Intervention Research in Mental Health Session 2: Innovations for Health & Mental Health Conditions

[Music] good afternoon everybody i'm john trotman henry meyer collegiate professor of social work and co-chair of the centennial it's my honor to welcome you to the second of three centennial lectures co-occurring health and mental health conditions as part of our centennial celebration we're excited to bring to you some of the groundbreaking work of our faculty at this point i want to turn it over to our associate dean to introduce the panelists hello everyone my name is joe hemley i'm a faculty member here at the school of social work and as john said the associate dean for faculty affairs um today's session provides examples of community-engaged and clinic-based research focused on multi-level interventions to address co-occurring health and mental health issues the interactive panel discussion will explore the diversity and promise of social work-based research now i get to introduce our speakers which will we'll do all together first uh our discussion for today's session and um is dr jamie mitchell jamie is associate professor of social work and is a health disparities researcher extensive experience conducting research on health behaviors health communication strategies uh with the focus of optimizing well-being and longevity for african americans with a particular emphasis on african-american men her reach research uh focuses on older african-american men's preventative health behaviors uh she has a recent nih r 24 grant involving the recruitment and retaining of older african americans in research so most recently dr mitchell has also taken on a role as a assistant director of the clinical research participation of clinical research participation at michigan medicine's robo cancer center so dr mitchell is our discussant our first panelist is dr jacqueline hawkins an assistant professor at social work in the school social work here associate director of the gender and health research lab and her dr hawkins's research agenda is focused on social determinants of health behavior in african americans and latinos with diabetes she's particularly interested in factors that contribute to and to contribute to excess as well as utilization of care and diabetes self-management she's particularly interested in community-based interventions targeting low-income african-american and latino men dr hawkins recently received an nihr 21 grant focused on diabetes self-management for african-american men our second panelist is dr david cordova uh dr cordova is an associate professor of social work also here at the university of michigan his research focuses on latino health inequities particularly as it relates to the prevention of substance use and hiv in adolescence professor cordova recently uh received an early career development award from the center for disease control and prevention to develop and test the efficacy of a family-based drug abuse and hiv in a preventative intervention to be delivered via the internet which we'll be hearing about later he's very interested in using community-based participatory research methods as well as qualitative and longitudinal methodologies to help us understand more about health equities and equities in latino populations next is professor brad zebrak a professor of social work here at the school his teaching and research interests are in the area of health medicine and quality of life he's particularly interested in the effects of cancer on the psychosocial growth and development of adolescents with and young adults his funded research also involves evaluation of implementation and psychosocial services and medical care settings he's uh recently a new principal investigator on an nih r01 grant focus on genetic mechanisms of health disparities among adolescents and young adults with cancer our final presenter is dr anal zhang he's an assistant professor at the school of social work also here at the university of michigan lots of good intervention researchers happening uh research happening here and he's a clinical research director of the adolescence and young adults oncology program mr at michigan medicine dr zhang is a health and mental health intervention researcher with a primary interest in psycho-oncology and adolescent and young adult cancer survivorship dr zhang is a principal investigator of a grant from julia's legacy of hope st baldrick's supportive care research program evaluating a tailored cognitive behavior therapy for aya or adolescent young adult cancer patients that you'll be hearing about later today so that is our panel so i think we will begin with dr jacqueline hawkins hi everyone i'm just going to go ahead and share my screen all right okay so um my my name's jacqueline hawkins um [Music] thank you for inviting me today i'm excited to talk with you all about my work especially as we celebrate the 100 year anniversary of the um school of social work i'm an assistant professor in the school of social work here at u of m i also am a graduate of the joint phd program in social work and sociology i just wanted to mention as well i'm the associate director of the curtis center for health equity and training and the co-director of the pilot and feasibility program for the michigan center for diabetes translational research and the title of my presentation today is program active african americans coming together to increase vital exercise a combination physical activity and cognitive behavioral therapy program but before i get started i just wanted to do a land acknowledgement really quickly so in the spirit of healing and health i acknowledge an honor that the university of michigan resides on the traditional territories of the three fires people the ojibwe ottawa and bodawami and that the great lakes region remains home to multiple tribal nations so our agenda for today is i'm going to share some background on the state of african american men and diabetes and what we know about their health behaviors next i'm going to discuss my current research including my research on programming for black men with diabetes and depression and then i'll just give some concluding remarks and i look forward to getting everyone's feedback and answering any questions at the end right so my research area is comprised of minority men's mental and physical health diabetes self-management and intervention development adaptation and testing for this population so the broader arc of my research right now is fundamentally concerned with the intersection of intervention research for minority men and specifically adapting existing interventions using implement and implementation science framework so first i'm going to go very briefly and give you all some background on diabetes it's relationship to mental health and then i'll discuss briefly the state of research on black men and diabetes self-management so nationally in 2020 about 34.2 million or around 10.5 percent of the population had diabetes and about 14 percent of men compared to around 11 to 12 percent of women had a diabetes diagnosis and in comparison the rates are slightly higher in michigan at about 11 and the disparities between men and women are slightly lower and compared to the us as a whole so in michigan 11.5 percent of men have a diabetes diagnosis versus 10 of women so for people in the room who may be unfamiliar with diabetes diabetes is a condition in which the body does not properly process food for use of use as energy so most of the food we eat is turned into glucose or sugar for our bodies to use as energy and the pancreas which is an organ that lies near the stomach makes a hormone called insulin to help to help glucose get into the cells of our bodies so when you have diabetes your body either doesn't make enough insulin which is type 1 diabetes or it can't use its own insulin as well as it should and that's type 2 diabetes this causes sugars to build up in your blood so why am i you know talking about type 2 diabetes and type 1 and giving you this background it's to impress upon you that it's a really serious chronic illness it's a very tough health condition to manage it can be and it has really severe and serious complications if it's not managed appropriately so engaging in several diabetes self-management behaviors is critical to living a healthy life with diabetes and again why is studying diabetes self-management specifically so important if it goes unmanaged it can be life-threatening so for example complications from diabetes can lead to health conditions such as diabetic retinopathy which can impact vision also because of the lack of blood flow caused by diabetes unmanaged diabetes can lead to nerve damage in the feet amputation and also kidney issues diabetes self-management means a daily adherence to a rigorous routine that's typically defined as checking your blood sugar daily taking any medications having a healthy diet regular exercise and checking your feet for sores and these are activities that individuals with diabetes must engage in every day or put themselves at risk for the serious health conditions i just mentioned i'm going to take a moment and do a poll people with type 2 diabetes cannot eat sweets people with type 2 diabetes need to watch their weight and maintain a healthy balanced diet but in moderation right so as part of a healthy meal plan desserts other sugary foods are definitely not off limits so another motivation for my work and what i'm going to be talking with you all about today is um thinking about diabetes and mental health so diabetes is associated with a significantly increased prevalence and risk for clinical depression and depressive symptoms so people with diagnosed with comorbid diabetes and depression frequently exhibit some sub-optimal health management a lower quality of life and increased diabetes related complications than persons with one or the other diagnosed only diagnosis only so even with successful treatment as many as 80 percent of patients with diabetes will experience a depression relapse often leading to a more pronounced expression of depression prior studies have reported also that african americans tend to under utilize mental health services compared to hispanic whites so due to the strong association between living with a chronic illness and implications for mental health in recent years the american diabetes association has called on clinicians and researchers to consider mental health when they're working with people with diabetes so what this table is describing here is that over the life course there are psychosocial symptoms and diagnoses you can expect to see in a person with diabetes based on the research so far and it also highlights the need for both physical and psychosocial care which means that people with diabetes should not only be seen by physicians and nurses but also should be interacting regularly with mental health care providers like social workers who which are critical in helping people with diabetes in particular deal with the psychosocial aspects of managing the disease which are just as important as prescriptions and testing and medicine and that's where my work comes in how can we utilize existing community infrastructures and mental health care providers like social workers to help people with the diabetes live healthier and happier lives but before i get back into the except for get into the exciting intervention step i say i want to take a step back and talk about the current state of men's health which is my population of interest so what we know from the research is that black men face a set of unique risk factors that have a negative impact on diabetes diagnosis rates and health outcomes including age cultural norms gender norms socioeconomic status and what we know from the research is that black men are disproportionately more likely to receive a type 2 diabetes diagnosis at later stages of the disease compared to black women and non-hispanic white men we also know that social context and other factors influence the types of masculinity that men construct and may

