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Elias H, Kisembe E, Nyariki S, Kiplimo I, Amisi J, Boit J, Tarus A, Mohamed N, Cornetta K. Impact of training on knowledge, confidence and attitude amongst community health volunteers in the provision of community-based palliative care in rural Kenya. BMC Palliat Care 2024; 23:97. [PMID: 38605309 PMCID: PMC11007868 DOI: 10.1186/s12904-024-01415-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 03/21/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVES Existing literature suggests multiple potential roles for community health volunteers (CHVs) in the provision of palliative care (PC) in low- and middle-income countries. In Kenya the role of CHV in the provision of PC has not been reported. The objective of this study was to assess knowledge, confidence, attitude, and clinical practice of community health volunteers after attending a novel palliative care (PC) training program. METHODS A total of 105 CHVs participated in a 3-day in person training followed by a 1-month in person and telephone observation period of the palliative care activities in the community. Structured questionnaires were used pre- and post-training to assess knowledge acquisition, impact on practice, and content delivery. A mixed method study design was conducted 12-month post training to assess impact on clinical practice. RESULTS Immediately after training, CHV provided positive ratings on relevance and content delivery. In the month following training, CHVs evaluated 1,443 patients, referred 154, and conducted 110 and 129 tele consults with the patients and PC providers respectively. The follow up survey at 12 months revealed improved knowledge and confidence in various domains of palliative care including symptom and spiritual assessment and provision of basic nursing and bereavement care. Focus group discussions revealed the CHVs ability to interpret symptoms, make referrals, improved communication/ interpersonal relationships, spiritual intervention, patient comfort measures and health care practices as newly learned and practiced skills. CONCLUSIONS We noted improved knowledge, new skills and change in practice after CHVs participation in a novel training curriculum. CHVs can make important contributions to the PC work force and be first line PC providers in the community as part of larger hub and spoke care model.
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Affiliation(s)
- Hussein Elias
- Department of Family Medicine, College of Health Sciences, Moi University, Eldoret, Kenya.
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.
| | - Evelyne Kisembe
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Sarah Nyariki
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ivan Kiplimo
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - James Amisi
- Department of Family Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Juli Boit
- Living Room International Hospital, Eldoret, Kenya
| | | | | | - Kenneth Cornetta
- Department of Family Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Medical and Molecular Genetics, School of Medicine, Indiana University, Indianapolis, IN, USA
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McLouth LE, Stapleton JL, Bursac V, Zelaya CM, Shelton BJ, Thakur K, Hands I, Blu C, Chih MY, McFarlin JM. Piloting a Patient Tool to Aid Palliative Care Referrals during Advanced Lung Cancer Treatment. J Pain Symptom Manage 2024; 67:337-345.e2. [PMID: 38219963 PMCID: PMC10939763 DOI: 10.1016/j.jpainsymman.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 01/02/2024] [Accepted: 01/06/2024] [Indexed: 01/16/2024]
Abstract
CONTEXT Patient misperceptions are a strong barrier to early palliative care discussions and referrals during advanced lung cancer treatment. OBJECTIVES We developed and tested the acceptability of a web-based patient-facing palliative care education and screening tool intended for use in a planned multilevel intervention (i.e., patient, clinician, system-level targets). METHODS We elicited feedback from advanced lung cancer patients (n = 6), oncology and palliative care clinicians (n = 4), and a clinic administrator (n = 1) on the perceived relevance of the intervention. We then tested the prototype of a patient-facing tool for patient acceptability and preliminary effects on patient palliative care knowledge and motivation. RESULTS Partners agreed that the intervention-clinician palliative care education and an electronic health record-integrated patient tool-is relevant and their feedback informed development of the patient prototype. Advanced stage lung cancer patients (n = 20; age 60 ± 9.8; 40% male; 70% with a technical degree or less) reviewed and rated the prototype on a five-point scale for acceptability (4.48 ± 0.55), appropriateness (4.37 ± 0.62), and feasibility (4.43 ± 0.59). After using the prototype, 75% were interested in using palliative care and 80% were more motivated to talk to their oncologist about it. Of patients who had or were at risk of having misperceptions about palliative care (e.g., conflating it with hospice), 100% no longer held the misperceptions after using the prototype. CONCLUSION The palliative care education and screening tool is acceptable to patients and may address misperceptions and motivate palliative care discussions during treatment.
