Cultural aspects of communication in cancer care

Interventions to enhance cross-cultural competence in oncology: A meta-analysis of effectiveness studies and a qualitative review

PURPOSE

Cross-cultural competence of healthcare providers is crucial to create a culturally safe environment. Cancer poses special challenges to cross-culturally competent communication and decision-making. Yet, no research synthesis on cross-cultural competence interventions has focused specifically on oncology.

METHODS

We conducted a meta-analysis and qualitative review of literature on the effectiveness of cross-cultural competence interventions in oncology. No limitations were placed on publication date, language, oncology setting, or geographic region. Of 1.565 citations identified, 15 articles met the inclusion criteria. Information on study design, samples, measured outcomes, and effectiveness statistics were coded. Average weighted effects were calculated applying meta-analysis methodology.

RESULTS

Studies were published between 2000 and 2020; more than half in the last seven years; two thirds in the USA. Overall study quality was at a low to moderate level, notably only one study provided a control-group-design. In sum, nurses constituted the largest occupational group among participants. Results of the meta-analysis indicate that cross-cultural competence interventions have differential effects. While the overall effect of cross-cultural competence interventions was not statistically significant, results showed that the cross-cultural competence dimensions of knowledge and behavior did improve. Effects beyond that remain unclear.

CONCLUSIONS

We provide valuable information on research gaps. The lack of studies and insufficient methodological rigor of available studies show that more research is needed to support the claim that interventions actually improve the various dimensions of cross-cultural competence in oncology. To build a stronger evidence base, it is necessary to include patient-reported outcomes and to center their experiences in future research.

German translation and validation of the brief Epilepsy Anxiety Survey Instrument (brEASI)

BACKGROUND

Anxiety disorders remain undiagnosed in routine clinical practice in up to two thirds of affected patients with epilepsy despite their significant impact on medical and psychosocial outcomes. The study objective was to translate and validate the German 8-item "brief Epilepsy Anxiety Survey Instrument" (brEASI) to facilitate effective screening for the presence of anxiety disorders in German-speaking patients.

METHODS

After expert translation into German, the brEASI was completed by consecutive adult inpatients with epilepsy hospitalized for seizures at an academic reference epilepsy center. Patients also completed the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), the Generalized Anxiety Disorder scale (GAD-7) for external validity, and underwent a standardized interview (Mini-DIPS-OA) as a gold standard to determine the presence of an ICD-10 anxiety disorder (generalized anxiety disorder (GAD), panic disorder, agoraphobia, and social phobia). Receiver operating characteristics (ROC) were calculated to determine the diagnostic accuracy of the brEASI, including the associated area under the curve (AUC) statistics to determine the potential of the brEASI to identify ICD-10 anxiety disorders diagnosed by interview. For comparative purposes, these analyses were also conducted for the GAD-7.

RESULTS

Of 80 recruited adult inpatients with epilepsy, 18 (23 %) were found to have a current anxiety disorder through standardized interview. In this study, both brEASI and GAD-7 showed a better diagnostic performance at a cutoff of >5 than at the previously reported cutoff values of >6 and >9, respectively. The AUC of the German brEASI was outstanding (AUC = 0.90, 95 % confidence interval (CI) = 0.82-0.96) for detecting all anxiety disorders and excellent for detecting non-GAD disorders (AUC = 0.85, CI = 0.76-0.92) at a cutoff of >5. At this optimal cutoff of >5 the brEASI demonstrated better sensitivity and specificity (89 % and 84 %) for identifying anxiety disorders than the GAD-7 (83 % and 74 %). The final German version of the brEASI is free to download at https://www.v-neuro.de/veroeffentlichungen/.

CONCLUSION

The German version of the brEASI represents a valid and reliable epilepsy-specific anxiety screening instrument. A positive screening result should be followed by further diagnostic procedures. Appropriate therapeutic steps should be initiated if the presence of an anxiety disorder or other psychiatric disorders is confirmed.

Awareness of and preference for disease prognosis and participation in treatment decisions among advanced cancer patients in Myanmar: Results from the APPROACH study

AIM

To investigate prognostic awareness, preference for prognostic information, and perceived and preferred roles in decision making among patients with advanced cancer in Myanmar.

METHODS

A cross-sectional survey was administered at the Yangon General Hospital to stage 4 cancer patients who were at least 21 years old and aware of their cancer diagnosis. Patients were asked questions about their prognosis, participation in treatment decisions, sociodemographic and clinical information. Data from 131 patients were analyzed using descriptive statistics and logistic regressions.

