This study aims to provide a systematic compilation of existing measures of self-efficacy developed specifically for use in cancer patients and provide descriptions and comparative evaluations of the characteristics, psychometric properties and performance parameters.A systematic electronic database search was conducted in PubMed, Ovid (PsyINFO), EBSCO, Elsevier, Scopus to identify self-efficacy assessment tools for cancer patients, between January 1977 to February 2018. The characteristics of target population, instrument, development process and psychometric properties were summarized. All included instruments were subsequently appraised using a psychometric quality assessment tool based on previous publications. Validity of the quality assessment was reviewed and confirmed by five experts.Fifteen cancer-related self-efficacy instruments were identified. Among them, (40.0%) 6/15 were task-specific, focusing on cancer-related health issues such as fatigue, communication, rehabilitation, exercise, and narcotic pain killer usage. Six instruments were disease-specific for breast cancer, lung cancer, or advanced cancer. Weaknesses of the development processes included the singularity of instrument construction methods, and non-transparent selection of the final items. The main limitation seen in the validation processes was that some important properties of instruments  were not evaluated.This review summarizes the limitations and strengths of current self-efficacy instruments for cancer patient. The information reported here can assist clinicians and researchers in the selection of the appropriate instrument. Finally, it points out the need for reporting validation statistics to facilitate the use of these instruments.The online version of this article (10.1186/s12955-018-1066-9) contains supplementary material, which is available to authorized users. Cancer diagnosis, treatment and survivorship challenge the patients’ physical and psychosocial well-being. Cancer patients must manage a number of practical and emotional tasks to cope with the experience over both short and long terms . Self-maAccording to Bandura, self-efficacy regulates an individual through cognitive, motivational, affective, and decisional processes to affect one’s motivation to persevere in the face of difficulties . People When incorporated into a comprehensive cancer plan of care, instruments that measure self-efficacy inform both researchers and clinicians about patients’ beliefs, capabilities, and motivations . UnderstToward this goal, a variety of cancer-specific self-efficacy measures have been developed and validated. To ensure robust application of any instrument, a clearly delineated developmental process  and critical validation  are required –13. Not The aim of this study was to provide a systematic compilation of existing measures of self-efficacy developed specifically for use in cancer patients and provide descriptions and comparative evaluations of the characteristics, psychometric properties and performance parameters to help clinicians and researchers select an appropriate instrument.This study was conducted following the guideline of the preferred reporting items for systematic reviews and meta-analysis (PRISMA statement) . ArticleA systematic search of the following databases was conducted: PubMed, Ovid (PsyINFO), EBSCO, Elsevier, Scopus. Google Scholar was used as an additional search engine to discover non-duplicate items. Papers published between January 1977 (self-efficacy was first mentioned by Bandura in 1977) to February 2018 assessing the self-efficacy of cancer patients were identified by entering the following keywords or MeSH: “cancer or neoplasm* or oncology* or carcinoma*” AND “self-efficacy or mastery or confiden*” AND “instrument* or scale* or questionnaire or assessment* or measure* or psychometric* or reliab* or valid*”.No language restriction for the instruments was applied, but only articles published in English were reviewed. The reference lists of all selected studies and reviews were also examined for relevance.The electronic, multi-database search strategy produced 845 potential studies on self-efficacy in adult cancer populations. Two authors (FFH and QY) independently reviewed the same set of articles and selected the instruments. Discrepancies were resolved by discussion with a third reviewer (JPZ). Authors of the articles were contacted for additional information such as full text when only abstract was found, if needed.After instrument identification, data were collected in the four main areas: 1) characteristics of the target population   instruments measured the self-efficacy of general health strategies in cancer, such as self-care , 16, selSeven instruments were initially used in adult cancer populations in the USA, four in China, two in Australia, and one each in Japan and Korea Table . Sample As shown in Table A total of 54 domains were obtained from all instruments. Nineteen domains focused on self-efficacy in the management of cancer-related physical symptoms, including coping with symptoms or side-effects (15 domains), fatigue management (2 domains) and pain control (2 domains). Eighteen domains were related to psychological management, such as affective management (5 domains), stress reduction (6 domains), positive attitude (5 domains), and problem-solving (2 domains). Eight domains focused on lifestyle, such as activity or exercise (4 domains), sexual life (1 domain) and maintenance of healthy lifestyle (3 domains). Eight domains were about understanding and participating in medical procedures, including communication (1 domain), medical decision-making (5 domains), and information acquisition (2 domains). One domain was general self-efficacy.Data on the feasibility