Switching away from Cigarettes across 12 Months among Adult Smokers Purchasing the JUUL System.

Objectives: In this study, we assessed complete switching away from cigarette smoking among adult smokers who purchased a JUUL Starter Kit (JSK). Methods: Adult (age ≥ 21) established smokers (smoked ≥ 100 lifetime cigarettes) who purchased a JSK in 2018 were invited to complete online surveys 1, 2, 3, 6, 9 and 12 months after initial JSK purchase. Point prevalence of switching (no past 30-day smoking) was assessed at each follow-up. Repeated measures logistic regression models evaluated associations of sociodemographic factors, baseline smoking characteristics and time-varying JUUL System ("JUUL") use characteristics and switching across the 12-month period. Results: Respondents (N = 17,986) were 55.0% male, 78.3% white, mean age = 32.65 years (SD = 10.81), mean baseline cigarettes/day = 11.10 (SD = 8.16). The proportion self-reporting switching increased over time: one-month (27.2%[3718/13,650]), 2-month (36.4%[4926/13,533]), 3-month (41.0%[5434/13,257]), 6-month (46.6%[5411/11,621]), 9-month (49.4%[6017/12,186]), and 12-month (51.2%[6106/11,919]); 33.1% reported switching at both 9-month and 12-month follow-ups. In prospective analyses, smokers with lower cigarette dependence, shorter smoking history, lower cigarette consumption, more frequent JUUL use, greater satisfaction from initial JUUL use, and higher JUUL dependence were significantly more likely to switch. Conclusions: Rates of switching with JUUL increased over time. Over 50% of respondents reported complete switching away from cigarettes 12 months following purchase. Greater use of and dependence on JUUL predicted switching.

Switching away from Cigarette Smoking with JUUL: Populations of Special Interest.

Objectives: In this study, we examined complete switching away from cigarettes across various medico-socio-demographic subpopulations of adult smokers who purchased a JUUL Starter Kit (JSK) electronic nicotine delivery system. Methods: We analyzed trajectories of smoking over 12 months in 17,986 adult smokers who purchased a JSK. Populations of special interest were characterized by race/ethnicity, income, diagnoses of potentially smoking-related illness (SRI), depression, and anxiety. Results: Across all 16 subgroups examined, a consistent pattern of trends was observed where complete switching increased, and dual-use decreased over time. Non-Hispanic Asian race/ethnicity, low income, diagnoses of potential SRI, depression, and anxiety were associated with significantly lower switching rates; however, complete switching rates at month 12 were near 50% for all groups, and surpassed the dual-use rates in all subgroups except for those with potential SRI. Conclusions: Substantial rates of complete switching were consistently achieved across all medico-socio-demographic subgroups 12 months following the purchase of the JSK. The potential benefits of switching with JUUL on smokers are likely to be experienced by a wide range of adult smokers.

Cigarette Smoking Trajectories in Adult Former Smokers Using the JUUL System.

Objective: In this study, we assessed cigarette smoking over 12 months among adult former smokers who newly purchased a JUUL Starter Kit (JSK). Methods: Prevalence of past 30-day smoking and factors associated with smoking were assessed among adult (age ≥ 21) former established smokers, stratified as recent (quitting ≤ 12 months) and long-term quitters (> 12 months), who purchased a JSK and completed ≥ 1 of 6 follow-up assessments (N = 4786). Results: Recent quitters had higher rates (16.6%-19.9%) of past 30-day smoking than long-term quitters (6.4%-9.2%) across the 12-month period; smoking prevalence did not significantly increase over time in either subgroup. Few participants (6.5% of recent quitters, 2.8% of long-term quitters) reported smoking at both 9 and 12 months, a pattern that might indicate persistent smoking. Past 30-day JUUL use remained high (≥ 87%) across the 12 months. Participants who used JUUL more frequently were less likely to smoke. Conclusions: Among former smokers who purchased JUUL, prevalence rates of smoking were low and stable across the 12-month period, suggesting there was not a growing cohort of former smokers resuming smoking. Smoking was more common in recent quitters than long-term quitters. Greater use of JUUL was associated with reduced odds of smoking resumption.

Improving Patient Safety in Public Hospitals: Developing Standard Measures to Track Medical Errors and Process Breakdowns.

