The experience of outdoor physical activity for skin cancer survivors: understanding the importance of the built and natural environments.

PURPOSE: Cancer patients are encouraged to do more physical activity (PA). Exercising in outdoor settings, however, may expose people to UV radiation, which is the main risk factor of melanoma. This study aimed to understand how melanoma diagnoses affect people's perception of the outdoor environment for PA. METHOD: In-depth interviews were conducted among 19 individuals (20-85 years) with a history of melanoma at a skin cancer clinic in the Denver metropolitan area. Transcribed interviews were coded for emergent themes. The coding framework included topics related to PA behavior, sun protection, and perceptions of outdoor environment. RESULTS: Respondents reported no change in their level of outdoor activity after the melanoma diagnosis; they tried to reduce the risk of sun exposure by using sunscreen and sun-protective clothing. They also reported seeking shade, trees, and groundcover along urban corridors, in order to avoid sun exposure, reflective surfaces, and heat while being active outdoors. CONCLUSION: Given the public health significance of UV exposure and extreme heat, further investments should be made to craft streetscape design guidelines and implement sun-proof spaces across public facilities, including parks, schools, and sport fields in order to ameliorate environmental risks for skin cancer survivors, to prevent future cancers among those that are vulnerable to the hazards of excessive UV exposure and extreme heat, and to promote outdoor PA. IMPLICATIONS FOR CANCER SURVIVORS: Skin cancer survivors and other vulnerable population subgroups will benefit from discussions around neighborhood-based design interventions that promote PA while accounting for sun safety.

Internal medicine residents reject "longer and gentler" training.

BACKGROUND: Increasing complexity of medical care, coupled with limits on resident work hours, has prompted consideration of extending Internal Medicine training. It is unclear whether further hour reductions and extension of training beyond the current duration of 3 years would be accepted by trainees. OBJECTIVE: We aimed to determine if further work-hour reductions and extension of training would be accepted by trainees and whether resident burnout affects their opinions. DESIGN: A postal survey was sent to all 143 Internal Medicine residents at the University of Colorado School of Medicine in May 2004. MEASUREMENTS: The survey contained questions related to opinions on work-hour limits using a 5-point Likert scale ranging from strongly agree to strongly disagree. Burnout was measured using the Maslach Burnout Inventory, organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment, with burnout defined as high EE or DP. RESULTS: Seventy-four percent (106/143) of residents returned the survey. The vast majority (84%) of residents disagreed or strongly disagreed with extending training to 4 or 5 years. Burnout residents were less averse to extending training (strongly agree or agree, 18.9% vs 4.3%, P = .04). The majority of residents (68.9%) disagreed or strongly disagreed with establishing a 60-hour/week limit. Residents who met the criteria for burnout were more likely to agree that a 60-hour limit would be better than an 80-hour limit (strongly agree or agree, 22% vs 8%, P = .02). CONCLUSIONS: In this program, most Internal Medicine residents are strongly opposed to extending their training to 4 or 5 years and would prefer the current 80 hours/week cap. A longer, less intense pace of Internal Medicine training seems to be less attractive in the eyes of current trainees.

Physician sex and other factors associated with type of breast cancer surgery in older women.

HYPOTHESIS: Physician-related factors as well as patient characteristics may explain why women aged 65 years or older with early-stage breast cancer undergo lumpectomy less often than younger women, despite National Institutes of Health recommendations favoring lumpectomy over mastectomy. DESIGN: A descriptive and analytical retrospective computer-assisted telephone survey. SETTING: A population-based random sample of breast cancer survivors in Colorado, identified from the Colorado Central Cancer Registry. PATIENTS: Women aged 65 to 84 years when diagnosed as having stage I or II breast cancer, treated 1 to 6 years previously with mastectomy or lumpectomy, and without recurrence or second primary cancers. Among women contacted, 58% participated. Results of 198 interviews are reported. METHODS: Survey questions included patient decision-making participation and physician recommendations, sources and amount of treatment information provided by physicians, physician characteristics, and patient surgery preferences and demographic characteristics. A multivariate logistic regression model identified factors independently associated with lumpectomy. RESULTS: Lumpectomy was strongly associated with higher patient education, female physician sex, patient age 75 years or older, and amount of physician-provided information. The number of physician-provided information sources was associated with surgery explanations, and female physicians provided more sources of information. A physician decision or recommendation for surgery type was reported by 61% of women, of whom 93% underwent the recommended procedure. A subset of patients (13%) reported deferring the surgery decision to someone else. CONCLUSIONS: These results suggest that better-educated and better-informed older women are more likely to undergo lumpectomy, and that physicians may influence breast cancer patients' decisions about surgery type.

