Burden of self-care in seriously ill patients: impact on adjustment.

Perceived, but not actual, control over the treatment has been consistently related to better adjustment in chronic illness. This study examined the relationship between actual control over treatment and severity of illness and their influence on depression in a chronically ill population of end-stage renal disease (ESRD) patients. The authors hypothesized that as severity of illness increases, the burden of control over treatment would increase depression. Severity of illness and depression were assessed for 98 ESRD patients. Control over treatment was represented by whether dialysis patients were self-administering treatment (high control) or were receiving treatment from the medical staff (low control). Results indicated that for the most severely ill patients, high control over treatment resulted in poorer adjustment. Furthermore, this effect was due in part to how illness interferes with social relationships in seriously ill, self-care patients.

Disease severity, physical limitations and depression in HIV-infected men.

Previous research has failed to identify a consistent relationship between HIV disease severity and depression. However, HIV/AIDS can lead to substantial physical limitations in those with advanced disease, which may influence mood. This study examined the extent to which HIV disease severity and physical limitations were associated with depressive symptoms in 49 HIV-infected men at the final stages of a 5-year prospective study. No differences were found in depression or quality of life among men who were asymptomatic, symptomatic, or diagnosed with AIDS. Forty-three percent of subjects reported substantial physical limitations, which were associated with higher depression scores and poorer quality of life. Degree of physical limitation predicted depression concurrently as well as depression 6 months later, after controlling for disease stage, physical symptoms, and CD4 cell counts. Findings suggest that physical limitations are more important than laboratory markers of disease progression in understanding psychological adjustment to illness in HIV-infected men.

Preventing binge drinking during early adolescence: one- and two-year follow-up of a school-based preventive intervention.

The authors examined the effectiveness of a school-based prevention program on reducing binge drinking in a sample of minority, inner-city, middle-school students. Rates of binge drinking were compared among youth who received the program beginning in the 7th grade (n = 1,713) and a control group (n = 1,328) that did not. The prevention program had protective effects in terms of binge drinking at the 1-year (8th grade) and 2-year (9th grade) follow-up assessments. The proportion of binge drinkers was over 50% lower in the intervention group relative to the control group at the follow-up assessments. There were also several significant program effects on proximal drinking variables, including drinking knowledge, pro-drinking attitudes, and peer drinking norms. These findings indicate that a school-based drug abuse prevention approach previously found to be effective among White youth significantly reduced binge drinking among urban minority youth.

Protective role of personal competence skills in adolescent substance use: psychological well-being as a mediating factor.

Adolescents who use a variety of cognitive and behavioral self-management strategies have been shown to report reduced rates of early-stage substance use, but little is known about how these personal competence skills may be protective. In a series of structural equation models, this study examined the association between competence skills and substance use over a 3-year period among 849 suburban junior high school students, and whether psychological distress, well-being, or both mediated this relation. Findings indicated that well-being fully mediated the relation between early competence and later substance use, but distress did not. Youth with good competence skills reported greater subsequent well-being, which in turn predicted less later substance use. Findings suggest that competence skills protect youth by enhancing well-being and that prevention programs should aim to enhance competence in order to promote resilience.

Parenting practices as predictors of substance use, delinquency, and aggression among urban minority youth: moderating effects of family structure and gender.

This study examined how parenting factors were associated with adolescent problem behaviors among urban minority youth and to what extent these relationships were moderated by family structure and gender. Sixth-grade students (N = 228) reported how often they use alcohol, smoke cigarettes, or engage in aggressive or delinquent behaviors; a parent or guardian reported their monitoring and other parenting practices. Findings indicated that boys and those from single-parent families engaged in the highest rates of problem behavior. More parental monitoring was associated with less delinquency overall, as well as less drinking in boys only. Eating family dinners together was associated with less aggression overall, as well as less delinquency in youth from single-parent families and in girls. Unsupervised time at home alone was associated with more smoking for girls only. Implications for prevention interventions are discussed.

Role of general and specific competence skills in protecting inner-city adolescents from alcohol use.