OBJECTIVE: The aim of the study was to develop standards for tracking patient safety gaps in ambulatory care in safety net health systems. METHODS: Leaders from five California safety net health systems were invited to participate in a modified Delphi process sponsored by the Safety Promotion Action Research and Knowledge Network (SPARKNet) and the California Safety Net Institute in 2016. During each of the three Delphi rounds, the feasibility and validity of 13 proposed patient safety measures were discussed and prioritized. Surveys and transcripts from the meetings were analyzed to understand the decision-making process. RESULTS: The Delphi process included eight panelists. Consensus was reached to adopt 9 of 13 proposed measures. All 9 measures were unanimously considered valid, but concern was expressed about the feasibility of implementing several of the measures. CONCLUSIONS: Although safety net health systems face high barriers to standardized measurement, our study demonstrates that consensus can be reached on acceptable and feasible methods for tracking patient safety gaps in safety net health systems. If accompanied by the active participation key stakeholder groups, including patients, clinicians, staff, data system professionals, and health system leaders, the consensus measures reported here represent one step toward improving ambulatory patient safety in safety net health systems.

Cancer patient perspectives on survivorship goals from the Smart Patients online community.

BACKGROUND: Cancer impacts individuals' life goals. Recent cancer care guidelines recommend discussing life goals as part of patient-provider communication. The goal of this study was to understand patients' attitudes toward goal sharing with their cancer care providers. PATIENTS AND METHODS: Semi-structured questionnaires were conducted via email with cancer patients and survivors (n = 39) on an online social network called Smart Patients. Participants answered open-ended questions about their life goals. They then completed a survey regarding their attitudes toward goal sharing with healthcare providers. The study team used an integrated inductive-deductive qualitative analysis to identify conceptual themes. RESULTS: Participants listed goals related to improving physical activity, control, enjoyment/leisure, and inner strength while reducing pain, anxiety, fear of recurrence, and uncertainty. Most of these goals were life goals rather than goals specifically related to medical care. Across all goals, there was a focus on returning to normality. Our findings show that 87% of participants expect their cancer specialist to discuss their treatment preferences and goals regularly with them. However, participants were reluctant to share their goals with their providers. Respondents felt that their providers did not have an interest in their life goals or time to address them in addition to their medical treatment. CONCLUSION: Even though cancer patient-provider communication guidelines advocate for discussions around life goals, participants in this study expressed reluctance to share life goals with providers. Further efforts to align expectations of patients and providers may facilitate adherence to cancer communication guidelines about life goals. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors should be aware that discussing life goals is part of recommended communication with their cancer care teams.

Egocentric social networks, lifestyle behaviors, and body size in the Asian Community Health Initiative (CHI) cohort.

BACKGROUND: Social networks have been shown to influence lifestyle behaviors in non-Latinx white (NLW) populations. We examined their influence in Asian American, Native Hawaiian and Pacific Islander (AANHPI) women. METHODS: We included 477 AANHPI women from the Asian Community Health Initiative Study who provided egocentric (degree, density, composition) and epidemiologic (size, types of ties) social network data and data on alcohol intake, physical activity, smoking, diet, and body size. We used logistic regression to evaluate associations of social network measures and dichotomous outcomes, and linear regression for continuous outcomes. RESULTS: In multivariable-adjusted analyses, higher degree and/or proportion of friends were significantly related to higher Western diet, higher odds of any alcohol consumption, and lower odds of physical inactivity and body mass index (BMI)≥23 kg/m2. Additionally, a higher proportion of NLW in women's networks was related to lower Asian diet but also lower waist size. Community participation was related to higher Western diet and lower Asian diet. By contrast, degree and/or proportion of relatives were positively related to BMI, waist size and to a higher odds of BMI≥23 kg/m2 and of ever smoking 100 cigarettes. Being married was related to fewer alcoholic drinks per week and higher Asian diet. A higher density of relationships with frequent contact was also associated with higher Asian diet. CONCLUSIONS: AANHPI women with larger proportions of friends and NLWs in their networks had more Western health behaviors and smaller body size. Norms for health behaviors and body size may be influenced by the size, composition, and structure of social networks, relevant to chronic disease prevention.

Content shared on social media for national cancer survivors day 2018.

