Correlates of quality of life among African American and white cancer survivors.

BACKGROUND: African Americans continue to suffer disproportionately from cancer morbidity and mortality, with emerging evidence suggesting potential quality of life (QOL) disparities in the survivorship period. OBJECTIVE: The objective of the study was to assess sociodemographic, clinical, and psychosocial factors associated with physical and mental health QOL (PHQOL and MHQOL) among African American and white cancer survivors. METHODS: Patients were recruited from tumor registries. Telephone interviews were conducted with 248 African American and 244 white respondents with a history of breast, prostate, or colorectal cancers. Multivariate regression models were used to assess what factors were associated with PHQOL and MHQOL. RESULTS: Key racial differences in adjusted analyses included poorer MHQOL scores among African Americans compared with white survivors. Furthermore, race moderated the relationship between perceived social support and MHQOL, where higher social support levels were associated with increased MHQOL among African Americans. Other correlates of QOL impacted racial groups similarly. For example, factors associated with PHQOL scores included being unemployed, being uninsured, the presence of medical comorbidities, a longer time since diagnosis, and higher levels of cancer-related stress appraisals. Factors associated with MHQOL scores included being unemployed, higher levels of daily stress, higher levels of stress associated with the diagnosis, higher levels of education, higher levels of perceived social support, and higher levels of spirituality. CONCLUSION: Interventions aimed at increasing social support may have important implications for improving QOL outcomes among African Americans. IMPLICATIONS FOR PRACTICE: Measuring and understanding factors associated with QOL have important implications for patient adjustment and clinical decision making.

Dissemination strategies to improve implementation of the PHS smoking cessation guideline in MCH public health clinics: experimental evaluation results and contextual factors.

We report results from an experimental study that tested the effectiveness of dissemination interventions to improve implementation of smoking cessation guidelines in maternal and child public health clinics. We additionally examine individual clinic results for contextual explanations not apparent from the experimental findings alone. Twelve clinics in Illinois were randomized to three dissemination strategies: (i) core dissemination (provision of the 2000 Public Health System Clinical Practice Guideline and a tested smoking cessation program, including program supplies and training), (ii) core dissemination and access to telephone counseling and (iii) core dissemination, telephone counseling access and outreach visits to clinics. Implementation outcomes were post-dissemination improvements over baseline in the percent of smokers reporting receipt/exposure to (i) provider advice, (ii) self-help booklet, (iii) videos, (iv) posters and (v) an adjunct intervention. Results showed significant increases in the percent of smokers receiving a booklet (overall) and an adjunct intervention (Groups 2 and 3). There were no increases in smoker-reported provider advice or videos and poster exposure. Examination of individual clinic findings showed that seven clinics accounted for all the experimental effectiveness. Smoker-reported provider advice to quit also increased in these clinics. Type of clinic and the absence of disruptive events distinguished clinics with and without effective dissemination outcomes.

Are racial differences in patient-physician cancer communication and information explained by background, predisposing, and enabling factors?

Research shows that African Americans tend to have poorer and less informative patient-physician communication than Whites. We analyzed survey data from 248 African American and 244 White cancer patients to examine whether this disadvantage could be explained by race variability on several other variables commonly reported to affect communication. These variables were organized into background, enabling, and predisposing factors, based on the Precede-Proceed Model. Multivariate regressions were used to test whether race differences in communication and information variables persisted after successively controlling for background, enabling, and predisposing factors. African American patients had higher interpersonal communication barriers than Whites, but this difference did not persist after controlling for background factors. African Americans also had higher unmet information needs and were less likely to receive the name of a cancer expert. These differences persisted after controlling for all other factors. Future research should focus on the informational disadvantages of African American patients and how such disadvantages may affect cancer treatment decisions.

Why implementation processes vary across the 5A's of the Smoking Cessation Guideline: administrators' perspectives.

Unrelated to any research, 18 maternal and child health case management agencies adopted a smoking cessation program that included the ask, advise, assess, assist, and arrange components of the 2000 U.S. Public Health Service Smoking Cessation Guideline. To better understand what influences program implementation in practice, a study was conducted 18 months later at 16 (89%) of the agencies. Open-ended interviews with key administrative informants examined implementation processes (i.e., how each program component had been implemented at the organization level) and the administrators' rationales for such implementation. A separate structured telephone survey of the agency case managers (N = 63) assessed their implementation of each program component with smokers. Results showed that all agencies implemented the ask and advise components. Implementation of these components was well supported by the policies, contractual requirements, and operational tools that guided and coordinated all case management activities. No agency implemented the initially adopted program or any other structured approach to implementing the assess, assist, and arrange components. Administrative explanations indicated that these components (a) were not addressed by, and could not be easily incorporated into, the above existing policies and operational tools and (b) were perceived to be in the realm of case manager responsibilities and professional decisions, not requiring administrative attention. Several administrators also cited time constraints, other pressing case management issues, or lack of resources as additional barriers. Based on the findings, recommendations for systemic program support strategies are offered that could improve case management implementation of smoking cessation interventions beyond basic advice to quit.

Smoking cessation processes in low-SES women: the impact of time-varying pregnancy status, health care messages, stress, and health concerns.