and burden of administration were scant. While majority of the patients participated in the initial studies had high school education or above, only one instrument, Communication and Attitudinal Self-Efficacy for Cancer (CASE-cancer) , specifiThe majority of instruments used the classical test theory (CTT) method for construction, except CASE-cancer and Self-efficacy Scale for Rehabilitation Management for postoperative lung cancer patients (SESPRM-LC) , which cThe two instruments found to have the most positive ratings in quality assessment were Strategies Used by People to Promote Health (SUPPH) and SESPRM-LC. SUPPH was used to measure the confidence of cancer patients to carryout self-care strategies at any point during the course of the disease. It has been widely used and translated for several languages, including Chinese (SUPPH-C). However, it appeared to not have a stable factor structure,including 2-factor, 3-factor and 4-factor . SESPRM-The next group of high quality assessment included SICPA, Brief version of Cancer Behavior Inventory (CBI-B) and PSEFSM. Similar to SUPPH, SICPA and CBI-B were used to measure the self-efficacy of general health strategies at any point during the cancer disease trajectory. The SCIPA has some outstanding weaknesses, especially regarding construct validity and content validity. It does not include items that represent management of cognitive tasks or side effects of chemo-radiation, which are critical components of the cancer experience. Compared to the 38-item SCIPA, the 12-item CBI-B presents improved efficiency suitable for screening in clinical settings. However, its reproducibility and concurrent validity wait investigation. PSEFSM was designed specifically for fatigue management and cannot be generalized to other aspects of cancer care.SMSFS-A had the lowest quality ratings. Due being in the pilot stage of development, the structure and validity of SMSFS-A have not been thoroughly characterized. Although SMSFS-A and PSEFSM both focused on fatigue management, the SMSFS further narrowed down to patients with advanced cancer.r < 0.7.In reliability analysis, 11/15 (73.33%) of instruments had satisfactory internal consistency, with a reported Cronbach’s alpha between 0.75 and 0.95. For the instruments that received negative ratings, two , 26 had Except for SICPA, all instruments reported content validity by providing feedback from patients, clinicians, experts, or pilot test. Evidence for construct validity was provided for 13 instruments, and four rated negative because of inadequate sample size (< 100). Six instruments used convergent or divergent validity analysis to estimate the degree to which the instrument is correlated with other measures of similar or dissimilar constructs. Ten performed exploratory factor analysis (EFA), and five also used confirmatory factor analysis (CFA) to further confirm construct validity. In studies using EFA, the total variance explained ranged between 43.6%  and 81.3The remaining psychometric properties — responsiveness, floor/ceiling effects and interpretability — were seldom assessed. Only five instruments reported responsiveness. SICPA  was sensThis systematic review examined the psychometric and performance characteristics of 15 existing instruments aimed at measuring self-efficacy in adult cancer populations. An increasing number of self-efficacy instruments have been published in the past three decades. Illustrating Bandura’s self-efficacy theory, most instruments were task- or disease- specific. Our analysis revealed both the strength and limitations of these instruments. While the majority of instruments cover a variety of domains pertinent to cancer self-management and have been tested in clinical situations, their wider applicability is eclipsed by singularities in instrument construction and item selection, and failure to report important psychometric parameters.Our review confirmed CTT as the most widely used approach for instrument development. Because the respondent characteristic of interest is quantified based on the raw score across all the items in the instrument, score interpretation in CTT is sample specific . To overWe discovered that a major obstacle in validation is longitudinal assessments. Only a third of the instruments were applied to measure how patients changed over time, with or without self-management intervention. Self-efficacy in cancer likely fluctuates as patients make progress on the path of diagnosis, treatment, and survivorship. Thus monitoring with valid measurements that have high test-retest reliability and sensitive to change becomes paramount. Without adequate data, we cannot discern whether a given instrument can be applied to a proposed intervention. Other areas awaiting improvement in instrument validation include analysis of item performance for refinement purposes, assessment of criterion-based and construct validities in large sample, and identification of cut-off, threshold and normal values to guide interpretation. Most studies did not provide information on clinical practicability of the self-efficacy instruments. Generally, reading level of 8th grade or below and time to completion of no more than 20 min are considered appropriate for cancer patients . In addiNotwithstanding the above considerations, based our review, we recommend SUPPH, SICPA and CBI-B for assessing cancer patients’ confidence in general self-care. For disease-specific instruments, we recommend a breast cancer self-efficacy scale (BCSES) for breast cancer and SESPRM-LC for lung cancer patients.Our study has several limitations. Only English articles were included,,and the information in dissertations, book chapters, manuals, reviews and other non-peer reviewed or “grey” literature were also not