PSYCHOSOCIAL FACTORS AND MOBILE HEALTH INTERVENTION: IMPACT ON LONG-TERM OUTCOMES AFTER LUNG TRANSPLANTATION

Identifying and intervening on modifiable risk factors may improve outcomes in lung transplantation (LTx), which, despite recent improvements, remain suboptimal. Evidence suggests that two modifiable risk factors, psychiatric disorders and nonadherence, may improve LTx outcomes in the short-term; however, neither has been explored in the long-term. Therefore, the overarching goal of this dissertation was to determine the long-term impact of these modifiable risk factors and intervention to attenuate them. First, we examined the relationship of pre- and early post-transplant psychiatric disorders on LTx-related morbidity and mortality for up to 15 years post-LTx. Our sample included 155 1-year LTx survivors enrolled in a prospective study of mental health post- LTx. We found that depression during the first year post-LTx increased risk of BOS, mortality and graft loss by nearly twofold, and that pre-transplant depression and pre- and post-transplant anxiety were not associated with clinical outcomes. Next, we examined the impact of a mobile health intervention designed to promote adherence to the post-LTx regimen, PocketPATH, on long-term LTx-related morbidity, mortality and nonadherence. We conducted two follow-up studies to the original yearlong randomized controlled trial in which participants assigned to PocketPATH showed improved adherence to the regimen, relative to usual care. Among the 182 LTx recipients (LTxRs) who survived the original trial, we found that PocketPATH had a protective indirect effect on mortality by promoting LTxRs’ communication with the LTx team during the first year. Among the 104 LTxRs who completed the follow-up assessment, we found that PocketPATH’s adherence benefits over the first year were not sustained into the long-term, although LTxRs assigned to PocketPATH were more likely than LTxRs assigned to usual care to perform the home self-care tasks of the regimen at follow-up. Median time since LTx for participants in both follow-up studies was 4.2 years (range, 2.8-5.7 years). This dissertation presents an important first step toward identifying and intervening on modifiable risk factors to improve long-term LTx outcomes. Mobile health technologies offer limitless potential to target these risk factors and others. More work is needed to determine specific features and long-term patient engagement strategies that will optimize and sustain intervention effectiveness

The Use of Technology to Support Precision Health in Nursing Science

PurposeThis article outlines how current nursing research can utilize technology to advance symptom and self‐management science for precision health and provides a roadmap for the development and use of technologies designed for this purpose.ApproachAt the 2018 annual conference of the National Institute of Nursing Research (NINR) Research Centers, nursing and interdisciplinary scientists discussed the use of technology to support precision health in nursing research projects and programs of study. Key themes derived from the presentations and discussion were summarized to create a proposed roadmap for advancement of technologies to support health and well‐being.ConclusionsTechnology to support precision health must be centered on the user and designed to be desirable, feasible, and viable. The proposed roadmap is composed of five iterative steps for the development, testing, and implementation of technology‐based/enhanced self‐management interventions. These steps are (a) contextual inquiry, focused on the relationships among humans, and the tools and equipment used in day‐to‐day life; (b) value specification, translating end‐user values into end‐user requirements; (c) design, verifying that the technology/device can be created and developing the prototype(s); (d) operationalization, testing the intervention in a real‐world setting; and (e) summative evaluation, collecting and analyzing viability metrics, including process data, to evaluate whether the technology and the intervention have the desired effect.Clinical RelevanceInterventions using technology are increasingly popular in precision health. Use of a standard multistep process for the development and testing of technology is essential.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151985/1/jnu12518.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151985/2/jnu12518_am.pd