BACKGROUND: Studies estimate that the number of cancer survivors will double by 2050 due to improvements in diagnostic accuracy and treatment efficacy. Despite the growing population of cancer survivors, there is a paucity of research regarding how these individuals experience the transition from active treatment to long-term surveillance. While research has explored this transition from more organized venues, such as support groups for cancer survivors, this paper explores the discourses surrounding cancer survivorship on social media, paying particular attention to how individuals who identify as cancer survivors represent their experience. METHODS: We identified social media posts relating to cancer survivorship on Twitter and Instagram in early June 2018, in order to coincide with National Cancer Survivorship Day on June 3, 2018. We used nine pre-selected hashtags to identify content. For each hashtag, we manually collected the 150 most recent posts from Twitter and the 100 most recent plus the top 9 posts from Instagram. Our preliminary sample included 1172 posts; after eliminating posts from one hashtag due to irrelevance, we were left with 1063 posts. We randomly sampled 200 of these to create a subset for analysis; after review for irrelevant posts, 193 posts remained for analysis (118 from Instagram and 75 from Twitter). We utilized a grounded theory approach to analyze the posts, first open-coding a subset to develop a codebook, then applying the codebook to the rest of the sample and finally memo writing to develop themes. RESULTS: Overall, there is substantial difference in the tone and thematic content between Instagram and Twitter posts, Instagram takes on a more narrative form that represents journeys through cancer treatment and subsequent survivorship, whereas Twitter is more factual, leaning towards advocacy, awareness and fundraising. In terms of content type, 120 posts (62%) of the sample were images, of which 42 (35%) were images of the individual posting and 28 (23%) were images of patients posted by family or friends. Of the remaining images, 14 (12%) were of support groups and 7 (6%) were of family or friends. We identified four salient themes through analysis of the social media posts from Twitter and Instagram: social support, celebrating milestones and honoring survivors, expressing identity, and renewal vs. rebirth. DISCUSSION: We observed a marked relationship between physical appearance, functional status and survivorship. Additionally, our findings suggest the importance of social support for cancer patients and survivors as well as the role social media can pay in identity formation. CONCLUSION: Our findings suggest that individuals who identify as survivors on social media define their identity fluidly, incorporating elements of physical, emotional and psychological health as well as autonomy.

Factors associated with biomedical research participation within community-based samples across 3 National Cancer Institute-designated cancer centers.

BACKGROUND: Engaging diverse populations in biomedical research, including biospecimen donation, remains a national challenge. This study examined factors associated with an invitation to participate in biomedical research, intent to participate in biomedical research in the future, and participation in biomedical research and biospecimen donation among a diverse, multilingual, community-based sample across 3 distinct geographic areas. METHODS: Three National Cancer Institute-designated cancer centers engaged in community partnerships to develop and implement population health assessments, reaching a convenience sample of 4343 participants spanning their respective catchment areas. Data harmonization, multiple imputation, and multivariable logistic modeling were used. RESULTS: African Americans, Hispanic/Latinos, and other racial minority groups were more likely to be offered opportunities to participate in biomedical research compared to whites. Access to care, history of cancer, educational level, survey language, nativity, and rural residence also influenced opportunity, intent, and actual participation in biomedical research. CONCLUSIONS: Traditionally underserved racial and ethnic groups reported heightened opportunity and interest in participating in biomedical research. Well-established community partnerships and long-standing community engagement around biomedical research led to a diverse sample being reached at each site and may in part explain the current study findings. However, this study illustrates an ongoing need to establish trust and diversify biomedical research participation through innovative and tailored approaches. National Cancer Institute-designated cancer centers have the potential to increase opportunities for diverse participation in biomedical research through community partnerships and engagement. Additional work remains to identify and address system-level and individual-level barriers to participation in both clinical trials and biospecimen donation for research.

Advancing Cancer Control in San Francisco: Cancer Screening in Under-Represented Populations.

