoms, and psychological experiences via a self-report questionnaire. Quantitative data were analyzed using simulation modelling analysis to examine within-day and cross-lagged correlations between perceived exertion and all other variables. Qualitative data were examined via thematic content analysis.

Results: Results showed that, on average, the participant experienced low levels of pain intensity, pain interference, fatigue interference, sleepiness, loneliness, boredom, anxiety, and frustration, in contrast to moderate scores for fatigue, restfulness, positive emotions, calmness, and confidence. There were statistically significant correlations between higher levels of perceived exertion and higher same-day levels of pain interference, fatigue, and fatigue interference, as well as lower same-day levels of calmness, loneliness, and boredom. Qualitative responses revealed 3 primary stressor types (internal physical, internal psychological, and external stressors) and 5 coping responses (acceptance/mindfulness, active response/problem solving, adjusting expectations/goal setting, distraction, and resignation).

Conclusions: Study findings indicate that the extreme athlete experienced physical and emotional challenges, but he demonstrated positive adjustment via the frequent experience of positive emotions and proficient use of a broad set of coping strategies matched to the daily stressor being addressed.
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http://dx.doi.org/10.1016/j.wem.2019.12.008DOI Listing
June 2020

Longitudinal pain and pain interference in long-term survivors of childhood cancer: A report from the Childhood Cancer Survivor Study.

Cancer 2020 06 30;126(12):2915-2923. Epub 2020 Mar 30.

Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee.

Background: The objective of this study was to characterize the prevalence and risk of pain, pain interference, and recurrent pain in adult survivors of childhood cancer in comparison with siblings.

Methods: This study analyzed longitudinal data from survivors (n = 10,012; 48.7% female; median age, 31 years [range, 17-57 years]; median time since diagnosis, 23 years) and siblings (n = 3173) from the Childhood Cancer Survivor Study. Survivors were diagnosed between 1970 and 1986 at 1 of 26 participating sites. Associations between risk factors (demographics, cancer-related factors, and psychological symptoms) and pain, pain interference, and recurrent pain (5 years apart) were assessed with multinomial logistic regression. Path analyses examined cross-sectional associations between risk factors and pain outcomes.

Results: Twenty-nine percent of survivors reported moderate to severe pain, 20% reported moderate to extreme pain interference, and 9% reported moderate to severe recurrent pain. Female sex, a sarcoma/bone tumor diagnosis, and severe/life-threatening chronic medical conditions were associated with recurrent pain. Depression and anxiety were associated with increased risk for all pain outcomes. Poor vitality mediated the effects of anxiety on high pain and pain interference (root mean square error of approximation, 0.002).

Conclusions: A large proportion of adult survivors report moderate to severe pain and pain interference more than 20 years after their diagnosis. Increased screening and early intervention for pain interference and recurrent pain are warranted.
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http://dx.doi.org/10.1002/cncr.32853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245551PMC
June 2020

Hypnosis for pain in pediatric oncology: relevant and effective or an intervention of the past?

Pain 2020 05;161(5):901-915

Department of Psychology, St. Jude Children's Research Hospital, Memphis, TN, United States.

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http://dx.doi.org/10.1097/j.pain.0000000000001790DOI Listing
May 2020

eHealth and mHealth interventions in pediatric cancer: A systematic review of interventions across the cancer continuum.

Psychooncology 2020 01 19;29(1):17-37. Epub 2019 Dec 19.

Department of Psychology, St. Jude Children's Research Hospital, Memphis, Tennessee.

Objectives: The primary objectives were to (a) identify current published research in electronic health (eHealth) and mobile health (mHealth) interventions for youth undergoing cancer treatment and child, adolescent, and young adult survivors of childhood cancer and (b) critically appraise the current scientific evidence on their effectiveness and efficacy. As an exploratory aim, we identified pediatric cancer patients' and survivors' perceptions, attitudes, and concerns related to eHealth and mHealth interventions.

