Beliefs and beyond: what can we learn from qualitative studies of lay people's understandings of cancer risk?

Informing existing technology acceptance models: a qualitative study with older persons and caregivers

New technologies can help older persons age in place and support their caregivers. However, they need to be accepted by the end-users to do so. Technology acceptance models, such as TAM and UTAUT and their extensions, use factors like performance expectancy and effort expectancy to explain acceptance. Furthermore, they are based on quantitative methods. Our qualitative study investigates factors fostering and hindering acceptance among older persons and their caregivers for a variety of assistive technologies, including wearables, ambient sensors at home with and without cameras and social companion robots. The goal of this paper is twofold: On the one hand, it investigates the factors of technology acceptance models in a qualitative setting. On the other hand, it informs these models with aspects currently overlooked by them. The results reveal that performance expectancy and effort expectancy are relevant for acceptance. We also find that reliability, anxiety around technology and different social aspects have an influence on acceptance of assistive technology in aged care for all end-user groups. Our findings can be used to update current technology acceptance models and provide in-depth knowledge about the currently used factors.

The long-term psychosocial consequences of screen-detected ductal carcinoma in situ and invasive breast cancer

OBJECTIVE

Ductal carcinoma in situ (DCIS) is a risk factor for invasive breast cancer (IBC). The prognosis of DCIS is considerably better than for IBC, yet women do not distinguish between the threat. We aimed to compare the psychosocial consequences of screen-detected DCIS and IBC, and to examine this comparison over time.

METHODS

We surveyed a Danish mammography-screening cohort from 2004 to 2018. We assessed outcomes at six-time points: baseline, 1, 6, 18, 36 months, and 14 years after the screening. We measured psychosocial consequences with the Consequences Of Screening - Breast Cancer (COS-BC): a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions. We used weighted linear models with generalized estimating equations to compare responses between groups. We used a 1% level of significance.

RESULTS

170 out of 1309 women were diagnosed with breast cancer (13.0%). 23 were diagnosed with DCIS (13.5%) and 147 with IBC (86.5%). From baseline to six months after diagnosis, there were no significant differences between women with DCIS and IBC. However, mean scores indicated that IBC generally was more affected than DCIS. After six months, we observed that women with DCIS and IBC might be affected differently in the long term; mean scores and mean differences showed that IBC were more affected on some scales, while DCIS were on others.

CONCLUSION

Overall, the DCIS and IBC experienced similar levels of psychosocial consequences. Women might benefit from renaming DCIS to exclude cancer nomenclature.

Long-term psychosocial consequences of false-positive screening mammography: a cohort study with follow-up of 12-14 years in Denmark

OBJECTIVE

To compare the long-term psychosocial consequences of mammography screening among women with breast cancer, normal results and false-positive results.

DESIGN

A matched cohort study with follow-up of 12-14 years.

SETTING

Denmark from 2004 to 2019.

PARTICIPANTS

1170 women who participated in the Danish mammography screening programme in 2004-2005.

INTERVENTION

Mammography screening for women aged 50-69 years.

OUTCOME MEASURES

We assessed the psychosocial consequences with the Consequences Of Screening-Breast Cancer, a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions.

RESULTS

Across all 14 psychosocial outcomes, women with false-positive results averagely reported higher psychosocial consequences compared with women with normal findings. Mean differences were statistically insignificant except for the existential values scale: 0.61 (95% CI (0.15 to 1.06), p=0.009). Additionally, women with false-positive results and women diagnosed with breast cancer were affected in a dose-response manner, where women diagnosed with breast cancer were more affected than women with false-positive results.

CONCLUSION

Our study suggests that a false-positive mammogram is associated with increased psychosocial consequences 12-14 years after the screening. This study adds to the harms of mammography screening. The findings should be used to inform decision-making among the invited women and political and governmental decisions about mammography screening programmes.