be similar but also different in important ways for african-american men and we know from the research that this construction can sometimes negatively influence their diabetes self-management and their interactions with care and lastly we know that there's a lack of research for both african-american men related to diabetes self-management and mental health care use so i published several articles that provide a foundation for studying diabetes in african-american men and i've looked closely at both psychosocial and gender related factors and how they impact diabetes self-management in this population but for the sake of time i won't go into detail about these studies the one that i will mention is a review that i did a few years ago with a couple of colleagues and we found after looking at diabetes self-management interventions from the last 20 years that black men who participated in that research were on average only 15 of the sample so in our existing research on african-americans related to diabetes self-management black men are underrepresented so next i'm going to go over next steps in my research uh with a specific focus on my intervention research that was heavily informed by my previous work um i also want to say you know i'm just going to go discuss this intervention really briefly but i'm happy to talk more about it with folks who are interested so i'm presently the pi on two pilot studies and the overarching goals of both of the studies are to improve health outcomes for black men with diabetes and my work focuses on the consistent evidence of failure to translate research findings into clinical practice i utilize the field of implementation science whose goal is to study determinants processes and outcomes of implementation of evidence-based interventions so i'm present presently conducting two studies the first is a peer leader diabetes self-management support intervention that's funded by nih and the second which i'll be talking with you about today is a physical activity and cognitive behavioral therapy intervention and that is a pilot study that was funded by the michigan center for diabetes translational research and the michigan department of health and human services all right so um i'm going to present on things a little differently um well most folks tend to present results i i'd like to talk with you all today about a study in its earlier stages so in terms of specific aims the first specific aim involved adapting an existing intervention in collaboration with black men with type 2 diabetes so we propose to adapt an evidence-based cognitive behavioral therapy and physical activity intervention called program active originally um and at the active stands for adults coming together to increase vital exercise and the second specific aim is to conduct a pilot randomized controlled trial of this adapted intervention to evaluate participant recruitment and retention rates how satisfied men were with the intervention of course the impact of the intervention on our primary outcomes which were depressive symptoms and glycemic control or hba1c and also to assess the impact of the intervention on our secondary outcomes which are diabetes social support and diabetes self-management behaviors so my proposed intervention is based on program active like i mentioned and the goal of program active originally was to assess the comparative effectiveness of cognitive behavioral therapy and exercise to usual care on depression and a1c outcomes that program was originally con conducted in rural appalachia and um also in an urban underserved environment all with folks with type 2 diabetes and it involved 10 individual counseling sessions and 12 weeks of community-based exercise so in terms of my ad adaptation we're still going to have um all the aspects i just mentioned however there's going to be some important changes so our intervention is going to focus obviously on african-american men um it's going to be based in detroit and due to the documented impact of gender norms thank you emma of gender norms on diabetes self-management and health behaviors in general we also included a gender norm scale in the in our study questionnaires and of course we're going to be incorporating ways to overcome the barriers that we identify to physical activity and mental health care use in the pre-implementation phase so i just wanted to say really quick you know why why cbt combined with physical activity specifically in the previous two inter iterations of program active depression remission among the participants um what in the in the intervention group was five to six times more likely and they sustained gains uh or rather not gains but improvement in their a1c over 12 months so after the program concluded folks in the intervention group had really great improvements in their blood sugar and when we checked or when the pi the original pi checked in with folks 12 months later they had sustained those improvements in their a1c so we know it works but how can we get black men with type 2 diabetes involved in a program like this that's very effective and beneficial so that's where program active with an extra a comes in in my work what we're proposing to do is to give all of the participants a nutrition education program we're going to randomize them to enhance usual care so they're going to receive referrals to community mental health providers and pedometers if they're in the control group in the first phase we're going to do two focus groups with black men with type 2 diabetes and the purpose of those focus groups is to assess barriers and facilitators to mental health care use and exercise and also to get their opinions on the feasibility and acceptability of these intervention materials uh our second phase will be to randomize to use the enhanced usual care and then also to randomize bulks to the combination cbt and exercise intervention and again that's 10 individual sessions and those are given in my study by licensed clinical social workers and they get 12 weeks of community-based exercise and those are six six of those classes are led by personal trainers um originally in the study also we had partnerships with the northwest activity center in the city of detroit and the detroit community health connection which is a federally qualified health center in detroit [Music] all right so the last thing i'll mention the last couple of slides here is uh while the intervention itself is 12 weeks we're conducting this study uh with a three-month assessment period to see if men were able to sustain any gains they had during the program our data is going to be collected at three time points baseline three months at the conclusion of the intervention and lastly we're going to collect like i mentioned three months post-intervention and this is below is just an example of what the men need to do each week for the intervention these are some of the study measures that we're going to be collecting um obviously we're going to be asking folks to come in we're going to get their biometrics um during the course of the intervention we ask them to keep a physical activity diary everyone gets a pedometer um and we get everyone's like like i said biometrics so these are the last slides i promise um so here's a poll people with diabetes can fill when their sugar levels are high or low false you may feel certain symptoms like weakness or fatigue if your blood sugar levels are low or high but the only way to know your blood sugar levels for sure is to test them so people who don't test regularly may have blood sugar levels that are high enough to damage the body without them even realizing it so i just want to conclude with some questions to consider as we move forward with doing this intervention some things that have come up is you know what's the best way to recruit and retain populations that typically do not participate in research and also have fewer interactions with health care and the second question that we are grappling with is what other existing community infrastructures might we utilize to help sustain the program in the long term and that's it i just want to thank everyone for coming today and i look forward to discussing all right good afternoon everyone i'm david cordova and i'm faculty in the school of social work and i'm excited to share with you a little bit today about our program of research that's focused on reducing substance use and sexual risk behaviors and enhancing hiv and sti testing among youth so just to tell you a little bit about the background of our program of research and the significance youth here on defined as adolescents and emerging adults 14 to 21 years of age are in a developmental period that can be characterized among other things of enhanced vulnerability and particularly what we're interested in here is the youth disproportionately engaged in many risk behaviors that are enhanced their vulnerability to mortality and morbidity so for example national surveillance data from the