Methods: A comprehensive search of the literature was performed to identify peer-reviewed journal articles that included the use of mHealth and eHealth interventions among youth receiving active cancer treatment and survivors of childhood cancer through the age range of childhood to young adulthood (mean age 21 years or younger at the time of diagnosis; mean age 39 years or younger at the time of intervention). The search was conducted via six electronic databases: PubMed, CINAHL, EMBASE, PsycINFO, IEEEXplore and the Cochrane Library.

Results: Of the 1879 potential records examined, 21 met criteria for inclusion for a total of 1506 participants. Of the investigations included, 13 were randomized controlled trials, and eight were nonrandomized studies. Findings demonstrated feasibility as well as acceptability with these approaches. Evidence of efficacy for interventions targeting emotional distress, health behaviors, health outcomes, and neurocognitive functioning was mixed.

Conclusions: Given the growing evidence of efficacy, coupled with increasing access to digital technologies, eHealth and mHealth may serve an important role in improving mental and physical health outcomes of youth undergoing cancer treatment and child, adolescent, and young adult survivors of childhood cancer.
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http://dx.doi.org/10.1002/pon.5280DOI Listing
January 2020

Understanding User Experience: Exploring Participants' Messages With a Web-Based Behavioral Health Intervention for Adolescents With Chronic Pain.

J Med Internet Res 2019 04 15;21(4):e11756. Epub 2019 Apr 15.

Department of Anesthesiology and Pain Medicine, School of Medicine, University of Washington, Seattle, WA, United States.

Background: Delivery of behavioral health interventions on the internet offers many benefits, including accessibility, cost-effectiveness, convenience, and anonymity. In recent years, an increased number of internet interventions have been developed, targeting a range of conditions and behaviors, including depression, pain, anxiety, sleep disturbance, and eating disorders. Human support (coaching) is a common component of internet interventions that is intended to boost engagement; however, little is known about how participants interact with coaches and how this may relate to their experience with the intervention. By examining the data that participants produce during an intervention, we can characterize their interaction patterns and refine treatments to address different needs.

Objective: In this study, we employed text mining and visual analytics techniques to analyze messages exchanged between coaches and participants in an internet-delivered pain management intervention for adolescents with chronic pain and their parents.

Methods: We explored the main themes in coaches' and participants' messages using an automated textual analysis method, topic modeling. We then clustered participants' messages to identify subgroups of participants with similar engagement patterns.

Results: First, we performed topic modeling on coaches' messages. The themes in coaches' messages fell into 3 categories: Treatment Content, Administrative and Technical, and Rapport Building. Next, we employed topic modeling to identify topics from participants' message histories. Similar to the coaches' topics, these were subsumed under 3 high-level categories: Health Management and Treatment Content, Questions and Concerns, and Activities and Interests. Finally, the cluster analysis identified 4 clusters, each with a distinguishing characteristic: Assignment-Focused, Short Message Histories, Pain-Focused, and Activity-Focused. The name of each cluster exemplifies the main engagement patterns of that cluster.

Conclusions: In this secondary data analysis, we demonstrated how automated text analysis techniques could be used to identify messages of interest, such as questions and concerns from users. In addition, we demonstrated how cluster analysis could be used to identify subgroups of individuals who share communication and engagement patterns, and in turn facilitate personalization of interventions for different subgroups of patients. This work makes 2 key methodological contributions. First, this study is innovative in its use of topic modeling to provide a rich characterization of the textual content produced by coaches and participants in an internet-delivered behavioral health intervention. Second, to our knowledge, this is the first example of the use of a visual analysis method to cluster participants and identify similar patterns of behavior based on intervention message content.
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http://dx.doi.org/10.2196/11756DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6487347PMC
April 2019

Treatment engagement in an internet-delivered cognitive behavioral program for pediatric chronic pain.

Internet Interv 2018 Sep 19;13:67-72. Epub 2018 Jul 19.

Center for Child Health, Behavior & Development, Seattle Children's Research Institute, Seattle, WA, USA.

