Social support and cancer screening among older black Americans.

BACKGROUND: Age-adjusted cancer mortality is 27% higher for Black Americans than for the general U.S. population, which may result from inappropriate use of cancer detection tests. Social support has been shown to affect adjustment to breast cancer and survival, but it has not been studied as a predictor of use of preventive health care services in the older population. Our hypothesis is that larger social networks are associated with greater utilization of cancer-screening tests in the older population. PURPOSE: The objective of this study was to examine the relationship between social support and use of cancer-screening tests among older Black Americans. METHODS: Data for this study were obtained from a 1986 baseline survey evaluation of a community intervention program to increase cancer awareness and a 1991 end-point survey of use of cancer detection tests. Our study sample consisted of 617 Black Americans aged 55 years or older who lived in San Francisco (Calif.), the control community, and in Oakland (Calif.), the target community for intervention. The survey included measures of 1) social network characteristics, as determined by a modified version of Berkman and Syme's Social Network Index; 2) demographic characteristics; and 3) use of six cancer-screening tests--mammography, occult blood stool examination, cervical smear, clinical breast examination, digital rectal examination, and sigmoidoscopy. RESULTS: Multiple logistic regression analysis of the Social Network Index results indicated statistically significant positive associations of social support with the use of mammography and occult blood stool examination but not with the other cancer-screening tests. There were statistically significant associations between having HMO (Health Maintenance Organization) insurance and increased use of mammography and occult blood stool examination, compared with having Medi-Cal or other insurance. The interval between the surveys had a statistically significant positive association with use of mammography. These significant associations were not explained by differences in the other variables, which included health status, age, gender, education, type of health insurance, interval between the surveys, and a regular source of care. CONCLUSIONS: Social support seems to be associated with increased use of mammography and occult blood stool examinations among older Black Americans. IMPLICATIONS: Interventions designed to increase utilization of social networks may be an effective way to increase use of cancer screening, which may ultimately lead to reduced mortality from cancer.

Psychosocial outcomes of cancer: a comparative analysis of Hodgkin's disease and testicular cancer.

PURPOSE: The psychosocial outcomes of testicular cancer and Hodgkin's disease were compared to test our hypotheses that more specific dysfunction and less hiding of symptoms would be found in the former group, as cancer visibly affects a sexual organ. Since those with Hodgkin's disease could more easily deny the disease, poorer psychosocial adjustment was predicted. PATIENTS AND METHODS: The sample consists of 85 men with Hodgkin's disease and 88 men with testicular cancer (seminomatous, n = 39; or nonseminomatous, n = 49). They were interviewed once, at least 1 year following the end of treatment. Measures of sociodemographic characteristics, physical functioning, psychologic distress, and social outcomes were collected. Treatment data were collected from medical records. RESULTS: Men with testicular cancer report more focused symptoms: less sexual enjoyment and poor health habits. Men with Hodgkin's disease report more generalized symptoms: fatigue, energy loss, and work impairment. Multivariate analysis indicates that most of these differences are site-related; independent effects of treatment on outcomes were found for more generalized symptoms. Contrary to expectations, both groups reported similar levels of infertility and erectile dysfunction. CONCLUSION: The response to testicular cancer is site-specific, while the response to Hodgkin's disease is related to both site and treatment (stage-related).

Group support for patients with metastatic cancer. A randomized outcome study.

The effects of weekly supportive group meetings for women with metastatic carcinoma of the breast were systematically evaluated in a one-year, randomized, prospective outcome study. The groups focused on the problems of terminal illness, including improving relationships with family, friends, and physicians and living as fully as possible in the face of death. We hypothesized that this invention would lead to improved mood, coping strategies, and self-esteem among those in the treatment group. Eighty-six patients were tested at four-month intervals. The treatment group had significantly lower mood-disturbance scores on the Profile of Mood States scale, had fewer maladaptive coping responses, and were less phobic than the control group. This study provides objective evidence that a supportive group intervention for patients with metastatic cancer results in psychological benefit. Mechanisms underlying the effectiveness of this group intervention are explored.

Factors affecting the use of screening mammography among African American women.

Our objective was to determine the influence of health consciousness in the utilization of mammography in asymptomatic African American women. The sample consisted of 670 women who participated in a household interview in two cities. Logistic regression was used to determine the independent effects of health consciousness, holding constant other factors believed to be related to mammography utilization. Health insurance, income below the poverty line, and an annual physical were not significant predictors. The single most important predictor of having a mammogram was the regular practice of breast self-examination; the group of women who practiced self-examination was almost twice as likely to have a mammogram.