included. Although we paid great attention to the inclusion of instruments that truly measure self-efficacy for cancer patients, we cannot exclude the possibility of having misclassified studies.Although self-efficacy is a well-established concept that has been shown to have high explanatory power , there iIn this systematic review, we summarized and evaluated the psychometric parameters of 15 currently available instruments for assessing self-efficacy in cancer patients. The information reported here could be a resource for clinicians and researchers by helping them understand the strengths and limitations of the instruments and select the most appropriate tool for cancer care and innovation. Knowing the rigor and suitability of the instrument can also guide their efforts to determine the factors that influence a patient’s capacity for self-efficacy. Additional research is needed to strengthen the practicality and applicability of the instruments.Additional file 1:Table S1. Psychometric properties of included instruments. Table S2. Quality criteria for psychometric properties of self-efficacy instruments for cancer patients. (DOCX 31 kb)


MMP-8 rs11225395 promoter polymorphism. Relevant studies published by 12 June 2019 were identified by systematically searching PubMed, Web of Science, Cochrane Library, CNKI and Wanfang databases. R programs and STATA software were used to calculate odds ratio (OR) and 95% confidence interval (CI). In total, 7375 cancer samples and 8117 controls were included by integrating 15 case-control data sets. Pooled estimates from the statistical analysis revealed no statistical significance for the association between this polymorphism and cancer risk. All pooled estimates resulting from subgroup analyses by cancer type and sample size were not materially altered and did not draw significantly different conclusions. The stratified analyses according to geographic region showed the statistical significance for increased cancer risk of the MMP-8 rs11225395 polymorphism in non-Asian populations under the allele model , homozygote model , heterozygote model , and dominant model . However, no statistical significance was detected in Asian populations. In conclusion, these findings suggested that the MMP-8 rs11225395 polymorphism is associated with elevated susceptibility to cancer in non-Asian populations.This meta-analysis aimed to systematically review the evidence on cancer risk of the  Cancer is still one of the most devastating diseases, leading to millions of deaths worldwide each year. As a multifactorial disease, this life-threatening malignancy could result from lifestyle factors, dietary habits, environmental impact, and genetic predispositions. Its relevance to genome variations, including single-nucleotide polymorphism (SNP), has been backed up with more and more scientific evidence ,2,3,4.Matrix Metallopeptidase 8 (MMP-8) gene, located on chromosome 11q22.2, encodes a collagenase participating in the process of extracellular matrix degradation and remodeling, whose deregulation could promote tumorigenesis and progression. Although several previous studies have reported the inhibitory effect of the MMP-8 gene on carcinogenesis and metastasis, conflicting evidence for its function as an oncogene also exists. In oral tongue squamous cell carcinoma, high MMP-8 expression could reduce tumor invasion and migration  and leadMMP-8 rs11225395 (C-799T) polymorphism could lead to a C to T single-nucleotide variation in the promoter region. Scattered evidence illustrated that the T allele of this polymorphism could lead to significantly higher promoter activity and protein expression than its C allele [The C allele ,14. ProgC allele , but theC allele . Based oMMP-8 rs11225395 polymorphism and cancer risk have been reported. The limited sample size of all these studies may also markedly reduce the statistical power of their conclusions. To better elucidate the genetic impact of the MMP-8 rs11225395 polymorphism, these scattered case-control studies should be pooled into a meta-analysis.Discrepant results for the association between the https://www.ncbi. nlm.nih.gov/pubmed), Clarivate Web of Science (https://www.webofknowledge.com/), Cochrane Library (https://www.cochranelibrary.com/advanced-search), CNKI (http://www.cnki.net/), and Wanfang Data (http://www.wanfangdata.com.cn/). The retrieval type consists keywords for polymorphism ID, gene name and symbol , aliases for cancer , and terms representing single-nucleotide polymorphism . Articles citing the studies involved in this meta-analysis were also retrieved by Google Scholar (https://scholar. google.com/). The references of the eligible articles and reviews were manually examined to identify additional relevant studies. Results retrieved from the inception of these databases up to 12 June 2019 were considered for this meta-analysis.Potentially eligible studies were queried in five literature databases: PubMed  not for cancer risk; (c) no genotype data for cancer and control samples. Inclusion criteria were as follows: (a) enough data for pooled estimates in at least one genetic model; (b) no benign tumor samples were included in the case group; (c) in Chinese or English.To evaluate the eligibility of each study, four authors independently screened the list of identified literature by sticking to the same inclusion and exclusion criteria. For a study to be excluded from further analysis, the full-text context should be accessible, and the study had to meet at least one of the following prespecified exclusion criteria: (a) not for the p < 0.05 indicates statistical significance) and then qualitatively labeled as a study characteristic. The Newcastle–Ottawa Scale (NOS) system was applied to evaluate the quality of the