monitoring the future study indicate that youth engage in many substance use behaviors and so the most widely used listed and illicit substance use behaviors include alcohol use and marijuana use in addition when we look at data from the centers for disease control and prevention many youth also engage in condomless sex and last sexual intercourse given that substance use and condomless sex are risk behaviors for both stis and hiv infection it should not be surprising then that youth are disproportionately impacted by sti and hiv infection in fact despite accounting for nearly 25 percent of the sexually active population youth accounted for nearly 50 percent of all new sti infections in the previous year in addition youth accounted for 25 of all new hiv infections despite the high prevalence of substance use and sexual risk behaviors and sti and hiv infection sti and hiv testing a national institutes of health research priority remain relatively low among youth in fact only nine percent of youth report having ever been tested for hiv in their lifetime in addition many youth are not routinely screened for asymptomatic stis as recommended by the centers for disease control and prevention and yet relatively few interventions have been developed to enhance the uptake of hiv and sti testing and prevent and reduce substance use and sexual risk behaviors among youth therefore the purpose of this study was to examine the preliminary efficacy of storytelling for empowerment in enhancing the uptake of hiv and sti testing across the trial and reducing substance use and sexual risk behaviors at three and six months among you so here we have our first poll question which i believe emma will be placing up all right so storytelling for empowerment is theory driven and informed by eco-developmental and empowerment framework so from an eco-developmental perspective youth are embedded in interrelated and interconnected contexts that both shape the youth and are shaped by the youth over time and so our research and that of others have demonstrated the utility of an eco-developmental framework to inform family-based interventions with a particular focus on enhancing parent and youth communication in the present study however

we focus on the clinic microsystem with the opportunity to focus on clinician youth communication in addition from an empowerment perspective youth have the necessary tools and resources and strengths and so here we have an opportunity to link them with important adult figures such as clinicians to reinforce and to enhance some of those strengths so a little bit about the storytelling for empowerment intervention so this is an adaptation of a best practice that's registered with the substance abuse and mental health services administration and has demonstrated in the face-to-face version effectiveness of preventing and reducing substance use and sexual risk behaviors among youth and so applying the principles of community-based participatory research in conjunction with knight of prevention principles we adapted the storytelling for empowerment intervention into a web-based mobile health app and so both youth and clinicians were involved in the adaptation process and informed all the decision-making processes of the research from the submission of the proposal to the dissemination of findings and so here for example youth were involved in developing the user interface and the user experience of this mobile health app so they through an iterative process selected the colors selected the landing page selected the content and the process of this web-based app and so s4e consists of an assessment a risk assessment followed by modules that focus on sexual risk behaviors substance use and hiv and sti testing so with youth interact with this web-based app they first complete a risk assessment that's focused on substance use sexual risk and hiv and sti testing practices following this assessment youth then are provided with targeted and tailored content so for example if during the risk assessment youth endorse substance use behavior such as marijuana use and having engaged in condomless sex then youth are recommended in initial five videos and interactive content and then in addition there's an additional 40 videos and interactive content that were also youth identified and developed that the youth can also engage with throughout the duration of the app and so as i mentioned the app consists of uh storytelling scenario videos and so here we developed characters that resonate with youth and place them in real world settings and contexts that reflect some of the situations that uh youth discuss during the formative research beyond the inter the storytelling uh videos youth also helped to develop interactive content including for example here the the characters um in here they're able to touch on their mobile device different parts of the body to see for example the effects of substances on various parts of the body so beyond the youth facing act we also developed a clinician-facing app that communicates synchronously with with the youth-facing app and so here we interviewed clinicians who informed us that their clinic's risk assessment wasn't doing a very good job of flagging the specific risk behaviors and also many were very lengthy and so we streamlined this risk assessment and more easily flagged the specific risk behaviors for the clinician and so what this did was facilitate a clinician-initiated risk reduction encounter where clinicians can then focus in on the specific risk behaviors that the youth reported which then allows them to provide targeted and tailored prevention services in addition we also provided the clinicians with the resource toolkit again this is based on the use risk responses where the clinician can then not only reinforce specific prevention messaging but also link the youth to important prevention services in the local community such as free hiv and sti testing and substance use prevention services and so now that storytelling for empowerment has demonstrated high feasibility acceptability and preliminary efficacy at 30 days post baseline in the present study we hypothesized that relative to the control condition participants in the s4e condition would see an enhanced uptake of both hiv and sti testing across the trial in addition we hypothesized that relative to the control condition participants in the s4e condition would report greater reductions in both condomless sex and substance use behaviors at three and six months post baseline although um given the preliminary efficacy nature of our study we didn't do any formal mediation analysis we did test changes in our potential mechanisms of change namely youth clinician communication as well as self-efficacy refusal skills and given the preliminary efficacy nature of our study we de-emphasize the significance testing and rather our purpose here was to establish the necessary parameters to inform a future randomized controlled trial okay so a little bit about the study design we recruited 100 participants in the current trial and to be eligible for this study participants had to be between the ages of 14 to 21 um be sexually sexually active defined as having had oral vaginal or anal sex in the past six months and that was because our primary outcomes for hiv and sti testing and then also report having access to a mobile device as well as report not having any tentative or firm plans to move out of southeast michigan and so participants were randomized and then assessed at baseline um and then reassessed at three and six months post baseline and notably at six months post baseline we had a 95 retention rate so a little bit about our participants we recruited a diverse sample of youth 44 reported as non-hispanic white 38 is african-american 5 hispanic with a mean age of approximately 19 years of age 25 were less than 18 years of age and approximately 66 percent identified as female so here's another poll question okay so with respect to hiv and sti testing relative to control group participants in the s4e group reported a higher uptake of both hiv and sti testing across the trial and this produced a small effect size with respect to past 90-day condomless sex participants i'm sorry my participants uh relative to the control group participants in the s4e group um reported greater reductions in past 90-day cognitive sex at both three and six months post-baseline with respect to past 90 day marijuana use participants relative to participants in the control group participants in the s4e group reported greater reductions at three and six months post baseline and um [Music] both participants in the s4e and control group reported a 10 reduction at six months post baseline in past 90 day alcohol use and so then we examined the potential mechanisms of change of our intervention and both youth and clinicians in the s4e group reported a higher level of youth clinician communication relative to both youth and clinician in the control group and this produced a large effect size additionally relative to youth in the control group youth in the s4e group reported a larger increase in self-efficacy refusal skills at six months post baseline and so our findings suggest that s4e demonstrated preliminary efficacy particularly in enhancing uh the uptake of hiv and sti tests sti testing across the trial as well as reducing condomless sex and marijuana use past 90 days at three and six months post baseline contrary to what we hypothesized participants in both the s4e and control groups reported similar reductions in alcohol use so it may be that perhaps s4e doesn't have an effect on on alcohol use or in line with nida prevention principles we may need to enhance the content and also incorporate some booster sessions that focus on alcohol prevention messaging in addition participants in the s4e group also reported higher increases in the potential mechanisms of change namely clinician youth communication and self-efficacy and so this is an important advancement in the scientific knowledge of mobile health interventions especially given that relatively few have identified potential mechanisms of change on substance use and sexual risk outcomes so finally show the promise of s4e particularly in the areas of hiv and sti testing and on substance use outcomes and indicate that perhaps maybe a larger efficacy trial may be warranted the study findings however should be interpreted in light of several limitations first you know this is conducted at one youth center community health clinic and is not representative of the entire clinic population nor the u.s general youth population and so this limits the generalizability in addition we relied on soft report measures and although researchers have shown the reliance of self-report measures future research may want to also incorporate some biomarkers in future research and finally this study also recruited participants who are currently seeking services at a clinic and so we may be missing a very vulnerable population and those youth who are currently not in services and so future research may work to to engage and recruit participants who are currently not seeking services nonetheless the present study plays an important role in advancing the scientific knowledge on mobile health interventions and the potential impact that they have on preventing and reducing substance use sexual risk behaviors and enhancing hiv and sti testing among a vulnerable population thank you all right i take it i'm good to go people out there hello you're good to go go ahead okay very good thank you uh hi everybody good afternoon good morning to you wherever you may