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Adolescent and young adult (AYA) cancer survivors experience unique psychosocial needs during and after treatment. Mobile health (mHealth) interventions are an emerging area of research to help address unmet psychosocial needs. However, few studies have examined provider perspectives on the design-to-implementation pipeline. Guided by the Consolidated Framework for Implementation Research (CFIR), our study aimed to examine provider perspectives on facilitators and barriers to implementing mHealth apps in routine clinical care. AYA oncology providers participated in a semistructured 1:1 interview on facilitators and barriers to incorporating mHealth apps as psychosocial standard of care. We conducted a directed content analysis of the interviews using a standardized CFIR codebook and construct definitions, with codebook adaptations for mHealth innovations and the population of AYAs with cancer. A total of 20 providers (mean 39, SD 7.0 years; 80% female and 70% non-Hispanic White) representing various medical and psychosocial roles participated in the interviews. The data were analyzed with 16 CFIR constructs. We identified the following facilitators to mHealth implementation across four CFIR domains: (1) Innovation: alignment with patient needs, patient-centered co-design, strong research evidence, and user-friendly design; (2) Outer Setting: shared commitment to addressing mental health needs and openness to mHealth use; (3) Inner Setting: openness to training on mHealth use; and (4) Individuals: engaging key implementation partners such as bedside nurses and social workers and strong clinical team buy-in. We identified the following barriers to mHealth implementation across three CFIR domains: (1) Innovation: associated costs, (2) Outer Setting: heavy clinical workloads, and (3) Inner Setting: lack of cross-team collaboration and communication and clinical workflow integration. Our findings highlight key considerations for mHealth co-design, the adoption of mHealth apps into routine care, implementation strategies, and provider training opportunities in the context of AYA cancer care. Partnering with AYA cancer survivors, families, and providers will be crucial for developing and implementing mHealth apps with the ultimate goal of advancing universally accessible evidence-based digital health care.

Individuals suffering intolerably from a medical condition are legally able to request medical assistance in dying (MAiD) under certain circumstances. MAiD can either entail a physician or nurse practitioner prescribing fatal drugs for the patient to self-administer (physician-assisted suicide) or a physician directly administering lethal drugs (euthanasia). Whereas laws regulating MAiD have been in effect in different areas of the world since 1942, Canada only recently decriminalized MAiD in 2016. Individuals under the age of 18 years are not permitted to receive MAiD in Canada. Because legislation exists in other countries that permit MAiD, the current review aims to (a) review legislation and data pertaining to MAiD in Canada and other countries with particular attention on legislation for minors; (b) address important ethical considerations for extending MAiD services to minors in Canada; and (c) provide recommendations for amendments to current MAiD legislation in Canada based on the findings. Combining data from other countries with ethical implications for offering all options to relieve suffering, it is recommended that Canada extend MAiD legislation to mature minors with the inclusion of psychologists in the assessment of decision-making capacity and informed consent. Les personnes souffrant d'une maladie intolérable sont légalement en mesure de demander de l'aide médicale à mourir (MAiD) dans certaines circonstances. L'aide médicale à mourir peut soit impliquer qu'un médecin ou un infirmier praticien prescrive au patient des médicaments mortels à s'administrer lui-même (suicide assisté par un médecin), ou qu'un médecin administre directement des médicaments mortels (euthanasie). Alors que des lois régissant l'aide médicale à mourir sont en vigueur dans différentes régions du monde depuis 1942, le Canada a seulement décriminalisé l'aide médicale à mourir en 2016. Les personnes âgées de moins de 18 ans ne sont pas autorisées à recevoir l'aide médicale à mourir au Canada. Étant donné que la législation existe dans d'autres pays qui permettent l'aide médicale à mourir, l'étude actuelle vise à a) examiner la législation et les données relatives à l'aide médicale à mourir au Canada et dans d'autres pays en portant une attention particulière à la législation relative aux mineurs; b) à tenir compte des considérations éthiques importantes pour l'élargissement des services d'aide médicale à mourir aux mineurs au Canada; et (c) formuler des recommandations sur les modifications apportées à la législation actuelle sur l'aide médicale à mourir au Canada en fonction des conclusions. En combinant les données d'autres pays avec des implications éthiques pour offrir toutes les options pour soulager les souffrances, il est recommandé que le Canada élargisse la législation de l'aide médicale à mourir aux mineurs matures, avec l'inclusion de psychologues dans l'évaluation de la capacité de prise de décision et du consentement éclairé. Public Significance Statement The decriminalization of medical assistance in dying is a recent development in Canadian law. This article examines data from other countries as well as current issues within Canadian practice to examine the implications of extending medical assistance in dying to mature minors. It is argued that this extension is feasible and that psychologists have expertise related to this practice area that should be utilized.