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Affiliation(s)
- Laurie E McLouth
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky, USA; Center for Health Equity Transformation, University of Kentucky, Lexington, Kentucky, USA; Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA.
| | - Jerod L Stapleton
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA; Department of Health, Behavior, and Society, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Vilma Bursac
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, Kentucky, USA; Center for Health Equity Transformation, University of Kentucky, Lexington, Kentucky, USA
| | - Carina M Zelaya
- Department of Communication, University of Maryland, Baltimore, Maryland, USA
| | - Brent J Shelton
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA; Department of Internal Medicine, Division of Cancer Biostatistics, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Kshitij Thakur
- Department of Internal Medicine, Gastroenterology, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
| | - Isaac Hands
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Chaney Blu
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA
| | - Ming-Yuan Chih
- Markey Cancer Center, University of Kentucky, Lexington, Kentucky, USA; Department of Health and Clinical Sciences, College of Health Sciences, University of Kentucky, Lexington, Kentucky, USA
| | - Jessica M McFarlin
- Department of Neurology, College of Medicine, University of Kentucky, Lexington, Kentucky, USA
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Varilek BM, Doyon K, Vacek S, Isaacson MJ. Palliative and End-of-Life Care Interventions with Minoritized Populations in the US with Serious Illness: A Scoping Review. Am J Hosp Palliat Care 2024:10499091241232978. [PMID: 38320752 DOI: 10.1177/10499091241232978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2024] Open
Abstract
INTRODUCTION Over the past 20 years, palliative care in the United States has grown significantly. Yet, access to and/or engagement with palliative care for minoritized persons with serious illness remains limited. In addition, the focus of palliative and end-of-life care research has not historically focused on equity-informed intervention development that collaborates directly with minoritized populations. Equity-informed interventions within palliative and end-of-life care research have the potential to champion collaborations with persons with serious illness and their families to mitigate health inequities. The purpose of this scoping review was to examine and describe the literature on the approaches used in the design and development of palliative and end-of-life care interventions with minoritized populations with serious illness. METHODS The Joanna Briggs Institute methodology for scoping reviews was followed for tracking and reporting purposes. Included articles were described quantitatively and analyzed qualitatively with content analysis. RESULTS Thirty-seven articles met the inclusion criteria: eight used quantitative methods, eight used qualitative methods, ten reported a community-based participatory research method, nine used mixed-methods, and two had research designs that could not be determined. The qualitative analysis revealed three themes: (1) stakeholder involvement and feedback, (2) intervention focus, and (3) target intervention population (population vs healthcare clinician). CONCLUSIONS Using an equity-informed research approach is vital to improve palliative and end-of-life care interventions for minoritized communities with serious illness. There is also a need for more robust publishing guidelines related to community-based participatory research methods to ensure publication consistency among research teams that employ this complex research method.