“Just Hemorrhoids, Not Cancer”: Perceptions of Colorectal Cancer Among Thai Colorectal Cancer Patients

Colorectal cancer is the leading cause of mortality among Thais. Understanding patients’ perceptions of colorectal cancer can help in the design of educational programs to enhance awareness of colorectal cancer among Thais. This study aims to elucidate illness explanatory models of colorectal cancer and their perceptions of colorectal cancer through the explanatory model. In-depth interviews with 30 patients about their perceptions and experiences of colorectal cancer were subjected to thematic analysis. The findings show that the patients were unaware of colorectal cancer, had misconceptions regarding colorectal cancer detection and screening; they considered the symptoms to be the result of hemorrhoids, karma, and heredity. Their explanatory model underlies the body of knowledge grounded in the lay explanation which results in perception, beliefs, relative experiences, and approaches to illness management. There is a need for further information about colorectal cancer symptoms to assist symptom recognition through cancer education and screening programs.

Perceptions of cervical cancer and motivation for screening among women in Rural Lilongwe, Malawi: A qualitative study

Introduction

Cervical cancer is the leading cause of cancer death among women in Malawi. Low awareness of cervical cancer and negative perceptions of screening can prevent women from participating in preventative strategies. We sought to explore perceptions and motivations for screening among women who participated in a cervical cancer screen-and-treat pilot study in rural Malawi.

Materials and methods

We conducted a qualitative sub-study of a community-based cervical cancer screen-and-treat pilot study in rural Lilongwe between July-August 2017. From October 2017-February 2018, 17 women who underwent screening using visual inspection with acetic acid (VIA) and same-day thermal ablation treatment were recruited at their 12-week follow-up visit post treatment to participate in this qualitative sub-study. Semi-structured interview guides that explored baseline knowledge of cervical cancer, perceptions, and motivation for screening were used for in-depth interviews (IDIs). IDIs were conducted in the local language, Chichewa, translated and transcribed to English. Data was analyzed using NVivo® V12.0.

Results

Findings included fatalistic views on cancer, but limited knowledge specific to cervical cancer. Misconceptions of cervical cancer screening were common; however, there was a unique understanding of screening as prevention (i.e., finding and treating early disease to prevent progression to worsening disease). This understanding appeared to stem from HIV prevention concepts known to the community. Motivations for screening included desire to know one’s health status, convenience of community-based screening, and peer encouragement.

Conclusion

Despite limited knowledge of cervical cancer and misconceptions of screening, the concept of screening for prevention, desire to know one’s health status, convenient access, and peers’ influence were motivators for participation in screening. Cervical cancer screen-and-treat programs in high HIV prevalence areas should consider utilizing language that parallels HIV prevention language to communicate the need for cervical cancer screening and treatment and utilize prevention concepts that may already be familiar to women living there.

Revisiting Candidacy: What Might It Offer Cancer Prevention?

The notion of candidacy emerged three decades ago through Davison and colleagues’ exploration of people’s understanding of the causes of coronary heart disease. Candidacy was a mechanism to estimate one’s own or others risk of disease informed by their lay epidemiology. It could predict who would develop illness or explain why someone succumbed to it. Candidacy’s predictive ability, however, was fallible, and it was from this perspective that the public’s reticence to adhere to prevention messages could be explained, as ultimately anybody could be ‘at-risk’. This work continues to resonate in health research, with over 700 citations of Davison’s Candidacy paper. Less explored however, is the candidacy framework in its entirety in other illness spheres, where prevention efforts could potentially impact health outcomes. This paper revisits the candidacy framework to reconsider it use within prevention. In doing so, candidacy within coronary heart disease, suicide prevention, diabetes, and cancer will be examined, and key components of candidacy and how people negotiate their candidacy within differing disease contexts will be uncovered. The applicability of candidacy to address modifiable breast cancer risk factors or cancer prevention more broadly will be considered, as will the implications for public health policy.

