Cati G. Brown-Johnson

Development and usability evaluation of the mHealth Tool for Lung Cancer (mHealth TLC): A virtual world health game for lung cancer patients

OBJECTIVE To test the feasibility and usability of mHealth TLC, an interactive, immersive 3-dimensional iPad health game that coaches lung cancer patients toward assertive communication strategies during first-person virtual clinics visits. METHOD We observed players and conducted semi-structured interviews. Research questions focused on scenario believability, the impact of technical issues, transparency of game goals, and potential of mHealth TLC to decrease lung cancer stigma (LCS) and improve patient-clinician communication. RESULTS Eight users confirmed mHealth TLC to be: (1) believable, (2) clinic-appropriate, and (3) helpful in support of informed healthcare consumers. Concerns were expressed about emotionally charged content and plans to use mHealth TLC in clinic settings as opposed to at home. CONCLUSIONS Although the dialog and interactions addressed emotionally charged issues, players were able to engage, learn, and benefit from role-play in a virtual world. Health games have the potential to improve patient-clinician communication, and mHealth TLC specifically may decrease LCS, and promote optimal self-management. PRACTICE IMPLICATIONS Process reflection revealed the need for health games to be created by experienced game developers in collaboration with health care experts. To prepare for this best practice, research institutions and game developers interested in health games should proactively seek out networking and collaboration opportunities.

Validity and reliability of the internalized stigma of smoking inventory: An exploration of shame, isolation, and discrimination in smokers with mental health diagnoses

BACKGROUND AND OBJECTIVES De-normalization of smoking as a public health strategy may create shame and isolation in vulnerable groups unable to quit. To examine the nature and impact of smoking stigma, we developed the Internalized Stigma of Smoking Inventory (ISSI), tested its validity and reliability, and explored factors that may contribute to smoking stigma. METHODS We evaluated the ISSI in a sample of smokers with mental health diagnoses (N = 956), using exploratory and confirmatory factor analysis, and assessed construct validity. RESULTS Results reduced the ISSI to eight items with three subscales: smoking self-stigma related to shame, felt stigma related to social isolation, and discrimination experiences. Discrimination was the most commonly endorsed of the three subscales. A multivariate generalized linear model predicted 21-30% of the variance in the smoking stigma subscales. Self-stigma was greatest among those intending to quit; felt stigma was highest among those experiencing stigma in other domains, namely ethnicity and mental illness-based; and smoking-related discrimination was highest among women, Caucasians, and those with more education. DISCUSSION AND CONCLUSION Smoking stigma may compound stigma experiences in other areas. Aspects of smoking stigma in the domains of shame, isolation, and discrimination were related to modeled stigma responses, particularly readiness to quit and cigarette addiction, and were found to be more salient for groups where tobacco use is least prevalent. SCIENTIFIC SIGNIFICANCE The ISSI measure is useful for quantifying smoking-related stigma in multiple domains.

Online Comments on Smoking Bans in Psychiatric Hospitals Units

Objective: Individuals with mental health concerns are disproportionately affected by and suffer the negative consequences of tobacco use disorder, perhaps because smoking has historically been part of psychiatrys culture. In the early 1990s, psychiatric inpatient facilities were exempted from U.S. hospital smoking bans, in response to public outcry with national media attention. Almost 2 decades later, the current study characterizes online conversation about psychiatric hospital smoking bans. Previous commenting studies have demonstrated commentings negativity, documenting the “nasty effect” wherein negative comments color perceptions of neutral articles. Thus, we focused particular attention on cited barriers to implementing health-positive smoke-free policies. Methods: We collected online comments (N = 261) responding to popular media articles on smoking bans in inpatient psychiatry between 2013 and 2014 and conducted an inductive and exploratory qualitative content analysis. Results: Verifying previous studies documenting the prevalence of negative commenting, of the comments explicitly supporting or refuting psychiatry smoking bans, there were over twice as many con comments (n = 44) than pro (n = 18). Many commenters argued for access to outdoor smoking areas and warned of patient agitation and risk posed to care workers. Identified content themes included psychiatric medication and negative side effects, broken mental health systems and institutions, denigration of the health risks of tobacco in the context of mental illness, typical pro-smoking arguments about “smokers’ rights” and alternatives (including e-cigarettes), addiction, and stigma. Conclusions: The current findings provide a platform to begin to understand how people talk about mental health issues and smoking. Our analysis also raised complex issues concerning forces that impact U.S. patients with serious mental illness but over which they have little control, including medication, the U.S. health system, stigma, perceptions that life with chronic serious mental illness is not worth living, and psychological and physical pain of coping with mental illness. In consideration of identified barriers raised in opposition to smoking bans in inpatient psychiatry, efforts should emphasize patient stakeholder involvement; patient, visitor, and staff protection from smoke exposure; the effectiveness of nicotine replacement for managing withdrawal; and the lack of evidence that cigarettes are therapeutic.