Internet-delivered cognitive-behavioral therapy (iCBT) is a promising treatment for chronic pain among youth, but effect sizes are small, and strategies aimed at enhancing treatment effects are needed. Participants' engagement with the program may be an important factor in determining treatment outcomes. The primary aim of the current study was to examine the relationship between treatment engagement and treatment outcomes. Secondarily, we sought to characterize participant engagement in an iCBT program for adolescents with chronic pain and their parents. Participants included 134 adolescents randomized to the intervention arm of a controlled trial examining iCBT for chronic pain. Overall engagement with the intervention by adolescents and parents was high. Parental engagement (number of modules completed by parents and number of parent logins) predicted adolescent activity limitations change scores at post-treatment. Contrary to our expectation, adolescent treatment engagement was not predictive of treatment outcomes. Results indicate that parental engagement with the program may be an important predictor of treatment outcomes. Further research is needed to better understand influences of treatment engagement on outcomes in iCBT for youth.
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http://dx.doi.org/10.1016/j.invent.2018.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112105PMC
September 2018

Chronic pain in survivors of childhood cancer: a developmental model of pain across the cancer trajectory.

Pain 2018 Oct;159(10):1916-1927

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada.

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http://dx.doi.org/10.1097/j.pain.0000000000001261DOI Listing
October 2018

Factors influencing risk-based care of the childhood cancer survivor in the 21st century.

CA Cancer J Clin 2018 03 29;68(2):133-152. Epub 2018 Jan 29.

Member, Department of Oncology and Department of Epidemiology and Cancer Control, St. Jude Children's Research Hospital, Memphis, TN.

The population of adult survivors of childhood cancer continues to grow as survival rates improve. Although it is well established that these survivors experience various complications and comorbidities related to their malignancy and treatment, this risk is modified by many factors that are not directly linked to their cancer history. Research evaluating the influence of patient-specific demographic and genetic factors, premorbid and comorbid conditions, health behaviors, and aging has identified additional risk factors that influence cancer treatment-related toxicity and possible targets for intervention in this population. Furthermore, although current long-term follow-up guidelines comprehensively address specific therapy-related risks and provide screening recommendations, the risk profile of the population continues to evolve with ongoing modification of treatment strategies and the emergence of novel therapeutics. To address the multifactorial modifiers of cancer treatment-related health risk and evolving treatment approaches, a patient-centered and risk-adapted approach to care that often requires a multidisciplinary team approach, including medical and behavioral providers, is necessary for this population. CA Cancer J Clin 2018;68:133-152. © 2018 American Cancer Society.
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http://dx.doi.org/10.3322/caac.21445DOI Listing
March 2018

Patient and provider perceptions of Internet-delivered cognitive behavior therapy for recent cancer survivors.

Support Care Cancer 2018 02 15;26(2):597-603. Epub 2017 Sep 15.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, NSW, 2109, Australia.

Purpose: Although most cancer survivors adjust well, a subset experiences clinical levels of anxiety and depression following cancer treatment. Internet-delivered cognitive behavior therapy (iCBT) is a promising intervention for symptoms of anxiety and depression among survivors; however, patient and provider perceptions of iCBT have not been examined.

Methods: We employed an exploratory qualitative method and conducted semi-structured interviews with 13 cancer survivors and 10 providers to examine iCBT strengths and weaknesses, areas for improvement, and perceived barriers to program completion. A thematic content analysis approach was used to analyze the data.

Results: The majority of survivors liked the flexible, convenient, and private nature of the program. Many viewed the program as helping them feel less alone following cancer treatment. Areas of improvement included suggestions of additional information regarding cancer treatment side effects. Barriers to completing the program were identified by a minority of survivors and included finding time to complete the program and current symptoms. Providers liked the program's accessibility and its ability to provide support to patients after cancer treatment. All providers perceived the program as useful in their current work with survivors. Concerns around the fit of the program (e.g., for particular patients) were expressed by a minority of providers.