Improving Understanding and Detection of Postpartum Anxiety

Background: Maternal mental health conditions are the most common complications in the postpartum period (Luca et al., 2019; US Preventive Services Task Force et al., 2019). Recognition that postpartum anxiety (PPA), anxiety during the post-partum period, is more prevalent than postpartum depression (PPD), and its significant impacts on maternal and infant outcomes, has raised interest in improving its detection (Accortt & Wong, 2017; Fairbrother et al., 2016; Fawcett et al., 2019). Yet, detection challenges remain including lack of diagnostic criteria for PPA (Jordan & Minikel, 2019; Zappas et al., 2020), difficulties differentiating between levels of anxiety (e.g., adaptive worry after childbirth, generalized anxiety, and postpartum-specific anxiety) (Howard & Khalifeh, 2020; Lorenzo, 2022; Zappas et al., 2020), and lack of consensus for a PPA-specific screening tool (Thorsness et al., 2018; Zappas et al., 2020). A better understanding of the course and temporal patterns of PPA, such as severity and influencing factors over time, is warranted to improve detection of PPA. Also, more descriptive research is needed to expand understanding of anxiety in postpartum contexts which may help to further delineate postpartum-specific anxiety from generalized anxiety and aid in detection and clinical management of the condition. Purpose: To describe the prevalence, stability, trends, and context of anxiety from the 3rd trimester of pregnancy (e.g., 27 to 40 weeks of pregnancy) to eight-weeks postpartum using multiple measurement modalities. Modalities included questionnaires to assess mood and ecological momentary assessments (mEMA) asking participants to rate daily anxiety levels and respond to open-ended mEMA questions guided by the Theory of Becoming a Mother (Mercer, 2004). Qualitative findings were compared between those with and without anxiety at eight-weeks postpartum and integrated with quantitative findings in a narrative synthesis. Sample and Setting: A convenience sample of 73 birthing people who planned to give birth to their infants at a large academic tertiary center in the Mid-Atlantic U.S. were enrolled. Study activities were performed remotely between August 2021 to March 2022. Methods: The study used a prospective, mixed-methods, cohort design for the purpose of development (i.e., mEMA daily anxiety ratings were used to develop a stratified sampling plan for the qualitative mEMA responses), and for the purpose of expansion (i.e., anxiety questionnaires were used to develop categories of participants by presence of anxiety). The State Trait Anxiety Inventory, State Scale (STAI-S) and Postpartum Specific Anxiety Scale (PSAS) were administered at baseline (3rd trimester, STAI-S only), one-, and eight-weeks postpartum. mEMA prompts were sent to participants to rate their daily anxiety on a scale of 0, “not at all” to 10, “very much so” and respond to open-ended questions regarding perceived stress, social support, role adjustment, environment, and source of daily anxiety. Established cut-off scores for anxiety on the STAI-S and PSAS were used to determine anxiety prevalence at each study timepoint using descriptive statistics. Stability of the STAI-S and PSAS was evaluated with a dependent samples t-test and repeated measures analysis of variance. Linear mixed modeling was used to evaluate trends in individuals’ daily anxiety ratings. The mode and variance of daily anxiety ratings for participants who returned ≥ 50% of mEMA prompts were used to stratify participants into four groups, from which 50% of the cases in each group were randomly selected for subsequent qualitative analysis (N = 34). Qualitative data were analyzed using qualitative descriptive methods and a theory-driven coding framework. Participants’ responses were organized into thematic-categories and major concepts. Eight-week STAI-S and PSAS scores were used to categorize participants by presence of anxiety based on established cut-off scores for anxiety (> 40 and > 112), respectively. Thematic-categories between anxiety classifications were compared using matrices, a joint display, and narrative synthesis to expand understanding. Findings: In our sample of mostly white (81%), partnered (90.4%), and highly educated (≥ graduate degree, 75%) people, mean STAI-S anxiety scores were significantly higher [F(1.85, 129.18) = 4.305, p = 0.018] at one week postpartum (36.4 11.0) than at eight-weeks postpartum (33.4 9.6). Mean PSAS scores were significantly higher [ t(70) = 3.047, p = 0.003] at eight-weeks postpartum (93.9 20.7) than at one-week (88.6 19.6). The proportion of the