INTRODUCTION: Cancer risk and screening data are limited in their ability to inform local interventions to reduce the burden of cancer in vulnerable populations. The San Francisco Health Information National Trends Survey was developed and administered to assess the use of cancer-related information among under-represented populations in San Francisco to provide baseline data for the San Francisco Cancer Initiative. METHODS: The survey instrument was developed through consultation with research and community partners and translated into 4 languages. Participants were recruited between May and September 2017 through community-based snowball sampling with quotas to ensure adequate numbers of under-represented populations. Chi-square tests and multivariate logistic regression were used between 2018 and 2019 to assess differences in screening rates across groups and factors associated with cancer screening. RESULTS: One thousand twenty-seven participants were recruited. Asians had lower rates of lifetime mammogram (p=0.02), Pap test (p<0.01), and prostate-specific antigen test (p=0.04) compared with non-Asians. Hispanics had higher rates of lifetime mammogram (p=0.02), lifetime Pap test (p=0.01), recent Pap test (p=0.03), and lifetime prostate-specific antigen test (p=0.04) compared with non-Hispanics. Being a female at birth was the only factor that was independently associated with cancer screening participation (AOR=3.17, 95% CI=1.40, 7.19). CONCLUSIONS: Screening adherence varied by race, ethnicity, and screening type. A collaborative, community-based approach led to a large, diverse sample and may serve as a model for recruiting diverse populations to add knowledge about cancer prevention preferences and behaviors. Results suggest targeted outreach efforts are needed to address disparate cancer screening behaviors within this diverse population.

Facts or stories? How to use social media for cervical cancer prevention: A multi-method study of the effects of sender type and content type on increased message sharing.

Social media has become a valuable tool for disseminating cancer prevention information. However, the design of messages for achieving wide dissemination remains poorly understood. We conducted a multi-method study to identify the effects of sender type (individuals or organizations) and content type (personal experiences or factual information) on promoting the spread of cervical cancer prevention messages over social media. First, we used observational Twitter data to examine correlations between sender type and content type with retweet activity. Then, to confirm the causal impact of message properties, we constructed 900 experimental tweets according to a 2 (sender type) by 2 (content type) factorial design and tested their probabilities of being shared in an online platform. A total of 782 female participants were randomly assigned to 87 independent 9-person online groups and each received a unique message feed of 100 tweets drawn from the 4 experimental cells over 5 days. We conducted both tweet-level and group-level analyses to examine the causal effects of tweet properties on influencing sharing behaviors. Personal experience tweets and organizational senders were associated with more retweets. However, the experimental study revealed that informational tweets were shared significantly more (19%, 95% CI: 11 to 27) than personal experience tweets; and organizational senders were shared significantly more (10%, 95% CI: 3 to 18) than individual senders. While rare personal experience messages can achieve large success, they are generally unsuccessful; however, there is a reproducible causal effect of messages that use organizational senders and factual information for achieving greater peer-to-peer dissemination.

Health Information-seeking Behaviors and Preferences of a Diverse, Multilingual Urban Cohort.

INTRODUCTION: In order to address health disparities, it is important to understand how vulnerable individuals seek information. This study used an adapted version of the Health Information National Trends Survey (HINTS) administered in English, Spanish, and Chinese to describe the behaviors and preferences of a diverse group of vulnerable urban residents. METHODS: We administered a modified HINTS survey in English, Spanish, and Chinese and used purposive sampling to ensure 50% were non-English speakers evenly divided between Spanish and Chinese speakers, and 50% of English-speakers identified as Black. We used multivariable logistic regression to determine characteristics associated with sources used for health information and preferences for delivery of health information. RESULTS: Among 1027survey respondents (514 English, 256 Spanish, 260 Chinese), 55% had adequate health literacy, and 50% reported household income <$20,000, but 77% reported owning a smartphone. A plurality sought health information on the Internet (39%) or from a health care provider (36%). In multivariable analyses, smartphone ownership predicted higher odds of seeking health information on the Internet [odds ratio, (OR) 2.98; 95% confidence interval (CI), 1.81-4.91]. Participants most preferred email (41%) and brochures (40%) for delivery of health information, but non-English survey respondents were less likely to prefer email: Spanish (OR, 0.30; 95% CI, 0.11-0.83) and Chinese (OR, 0.25; 95% CI, 0.09-0.71). Smartphone ownership predicted an email preference (OR, 2.19; 95% CI, 1.43-3.36). CONCLUSIONS: Among vulnerable populations, smartphone ownership and language preferences impact preferences for seeking and receiving health information. These preferences need to be considered in designing health messages.

Perceptions of cervical cancer prevention on Twitter uncovered by different sampling strategies.