Inhibitory effect of inositol phosphates on parathyroid hormone-induced bone resorption in organ cultures.

This study investigates the ability of phytic acid, its inositol phosphate derivatives (inositol penta-, tetra-, tri-, di-, and monophosphate), and inorganic phosphate to inhibit parathyroid hormone (PTH)-induced resorption of fetal rat long bones in organ culture. Pregnant rats injected with 45Ca on the 18th day of gestation were killed the next day and their fetuses removed. Half of each pair of dissected long bones was incubated in a chemically defined control medium, while the contralateral half was incubated in medium containing PTH or PTH plus the phosphate compound to be tested. 45Ca released into the medium was indicative of the amount of bone resorption. All phosphate compounds tested inhibited resorption. The inositol phosphates should be studied further to assess their suitability as therapeutic agents for treatment of metabolic bone diseases involving increased turnover.

Social support, accommodation to stress and adjustment to breast cancer.

A woman's emotional adjustment to breast cancer is the focus of this study. The social support the woman experiences is predicted to affect the adjustment process by improving her ability to cope. Current clinical research indicates that background factors, such as marital status, age, SES and life change, also affect adjustment; these variables are incorporated into the model as controls. Using multiple regression analysis (N = 130), the control variables are entered simultaneously with the indicators of social support to assess the independent effect of social support on adjustment. The relationship between social support, coping, and adjustment, as measured by psychological distress, self concept, and sense of power, is then examined. Two indicators of social support, perception of family cohesiveness and the amount of social contact have direct effects on coping and indirect effects on all three measures of adjustment, indicating that coping mediates the relationship between social support and adjustment. Contrary to predictions, being employed and of higher social status have significant effects on adjustment when it is measured by either self concept or sense of power.

The relationship of social support and health.

The objective of this research note is to challenge the research community to develop a cumulative body of knowledge on the relationship between social support and health. Fruitful approaches to this end include further explication of the concept of social support and its measurement, studies of the causal pathways between social supports and health, and further understandings of the relationship between the different dimensions of support and mental and physical health.

The relationship of two dimensions of social support to the psychological well-being and social functioning of women with advanced breast cancer.

Of interest to the field is the mechanism through which social support acts as a resistance resource for individuals undergoing stressful life circumstances. Women with advanced breast cancer (N = 86) were interviewed to determine how their outlook on life and social functioning were affected by the social support they received. Emotional support provided by the family was predicted to affect the woman's sense of well-being whereas the opportunities for social exchange provided by one's social activities were expected to effect the woman's social functioning. Consistent with the predictions, the data indicate that social support is multidimensional. Emotional support was strongly related to one's outlook. However, one's opportunities for social exchange affect not only one's social functioning, but also one's outlook on life, suggesting an interactive process whereby family support improves outlook, both outlook and opportunities for social exchange are related to one's sense of social functioning. These data explain the erosion of social support during life-threatening illness such as cancer as a result of the limitations imposed by the illness on one's opportunities for social exchange.

Nurse staffing patterns and hospital efficiency in the United States.

The objective of this exploratory study was to assess the effects of four nurse staffing patterns on the efficiency of patient care delivery in the hospital: registered nurses (RNs) from temporary agencies; part-time career RNs; RN rich skill mix; and organizationally experienced RNs. Using Transaction Cost Analysis, four regression models were specified to consider the effect of these staffing plans on personnel and benefit costs and on non-personnel operating costs. A number of additional variables were also included in the models to control for the effect of other organization and environmental determinants of hospital costs. Use of career part-time RNs and experienced staff reduced both personnel and benefit costs, as well as total non-personnel operating costs, while the use of temporary agencies for RNs increased non-personnel operating costs. An RN rich skill mix was not related to either measure of hospital costs. These findings provide partial support of the theory. Implications of our findings for future research on hospital management are discussed.

The effect of the social organization of work on the voluntary turnover rate of hospital nurses in the United States.

In light of current concerns over nursing shortages and productivity, voluntary turnover among hospital nurses in the United States has assumed renewed importance as a managerial issue. This study examines the thesis that the social organization of work in hospitals is an important determinant of the voluntary turnover rate among registered nurses. This perspective differs from previous work in this area in that both turnover and its determinants are conceptualized at the organizational rather than individual level, thus opening the way for administrative intervention to reduce turnover. The conceptual model is tested using multiple regression techniques on a sample of 435 hospitals. Results suggest that organizational characteristics and environmental conditions are important contributors to turnover. Organizational characteristics are stronger predictors of turnover than are economic factors.