RESULTS

Only 15% of patients surveyed were aware that their cancer was advanced and only a quarter (26%) of patients knew that treatment intent was noncurative. The likelihood of treatment-intent awareness was higher among patients who were male, high income, and aware that they had advanced cancer. Roughly 60% of patients reported playing an active or collaborative role in treatment decisions, with a strong preference (59%) for the latter. For the majority of patients (69%), perceived and preferred roles in decision making were the same. Sociodemographic characteristics did not predict perceived and preferred roles in decision making.

CONCLUSIONS

This is the first effort to analyze prognostic awareness and decision-making practices among advanced cancer patients in Myanmar. Patients had inadequate knowledge on their disease progression and intent of treatment. Yet, the majority of them were keen to be involved in treatment decisions.

The Role of Culture/Ethnicity in Communicating with Cancer Patients About Mental Health Distress and Suicidality

To explore the role of culture in communicating with cancer patients about mental health distress and suicidality. The Grounded Theory method of data collection and analysis was used. Healthcare professionals (HCPs) reported that language competency was a facilitator while being unable to speak the language or understand the nuances of their patient's communication could be a barrier. HCPs noted that being culturally matched with their patients helped them communicate effectively. HCPs also spoke about religious taboos on suicide as being a barrier to having conversations, either because patients did not feel comfortable discussing these issues, or because they perceived that this was not a topic they could bring up. Some HCPs reported that the culture/ethnicity of their patients had no effect on their ability to communicate effectively with them about mental health distress or suicidality. Advancing effective cross-cultural communication is a challenge faced by HCPs. Raising awareness about communication styles is an important step in addressing communication gaps about mental health and suicide with cancer patients. Training should facilitate skill development to engage in a culturally humble approach to cross-cultural communication including diversity training which encourages asking and actively listening to patients' needs and preferences.

The effectiveness of exercise programmes in patients with multiple myeloma: A literature review

A limited number of clinical studies have investigated the effectiveness of participation in exercise training programmes for patients with multiple myeloma (MM), exploring the different biomedical, physical, psychological and quality of life. The aim of this literature review is to evaluate current quantitative and qualitative evidence concerning the effectiveness of participation in exercise programmes for patients with MM in improving physiological and/or psychological status. A literature search encompassing studies published between January 1998 and July 2013 was conducted through ten electronic databases. This search was further expanded through citation chaining, manual grey literature searches, and peer review consultation. In total, seven interventional studies were identified and appraised using Critical Appraisal Skill Programme (CASP) or Centre for Evidence-Based Management of Amsterdam (CEBMa). Though the majority of the studies presented encouraging data, however, three studies that implemented individualized exercise interventions for patients at different stages of MM and myeloablative treatment showed mixed results. In conclusion, the effectiveness of participation in exercise programmes remains unclear for patients with MM, as the studies reviewed were flawed by relatively weak methodological approaches.

Expectations and Level of Satisfaction of Patients and Their Physicians: Concordance and Discrepancies

BACKGROUND

Identifying discrepancies between patients׳ expectations for support provided by their physicians, and physicians׳ appraisal of the support they provide to their patients, is a key factor in constructing effective doctor-patient communication.

OBJECTIVE

The current study proposes and explores a paradigm for assessing possible gaps and overlaps between perceptions of patients with cancer and physicians about the "actual" and the "ideal" (desired) emotional and cognitive support oncologists provide to patients.

METHODS

Participants included 1027 patients with cancer and 47 senior oncologists. Patients׳ and physicians׳ levels of expectations and satisfaction with the emotional and cognitive support offered by physicians were assessed using a quantitative measure of discrepancy between the actual and the ideal situation. The measure was developed for this study and tested on a random sample of 200 patients and 17 oncologists.

RESULTS

The results indicated consistency between physicians׳ and patients׳ perceptions of the needs and support that the patients received. Nevertheless, oncologists did not feel highly trusted by their patients, oncologists desired less involvement of patients in the treatment plan than the patients expected. Oncologists thought that they actually provided the desired levels of explanation to patients׳ families, whereas patients thought their families got less explanations than expected.

CONCLUSION

Actual and ideal levels of communication should be described from the points of view of both physicians and patients to better understand the complex picture of patient satisfaction. Oncologists should consider patients׳ expectations for support vs their own expectations to effectively address patients׳ needs.

