Telephone therapy for patients with breast cancer.

PURPOSE/OBJECTIVES: To test the value of telephone-administered cognitive-behavioral therapy in a study of patients with breast cancer. DESIGN: Women were assigned randomly to a therapy group or an assessment-only control group. SETTING: A tertiary cancer treatment center serving rural areas of North Dakota and Minnesota. SAMPLE: Women were recruited within three to four months of stage I (n = 27) or stage II (n = 26) breast cancer diagnosis. Age ranged from 30-82 (mean = 51.5 years). Most participants (n = 35) underwent a modified radical mastectomy; 17 underwent a lumpectomy. METHODS: Therapy involved 10 30-minute (or less) telephone sessions. Data that were collected from mailed questionnaires included psychological distress (Profile of Mood States), perceived stress, coping (Coping Response Indices-Revised), quality of life (Medical Outcome Scale), and satisfaction with therapy. Measures were completed at baseline and at 4- and 10-month follow-up intervals. MAIN RESEARCH VARIABLES: Telephone therapy, stress, coping, and quality of life. FINDINGS: With time, women in the therapy and control groups reported reduced stress and improved quality of life. However, significant reductions in some kinds of distress (anxiety, anger, depression, and confusion) were not observed. Most therapy participants liked the telephone treatment sessions but showed only modest improvement (less anxiety and confusion) compared with women in the control group. CONCLUSIONS: Most patients reported being comfortable with the telephone therapy and said that they felt better as a result of it. However, the outcome data showed that telephone therapy--as carried out in this study--produced only modest benefits. Researchers need to consider who is best for delivering such therapy. IMPLICATIONS FOR NURSING PRACTICE: Providing telephone therapy to patients with breast cancer has potential benefits, and nurses may be the appropriate professionals to administer the therapy.

Matched and mismatched interventions with young adult smokers: testing a stage theory.

This experiment tested the transtheoretical model (J.O. Prochaska & C.C. DiClemente, 1983) of smoking cessation by matching or mismatching interventions to smokers in a particular stage. The interventions were tested against a no-intervention condition with 92 college-aged daily smokers in the precontemplation stage of change. The stage-matched intervention asked smokers to think more about quitting smoking; the stage-mismatched intervention provided action-oriented activities typically used for those ready to quit smoking. The results failed to support the value of matching interventions to a smoker's stage of change. Instead, more smokers who received the action intervention tried to quit smoking. Matching interventions to an individual's current stage may be less important than the transtheoretical model suggests.

Coping and adjustment to breast cancer.

This study examined possible predictors of adjustment to breast cancer. Sixty-one women participated soon after they were diagnosed with Stage I or Stage II breast cancer. Measures were gathered at diagnosis and again 4 months later. Predictor variables included aspects of the disease and treatment process and reported coping behavior. The most consistent predictor of distress and, to a lesser extent, quality of life, was avoidant coping: women who reported more avoidant coping were more distressed. These data fit well with most previous research and suggest one way of identifying women who may be more at risk for special difficulties coping with the diagnosis of breast cancer.

Cancer screening decisions.

This review focuses on why people decide to obtain or to avoid screening for cancer. We discuss three topics: (a) physician prompts that may elicit compliant screening behavior, (b) the independent and joint effects of risk perceptions and worry, and (c) the costs and benefits of getting screened. Overall, the data suggest that each of these factors will influence screening. So, for example, people are more likely to seek screening if a physician recommends the behavior, if they feel personally vulnerable and worry a little about cancer, if insurance covers the screening, and if they believe that the test is an effective early detection procedure. Future research needs include studies comparing theories, longitudinal rather than cross-sectional studies, and true experiments. We also need to know more about why physicians are such powerful change agents and the trade-offs of increasing personal risk versus exacerbating worry. Practical recommendations for promoting cancer screening include encouraging physician interventions, explaining risk, and lowering the costs while emphasizing the benefits of screening.

Naive beliefs about breast cancer risk.

We examined the beliefs women have about their risk of breast cancer. Participants were 86 women, ages 18 to 90, with and without a family history of breast cancer. They were interviewed individually about their risk and their beliefs about risk factors for breast cancer. The results showed that participants form their risk estimates primarily from the absence or presence of a family history of breast cancer. When asked to compare their risk with the risk of others, only participants without a family history viewed their chances of getting breast cancer as lower than the chances of others. On an absolute risk measure, all participants overestimated their risk. Different risk measures can lead to different conclusions about how women perceive their risk. In addition, the nearly exclusive focus of women on family history may create difficulties for genetic counselors providing information about breast cancer risk.

A descriptive study of breast cancer worry.

Women with (n = 65) and without (n = 70) a family history of breast cancer reported on their thoughts and concern about the disease. Measures were taken across a 1-month interval and at a 1-year follow-up. Reported screening behaviors were also measured at baseline and the 1-year follow-up. Worry dissipated over time, suggesting that worry levels are affected by the measurement context. However, women with a family history of the disease maintained greater worry than those without such a history, suggesting that they may be chronically worried about the disease. Thinking and worrying about breast cancer were both modestly and positively related to the frequency of screening behaviors, suggesting that some kinds of worry can motivate self-protective behavior.

