A Randomized Controlled Trial of a Mobile Health Intervention to Promote Self-Management After Lung Transplantation.

Lung transplant recipients are encouraged to perform self-management behaviors, including (i) monitoring health indicators, (ii) adhering to their regimen, and (iii) reporting abnormal health indicators to the transplant coordinator, yet performance is suboptimal. When hospital discharge was imminent, this two-group trial randomized 201 recipients to use either the mobile health (mHealth) intervention (n = 99) or usual care (n = 102), to compare efficacy for promoting self-management behaviors (primary outcomes) and self-care agency, rehospitalization, and mortality (secondary outcomes) at home during the first year after transplantation. The mHealth intervention group performed self-monitoring (odds ratio [OR] 5.11, 95% confidence interval [CI] 2.95-8.87, p < 0.001), adhered to medical regimen (OR 1.64, 95% CI 1.01-2.66, p = 0.046), and reported abnormal health indicators (OR 8.9, 95% CI 3.60-21.99, p < 0.001) more frequently than the usual care group. However, the two groups did not differ in rehospitalization (OR 0.78, 95% CI 0.36-1.66, p = 0.51) or mortality (hazard ratio 1.71, 0.68-4.28, p = 0.25). The positive impact of the mHealth intervention on self-management behaviors suggests that the intervention holds promise and warrants further testing.

CHESS: ten years of research and development in consumer health informatics for broad populations, including the underserved.

This paper reviews the research and development around a consumer health informatics system CHESS (The Comprehensive Health Enhancement Support System) developed and tested by the Center for Health Systems Research and Analysis at the University of Wisconsin. The review will place particular emphasis on what has been found with regard to the acceptance and use of such systems by high risk and underserved groups.

Impact of surgery and chemotherapy on the quality of life of younger women with breast carcinoma: a prospective study.

BACKGROUND: Studies that prospectively and simultaneously evaluate, within the first year of diagnosis, the impact of surgery and chemotherapy on quality of life (QOL) of younger women (60 years or younger) with early stage breast carcinoma are limited. METHODS: Quality of life of 103 women who had surgery (lumpectomy, 49; mastectomy, 54) approximately 1 month before the start of the study was evaluated at baseline and again after 5 months. Thirty-two women received chemotherapy during the study. RESULTS: Over time, subjects reported improvement in body image and physical, emotional, and functional well-being (P < 0.001). They were less bothered by swollen/tender arms and worried less about risk of cancer to family members (P < 0.001). However, satisfaction with sex life, social support, and social/family well-being declined (P < 0.001). In the period closer to surgery, women with mastectomy reported poorer body image (P = 0.001) and worse functional (P = 0.08) and physical well-being (P = 0.10). Women with lumpectomy worried more about the effects of stress on their illness (P < 0.01) and had lower emotional well-being (P = 0.06). By 6 months after surgery, the two groups reported similar QOL scores. Chemotherapy had a negative impact on women's sexual functioning (P = 0.01) and their physical well-being (P = 0.09). Women who received chemotherapy also reported more shortness of breath (P = 0.07). Post hoc analysis showed that women with breast reconstruction had higher emotional well-being at baseline than those with lumpectomy (P = 0.001) and mastectomy alone (P < 0.01). CONCLUSIONS: Younger women with breast carcinoma could experience a range of adjustment problems at various points in the treatment cycle. Interventions that would help reduce the negative impact of treatment on QOL need to be designed and integrated into routine clinical practice.

Private events: Do they belong in a science of human behavior?

The role of thinking, feeling, and other private events has received a great deal of attention in mainstream psychology but has been virtually ignored in behavior analysis until recently. This paper introduces a series of papers from a symposium that explored the roles of private events in a science of human behavior. We briefly explore the role private events are assigned in several behavioral orientations. Next, we discuss several positions on how private events might be conceptualized within a behavior-analytic framework. We conclude by noting that the dearth of research and conceptualizations about private events unnecessarily limits the theoretical or conceptual understanding on which applied behavior analysts base their work. With this paper and the papers that follow, we hope to spark research, discussion, and yes, thinking, about the roles of thinking and feeling.

The quality of interactive computer use among HIV-infected individuals.

This study examined how HIV-infected individuals used an interactive health software package called CHESS (Comprehensive Health Enhancement Support System). CHESS packages information and support in a variety of ways; the research examined how a subset of users whose posttest scores in a larger randomized trial showed significant improvement in quality of life compared on use patterns of CHESS with those who did not improve. The evidence presented here points to the nature of CHESS use more than it does to the amount of CHESS use. Those whose quality of life improved were among the most involved in their use of CHESS information tools. That is, even though Discussion Group accounted for the majority of all CHESS uses and time spent with the system, total use and Discussion Group use appeared less important than use of the information tools, especially if that use was at least somewhat sustained and involved.