studies involved . A study scoring greater than or equal to seven out of nine will be labeled with ‘high quality’, four to six as ‘medium quality’ and less than four as ‘poor quality’.Four authors independently performed the data extraction. The following information regarding study design features and patient characteristics were recorded: (a) name of the first author, (b) year of publication, (c) cumulated genotype number in cancer and control groups, (d) geographic region of involved samples, (e) sample size, (f) genotyping method, (g) cancer type. Additionally, appropriateness of the Hardy–Weinberg equilibrium (HWE) in the control group was statistically measured  programmers were delegated to develop statistical analysis scripts for statistics analysis. Moreover, two STATA software  operators were also appointed to validate the results. Pooled odds ratio (OR) and 95% confidence interval (95% CI) were calculated to quantitatively assess the cancer risk in the allele model (T vs. C), homozygote model (TT vs. CC), heterozygote model (CT vs. CC), dominant model (CT+TT vs. CC), and recessive model (TT vs. CC+CT). A chi-squared Q-test was performed to detect the heterogeneity among studies . If significant between-study heterogeneity was identified, data were pooled using the DerSimonian–Laird algorithm (random effects model) [p was less than 0.05, publication bias was considered to be of statistical significance). A leave-one-out sensitivity analysis was conducted to evaluate the statistical stableness.Two R  . Otherwis model)  was appls model) . Publicas model)  and Beggs model)  were useAll processes in this meta-analysis strictly adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines .https://www.ncbi.nlm.nih.gov/snp/rs11225395#frequency_tab), such as the Population Architecture using Genomics and Epidemiology study , the 1000 genome project (1000 G) [https://gnomad.broadinstitute.org/).The workflow for the literature screen and data selection fully revealed our rigid adherence to the PRISMA guidelines . A syste(1000 G) , and theA random effects model was applied in the allele model, homozygote model, dominant model, and recessive model because significant between-study heterogeneity was identified. The observed overlaps between the vertical line showing the null hypothesis (OR = 1) and the 95% CIs for pooled estimates indicated no statistical significance for altered cancer risk  and Begg’s test  revealed no significance. These results ruled out the possibility of publication bias.Publication bias in all genetic models was graphically measured using the Begg’s funnel plots . No obviTo verify whether the significance of the results was driven by any single data set, a sensitivity analysis was executed. The pooled estimates showed no statistical significance, which indicated no material change . These dp = 0.16; homozygote model: p = 0.25; dominant model: p = 0.22; recessive model: p = 0.63). Re-calculated pooled estimates under these genetic models remained stable .To explore the source of between-study heterogeneity, we analyzed the statistics for heterogeneity in Galbraith plot analysis. Two data sets in the allele model ,26, two MMP-8 rs11225395 polymorphism on cancer risk. Based on the enlarged sample size and accumulated evidence, statistical power in the meta-analysis could be markedly enhanced, which consequently derives a more accurate and credible estimation. In this study, insignificant results were obtained for the impact of the MMP-8 rs11225395 polymorphism on cancer susceptibility for the overall population. Similarly, no evidence of differential cancer risk in subgroups of cancer type was found. Neither the subgroups with large sample size nor those with small sample size revealed increased cancer risk. However, to our surprise, when stratified according to region, the non-Asian populations showed a significant association between elevated cancer risk and the T allele. The regional difference may be interpreted by the ethnic variance of genetic backgrounds, which could result in a synergistic interaction with other genetic factors. Haplotype risk estimation should be implemented when detailed genotype data for more loci are available. Environmental and lifestyle differences between regions should also be considered. Further adjustment for confounding factors, including cigarette smoking, alcohol consumption, environmental pollution, occupational exposure to hazardous chemicals, sanitary condition, and diet habits for the pooled estimates should be performed to evaluate their combined effect with this polymorphism when clinical information is ready.Meta-analysis is a requirement before the evidence for a pathogenesis association can be regarded as reliable. The current epidemiologic literature was systematically summarized to quantitatively assess the genetic impact of the This meta-analysis is useful to clearly realize the magnitude of the effect of rs11225395 on cancer risk. An important note of caution should be sounded, as the limited number of involved studies and relatively small sample size in both Asian and non-Asian subgroups may consequently lead to insufficient statistical power to determine the significance and potentially restrict the interpretation of the pooled estimates for cancer risk, in particular, concerning the influence of the risk variant on a specific type of cancer. The effect of rs11225395 on cancer susceptibility needs to be confirmed further. In addition, specific meta-analysis per tumor site should be performed individually to derive a more precise estimation of its genetic effects.Significant between-study heterogeneity was identified in four genetic models. After removing the identified sources of heterogeneity from the Galbraith plot analyses, the