Perceived Threats toward Esophageal Cancer among Immediate Relatives of Sufferers: a Qualitative Study

PURPOSE

Considering life-threatening nature of cancer and the problems that it causes for patients and families, recognizing their perspectives toward this issue is important. Therefore, the aim of this study was to determine perceived threats by immediate relatives of patients with esophageal cancer.

METHODS

Using content analysis approach, the present qualitative study was conducted in Golestan Province (north of Iran) in 2018. Through purposive sampling, 23 immediate relatives of patients with esophageal cancer were included in the study. The research techniques included semi-structured and deep interviews. We continued data collection to ensure data saturation was achieved. All interviews were recorded, transcribed, and then analyzed with Graneheim and Lundman's approach of conventional content analysis. The MAXQDA 11 software was applied to conduct the coding process.

RESULTS

Following data analysis, two main categories including "perceived susceptibility" and "perceived severity" were identified for perceived threats. The main category of "perceived susceptibility" comprised of four subcategory, namely, perception of individual, environmental, psychological, and nutritional predisposing factors to the disease. Four subcategories were also extracted for the "perceived severity," including perception of physical, psychological, therapeutic, and social consequences of the disease.

CONCLUSIONS

Immediate relatives of patients with esophagus cancer perceived high severity and susceptibility toward this disease and considered themselves vulnerable to this disease. Hence, they suffered from a lot of psychological stress. Development of appropriate interventions regarding the effects of disease-related individual and environmental factors and empowerment of individuals with regard to preventive disease behaviors can be an important step for improving the health of this group.

REGISTRATION NUMBER

IRCT20180725040588N1, date registered: 2 October 2018.

The medicalization of cancer as socially constructed and culturally negotiated

Sociological considerations of medicalization frequently employ a limited use of the term that focuses on the transformation of social phenomena into issues subject to medical control. Informed by a salutogenic perspective, this essay argues that it is possible to understand cancer as having been medicalized. I show that far from exclusively a biophysical issue, the medicalization of cancer is a socially constructed and culturally negotiated process, with a fairly recent historical origin. While changing social relations of healing have led our medico-centric culture to a near single-minded understanding of cancer as a cellular pathology rooted in biology, Antonovsky's salutogenic perspective instructs that it is possible to understand and control cancer in non-medicalized ways. Indoor radon gas remediation is presented as an illustration of what form salutary cancer control and disease prevention may take.

A Cross-Sectional Study about Knowledge, Awareness and Perception of Risk Factors for Cancer among Cancer-Patients Relatives and Healthy Adults in Ho Chi Minh City, Vietnam

Background and Aims:

Although cancer is common in Ho Chi Minh city, Vietnam, the community awareness is still unknown. The primary objective of this study was to examine and compare the knowledge and risk perceptions of cancer possessed by cancer patients - relatives and healthy adults in Ho Chi Minh City, Vietnam.

Methods:

A cross-sectional study was conducted from June to August 2019. Cancer patients and their relatives were drawn from those who were hospitalized in the Oncology Hospital, Ho Chi Minh City. Healthy individuals were those without a known diagnosis of cancer, and they were drawn from the participants of the Vietnam Osteoporosis Study. A total of 533 participants including 249 patients and relatives (cancerous group) and 284 healthy individuals (healthy group), were asked to respond to a structured questionnaire that was comprised of items concerning cancer knowledge, risk factor perception, and general attitude towards cancer, using Yes, No, or Likert Scale for response.

Results:

The findings showed that patients hold poorer knowledge of pathology, signs, symptoms, prevention, and treatment and lower awareness of risk factors but more positive attitude towards cancer as compared to their healthy counterparts. Overall, both groups varied in their cancer knowledge, with many areas remain to be improved.

Conclusions:

Knowledge about cancer and its risk factors should be improved among the general population as well as among those with direct experiences with cancer. Practical implications: The findings provided by this study has major implications for the design of an educational program for cancer patients in clinical settings and awareness programs for the general public as a primary preventive measure for mitigating the cancer burden. Future studies with larger and more diverse samples or qualitative studies exploring the personal narratives of people living with cancer could take advantage from the preliminary data provided by this study.