Many long-term survivors of childhood cancer (LTSCC), individuals at least 5 years post-diagnosis or 2 years post-treatment, experience late- and long-term effects from their treatments, including pain. Yet, pain is poorly understood among LTSCC. The current study aimed to (1a) describe rates and multiple dimensions of pain; (1b) identify patterns of chronic pain; and (2) test correlates of chronic pain in LTSCC. Survivors (n = 140; 48.6% male, M age = 17.3 years (range = 8–25)) were recruited from across Canada. Between 2017 and 2019, participants completed the Pain Questionnaire, Pain Catastrophizing Scale, Pediatric Quality of Life Inventory, Patient-Reported Outcome Measurement Information System (PROMIS)–Pain Interference, Anxiety, and Depression scales, Child Posttraumatic Stress Scale, the Posttraumatic Stress Disorder Checklist for the DSM-V, and the Cancer Worry Scale. Results Twenty-six percent of LTSCC reported experiencing chronic pain. Exploratory cluster analysis showed 20% of survivors had moderate to severe chronic pain based on measures of pain intensity and interference. The combination of higher posttraumatic stress symptoms, older current age, more pain catastrophizing, and sex (being female) significantly predicted the presence of chronic pain in logistic regression, χ 2 (4, N = 107) = 28.10, p < .001. Higher pain catastrophizing (OR = 1.09; 95% CI = 1.02–1.16), older current age (OR = 1.20; 95% CI = 1.07–1.34), and higher posttraumatic stress (OR = 1.92; 95% CI = 1.01–3.63) were significant predictors of chronic pain. LTSCC should be screened for the presence and magnitude of chronic pain during long-term follow-up visits so appropriate interventions can be offered and implemented. Future research should investigate pain interventions tailored for this population. Relevance Findings support regular screening for the presence and magnitude of chronic pain in survivors of childhood cancer in long-term follow-up care.

Purpose Acute lymphoblastic leukemia (ALL) is the most common cancer diagnosed among individuals <14 years of age. The disease and its treatments are associated with negative side effects, including pain, which is both prevalent and distressing. Little is known about pain experiences in this population, which has slowed efforts to identify strategies to mitigate and cope with this adverse effect. This study sought to explore youth’s and their caregiver’s experiences with, and perspectives of, pain in the context of pediatric cancer treatment. Methods Youth and one of their caregivers were recruited through (omitted for peer review). Following completion of a demographic survey, youth and one of their caregivers were interviewed separately using a semi-structured, one-on-one interview guide. Demographic information was analyzed with descriptive statistics, and interviews were transcribed verbatim and analyzed using reflexive thematic analysis. Results Youth ( n  = 19; M age  = 15.3 years) and caregiver ( n  = 19; M age  = 45.4 years) perspectives informed 4 themes: (1) my pain experience is nuanced, multidimensional, and is changing over time; (2) the cancer experience has changed the way I experience and respond to pain; (3) I used strategies to manage pain, and not all of them worked; and (4) my pain experience was influenced by people around me. Conclusions Findings extend prior work, suggesting that pain is common, distressing, multidimensional, and influenced by social context. Results highlight the number of ways in which youth and their caregivers attempt to manage their pain and factors influencing pain experiences. Greater efforts are needed to address pain during cancer treatment and survivorship.