Bridging barriers between paradigms: making cognitive concepts relevant for behavior analysis.

We sketch the cognitive-behavioral debate and outline the purpose of the subsequent articles. Together, these articles constitute a symposium designed to show how behavior analysts can learn from the work of cognitivists and cognitive-behavior therapists. This is done by interpreting some cognitive concepts in terms that are familiar and acceptable to behavior analysts. When behavior analysts can understand these concepts in their own terms, perhaps they can incorporate them in their language about behavior and their work with clients.

The behavior analytic perspective: its nature, prospects, and limitations for behavior therapy.

Behavior analysis is defined as a natural science approach to behavior--with both basic and applied branches--and contrasted with cognitive psychology. Behavior analysis is described as an integrated science that views a person's interactions with the environment as selecting certain behaviors--or rather, environment-behavior relations--making them more probable, given certain subsequent stimulus situations. It seeks an understanding that promotes effective action, which fits the clinical interests of behavior therapy. It promotes persistent searching for environmental causes, which has resulted in a remarkable range of successes, clinical and other. We explore the reasons that all behavior therapists are not behavior analysts and suggest needed future developments.

Environment-behavior relations, behavior therapy and the process of persuasion and attitude change.

The phenomena described by the cognitive dissonance literature, especially to explain attitude change, have important relevance to understanding certain aspects of therapy. Contrary to popular beliefs, these phenomena can be described in behavior-analytic terms. To do so requires an analysis of learning histories that select and maintain consistency in what individuals say and do. An understanding of the environmental variables that produce consistency can then be applied to the kinds of attitude change and stability found in the cognitive dissonance literature that have therapeutic importance.

DSM-IV and disorders of childhood and adolescence: can structural criteria be functional?

The structural, descriptive basis of the diagnostic categories outlined in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) is contrasted to a system of functional analysis, with regard to (a) clinical diagnosis, (b) target behavior identification, (c) treatment design, (d) treatment evaluation, and (e) clinical research. It is noted that structural classification is a useful starting point for these activities but that functional analysis has greater utility for target behavior identification and treatment design by giving consideration to antecedent and consequent events, skills repertoires, response interrelations, and support systems. Examples of melding structural classification and functional analytic systems are provided with reference to certain childhood disorders: mental retardation, disruptive behavior disorders, and anxiety disorders. Recommendations are made for an elaboration of the DSM axes to include (a) psychosocial and environmental resources and deficits, and (b) idiographic case analysis. It is suggested that these axes will assist in systematizing functional analysis and making it more accessible to all clinicians and researchers.

Cognitive vs. contextual causation: different world views but perhaps not irreconcilable.

In this commentary, we address some of the divisive issues between cognitive theorists and behavior analysts concerning the aims and goals of science and differing views of causality. We suggest that evidence for the causal status of cognition has been inconclusive, largely due to the fact that most of this research can be framed in terms of environmental causes. We examine (1) what we can consider as causes of behavior and (2) how we can manipulate these causes in therapy. We conclude that a rapprochement between cognitivists and behavior analysts will require more careful description of the multiple causal pathways responsible for experimental and therapeutic effects.

CHESS (Comprehensive Health Enhancement Support System): an interactive computer system for women with breast cancer piloted with an underserved population.

The Comprehensive Health Enhancement Support System (CHESS) is an interactive computer system containing information, social support, and problem-solving tools. It was developed with intensive input from potential users through needs-assessment surveys and field testing. CHESS had previously been used by women in the middle and upper socioeconomic classes with high school and college education. This article reports on the results of a pilot study involving eight African-American women with breast cancer from impoverished neighborhoods in Chicago. CHESS was very well received; was extensively used; and produced feelings of acceptance, motivation, understanding, and relief.

Monitoring outcomes of services to children and youths with severe emotional disorders: an economical follow-up procedure for mental health and child care agencies.

Human services have been slow to develop and implement procedures for measuring the outcomes they are committed to achieve with clients. This is as true in child mental health and child care services as in other services. A method is described for getting follow-up data on youngsters with severe maladjustment (emotional disturbance, behavior disorder) at modest cost, yet high relevance. The method is part of the program monitoring and evaluation conducted routinely by the Pressley Ridge Schools and involves telephone interviews with each youngster and others during the summer of the year after the youngster's discharge from treatment. The process yields two kinds of reports with different functions: quantitative summaries of data and individual narratives that sketch each youngster's experience. The method, developed over eight years, has had favorable effects on the agency's services.

Predicting adolescent problem use of marijuana: development and testing of a Bayesian model.

This paper reports on the development and testing of a risk assessment index for problem marijuana use designed to guide teenagers through an extensive computer-based support system intended to help them improve marijuana-related behaviors. Bayesian decision theory, used as the basis of the index development process, offers the advantage of building the index on subjective judgments of experts and does not require a large empirical data base. The index was found to predict an independent panel's ratings of teenager risk, and predict the marijuana use of 10th graders using self-reports of their profiles in the 7th grade. Implications for future risk assessment developments are discussed.

