BACKGROUND:The relative contributions of common patient-reported social determinants of health on 30- and 90-day post-discharge outcomes among patients with acute coronary syndromes (ACS) is unclear. OBJECTIVE:The aim of this article is to examine the independent associations of social determinants with readmission or death, accounting for medical history. METHODS:Participants included adults who were hospitalized with ACS at an academic medical center. Domains measured were social support, health literacy/numeracy, and socioeconomic status (SES) (including education and difficulty paying bills). We employed multivariable Cox proportional hazard models to study associations with time to all-cause readmission or death, up to 30 or 90 days after discharge, and adjusted for demographics and medical history (prior admissions and Elixhauser comorbidity index). KEY RESULTS:Among 1,168 patients with ACS and no history of heart failure, more prior admissions, and higher comorbidity index (the medical history domain) were associated with higher rates of 30- and 90-day readmission or death (domain p values <.01 and <.0001, respectively). The social support domain was not associated with outcomes. Higher health literacy and numeracy were associated with lower rates of 30- and 90-day readmission or death (domain p values .016 and .002, respectively). Higher education and less difficulty paying bills (the SES domain) was marginally associated with lower rates of 90-day readmission or death (domain, p = .052). CONCLUSIONS:In addition to medical history, the domain of health literacy and numeracy was independently associated with readmission or death of patients with ACS during the 90 days after hospital discharge. [HLRP: Health Literacy Research and Practice. 2024;8(4):e212-e223.].

Background Breast cancer is the most common tumor among women throughout the world. Diagnosis and treatment of breast cancer are associated with stress and depression. Self-efficacy is one of the most important personal characteristics, studied in cancer, and is correlated with depression and immunity. The aim of the study is as follows: 1. Examining the correlation between coping self-efficacy with depression, DHEA levels, and immunity 2. Examining the correlation between depression and DHEA levels 3. Studying the effect of depression and DHEA levels on immunity 4. Examining the intermediate effect of DHEA levels on the correlation between coping self-efficacy and immunity Methods Thirty newly diagnosed breast cancer patients recruited from the Oncology Department, Kasr EL-Aini, Cairo University (ages 51.40 + 8.24 years) responded to two questionnaires: Coping Self-Efficacy Scale (CSES) and Patient Health Questionnaire-9 (PHQ-9); blood samples were collected to measure the phenotype of patients’ cellular immunity and DHEA levels by flowcytometry and ELISA technique. Results There was a significant negative correlation between CSES and PHQ-9, a significant positive correlation between PHQ-9 and B-cell count, and there is a significant negative correlation between CSES and B-cell count. The presence of DHEA has no mediatory role on correlation between CSES and B-cell count. Conclusion This paper presents a new model of psychoneuroimmunology by suggesting an effect of coping self-efficacy on immunity against breast cancer patients.

Background: Ethical issues in trauma surgery are commonplace but scarcely studied. We aim to characterize the ethical dilemmas trauma surgeons encounter in clinical practice and describe perceptions about the ability to manage these dilemmas and strategies they use to address them. Methods: Members of a U.S. trauma society were electronically surveyed on handling ethically challenging scenarios. The survey instrument was developed using published ethics literature and iterative cognitive interviews. Domains included perceived frequency of encountering and self-efficacy of managing ethical situations in trauma surgery. Common situations were defined as those encountered monthly or weekly. Ethical problems were categorized within 7 larger categories: general ethics, autonomy, communication, justice, end-of-life, conflict, and other. Descriptive analyses were performed; group comparisons were analyzed using analysis of variance. Results: Of 1,748 surveyed, 548 responded (30.6%) and 154 (28%) were female. Most were White, under 55 years age, had completed fellowship training, and were practicing at a level I or II trauma center. The most encountered ethical categories were generic ethics and communication (79%). Issues involving conflict were least frequent (21%). Respondents felt most uncomfortable with autonomy topics. Respondents with high self-efficacy in handling ethical situations were older, in practice >15 years, served on an ethics committee, and/or frequently experienced ethical challenges. Conclusion: Most trauma surgeons regularly encounter ethical challenges, especially those related to communication. Trauma surgeons encounter ethical issues involving conflict least often, and lowest self efficacy scores with issues involving autonomy. Experienced trauma surgeons reported higher self efficacy scores in managing ethical issues. Future work should examine how self-efficacy translates to observed behavior, and how trauma surgeons build and enhance their ethical skillsets in the care of the injured patient.Published by Elsevier Inc.