Physician referral patterns to a breast cancer support program.

PURPOSE: The purpose of this study was to describe the differences between physicians who did and did not refer their patients with breast cancer to the American Cancer Society's Reach to Recovery program, as well as to determine the factors associated with these physician referral patterns. DESCRIPTION OF STUDY: This descriptive cross-sectional study included 54 physicians who had and 23 physicians who had not referred their patients with breast cancer to the Mile High Unit Reach to Recovery program in 1999. Participating physicians completed a questionnaire about their knowledge, behaviors, and beliefs regarding Reach to Recovery, the characteristics of the patients they referred, and their own demographic and practice characteristics. RESULTS: General surgeons were more likely than all other specialties to refer patients to the Reach to Recovery program. The program is a part of the American Cancer Society. Feedback from patients about their experiences with Reach to Recovery and the proportion of patient time spent caring for patients with breast cancer were all positively associated with referral. CLINICAL IMPLICATIONS: These findings show that those providing support programs, such as Reach to Recovery, need to use targeted strategies to ensure that physicians are aware of the services they provide and that patients relay their experiences back to their referring physician. Because the value of social support programs for women with breast cancer has been established, physicians can become valuable partners in helping more women gain access to these programs.

Young Latinas and abortion: the role of cultural factors, reproductive behavior, and alternative roles to motherhood.

Latina women have often been portrayed as holding strong traditional family values leading to a greater propensity for rejection of contraception and abortion. Increasingly, the literature has consistently shown that Latina women use contraception effectively when available; however, much less is known about the prevalence of abortion and the factors related to its use in this population. In this article we examine Latinas' use of abortion and identify factors affecting its use among 1,207 ever-pregnant Latina women age 14-24 recruited at two federally-funded family planning clinics in the Los Angeles metropolitan area. Only a small proportion of the young women in our sample (7.5%) had ever had an induced abortion. In multivariate analysis the variables significantly associated with past abortion included less traditional attitudes about women's roles, higher gravidity, shorter periods of sexual activity, and a higher number of lifetime sexual partners. We conclude that use of abortion among Latinas is driven by role orientation and reproductive variables.

Effectiveness and cost-effectiveness of multiple outcalls to promote mammography among low-income women.

A multiple outcall approach based on the Transtheoretical Model was used to encourage mammography behavior in low-income women in the state of Colorado. Women (n = 983) were recruited in person at grocery and discount stores and were then called over the telephone to receive the multiple outcall intervention. These women were compared with 3,080 women who were recruited by telephone and randomly assigned to three study groups: health survey only (control); single outcall; or advance card + single outcall. Subsequent mammography behavior was assessed through a telephone interview conducted 6 months after initiation of the protocol. After controlling for baseline differences between groups in age, education, income, health status, and previous mammography behavior, the multiple outcall intervention was significantly related to mammography behavior among women nonadherent at baseline (odds ratio, 2.58; 95% confidence interval, 1.45-4.60). Furthermore, women who received the multiple outcall intervention had higher "stage of change" at follow-up and more positive attitudes toward mammography. Cost-effectiveness analysis indicated that although the multiple outcall intervention was more costly to deliver ($14.84 per subject compared with about $7.00 for the single outcall interventions), it cost considerably less per subject converted from nonadherent to adherent. Despite study design limitations, the multiple outcall intervention appears to be an effective method of promoting mammography among previously nonadherent women. The results suggest that a combined approach, in which nonadherent women receive multiple calls promoting screening behavior, followed by single calls at the appropriate intervals to promote repeat screening, may be a useful strategy in defined populations.