Conclusions: Results provide additional evidence for the acceptability of an iCBT program among recent cancer survivors and providers in oncology settings. The current study highlights the value of research exploring iCBT for cancer survivors and provides insights for other groups considering Internet-delivered care for survivors.
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http://dx.doi.org/10.1007/s00520-017-3872-8DOI Listing
February 2018

Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial.

Pain 2017 04 15;158(4):593-604. Epub 2016 Dec 15.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

Fibromyalgia (FM) is a common and often debilitating chronic pain condition. Research shows that symptoms of depression and anxiety are present in up to three quarters of individuals with FM. Of concern, most adults with FM cannot access traditional face-to-face cognitive behavioural pain management programs, which are known to be beneficial. Given known difficulties with treatment access, the present study sought to explore the efficacy and acceptability of a previously developed Internet-delivered cognitive behavioural pain management course, the Pain Course, for adults with FM. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email, with a guide throughout the course. Participants were randomized either to the Pain Course (n = 30) or to a waiting-list control group (n = 30). Symptoms were assessed at pre-treatment, post-treatment and 4-week follow-up. Completion rates (87%) and satisfaction ratings (86%) were high. Improvements were significantly greater in treatment group participants compared to waiting-list group participants on measures of FM (Cohen's d =.70; 18% reduction), depression (Cohen's d =.63-.72; 20-28% reduction), pain (Cohen's d =.87; 11% improvement) and fear of pain (Cohen's d =1.61; 12% improvement). Smaller effects were also observed on measures of generalized anxiety and physical health. The changes were maintained at four-week follow-up. The current findings add to existing literature and highlight the specific potential of Internet-delivered cognitive behavioural pain management programs for adults with FM, especially as a part of stepped-care models of care. Future research directions are described.
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http://dx.doi.org/10.1097/j.pain.0000000000000802DOI Listing
April 2017

Characterizing the Pain Narratives of Parents of Youth With Chronic Pain.

Clin J Pain 2016 10;32(10):849-58

*Department of Psychology, University of Calgary †Alberta Children's Hospital Research Institute, Calgary, AB, Canada ‡Center for Child Health, Behavior & Development, Seattle Children's Research Institute §Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA.

Objectives: Questionnaire-based research has shown that parents exert a powerful influence on and are profoundly influenced by living with a child with chronic pain. Examination of parents' pain narratives through an observational lens offers an alternative approach to understanding the complexity of pediatric chronic pain; however, the narratives of parents of youth with chronic pain have been largely overlooked. The present study aimed to characterize the vulnerability-based and resilience-based aspects of the pain narratives of parents of youth with chronic pain.

Methods: Pain narratives of 46 parents were recorded during the baseline session as part of 2 clinical trials evaluating a behavioral intervention for parents of youth with chronic pain. The narratives were coded for aspects of pain-related vulnerability and resilience.

Results: Using exploratory cluster analysis, 2 styles of parents' pain narratives were identified. Distress narratives were characterized by more negative affect and an exclusively unresolved orientation toward the child's diagnosis of chronic pain, whereas resilience narratives were characterized by positive affect and a predominantly resolved orientation toward the child's diagnosis. Preliminary support for the validity of these clusters was provided through our finding of differences between clusters in parental pain catastrophizing about child pain (helplessness).

Discussion: Findings highlight the multidimensional nature of parents' experience of their child's pain problem. Clinical implications in terms of assessment and treatment are discussed.
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http://dx.doi.org/10.1097/AJP.0000000000000346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4935638PMC
October 2016

Internet-delivered cognitive-behaviour therapy for recent cancer survivors: a feasibility trial.

Psychooncology 2017 01 11;26(1):137-139. Epub 2015 Nov 11.

eCentreClinic, Department of Psychology, Macquarie University, Sydney, Australia.

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http://dx.doi.org/10.1002/pon.4032DOI Listing
January 2017

Do people with and without medical conditions respond similarly to the short health anxiety inventory? An assessment of differential item functioning using item response theory.

J Psychosom Res 2015 Apr 2;78(4):384-90. Epub 2015 Jan 2.