be i'm brad zebrak professor here in the school of social work um and uh first just want to start by expressing my gratitude for the invitation to uh take part in this 100 year anniversary of the school social work which has played a big role in my education versus a doctoral student in the joint program in social work and sociology and now having been on faculty here at the university of michigan for the past 13 years i'm going to start you off with my poll question so emma you can go ahead and post that up and i'll actually take a little take a pause for a few seconds and give folks a chance to answer here i'm talking about cancer i'm talking about support cancer support for people affected by cancer so uh who is it that provides psychological and supportive care for cancer patients and their families is it nurses is it physicians is it social workers or is it all of the above there we go most of you did sort of catch that this was a little bit of a trick question um it is true um that all of these folks do provide support to cancer patients and their families and i'm having a little trouble advancing my slides here there we go um and yet even though that all these providers do provide support and care to some extent i would argue that social workers are the only professionals who are specifically trained um uh and skilled to facilitate access to the services and the resources that are required uh to respond to the full range of needs expressed by patients and families affected by cancer social workers the most knowledgeable in terms of the evidence base and they're most skilled to implement the effective and evidence-based interventions within clinical care and they're also oriented to issues of equity and justice in their education and and training so in my presentation today i'm not necessarily focusing on a specific intervention i'm really making the argument that social workers are critical interventionists in optimizing care for people affected by cancer as well as for achieving equity and addressing the disparities which i'll talk about a little bit um first a little bit of background on cancer and really who was affected here in the united states um the lifetime incidence of cancer for adults in the united states is one in two males and one in three females so in essence uh one in one out of every two males are expected to be diagnosed with cancer at some point in their lifetime and one in point one in three females are expected and you could see that if and when diagnosed with cancer these are the the three leading types of cancer that both males and females would would or could be diagnosed with as well as the leading cause of death when cancer is the cause of death you could see that pretty much both males and females lung cancer followed by prostate cancer for men and breast cancer for females and colorectal cancer are the leading causes of the death so in essence everybody in this country at some point in their life will know somebody with cancer and for the last 60 years or so malignant neoplasms which is cancer along with heart disease have been the two leading causes of death for citizens in the united states accounting for about 44 percent of all deaths this is data from 2017. these figures have been a slightly decrease in in terms of numbers of death absolute number of death uh deaths over the last few years but have pretty much rest been steady um since 2017. what i do want to point out given that we've all now been through about a year and a half worth of of the covid um virus um in one year ranging from 2020 to 2021 kovit has with over 500 000 deaths uh can be um identified as the third leading cause of death in the united states over the last year following cancer and and heart disease now some people have tried to argue that given that people with chronic conditions such as heart disease or cancer are then most likely to be the ones that died with their deaths attributable to covid that perhaps those numbers for cancer and and heart disease would actually be lower you know again given if folks if they've moved from cancer or heart disease is the cause of their death to covid um that that those numbers would decrease but in fact what we see and from data reported by the cdc that actually the opposite is true that given covid we've actually seen an increase in the excess deaths attributable to cancer so in 2020 if you're looking at this this bar chart here for both colorectal cancer and breast cancer colorectal cancer and breast cancer we saw about 500 to 600 more deaths than we would have had covid not occurred in this country and what we're seeing projected over the next 10 years are actually increases in the projected rates of death attributable to colorectal cancer or breast cancer because of covid and the explanations that have been provided is that covid has led to a lot of other pressures within our health care system which is which has attribute contributed to delays in diagnosis we know that early detection and prevention is one of the key ways of preventing morbidity and mortality due to cancer but because of covid we've seen many delays in diagnosis we've also seen interruptions or alterations and treatment regimen folks showing up to the hospital or not even going to the clinic for their chemotherapy or their radiation because those spaces within hospitals have been taken up by people who have coveted and need that that kind of attention the loss of employment as well as the associated loss of health insurance has minimized has led to a decrease in access to care again without that that key without that health insurance key to get in to see a doctor um that's going to contribute to delays um and further contribute to these risks of morbidity and mortality due to cancer we've also seen decreases in practices of preventive care we've seen increases in small of this excess rate of death attributable to cancer and influenced by covet 19. um the federal government and she conceptualized cancer as not just a disease process with associated medical treatment but also a succession of social interactions and psychological conditions that accompany uh including um uh holland and roland who have uh date back to some of the original founders of this notion of integrating the psychological and social aspects of of life into cancer care they've identified these five different domains in which people our lives are disrupted or affected um uh when when impacted by cancer sometimes referred to as the five d's this first in terms of distance cancer impacts on on uh distance between in relationships altering interpersonal relationships um there's disfigurement the experience of body image or sexual image and integrity of the physical body people feel that um in their effects of cancer in their body it's disabling uh including a disabling of of people who in their life their life goals and and dreams that they have for their future uh regardless of however old they might be um they experience those disruptions when cancer strikes um they're oftentimes forced into dependence on others you know living wanting perhaps desiring to live independent lives and yet oftentimes then having to require help from others being positioned to have to ask for help from others can be a very challenging and uncomfortable position for folks and then of course confronting one's own mortality uh when diagnosed with cancer so the the psychological and emotional fallout that occurs alongside the biology and the treatment for cancer are really key and critical to attend to and i would argue that this is really the domain for for social work and cancer care there have also been conceptualization uh conceptualizations of cancer as being experienced as psychological trauma um here you can see some some theoretical uh presentations particularly by george bonanno uh well known in the field of psychology and trauma where he's theorized that when when folks are exposed to trauma they might follow one of four different trajectories over a period of time that for some people and if you look at that line there at the top of this this bar chart i'm sorry top of this graph line graph you'll see that um for some people at the at their experience of trauma their psychological response their their their psychological social functioning is severely impacted and that over time um that impact uh remains severe over time and he has labeled that a chronic a chronic trajectory of trauma the second line which begins that dash line and then and then decreases over time that some people at that exposure to trauma experience perhaps moderate levels of distress at the time of exposure but then recover over time assumedly because they have access to either intrapersonal interpersonal community-based resources uh that play a key role in in their emotional or psychological recovery over time uh for others who may experience a moderate moderate level of distress at the time of exposure um that that level may actually increase over time and is labeled a delayed trajectory and there may be again other environmental social factors that come into play that increase the likelihood that these folks will actually increase in their levels of distress over time after being exposed to that trauma and then finally is a subset of group of folks following what's called a resilience trajectory that they have they they presumably have intrapersonal and and environmental resources available to them at the time of their exposure to trauma which may minimize that uh their emotional response to that trauma and and and remains um within somewhat of a mild trajectory over time so i was interested in testing whether or not this this model actually applied to teenagers and young adults impacted by cancer a population that i've been interested in uh both as a clinician working in the