The experience of living after ECT: a qualitative meta-synthesis

BACKGROUND

Electroconvulsive therapy (ECT) is a controversial treatment. Research has predominantly focused on clinician assessment of short-term efficacy and, occasionally, on participant experiences of the treatment itself. While service user accounts of the long-term impacts of ECT are reported, they are dispersed throughout the literature and typically tangential to studie's main foci.

AIM

The aim of this study was to synthesise service-user accounts, within peer-reviewed literature, of long-term impacts of ECT in their daily lives.

METHODS

A qualitative meta-synthesis was conducted. A systematic literature search identified qualitative articles meeting the inclusion criteria. Results sections of eligible papers were analysed thematically.

RESULTS

From 16 eligible papers, the review identified 11 long-term impacts, four social influences and five strategies that people employed to navigate these long-term impacts.

CONCLUSION

Limited research has examined long-term experiences of ECT from service-user perspectives. These lived experience perspectives are required to facilitate peer-to-peer learning and assist future service delivery to align with needs of people living with long-term ECT impacts.

Effect of interventions including provision of personalised cancer risk information on accuracy of risk perception and psychological responses: A systematic review and meta-analysis

OBJECTIVE

To synthesize the literature on the effect of provision of personalised cancer risk information to individuals at population level risk on accuracy of risk perception and psychological responses.

METHODS

A systematic review and random effects meta-analysis of articles published from 01/01/2000 to 01/07/2017.

RESULTS

We included 23 studies. Immediately after provision of risk information 87% of individuals were able to recall the absolute risk estimate. Less than half believed that to be their risk, with up to 71% believing their risk to be higher than the estimate. Provision of risk information increased accuracy of perceived absolute risk immediately after risk information compared with no information (pooled RR 4.16 (95%CI 1.28-13.49), 3 studies). There was no significant effect on comparative risk accuracy (pooled RR 1.39 (0.72-2.69), 2 studies) and either no change or a reduction in cancer worry, anxiety and fear.

CONCLUSION

These findings highlight the complex cognitive processes involved in the conceptualisation of risk.

PRACTICE IMPLICATIONS

Individuals who appear to understand and are able to recall risk information most likely do not believe it reflects their own risk.

How Uncertainty Influences Lay People's Attitudes and Risk Perceptions Concerning Predictive Genetic Testing and Risk Communication

The interpretation of genetic information in clinical settings raises moral issues about adequate risk communication and individual responsibility about one's health behavior. However, it is not well-known what role numeric probabilities and/or the conception of disease and genetics play in the lay understanding of predictive genetic diagnostics. This is an important question because lay understanding of genetic risk information might have particular implications for self-responsibility of the patients. Aim: Analysis of lay attitudes and risk perceptions of German lay people on genetic testing with a special focus on how they deal with the numerical information. Methods: We conducted and analyzed seven focus group discussions (FG) with lay people (n = 43). Results: Our participants showed a positive attitude toward predictive genetic testing. We identified four main topics: (1) Anumeric risk instead of statistical information; (2) Treatment options as a factor for risk evaluation; (3) Epistemic and aleatory uncertainty as moral criticism; (4) Ambivalence as a sign of uncertainty. Conclusion: For lay people, risk information, including the statistical numeric part, is perceived as highly normatively charged, often as an emotionally significant threat. It seems necessary to provide lay people with a deeper understanding of risk information and of the limitations of genetic knowledge with respect to one's own health responsibility.

