Health literacy is related to a broad range of health outcomes. This study was designed to develop a psychometrically sound instrument designed to measure cancer health literacy along a continuum (CHLT-30), to develop another instrument designed to determine whether a patient has limited cancer health literacy (CHLT-6), and to estimate the prevalence of limited cancer health literacy. The Cancer Health Literacy Study involving 1,306 Black and White cancer patients was conducted between April 2011 and April 2013 in the Virginia Commonwealth University Massey Cancer Center and surrounding oncology clinics. A continuous latent variable modeling framework was adopted to dimensionally represent cancer health literacy, whereas discrete latent variable modeling was used to estimate the prevalence rates of limited cancer health literacy. Self confidence about engaging in health decisions was used as the primary outcome in external validation of new instruments. Results from a comprehensive analysis strongly supported the construct validity and reliability of the CHLT-30 and CHLT-6. For both instruments, measurement invariance tests ruled out item/test bias to explain gender and race/ethnicity differences in test scores. The limited cancer health literacy rate was 18%, a subpopulation consisting of overrepresented Black, undereducated, and low-income cancer patients. Overall, the results supported the conclusion that the CHLT-30 accurately measures cancer health literacy along a continuum and that the CHLT-6 efficiently identifies patients with limited cancer health literacy with high accuracy.

Multiple existing studies have developed multivariate growth models with nonlinear functional forms to explore joint development where two longitudinal records are associated over time. However, multiple repeated outcomes are not necessarily synchronous. Accordingly, it is of interest to investigate an association between two repeated variables on different occasions, for example, how a short-term change of one variable affects a long-term change of the other(s). One statistical tool for such analyses is longitudinal mediation models. In this study, we extend latent growth mediation models with linear trajectories (Cheong et al., 2003) and develop two models to evaluate mediational processes where the bilinear spline (i.e., the linear-linear piecewise) growth model is utilized to capture the change patterns. We define the mediational process as either the baseline covariate or the change of covariate influencing the change of the mediator, which, in turn, affects the change of the outcome. We present the proposed models by simulation studies. Our simulation studies demonstrate that the proposed mediational models can provide unbiased and accurate point estimates with target coverage probabilities with a 95% confidence interval. To illustrate modeling procedures, we analyze empirical longitudinal records of multiple disciplinary subjects, including reading, mathematics, and science test scores, from Grade K to Grade 5. The empirical analyses demonstrate that the proposed model can estimate covariates' direct and indirect effects on the change of the outcome. Through the real-world data analyses, we also provide a set of feasible recommendations for empirical researchers. We also provide the corresponding code for the proposed models.

Adverse childhood experiences (ACEs) have been linked to early sexual debut, which has been found to be associated with multiple adverse health outcomes. Sexual minorities and men tend to have earlier sexual debut compared to heterosexual populations and women, respectively. However, studies examining the association between ACEs and early sexual debut among men and sexual minorities are lacking. The aim of this study was to examine the sex and sexual orientation disparities in the association between ACEs and age at sexual debut. Data were obtained from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic and linear regression model were used to obtain crude and adjusted estimates and 95% confidence intervals adjusting for age, race/ethnicity, income, education, insurance and marital status for the association between ACEs (neglect, physical/psychological abuse, sexual abuse, parental violence, and parental incarceration and psychopathology) and early sexual debut. Analyses were stratified by sex and sexual orientation. Larger effect estimates depicting the association between ACEs and sexual debut were seen for women compared to men, and among sexual minorities, particularly among men who have sex with men (MSM) and women who have sex with women (WSW), compared to heterosexuals. Sexual health education programs with a focus on delaying sexual debut among children and adolescents should also consider addressing ACEs, such as neglect, physical, psychological and sexual abuse, witnessing parental violence, and parental incarceration and psychopathology. Public health practitioners, researchers and sexual health education curriculum coordinators should consider these differences by sex and sexual orientation when designing these programs.

Objective: Knee arthroplasty (KA) is an effective surgical procedure. However, clinical studies suggest that a considerable number of patients continue to experience substantial pain and functional loss following surgical recovery. We aimed to estimate pain and function outcome trajectory types for persons undergoing KA, and to determine the relationship between pain and function trajectory types, and pre-surgery predictors of trajectory types. Design: Participants were 384 patients who took part in the KA Skills Training randomized clinical trial. Pain and function were assessed at 2-week pre-and 2-, 6-, and 12-months post-surgery. Piecewise latent class growth models were used to estimate pain and function trajectories. Pre-surgery variables were used to predict trajectory types. Results: There was strong evidence for two trajectory types, labeled as good and poor, for both Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain and Function scores. Model estimated rates of the poor trajectory type were 18% for pain and function. Dumenci's latent kappa between pain and function trajectory types was 0.71 (95% CI: 0.61e0.80). Pain catastrophizing and number of painful body regions were significant predictors of poor pain and function outcomes. Outcome-specific predictors included low income for poor pain and baseline pain and younger age for poor function. Conclusions: Among adults undergoing KA, approximately one-fifth continue to have persistent pain, poor function, or both. Although the poor pain and function trajectory types tend to go together within persons, a significant number experience either poor pain or function but not both, suggesting heterogeneity among persons who do not fully benefit from KA.