PurposeYouth diagnosed with acute lymphoblastic leukemia (ALL) and their caregiver’s experience a myriad of challenges in all domains of health that extend beyond treatment. Yet, little is known about how the cancer experience, and recollections associated with the experience, impact survivorship. We explored pediatric ALL survivors’ and their caregivers’ autobiographical memories of the cancer experience from diagnosis onwards.MethodsSurvivors of ALL, and one of their caregivers, were recruited through a local clinic. Survivors and their caregivers completed a demographic survey and semi-structured, private, one-on-one interviews. Demographic information were analyzed using descriptive statistics. Interviews were transcribed verbatim and analyzed using reflexive thematic analysis at the level of the individual and dyad.ResultsInsights from survivors (N = 19; Mage = 15.3 years) and their caregivers (n = 19; Mage = 45.4 years) were captured. Analyses generated two themes contingent on role (i.e., survivor or caregiver): (1) It is hard to recall my cancer experience and (2) We did as much as we could to manage our child’s cancer experience and two unified themes (present in both survivors and their caregivers): (3) It took a village to get through the cancer experience and (4) The cancer diagnosis and experience has had a lasting impact.ConclusionsFindings highlight the varied and long-lasting ways cancer impacts survivors of pediatric ALL and their caregivers. Survivors had difficultly remembering their experience or felt that information was withheld and were acutely aware of their caregiver’s distress. Caregivers were cautious and intentionally limited the information they shared.Implications for cancer survivorsSurvivors desired to be included within, or told about, decisions related to their healthcare and were acutely aware of their caregiver’s distress. Efforts should be made to communicate with survivors (from diagnosis onward) openly and to consider strategies to minimize the short- and long-term impacts of pediatric ALL among survivors and their caregivers.

There is a growing focus on describing both negative and positive outcomes in the wake of childhood cancer. The purpose of this study was to describe and explore the relationships between posttraumatic stress symptoms (PTSS) and posttraumatic growth (PTG) among children living beyond cancer and one of their parents. As part of a larger online survey, 113 children (Mage at time of study = 15.82 (SD = 4.81); Mage at diagnosis = 5.86 (SD = 4.66)) and one of their parents completed questionnaires assessing PTSS and PTG. Descriptive statistics were used to describe the sample and levels of PTSS and PTG. Data were z-transformed and analyzed using bivariate correlations and t-tests. An actor–partner interdependence model (APIM) was used to test whether children’s and their parents’ PTSS was associated with their own PTG (actor effect) and the others’ PTG (partner effect). PTSS was low and PTG was moderate in this sample relative to scale ranges. There were no significant differences between the children’s and their parents’ PTSS (p = 0.535) or PTG (p = 0.534). Results from the APIM showed no significant actor effects (p = 0.185). A significant overall partner effect (p = 0.020) emerged. Lower PTSS for children was associated with greater PTG for their parents (b = −0.29, p = 0.018), but parent’s PTSS was not associated with children’s PTG (p = 0.434). This sample reported similar levels of PTSS and PTG to that which has been reported in the literature. Children and their parents’ scores on PTSS and PTG measures were not significantly different from one another. Children’s PTSS was negatively associated with their parents PTG, illuminating the ways in which PTSS and PTG may be related in the context of childhood cancer. Exploring family-based strategies to reduce PTSS and enhance PTG may be warranted, though further studies are required.

Purpose The revised Psychosocial Assessment Tool (PATrev) is a common family-level risk-based screening tool for pediatric oncology that has gained support for its ability to predict, at diagnosis, the degree of psychosocial support a family may require throughout the treatment trajectory. However, ongoing screening for symptoms and concerns (e.g., feeling alone, understanding treatment) remains underutilized. Resource limitations necessitate triaging and intervention based on need and risk. Given the widespread use of the PATrev, we sought to explore the association between family psychosocial risk, symptom burden (as measured by the revised Edmonton Symptom Assessment System (ESAS-r)), and concerns (as measured by the Canadian Problem Checklist (CPC)). Methods Families ( n  = 87) with children ≤ 18 years of age ( M  = 11.72, male: 62.1%) on or off treatment for cancer were recruited from the Alberta Children’s Hospital. One parent from each family completed the PATrev and the CPC. Participants 8–18 years of age completed the ESAS-r. Results. Risk category (universal/low risk = 67.8%, targeted/intermediate risk = 26.4%, clinical/high risk = 5.7%) predicted symptom burden ( F [2, 63.07]  = 4.57, p  = .014) and concerns ( F [2, 82.06]  = 16.79, p  < .001), such that universal risk was associated with significantly lower symptom burden and fewer concerns. Conclusion Family psychosocial risk is associated with cross-sectionally identified concerns and symptom burden, suggesting that resources might be prioritized for families with the greatest predicted need. Future research should evaluate the predictive validity of the PATrev to identify longitudinal concerns and symptom burden throughout the cancer trajectory.