Black and Minority Ethnic women's decision-making for risk reduction strategies after BRCA testing: Use of context and knowledge

Within the field of breast cancer care, women concerned about their family history are offered genetic testing and subsequent treatment options based on several factors which include but are not limited to personal and family cancer disease histories and clinical guidelines. Discussions around decision-making in genetics in Black and Minority Ethnic (BME) groups are rarely documented in literature, and information regarding interactions with genetics services is usually discussed and linked to lack of scientific knowledge. As such, counselling sessions based only on scientific and medical information miss out the many reasons participants consider in making health decisions, information which can be used to encourage BME women to engage in cancer genetics services. 10 BME women with a mixed personal and family history of breast and ovarian cancer backgrounds, were interviewed in a study exploring issues of knowledge about familial breast cancer syndromes, to understand how they created and used familial knowledge for health decisions, with a particular focus on attitudes towards risk reducing strategies. Study results show that our participants are not unique in the ways they make decisions towards the use of cancer genetics and risk reduction strategies and as such, there are no specific ethnically defined pathways for decision-making. Our participants demonstrated mixed biomedical, social and individual cultural reasons for their decision-making towards risk reduction surgeries and treatment options which are similar to women from different ethnicities and are individual rather than group-specific. Narratives about suspicion of scientific utility of genetic knowledge, the perceived predictive value of mutations for future cancers or the origin of mutations and family disease patterns feature heavily in how participants evaluated genetic information and treatment decisions. The diversity of results shows that our participants are interested in engaging with genetic information but use multiple sources for evaluating the extent of involvement in genetic services and the place of genetic information and treatment options for themselves and their families. Genetic information is considered within various bio-social scenarios before decision-making for risk reduction is undertaken. BME women are shown to undertake evaluative processes which clinicians are encouraged to explore for better patient support. Continuing to focus on links between superficial and un-representative meanings of ethnicity, ethnic identity and attitudes and behaviours by only searching for differences between ethnic groups, are unhelpful in further understanding how women from those diverse backgrounds make decisions towards risk reduction interventions. Future research must find ways of investigating and understanding populations in ways that are not focussed solely on ethnic differences but on how meaning is created out of social circumstances and experiences.

Views of Low-Income Women of Color at Increased Risk for Breast Cancer

Individual risk assessment (IRA) for breast cancer may increase adherence to risk-appropriate screening and prevention measures. However, knowledge gaps exist regarding how best to communicate IRA results and support women at increased risk in future health care decisions, in part because patients conceptualize and make meaning of risk differently from the medical community. Better understanding the views of low-income women of color identified as being at increased risk for breast cancer can inform efforts to conduct IRA in an ethical and respectful manner. We conducted in-depth interviews with 13 low-income African American and Latina women who receive care at a federally qualified health center (FQHC) and had recently learned of their increased risk for breast cancer. These interviews explored their experience of the IRA process, their interpretation of what being at increased risk means, and their reactions to provider recommendations. Eight key themes were identified. We conclude with recommendations for the implementation of IRA for breast cancer in underserved primary care settings.

Influencing Cancer Screening Participation Rates-Providing a Combined Cancer Screening Program (a 'One Stop' Shop) Could Be a Potential Answer

Introduction

Participation in established cancer screening programs remains variable. Therefore, a renewed focus on how to increase screening uptake, including addressing structural barriers such as time, travel, and cost is needed. One approach could be the provision of combined cancer screening, where multiple screening tests are provided at the same time and location (essentially a ‘One Stop’ screening shop). This cohort study explored both cancer screening behavior and the acceptability of a combined screening approach.

Methods

Participants of the North Western Adelaide Health Study (NWAHS), South Australia were invited to participate in a questionnaire about cancer screening behaviors and the acceptability of a proposed ‘One Stop’ cancer screening shop. Data were collected from 10th August 2015 to 18th January 2016, weighted for selection probability, age, and sex and analyzed using descriptive and multivariable logistic regression analysis.