field of pediatric oncology uh as a social worker and then making this the focus of my uh academic research and in fact in our in our uh a longitudinal study of 152 adolescent young adult cancer patients uh we did find over time that um the that subgroups did follow these different trajectories so you can see here uh that in terms of a chronic trajectory uh 11.8 percent almost 12 percent of our sample remained um uh at a significant uh clinically significant levels of distress over time another 15 of them followed that delayed trajectory uh about just under 20 followed that recovery trajectory and about half um followed a resilience trajectory and then to the right in the other column you can see there was a comparable study published in the literature that did a similar work with adult patients diagnosed with colorectal cancer and again found a subset of folks following in both the chronic the delayed the recover and the resilience trajectories and i think this that this work is um is meaningful and significant particularly today in an era where you hear discussions around what's called precision medicine the ability to identify uh or detect um or predict which which folks are going to be most significantly impacted in in negative ways by their condition uh so that we can really focus our resources on those folks who are at the highest risk and then titrate or or moderate or modify uh the attention given to others based on the times time points at which they might express express a need within the cancer field regardless of type of cancer diagnosed regardless of the age of the the sample and the study we've seen consistent findings of anywhere from 30 to 40 percent of people diagnosed with cancer uh demonstrate symptoms of psychological distress which could be attributable to symptoms of depression or anxiety they may be a function of of um of tension in in relationships intimate relationships uh there may be other challenges in in the home in the family uh that are that are contributing to their distress and and may subsequently serve uh as impediments or barriers to accessing or receiving um optimal care so in terms of the role that psych uh that social workers play within the the the domain of cancer care um the institute of medicine has defined psychosocial services as the psychological and social services or interventions that enable patients their families and health care providers to optimize biomedical care and manage the psychological behavior social aspects of illness and its consequences the point here is that managing the psychological and social impact is is equally as important to the provision of the the biomedical care because without attending to the barriers of care what good is the chemotherapy what good is the the medical intervention if folks can't get there if folks can't optimize their um their access utilization and benefit of that treatment and if we look at at psychosocial the research in this field um since the 1970s the first those are the first empirical studies of psychological and social impact of cancer identifying these domains and what social workers practice um but then by around 2008 a landmark study by the institute of medicine came out uh looking at the extent to which psychological and supportive care was being made available uh to patients and families in the extent that they were benefiting from that and they reported that most folks in need were also the least likely to get those needs met and then some work in 2016 looking at the organizational structures uh the resources across cancer centers in the united states there was an uneven and unequal capacity some centers across the country were very highly resourced uh had had very well established ratios of social workers to patients uh whereas on the other end uh there were some uh centers that were really doing you know poorly in terms of having resources including social workers available uh for their patient population um i want to finish up in the last few minutes by introducing an emerging scientific area one that i've been pretty interested and excited about uh that also aligns with contemporary attention to social determinants of health and looking at the upstream factors that contribute to downstream needs and particularly in the field of cancer i've always been intrigued by sarah gillard's work in which she has posed this question about trying to get an understanding of how the the environment gets under people's skin to literally affect their health outcomes and then disparities in those outcomes um and if we look at the way that cancer treatments have evolved over the years we can kind of see and recognize the ecological context that has driven not only the biomedical approach to cancer treatment but also the psychosocial care i think most folks are unders understand the notion that chemotherapy literally chemicals that are injected into people's bodies as a way to attack cancer cells cancer cells are are mutating genes they're they're they're genes that are replicating out of control and the purpose of the chemotherapy is in essence to stop that um that reproduction of those of those um uh mutating genes um but we've we've made advances uh primarily due to the advances in in genetics and genomics where we're now understanding that those cancer cells exist within it sort of if we're thinking ecologically here the microbiome those cancer cells are living in a neighborhood of other cells and some of those other cells feed those mutating cells feed those cancer cells so the next level of of treatment evolved to to start thinking about well maybe if we if we also can target the neighborhood of those cancer cells perhaps starve off the the energy to those cancer cells that could become another viable way of treatment and we've seen that evolution in in cancer treatment over the years attacking or addressing the microbiome but that microbiome exists within a next level of concentric circle or context which is the immune system and today we've seen emerging therapies particularly gleevac for those folks diagnosed with uh particular levels of types of leukemia and lymphoma as well as the emergence of immunotherapies car t being one of the more recent inventions here that that target the immune system uh recognizing that the immune system operating uh uh can affect both that microbiome that neighborhood of the cancer cells as well as the cancer cells themselves and that the immune system can be observed in terms of a genetic profile and this whole basis now for precision medicine really has to do with identifying biomarkers being able to to look at a gene profile and and and look at its association with the function of the immune system and then be able to assign a particular immunotherapy that will be responsive to the genes that are being activated um in this particular case so when we hear about searches for biomarkers this is what our biomedical scientists are trying to do they're trying to look at a at a gene profile and use it as a way to predict which patients are more or less likely to respond to a particular um a particular therapy well again moving on thinking conceptually those those biomarkers our genes are responsive to the brain the brain is the conductor of gene activation it's the conductor of our our entire bodily function and we know that the that the brain is susceptible to stresses uh to hormonal stimulation and these are the things that come from our social environment thus we're making the connection and here we get an example tamoxifen therapy for women diagnosed and treated for breast cancer are often put on tamoxifen afterwards as a way to sustain or maintain brain function cns function in order to influence gene function which then leads to controls of physiology of bodily systems and bodily functions so what i'm doing here is saying that if all of this is then being driven by the brain and we know the brain confident to engage in their own care even their their their psychological set their intention to uh attribute meaning or have a sense of purpose in life uh related to cancer um this is the domain of social work and this is where we can play a key role um in in responding and um and uh complementing uh treatments for cancer um this is um where things are at today this is i just probably tried to cram in a whole semester's worth of of biology in a short 20 it looks like brad might be having some trouble with the uh camera but i think he was just about to end up so i think what we'll do is move on to and now uh looks like we have a poll question we'll move on to dr zhang and then there'll be a chance later for dr zebrak to uh answer some questions thanks a ton brad really great i hope everyone can see my screen yes if you cannot okay cool all right let me restart my timer okay um good day everyone it is really a pleasure having the chance to share with you some of the work that i have been glad in collaboration with my colleagues from um school of social work michigan medicine in supporting the complex psychosocial needs among adolescent and young adult aya's diagnosed with cancer my name is danielle john i am an assistant professor at the um school of social work it's always nice to do a cancer related presentation following brad zirak just because he lays such a nice ground and foundation for the important context of psychosocial care for cancer survivors and in this case i wanted to argue that for aya aya is an age defined population with cancer between the age of 15 to 39 years old which include three distinct developmental stages which are mid to late adolescence those 15 to 18 years old emerge in adulthood 18 to 25 years old and the young adulthood which is 26 to 39 years old and throughout their cancer journey ayas with cancer are continuously confronted with multiple stressors including invasive curative treatment options that are often painful and burdensome for them the immediate treatment symptoms and side effects such as nausea insomnia and significant changes in one's appearance also there's a long-term and often irreversible impact on ai's fertility capacity lung or heart health health etc and of course there are many unique psychosocial challenges that are specifically belonging to the aoi population which includes uncle fertility financial toxicity sexual health just to name a few and many of these have long term and lifelong implications for the wellness of aoi is diagnosed with cancer so when combined all these factors put aya with cancer at significantly higher risk of experiencing psychological distress especially depression and anxiety so before we start the first poi i want to provide you the context and then we'll do the poll so according to the national institute of mental health and data from the 2019 nas nhd uh data set there is an estimated 7.8 of the u.s adults the general adult population 7.8 of them experience depression so the poor question here is what is the estimated rate of depression among adolescents and young adults with cancer brad kind of has already allured to that idea a little bit we know it's definitely higher than the general population but i would just give everyone maybe 10 seconds trying to you know putting your thoughts with regard to the prevalence rate of depression among aye is diagnosed with cancer all right you can keep voting but i'm going to give you out the answer the answer is 25 so while there exists no rigorous data to systematically evaluate the rate of depression among aye is diagnosed with cancer existing studies estimated the prevalence rate of depression among ays with cancer ranged between 16 to 42 with the recent meta-analyses estimating an overall prevalence rate of 25 aya survivors having depressive symptoms um we have a next pool um and uh we can pull out the point and i'm going to read out the question right so for me as a clinical social worker my immediate i i would immediately start to wonder now so we know that depressive symptom is highly prevalent among ayas but when do