There are over 500,000 survivors of childhood cancer in North America alone. One in 4 survivors experiences chronic pain after treatment has been completed. Youths with chronic pain report increased anxiety, depression, activity limitations, and sleep disturbances. An 8-week web-based cognitive behavioral treatment for chronic pain (Web-Based Management of Adolescent Pain [WebMAP]) has demonstrated a reduction in pain in youths but has not yet been explored in survivors. The objectives of this study are to (1) test the feasibility and acceptability of WebMAP for a sample of survivors with chronic pain and their parents; (2) assess the acceptability of WebMAP using qualitative interviews; (3) assess WebMAP's effect on activity limitations, pain intensity, depression and anxiety symptoms, and sleep disturbances; and (4) assess WebMAP's effect on parent pain catastrophizing and parental response to their child's pain. A single-arm mixed methods pre-post intervention study design will be used. Participants will be 34 survivors and at least one of their parents or caregivers. Inclusion criteria are (1) a cancer history, (2) current age of 10-17 years, (3) >2 years post treatment or >5 years post diagnosis, (4) pain present over prior 3 months impairing >1 area of daily life and occurring >1 time per month, and (5) computer access with broadband internet. Survivors will complete a pretreatment questionnaire, which will include the following: the Child Activity Limitations Interview, the pain intensity Numerical Rating Scale, Patient-Reported Outcomes Measurement Information System (PROMIS)-Pain Interference, Anxiety, Depression, Insomnia Severity Index, and Adolescent Sleep Wake Scale. Parents will complete the Pain Catastrophizing Scale-Parent Version and the Adult Responses to Child Symptoms. Upon completion of pretreatment questionnaires (T0), survivors will begin WebMAP. After the 8-week intervention, survivors will complete the same measures (T1), and at 3-month follow-up (T2). Posttreatment interviews will be conducted to determine acceptability. Feasibility will be assessed via recruitment and retention rates. Treatment engagement will be measured by number of modules completed. Pre-post outcome data will be assessed using linear mixed models. Qualitative data will be analyzed using thematic analysis. Patient partners will be involved in study design, recruitment, interpretation of results, and knowledge translation. This study has been funded in January 2022. Data collection started in May 2022 and is projected to end in August 2023. We have enrolled 10 participants as of December 2022. Investigating whether WebMAP is useful to survivors will be an important step in improving pain management in this population. ClinicalTrials.gov NCT05241717; https://clinicaltrials.gov/ct2/show/NCT05241717. DERR1-10.2196/45804.

This dissertation consists of three essays exploring how human capital heterogeneity within cities enhances individual productivity. Agglomeration theory suggests productivity is driven by rapid and frequent interactions with others in spatially-constrained areas. Using formal education data from the 2011 American Community Survey, we empirically test that theory by estimating the effects of local human capital stock characteristics on individual wages. In essay one, we posit that some kinds of knowledge are harder to exchange remotely and thus workers possessing those knowledge types benefit more from close physical proximity to others. Our theoretical framework demonstrates the returns to finding a partner to exchange ideas with are heterogeneous across knowledge types. We propose agglomerative environments favor “soft skills” where creativity and informal networking are important. Our empirical results show people with non-STEM majors benefit more from locating within a city. Conversely, terminal degrees such as a J.D. or M.D. experience a smaller urban wage premium. Essay two studies the role of specialization of human capital types for individual productivity. Glaeser et al. (1992) finds local industrial specialization has a non-increasing effect on employment and wage growth. Our empirical results indicate specialization of knowledge can play an important role in promoting productivity when simultaneously controlling for a population size effect via the urban wage premium. We find STEM-related knowledge benefits greatly from local specialization of knowledge. However, the urbanization effect from city population size often exceeds the specialization effect. The third essay studies how workers in cities learn from one another in dense economic settings. Following Winters (2014), we estimate the impact of changes in the local stock of particular knowledge types on individual wages. The richness of our data allows us to estimate the productivity effects from over 400 different combinations of human capital interactions. We find most knowledge types are more productive when local STEM presence increases. The effect is strongest among workers with higher levels of educational attainment in the earlier stages of their careers. Similarly, areas such as government and psychology generate productivity gains among others. However, the lowest productivity gains occur from interactions with religious or education backgrounds.