Results

1,562 people, 52% female (mean age 54.1 years ± 15.2) participated. Reported screening participation was low, the highest being for Pap Smear (34.4%). Common reasons for screening participation were preventing sickness (56.1%, CI 53.2–59.0%), maintaining health (51%, CI 48–53.9%), and free program provision (30.9%, CI 28.2–33.6%). Females were less likely to state that screening is not beneficial [OR 0.37 (CI 0.21–0.66), p < 0.001] and to cite sickness prevention [OR 2.10 (CI 1.46–3.00), p < 0.001] and free program [OR 1.75 (CI 1.22–2.51), p < 0.003] as reasons for screening participation. Of those who did not participate, 34.6% (CI 30.3–39.1%) stated that there was nothing that discouraged them from participation, with 55- to 64-year olds [OR 0.24 (CI 0.07–0.74), p < 0.04] being less likely to cite this reason. 21% (CI 17.2–24.8%) thought they did not need screening, while a smaller proportion stated not having time (6.9%, CI 4.9–9.7%) and the costs associated with screening (5.2%, CI 3.5–7.7%). The majority of participants (85.3%, CI 81.9–88.2%) supported multiple screening being offered at the same time and location.

Conclusion

Identified screening behaviors in this study are similar to those reported in the literature. The high support for the concept of combined cancer screening demonstrates that this type of approach is acceptable to potential end users and warrants further investigation.

'Why worry about something you can't control?' Negotiated risk, longevity and health behaviours

While we know about lay attitudes towards death and dying, we understand little about the ways people estimate their overall personal risk of life-limiting disease and/or death. This study contributes to the limited literature on lay longevity reckonings, with a particular focus on how these reckonings may influence health behaviours. Semi-structured interviews were held with 21 young older adults (54-65 years), addressing the core questions of 'What do you think you will die from, and how long do you expect to live?' Participants indicated their longevity estimation was guided by three key frameworks: family history, environment and lifestyle factors and lived experience. The reckoning process was also moderated by assumptions about loci of control and self-efficacy and the information available to participants. A tripartite model of death risk assessment is proposed, extending the idea of 'negotiated risk' beyond the scope of family history where it has received most attention. We argue that by drawing on the three risk-assessment frameworks, determining patients' predisposition for external/internal attributions of control and perceptions of self-efficacy, clinicians will be better equipped to understand - and thus guide - patients' reckonings of longevity and health behaviours that are influenced by it.

GP-patient communication about possible cancer in primary care: Re-evaluating GP as gatekeeper

As possibilities for the early detection of indolent cancers, and precursors to cancer, multiply, GPs will increasingly be involved in discussions with patients about risks and benefits of early diagnosis and treatment. Over time, improvements in evidence may decrease uncertainty about outcomes for patients and clinicians. However, where survival benefits are small, or uncertain, or risks are unacceptable to patients, grounds for preference-sensitive decision-making will remain. How risks and benefits of early detection, and the significance of indolent or low risk cancers, are communicated, will be key, if overtreatment and overdiagnosis are to be avoided.

Family-building After Breast Cancer: Considering the Effect on Adherence to Adjuvant Endocrine Therapy

Adherence to endocrine therapy (ET) is a longstanding problem in breast cancer (BC) survivorship care, particularly among younger women. Younger patients have reported lower ET initiation rates and greater rates of early discontinuation and are considered an "at risk" group for nonadherence. For women who hope to have children in the future, concerns about premature menopause and the implications of postponing childbearing for the 5 to 10 years of ET are widespread. Preliminary evidence suggests that prioritizing fertility, along with concerns about side effects, leads to ET noninitiation and early discontinuation. Clinical efforts to improve adherence might need to consider patients' family-building goals during the course of treatment and to appropriately counsel patients according to their priorities and family-building intentions. Educational materials about family building after cancer are still not consistently available or provided. Helping patients to access trusted informational resources and decision support tools, in conjunction with medical counseling, will promote informed decisions regarding ET adherence and pregnancy that are medically appropriate. Such shared patient-provider decision-making about ET adherence and pregnancy could help to maximize patient autonomy by incorporating their values, preferences, and priorities into decisions, using providers' medical expertise.