Testing for Chlamydia and sexual history taking in adolescent females: results from a statewide survey of Colorado primary care providers.

OBJECTIVES: Little is known about the practice patterns of primary care providers as they relate to assessing risk of and screening for chlamydial infections, an important cause of preventable reproductive morbidity in young women in the United States. The present cross-sectional study was undertaken to assess levels of chlamydia testing, sexual history taking, and prevention practices by Colorado primary care physicians, nurse practitioners, and physician assistants who provide gynecologic care to adolescent females (13-19 years old). METHODS: Between July 1998 and October 1998, an anonymous, self-administered questionnaire was mailed to a 25% random sample (n = 1265) of Colorado physicians (family practitioners, internal medicine specialists, obstetrician-gynecologists, and pediatricians), nurse practitioners, and physician assistants. Practitioners were identified through professional organization membership, state-licensing bodies, and listings in the yellow pages. RESULTS: After estimating the eligibility rate among non-respondents, the adjusted response rate was 71.5%. Only 53.8% of providers reported regularly testing sexually active female adolescents for chlamydia; 71.8% of providers regularly took a sexual history. Female providers reported significantly higher levels of regularly taking a sexual history (87. 2% vs 60.6% of males), feeling comfortable discussing sex (94.4% vs 77.8%), discussing sexually transmitted disease (STD) prevention (81. 5% vs 71.3%), and testing for chlamydia (64.4% vs 38.6%). Among provider types, obstetrician-gynecologists, nurse practitioners, and pediatricians were most likely to report regularly taking a sexual history (90.1%, 88.6%, and 76.0%, respectively). Internal medicine specialists were the least likely to report taking a sexual history (43.9%). Pediatricians and nurse practitioners were the most likely to report testing sexually active adolescent females for chlamydia (74.1% and 70.1%, respectively), whereas physician assistants and internal medicine specialists were the least likely (46.0% and 38.5%, respectively). In multivariate analysis, variables independently associated with regularly taking a sexual history included female provider gender (odds ratio [OR]: 5.5; 95% confidence interval [CI]: 2.9-10.9), obstetrics/gynecology specialty (OR: 4.0; 95% CI: 1.7-10. 3; referent group: family practitioners), and provider comfort level in discussing sex (OR: 4.9; 95% CI: 2.3-11.1). Variables independently associated with regularly testing adolescent females for chlamydia included female provider gender (OR: 2.8; 95% CI: 1. 6-4.8), regularly discussing STD prevention (OR: 2.1; 95% CI: 1.1-4. 1), and regularly discussing limiting the number of patients' sex partners (OR: 2.4; 95% CI: 1.4-4.1). CONCLUSIONS: Only a little over one half of providers (54%) reported regularly performing chlamydia tests on adolescent females who are sexually active by history. Because this falls well short of the recommendations of the Centers for Disease Control and Prevention to test all sexually active female adolescents, efforts are needed to improve STD clinical practices of Colorado physician and nonphysician providers of primary care for adolescent females. Particular efforts are needed to close the provider gender gap.

Public beliefs and use of antibiotics for acute respiratory illness.