statistic for heterogeneity showed no statistical significance, and the pooled estimates remained stable. These results illustrated the robustness of our conclusions.A principal limitation is that our data sets search strategy was only used for databases in which the literature is in Chinese and English. Foreign languages, including French, German, and Japanese, were not taken into account due to our language limitation. Although the use of the five particular cyber databases in our systematic review provides significant data coverage security, additional data sets might have been retrieved if more databases had been queried. Furthermore, another primary limitation of this review is the statistically substantial heterogeneity for the results of pooled estimates, limiting the capability to precisely assess the size of the effects. Last but not least, analyzing rare events represents an inherent limitation because small variances in data could lead to material change for statistical significance. The use of relative measures of effect  in meta-analysis could further exaggerate the instability of the results . These lThe main superiority of this systematic review is the methodology, including the literature search, study selection, information extraction, statistical analysis, and data interpretation, was rigorous. Most involved studies were identified to be of a good or moderate quality. Moreover, the advantage in sample size over a single case-control study led to the increased statistical power. Finally, the robustness and veracity of the pooled estimates were statistically ensured by our publication bias and sensitivity analyses. All these preponderances guaranteed the reliability of this meta-analysis.MMP-8 rs11225395 polymorphism and cancer risk are reassuring, and suggest that this polymorphism is associated with elevated susceptibility to cancer in non-Asian populations. However, more large-scale case-control and prospective studies are needed to validate this population-specific correlation.Our results of this meta-analysis evaluating the relationship between the


Objective: Children in immigrant families (CIF) are at elevated risk of experiencing adverse social determinants of health (SDH), particularly material hardship, which contribute to disparate health outcomes. Previous studies have found that SDH screening programs integrated into pediatric practices have increased receipt of social service resources. Few studies have examined use of social services in these programs among ethnically-diverse patient populations and associations with caregiver immigrant status or limited English proficiency (LEP).Methods: Caregivers of children (<18 years) were routinely screened in a practice-based, SDH screening program offering referral, assisted navigation and follow-up support. Information on caregiver race/ethnicity, US nativity, citizenship status and self-reported English proficiency was collected. Associations with utilization of referral resources at 12 weeks were measured using Chi-square and Fisher's Exact tests.Results: Of 148 caregivers, most were mothers (83.2%) and non-White (91.9%). Over half were born outside of the U.S (59.7%) and one-third were LEP (33.6%). Approximately one-third (30.9%) successfully utilized program-provided resources at 12-week follow-up. LEP caregivers and undocumented caregivers were more likely to be lost-to-follow-up. However, LEP caregivers who remained in the program utilized resources more than English-proficient caregivers . Similarly, significantly more non-citizen caregivers utilized referrals compared to US citizens .Conclusions: Families with non-US citizen or LEP caregivers were at highest risk of being lost-to-follow-up, but if engaged, were more likely to utilize resources. These findings indicate the need for larger studies to determine how to prevent loss-to-follow-up among immigrant and LEP caregivers participating in SDH screening programs. Children in immigrant families (CIF) represent one-quarter of all children living in the US—and is projected to rise to one in three US children by 2050 . These cIn light of the clear health impacts of material and economic hardship, there have been new recommendations for pediatric practices to expand their activities to include identification of unmet social needs and referral to local resources . ResearcHowever, immigrant families face unique obstacles within the pediatric medical home that may impair the effectiveness of social need screening programs, including language barriers, mixed eligibility for services, low health literacy, poor patient-provider communication and perception of cultural insensitivity to values and customs , 23. ForThis is a secondary data analysis of results from a pilot program to integrate routine SDH screening aligned with referral, assisted navigation services and follow-up within a hospital-based pediatric practice.This study was conducted in Queens, New York at a large hospital-based pediatric ambulatory practice, with a catchment population that spans all 5 boroughs of New York City and the entire peninsula of Long Island. Patients served by this practice are ethnically and socio-economically diverse with greater than half of patients living in immigrant families from Latin America, East Asia, South Asia, non-Hispanic Caribbean, the Middle East, and Africa; over two-thirds of patients receive health insurance coverage through Medicaid or Medicaid managed care.The Family Needs Screening Program (FAMNEEDS) was started in August 2016 to identify and address family material and psychosocial needs of patients through: (1) universal screening and assessment of social needs at pediatric preventive care visits for children aged 0–18 years using the FAMNEEDS screening