INTRODUCTION: Cervical cancer prevention is possible through use of the HPV vaccine and Pap tests, yet the vaccine remains underutilized. METHODS: We obtained publicly-available Twitter data from 2014 using three sampling strategies (top-ranked, simple random sample, and topic model) based on key words related to cervical cancer prevention. We conducted a content analysis of 100 tweets from each of the three samples and examined the extent to which the narratives and frequency of themes differed across samples. RESULTS: Advocacy-related tweets constituted the most prevalent theme to emerge across all three sample types, and were most frequently found in the top-ranked sample. A random sample detected the same themes as topic modeling, but the relative frequency of themes identified from topic modeling fell in-between top-ranked and random samples. DISCUSSION: Variations in themes uncovered by different sampling methods suggest it is useful to qualitatively assess the relative frequency of themes to better understand the breadth and depth of social media conversations about health. CONCLUSIONS: Future studies using social media data should consider sampling methods to uncover a wider breadth of conversations about health on social media.

Social Media as a Tool to Promote Health Awareness: Results from an Online Cervical Cancer Prevention Study.

Online social media platforms represent a promising opportunity for public health promotion. Research is limited, however, on the effectiveness of social media at improving knowledge and awareness of health topics and motivating healthy behavior change. Therefore, we investigated whether participation in an online social media platform and receipt of brief, tailored messages is effective at increasing knowledge, awareness, and prevention behaviors related to human papillomavirus (HPV) and cervical cancer. We conducted an online study in which 782 recruited participants were consecutively assigned to nine-person groups on a social media platform. Participants were shown a unique random set of 20 tailored messages per day over five days. Participants completed a baseline and post survey to assess their knowledge, awareness, and prevention behaviors related to HPV and cervical cancer. There were no statistically significant changes in knowledge and prevention behaviors from the baseline to the post survey among study participants. There was a modest, statistically significant change in response to whether participants had ever heard of HPV, increasing from 90 to 94% (p = 0.003). Our findings suggest that most study participants had substantial knowledge, awareness, and engagement in positive behaviors related to cervical cancer prevention at the start of the study. Nevertheless, we found that HPV awareness can be increased through brief participation in an online social media platform and receipt of tailored health messages. Further investigation that explores how social media can be used to improve knowledge and adoption of healthy behaviors related to cervical cancer is warranted.

Using Social Media to Target Cancer Prevention in Young Adults: Viewpoint.

Focusing on primary cancer prevention can reduce its incidence. Changing health behaviors is critical to cancer prevention. Modifiable cancer risk factors include lifestyle behaviors related to vaccination, physical activity, weight control and maintenance, alcohol consumption, and tobacco use. These health habits are often formed in young adulthood, a life stage which currently intersects with the growing population of digital natives whose childhood occurred in the internet era. Social media is a critical communication medium to reach this population of digital natives. Using a life course perspective, the purpose of this viewpoint paper is to describe the current landscape of nascent research using social media to target cancer prevention efforts in young adults and propose future directions to strengthen the scientific knowledge supporting social media strategies to promote cancer prevention behaviors. Leveraging social media as a health promotion tool is a promising strategy to impact modifiable behavioral risk factors for cancer and warrants further research on developing effective communication strategies in young adults to prevent cancer in the future generations.

The Role of Physician Recommendation in Colorectal Cancer Screening Receipt Among Immigrant Chinese Americans.

Chinese Americans have low colorectal cancer (CRC) screening rates. It is unclear whether physicians should offer all CRC screening modalities (fecal occult blood test [FOBT], sigmoidoscopy, colonoscopy) to Chinese Americans to increase screening. Seven hundred and twenty-five Chinese Americans were asked in a survey if their physician had ever recommended CRC screening and to self-report receipt and type of CRC screening. Participants whose physician had recommended all CRC screening modalities were significantly more likely to report ever having screening (adjusted odds ratio 4.29, 95% CI 1.26-14.68) and being up-to-date (4.06, 95% CI 2.13-7.74) than those who reported that their physician only recommended FOBT. Participants who received a recommendation of only one type of screening did not report a significant difference in ever having or being up-to-date for screening. A potential strategy to increase CRC screening among Chinese Americans is for clinicians to recommend all available CRC screening modalities to each patient.

Colorectal Cancer Screening and Chinese Americans: Efficacy of Lay Health Worker Outreach and Print Materials.

