Expressive Interviewing Agents to Support Health-Related Behavior Change: A Study of COVID-19 Behaviors.

BACKGROUND: Expressive writing and motivational interviewing are well-known approaches to help patients cope with stressful life events. While these methods are often applied by human counselors, it is less well understood if an automated AI approach can benefit patients. Providing an automated method would help expose a wider range of people to the possible benefits of motivational interviewing, with lower cost and more adaptability to sudden events like the COVID-19 pandemic. OBJECTIVE: This study presents an automated writing system and evaluates possible outcomes among participants with respect to behavior related to the COVID-19 pandemic. METHODS: We developed a rule-based dialogue system for "Expressive Interviewing" to elicit writing from participants on the subject of how COVID-19 has impacted their lives. The system prompts participants to describe their life experiences and emotions, and provides topic-specific prompts in response to participants' use of topical keywords. In May-June 2021, we recruited participants (N=151) via Prolific to complete either the Expressive Interviewing task or a control task. We surveyed participants immediately before the intervention, immediately after, and again two weeks after the intervention. We measured participants' self-reported stress, general mental health, COVID-related health behavior, and social behavior. RESULTS: Participants generally wrote long responses during the task (53.3 words per response). In aggregate, task participants experienced a significant decrease in stress in the short-term (~23% decrease, P<.001) and a slight difference in social activity compared to the control group (P=.030). No significant differences in short-term or long-term outcome were detected between participant sub-group (e.g., male versus female participants), except for some within-condition differences by ethnicity (e.g., higher social activity among African American people participating in Expressive Interviewing vs. participants of other ethnicities). For short-term effects, participants showed different outcomes based on their writing. Using more anxiety-related words was correlated with a greater short-term decrease in stress (R=-0.264, P<.001), and using more positive emotion words was correlated with a more meaningful experience (R=0.243, P=.001). As for long-term effects, writing with more lexical diversity was correlated with an increase in social activity (R=0.266, P<.001). CONCLUSIONS: Expressive Interviewing participants exhibited short term positive changes in mental health, but not long-term, and some linguistic metrics of writing style were correlated with positive change in behavior. While there were no significant long-term effects observed, the positive short term effect suggests that the Expressive Interviewing intervention could be used in cases where a patient lacks access to traditional therapy and needs a short-term solution.

Facebook Intervention to Connect Alaska Native People with Resources and Support to Quit Smoking: CAN Quit Pilot Randomized Controlled Trial.

INTRODUCTION: There is some evidence that social media interventions can promote smoking cessation. This randomized controlled pilot study is the first to evaluate the feasibility and potential efficacy of a Facebook smoking cessation intervention among Alaska Native adults. METHODS: Recruitment and data collection occurred December 2019-March 2021. Participants were recruited statewide in Alaska using Facebook advertisements with a targeted sample of 60 enrolled. Participants were stratified by gender, age, and rural/urban residence and randomly assigned to receive referral resources on evidence-based cessation treatments (EBCTs) (control, n=30) or these resources plus a three-month, closed/private, culturally tailored, Facebook group (intervention, n=31) that connected participants to EBCT resources and was moderated by two Alaska Native Trained Tobacco Specialists. Assessments were conducted online post-randomization at one, three, and six months. Outcomes were feasibility (recruitment, retention, intervention engagement), self-reported use of EBCTs, and biochemically confirmed seven-day point-prevalence smoking abstinence. RESULTS: Of intervention participants, 90% engaged (e.g., posted, commented) more than once. Study retention was 57% at six months (no group differences). The proportion utilizing EBCTs was about double for intervention compared with the control group participants at three and six months. Smoking abstinence was higher for intervention than control participants at three months (6.5% vs. 0%, p=0.16) but comparable at six months (6.4% vs. 6.7%, p=0.97). CONCLUSIONS: While additional research is needed to promote long-term cessation, this pilot trial supports recruitment feasibility during the COVID-19 pandemic, consumer uptake, and a signal for intervention efficacy on the uptake of cessation treatment and short-term smoking abstinence. IMPLICATIONS: This study is the first evaluation of a social media intervention for smoking cessation among Indigenous people. We learned that statewide Facebook recruitment of Alaska Native adults who smoke was feasible and there was a signal for the efficacy of a Facebook intervention on the uptake of evidence-based cessation treatment and short-term (three months) biochemically verified smoking abstinence. Clinically, social media platforms may complement current care models by connecting Alaska Native individuals and others living in hard-to-reach communities to cessation treatment resources.