University of Regina, Canada. Electronic address:

Objective: Individuals with medical conditions are likely to have elevated health anxiety; however, research has not demonstrated how medical status impacts response patterns on health anxiety measures. Measurement bias can undermine the validity of a questionnaire by overestimating or underestimating scores in groups of individuals. We investigated whether the Short Health Anxiety Inventory (SHAI), a widely-used measure of health anxiety, exhibits medical condition-based bias on item and subscale levels, and whether the SHAI subscales adequately assess the health anxiety continuum.

Methods: Data were from 963 individuals with diabetes, breast cancer, or multiple sclerosis, and 372 healthy individuals. Mantel-Haenszel tests and item characteristic curves were used to classify the severity of item-level differential item functioning in all three medical groups compared to the healthy group. Test characteristic curves were used to assess scale-level differential item functioning and whether the SHAI subscales adequately assess the health anxiety continuum.

Results: Nine out of 14 items exhibited differential item functioning. Two items exhibited differential item functioning in all medical groups compared to the healthy group. In both Thought Intrusion and Fear of Illness subscales, differential item functioning was associated with mildly deflated scores in medical groups with very high levels of the latent traits. Fear of Illness items poorly discriminated between individuals with low and very low levels of the latent trait.

Conclusions: While individuals with medical conditions may respond differentially to some items, clinicians and researchers can confidently use the SHAI with a variety of medical populations without concern of significant bias.
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http://dx.doi.org/10.1016/j.jpsychores.2014.12.014DOI Listing
April 2015

Linking Illness in Parents to Health Anxiety in Offspring: Do Beliefs about Health Play a Role?

Behav Cogn Psychother 2016 Jan 25;44(1):18-29. Epub 2014 Jun 25.

Dalhousie University,Halifax,Canada.

Background: The cognitive behavioural (CB) model of health anxiety proposes parental illness leads to elevated health anxiety in offspring by promoting the acquisition of specific health beliefs (e.g. overestimation of the likelihood of illness).

Aims: Our study tested this central tenet of the CB model.

Method: Participants were 444 emerging adults (18-25-years-old) who completed online measures and were categorized into those with healthy parents (n = 328) or seriously ill parents (n = 116).

Results: Small (d = .21), but significant, elevations in health anxiety, and small to medium (d = .40) elevations in beliefs about the likelihood of illness were found among those with ill vs. healthy parents. Mediation analyses indicated the relationship between parental illness and health anxiety was mediated by beliefs regarding the likelihood of future illness.

Conclusions: Our study incrementally advances knowledge by testing and supporting a central proposition of the CB model. The findings add further specificity to the CB model by highlighting the importance of a specific health belief as a central contributor to health anxiety among offspring with a history of serious parental illness.
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http://dx.doi.org/10.1017/S1352465814000319DOI Listing
January 2016

Parental illness, attachment dimensions, and health beliefs: testing the cognitive-behavioural and interpersonal models of health anxiety.

Anxiety Stress Coping 2014 13;27(2):216-28. Epub 2013 Sep 13.

a Department of Psychology , University of Regina , Regina , SK , Canada.

The cognitive-behavioral and interpersonal models of health anxiety propose that parental illness could be a contributory factor to the development of health anxiety but through different mechanisms. The cognitive-behavioral model suggests that exposure to parental illness may lead to health beliefs that could increase health anxiety. In contrast, the interpersonal model proposes that parental illness may contribute to the development of an insecure attachment pattern and consequently health anxiety. To assess the additive value of the models, 116 emerging adults (i.e. aged 18-25) who had a parent diagnosed with a serious medical illness (e.g. cancer, multiple sclerosis) completed measures of health anxiety, adult attachment dimensions, and health beliefs. Attachment anxiety, attachment avoidance, health beliefs, and death of the ill parent were statistically significant predictors of health anxiety. The results provide support for both models of health anxiety. Theoretical implications and directions for future research are discussed.
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http://dx.doi.org/10.1080/10615806.2013.835401DOI Listing
October 2014

The Short Health Anxiety Inventory: a systematic review and meta-analysis.