Sources of support and the physical and mental well-being of young women with breast cancer.

Women following the stress resulting from the diagnosis and treatment for breast cancer draw resources from their network of friends and relatives. These resources include both emotional support and instrumental resources such as getting a ride to a medical appointment. Emotional support buffers the effects of the stresses they face and improves their mental well-being while the existence, rather than the use, of instrumental supports is positively related to physical well-being. These hypotheses are tested on a population-based cohort of 336 women in the United States, diagnosed and treated for breast cancer when aged 50 or less. Most are married (65%), work (75%), have dependent children (63%), are white (70%), and had a mastectomy (51%). Results of the multi-variate analyses indicate that consistent with predictions, controlling for socio-demographic and treatment-related variables, the size of the social network was related to greater emotional and instrumental support, and greater emotional support was related to better mental well-being. Contrary to predictions, greater use of instrumental resources was related to poorer physical well-being. The results indicate the importance of social resources on well-being following life-threatening illness.

Hypertension control through the design of targeted delivery models.

If we discard some of the assumptions upon which curatively oriented medical care is based, we can design models to deliver more effective services for those with chronic diseases. Assumptions to be discarded are--that disease processes can be cured through the delivery of a "magic bullet" rather than controlled through continuous surveillance, -that the physician must be an active decision maker and thus act as gatekeeper and monitor for all disease victims, and -that care for a family of consumers must be provided together. Models for the delivery of services can then be designed to provide continuity of care for those with a specific chronic disease, and paraprofessionals can be used as gatekeepers and monitors, in combination with physicians, rather than physicians alone, to give services. Models can be targeted to reach specific high-risk groups within the population at the workplace, the school, unemployment office, or wherever groups routinely congregate for purposes other than health care. Building targeted models requires extensive knowledge of the specific geographic area and its population as well as knowledge of the natural history of the disease and its treatment. For hypertension programs, goals can be set in terms of numbers of persons whose disease is controlled and the number of new programs initiated as the result of the control efforts.

Evaluation of an extended degree program in public health for working professionals.

The faculty of the School of Public Health, University of California at Berkeley, developed an extended degree program in health services administration for persons who could not attend the university full time. Course formats were redesigned so the courses could be taught off campus in Sacramento and in the San Francisco Bay Area. The extended degree program was designed to be the equivalent of the in-residence program in all respects: the minimum number of units required for the degree was the same and regular faculty taught in both programs. The course of study for the two programs was similar; a major difference, however, was that many more electives were available to on-campus students. Two cohorts of extended degree students were admitted (34 and 37), and 61 completed the program. This article evaluates the success of that program. Evaluation began in 1980, 4 years after the first cohort, and 2 years after the second cohort were graduated--sufficient time for the graduates and faculty to reflect on their experiences. By the measures used--entering grade point average, graduating grade point average, and scores on a common comprehensive examination--the two groups were comparable. Faculty and students alike evaluated the program favorably. All but one graduate stated that they would recommend this program to others if it were available.

Emotional support following cancer: a test of the stigma and social activity hypotheses.

Reports of changes in emotional support following surgery for breast cancer can be attributed to one of two factors: (1) the stigma associated with cancer, or (2) illness-imposed restrictions in one's activities. These explanations were assessed using data from a longitudinal study of women, following their surgical treatment for early breast cancer (N = 145), gallbladder disease (N = 90), benign breast disease (N = 87), or no surgery (N = 90). Multiple regression analysis was used to test the two models. Contrary to the cancer stigma hypothesis, women with breast cancer initially perceived themselves to have more emotional support, rather than less. Type of surgery did not explain the level of emotional support as post-surgery time increased. Instead, support for the social activity hypothesis was found. The results are interpreted as indicating that breast cancer no longer carries with it a stigma, at least not to the extent of reducing the level of women's emotional support.

Implementing capitation of Medicaid mental health services in Colorado: is "readiness" a necessary condition?

Two consortia of community mental health centers in Colorado varied in their administrative readiness for changing to a capitated system and, ultimately, implemented capitation using different organizational arrangements. The objective was to assess the impact of this natural experiment on administrative change, costs, and utilization of services during the first two years postcapitation. Prior to capitation, one was rated as having greater "readiness" than the other and received a capitation contract from the state, while the other did not. A private, for-profit managed behavioral health organization was awarded a contract and formed a joint venture with the less "ready" consortium, providing managed care expertise to complement the consortium's expertise in delivering mental health services. Two years later, these consortia do not look different either administratively or in their patterns of service utilization and costs. These findings suggest alternative ways of successfully implementing a capitated public mental health system.