Objective To determine at which phase in the recruitment process for participation in clinical research studies do health literacy and other patient characteristics influence recruitment outcomes. Patients and Methods Using a sample of 5872 patients hospitalized with cardiovascular disease approached for participation in the Vanderbilt Inpatient Cohort Study from October 2011 through December 2015, we examined the independent association of patients' health literacy with two steps in their research participation decision-making process: (1) research interest — willingness to hear more about a research study; and (2) research participation — the decision to enroll after an informed consent discussion. Best practices for effective health communication were implemented in recruitment approaches and informed consent processes. Using logistic regression models, we determined patient characteristics independently associated with patients' willingness to hear about and participate in the study. Results In unadjusted analyses, participants with higher health literacy, and those who were younger, female, or had more education had higher levels of both research interest and research participation. Health literacy remained independently associated with both outcomes in multivariable models, after adjustment for sociodemographic factors. Conclusion Because identical variables predicted both research interest and eventual consent, efforts to recruit broad populations must include acceptable methods of approaching potential participants as well as explaining study materials.

BACKGROUND Family and friends have both helpful and harmful effects on adults' diabetes self-management. Family-focused Add-on to Motivate Self-care (FAMS) is a mobile phone-delivered intervention designed to improve family/friend involvement, self-efficacy, and self-care via monthly phone coaching, texts tailored to goals, and the option to invite a support person to receive texts. PURPOSE We sought to evaluate how FAMS was received by a diverse group of adults with Type 2 diabetes and if FAMS improved diabetes-specific family/friend involvement (increased helpful and reduced harmful), diabetes self-efficacy, and self-care (diet and physical activity). We also assessed if improvements in family/friend involvement mediated improvements in self-efficacy and self-care. METHODS Participants were prospectively assigned to enhanced treatment as usual (control), an individualized text messaging intervention alone, or the individualized text messaging intervention plus FAMS for 6 months. Participants completed surveys at baseline, 3 and 6 months, and postintervention interviews. Between-group and multiple mediator analyses followed intention-to-treat principles. RESULTS Retention, engagement, and fidelity were high. FAMS was well received and helped participants realize the value of involving family/friends in their care. Relative to control, FAMS participants had improved family/friend involvement, self-efficacy, and diet (but not physical activity) at 3 and 6 months (all ps < .05). Improvements in family/friend involvement mediated effects on self-efficacy and diet for FAMS participants but not for the individualized intervention group. CONCLUSIONS The promise of effectively engaging patients' family and friends lies in sustained long-term behavior change. This work represents a first step toward this goal by demonstrating how content targeting helpful and harmful family/friend involvement can drive short-term effects. TRIAL REGISTRATION NUMBER NCT02481596.

Increasing home dialysis prevalence is an international priority. Many patients start peritoneal dialysis, then transition to hemodialysis after complications. New strategies are needed to support modality persistence. Health mindset refers to individual belief about capacity to change to improve health. Mindset was measured in a cross-section of 101 adult peritoneal dialysis patients from April 2019 to June 2020. The Health Mindset Scale was administered to characterize the continuum of fixed vs. growth mindset with respect to health. Health literacy and health self-efficacy were also assessed. Participants were 43% female, 32% African American, and 42% diabetic. Health mindset scores were skewed toward growth (range 3–18), with average (SD) 12.83 (4.2). Growth mindset was strongly associated with health self-efficacy. Adults receiving peritoneal dialysis report health mindset variation. Growth mindset and health self-efficacy correlation suggests measurement of similar constructs, demonstrating convergent validity. The Health Mindset Scale may identify individuals who could benefit from targeted interventions to improve mindset, and foster peritoneal dialysis modality persistence.