Measurement and Validation of the Comprehensive Score for Financial Toxicity (COST) in a Population With Diabetes.

OBJECTIVE: The Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy (COST-FACIT) is a validated instrument measuring financial distress among people with cancer. The reliability and construct validity of the 11-item COST-FACIT were examined in adults with diabetes and high A1C. RESEARCH DESIGN AND METHODS: We examined the factor structure (exploratory factor analysis), internal consistency reliability (Cronbach α), floor/ceiling effects, known-groups validity, and predictive validity among a sample of 600 adults with diabetes and high A1C. RESULTS: COST-FACIT demonstrated a two-factor structure with high internal consistency: general financial situation (7-items, α = 0.86) and impact of illness on financial situation (4-items, α = 0.73). The measure demonstrated a ceiling effect for 2% of participants and floor effects for 7%. Worse financial toxicity scores were observed among adults who were women, were below the poverty line, had government-sponsored health insurance, were middle-aged, were not in the workforce, and had less educational attainment (P < 0.01). Worse financial toxicity was observed for those engaging in cost coping behaviors, such as taking less or skipping medicines, delaying care, borrowing money, "maxing out" the limit on credit cards, and not paying bills (P < 0.01). In regression models for the full measure and its two factors, worse financial toxicity was correlated with higher A1C (P < 0.01), higher levels of diabetes distress (P < 0.01), more chronic conditions (P < 0.01), and more depressive symptoms (P < 0.01). CONCLUSIONS: Findings support both the reliability and validity of the COST-FACIT tool among adults with diabetes and high A1C levels. More research is needed to support the use of the COST-FACIT tool as a clinically relevant patient-centered instrument for diabetes care.

Exploring the perceived effectiveness and cultural acceptability of COVID-19 relevant social media intervention content among Alaska Native people who Smoke: The CAN Quit study.

Social media platforms have potential for reach and effectiveness to motivate smoking cessation and use of evidence-based cessation treatment, even during the worldwide COVID-19 pandemic. This study builds on our prior community participatory approach to developing content postings for the CAN Quit Facebook intervention among Alaska Native (AN) people who smoke. With input from a community advisory committee, we selected new content on COVID-19 preventive practices (e.g., masking) and evaluated them using a validated, six-item perceived effectiveness scale and a single item assessing cultural relevance. We obtained feedback on six content postings (two videos and four text/pictures) from an online survey administered to 41 AN people (14 men, 27 women; age range 22-61 years) who smoke in Alaska statewide with 49 % residing in rural Alaska. Perceived effectiveness scale scores were high across postings, ranging from 3.9 to 4.4 out of a maximum score of 5.0. Cultural relevance item scores ranged from 3.9 to 4.3. We found no appreciable differences by sex, age, or rural/urban location for either score. This study adds new information on the adaptation, acceptability, and perceived effectiveness of content on COVID-19 preventive practices for future inclusion in a social media-based intervention for smoking cessation specifically tailored for AN people.

Characterization of US State COVID-19 Vaccine Incentive Programs.

This cross-sectional study describes and compares key characteristics of state COVID-19 vaccine incentive programs in the US.

Impacts of the COVID-19 pandemic on unmet social needs, self-care, and outcomes among people with diabetes and poor glycemic control.