tool; (2) assisted navigation and referral to local community resources by trained student “navigators” and (3) periodic follow-up to ensure successful linkages. This program complements the existing social services support for families, which includes 2 part-time social workers and a full-time child psychologist.The FAMNEEDS tool, which has recently been revised  for a preventive care visit were provided with the FAMNEEDS screening tool by a medical assistant after triage, and instructed to complete the screen and give to their provider for review at the start of the visit. Providers were trained to identify positive screens  among families that desired assistance and informed caregivers that they would receive a follow-up phone call in 48 h from a resource navigator. “Resource navigators” were undergraduate students, trained to navigate online social service databases and/or provide referrals to social service case managers at designated partner community-based organizations. The students' undergraduate field of study included pre-medicine, pre-nursing, sociology, public health, or community health sciences. In order to ensure linguistic and cultural concordance with the ethnically diverse patient population, resource navigators were bilingual in English and at least one of the most common languages spoken by the patient population.Navigators are rigorously trained in use of 2 comprehensive online social service databases, from which the navigator is able to provide contact information for families with social needs. In addition, the navigator can send direct e-referrals to partner community-based organizations (CBO). Common needs include public benefits such as: Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Social Security Insurance (SSI), Medicaid and other health insurances, legal assistance, immigration assistance, tax assistance, Home Energy Assistance program (HEAP)/ Energy Share applications, childcare, adult education classes, after school programs, and counseling services. When a positive screen with a caregiver requesting help was identified, navigators would conduct an initial “intake” call to obtain detailed information within 48 h and then research potential resources. Identified resources with contact information were provided within 1 week after the intake call. Resource navigators also conducted follow-up phone calls every 2 weeks for a total of 8 weeks to ascertain progress on the referral and/or provide alternative resources, as needed. Lastly, the final “follow-up call” was performed at 3 months post-intake to assess the status of the referral. Three attempts are made for each follow-up call to refer caregivers to appropriate resources or check the status of a previous referral. The Navigator documents all screening information, follow-up call information and outcomes of each call in a HIPAA- compliant, IRB-approved data registry.The main outcome of interest was caregiver self-report of utilization of referral resources at the caregiver 3-month final phone call. This outcome was separated into three categories: successfully used or in progress of using at least one of the referral resources vs. non-utilization of resources vs. lost-to-follow-up . As an additional validity check, we also included a randomly selected subset of 50 caregivers, and compared their self-report to actual use of resources directly through data from a main partner community-based organization, Single Stop. This organization was a direct partner with our program and assisted referred families using a case manager .The main predictors assessed included self-reported demographic and socio-cultural information of the child/caregiver dyad. Specifically, these factors included child characteristics such as age, insurance type and caregiver characteristics, such as race/ethnicity, educational attainment, US nativity, citizenship status and LEP. Of note, citizenship status and LEP (using the US Census question “How well do you speak English?”) was determined by self report.n = 299). Of these families, only those that accepted patient navigator assistance for referrals were included in the analysis (n = 148). Descriptive statistics, using univariate frequencies were used to compare the prevalence of successful utilization of resources vs. unsuccessful utilization vs. those that were lost to follow-up among the analytic sample. Chi-square tests were then utilized to determine demographic factors with statistically significant bivariate association  with successful/in-process utilization vs. non-utilization of referrals vs. lost-to-follow-up. Lastly, multivariate logistic regression was conducted to control for confounding and identify predictive factors that remained significantly associated with successful utilization. Variables that had >10% missing data were excluded from the final model. SPSS 24.0 was used for all analyses and the study was approved from the Northwell Health Institutional Review Board.Of the 703 caregivers that were screened, the analytic sample for this study was restricted to families that indicated a need on the screening tool (p = 0.031). However, LEP caregivers were more likely to be lost-to-follow-up, as well. Immigration status was significantly associated with 12-week follow-up outcome. US citizens were the most likely to not utilize referrals compared to documented and undocumented immigrants .Of the 148 caregivers in the study, the majority were mothers (83.2%), non-White (91.9%) and graduated HS or obtained a GED (80.6%)  if engaged, children living in households with non-US citizen or LEP caregivers are more likely to utilize resources provided in SDH screening programs offering navigation and follow-up support, but (2) are the most at risk for difficulty in maintaining