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Affiliation(s)
- Brandon M Varilek
- College of Nursing, South Dakota State University, Sioux Falls, SD, USA
| | | | - Shelie Vacek
- Wegner Library, University of South Dakota, Sioux Falls, SD, USA
| | - Mary J Isaacson
- College of Nursing, South Dakota State University, Rapid City, SD, USA
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Shabnam J, Timm HU, Nielsen DS, Raunkiaer M. Development of a complex intervention (safe and secure) to support non-western migrant patients with palliative care needs and their families. Eur J Oncol Nurs 2023; 62:102238. [PMID: 36459811 DOI: 10.1016/j.ejon.2022.102238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/31/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022]
Abstract
PURPOSE International evidence supports the benefits of early use of palliative care, although the best use of services is often under-utilised among Danish migrants. The study aims to develop a theoretically informed, evidence-based intervention to increase support in palliative care service provision among non-western migrant patients with a life-threatening disease and their families in Denmark. METHODS The overall approach was guided by the United Kingdom Medical Research Council framework for developing and evaluating complex interventions by involving stakeholders for example patients, family caregivers, and healthcare professionals. The intervention was developed iteratively by incorporating theory and evidence. Evidence was synthesized from a systematic review, semi-structured interviews, and group discussions with patients (n = 8), family caregivers (n = 11), healthcare professionals (n = 10); and three workshops with migrants (n = 5), social and healthcare professionals (n = 6). The study took place in six different settings in two regions across Denmark. RESULTS The safe and secure complex intervention is a healthcare professional (e.g. nurse, physiotherapist, or occupational therapist) led patient-centred palliative care intervention at the basic level. The final intervention consists of three components 1. Education and training sessions, 2. Consultations with the healthcare professional, and 3. Coordination of care. CONCLUSION This study describes the development of a supportive palliative care intervention for non-western migrant patients with palliative care needs and their families, followed by a transparent and systematic reporting process. A palliative care intervention combining multiple components targeting different stakeholders, is expected that safe and secure is more suitable and well customized in increasing access and use of palliative care services for non-western migrant families in Denmark.
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Affiliation(s)
- Jahan Shabnam
- REHPA, Danish Knowledge Centre of Rehabilitation and Palliative Care, Odense University Hospital, Vestergade 17, 5800 Nyborg, Denmark; Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark.
| | - Helle Ussing Timm
- National Institute of Public Health, University of Southern Denmark, Studiestraede 6, 1455, Copenhagen, K, Denmark; University Hospitals Center for Health Research (UCSF), Rigshospital, Denmark.
| | - Dorthe Susanne Nielsen
- Geriatric Department G, Odense, Odense University Hospital, Kløvervænget 23, 5000, Odense C, Denmark.
| | - Mette Raunkiaer
- REHPA, Danish Knowledge Centre of Rehabilitation and Palliative Care, Odense University Hospital, Vestergade 17, 5800 Nyborg, Denmark; Department of Clinical Research, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark.
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Graham-Wisener L, Nelson A, Byrne A, Islam I, Harrison C, Geddis J, Berry E. Understanding public attitudes to death talk and advance care planning in Northern Ireland using health behaviour change theory: a qualitative study. BMC Public Health 2022; 22:906. [PMID: 35524295 PMCID: PMC9077935 DOI: 10.1186/s12889-022-13319-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 04/19/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES Advance care planning is a key preparatory step in ensuring high-quality palliative and end of life care, and should be considered as a process, beginning with community-level conversations among lay persons. There is, however, indication that death talk among community-dwelling adults is not occurring, and there is a dearth of research examining why this is the case. This study aims to provide the first examination of barriers and facilitators to talking about death and dying among the general population in a UK region (Northern Ireland), and to provide a novel application of health behaviour change theory towards developing a theoretical understanding of the sources of this behaviour. METHODS The study involved qualitative analysis of responses (n = 381 participants) to two open-ended questions within a cross-sectional online survey, with recruitment via social media of adults currently living in Northern Ireland. Reflexive thematic analysis was conducted on open text responses per question, with the barriers and facilitators mapped on to health behaviour change models (the Behaviour Change Wheel COM-B and the Theoretical Domains Framework). RESULTS The findings evidence a myriad of barriers and facilitators to engaging in death talk, with themes aligning to areas such as lack of acceptance of death in social contexts and fear of upsetting self or others, and a need to improve interpersonal communication skills for facilitating conversations and improve knowledge of the existing services around death and dying. A theoretical understanding of the drivers of death talk is presented with findings mapped across most components of the COM-B Behaviour Change Model and the Theoretical Domains Framework. CONCLUSIONS This study contributes to a small but emergent research area examining barriers and facilitators to talking about death and dying. Findings from this study can be used to inform new public health programmes towards empowering adults to have these conversations with others in their community towards upstreaming advance care planning.