we have evidence-based interventions for us to support this population and the question here is when compared with interventions for pediatric cancer survivors psychosocial interventions for psychological outcomes among aye survivors are equally effective more effective than the pediatric cancer survivors less effective than or the evidence remain inconclusive [Music] so our team recently published the meta analysis in the journal critical reviews in concology hematology we looked across 61 clinical trials of supportive interventions for pediatric and ay cancer survivors and one of the key findings unfortunately for me as an aoi cancer researcher was that on average psychosocial and supported treatments effect was significantly lower among aya cancer survivors than their pediatric counterparts were diagnosed with cancer this means that although we know that efficacious depressive treatments are available for ayac in general meaning most of those without cancer such as cognitive behavior therapy when it comes to deliver research-supported treatments like cbt to ay cancer survivors these interventions are not as effective as they stand now and published studies have found that cbt is only effective for ay cancer survivors when first the treatment option is available and easily accessible to the population and more importantly when aya cancer survivors are compliant engaged and cooperative with available treatment options both sets of requirements however have not been successfully or at least to my knowledge actualized in the real world practices of psychosocial oncology supporting ays with depression first um i think it doesn't come as a surprise that cbt is often not easily available or accessible to ais with cancer mimicking the pattern of mental health professional workforce shortage nationally and internationally studies have consistently reported additional factors that contribute to the mental health workforce shortage in psychosocial oncology supporting ayas one factor being the required expertise to address mental health conditions co-morbid with cancer and even for those nci designated comprehensive cancer centers such as michigan medicine that have certain level of mental health resources and workforce available a waitlist is often long between usually between one to three months and not all providers are fully trained in delivering evidence-based therapeutic intervention such as cognitive behavior therapy and with recent advances in computer and mobile technologies tech-assisted cbt's tcbts have been found as a promising solution to reduce the access barriers facing many aya cancer survivors in need of mental health support with that said however although tech assisted cbt's tcpts are highly promising in addressing access areas most programs are academically oriented and text heavy and does not engage clients effectively in addition to our knowledge there exists no tcpt that specifically is designed to meet the unique medical and psychosocial challenges confronting aoi is diagnosed with cancer leaving a major gap in the aoi psycho-oncology literature so taken all together our team identified four key areas of improvement that are needed to address depression among ays diagnosed with cancer first it is important to integrate cancer-specific disease management and educational content into tcbt treatment to ensure content relevance second it is critical to be innovative to create fun and engaging treatment content that are attractive to aya cancer survivors a younger population that is known to be difficult to engage in the therapeutic process third it is also important to accommodate visual materials that are aesthetically appealing and developmentally attractive to aya populations including as specific especially for those who are traditionally underserved like racial and ethnic minority aya cancer survivors and finally it is critical to consider platform-based based tailoring features that are easy flexible and allow low-cost tailoring to maximize individualized treatment options and maximize treatment uptake the program that i'm sharing with you all today is highly pro is a highly promising platform that simultaneously meets many of if not all of the areas that were mentioned the previous slide the program is called mind your total health the myth program which was named by a group of young adult cancer survivors who overwhelmingly expressed their preferences of not having the word cancer in the naming of the program and also found somewhat the acronym myth being cool the myth program is an aya cancer specific tcpt program that is tailored based on its parent program entertainment well which was co-developed by doctors addie weaver and joe hemley with support from the national institute of mental health and for those of you who attended the first lecture series dr weber shared her work delivering the ross program to rural residents with depression and there's a sister program with the myth program inheriting many strengths of the parent program the myth program engages its user with a retrospective engaging storyline and include most sessions ending with a cliffhanger to boost treatment compliance in addition myth utilizes platform-based tailoring features from entertainment ul and thoroughly modify those educational and motivational panels for developmental medical and the psychosocial needs of ay cancer survivors which i will further elaborate just in a minute but first and foremost myth contains core therapeutic components of cbt interventions including cognitive restructuring behavior activation and problem solving although platform-based tailoring features are available in the myth platform those contents related to core cbt fatality including the order of delivering certain content are locked in a sense and cannot be easily changed to ensure program and treatment fidelity when we are tailoring the program we engage in a community and stakeholder engaged process we interviewed aya cancer survivors themselves uh leaders asking for their imp the static and potential helpfulness of the client of the content so here are just some of the screenshots of the storyline throughout the sessions as billy the main character the blue the blue balloon uh retrospectively walking the user through their experiences of overcoming depression as briefly mentioned earlier a notable innovation of the program includes a cliffhanger effect and just to give you an example in session six the story line ended with billy the balloon debating whether she should take up in an offer to meet with her just reunited high school sweetheart johnny at the diner but still haven't heard back from the text that she sent johnny earlier and that's the end scene of that session naturally uh the users would need to come back to session seven to figure out what happened to billy did billy go did billy not go so that's what we were thinking about the cliffhanger and that is an effect that occurs in most of the sessions in addition we also made major tailoring of visual materials motivational quotes and cbt related examples throughout the sessions to better reflect the program's relevance to a population that has cancer and are younger and as you can see we were also mindful in ensuring those materials that are inclusive of different identities to the best of our abilities most importantly we were very intentional in integrating cancer-related content into the tcbt component such as behavior activation just give you an example the screenshot on the lower left side is a tailored educational panel doing brainstorm sessions with aya survivors on potential

activities for pleasurable and for achievement activities um as you can see we included some low intensity physical activities taking into account the likely physical limitations and some of them are timely some of our more long-term during and after one's cancer treatment and we also suggested cancer management as part of the activities for achievement to encourage users aoi survivors better health management behaviors finally i just wanted to underscore kind of the full potential of the platform and it can be easily achieved for us to create more individualized platform materials such as an educational panel specifically designed for ayes serving in the military with the diagnosis of lymphoma on the lower right side of the slide and our team have recently submitted an ron application to the department of defense proposing a military-specific aya program we were beyond grateful to receive the psychosocial grant from julius lexi of hope uh hero fund through the baltics foundation to conduct a pilot randomized control trial to evaluate the feasibility and preliminary efficacy of the myth program in reducing ay cancer survivor's depressive symptoms using primarily a clinic-based recruitment strategy at michigan medicine in conjunction with um community-based participant self-referral we recruited participants between the age of 15 to 26 years old with a current cancer diagnosis and experienced moderate or greater depression a participant can either receive active curative treatment or within five years of post-treatment survivorship and the exclusion criteria include if participants as receiving end of life care or current currently experiencing acute mental health conditions such as active psychosis or at an elevated level of self-harm over over a eight month period between september 2020 to april 2021 our team con contacted 49 potentially eligible participants 20 of these participants were not interested in the study for various reasons such as identified not depressed uh or not interested in a computer-based program due to overexposure to computer and uh in addition 12 potential participants did not meet the study inclusion criteria including nine with a a low level of depression two participants were receiving end of life care and one participant reported history of suicide attempts over the past two months consequently this study has resulted in 17 participants being randomized into the treatment alarm and the control arm so participants in the treatment arm received the myth program which is an individual based a session tcbt delivered on a weekly basis the participants were instructed to complete the program weekly but they have up to 10 weeks to complete all eight sessions upon completion of each session a master's level trained research assistant would follow up with a five to ten minute checking phone call to reinforce session content and link specific session content with participants cancer management all research assistants were instructed not to provide additional therapy we decided to add this clinician follow-up based on the best practice guideline of the literature but the brevity of the clinical contact here is important because five to 10 minutes of the of the interpersonal follow-up does not really further strengthen the mental health workforce given the