OBJECTIVE: To better understand public beliefs and use of antibiotics for acute respiratory illnesses. DESIGN: Cross-sectional telephone survey. PARTICIPANTS: Three hundred eighty-six adult members (aged 18 years or older) of a group-model HMO in the Denver metropolitan area. MEASUREMENTS AND MAIN RESULTS: Two hundred seventy-three (70%) of the respondents reported that antibiotics were beneficial for bacterial respiratory illnesses, 211 (55%) reported that antibiotics were beneficial for viral respiratory illnesses, and 82 (21%) reported that antibiotics were beneficial for bacterial but not for viral illness. Multivariate regression analysis identified consulting an advice nurse (odds ratio [OR] 2.9; 95% confidence interval [CI] 1.7, 5.3), ever being told by a provider that antibiotics were not needed for a respiratory illness episode (OR 2.0; 95% CI 1.2, 3.6), having a chronic medical condition (OR 2.0; 95% CI 1.0, 3.9), and believing antibiotics to be helpful for viral (OR 2.5; 95% CI 1.3, 4.7) or bacterial (OR 2.6; 95% CI 1.2, 6.7) respiratory illnesses to be independently associated with antibiotic use for respiratory illnesses during the previous year. There was a trend toward lower previous antibiotic use among those believing antibiotics to be helpful for bacterial illness but not for viral illness. CONCLUSIONS: A lack of understanding about antibiotic effectiveness exists in the community. Increased previous antibiotic use among those believing antibiotics to be effective for viral illnesses suggests that improvements are needed in communications to patients and the public about antibiotic appropriateness.

Age-related differences in the quality of life of breast carcinoma patients after treatment.

BACKGROUND: The objective of this study was to compare the quality of life (QOL) of younger (< or =50 years) versus older (>50 years) women on recent completion of treatment of breast carcinoma. METHODS: Data reported herein were obtained from a baseline assessment of 304 breast carcinoma patients. These patients were enrolled in a multiinstitutional, randomized trial testing a psychosocial telephone counseling intervention for breast carcinoma patients immediately after treatment. The assessment was made using a self-administered (mail) questionnaire, with an overall response rate of 86%. Included in this questionnaire were standardized measures of QOL using the Functional Assessment of Cancer Therapy-Breast instrument, the Center for Epidemiologic Studies Depression Scale, and the Impact of Event Scale. RESULTS: Comparisons of baseline data analyzed according to age approximating menopausal status (< or =50 years and >50 years) indicated that younger women reported significantly greater QOL disturbance. QOL was significantly worse for younger women globally (P = 0.021), and with regard to domains of emotional well-being (P = 0.0002) and breast carcinoma specific concerns (P = 0.022). Furthermore, symptoms of depression (P = 0.041) and disease specific intrusive thoughts (P = 0.013) were significantly worse for younger women. No significant sexual dysfunction or body image differences were noted. CONCLUSIONS: Results from this analysis suggest that younger women with breast carcinoma should be considered to be at high risk for QOL disruption and significant clinical distress. Targeted interventions for this cohort are recommended.

"Block the sun, not the fun": evaluation of a skin cancer prevention program for child care centers.

INTRODUCTION: This paper describes the evaluation of a skin cancer prevention program for preschools and daycare centers. The intervention was targeted primarily at staff of child care centers, with the aim of increasing use of sun protection practices for young children while attending these centers. Secondary target groups included parents and the children themselves. The intervention, which adopted the slogan, "Block the Sun, Not the Fun," included workshops for child care center staff, and information/activity packets for parents. METHODS: Twenty-seven preschools and daycare centers were randomly assigned to an intervention or wait-list control group. The intervention group received the intervention during the spring of 1994; the wait-list control group received the intervention during the spring of 1995. Evaluation consisted of interviews with center directors, observations of practices, and review of written policies before the intervention (in summer, 1993) and after the intervention (in summer, 1994). A survey of 201 parents was conducted during late summer 1994. RESULTS: While the intervention did not appear to change the sun protection attitudes or practices of parents, or use of clothing and shade at child care centers, results suggested significant changes in the sun protection knowledge/attitudes of center directors and the use of sunscreen at child care centers. Additionally, parents with children attending centers in the intervention group were more likely to be satisfied with sun protection practices at their centers. CONCLUSION: This low-intensity intervention appears to be effective at changing sun protection attitudes and sunscreen use at child care centers, and can be easily replicated. However, high staff turnover at child care centers would suggest that "boosters" will be necessary to sustain the impact. More intensive efforts directed at social norms are likely to be necessary to change clothing and outdoor play practices.

Smokers hospitalized in an urban, public hospital: addiction, stages of change, and self-efficacy.