The use and impact of a computer-based support system for people living with AIDS and HIV infection.

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing AIDS/HIV Infection and other health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS is designed to improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has been evaluated in a random-assignment study with over 200 men and women living with AIDS and HIV infection. When CHESS was placed in subjects' homes for 3-6 months, use of CHESS was extremely heavy, with the average subject using CHESS 138 times for 39 hours. Compared with a control group which did not receive CHESS, subjects who used CHESS reported significantly higher quality of life in several dimensions, including social support and cognitive functioning. Users also reported significant reductions in some types of health care costs, especially inpatient services (hospitalizations). All segments of the study population used and benefited from CHESS, including women, minorities and those subjects with lower levels of education. Thus, CHESS appears to be an effective means of delivering education and support to the diverse populations which are affected by AIDS and HIV infection.

Applied behavior analysis at West Virginia University: A brief history.

The development of an emphasis on applied behavior analysis in the Department of Psychology at West Virginia University is traced. The emphasis began primarily in the early 1970s, under the leadership of Roger Maley and Jon Krapfl, and has continued to expand and evolve with the participation of numerous behavior analysts and behavior therapists, both inside and outside the department. The development has been facilitated by several factors: establishment of a strong behavioral emphasis in the three Clinical graduate programs; change of the graduate program in Experimental Psychology to a program in basic Behavior Analysis; development of nonclinical applied behavior analysis within the Behavior Analysis program; establishment of a joint graduate program with Educational Psychology; establishment of a Community/Systems graduate program; and organization of numerous conferences. Several factors are described that seem to assure a stable role for behavior analysis in the department: a stable and supportive "culture" within the department; American Psychological Association accreditation of the clinical training; a good reputation both within the university and in psychology; and a broader community of behavior analysts and behavior therapists.

Primary closure of choledochotomy using CO2 laser: comparison with suture closure.

This study was designed to compare laser welding to suture closure of the common bile duct (CBD). A 12 mm linear choledochotomy was closed in 12 mongrel dogs using tissue welding low-energy CO2 laser. Tissue welding was accomplished at 5.0 w/cm2 for 120 sec. Twelve similar mongrel dogs (control) were treated with CBD closure using 5/0 Vicryl (polyglactin 910, Ethicon, Inc., Somerville, NJ) interrupted simple stitches. All animals were sacrificed at six weeks. Gross and histologic evaluation of the choledochotomy site were performed. There were no statistical differences in parameters of comparison in the two groups. These parameters were pre- and post-treatment measurements of liver function tests, stenosis, and dehiscence. However, it must be noted that there was a 33% (4/12) incidence of dehiscence and death in the CO2 laser welded choledochorrhaphy. This result, although not statistically significant, is clinically significant. We conclude that the tensile strength of CO2 laser welded CBDs must be optimized and that these results are preliminary and still unreliable to recommend for clinical adaptability.

Will HIV-positive people use an interactive computer system for information and support? A study of CHESS in two communities.

A study of use of an interactive computer system (CHESS--Comprehensive Health Enhancement Support System) by HIV-Positive people was conducted in Madison and Milwaukee during Fall 1992 and Winter 1993. Computers were placed in homes, and use monitored by the computer. Results showed that the system was used heavily by both samples, and that gender (women used it more) age, (younger used it more), living arrangements (those living alone used it more), and need for health care information (those who felt the most need used it more) but not education predicted use of CHESS. The authors argue that heavy CHESS use by a wide variety of HIV-positive people suggests that the computer can overcome "information poor" barriers in health information campaigns.

CHESS: a computer-based system for providing information, referrals, decision support and social support to people facing medical and other health-related crises.

CHESS (the Comprehensive Health Enhancement Support System) is an interactive, computer-based system to support people facing health-related crises or concerns. CHESS provides information, referral to service providers, support in making tough decisions and networking to experts and others facing the same concerns. CHESS will improve access to health and human services for people who would otherwise face psychological, social, economic or geographic barriers to receiving services. CHESS has developed programs in five specific topic areas: Academic Crisis, Adult Children of Alcoholics, AIDS/HIV Infection, Breast Cancer and Sexual Assault. The lessons learned, and the structures developed, will serve as a model for future implementation of CHESS programs in a broad range of other topic areas. CHESS is designed around three major desired outcomes: 1) improving the emotional health status of users; 2) increasing the cost-effective use of health and human services; and 3) reducing the incidence of risk-taking behaviors that can lead to injury or illness. Pilot-testing and initial analysis of controlled evaluation data has shown that CHESS is extensively used, is useful and easy-to-use, and produces positive emotional outcomes. Further evaluation in continuing.