UNLABELLED: We tracked smoking outcomes - quitting, stage of readiness, action, motivation, self-efficacy, and confidence - over time among 943 low-SES women smokers accrued in an earlier smoking cessation intervention trial conducted in public health clinics. We assessed outcomes at 2, 6, 12 and 18 months post-initial clinic visit. Controlling for baseline characteristics and earlier program participation, we used hierarchical linear modeling to assess how intervening life events - pregnancy and exposure to subsequent clinic smoking interventions - affected smoking outcomes directly and indirectly, through the mediators, perceived stress and health concerns. RESULTS: All longitudinal smoking outcomes were positively related to health concerns and negatively related to perceived stress. Pregnancy favorably influenced all smoking outcomes but confidence, but exposure to additional interventions affected only motivation. Health concerns and stress partially mediated the positive impact of pregnancy. CONCLUSION: Public health efforts targeted to low-SES women smokers should continue to emphasize the benefits of quitting smoking for health maintenance and incorporate more effective stress-coping mechanisms. Pregnancy increases abstinence, but preventing post-delivery relapse may require stress management and re-focusing of health concerns.

A path model of smoking cessation in women smokers of low socio-economic status.

The goals of this study were to (i) determine how factors commonly implicated in smoking cessation processes influenced smoking cessation in low socio-economic status (SES) women and (ii) elucidate the pathways through which these factors may lead to quitting smoking. Secondary analysis was conducted on data from 644 women smokers aged 18-45 years who had participated in an earlier experimental evaluation of a smoking cessation program, were still smokers at the 2-month post-intervention survey and completed an interview 6 months later. Path analysis (LISREL 8) was used to test a conceptual model in which (i) factors considered as precursors to quitting (motivation, self-efficacy, confidence, action and intention to quit) directly predicted subsequent quitting and (ii) health concerns, social pressure to quit and daily stress influenced quitting indirectly through their effects on the precursor factors and (iii) mediated the effects of background characteristics (race, education, single motherhood, pregnancy and exposure to the earlier smoking cessation intervention) on quitting. Overall, results supported this conceptual model and its applicability to low-SES women smokers and indicated significant pathways among specific factors. In particular, (i) only plans to quit, confidence and social pressure to quit directly predicted quitting; (ii) both health concerns and social pressure increased motivation to quit and (iii) the negative effect of daily stress on quitting was mediated through decreased self-efficacy.

Long-term effects (up to 18 months) of a smoking cessation program among women smokers in public health clinics.

BACKGROUND: We conducted longitudinal analysis of long-term outcomes of a motivational smoking cessation program. The program consisted of clinic-based minimal interventions delivered to women smokers in public health clinics by clinic personnel, a reminder letter, and an optional brief telephone counseling. METHODS: Subjects seen in six intervention (N=541) and six control clinics (N=527) were interviewed by telephone 2, 6, 12, and 18 months later. At each measurement point, unadjusted percent abstinence and mean action, motivation, and readiness scores by study group were compared with standard bivariate comparisons tests. Hierarchical linear modeling that adjusted for clustering of subjects within clinics and clustering of results over 18 months (four waves) within individuals was used to compare outcomes by study group. RESULTS: Number of actions toward quitting, motivation, and stage of readiness to quit remained better in the intervention than in the control group up to 18 months. The program effect on abstinence was still significant at 12 months, but not at 18 months. CONCLUSIONS: Exposure to one-time, brief interventions in public health clinics appears sufficient to enhance abstinence up to 12 months, and action toward quitting and motivation and readiness to quit up to 18 months.

The determinants and consequences of information seeking among cancer patients.

This research was designed to examine information seeking behavior among cancer patients. We present a model which identifies the determinants and consequences of information seeking and, in turn, examines the effects of prior variables on four outcome variables: whether patients discussed with their physicians information that they received from other sources, whether the information they obtained helped them make decisions about treatment or care, whether the patient sought a second opinion about his/her diagnosis or treatment, and changes in self-reported stress levels from diagnosis to the time of interview. The model is estimated separately for three groups: patients who sought information from multiple sources including the National Cancer Institute's Cancer Information Service, patients who sought information from multiple sources but did not call the Cancer Information Service, and patients who did not seek information other than from their physician(s). We discuss variables that have similar impacts on outcome variables in all three groups as well as variables that operate differently within the groups. The results indicate that the desire for information and the desire for involvement in medical care decisions are independent factors. Some patients have a strong desire for both information and involvement in making health care decisions. These patients actively seek involvement in their treatment plans. Other patients, however, want to be informed about their disease and treatment but prefer to delegate most decision-making to their physicians. Still other patients choose to delegate information gathering and decision making exclusively to their physicians. We discuss the implications of these results for both patients and providers.

Factors influencing medical information seeking among African American cancer patients.

Qualitative research methods were used to explore factors that may affect medical information seeking, treatment engagement, and emotional adjustment among African American cancer patients. Focus group findings suggest that an array of cultural and socioeconomic factors plays important roles in the behavior of African American cancer patients. Participants described a number of important barriers and facilitators of medical information seeking and treatment participation. Factors linked to the health care-related behaviors and adjustment of African American cancer patients included limited knowledge and misinformation about cancer, mistrust of the medical community, concerns about privacy, lack of insurance, religious beliefs, and emotional issues such as fear and stigma associated with seeking emotional support. Recommendations are made that may assist mental and physical health providers in improving patient information and mental and physical health outcomes of African American cancer patients.