Background My Diabetes Care (MDC) is a novel, multifaceted patient portal intervention designed to help patients better understand their diabetes health data and support self-management. MDC uses infographics to visualize and summarize patients' diabetes health data, incorporates motivational strategies, and provides literacy level-appropriate educational resources. Objectives We aimed to assess the usability, acceptability, perceptions, and potential impact of MDC. Methods We recruited 69 participants from four clinics affiliated with Vanderbilt University Medical Center. Participants were given 1 month of access to MDC and completed pre- and post-questionnaires including validated measures of usability and patient activation, and questions about user experience. Results Sixty participants completed the study. Participants' mean age was 58, 55% were females, 68% were Caucasians, and 48% had limited health literacy (HL). Most participants (80%) visited MDC three or more times and 50% spent a total of >= 15minutes on MDC. Participants' median System Usability Scale (SUS) score was 78.8 [Q1, Q3: 72.5, 87.5] and significantly greater than the threshold value of 68 indicative of "above average" usability ( p <0.001). The median SUS score of patients with limited HL was similar to those with adequate HL (77.5 [72.5, 85.0] vs. 82.5 [72.5, 92.5]; p =0.41). Participants most commonly reported the literacy level-appropriate educational links and health data infographics as features that helped them better understand their diabetes health data (65%). All participants (100%) intended to continue to use MDC. Median Patient Activation Measure<(R)> scores increased postintervention (64.3 [55.6, 72.5] vs. 67.8 [60.6, 75.0]; p =0.01). Conclusion Participants, including those with limited HL, rated the usability of MDC above average, anticipated continued use, and identified key features that improved their understanding of diabetes health data. Patient activation improved over the study period. Our findings suggest MDC may be a beneficial addition to existing patient portals.

Objective: Textmessaging interventions have high potential for scalability and to reduce healthdisparities; however, more rigorous, long-term trials are needed. We examinedthe long-term efficacy and mechanisms of a tailored text messaging intervention.Research Design and Methods: Adultswith type 2 diabetes participated in a parallel-groups, 15-month randomizedtrial, assigned to receive REACH (Rapid Education/Encouragement andCommunications for Health) for 12 months or control. REACH included interactivetexts and tailored texts addressing medication adherence, and non-tailoredtexts supporting other self-care behaviors. Outcomes included HbA1c, diabetesmedication adherence, self-care, and self-efficacy. Results: Participants (N=506)were approximately half racial/ethnic minority and half were underinsured, hadannual household incomes <$35,000 USD and ≤ high school education; 11% werehomeless. Average baseline HbA1c was 8.6%±1.8%; 70.0±19.7 mmol/mol) with n=219having HbA1c≥8.5% (69 mmol/mol) and half were prescribed insulin. Retentionwas over 90%. Median response rate to interactive texts was 91% (interquartilerange 75%, 97%). The treatment effect on HbA1c at 6 months (-0.31%; 95% CI[-0.61%, -0.02%]) was greater among those with baseline HbA1c≥8.5% (-0.74%; 95%CI [-1.26%, -0.23%]), and there was not evidence of effect modification by race/ethnicityor socioeconomic disadvantage. REACHimproved medication adherence and diet through 12 months, and self-efficacythrough 6 months. Treatment effects were not significant for any outcome at 15months. REACH reduced barriers to adherence, but barrier reduction did notmediate outcome improvements. Conclusions: REACHengaged at-risk patients in diabetes self-management and improved short-termHbA1c. More than texts alone may be needed to sustain effects.