sample above the cut-off for anxiety on the STAI-S (> 40) in descending order was greatest at one-week postpartum (28.8%), lower at eight weeks (23.9%), and lowest at baseline (3rd pregnancy trimester) (21.9%). The proportion above the cut-off for anxiety on the PSAS (> 112) in descending order was greatest at eight-weeks (21.1%) and lowest at one-week postpartum (12.3%). The proportion who met anxiety thresholds on either the STAI-S or PSAS was greater at eight-weeks (35.2%) than one-week postpartum (31.5%). Only 33% of the sample’s responses for daily anxiety ratings between one- to eight-weeks postpartum (968/2936) indicated no level of daily anxiety (e.g., 0). Aggregated mean daily anxiety ratings were highest at two-weeks, declined and stabilized, then trended upward toward week eight postpartum, t(65.56) = 2.15, p = 0.036, 95% CI, [0.000034, 000944]. Individuals who met cut-offs for anxiety at eight-weeks postpartum described feeling more overwhelmed, having less support, experiencing more relationship conflict, difficulty adjusting to maternal roles, and having less positive environmental influences than those without anxiety. Further, there were qualitative differences between participants with anxiety per the STAI-S and anxiety per the PSAS. Specifically, participants with anxiety per the PSAS alternated between feeling able to “manage” their responsibilities and “overwhelmed” by their responsibilities over the study period. Alternatively, participants with anxiety per the STAI-S consistently reported feeling overwhelmed. Regarding support, participants with anxiety per the PSAS reported task-related support in the early weeks postpartum that declined as the time from birth lengthened, while participants with anxiety per the STAI-S consistently described lack of support. Further, individuals with anxiety per the PSAS reported relationship conflict more often and described daily sources of anxiety (e.g., infant-related concerns and return to the workplace) that were different than daily sources of anxiety per the STAI (e.g., self-health, finances, and partner work/travel). Participants with anxiety based on either questionnaire shared similar response patterns for perceived stress, social support, and role adjustment. Regarding environmental influences, participants with anxiety per the STAI-S often mentioned the negative influences of fatigue, deficient support systems, infant temperaments, and/or other children’s needs. Alternatively, participants with anxiety per the PSAS reported similarly negative environmental influences from relationship conflict and deficient support as those with anxiety per the STAI-S or both the STAI-S and PSAS, but also recounted more positive influences from socialization opportunities that the other categories of anxiety did. Conclusions: Our study found that mean anxiety scores decreased from one- to eight-weeks postpartum per the STAI-S, but increased from one- to eight-weeks postpartum per the PSAS. These findings suggest postpartum-specific anxiety may worsen as the time from birth lengthens. Our findings also corroborate reportedly high anxiety prevalence at eight-weeks postpartum, where per the STAI-S, 23.9% of the sample had anxiety and per the PSAS, 21%. Although more participants met the cut-off for anxiety per the STAI-S at eight-weeks postpartum, consideration should be given to the potential that STAI-S scores were falsely inflated, as instrument items were developed to measure somatic symptoms in general and not postpartum populations (Infante-Gil et al., 2022; Meades & Ayers, 2011; Spielberger et al., 1983). Daily anxiety ratings showed that anxiety is a shared experience across the postpartum; for most peaking at two-weeks, declining and stabilizing, then trending upward toward week eight postpartum. However, for some, daily anxiety ratings increase more dramatically as the time from birth lengthens. Responses to theory-driven mEMA questions offered qualitative validation for existing assumptions regarding relationships between high perceived stress, low social support, relationship conflict, and maternal role adjustment and provide possible new directions for anxiety detection strategies (e.g., assessing presence of relationship conflict, negative environmental influences, or sources of anxiety). Future studies should explore the course and stability of anxiety beyond eight-weeks postpartum, the influence of other participant characteristics on anxiety (e.g., demographics, obstetrical history, presence of pregnancy or birth-related complication), and the relationship between postpartum-specific anxiety and generalized anxiety in postpartum populations