BACKGROUND: This study characterizes adult smokers on the medicine service of an urban, public hospital, including stage of change, self-efficacy to quit, and nicotine dependence, and explores relationships between perceived and actual smoking-related illness and these three predictive variables. METHODS: Adult patients (n = 154) admitted to the Medicine service of Denver Health Medical Center in October and November 1996 were surveyed using a written questionnaire. RESULTS: The proportion of smokers in this population was 45.7% (95% CI = 42.0%, 49.4%). Adjusted for age and sex, the proportion of smokers in this population was significantly greater than in Colorado (28.8% vs 21.8%, P < 0.001). About half (54.2%) were willing to try free nicotine patches during hospitalization. Among smokers with diseases recognized as smoking-related, 30.4% believed their reason for admission was related to smoking, compared to 20.4% among those with no smoking-related diseases (P = 0.18). Patients who believed their hospitalization was due to smoking had greater intentions (P = 0.001) and self-efficacy (P < 0.001) to quit. CONCLUSIONS: Targeting smokers who perceive that their illness is smoking-related may optimize inpatient smoking interventions.

The cancer information service research consortium: an emerging laboratory for cancer control research.

The Cancer Information Service (CIS) was established in 1975 by the National Cancer Institute (NCI) to provide accurate, up-to-date information about cancer to the nation. Although the CIS has in the past served as a venue for cancer communications research, up until very recently the research capacity of the CIS was underutilized. In 1993, this situation changed dramatically with funding from the NCI to form the Cancer Information Service Research Consortium (CISRC). In this article the CISRC is described for the first time, including its research agenda and administrative structure. Early indications from the CISRC suggest that the CIS can serve as one of the premiere laboratories in the country for cancer communications and cancer control research. Several factors are suggested for the early success of the CISRC in sustaining this collaborative effort with the CIS. The progress that has been made by the CISRC could provide a useful model for other large health information programs to maximize their contributions to behavioral science and health promotion research, as well as to establish their own program of policy-relevant research.

Cancer information service-initiated outcalls to promote screening mammography among low-income and minority women: design and feasibility testing.

BACKGROUND: The telephone information service of the Cancer Information Service (CIS) historically is most effective in eliciting calls from higher income, white women. This article describes the design and feasibility of a project that tested the use of telephone outcalls to extend the reach of the telephone information service to underserved women. METHODS: Neighborhoods throughout Colorado were identified using a geodemographic database (INFORUM) that allowed selection of census block groups according to demographic characteristics. Households were assigned randomly to: (1) a control group; (2) an outcall-only group, which received "cold" telephone outcalls promoting screening mammography; and (3) an advance card plus outcall group, which received a card introducing the program prior to the outcall. RESULTS: The use of INFORUM to target low-income, less educated, and black women was largely successful. While quality of intervention delivery was high, the protocol was labor intensive, requiring an average of 40 min to identify and counsel each eligible woman. The advance card did not increase acceptance of the outcalls. CONCLUSIONS: This approach successfully extended the CIS's audience; however, its labor intensity may limit its applicability. Strategies for increasing the efficiency of outcall efforts are suggested.

Effectiveness of a telephone outcall intervention to promote screening mammography among low-income women.

BACKGROUND: This study evaluated the impact of a telephone outcall intervention (based on the Transtheoretical Model) on screening mammography behavior among lower income, older women. METHODS: A geodemographic database, INFORUM, was used to identify low-income and minority neighborhoods throughout the state of Colorado. Residences were assigned randomly to three study groups: (1) control, (2) outcall only, and (3) advance "invitation" + outcall. Information Specialists of the Cancer Information Service implemented the protocol. Mammography adherence was assessed in telephone interviews conducted 6 months and 2 years after the initial call. RESULTS: Neither intervention had a significant effect on the main outcome, receipt of mammography in the 6-month follow-up period. At 6 months, intentions to have a mammogram were significantly stronger in the intervention groups compared with the control group, particularly among those who were precontemplators at baseline. The 2-year follow-up indicated a small increase in mammography adherence attributable to the advance invitation + outcall, but this effect was restricted to those adherent at baseline. Mammography behavior during the 6-month follow-up period was predicted strongly by decisional balance, intentions, receipt of a physical and clinical breast exam, and previous mammography behavior. CONCLUSIONS: The intervention promoted minimal movement in the stages of change for mammography. Outcall interventions may have promise for encouraging repeat mammography behavior, but more intensive interventions are likely to be necessary to promote behavior change among nonadherent women.