Examining cultural factors that influence treatment decisions: a pilot study of Latino men with cancer

The objective of this study was to explore beliefs and treatment decisions of foreign-born Latino men from Cuba, Mexico, Colombia, and Venezuela, who have been diagnosed with cancer and who live in Central Florida, USA. Experiences related to knowledge of diagnosis, treatment decisions, communication with health providers, family involvement, and advance care planning (ACP) discussions following the diagnosis of cancer are central to this study. This study used qualitative in-depth semi-structured interviews and thematic analysis. The interviews were conducted with 15 Latino men who have been diagnosed with cancer within the past 5 years and who reside in the community. The interviews were conducted and transcribed in Spanish and then translated into English. The median age was 55.4 years. Nine Latino men had prostate cancer, two had brain cancer, two had colorectal cancer, and two had lung cancer. Emerging themes involved the suddenness of the diagnosis, fear of dying, expectations of diagnosis-related communication, reliance on physicians for treatment decisions, limited information pertaining to ACP, family support, and role changes. Latino men's limited knowledge of cancer diagnosis and treatment options coupled with their fear led them to immediately believe that they were going to die. Knowledge gaps regarding diagnosis-related communication, treatment decisions, and ACP varied among the men. The forthright diagnosis communication and the expectation to engage in decision making are contrary to Latinos men's beliefs of reliance on health providers decisions. The findings contribute to understanding Latino men's beliefs about a cancer diagnosis and treatment decisions.

Advance care planning among Colombian, Mexican, and Puerto Rican women with a cancer diagnosis

PURPOSE

Limited knowledge exists pertaining to advance care planning (ACP) among Colombian, Mexican, and Puerto Rican women with a cancer diagnosis living in Central Florida, in the USA. The purpose of the study is to identify factors that facilitated the completion of ACP and decisions making patterns among the three groups of Latinas.

METHODS

The research method used was an exploratory qualitative in-depth open-ended semi-structured interview with a grounded theoretical approach and thematic analysis. The interviews were conducted in Spanish with a purposeful sample of 45 Latinas (15 in each group) diagnosed with cancer.

RESULTS

A total of ten women (22 %) in the study documented at least one form of ACP. Thirty-five women identified obstacles to accessing information regarding ACP, relating this to insurance and financial factors. Among the Colombian women, one completed a living will, health care surrogate, and power of attorney (all forms of ACP), and three just a living will. Two Puerto Rican women completed all, two a living will, and one both a living will and an enduring power of attorney. Only one Mexican woman completed a living will.

CONCLUSIONS

This study identifies a knowledge gap regarding ACP among Latina women with cancer diagnosis living in Central Florida, in the USA. Differences between the three groups exist as a result of migration/immigration history, family support, education, English language proficiency, income, knowledge gaps, and information ascertained by medical and health professionals. These differences contribute to their readiness, receptiveness, and willingness to engage in documenting a living will, a health care surrogate, and an enduring power of attorney for health decisions.

Physician, patient and family attitudes regarding information on prognosis: a Brazilian survey

BACKGROUND

Communication between physicians and patients is a fundamental aspect of cancer care, yet most physicians' perceptions are often inconsistent with the patients' stated preferences while prognostic information is the most misunderstood.

PATIENTS AND METHODS

Members of the Brazilian Society of Oncology Physicians (n=609) were identified and asked to complete a mailed questionnaire. Outpatients (n=150) and their family members (n=150), oncologists and fellows (n=55) from a public healthcare hospital and a tertiary cancer hospital in Sao Paulo were also personally invited to participate.

RESULTS

A total of 202 physicians, 150 outpatients and 150 family members were participated. The majority of patients (92%) believe they should know about their terminal stage compared with 79.2% of physicians and 74.7% of families (P=0.0003). Cancer patients were most likely to support disclosure of diagnosis and terminality (P=0.001), to consider that this disclosure was not stressful (P<0.0001) and that this knowledge would improve their quality of life (P<0.0001).

CONCLUSIONS

Cancer patients seen in these centers in Southeastern Brazil prefer to know the truth about their poor prognosis more than their physicians and families think. Further studies with larger samples of patients and physicians are necessary to show if our results are representative of all Brazilian situations.

Meeting expectations of patients with cancer: relationship between patient satisfaction, depression, and coping

PURPOSE

This study assessed satisfaction of patients with cancer and the correlation between patient levels of satisfaction and the sociodemographic, medical, and psychological variables. Satisfaction measures were based on patient expectations for emotional and cognitive support by the oncologists.

PATIENTS AND METHODS

A total of 1,027 patients with cancer were recruited from the outpatient departments and daycare treatment centers of four oncology institutes in Israel. Patient levels of expectations and satisfaction were assessed by using measures developed for this study. Patient psychological variables were assessed by using the Brief Symptoms Inventory, Impact of Events Scale, and Mental Adjustment to Cancer. chi(2) and Student t tests were used to assess differences between the highly satisfied group and the less satisfied group.

RESULTS

Lower values of satisfaction were reported on the dimensions that included the patient in the treatment plan and that included explanations to the family. Higher percentages of women, single patients, younger patients, and patients in stages II to III were found in the less satisfied group. This group reported significantly higher levels of psychological distress, anxious preoccupation, and helplessness and lower levels of fighting spirit.