What is the relationship between breast cancer risk and mammography screening? A meta-analytic review.

This meta-analytic review addresses the issue of how a woman's risk of breast cancer relates to the likelihood that she will obtain mammography screenings. Studies that compared women with or without a family history of breast cancer (n = 19) showed that women with a family history were more likely to have been screened. Studies that measured perceived risk (n = 19) showed that feeling vulnerable to breast cancer was positively related to having obtained a screening. Studies that compared women who did or did not have a history of breast problems (n = 10) showed that those with a positive history were more likely to have been screened. Finally, studies that measured worry (n = 6) showed that greater worry was related to higher screening levels. Taken together, these data suggest that increasing perceptions of personal vulnerability may increase screening behavior for breast cancer.

Breast cancer worry and screening: some prospective data.

Breast cancer concerns were measured among 353 women, ages 40-75, from North Dakota. One year later, participants were recontacted and asked about their screening behavior during the previous year. Greater concern about breast cancer, even the highest level of concern, was related to a higher likelihood that women performed breast self-examination, had a mammography screening, and had a clinical breast examination. These data do not support the idea that worry inhibits action; instead, they suggest that nonpathological worry motivates self-protective behavior.

Participation in worksite health promotion: a critique of the literature and recommendations for future practice.

One of the major rationales for conducting health promotion/disease prevention activities at the worksite is the potential to reach a high percentage of employees, including many who would otherwise be unlikely to engage in preventive health behaviors. Most studies of worksite health promotion do not report participation data, but among those that do, definitions of participation and participation rates vary dramatically. In general, men and blue-collar employees appear less likely to participate, but little is known about other employee variables related to participation. There have been few studies of worksite characteristics associated with participation and even fewer experimental evaluations of interventions to increase participation. In this paper we review what is known about participation in worksite health promotion programs and recommend procedures for defining participation for different types of programs, for reporting determinants of participation, and for increasing participation. We conclude that participation is both an important process measure and an outcome that should be reported routinely. Participation data have important implications for generalizability of results, feasibility of interventions, and health outcomes.

Winning, losing, mood, and testosterone.

In two experiments, male college students either won or lost $5 on a task controlled entirely by chance. In both studies, winners reported a more positive mood change than did losers and, in Experiment 2, winners reported a more positive mood change than a neutral group that did not win or lose money. After the task was completed, winners exhibited significantly higher testosterone levels than losers. Levels of cortisol, a hormone associated with stress and arousal, did not differ among the groups, suggesting that a hormone-behavior response pattern for winning and losing is specific to testosterone. These data suggest that winning can alter testosterone levels in men and that mood may mediate such changes.

The problem of creating habits: establishing health-protective dental behaviors.

We describe three experiments testing treatments to promote the performance of health-protective dental behaviors. Subjects included 55 women from an introductory psychology course (Experiment 1), 45 men and women (Experiment 2), and 81 older-than-average students identified as at risk for gum disease (Experiment 3). The interventions, derived from social cognitive theory, included health education, skills training, and self-monitoring. In each study, we examined the contribution of additional treatment components, including social support (Experiment 1), intensive contact (Experiment 2), and flexible goal setting (Experiment 3). Across experiments, the behavioral results were remarkably similar: Subjects exhibited excellent adherence while in the study but, at follow-up, reported behavior that differed little from baseline. We discuss parallels between attempts to promote health-protective dental behaviors and other health-promotion programs, and we describe different perspectives from which to address the problem of creating healthy habits.

Does distraction reduce pain-produced distress among college students?

College students in four experiments placed their hands in ice water (the cold-pressor task) and reported their distress. They simultaneously engaged in different reaction-time (RT) tasks that varied in the amount of attention required for successful performance. In each experiment, which differed in numerous procedural details, RT, error-rate, and self-report measures all demonstrated that the distraction tasks differed in the degree of attention required. Greater distraction, however, failed to reduce physiological, self-report, or behavioral responses to the cold-pressor task. These data call into question the hypothesis that attention mediates the process whereby distraction tasks reduce pain-produced distress.

Diabetes regimen behaviors. Predicting adherence.

In this study, Social Learning Theory was used to generate psychosocial predictors of regimen adherence among persons with insulin-dependent diabetes mellitus (IDDM). Four categories of predictors were formed: knowledge, expectancies, skills, and environmental support. Persons with IDDM (84 adults and 23 adolescents) completed measures within each predictor category on two occasions, separated by 6 months. Multimethod assessment procedures (self-monitoring, interviews, mechanical devices) were used to measure adherence to four aspects of the IDDM regimen: insulin injections, glucose testing, diet, and exercise. Bivariate analyses demonstrated that measures of expectancies and environmental support were reliably related to several adherence behaviours. In particular, self-efficacy expectations were related to adherence across almost all regimen areas for both adolescents and adults. Skills were also important, though only for adolescents, whereas regimen knowledge was unrelated to adherence for either adults or adolescents. Multivariate analyses showed that expectancies were consistently predictive of adherence and that, in general, psychosocial variables were better predictors of insulin administration and glucose testing than of diet or exercise. The implications of these findings for diabetes education programs are discussed.