OBJECTIVE: The purpose of this longitudinal investigation was to test whether higher levels of general competence are linked to greater refusal assertiveness that is, in turn, related to less subsequent alcohol use among inner-city adolescents. METHOD: A large sample of students attending 22 middle and junior high schools in New York City participated. Students completed surveys at baseline, at 1-year follow-up and at 2-year follow-up (N = 1,459; 54% female). The students self-reported alcohol use. decision-making skills, self-efficacy and refusal assertiveness. Teams of three to five data collectors administered the questionnaire following a standardized protocol. The data were collected in school during a regular 40-minute class period. RESULTS: According to the tested structural equation model, Decision Making (beta = .07, p < .05) and Self-Efficacy (beta = .24, p < .001) predicted higher Refusal Assertiveness and this greater assertiveness predicted less drinking at the 2-year follow-up (beta = -.21, p < .001). Earlier drinking predicted 2-year follow-up drinking (beta = .40, p < .001). Goodness-of-fit indices were excellent (chi2 = 1107.9, 238 df, N = 1,438, p < .001; NFI = .93, NNFI = .94, CFI = .95). CONCLUSIONS: The tested model had a good fit and was parsimonious and consistent with theory. This research highlights the importance of addressing decision-making skills, self-efficacy and refusal assertiveness within adolescent alcohol prevention programs.

Psychosocial and behavioral factors in early adolescence as predictors of heavy drinking among high school seniors.

OBJECTIVE: Most adolescents experiment with alcohol, and the use of alcohol typically escalates during the teenage years. The present study examined how several risk and protective factors measured during early adolescence were associated with heavy drinking in a sample of high school seniors. METHOD: As part of a school-based survey, seventh-grade students (N = 1,132) reported degrees of experimentation with alcohol and cigarettes. Several psychosocial factors deemed to be important in the etiology of drinking were also assessed. Students were followed-up in the twelfth grade, when 16% were categorized as heavy drinkers based on drinking and drunkenness frequency and quantity typically consumed. RESULTS: Logistic regression analyses revealed that heavy drinking was predicted by having had experimented with alcohol or cigarettes, having had a majority of one's friends drink and having had poor behavioral self-control in early adolescence. In addition, several effects were limited to either boys or girls. For example, positive alcohol expectancies predicted greater later heavy drinking in boys, while friends' smoking predicted later heavy drinking in girls. CONCLUSIONS: The findings suggest that early intervention programs aimed at preventing alcohol use by addressing the social and psychological determinants of alcohol use may have important preventive effects in terms of later heavy drinking.

Preventing illicit drug use in adolescents: long-term follow-up data from a randomized control trial of a school population.

National survey data indicate that illicit drug use has steadily increased among American adolescents since 1992. This upward trend underscores the need for identifying effective prevention approaches capable of reducing the use of both licit and illicit drugs. The present study examined long-term follow-up data from a large-scale randomized prevention trial to determine the extent to which participation in a cognitive-behavioral skills-training prevention program led to less illicit drug use than for untreated controls. Data were collected by mail from 447 individuals who were contacted after the end of the 12th grade, 6.5 years after the initial pretest. Results indicated that students who received the prevention program (Life Skills Training) during junior high school reported less use of illicit drugs than controls. These results also support the hypothesis that illicit drug use can be prevented by targeting the use of gateway drugs such as tobacco and alcohol.

Alcohol and marijuana use among rural youth: interaction of social and intrapersonal influences.

Epidemiological research indicates that the prevalence rate of drug use among adolescents has risen steadily during this decade, and although alcohol use has stabilized it is still highly prevalent. Psychosocial etiological models have typically examined main effects of risk and protective factors. This study examined moderating effects of intrapersonal skills on social (peer and parental) risks associated with alcohol and marijuana use among eighth-grade rural adolescents, an understudied population. Results indicated that the relationships of peer and parental attitudes, and peer usage to alcohol and marijuana use, are moderated by adolescents' decision-making and self-reinforcement skills. Social risk factors were strongly associated with increased alcohol and marijuana use among adolescents with poor intrapersonal skills. However, good decision-making and self-reinforcement skills diminished the influence of social risk factors on substance use. Results are discussed in terms of implications for psychosocial models of alcohol and drug use, and for designing effective school-based universal prevention interventions.

Comparison of quality of life in hemodialysis and peritoneal dialysis patients.

This study was designed to compare severity of illness and quality of life variables in chronic peritoneal dialysis (PD) and hemodialysis (HD) patients. The patient sample consisted of 63 PD patients (38 male, 25 female; mean age 54.5 years) and 35 HD patients (23 male, 12 female; mean age 54.9 years). Disease severity was greater in in-center HD patients than in PD patients (p < 0.008), although there were no significant differences in functional status as measured by the Karnofsky Index between HD patients (68.6 +/- 2.3) and PD patients (71.9 +/- 1.7). While both patient groups reported the same number of overall physical symptoms. HD patients reported significantly greater overall discomfort from symptoms than PD patients (p < 0.008). In terms of psychological adjustment, analyses revealed that 22 PD patients (36.7%) and 9 HD patients (25.7%) were classified as clinically depressed. PD patients reported higher anxiety scores than HD patients (p < 0.02) and lower positive mood scores (p < 0.021). HD patients were more severely ill and appeared to suffer from physical symptomatology to a greater degree than PD patients, although they were not more impaired in terms of functional status. Moreover, HD patients showed better psychological adjustment along several dimensions when compared to PD patients. One reason for this finding may be that PD patients experience greater distress, and isolation due to a lack of social support from similar others and medical staff in comparison to in-center HD patients.