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Affiliation(s)
- L Graham-Wisener
- Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, Belfast, UK.
| | - A Nelson
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - A Byrne
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - I Islam
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, UK
| | - C Harrison
- Marie Curie Northern Ireland, Belfast, UK
| | - J Geddis
- Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, Belfast, UK
| | - E Berry
- Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, Belfast, UK
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Lee KT, Zale AD, Ibe CA, Johnston FM. Patient Navigator and Community Health Worker Attitudes Toward End-of-Life Care. J Palliat Med 2021; 24:1714-1720. [PMID: 34403597 DOI: 10.1089/jpm.2021.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: There are racial/ethnic disparities in hospice use and end-of-life (EOL) care outcomes in the United States. Although the use of community health workers (CHWs) and patient navigators (PNs) has been suggested as a means of reducing them, CHW/PNs' attitudes toward a palliative care philosophy remain unknown. The purpose of this study was to examine how personal attributes affect a CHW/PN's attitude toward EOL care. Methods: CHWs/PNs were recruited from two state-wide organizations and invited to complete an online survey. We collected information on demographics, attitudes toward the palliative care philosophy, and comfort with caring for patients at the EOL. Results: Of the 70 CHWs/PNs who responded to the survey, 82.5% identified as female, 56.4% identified as black, and 56.2% had a four-year college degree or higher. The mean score on a validated scale to assess attitudes toward EOL care was 33.5 (SD = 4.9; possible range, 8-40). Eighty percent strongly agreed or agreed with being open to discussing death with a dying patient. Higher self-efficacy scores were associated with more favorable attitudes toward hospice (r = 0.306, p = 0.016). Conclusions: CHWs/PNs have an overall favorable attitude toward the palliative care philosophy and may be inclined to providing EOL care.
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Affiliation(s)
- Kimberley T Lee
- Moffitt Cancer Center, Departments of Breast Oncology and Health Outcomes and Behavior, Tampa, Florida, USA.,Johns Hopkins University, School of Medicine, Department of Oncology, Baltimore, Maryland, USA
| | - Andrew D Zale
- Johns Hopkins University, School of Medicine, Baltimore, Maryland, USA
| | - Chidinma A Ibe
- Johns Hopkins University, School of Medicine, Department of Internal Medicine, Baltimore, Maryland, USA
| | - Fabian M Johnston
- Johns Hopkins University, School of Medicine, Department of Surgery, Baltimore, Maryland, USA
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Larson KL, Mathews HF, Moye JP, Congema MR, Hoffman SJ, Murrieta KM, Johnson LA. Four Kinds of Hard: An Understanding of Cancer and Death among Latino Community Leaders. Glob Qual Nurs Res 2021; 8:23333936211003557. [PMID: 33816705 PMCID: PMC7992742 DOI: 10.1177/23333936211003557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 02/26/2021] [Accepted: 03/01/2021] [Indexed: 11/17/2022] Open
Abstract
Early integration of palliative care after a diagnosis of cancer improves outcomes, yet such care for Latino populations is lacking in rural regions of the United States. We used a participatory action research design with Latino community leaders from emerging immigrant communities in North Carolina to explore sociocultural perspectives on cancer and death. Thematic analysis was conceptualized as Four Kinds of Hard represented by four themes: Receiving an Eviction Notice, Getting in the Good Book, Talking is (Sometimes) Taboo, and Seeing Their Pain Makes us Suffer. These themes captured fears of deportation, coping with cancer through faithfulness, ambivalence about advance care planning, and a desire to spare families from suffering. Findings suggest strategies to improve conversations about end-of-life wishes when facing advanced illness and death. This study demonstrates the importance of training Latino community leaders to improve palliative care and bridge service gaps for Latino families living in emerging rural communities.