Public awareness of the link between alcohol and cancer in England in 2015: a population-based survey

BACKGROUND

Public knowledge of the association between alcohol and cancer is reported to be low. We aimed to provide up-to-date evidence for England regarding awareness of the link between alcohol and different cancers and to determine whether awareness differs by demographic characteristics, alcohol use, and geographic region.

METHODS

A representative sample of 2100 adults completed an online survey in July 2015. Respondents were asked to identify which health outcomes, including specific cancers, may be caused by alcohol consumption. Logistic regressions explored whether demographic, alcohol use, and geographic characteristics predicted correctly identifying alcohol-related cancer risk.

RESULTS

Unprompted, 12.9% of respondents identified cancer as a potential health outcome of alcohol consumption. This rose to 47% when prompted (compared to 95% for liver disease and 73% for heart disease). Knowledge of the link between alcohol and specific cancers varied between 18% (breast) and 80% (liver). Respondents identified the following cancers as alcohol-related where no such evidence exists: bladder (54%), brain (32%), ovarian (17%). Significant predictors of awareness of the link between alcohol and cancer were being female, more highly educated, and living in North-East England.

CONCLUSION

There is generally low awareness of the relationship between alcohol consumption and cancer, particularly breast cancer. Greater awareness of the relationship between alcohol and breast cancer in North-East England, where a mass media campaign highlighted this relationship, suggests that population awareness can be influenced by social marketing.

Cancer beliefs in ethnic minority populations: a review and meta-synthesis of qualitative studies

People from ethnic minorities often experience poorer cancer outcomes, possibly due to later presentation to healthcare and later diagnosis. We aimed to identify common cancer beliefs in minority populations in developed countries, which can affect symptom appraisal and help seeking for symptomatic cancer. Our systematic review found 15 relevant qualitative studies, located in the United Kingdom (six), United States (five), Australia (two) and Canada (two) of African, African-American, Asian, Arabic, Hispanic and Latino minority groups. We conducted a meta-synthesis that found specific emotional reactions to cancer, knowledge and beliefs and interactions with healthcare services as contributing factors in help seeking for a cancer diagnosis. These findings may be useful to inform the development of interventions to facilitate cancer diagnosis in minority populations.

Living under a cloud of threat: the experience of Iranian female caregivers with a first-degree relative with breast cancer

BACKGROUNDS

Breast cancer is a global threat to all women, especially those having close relatives with breast cancer. Women who were caregivers to relatives with breast cancer are more vulnerable to stress caused by the perception of heightened risk of cancer. Because health measures and breast health are affected by cultural beliefs and social status, information about breast cancer should consider the cultural beliefs and values of the society.

OBJECTIVES

This study explored the experiences of Iranian women who were caregivers to relatives with breast cancer.

METHODS

In this qualitative content analysis study, 21 female caregivers of breast cancer patients were chosen by purposive sampling. Data were collected through interviews and analyzed using content analysis.

RESULTS

Data analysis developed 3 categories: perception of the concept of risk, changing views about femininity, and management of perceived threat. Perception of the risk of breast cancer increased in caregivers, and they tried to manage the perceived threat. They considered the breast to be an important part of women's lives, and breast cancer in relatives changed their view of femininity.

CONCLUSION

Understanding the experiences of breast cancer family caregivers in different cultures can help in planning, counseling, and effective intervention.

Family-clinician interactions in children's health services: a secondary analysis of occupational therapists' practice descriptions

BACKGROUND

Effective family-clinician interactions are important for good health outcomes. Two types of interactions are consistently recommended: relational (e.g. listening, empathy, and respect) and participatory (e.g. shared decision-making, planning and problem-solving), but there is little specific guidance on how to implement these interactions in practice.

OBJECTIVE

To identify specific, practice-based examples of relational and participatory family-clinician interactions in children's occupational therapy.

DESIGN

A qualitative secondary analysis was used. The data consisted of a list of occupational therapists' self-reported practice actions (n = 217) and direct quotes describing their content and context. The practice actions were categorized into a range of relational and participatory family-centred interactions using a modified framework analysis.