Competence skills help deter smoking among inner city adolescents.

OBJECTIVE: To test whether higher levels of general competence are linked to more frequent use of refusal assertiveness that is in turn related to less subsequent smoking among inner city adolescents. METHODS: Longitudinal study conducted during three year middle school or junior high school period. A sample of 1459 students attending 22 middle (ages 11-14 years) and junior high (ages 12-15 years) schools in New York City participated. Students completed surveys at baseline, one year follow up, and two year follow up. The students self reported smoking, decision making skills, personal efficacy, and refusal assertiveness. Teams of three to five data collectors administered the questionnaire following a standardised protocol. These data were collected in school during a regular 40 minute class period. RESULTS: Based on the tested structural equation model, decision making and personal efficacy (that is, general competence) predicted higher refusal assertiveness and this greater assertiveness predicted less smoking at the two year follow up. The tested model had a good fit and was parsimonious and consistent with theory. CONCLUSIONS: Adolescent smoking prevention programmes often teach refusal skills in order to help youth resist peer pressure to smoke. The present findings suggest that teaching general competence skills as well may help to reduce smoking because youth with better personal efficacy and decision making skills are better able to implement smoking refusal strategies.

Risk taking and refusal assertiveness in a longitudinal model of alcohol use among inner-city adolescents.

Risk taking and refusal assertiveness have been shown to be important determinants of adolescent alcohol use. However, it remains unclear whether youth predisposed to risk taking would be less likely to assertively refuse. This study examined the relationships among risk taking, refusal assertiveness, and alcohol use in a sample of inner-city minority students (N = 1,459), using a cross-lagged longitudinal structural equation model. Data collectors administered the questionnaire to students following a standardized protocol during a 40-min class period. Based on the tested model, risk taking was more stable over time than refusal assertiveness. Furthermore, high risk takers reported less frequent subsequent refusal assertiveness, and less frequent refusal assertiveness predicted greater drinking. A predisposition toward risk taking appears to be an enduring characteristic that is associated with low refusal assertiveness and increased alcohol use. These findings suggest that alcohol prevention programs that emphasize refusal skills training may be less effective for high risk takers. But programs that focus on enhancing competence or reducing normative expectations for peer alcohol use might be more effective for high risk-taking youth.

Measuring disease severity in patients with end-stage renal disease: validity of the Craven et al. ESRD Severity Index.

The validity of a recently developed measure of disease severity, the End-stage Renal Disease Severity Index (Craven et al. 1991) was examined in haemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients (total N = 82). Scores on the ESRD Severity Index were compared with three commonly identified components of disease severity: physiological indices of severity, functional status, and psychological burden of illness. For the entire group of subjects, scores on the ESRD Severity Index were negatively associated with functional ability and positively related to physiological severity. ESRD Severity Index scores showed a weaker relationship with psychological burden of illness which depended in part on treatment mode. Disease severity scores were positively related to depression in CAPD patients but not in HD patients. These findings suggest that the ESRD Severity Index is a valuable research tool with construct validity.

The effect of a patient education program on emergency room use for inner-city children with asthma.

An educational program for children with asthma designed to reduce emergency room (ER) use enrolled all eligible children (n = 253 primarily low-income Black) within a health maintenance organization (HMO) who had used the hospital or ER for asthma during the pre-enrollment period and randomized them into two groups. Twenty-four of the experimental group patients had 55 ER visits and 18 of the control patients had 39 ER visits during the first 12 months post-intervention. This program did not achieve its goal.

A model of smoking among inner-city adolescents: the role of personal competence and perceived social benefits of smoking.

BACKGROUND: Based on current trends, smoking will remain a major public health problem in the 21st century. Effective smoking prevention approaches offer the best hope for decreasing the rise in adolescent smoking rates. Competence enhancement approaches to smoking prevention are among the most successful. Yet, there is not a full understanding of how effective prevention approaches work. This study tests whether a deficiency in competence (poor decision-making skills and low personal efficacy) is linked to acquiring beliefs in the perceived benefits of smoking and whether these perceived benefits are then related to subsequent smoking. METHODS: A sample of 1459 students attending 22 middle and junior high schools in New York City participated. Students completed surveys at baseline, 1-year follow-up and 2-year follow-up during a regular class period. They self-reported smoking, decision-making skills, personal efficacy and beliefs in the perceived benefits of smoking. RESULTS: The tested structural equation model had a good fit and was parsimonious and consistent with the theory underlying the competence approach to smoking prevention. CONCLUSIONS: This research highlights the importance of addressing decision-making skills, personal efficacy, and beliefs in the social benefits of smoking within adolescent smoking prevention programs.