INTRODUCTION: Chinese Americans have low colorectal cancer (CRC) screening rates. Evidence-based interventions to increase CRC screening in this population are lacking. This study aims to compare the efficacy of two interventions in increasing CRC screening among Chinese Americans. DESIGN: Cluster randomized comparative trial. SETTING/PARTICIPANTS: From 2010 to 2014, a community-academic team conducted this study in San Francisco, CA with Chinese Americans aged 50-75 years who spoke English, Cantonese, or Mandarin. INTERVENTION: Lay health worker (LHW) intervention plus in-language brochure (LHW+Print) versus brochure (Print). LHWs in the LHW+Print arm were trained to teach participants about CRC in two small group sessions and two telephone calls. MAIN OUTCOME MEASURES: Change in self-reports of ever having had CRC screening and being up to date for CRC screening from baseline to 6 months post-intervention. Statistical analysis was performed from 2014 to 2015. RESULTS: This study recruited 58 LHWs, who in turn recruited 725 participants. The average age of the participants was 62.2 years, with 81.1% women and 99.4% foreign born. Knowledge increase was significant (p<0.002) for nine measures in the LHW+Print group and six in the Print group. Both groups had increases in having ever been screened for CRC (LHW+Print, 73.9%-88.3%, p<0.0001; Print, 72.3%-79.5%, p=0.0003) and being up to date for CRC screening (LHW+Print, 60.0%-78.1%, p<0.0001; Print, 58.1%-64.1%, p=0.0003). In multivariable analyses, the intervention OR for LHW+Print versus Print was 1.94 (95% CI=1.34, 2.79) for ever screening and 2.02 (95% CI=1.40, 2.90) for being up to date. CONCLUSIONS: Both in-language print materials and LHW outreach plus print materials increased CRC screening among Chinese Americans. The combination of LHW+Print was more effective than Print alone. These findings can guide clinicians and policymakers in choosing appropriate interventions to increase CRC screening among Chinese American immigrants. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT00947206.

Improving advance care planning for English-speaking and Spanish-speaking older adults: study protocol for the PREPARE randomised controlled trial.

INTRODUCTION: Advance care planning (ACP) is a process that allows patients to identify their goals for medical care. Traditionally, ACP has focused on completing advance directives; however, we have expanded the ACP paradigm to also prepare patients to communicate their wishes and make informed decisions. To this end, we created an ACP website called PREPARE (http://www.prepareforyourcare.org) to prepare diverse English-speaking and Spanish-speaking older adults for medical decision-making. Here, we describe the study protocol for a randomised controlled efficacy trial of PREPARE in a safety-net setting. The goal is to determine the efficacy of PREPARE to engage diverse English-speaking and Spanish-speaking older adults in a full spectrum of ACP behaviours. METHODS AND ANALYSIS: We include English-speaking and Spanish-speaking adults from an urban public hospital who are ≥55 years old, have ≥2 chronic medical conditions and have seen a primary care physician ≥2 times in the last year. Participants are randomised to the PREPARE intervention (review PREPARE and an easy-to-read advance directive) or the control arm (only the easy-to-read advance directive). The primary outcome is documentation of an advance directive and/or ACP discussion. Secondary outcomes include ACP behaviour change processes measured with validated surveys (eg, self-efficacy, readiness) and a broad range of ACP actions (eg, choosing a surrogate, identifying goals for care, discussing ACP with clinicians and/or surrogates). Using blinded outcome ascertainment, outcomes will be measured at 1 week and at 3, 6 and 12 months, and compared between study arms using mixed-effects logistic regression and mixed-effects linear, Poisson or negative binomial regression. ETHICS AND DISSEMINATION: This study has been approved by the appropriate Institutional Review Boards and is guided by input from patient and clinical advisory boards and a data safety monitoring board. The results of this study will be disseminated to academic and community stakeholders. TRIAL REGISTRATION NUMBERS: NCT01990235; NCT02072941; Pre-results.

Applying Sparse Machine Learning Methods to Twitter: Analysis of the 2012 Change in Pap Smear Guidelines. A Sequential Mixed-Methods Study.