Factors associated with antibiotic use for acute bronchitis.

OBJECTIVES: To describe the clinical features of adults diagnosed with acute bronchitis, and to identify clinical variables associated with antibiotic treatment of acute bronchitis. DESIGN: Prospective, cohort study. SETTING: Primary care office practices at a group-model HMO in the Denver metropolitan area. PATIENTS/PARTICIPANTS: Patients were adults seeking care for acute respiratory illnesses. Participating clinicians included internists, family medicine physicians, nurse practitioners, physician assistants, and registered nurses. MEASUREMENTS AND MAIN RESULTS: Clinicians voluntarily completed encounter forms for patients presenting with acute respiratory illnesses between February and May, 1996. Acute bronchitis was the primary diagnosis in 16% of acute respiratory illness visits (n = 1,525). The most frequent symptoms of acute bronchitis were cough (92%), phlegm production (63%), "runny nose" (50%), and throat pain (50%). The most frequent physical examination findings were pharyngeal erythema (45%), cervical lymphadenopathy (19%), wheezes (18%), and rhonchi (17%). Antibiotics were prescribed to 85% of patients diagnosed with acute bronchitis. Purulent nasal discharge by patient report, and sinus tenderness on physical examination were moderately associated with antibiotic treatment (p = .06 and .08, respectively). Antibiotic prescription rates did not vary by patient age or gender, duration of illness, days of work lost due to illness, or clinician type. CONCLUSIONS: Acute bronchitis is frequently treated with antibiotics in ambulatory practice. The clinical factors we identified to be associated with antibiotic use for acute bronchitis appear to play a minor role in explaining the excessive use of antibiotics for this condition. These findings suggest that clinicians use the diagnosis of acute bronchitis as an indication for antibiotic treatment, despite clinical trials and expert recommendations to the contrary.

Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a randomized trial testing an intensive follow-up protocol and economic incentives.

OBJECTIVES: This study evaluates the efficacy of two interventions designed to reduce loss-to-follow-up among women with abnormal Pap smears. METHODS: The two interventions were evaluated in two large public hospitals using a randomized 2 x 2 factorial design. One intervention involved an intensive follow-up protocol that relied on multiple attempts (mail and telephone) to contact the patient. The second intervention provided patients with economic vouchers to offset out-of-pocket expenses associated with the follow-up visits. Loss-to-follow-up was addressed by medical chart reviews and telephone interviews. RESULTS: The study population (n = 1453) was primarily Hispanic, married or otherwise living with a significant other, relatively young in age, and with no source of payment for health care. Overall, 30% of the total sample was loss-to-follow-up (i.e., no return visits). Among patients assigned to the control condition, loss-to-follow-up was 36.1% compared with 27.8% for the intensive follow-up condition, 28.8% for the voucher condition, and 29.0% for the intensive follow-up plus voucher condition. Both intervention conditions significantly improved follow-up rates. The odds ratio for intensive follow-up was 1.56 compared with 1.50 for the voucher intervention. The combined intervention condition (intensive follow-up x voucher program) did not have a significant effect after taking into account the main effects of the two interventions. Correlates of loss-to-follow-up included age (younger women had lower return rates), race/ethnicity (African American women had lower return rates), live-in relationship (women who were not married or living as married had lower return rates), and severity of the abnormal Pap smear (less severe abnormalities were associated with lower return rates). CONCLUSIONS: Both interventions were associated with moderate reductions in loss-to-follow-up in this underserved population. The implications of these findings are discussed relative to implementing cervical cancer control programs within state and local health departments.