CONCLUSION

Given the importance of patient satisfaction to treatment compliance, oncologists should consider evaluating patient expectations for support, especially in issues concerning planning the treatment and involving the family in medical decisions. Oncologists should take into account the possible interdependence between psychological variables and medical-care satisfaction.

Time-related communication skills from the cancer patient perspective

OBJECTIVE

Although it is well recognized that skilled communication is an essential element of effective cancer care, lack of time to communicate is often cited as an explanation for the ongoing cancer care communications problems patients report. In this study, we sought to answer the question: How do cancer patients describe and explain the effects of health care communication upon their experience of time?

METHODS

We conducted a qualitative secondary analysis, using interpretive description methodology, on a large data set that comprised transcribed interview data from two studies of cancer communication from the patient perspective. One primary study represented a cross-sectional study of helpful and unhelpful communications (n=200) and the other a longitudinal study of changes in communication needs and preferences over the illness trajectory (n=60).

RESULTS

We found time a meaningful and symbolic construct for cancer patients. They describe clinician time-related attitudes and behaviors as significant factors in shaping the impact of clinical encounters on their overall psychosocial cancer experiences. They report a number of ways in which clinician communications have been particularly effective in buffering and manipulating the impact of time pressures and describe a capacity within exceptionally skilled clinicians to manufacture a perception of available time even in the context of such pressures.

CONCLUSIONS

We believe that the patient perspective on cancer care communication provides an important angle of vision from which to discern strategies that may assist clinicians to buffer the untoward effects of the time pressure under which most care systems currently operate.

Patient--provider communication: understanding the role of patient activation for Latinos in mental health treatment

This article highlights results from the Right Question Project-Mental Health (RQP-MH), an intervention designed to teach skills in question formulation and to increase patients' participation in decisions about mental health treatment. Of participants in the RQP-MH intervention, 83% were from a Latino background, and 75% of the interviews were conducted in Spanish. The authors present the steps participants undertook in the process of becoming "activated" to formulate effective questions and develop decision-making skills in relation to their care. Findings suggest that patient activation and empowerment are interdependent because many of the skills (i.e., question formulation, direct patient-provider communication) required to become an "activated patient" are essential to achieve empowerment. Also, findings suggest that cultural and contextual factors can influence the experience of Latinos regarding participation in health care interactions. The authors provide recommendations for continued research on the patient activation process and further application of this strategy in the mental health field, especially with Latinos.

Cultural aspects of communication in cancer care

Cultural competence in oncology requires the acquisition of specific knowledge, clinical skills, and attitudes that facilitate effective cross-cultural negotiation in the clinical setting, thus, leading to improved therapeutic outcomes and decreased disparities in cancer care. Cultural competence in oncology entails a basic knowledge of different cultural attitudes and practices of communication of the truth and of decision-making styles throughout the world. Cultural competence always presupposes oncology professionals' awareness of their own cultural beliefs and values. To be able to communicate with cancer patients in culturally sensitive ways, oncologists should have knowledge of the concept of culture in its complexity and of the risks of racism, classism, sexism, ageism, and stereotyping that must be avoided in clinical practice. Oncologists should develop a sense of appreciation for differences in health care values, based on the recognition that no culture can claim hegemony over others and that cultures are evolving under their reciprocal influence on each other. Medical schools and oncology training can teach communication skills and cultural competence, while fostering in all students and young doctors those attitudes of humility, empathy, curiosity, respect, sensitivity, and awareness that are needed to deliver effective and culturally sensitive cancer care.

ALS patients and caregivers communication preferences and information seeking behaviour

To evaluate information preferences and information seeking behaviour in ALS patients and caregivers. Sixty ALS patients and caregivers couples were interviewed using a structured questionnaire about the content of diagnosis communication and their information seeking behaviour. The patients (35 men and 25 women) had a mean age of 63.4 years (SD 9.5). The caregivers (21 men and 39 women) had a mean age of 53.3 years (SD 14.9). The overall satisfaction with bad news communication and the impression that the physician had understood their feelings were higher amongst patients. Both parties indicated that the most important aspects to be informed were current researches, disease-modifying therapies and ALS outcome. Approximately 55% of patients and 83.3% of caregivers searched for information from sources outside the healthcare system. The most frequently checked source was internet, although its reliability was rated low. The caring neurologist should better attune the content of communication to patients' and caregivers' preferences, trying to understand what they want to know and encouraging them to make precise questions. Health professionals should be aware that ALS patients and caregivers often use internet to obtain information and should help them to better sort-out and interpret the news they found.