This cross-sectional study of 56 dialysis providers from 3 dialysis clinics examined providers' attitudes and perception of autonomy support for patients' medication adherence behaviors. Respondents completed surveys assessing attitudes and perception of autonomy support. Compared to all other provider types, physicians and nurse practitioners (MD/NP) thought it was "less true" that phosphate binder medications are very important for dialysis patients (MD/NP vs others: 5.1 [1.4] vs 6.1 [1.1]; P = 0.02). More dialysis technicians (19%) offered the highest level of support. Attitudes and perception of autonomy support for medication adherence are suboptimal, vary by dialysis provider type, and are targets for quality improvement in dialysis care. This study addresses critical gap in existing knowledge about these two novel provider-based psychosocial factors and their potential impact on phosphate binder medication adherence.

Diabetes stigma is an emerging determinant of behaviors and outcomes. The theoretically-informed validated Comprehensive Diabetes Stigma Scale (CDSS), evaluates diabetes stigma and includes four subscales measuring enacted, perceived and self-stigma and concealment. This study tested associations between CDSS scores, medication adherence and HbA1c in a prospective cohort. We hypothesized that greater diabetes stigma would be associated with worse diabetes medication adherence and HbA1c. Pearson’s correlations and multivariable linear regression models adjusting for age, sex, race, education, insurance, partner status, diabetes duration and insulin use quantified the association of baseline CDSS scores and with ARMS-D scores and HbA1c assessed 3-6 months after enrollment. Participants (n=254) were 60 (SD 11) years old, 53% female, 80% White, 61% used insulin, mean HbA1c 7.7% (SD 1.6), and were living with diabetes for 14 (SD 9) years. CDSS scores and bivariate correlations shown in the Table. In adjusted models, CDSS overall score was associated with worse medication adherence (β 95%CI: 0.70, 0.01 - 1.39; p=0.05), but not with HbA1c (0.21, -0.05- 0.47; p=0.45). Only concealment was associated with worse HbA1c (0.48, 0.18-0.78; p=0.01). Prospective adjusted associations underline the importance of addressing concealment as a behavioral response to stigma leading to worse clinical outcomes in diabetes. Disclosure K. Cavanaugh: None. L.B. Beach: None. A.J. Hackstadt: None. K. Wallston: None. T. Elasy: None. L.S. Mayberry: None. Funding National Institutes of Health (P30DK92986-09, P30DK020593, UL1TR002243, K12HL143959)

Background. Religiosity, encompassing spirituality and religious practices, is associated with reduced disease incidence among individuals of low socioeconomic status and who self-identify as Black. We hypothesized that religiosity associates with reduced endstage kidney disease (ESKD) risk among Black but not White adults of low socioeconomic status. Design. Cox models of religiosity and ESKD risk in 76,443 adults. Results. Black adults reporting high spirituality had reduced ESKD risk after adjusting for demographic characteristics [Hazard Ratio (HR) .82 (95% Confidence Interval (CI)) (.69-.98)], depressive symptoms, social support, and tobacco use [HR .81 (CI .68-.96)]. When clinical covariates were added, associations between spirituality and ESKD were slightly attenuated and lost significance [HR .85 (CI .68-1.06)]. Associations were not demonstrated among White adults. Conclusions. Spirituality associates with reduced ESKD risk among Black adults of low socioeconomic status independent of demographic, psychosocial, and behavioral characteristics. Effect modification by race was not statistically significant.

CONTEXT:Psychological distress is associated with adverse health outcomes in serious illness and magnified among patients of low socioeconomic status. Aspects of one's culture, such as religion and spirituality, can influence these patients' coping response to distress. Advanced chronic kidney disease (CKD) is a serious illness that disproportionately affects patients of low socioeconomic status, but a theory-based understanding of this group's lived experience of CKD is lacking. OBJECTIVES:We explored the cognitions, emotions, and coping behaviors of patients with CKD with emphasis on those of low socioeconomic status. We further inquired into any influences of religion or spirituality. METHODS:We interviewed 50 English-speaking or Spanish-speaking adults with advanced CKD from three medical centers in Nashville, Tennessee. Analyses occurred with isolation of themes; development of a coding system; and creation of a conceptual framework using an inductive-deductive approach. RESULTS:Median age was 65 years; median annual income was $17,500 per year; and 48% of participants had not progressed beyond high school. Key beliefs (awareness of mortality and lack of control) influenced patients' emotions (existential distress in the form of death anxiety, prognostic uncertainty, and hopelessness) and coping behaviors (acceptance, avoidance, emotion regulation via spirituality, and seeking socialsupport via a religious community). CONCLUSION:Individuals with advanced CKD and low socioeconomic status lack control over disease progression, experience death anxiety and existential distress, and emphasize spirituality to cope. Our study identifies novel components for a psychotherapeutic intervention for patients with advanced CKD at high risk for adverse health outcomes.