J Anxiety Disord 2013 Jan 9;27(1):68-78. Epub 2012 Nov 9.

Department of Psychology, University of Regina, Canada.

Introduction: The Short Health Anxiety Inventory (SHAI) measures health anxiety in medical and non-medical contexts.

Objective: To review the literature pertaining to the psychometric properties of the SHAI in non-clinical, clinical, and medical samples. Meta-analysis was also conducted to examine the strength of associations between the SHAI and other constructs.

Methods: Direct search of digital databases for papers that cited the original SHAI publication.

Results: Seventy-eight papers were identified, with 42 providing relevant information. The SHAI has acceptable Cronbach's alpha scores, strong construct validity, and is sensitive to treatment. Discrepancies have been observed between the findings of factor analytic studies, largely as a result of varying methods used. Overall, there appears to be greatest support for the original two factors, with one factor assessing health anxiety and one factor assessing negative consequences of illness. As expected, individuals with hypochondriasis score higher as compared to non-clinical samples. The strongest association was observed between the SHAI and other measures of health anxiety, followed by measures related to health anxiety vulnerability, and then general anxiety and worry.

Conclusions: The SHAI is a psychometrically sound tool for assessing health anxiety across samples. Future studies are needed, however, to assess test-retest reliability, incremental validity, and cut-off scores as well as use of the SHAI among diverse samples.
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http://dx.doi.org/10.1016/j.janxdis.2012.10.009DOI Listing
January 2013

Cultural self-efficacy of Canadian nursing students caring for aboriginal patients with diabetes.

J Transcult Nurs 2012 Jul 3;23(3):306-12. Epub 2012 Apr 3.

University of Regina, Regina, Saskatchewan, Canada.

Cultural self-efficacy refers to how capable one feels functioning in culturally diverse situations. The purpose of this study was to gain a better understanding of cultural self-efficacy among nursing students, specifically in relation to individuals of Aboriginal ancestry. The authors examined the extent to which intercultural anxiety, intercultural communication, and experience with persons of Aboriginal ancestry predicted two aspects of cultural self-efficacy, namely, knowledge and skills. In this correlational study, non-Aboriginal Canadian nursing students (N = 59) completed a survey assessing these variables. Overall, cultural self-efficacy was rated as moderate by nursing students. Regression analyses indicated that greater intercultural communication skills and experience with persons of Aboriginal ancestry were significant unique predictors of higher cultural knowledge self-efficacy. Greater intercultural communication and lower intercultural anxiety significantly predicted higher cultural skills self-efficacy. The results provide direction to nursing programs interested in facilitating higher levels of cultural self-efficacy among nursing students.
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http://dx.doi.org/10.1177/1043659612441023DOI Listing
July 2012

Dementia anxiety among older adult caregivers: an exploratory study of older adult caregivers in Canada.

Int Psychogeriatr 2011 Aug 22;23(6):880-6. Epub 2011 Mar 22.

Department of Psychology, University of Regina, Regina, Saskatchewan, Canada.

Background: Although caring for individuals with dementia is known to result in increased burden and depression among caregivers, little research has investigated caregiver's anxiety or concern about eventually developing dementia themselves (i.e. dementia anxiety). Existing research reports mixed findings regarding variables (e.g. relationship to care recipient, sex, education) that predict dementia anxiety among caregivers and non-caregivers. Potential relationships among burden, depression and dementia anxiety have not been extensively examined. The present study explored caregiver and care recipient factors as predictors of dementia anxiety in older adult caregivers.

Methods: A sample of 116 older adult caregivers answered demographic/background questions and completed a series of self-report measures assessing dementia anxiety, caregiver burden, depression, and the physical disability of the care recipient.

Results: The majority of caregivers were female, Caucasian, and reported caring for a spouse. Analyses revealed that background variables were generally not related to dementia anxiety, while depression and caregiver burden were significantly associated. Using linear regression analysis, it was found that a diagnosis of dementia in the care recipient and caregiver depression were both significant predictors of caregiver dementia anxiety.