Associations with E-cigarette use among Asian American and Pacific Islander young adults in California

With attention to the rapidly growing market of electronic nicotine delivery systems (ENDS/e-cigarettes) and the fastest growing US ethnic minority group, the current study explored associations between awareness, perceived risks, and use of ENDS among Asian American and Pacific Islander (AAPI) young adults. AAPI young adults (ages 18–25) in California were recruited via social media, college classes, listservs for AAPI-serving non-profits, and snowball sampling to complete an anonymous survey between 2014 and 2015. The sample (N = 501) was 57% women, 15% LGBTQIA; with a mean age of 21; 26% foreign-born; identifying as Filipino (29%), Chinese (24%), Vietnamese (14%), mixed-AAPI heritage (13%), or 21% other. Nearly half the sample (44%) reported ever ENDS use; 11% were current users. Current ENDS use was twofold greater for: Filipino and Vietnamese compared to Chinese respondents; men versus women; LGBTQIA-identified respondents; those vocationally trained; and employed. Awareness of ENDS from peers/friends was most common and was associated with ever though not current ENDS use. Most respondents perceived ENDS as harmful (62%); low compared to high risk perception was associated with a three-fold greater likelihood of ever use and six-fold greater likelihood of current use. Popular flavors were fruit (49%, e.g., lychee, taro) and candy/sweets (26%). Current users viewed ENDS as a healthier alternative or quit aid for conventional cigarettes (42%); recreation/social use (33%) also was common. Findings indicate ENDS visibility among AAPI young adults in California with affinity for flavors and many engaging in trial and current use for harm reduction and recreational/social aims.

Latino Adults’ Perspectives on Treating Tobacco Use Via Social Media

Background Latinos are the largest minority group in the United States, and in California they outnumber non-Hispanic whites. Smoking cessation programs tailored for Latino culture, and this population’s specific smoking patterns, are needed. Online social networks for smoking cessation have high potential for Latinos, but have not been tested to date. Objective Building a research program on social media apps for cancer prevention in diverse populations, this qualitative study assessed acceptability of tobacco treatment that was distributed via social media for Latino smokers. Methods We conducted three focus groups with Latino adults who were former and current smokers recruited from Santa Clara County, California in 2015 (N=32). We assessed participants’ smoking histories, attempts to quit, social media exposure, and receptivity to a social media-based smoking cessation intervention. Audio transcripts were translated and coded for themes. Results Participants reported factors driving their tobacco use and motivations to quit, and emphasized the importance of community and family in influencing their smoking initiation, cravings and triggers, attempts to quit, and abstinence. Participants valued the communal aspect of social media and suggested strategically tailoring groups based on key features (eg, age, gender, language preference). Participants reported preferring visual, educational, and motivational messages that were connected with existing services. Conclusions Participants generally voiced acceptability of a social media-delivered intervention to help them quit smoking, viewed the intervention as well-equipped for catering to the strong community orientation of Latinos, and suggested that the platform was able to address variation within the population through strategic group creation. As a group member reflected, “Podemos hacerlo juntos” (We can do it together).

Shame-based appeals in a tobacco control public health campaign: potential harms and benefits.

Smoking is the leading preventable cause of death worldwide, responsible for 1 in 10 deaths globally (>5 million a year). Tobacco use adversely impacts not just smokers, but also those around them through secondhand smoke exposure. Given the significant personal and societal costs of tobacco use, any strategy to reduce smoking should be considered. In this issue, Amonini et al 1 report on development and evaluation of a shame-based public health campaign in Perth, Australia. Public health media campaigns in Australia, in particular, have raised awareness and instigated behaviour change via approaches ranging from direct and forceful (eg, ‘Belt Up or Suffer the Pain’ seatbelt campaign2) to humorous and memorable (eg, ‘Slip! Slop! Slap!’ for skin cancer prevention3). In developing their tobacco control ad campaign, Amonini et al conducted focus groups with smokers and interviewed former smokers, identifying salient themes of social isolation (eg, “you feel like a ‘leper’”). Next, they created and piloted an ad prototype in an experimental setting, which demonstrated believability/relevance and perceived efficacy in stopping smokers from smoking. Finally, they created the shame-based ad, evaluating it in a publicly launched campaign where a majority of respondents self-reported in the first several weeks that they reduced cigarette consumption (36%), attempted cessation (16%) or quit (2%). While suggestive as a promising public health approach, …

Electronic Release of Pathology and Radiology Results to Patients: Opinions and Experiences of Oncologists

PURPOSE There is an emerging standard to provide patients rapid electronic access to elements of their medical records. Although surveys of patients generally support it, this practice is controversial among oncologists, because few empiric data are available for scenarios of potentially life-threatening conditions like cancer. We report the views of oncologists about patient electronic access to radiology and pathology results that could potentially indicate disease progression. METHODS Four months before oncologists were surveyed, final results of radiology/pathology reports were routinely made available to patients online through a secure portal after a 7-day, hold to provide clinicians time to review and communicate results with the patients. Mixed methods were used to assess physician attitudes and experiences toward this change. RESULTS One hundred twenty-nine oncologists were surveyed, and 82 (64%) responded. A small majority (54%) responded that the release of reports was somewhat or very beneficial for patients who received normal radiology/pathology results before discussion with a physician, but 87% said it was somewhat or very harmful for patients to receive abnormal results before discussion. Forty-nine percent reported that release of reports had a somewhat or very negative impact on communication with their patients. CONCLUSION Almost half of oncologists reported that sharing digital radiology and pathology records had a negative impact on their communication with patients. Patient surveys in similar cancer populations would complement the physician perspective. Efforts are needed to improve consensus among oncologists and patients on how to best communicate such results in a timely fashion.