contact for follow-up support.Our rate of 31% of families successfully utilizing resources is consistent with other published studies describing practice-based health-related social needs (HRSN) screening programs. Prior work has shown that the integration of navigation services in conjunction with screening and referral has increased effectiveness , 25. ConIn contrast, few studies have examined socio-cultural differences in successful resource utilization. The finding of elevated lost-to-follow-up rates among foreign-born parents, particular those with undocumented status, does point to whether cultural differences are contributing to this differential. Qualitative work from Silverstein et.al, identified multiple barriers among ethnic minority and immigrant parents to engagement with community resources for SDHs including: disconcordance with cultural and personal values of self-sufficiency, cultural stigma of help-seeking, fear of governmental intrusion, and negative past experiences that were deemed judgmental or culturally insensitive . InteresThis analysis is to be considered exploratory due to limitations including a small sample size, which lacks the power to detect smaller, clinically relevant differences between groups. We were also unable to utilize regression analyses to control for potential confounding factors. Additional limitations were that our sample included only caregivers who had already accepted navigator assistance for referrals, and utilization of resources, LEP and citizenship were all measured by self-report. The study may be less generalizable as concerted efforts were made to ensure that our program was as culturally sensitive as possible in design and implementation. The screening tool was available in several different languages and bi/multilingual patient navigators were recruited to reflect the needs/accommodate our large, urban immigrant patient population.Currently, national pediatric recommendations support embedding screening of SDHs into well-child visits and underscore the need for larger studies to determine if SDH screening programs are effective across sub-populations, particularly children in immigrant families. Additionally, qualitative work is warranted to gauge family experiences in these programs, which may help explain the disparate loss-to-follow-up found among undocumented and LEP caregivers. However, if these families are supported with assisted navigation and follow-up, they may have better outcomes than the general pediatric population. The observed differences in utilization outcomes highlight parental English proficiency and nativity as potential demographics to capture in SDH screening tools for consideration when developing SDH screening tools for disadvantaged patient populations.OU conducted the study, conceptualized and designed the manuscript, conducted analysis of the interpreted the data and critically revised manuscript. HM conducted analysis of the data, drafted the manuscript, interpreted the data and critically revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewers, PW and RS, and handling Editor declared their shared affiliation.


There is growing evidence that visuospatial neglect (VSN) is associated with lower functional performance in other modalities and is not restricted to the lesioned hemisphere alone, and may also affect the non-lesioned hemisphere in severe first-ever strokes. We aimed to investigate the longitudinal association between the severity of VSN, as reflected by the extent of ipsilesional and contralesional spatial attention deficit, and clinical severity of stroke.This is a secondary data analysis with merged data from two prospective cohort studies. Resulting in 90 patients and 8 longitudinal measurements at 1, 2, 3, 4, 5, 8, 12, and 26 weeks post-stroke onset. A letter cancellation test (LCT) was used as the primary outcome measure to demonstrate presence and severity of VSN. The clinical severity of stroke was classified using the Bamford Classification.No significant association between clinical severity and the number of ipsilesional, as well as contralesional, omissions on the LCT was observed. Recovery of VSN at the contralesional hemiplegic, as well as ipsilesional non-hemiplegic side, was only dependent on ‘time’ as a reflection of spontaneous neurobiological recovery post-stroke. The recovery of the ipsilesional extension of VSN was significantly slower for the total anterior circulation infarct (TACI) group compared to the non-TACI group.Larger strokes have a significant negative impact on recovery of visual attention at the non-hemiplegic side. No clinical determinants that regulate spontaneous time-dependent recovery of VSN were found. While early ‘stroke severity’ has been regarded as a strong predictor of functional outcome at a group level, other prognostic factors  need to be determined.http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1424EXPLICIT-stroke Trial: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1665Stroke Intensity Trial:  Visuospatial neglect (VSN) is a frequent disorder following stroke, leaving patients with impaired or even lost awareness for contralesional stimuli and/or events (i.e. side of space opposite to the lesioned hemisphere). In very severe cases of VSN, the deficit may also encompass stimuli and/or events at the ipsilesional side, in other words, the same side of space as the lesioned hemisphere. Either due to hypo-attention to the contralesional field , 2, hypeAlthough spontaneous neurobiological recovery of VSN occurs naturally in most patients within the first 10–12 weeks post-stroke onset , it remaTherefore, the primary aim of the current study was to investigate the association between the severity of VSN after right hemisphere stroke, as