Amid increasing interest in improving the patient-centeredness of research, new forms of engagement are emerging that enable researchers to get input from community members on research goals, methods, and implementation. This input often includes stories, which are useful for understanding lived experiences of illness and encounters with health care organizations, and for locating these experiences within larger meta-narratives of specific communities. We analyzed the stories in transcripts of 13 Community Engagement Studios and identified 4 major functions that the stories served in the sessions. Major functions included: (1) establishing mutual understanding, (2) adding expansion and depth, (3) characterizing abstract concepts, and (4) providing context for experience, with the latter being the most frequent. We assert that stories can serve to better communicate the complex contexts of patient experiences, helping to align research priorities and research design with community interests, leading to more patient-centered innovations in clinical practice.

This study aimed to develop a self-efficacy measure for mindfulness meditation practice (Self-efficacy for Mindfulness Meditation Practice scale). The scale was developed through a process of expert consensus, cognitive interviewing, and evaluation among 199 mindfulness meditation practitioners who completed an online survey. The 9-item Self-efficacy for Mindfulness Meditation Practice scale was unidimensional with three subconstructs of attention, compassion, and emotion. The omega hierarchical coefficient for the total scale was 0.78, and test-retest reliability was intraclass correlation coefficient = 0.85 (95% confidence interval: 0.80, 0.89). This study provides preliminary evidence that Self-Efficacy for Mindfulness Meditation Practice scale is a reliable and valid measure of self-efficacy for mindfulness meditation practice.

Background Text message–delivered interventions are a feasible and scalable approach for improving chronic disease self-care and reducing health disparities; however, information on long-term user engagement with these interventions is limited. Objective The aim of this study is to examine user engagement in a 12-month text message–delivered intervention supporting diabetes self-care, called REACH (Rapid Education/Encouragement And Communications for Health), among racially and socioeconomically diverse patients with type 2 diabetes (T2D). We explored time trends in engagement, associations between patient characteristics and engagement, and whether the addition of a human component or allowing patients to change their text frequency affected engagement. Qualitative data informed patients’ subjective experience of their engagement. Methods We recruited patients with T2D for a randomized trial evaluating mobile phone support relative to enhanced treatment as usual. This analysis was limited to participants assigned to the intervention. Participants completed a survey and hemoglobin A1c (HbA1c) test and received REACH text messages, including self-care promotion texts, interactive texts asking about medication adherence, and adherence feedback texts. For the first 6 months, texts were sent daily, and half of the participants also received monthly phone coaching. After 6 months, coaching stopped, and participants had the option to receive fewer texts for the subsequent 6 months. We defined engagement via responses to the interactive texts and responses to a follow-up interview. We used regression models to analyze associations with response rate and thematic and structural analysis to understand participants’ reasons for responding to the texts and their preferred text frequency. Results The participants were, on average, aged 55.8 (SD 9.8) years, 55.2% (137/248) female, and 52.0% (129/248) non-White; 40.7% (101/248) had ≤ a high school education, and 40.7% (101/248) had an annual household income <US $25,000. The median response rate to interactive texts was 91% (IQR 75%-97%) over 12 months. Engagement gradually declined throughout the intervention but remained high. Engagement did not differ by age, gender, education, income, diabetes duration, insulin status, health literacy, or numeracy. Black race and worse baseline medication adherence and HbA1c were each associated with lower engagement, although the effects were small. Nearly half of the participants chose to continue receiving daily texts for the last 6 months of the intervention. Participants who continued daily text messages said they wanted to continue experiencing benefits to their health, whereas those who chose fewer texts said that the daily texts had helped them create routines and they no longer needed them as often. Engagement was not impacted by receiving coaching or by participants’ chosen text frequency. Conclusions Well-designed interactive text messages can engage diverse patients in a self-care intervention for at least 1 year. Variation in and reasons for frequency preference suggest that offering a frequency choice may be important to users’ engagement.