Preventive intervention effects on developmental progression in drug use: structural equation modeling analyses using longitudinal data.

This study examined the plausibility of the gateway hypothesis to account for drug involvement in a sample of middle school students participating in a drug abuse, prevention trial. Analyses focused on a single prevention approach to exemplify intervention effects on drug progression. Improvements to social competence reduced multiple drug use at 1- and 2-year follow-ups. Specific program effects disrupted drug progression by decreasing alcohol and cigarette use over 1 year and reducing cigarette use over a 2-year period. Controlling for previous drug use, alcohol was integrally involved in the progression to multiple drug use. Subgroup analyses based on distinctions of pretest use/nonuse of alcohol and cigarettes provided partial support for the gateway hypothesis. However, evidence also supported alternate pathways including cigarette use as a starting point for later alcohol and multiple drug use. Findings underscore the utility of targeting more than one gateway substance to prevent escalation of drug involvement and reinforce the importance of social competence enhancement as an effective deterrent to early-stage drug use.

Effects of environmental demands, stress, and mood on health practices.

The present study examined how environmental demands, stress, and positive and negative affect were related to health practices. College undergraduates (N = 79) completed measures of stress, mood, and health practices during periods of low and high academic demands. Positive affect was positively related to exercise, nutrition, self-care practices, and overall health practices at two measurement points. Levels of stress (daily hassles, perceived stress, academic stress) increased over time, but increases in daily hassles and perceived stress were unrelated to health practices. Increases in academic demands completed in the previous week were associated with improvements in nutrition and self-care practices, greater drug avoidance, and greater overall health practices. This pattern indicates that a "rebound effect" may occur after high demand periods, during which individuals engage in more health-promoting activities. The results also suggest that the determinants of positive health practices may differ from those of negative health practices.

Ethnic and gender differences in psychosocial risk, protection, and adolescent alcohol use.

Theoretical models suggest that many diverse psychosocial factors contribute to the etiology of substance use among youth. It has been suggested that substance use is a function of the total number of etiologic factors, rather than a specific type or set of factors. This study examined whether cumulative psychosocial risk and protection measured in the 7th grade predicted alcohol use in the 9th grade across ethnically diverse samples of adolescents. Participants consisted of black (n = 775) and Hispanic (n = 467) inner-city youth and white suburban youth (n = 708). Prevalence rates for alcohol use and risk/protection varied more widely based on ethnic group compared to gender. Black youth reported the fewest risk factors and lowest levels of alcohol use, white youth reported the most risk factors and highest levels of alcohol use, and Hispanic youth reported the fewest protective factors and intermediate levels of alcohol use. Despite these differences, structural equation modeling indicated that a latent factor consisting of cumulative risk, protection, and their interaction significantly predicted later alcohol use for the combined sample as well as for each ethnic/ gender subgroup. However, the proportion of variance explained in alcohol use varied across subgroups, and moderator analyses indicated that protection significantly buffered the effects of risk differentially across subgroups. The strongest protective effects were observed among black inner-city youth. Findings suggest that prevention approaches should focus on enhancing protection in addition to reducing risk, particularly among youth with lower levels of psychosocial protection.

Distress and disease status among patients with rheumatoid arthritis: roles of coping styles and perceived responses from support providers.

Previous research has shown that social support can have a beneficial impact on coping processes and psychological adjustment in patients with rheumatoid arthritis (RA). The association of individual coping styles and perceived responses from others to one's pain episodes with patients 'distress and disease status over time was investigated. The sample consisted of 42 middle-aged patients with RA who were predominantly White (98%), female (64%), and married (88%). Participants completed surveys and their rheumatologist completed clinical assessments of patient disease status at 2 time points over a 9-month period. Although punishing responses from others (e.g., getting irritated or angry when the patient is in pain) were perceived as relatively infrequent, they were associated with a patient coping style of focusing on and venting of negative emotion as well as elevated negative affect (NA). Findings also indicated that those who perceived punishing responses from close others and coped by venting negative emotions reported increased NA over time and were rated by their rheumatologist as having more severe RA disease status over time. Implications for psychosocial intervention and directions for future research are discussed.