reflected by the extent of ipsilesional visuospatial attention deficit  and clinical severity of stroke indicated with the Bamford Classification . The cliwww.trialregister.nl, TC1424) and the Stroke Intensity trial [This is a secondary data analysis with data merged from two prospective cohort studies: the EXPLICIT-stroke trial , 15 were included in the present study  and approved by the by the Medical Ethics Review Committees of Leiden University Medical Center (No. P08.035) and the Dutch Central Committee on Research Involving Human Subjects (CCMO: No. NL21396.058.08). The Intensity Trial was registered in the Dutch Trial Registrey  and approved by the local Ethical Committee of the VU University Medical Centre, Amsterdam, the Netherlands (https://www.vumc.nl/afdelingen/METc/METc/). The authors confirm that all related trials for this intervention were registered.Only patients with VSN were included for the statistical analyses in the present study. From the 260 stroke patients from both cohort studies, 90 patients with a first-ever, ischemic, right-hemisphere stroke see also ). InformFor both trials, the research protocols were implemented within 14 days post-stroke onset. The interventions were focussed at functional motor recovery. Final outcome was defined at 26 weeks for the EXPLICIT-stroke trial and 52 weeks for the Stroke Intensity trial. For the current study, this resulted in 8 longitudinal, weekly measurements at weeks 1 up to 5, and follow-up measurements at weeks 8, 12, and 26. All outcome measures were obtained during these measurements.In the present study, the letter cancellation test (LCT) was used as the primary outcome measure to demonstrate presence and severity of VSN. Here, patients had to cancel O-s among other letters on a sheet of A4 paper containing 20 O-s on the left side, 20 O-s on the right side, among 425 distractors in total . Both taThe clinical severity of stroke was classified using the Bamford classification . This clThe patients’ medical records were also reviewed to capture the following relevant data: age, sex, and time post-stroke onset. Additionally, intervention type  and clinical assessments were noted: cognitive impairments as measured with the mini mental state examination (MMSE), synergistic motor control of the paretic arm as measured with the Fugl-Meyer assessment (FMA-arm), motor strength of the paretic arm as measured with the motricity index (MI-arm), and independence in activities of daily living as measured with the Barthel index (BI).The MMSE  examinesThe FMA-arm  is a strThe MI-arm  consistsThe BI  measuresFirst, demographic and clinical stroke characteristics were compared between the two groups, patients with a TACI versus patients with a non-TACI, using non-parametric tests.Next, the regression coefficient was estimated for the association between the predictor clinical severity (i.e. TACI versus non-TACI) and outcome  adjusted for study population. In a separate model this association was also adjusted for time. Moreover, in this latter model interaction terms between clinical severity and time were added to investigate whether this severity was dependent on time. The data structure was clearly hierarchical, as repeated observations (level 1) were nested within patients (level 2). The data analysis required implementation of multilevel random coefficient analysis, which was performed using MLWIN version 2.26. The restricted iterative generalised least-squares (RIGLS) estimation procedure was used to estimate the regression coefficients of the derived model. Assumptions required for conducting regression analyses were assessed by inspecting normal probability plots and plots of standardized residuals versus predicted values. We controlled for clinical trial (because studies had different inclusion criteria) in the multilevel analyses. The time-dependency of both ipsilesional and contralesional VSN data was investigated by using random coefficient analyses, corrected for type of intervention. For all tests, a two-tailed significance level of .05 was used. The Wald-test was used to obtain p-values for the regression coefficients.2 = 1.600, p = .206), time post-stroke onset , MMSE , BI , FMA-arm , MI-arm , and contralesional  and ipsilesional omissions . Type of treatment was unequally distributed across groups .An overview of demographic and stroke characteristics at baseline is given in In Overall, no significant association was observed between clinical severity (TACI versus non-TACI) and number of ipsilesional omissions measured with the LCT . HoweverOverall, no significant association was observed between clinical severity (TACI versus non-TACI) and number of contralesional omissions . Also, nThe current study shows no significant overall association between clinical severity assessed within the first 2 weeks post-stroke onset and the number of ipsilesional, as well as contralesional omissions measured, with the LCT. Recovery of VSN at the contralesional hemiplegic, as well as ipsilesional non-hemiplegic side, was only dependent on ‘time’ as a reflection of spontaneous neurobiological recovery post-stroke. Recovery of VSN at the contralesional and ipsilesional side was comparable between both groups, yet a trend toward lower omission scores was observed for the ipsilesional side only.Irrespective of initial severity of stroke, only progress of time, as a reflection of spontaneous neurobiological recovery , seems tEven though the present study reflects one of the largest patient cohorts suffering from VSN post-stroke, some limitations need to be addressed. First, we did not have direct measures for lesion size and lesion location. Even though the Bamford classification is a widely used, reliable and valid clinical measure , it obvi