BACKGROUND: It is difficult to synthesize the vast amount of textual data available from social media websites. Capturing real-world discussions via social media could provide insights into individuals' opinions and the decision-making process. OBJECTIVE: We conducted a sequential mixed methods study to determine the utility of sparse machine learning techniques in summarizing Twitter dialogues. We chose a narrowly defined topic for this approach: cervical cancer discussions over a 6-month time period surrounding a change in Pap smear screening guidelines. METHODS: We applied statistical methodologies, known as sparse machine learning algorithms, to summarize Twitter messages about cervical cancer before and after the 2012 change in Pap smear screening guidelines by the US Preventive Services Task Force (USPSTF). All messages containing the search terms "cervical cancer," "Pap smear," and "Pap test" were analyzed during: (1) January 1-March 13, 2012, and (2) March 14-June 30, 2012. Topic modeling was used to discern the most common topics from each time period, and determine the singular value criterion for each topic. The results were then qualitatively coded from top 10 relevant topics to determine the efficiency of clustering method in grouping distinct ideas, and how the discussion differed before vs. after the change in guidelines . RESULTS: This machine learning method was effective in grouping the relevant discussion topics about cervical cancer during the respective time periods (~20% overall irrelevant content in both time periods). Qualitative analysis determined that a significant portion of the top discussion topics in the second time period directly reflected the USPSTF guideline change (eg, "New Screening Guidelines for Cervical Cancer"), and many topics in both time periods were addressing basic screening promotion and education (eg, "It is Cervical Cancer Awareness Month! Click the link to see where you can receive a free or low cost Pap test.") CONCLUSIONS: It was demonstrated that machine learning tools can be useful in cervical cancer prevention and screening discussions on Twitter. This method allowed us to prove that there is publicly available significant information about cervical cancer screening on social media sites. Moreover, we observed a direct impact of the guideline change within the Twitter messages.

Strategies for recruiting representative samples of Asian Americans for a population-based case-control study.

BACKGROUND: Data are limited on effective methods for recruiting persons, especially from ethnically diverse populations, into population-based studies. The goal of this study was to evaluate the variation among and representativeness of controls identified using multiple methods for a population-based case-control study of breast cancer among Asian Americans, Native Hawaiians and Pacific Islanders (AANHPIs) in the San Francisco Bay Area. METHODS: We used a unique combination of targeted recruitment strategies, including address-based sampling, community-based methods, and internet-based and media-based approaches for recruiting controls, frequency matched on age and ethnicity to a population-based sample of cases. To characterise the participating controls, we compared the distribution of sociodemographic characteristics and cancer risk factors between recruitment sources using χ(2) tests. To ensure that the controls we recruited were representative of the underlying at-risk population, we compared characteristics of the controls, by ethnicity and in aggregate, to data from the California Health Interview Survey (CHIS), and adjusted the relative mix of recruitment strategies throughout the study as needed to achieve representativeness. RESULTS: As expected, controls (n=483) recruited by any single method were not representative. However, when aggregated across methods, controls were largely representative of the underlying source population, as characterised by CHIS, with regard to the characteristics under study, including nativity, education, marital status and body mass index. CONCLUSIONS: A multimode approach using targeted recruitment strategies is an effective and feasible alternative to using a single recruitment method in identifying a representative, diverse control sample for population-based studies.

Educational Interventions to Promote Healthy Nutrition and Physical Activity Among Older Chinese Americans: A Cluster-Randomized Trial.

OBJECTIVES: To evaluate the efficacy of an in-language intervention of 2 lectures plus printed materials versus printed materials alone on knowledge and adherence to nutrition and physical activity guidelines among older Chinese Americans in San Francisco, California. METHODS: From August 2010 to September 2013, we randomized 756 Chinese Americans aged 50 to 75 years to either lectures plus print (n = 361) or print (n = 357). Clusters were the participants recruited by each lay health worker. Intervention outcomes were changes in knowledge of recommended vegetable intake, fruit intake, and physical activity level and adherence to those recommendations from pre- to 6 months postintervention. RESULTS: The retention rate was 99%. At baseline, knowledge and adherence to recommendations were low. Print yielded increases in knowledge of recommended vegetable intake and physical activity level and adherence to fruit intake and physical activity recommendations. Lectures plus print had significant increases in all 6 outcomes. In multivariable models, lectures plus print was superior to print for knowledge of vegetable (adjusted odds ratio [AOR] = 12.61; 95% confidence interval [CI] = 6.50, 24.45) and fruit (AOR = 16.16; 95% CI = 5.61, 46.51) intake recommendations and adherence to vegetable intake recommendations (AOR = 5.53; 95% CI = 1.96, 15.58). CONCLUSIONS: In-language print materials, alone and combined with lectures, increased nutrition and physical activity knowledge and behaviors among older Chinese Americans.