BACKGROUND:Recent studies indicate the immune dysfunction in cancer patients in comparison with healthy individuals. The quality and quantity of this dysfunction are not equal in all patients even with similar cancer type. AIM:This study aims to correlate health locus of control (HLC) beliefs with CD4+ helper T (Thelper) cells, T regulatory (Treg) cells, NK cells, IL-1ß and TNF-a in breast cancer patients. PATIENTS AND METHODS:The study included 30 early diagnostic breast cancer patients who responded to Form C of the MHLC questionnaire that assessed internal (IHLC), chance (CHLC), doctor (DHLC) and other person's (OHLC) control of the patient's health status. Peripheral blood samples were collected to analyze the numbers and phenotype of Thelper cells, Treg cells and NK cells by flow cytometry and to measure gene expression of IL-1ß and TNF-a with real time PCR. RESULTS:A significant positive correlation was found between IHLC with Thelper cells and NK cells. However, a significant inverse correlation was found between DHLC with NK, Thelper and Treg cells. CONCLUSION:There is strong probability that the quality of immunity in cancer patients is related to their MHLC beliefs. Further research is recommended for studying whether MHLC beliefs of patients with other types of cancer can improve their immune responses and how beliefs control immune system.

Background The ability to understand another’s emotions and act appropriately, empathy, is an important mediator of relationship function and health intervention fidelity. We adapted the Interpersonal Reactivity Index (IRI) – an empathy scale – among seroconcordant expectant couples with HIV in the Homens para Saúde Mais (HoPS+) trial – a cluster randomized controlled trial assessing couple-based versus individual treatment on viral suppression – in Zambézia Province, Mozambique. Methods Using baseline data from 1332 HoPS+ trial participants (666 couples), an exploratory factor analysis assessed culturally relevant questions from the IRI. Because empathy is interdependent among couples, we validated the results of the exploratory factor analysis using a dyadic confirmatory factor analysis (CFA) with dyadic measurement invariance testing. Finally, we assessed the relationship between scores on our final scale and basic demographic characteristics (sex, age, education, and depression) using t-tests. Results We found two subscales: 1) a seven-item cognitive empathy subscale (Cronbach’s alpha 0.78) and 2) a six-item affective empathy subscale (Cronbach’s alpha 0.73). The dyadic CFA found acceptable model fit and metric invariance across partners (Comparative Fit Index (CFI) = 0.914, Tucker Lewis Index = 0.904, Root Mean Squared Error of Approximation = 0.056, ΔCFI = 0.011). We observed higher cognitive ( p : 0.012) and affective ( p : 0.049) empathy among males and higher cognitive ( p : 0.031) and affective ( p : 0.030) empathy among younger participants. More educated participants had higher affective empathy ( p : 0.017) and depressed participants had higher cognitive empathy ( p : < 0.001). This two-subscale, 13-item version of the IRI measures cognitive and affective empathy in HoPS+ trial participants and adults while accounting for the interdependent nature of empathy within partner dyads. Conclusions This scale will allow us to assess the interplay between empathy and other psychometric constructs (stigma, social support, etc.) in the HoPS+ trial and how each relates to retention in HIV, adherence to treatment, and prevention of maternal to child HIV transmission. Furthermore, this scale can be adapted for other sub-Saharan African populations, which will allow researchers to better assess HIV-related intervention efficacy. Trial registration This study is within the context of the HoPS+ trial, registered at ClinicalTrials.gov as number NCT03149237 . Registered May 11, 2017.