The nurse practitioner and hypertension control: a pilot study.

Hypertension is the major health problem affecting blacks today. Socioecological stress is implicated in areas in which excess mortality exists. The nurse practitioner, whose role has been established in providing medical treatment for hypertension, also has a role in alleviating social stressors. The objective in this study was to determine the nurse practitioner's effectiveness in reducing stress and whether stress reduction resulted in blood pressure reduction. The results indicate that the nurse practitioner's intervention was effective--when patients complied with her suggestions both socioecological stress and blood pressure were significantly reduced.

The impact of risk shifting and contracting on mental health service costs in California.

This paper identifies the impact of "program realignment," a 1991 California state policy that significantly enhanced local governments' financial risk and programmatic authority for public mental health services, on treatment costs per user, and on the mix of inpatient and outpatient service costs. The study employs a natural pre-realignment and post-realignment design using the 59 California local mental health authorities (LMHAs) as the unit of analysis over a seven-year period spanning policy implementation. Total treatment and inpatient cost per user decreases and outpatient cost per user increases after program realignment. Higher levels of contracting with private providers tend to enhance this trend, while risk for institutional services reduces user costs uniformly. Financial and programmatic decentralization can enhance cost efficiency in treatment, while promoting substitution of outpatient services for inpatient services. Local conditions such as risk and contracting determine the extent of the policy response.

Influence of Meloidogyne incognita on Fusarium Wilt of Tomato at or below the Minimum Temperature for Wilt Development.

'Bonny Best' tomato plants were grown at 16, 21, or 24 C for 28 d in soil infested with either of two isolates of Fusarium oxysporum f. sp. lycopersici race 1 and Meloidogyne incognita. Significant levels of fusarium wilt occurred at all temperatures including 16 C, which has not been reported previously. One Fusarium isolate resulted in the highest levels of disease incidence at 21 and 24 C in the presence of root-knot nematodes, and at 24 C when the nematodes were not present. At 16 C there was no significant difference in the number of plants infected by the second Fusarium isolate alone or in combination with root knot nematodes, although the presence of nematodes resulted in a significant increase in the percentage of disease occurrence and vessel infection at 21 C.

Interaction of Uromyces phaseoli and Meloidogyne incognita on Bean.

Uromyces phaseoli, the causal agent of bean rust, suppressed shoot and root growth of three bean cultivars, reducing root weight more than shoot weight. The greatest suppression of root weight was on the cultivar that appeared most susceptible by visual ratings of shoot symptoms. Meloidogyne incognita suppressed shoot and root growth of all test cultivars; root weight reductions differed among cultivars identical in susceptibility to this pathogen in root-gall rating tests. Infection of plants with both pathogens suppressed plant weights significantly more than did infection by either pathogen alone, evidencing an additive effect. U. phaseoli and M. incognita on the same plant influenced the reproduction of one another, presumably through effects on the host. Fungal uredia were reduced in size and sporulation capacity; M. incognita produced fewer root galls, and fewer eggs per egg mass.

The influence of Pratylenchus penetrans on the incidence and severity of verticillium wilt of potato.

The influence of Pratylenchus penetrans on the incidence and severity of Verticillium wilt was examined in the potato cultivars 'Kennebec', 'Katahdin', and 'Abnaki'. Single-stem plants were grown in soil maintained at a temperature of 22 +/- 1 C. Axenically cultured nematodes were suspended in water and introduced to the soil, at a rate of ca 5,000/25.4-cm pot, through holes made around each stem. Ten days after infestation with nematodes, conidial suspensions of Verticillium albo-atrum were introduced into the soil at a rate of ca 1,000,000/pot. Among Katahdin plants, the severity of foliar symptoms was increased in the presence of both pathogens 2 and 3 weeks after soil intestation. During the remaining 5 weeks, severity of foliar symptoms was not different between plants infected by both pathogens and those infected by Verticillium alone. Within the wilt-susceptible cultivar Kennebec and the resistant eultivar Abnaki, no effects on foliar symptom severity were observed. When plant heights, shoot weights, and tuber yields were analyzed, a Pratylenchus-Verticillium interaction was not evident within any of the cultivars tested. Nematode populations in roots and rhizosphere were suppressed in Kennebec and Katahdin plants in the presence of Verticillium.