Trust in Health Information Sources: Survey Analysis of Variation by Sociodemographic and Tobacco Use Status in Oklahoma

Background Modern technology (ie, websites and social media) has significantly changed social mores in health information access and delivery. Although mass media campaigns for health intervention have proven effective and cost-effective in changing health behavior at a population scale, this is best studied in traditional media sources (ie, radio and television). Digital health interventions are options that use short message service/text messaging, social media, and internet technology. Although exposure to these products is becoming ubiquitous, electronic health information is novel, incompletely disseminated, and frequently inaccurate, which decreases public trust. Previous research has shown that audience trust in health care providers significantly moderates health outcomes, demographics significantly influence audience trust in electronic media, and preexisting health behaviors such as smoking status significantly moderate audience receptivity to traditional mass media. Therefore, modern health educators must assess audience trust in all sources, both media (traditional and digital) and interpersonal, to balance pros and cons before structuring multicomponent community health interventions. Objective We aimed to explore current trust and moderators of trust in health information sources given recent changes in digital health information access and delivery to inform design of future health interventions in Oklahoma. Methods We conducted phone surveys of a cross-sectional sample of 1001 Oklahoma adults (age 18-65 years) in spring 2015 to assess trust in seven media sources: traditional (television and radio), electronic (online and social media), and interpersonal (providers, insurers, and family/friends). We also gathered information on known moderators of trust (sociodemographics and tobacco use status). We modeled log odds of a participant rating a source as “trustworthy” (SAS PROC SURVEYLOGISTIC), with subanalysis for confounders (sociodemographics and tobacco use). Results Oklahomans showed the highest trust in interpersonal sources: 81% (808/994) reported providers were trustworthy, 55% (550/999) for friends and family, and 48% (485/998) for health insurers. For media sources, 24% of participants (232/989) rated the internet as trustworthy, followed by 21% of participants for television (225/998), 18% for radio (199/988), and only 11% for social media (110/991). Despite this low self-reported trust in social media, 40% (406/991) of participants reported using social media for tobacco-related health information. Trust in health providers did not vary by subpopulation, but sociodemographic variables (gender, income, and education) and tobacco use status significantly moderated trust in other sources. Women were on the whole more trusting than men, trust in media decreased with income, and trust in friends and family decreased with education. Conclusions Health education interventions should incorporate digital media, particularly when targeting low-income populations. Utilizing health care providers in social media settings could leverage high-trust and low-cost features of providers and social media, respectively.

“You have the right to protect your health”: Perceptions of Secondhand Smoke and Exposure Mitigation Strategies in Low-Income Patients With Heart Disease, San Francisco, 2011–2012

We examined the understanding of the harms of secondhand smoke (SHS) exposure among low-income, hospitalized adults with cardiovascular disease. Participants were 15 nonsmokers reporting daily SHS exposure and 15 light or nondaily cigarette smokers. We coded responses from audiotaped semistructured interviews for themes. No participant spontaneously identified heart risks related to SHS exposure. Strategies to avoid SHS included verbal requests to not smoke and physically avoiding smoke; both smokers and nonsmokers prioritized politeness over urgency. Most participants thought a blood test quantifying SHS exposure would be clinically useful. Health education, assertiveness communication training, and protective policies (eg, smoke-free multiunit housing) also were supported.

A corpus-based analysis of potential linguistic indicators of corporate deception in tobacco industry documents

Abstract Introduction: To more fully understand the impact of specific language attributes on deception in corporate communication, we used a stratified random sample of tobacco industry documents to test a small number of individual potential automated linguistic indicators of corporate deception: cognitive-emotional verbs, allness and superlative terms, nonbinding verbs, and group mentality. Methods: Texts from the Tobacco Documents Corpus were categorized by audience addressed (industry internal/external) and company of origin, and compared for incidence of the deceptive language indicators. Results: Cognitive-emotional verbs were strongly associated with likely deception and most prevalent for external audiences and documents produced by the Tobacco Institute, an industry front group. Cognitive-emotional verbs include believe, think, seem, feel and realize, in opposition to action verbs (e.g. throw). Discussion: Linguistic measurements of cognitive-emotional verbs may help pinpoint deceptive and misleading corporate communication. Verb choice and the use of different classes of verbs may reflect corporate linguistic deception.