gravity of the content similarly participants in the control arm received an existing tcpt program beating the blues which is as you can see had very similar intensity in their frequency as the myth program uh the other protocols were all identical with the treatment arm the only difference is that the beating blue is a rather academic and a text-heavy generic version for depression and it does not have cancer-specific tailoring for the for the participants so we evaluated the feasibility acceptability and participants clinical improvements using well-established and psychometrically validated scales given the constraint of time i just wanted to highlight some of the key findings here first eighty percent of the participants in experimental arm achieved the feasibility and point evidence by completing six out of eight mid sessions versus in the control the feasibility endpoint was reached by 71.4 percent of the participant there are two more nuanced pieces that i would like to share uh six out of the eight participants in experimental arm who achieved the feasibility endpoint completed all eight sessions whereas only two participants in a control arm completed all age sessions and one participants in the control condition reported the intervention not being helpful as a reason for drop out whereas now no participants cited this reason for the myth program in terms of the treatment and efficacy participants in both groups reported a statistically significant reduction in depressive symptoms measured by the phq-9 scale but it's worth noting that the between group effect size was large in its magnitude meaning participants receiving the myth intervention reported significantly and clinically greater reduction in depressive symptoms than their counterparts in a control arm additionally it was encouraging for us to observe that participants in the experimental arm reported a statistically significant reduction in anxiety as measured by g87 but not in the control condition some key strengths that we learned from the participants about the platform the first is that participants really liked the cliffhanger effect and they found it very effective to engage them to come back to the sessions several participants also considered the program as a valuable mental health treatment option that can be embedded or integrated into their cancer care especially for those who are doing outpatient chemo or infusion where they probably don't have other things to do and they think this can be a good way to keep them distracted but also to learn something about cbt and their depression all participants appreciated the privacy and the safety of receiving cbt remotely and many participants praised the taylor content being medically relevant and their experiences are uh and uh and the they founded the platform aesthetically attractive to them a couple of key kind of learning lessons learned uh unanimously participants wish that billy and herself is a cancer survivor because currently we really we need to develop an entirely new storyline to make that feasible and our team are really working hard to to obtain external funding to make that possible they also recommended uh having integrative homeworks to having homework centers to have a cell phone based application to facilitate cv to facilitate cbt homeworks that allow a linkage with their mobile notifications or calendars and a system integration with their current cancer care between the program and their current uh current medical facility um i wanted to acknowledge my collaborators from um school of social work and michigan medicine and again uh the generous uh support from julius legacy of hope uh herobot from symboltrix for stephanie this study and i would like to end with this quote which was actually a julia's favorite quote which says you never know how strong you are until being strong is the only choice you have one of the greatest privilege of the job that i have and the research i do is witnessing the never lasting strengths uh resilience and everlasting strengths and resilience and hope from those who are battling with cancer at a younger age they have been a constant source from my own strengths and motivation and i thank them very much for that and i thank you for listening terrific thank you so much now and uh sorry i had to sorry i cut brad off with the technical stuff he will be uh present of course for the question and answers i need to turn now uh a great opportunity to sum up these talks and give some messages of her own dr jamie mitchell as our discussion thank you jamie hello everyone um what a wonderful set of panelists and presentations so i just have a few concluding remarks all of the innovative programs of research that we just heard about today are reaching populations that are understudied underserved and or disproportionately overburdened by chronic conditions and health needs such as diabetes in black men with dr hawkins enhancing hiv and sti testing among youth with dr cordova mental health among adolescent and young adult cancer survivors with dr zhang and psychosocial and supportive cancer care with dr zebrak each of these presentations demonstrates the future of social work research specifically how as our social work grand challenges state we can leverage the power of technology for social good for example dr cordova is at the forefront of using developmentally and culturally tailored technology-based preventive interventions in this case a mobile app to reach youth clearly dr cordova understands how this intervention can help clinicians flag risky behaviors and then how this technology can also provide direct feedback to clinicians to improve the interventions they deliver and the linkages that clinicians can provide to services in the local community further dr zhang is advancing the science of reaching adolescent and young adult survivors of cancer who are experiencing depression and he's reaching this population with fun engaging developmentally appropriate and well-tailored interventions as with all of our incredible social work sciences he's using a person and environment approach that integrates specific knowledge of the cancer experience into the intervention to make it more meaningful and efficacious for those that it's designed to serve we also saw a common theme of cognitive behavioral therapy as an intervention across multiple presentations today this signals to me that our social work researchers such as dr jackie hawkins are ensuring the interventions designed to tackle persistent health disparities particularly in communities of color are using holistic approaches that bring together the best available science in addressing physical health and mental health concurrently it's so incredibly gratifying to see examples of rigorous scientific interventions that are actually designed for real people with real problems and not only abstract interventions designed for only ideal laboratory convention conditions for example dr zebrak illuminated how cancer is experienced as trauma impacting the psychological functioning of individuals and families and producing harmful chronic stress over time his work gives us a hopeful glimpse into the future of social work research where social work scientists are working actively alongside basic and medical scientists to apply precision precision medicine to predict or identify individuals who may most benefit from certain targeted therapies to improve both cancer outcomes and psychosocial and supportive cancer care dr zebrak's research on the emerging area of social genomics or how social conditions in the environment literally get under the skin to affect health outcomes and disparities nicely ties together an underlying thread among all of the panelists each of these panelists are addressing social conditions in physical and mental health and the integration of both that are powerful factors such as stress sexual health exercise mental health that shape opportunities for health and longevity particularly amongst vulnerable or underrepresented populations these are also factors that shape longevity and well-being across the lifespan we are so fortunate to have such a wealth of scholars doing this work in this school of social work at this time the research collaboration and innovation that our panelists displayed and that really is indicative of our entire faculty and staff in the school of social work is an excellent representation not only of the previous 100 years of work that we have achieved but also it's a peek into the future of where social work science is headed for the next 100 years to come thank you all right we're going to be moving in to our q a portion now so jamie you should see some questions um in the chat or in the q a let's go ahead and prioritize those and then when you've run out i can send you the ones that came through from the chat okay wonderful can you get us started just so i'm not uh clicking around you bet all right so our first question is actually for brad um did you also look at parents of youth and their trauma reactions i have not in in my own work um although it would certainly make sense to to acknowledge people within the context of their families uh there is a pretty sizable body of research um around the experience of caregivers of loved ones uh of folks who are experiencing not just cancer but other other chronic conditions um you know just to to give you a brief you know picture of what this what this often looks like um you know our current system of care um excuses folks from a health care system very quickly you have cancer patients who are going home with ports and they're told to keep those those ports those catheters cleans for the for their repeat of visits to the to the cancer center for their chemotherapy and and and oftentimes it's the the spouse the partner the significant other the cancer patient who receives either an implicit or explicit message about how you have to keep this catheter clean so that your your loved one doesn't get an infection um and have to come back to the hospital i mean just imagine how stressful and scary that must be for a family member to be to be told that so i think the question is on target personally my own work hasn't hasn't focused on that that question but there are folks out there doing that work thank you so much brad um there's another question here in the q a regarding the cancer presentation and i think this actually could go to both dr zebra and dr zhang um with the prevalence of cancer skyrocketing and even more so in the years to come this attendee is wondering why insurance companies may make it more difficult to get certain screenings for specific cancers to jump through hoops or meet certain age requirements even if the age of onset for some of these cancers may be decreasing do either of you have any insight into that cancer is cancer treatment is business and the finances of cancer care and