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Sedhom R, Nudotor R, Freund KM, Smith TJ, Cooper LA, Owczarzak JT, Johnston FM. Can Community Health Workers Increase Palliative Care Use for African American Patients? A Pilot Study. JCO Oncol Pract 2021; 17:e158-e167. [PMID: 33476179 PMCID: PMC8257996 DOI: 10.1200/op.20.00574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/01/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE African American patients with cancer underutilize advance care planning (ACP) and palliative care (PC). This feasibility study investigated whether community health workers (CHWs) could improve ACP and PC utilization for African American patients with advanced cancer. METHODS African American patients diagnosed with an advanced solid organ cancer (stage IV or stage III disease with a palliative performance score < 60%) were enrolled. Patients completed baseline surveys that assessed symptom burden and distress at baseline and 3 months post-CHW intervention. The CHW intervention consisted of a comprehensive assessment of multiple PC domains and social determinants of health. CHWs provided tailored support and education on the basis of iterative assessment of patient needs. Intervention feasibility was determined by patient and caregiver retention rate above 50% at 3 months. RESULTS Over a 12-month period, 24 patients were screened, of which 21 were deemed eligible. Twelve patients participated in the study. Patient retention was high at 3 months (75%) and 6 months (66%). Following the CHW intervention, symptom assessment as measured by Edmonton Symptom Assessment System improved from 33.8 at baseline to 18.8 (P = .03). Psychological distress improved from 5.5 to 4.7 (P = .36), and depressive symptoms from 42.2 to 33.6 (P = .09), although this was not significant. ACP documentation improved from 25% at baseline to 75% at study completion. Sixty-seven percentage of patients were referred to PC, with 100% of three decedents using hospice. CONCLUSION Utilization of CHWs to address PC domains and social determinants of health is feasible. Although study enrollment was identified as a potential barrier, most recruited patients were retained on study.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen M. Freund
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Thomas J. Smith
- Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jill T. Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Fabian M. Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Rosenzweig MQ, Althouse AD, Sabik L, Arnold R, Chu E, Smith TJ, Smith K, White D, Schenker Y. The Association Between Area Deprivation Index and Patient-Reported Outcomes in Patients with Advanced Cancer. Health Equity 2021; 5:8-16. [PMID: 33564735 PMCID: PMC7868579 DOI: 10.1089/heq.2020.0037] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2020] [Indexed: 12/13/2022] Open
Abstract
Background: This analysis describes associations between area deprivation and patient-reported outcomes among patients with advanced cancer. Methods: This is a cross-sectional analysis of baseline data from a multisite primary palliative care intervention trial. Participants were adult patients with advanced cancer. Patient-level area deprivation scores were calculated using the Area Deprivation Index (ADI). Quality of life and symptom burden were measured. Uni- and multivariate regressions estimated associations between area deprivation and outcomes of interest. Results: Among 672 patients, ∼0.5 (54%) were women and most (94%) were Caucasian. Mean age was 69.3±10.2 years. Lung (36%), breast (13%), and colon (10%) were the most common malignancies. Mean ADI was 64.0, scale of 1 (low)-100 (high). In unadjusted univariate analysis, Functional Assessment of Cancer Therapy-Palliative (p=0.002), Edmonton Symptom Assessment Scale (p=0.025) and the Hospital Anxiety and Depression Scale anxiety (p=0.003) and depression (p=0.029) scores were significantly associated with residence in more deprived areas (p=0.003). In multivariate analysis, controlling for patient-level factors, living in more deprived areas was associated with more anxiety (p=0.019). Conclusion: Higher ADI was associated with higher levels of anxiety among patients with advanced cancer. Geographic information could assist clinicians with providing geographically influenced social support strategies.
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Affiliation(s)
- Margaret Quinn Rosenzweig
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Address correspondence to: Margaret Quinn Rosenzweig, PhD, CRNP, AOCNP, FAAN, Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Victoria Building, Pittsburgh, PA 15261, USA,
| | - Andrew D. Althouse
- Center for Research on Health Care Data Center, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lindsay Sabik
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert Arnold
- Division of General lnternal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Edward Chu
- Division of Hematology/Oncology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Thomas J. Smith
- Harry J. Duffey Family Professor of Palliative Medicine, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland, USA
| | - Kenneth Smith
- Division of General lnternal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Douglas White
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Division of General lnternal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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