Objective We determined outcomes for patients classified as appropriate, inconclusive or inappropriate for total knee arthroplasty (TKA) using a modified version of a validated appropriateness algorithm. Outcome measurement was conceptualized as short-term postoperative change attributable primarily to surgery and rehabilitation (two-months) and as longer term post-operative change and recovery (one- and two-year). Methods Pre-operative and yearly post-operative WOMAC Function, KOOS Symptoms and KOOS Pain scores were examined for persons undergoing primary TKA in the Osteoarthritis Initiative. Multi-group two-piece latent growth curve modeling was used to determine differences in outcome variable changes for each group from pre- to two-months post-surgery as well as over a two-year post-operative period. Results Data from 167 persons with primary TKA were examined. Prevalence rates of appropriate, inconclusive and inappropriate judgments were 47.9%, 20.8%, and 31.3%, respectively. The inappropriate group showed no change at two months following surgery while appropriate and inconclusive groups had substantial improvement in all outcomes. One-year and two-year post-operative recovery outcomes were not significantly different among the three groups. Conclusion The inappropriate group was unchanged two months after surgery and, on average, improved by 2.3 WOMAC Function points from pre-surgery to one year following surgery based on our models. Appropriate and inconclusive groups improved by an average of 19.8 WOMAC Function points at one year post-surgery. These data provide a compelling case for consensus building efforts to define eligibility criteria for TKA with the goals of reducing variation in patient selection and optimizing both change over time and final outcomes.

Background: Pain catastrophizing has been identified as a prognostic indicator of poor outcome following knee arthroplasty. Interventions to address pain catastrophizing, to our knowledge, have not been tested in patients undergoing knee arthroplasty. The purpose of this study was to determine whether pain coping skills training in persons with moderate to high pain catastrophizing undergoing knee arthroplasty improves outcomes 12 months postoperatively compared with usual care or arthritis education. Methods: A multicenter, 3-arm, single-blinded, randomized comparative effectiveness trial was performed involving 5 university-based medical centers in the United States. There were 402 randomized participants. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Pain Scale, measured at baseline, 2 months, 6 months, and 12 months following the surgical procedure. Results: Participants were recruited from January 2013 to June 2016. In 402 participants, 66% were women and the mean age of the participants (and standard deviation) was 63.2 ± 8.0 years. Three hundred and forty-six participants (90% of those who underwent a surgical procedure) completed a 12-month follow-up. All 3 treatment groups had large improvements in 12month WOMAC pain scores with no significant differences (p > 0.05) among the 3 treatment arms. No differences were found between WOMAC pain scores at 12 months for the pain coping skills and arthritis education groups (adjusted mean difference, 0.3 [95% confidence interval (CI), 20.9 to 1.5]) or between the pain coping and usual-care groups (adjusted mean difference, 0.4 [95% CI, 20.7 to 1.5]). Secondary outcomes also showed no significant differences (p > 0.05) among the 3 groups. Conclusions: Among adults with pain catastrophizing undergoing knee arthroplasty, cognitive behaviorally based pain coping skills training did not confer pain or functional benefit beyond the large improvements achieved with usual surgical and postoperative care. Future research should develop interventions for the approximately 20% of patients undergoing knee arthroplasty who experience persistent function-limiting pain.

Six in ten people in the general population have been exposed to adverse childhood experiences (ACEs). Intimate partner violence (IPV) is a major public health problem in the US. The main objective of this study was to assess sex differences in the role of posttraumatic stress disorder (PTSD), substance abuse, and depression as mediators in the association between ACEs and intimate partner aggression. Data were obtained from Wave 2 (2004–2005) of the National Epidemiologic Survey on Alcohol and Related Conditions. Structural equation modeling was used to determine the mediational role of PTSD, substance abuse and depression in the association between ACE constructs (neglect, physical/psychological abuse, sexual abuse, parental violence, and parental incarceration/psychopathology) and intimate partner aggression. Among men, PTSD mediated the relationship between sexual abuse and intimate partner aggression. However, among men and women, substance abuse mediated the relationship between physical and psychological abuse and intimate partner aggression. IPV programs geared towards aggressors should address abuse (sexual, physical and psychological), which occurred during childhood and recent substance abuse and PTSD. These programs should be implemented for men and women. Programs aimed at preventing abuse of children may help to reduce rates of depression and PTSD in adulthood, and subsequent intimate partner aggression.

This study proposes transformation functions and matrices between coefficients in the original and reparameterized parameter spaces for an existing linear-linear piecewise model to derive the interpretable coefficients directly related to the underlying change pattern. Additionally, the study extends the existing model to allow individual measurement occasions and investigates predictors for individual differences in change patterns. We present the proposed methods with simulation studies and a real-world data analysis. Our simulation study demonstrates that the method can generally provide an unbiased and accurate point estimate and appropriate confidence interval coverage for each parameter. The empirical analysis shows that the model can estimate the growth factor coefficients and path coefficients directly related to the underlying developmental process, thereby providing meaningful interpretation.