Conclusion: Health care providers should be aware that dementia anxiety is associated with caring for individuals with dementia as well as with depression. Dementia anxiety may place additional strain on caregivers of individuals who have dementia and are suffering from depression and thus should be the focus of future research.
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http://dx.doi.org/10.1017/S1041610211000299DOI Listing
August 2011

Health anxiety: comparison of the latent structure in medical and non-medical samples.

J Anxiety Disord 2011 May 26;25(4):612-4. Epub 2011 Feb 26.

Department of Psychology, University of Regina, Regina, SK, Canada.

The Short Health Anxiety Inventory (SHAI; Salkovskis, Rimes, Warwick, & Clark, 2002) is a self-report measure designed to assess health anxiety in both medical and non-medical samples. The invariance of the factor structure across these samples has not been examined in the 14-item version of the SHAI. In the current study, the SHAI was completed by a community sample with no serious medical conditions (n=232) and a medical sample with multiple sclerosis (n=245). Factor analysis implied the same two-factor solution for both samples, with the two factors labelled: (1) Thought Intrusion, and (2) Fear of Illness. Item loadings were invariant across the medical and non-medical samples, but the two factors were more strongly correlated in the non-medical sample. Implications of the findings as well as directions for future research are discussed.
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http://dx.doi.org/10.1016/j.janxdis.2011.01.011DOI Listing
May 2011

Inverse reference in adults-elementary arithmetic.

Can J Exp Psychol 2010 Jun;64(2):77-85

Department of Psychology, University of Saskatchewan, Saskatchewan, Saskatoon, Canada.

Mauro, LeFevre, and Morris (2003) and Campbell (2008) manipulated problem format to assess university students' simple division and subtraction. Large division problems (dividend > 25; e.g., 42 / 6 = _) and large subtraction problems (minuend > 10; e.g., 13 - 6 = _), but not small problems, were solved more quickly when presented in inverse operation format (e.g., 6 x _ = 42 for division; 6 + _ = 13 for subtraction). They concluded that adults often solve large simple division and subtraction problems by reference to the inverse operation but rely on direct memory retrieval for smaller problems. Their findings, however, might have resulted from unequal practice or mixing of the inverse operations. Here, in Experiment 1 (division) and Experiment 2 (subtraction) normal and inverse formats received equal practice and only one operation was practiced (i.e., division or subtraction). Large divisions and subtractions were solved substantially faster when presented in inverse format, but there was also evidence that subtraction ties (e.g., 12 - 6 = 6) and small subtractions (minuend
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http://dx.doi.org/10.1037/a0015720DOI Listing
June 2010

Operation-specific effects of numerical surface form on arithmetic strategy.

J Exp Psychol Learn Mem Cogn 2009 Jul;35(4):999-1011

Department of Psychology, University of Saskatchewan, Saskatoon, Canada.

Educated adults solve simple addition problems primarily by direct memory retrieval, as opposed to by counting or other procedural strategies, but they report using retrieval substantially less often with problems in written-word format (four + eight) compared with digit format (4 + 8). It was hypothesized that retrieval efficiency is relatively low with word operands compared with digits and that this promotes a shift to procedural backup strategies. Consistent with this hypothesis, Experiment 1 demonstrated greater word-format costs on retrieval usage for addition than subtraction, which was due to increased counting for addition but not subtraction. Experiment 2 demonstrated greater word-format costs on retrieval for division than multiplication, which was due to increased use of multiplication-fact reference to solve division problems. Format-related strategy shifts away from retrieval reflected both the efficiency of retrieval for a given operation and the availability of viable alternative strategies. The results demonstrate that calculation processes are not abstracted away from problem surface form. The authors propose that retrieval efficiency for arithmetic connects diverse performance and strategy-related effects across key arithmetic factors, including arithmetic operation, numerical size, and numeral format.
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http://dx.doi.org/10.1037/a0015829DOI Listing
July 2009