A review of cervical cancer screening intervention research: implications for public health programs and future research.

In this paper we review the published literature with respect to cervical cancer screening intervention research. Mass media campaigns appear to work best in promoting cervical cancer screening when multiple media are used, when they promote specific screening programs that eliminate or reduce access barriers, or when they are used in combination with other strategies. Many positive examples of using outreach staff to promote cervical cancer screening, as well as using mobile examination rooms in the community, were found. Substantial evidence that letters mailed to patient populations are efficacious was found, especially in promoting interval screening; however, bulk mailings to nonpatient populations have generally not been successful. Both physician and patient prompts have shown promise as well as opportunistic screenings in both the outpatient and the inpatient settings. In addition, several strategies for reducing loss to follow-up among women with abnormal test results were identified, including telephone follow-up, educational mailouts, audiovisual programs, clinic-based educational presentations and workshops, transportation incentives, and economic vouchers. Of special note is the success of other countries in establishing centralized recall systems to promote interval screening for cervical cancer. Ultimately, such systems could replace the need for opportunistic screening in underserved populations and perhaps many community outreach efforts. It is argued that health departments represent a logical starting point for developing a network of recall systems in the United States for underserved women.

Telephone counseling of breast cancer patients after treatment: a description of a randomized clinical trial.

The Telephone Counseling Trial for Breast Cancer Survivors is a randomized, controlled study designed to test the impact of a telephone-based counseling intervention on quality of life of early-stage breast cancer patients who have completed adjuvant treatment. A psychoeducational counseling model is utilized to promote adaptive coping to re-entry stressors and survivorship issues. Adaptation is fostered through the exploration of thematic materials, application of active coping strategies, encouragement of a personal expression of the breast cancer experience and the provision of psychological support. Patients are being recruited in collaboration with two NCI-designated clinical cooperative oncology groups: the Eastern Cooperative Oncology Group (ECOG) and the Southwest Cooperative Oncology Group (SWOG). The recruitment goal is 400 breast cancer survivors with Stage 1, Stage 2 and Stage 3 disease (with no greater than 10 positive lymph nodes involved). Patients are being enrolled by data managers on-site during their last treatment visit. The intervention is being delivered by the Cancer Information and Counseling Line (CICL) of the AMC Cancer Research Center. It includes 16 telephone outcalls which are delivered over a 12-month period. Primary outcome measures are quality of life, mood, social support, self-efficacy, and sexual functioning, assessed at baseline, 3, 6, 12 and 18 months follow-up. This article provides a description of the intervention protocol and study design. It is argued that this study could provide a model for developing and testing other psychosocial interventions within clinical cooperative groups nationwide.

Social support and adherence behavior among women with abnormal Pap smears.

BACKGROUND: Studies of hypertension, diabetes, and diet have indicated a relationship between social support and adherence to treatment regimens. Estimates of nonadherence following abnormal Pap test results range as high as 40%. In this study, the relationship between social support and adherence behavior was examined in a population of low-income, public-health-department patients with abnormal Pap smears. METHODS: Medical record reviews ascertained adherence behavior and interviews determined receipt of social support for 498 women. RESULTS: Related to adherence were: receipt of any social support; receipt of each of three types of support (informational, emotional, and tangible support); amount of support received; satisfaction with support; and source of support. Reported need for support was not related to adherence behavior. Receipt of social support was more strongly related to adherence when the woman's emotional response to the notification of the abnormal Pap smear was greater, and when acculturation was higher (among Latinas). Knowledge of the results of the Pap test was found to be an intervening variable between receipt of informational support and adherence. Knowledge of the purpose of the Pap smear was found to be independently related to adherence. Among black women, emotional support was most strongly related to adherence, while among Latinas, tangible support was most strongly related to adherence. In a multivariate model, Pap-test knowledge and the interaction between emotional response and receipt of any social support were significantly related to adherence. CONCLUSIONS: Findings suggest that supportive interventions, including provision of medical information, emotional support, child care, and transportation, could help to reduce nonadherence.