health care in general just like any other business any other corporation are looking to minimize financial risk and maximize profit very succinct there's actually a related question and that is directed toward dr zhang and that is in addition to the shortage of mental health providers does lack of or type of insurance potentially impact access to cbt treatment and how so it does and i think that's such a great and an important question just a story to share while we're doing this study we're doing uh cbt for aoi cancers we've been approached by younger parents of younger cancer patients and survivors and older and they'll reach out to us to the study just because that at that time they didn't have insurance to cover uh their mental health services and they were unfortunately desperate at a time and just want to find anything that can be supported to them um so i think that's just an attestment to this great question that insurance status does uh significantly impact the access um and if i may just quickly add i i think it also speaks to the importance of having social work researchers doing interventional research because uh i think it's fair to to say on behalf of all my colleagues that we also think from a social justice lens and health equity lens when we're thinking about treatment access as we're developing this so i think you know as we further grow into the field as a profession in terms of the technology assisted intervention we may be able to move the needle a little bit wonderful there's another question about whether uh essentially what is the literature base or well you know are there any studies on the benefits of support groups for any of these populations and so i think we're hearing a lot about technology assisted interventions but support group still seems to be a tried and true potential intervention would anyone like to speak to that in any of the populations that we heard about today in in terms of of cancer support groups i think the um uh you know the empirical studies have shown that support groups have a um a moderate effect um but i think in you know what you're what you're seeing in those studies is is an average uh that for some people support groups are critical to their mental health and their their survival and their adaptability while dealing with cancer uh there are other folks who they're you know they're attending really doesn't have any uh measurable effect at all so you get the average um which comes back to the point that i was trying to make around precision medicine you know there are a lot of therapeutic psychosocial modalities out there and i think our challenge ahead is to get folks matched up with the treatment modality that is most likely to benefit them in a personal way wonderful and dr hawkins i know that you're it's not the study you presented today but you have done uh quite a bit of work on peer interventions um and so not traditionally support group but certainly um interventions that utilize peers um can you illuminate any of the the work that you've done or research that you know about in that area um yeah so actually we do call them support groups but they're they are very specific to diabetes self-management so they're diabetes self-management support groups and the other work that i do i was part of a project called praise that was done in 21 churches in flint um toledo and detroit and we trained peer leaders so folks from the community to run the support groups and the way that they run them is you know whatever issues come up so it's not a scripted or lecture style it's more of a dialogue and the great thing um that happened from those support groups with the peer leaders is that people were able to learn from each other it really normalized the stigma that can sometimes come up around having diabetes and the different issues that folks face support groups are a really powerful tool and i'll say for the work that i do we are um focused on doing those types of support groups and training through leaders specifically for men and i found that there are some issues i apologize mcdonald's there are some issues that are specific to men um that that come up um specifically uh in these groups that didn't come up in

the groups with men and women fantastic and dr cordova i want to pull you into the chat as well have you done work or are you aware of work that utilizes the power of peer support and some of the work that you're doing in sexual health with um with youth yeah so actually it's interesting we uh we actually had some pilot funding to have uh peers deliver the intervention as opposed to clinicians and so we had put that during the covet we put that on pause but we're now starting to resume that and so we're now laying the foundation for that as a way to see if um if there's any preliminary efficacy feasibility acceptability with having peers deliver the intervention wonderful it sounds like there's a lot of literature and a lot of research even being done within these projects in the peer space i want to return to you dr zhang there's several questions in the chat about the next directions for your research as well as uh whether some of the inclusion and exclusion criteria um there was one question about whether uh in your work uh did it include or exclude patients that were initially diagnosed as pediatric patients and then relatedly are you at all concerned about a relatively low sample size in this initial work thank you for this great question i also saw one uh ask about the cliffhanger effect i do want to give credit to both joe hemley and natty weaver both the co-developers of the program and with regard to the low level of participation i am at this moment not as concerned because of the timeline as you can see we started around october 2020 and then clearly covet uh during the during the covet and then that's that's the majority of our period of time so both the cs mod children's hospital and rogue cancer center were strictly shut down which has impacted our recruitment and just based on our actual recruitment phase we were very pleased to see the level of responses the clinical referrals that we got so i'm not as concerned about the the low number of um inclusion and with regard to future directions um i think the next step is really my dream is to have a cancer specific storyline and and i think the platform itself is so powerful and the main character doesn't have a cancer diagnosis and i would hope that i would have a cancer specific storyline and then that platform would allow future teams not just our team but future teams who wanted to specialize for example in prostate cancer to develop their own story or breast cancer to develop their own story which i think is highly feasible um and i think i answered all the questions right yeah absolutely thank you i want to bring it back to dr hawkins as we run out of time here there's a couple of questions in the chat specifically about what cbt looks like in some of these interventions and any good resources or recommendations you can provide for folks to learn more and actually anyone can answer i just wanted to make sure that dr hawkins had an opportunity to address her work as well well thank you um i'll go ahead and let someone else answer though um we have uh cbt is something that i um am just beginning to work on and so um i also want to say that uh like dr zhang and other folks um who've been doing this work much longer uh it would be maybe a better idea for in terms of resources that question i'm not sure about to like washington county or on you know any of the other panelists feel free to jump in and i want to specify it did say t cbt okay yeah so so i can chime in quickly um my impression and i'm pretty sure because cbt often is a um in my view too widely utilized a a term and so when i every time talk about cbt specifically i would as i was emphasizing the presentation it needs to be adhered to the core components because that we know that's what is the most effective aspect of cbt so what it looks like it it should at least in principle in spirit and include those three components i think a lot of the variations in innovations comes to the delivery of those core components into the targeted population which i think does require some a lot more research with regard to specific populations and with regard to resources i think there are a lot of entry-level even just online websites to start read about cbt the academy of cognitive behavioral therapy can be a good resources and the association of cognitive behavior therapy can be another good source to start with fantastic and i'll close out the questions with you dr hawkins and that is um there's a question that says do you think that having african-american men participate by leading uh in providing information and support is a strategy to

keep them more engaged or more fully engaged oh absolutely um you know the issue isn't necessarily um i think there's a misconception that um the research sometimes perpetuates with um african-american men with chronic illnesses is that you know they're they're not engaged in their care they um for whatever reason don't care about taking care of themselves or going to the doctor when really they face real barriers uh to getting to the doctor in the first place and participating in programs like this so absolutely getting them together it's really wonderful to see all of the amazing things that they share how engaged they are and how they support each other the issue really in programs like these is finding them in the first place and then thinking about how we can remove the barriers to get them to stay in a program long term and certainly one of those strategies is to get them in a group with folks who have similar experiences who are talking about things that are relevant to them what i will say is the traditional diabetes self-management education that's delivered by a certified diabetes educator is typically in a lecture style format and there's some ridiculous number folks go to the first session and about ninety percent of people don't come back um and so we clearly need to rethink how we're engaging folks absolutely that's a great point do any of the panelists have any final thoughts before we turn it back over to emma no well thank you everyone and emma i'll turn it back over to you yeah i think joe might have a few comments to close this out i'm gonna add him to screen right now oops i didn't that's okay but anyway uh just thanks to everyone and to emma for organizing this and uh super excited to see all this amazing work and great talks inspirational work here at the school of social work and thanks to everyone for attending uh this second in the series of three talks on uh intervention research which there's plenty of great stuff happening here at the school so thanks so much for attending great thanks everyone we'll see you next time happy birthday school of social work you