AIMS: The purpose of this study was to examine whether pandemic exposure impacted unmet social and diabetes needs, self-care behaviors, and diabetes outcomes in a sample with diabetes and poor glycemic control. METHODS: This was a cross-sectional analysis of participants with diabetes and poor glycemic control in an ongoing trial (n = 353). We compared the prevalence of unmet needs, self-care behaviors, and diabetes outcomes in successive cohorts of enrollees surveyed pre-pandemic (prior to March 11, 2020, n = 182), in the early stages of the pandemic (May-September, 2020, n = 75), and later (September 2020-January 2021, n = 96) stratified by income and gender. Adjusted multivariable regression models were used to examine trends. RESULTS: More participants with low income reported food insecurity (70% vs. 83%, p < 0.05) and needs related to access to blood glucose supplies (19% vs. 67%, p < 0.05) during the pandemic compared to pre-pandemic levels. In adjusted models among people with low incomes, the odds of housing insecurity increased among participants during the early pandemic months compared with participants pre-pandemic (OR 20.2 [95% CI 2.8-145.2], p < 0.01). A1c levels were better among participants later in the pandemic than those pre-pandemic (ß = -1.1 [95% CI -1.8 to -0.4], p < 0.01), but systolic blood pressure control was substantially worse (ß = 11.5 [95% CI 4.2-18.8, p < 0.001). CONCLUSION: Adults with low-incomes and diabetes were most impacted by the pandemic. A1c may not fully capture challenges that people with diabetes are facing to manage their condition; systolic blood pressures may have worsened and problems with self-care may forebode longer-term challenges in diabetes control.

Perspectives on Oncology-Specific Language During the Coronavirus Disease 2019 Pandemic: A Qualitative Study.

IMPORTANCE: The novel coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the US health care system, causing an influx of patients who require resources. Many oncologists are having challenging conversations with their patients about how the COVID-19 pandemic is affecting cancer care and may desire evidence-based communication guidance. OBJECTIVES: To identify the clinical scenarios that pose communication challenges, understand patient reactions to these scenarios, and develop a communication guide with sample responses. DESIGN, SETTING, AND PARTICIPANTS: This qualitative study that was conducted at a single Midwestern academic medical center invited physicians to respond to a brief semistructured interview by email or telephone and then disseminated an anonymous online survey among patients with cancer. Oncology-specific, COVID-19-related clinical scenarios were identified by the physicians, and potential reactions to these scenarios were gleaned from the patient responses to the survey. Health communication experts were invited to participate in the iterative development of a communication guide, comprising 3 essential communication principles and strategies and informed by insights from physicians and patients. This study was conducted from March 25, 2020, to April 2, 2020. INTERVENTIONS: Expert review, interviews, and surveys assessing challenging situations specific to cancer management during the COVID-19 pandemic. MAIN OUTCOMES AND MEASURES: Oncology-specific, COVID-19-related clinical scenarios from physician interviews; responses to each scenario from patient surveys; and applicable communication principles from health communication expert literature review. RESULTS: Of the 8 physicians who participated in interviews, 4 were men (50%) and 4 were women (50%). These physicians represented the following disciplines: internal medicine (n = 1), hematology/oncology (n = 2), radiation oncology (n = 3), and surgical oncology (n = 2). Their disease site specialization included cancers of the breast, head and neck, melanoma, and gastrointestinal and genitourinary tracts. A total of 48 patients with cancer completed the online survey; no demographic information was collected from the patients. The physicians identified 8 oncology-specific, COVID-19-related scenarios in which communication might be challenging: (1) worse outcomes from COVID-19, (2) delay in cancer screening, (3) delay in diagnostic workup, (4) delay in initiation of treatment, (5) offer of nonstandard treatment, (6) treatment breaks, (7) delay in follow-up imaging or care, and (8) inability to be admitted into the hospital for management. Potential patient reactions to each of these scenarios were compiled from survey responses. For most scenarios, patient reactions involved anger, fear, and anxiety (eg, "I'm scared"; "This isn't fair. I am upset."). These emotional patient responses informed the selection of the 3 general communication principles, which suggested language and strategies that physicians can use to respond to patients. CONCLUSIONS AND RELEVANCE: In this qualitative study, physicians and patients identified communication needs used by health communication experts to inform the development of a practical, evidence-based communication guide for oncology care during the COVID-19 pandemic.