Self-care behaviors and glycemic control in type I diabetes.

This study investigated the degree of adherence to different aspects of the diabetic treatment regimen (insulin injections, glucose testing, diet, and exercise), the consistency of adherence across different regimen areas, and relationships between adherence and glycemic control. A predominantly adult community sample of 93 insulin dependent outpatients participated in the prospective study that involved two series of home interviews separated by a 6-month interval. Multiple measures of adherence (e.g. self-report, interview/recall, self-monitoring, and objective indices) were collected for each regimen area. Results indicated that the degree of adherence was higher for medication taking and glucose testing than for regimen tasks requiring greater lifestyle modifications such as diet and exercise; there were few strong relationships between subjects' adherence to one area of the regimen and the extent to which they adhered to other regimen tasks; and no clear relationship between adherence and glycemic control could be demonstrated through either bivariate or multivariate analyses. It is recommended that regimen adherence be considered in the context of other factors that may influence glycemic control (e.g. stress, individual metabolic factors, appropriateness of regimen prescriptions) rather than assuming a one-to-one relationship between adherence and control.

Supportive and nonsupportive family behaviors: relationships to adherence and metabolic control in persons with type I diabetes.

The Diabetes Family Behavior Checklist (DFBC) was administered to 54 adults and 18 adolescents (less than 19 yr of age) with insulin-dependent diabetes mellitus (IDDM). Subjects and family members completed parallel forms of the DFBC at initial and 6-mo follow-up home interviews. During each of these periods, adherence was assessed via self-report, 1 wk of self-monitoring, and 24-h dietary recalls. The results showed reliable differences between adolescents and adults. More negative interactions with family members were reported by adolescents and their family members, and adolescents were in poorer metabolic control. For adults but not adolescents, negative DFBC scores were prospectively predictive of poorer regimen adherence over the 6-mo interval for measures of glucose testing, insulin injection, and dietary adherence. In addition, higher negative DFBC scores for adults were marginally associated with higher HbA1 levels (P less than 0.10). We conclude that the DFBC is a promising measure of family interaction related specifically to the IDDM regimen and that, for adults, higher levels of nonsupportive family behaviors may be related to reduced regimen adherence and poor control.

Barriers to regimen adherence among persons with insulin-dependent diabetes.

The present study was designed to assess the frequency of different barriers to adherence among persons with insulin-dependent diabetes mellitus (IDDM) and to determine the relationship between such barriers and adherence to insulin injection, glucose testing, and dietary and exercise components of the regimen. The behavior analytic model was used to develop a Barriers to Adherence Scale for adults and adolescents with IDDM. Sixty-five outpatient subjects were then interviewed in their home and reassessed 6 months later. Subjects reported the greatest number of barriers to dietary and exercise adherence and the fewest barriers to insulin injections. Females reported more barriers than males, but age was not associated with barriers scores. Self-report measures of adherence revealed consistent relationships between barriers and all areas of regimen adherence assessed. Adherence indices based on self-monitoring and dietary recall data correlated less consistently with barriers scores. We conclude that the behavior analytic model has great potential for use in the development of psychosocial assessment procedures for diabetes.

Predicting levels of preventive dental behaviors.

This study examined the value of SLT as a model for predicting levels of dental hygiene behaviors. The brushing and flossing frequency of 131 adults was measured both retrospectively (via questionnaire) and prospectively (via self-monitoring records). Two types of SLT variables--expectations and environmental influences--were reliably related to dental hygiene behaviors. Such variables (for example, self-efficacy expectations and the dental behaviors of significant others) accounted for up to 38% of the variance in brushing frequency and 33% of the variance in flossing frequency. Overall, a SLT model appears to hold promise for identifying psychosocial variables that are related to dental hygiene behaviors. The findings suggest that educational programs intended to increase the frequency of such behaviors should focus on increasing self-efficacy, reducing structural and life-style barriers to adherence, and involving significant others in educational efforts.

Preventing adolescent smoking: what have we learned about treatment construct validity?

In recent years, numerous programs introduced to prevent adolescent smoking have demonstrated some success. This paper reviews the treatment construct validity of such programs; that is, we seek to determine how and why programs reduce adolescent smoking. The review leads to the conclusion that little is presently known about the construct validity of successful programs, a problem that results primarily from the neglect of process assessment and analyses. The advantages and disadvantages of several future research approaches are discussed, including: (a) utilization of process measures within large scale treatment/no-treatment designs, (b) small-scale studies to test the effects of prevention components on process measures (e.g., attitudes, intentions to smoke), and (c) combinations of these two approaches.