RESULTS

Of the 217 practice actions, the majority [121 (55.76%)] did not describe examples of therapists implementing family-clinician interactions. Of the remaining practice actions, 19 (8.76%) described 'relational' interactions (e.g. 'Listen to carer', 'Gather perspectives from others'); 47 (21.66%) described 'participatory' interactions (e.g. 'Identify the family's goals and priorities', 'Allow the family to choose'); 2 (0.92%) described both ('Take guidance from carers'); and 28 (12.9%) were excluded from the analysis.

DISCUSSION AND CONCLUSIONS

A range of relational and participatory interactions were identified. Descriptions of participatory interactions were more frequent than descriptions of relational interactions, and overall the therapists described their family-clinician interactions less frequently than their other practice actions. The specific, real-life examples of different types of interactions identified in the study can be used as a basis for reflection on practice and developing more specific guidance.

A systematic review of low back pain and sciatica patients' expectations and experiences of health care

BACKGROUND CONTEXT

Previous systematic reviews of patients' experience of health services have used mixed qualitative and quantitative studies. This review focused on qualitative studies, which are more suitable for capturing experience, using modern methods of synthesis of qualitative studies.

PURPOSE

To describe the experience of health care of low back pain and sciatica patients and the sources of satisfaction or dissatisfaction with special reference to patients who do not receive a diagnosis.

STUDY DESIGN

A systematic review of qualitative studies.

SAMPLE

Primary qualitative studies identified from Medline, Embase, CINAHL, and Psychinfo databases.

OUTCOME MEASURES

Conceptual themes of patients' experiences.

METHOD

Data collection and analysis were through thematic content analysis. Two reviewers independently screened titles and collected and analyzed data. The authors were in receipt of a Primary Care Research Bursary from National Health Service Suffolk and Norfolk Research Departments, a not-for-profit organization.

RESULTS

Twenty-eight articles met the inclusion criteria. Most studies were of high quality. Nine themes emerged: the process and content of care, relationships and interpersonal skills, personalized care, information, the outcome of care, the importance of a diagnosis, delegitimation, recognizing the expert, and service matters. How care was given mattered greatly to patients, with importance given to receiving a perceived full assessment, consideration for the individual's context, good relationships, empathy, and the sharing of information. These aspects of care facilitated the acceptance by some of the limitations of health care and were spread across disciplines. Not having a diagnosis made coping more difficult for some but for others led to delegitimation, a feeling of not being believed. Service matters such as cost and waiting time received little mention.

CONCLUSIONS

Although much research into the development of chronic low back pain (LBP) has focused on the patient, this review suggests that research into aspects of care also warrant research. The benefits of generic principles of care, such as personalization and communication, are important to patients with LBP and sciatica; so, practitioners may help their patients by paying as much attention to them as to specific interventions. When neither cure nor a diagnostic label is forthcoming, generic skills remain important for patient satisfaction.

Understanding the needs of women considering risk-reducing salpingo-oophorectomy

BACKGROUND

Because of the significantly increased lifetime risk of ovarian cancer associated with inheritance of a germline mutation in the BRCA1/2 genes, women with a deleterious mutation are recommended to undergo risk-reducing salpingo-oophorectomy at age 35 years or once child-bearing is complete. Significant time is often spent by nurses trained in genetics providing counseling to improve the decision-making process. The decision to undergo surgery is complex and laden with several sources of uncertainty.

OBJECTIVE

We conducted a qualitative study among female carriers of deleterious BRCA1/2 mutations to address these uncertainties.

METHODS

Twelve qualitative interviews were conducted with women who had received a positive BRCA1/2 test result to explore their understanding of ovarian cancer risk, prevention options, and resource needs. Qualitative content analysis was performed.

RESULTS

Significant information gaps in level of risk, other factors associated with ovarian cancer, and details of prophylactic oophorectomy were identified. Personal experience with cancer colored the degree of risk perception associated with the inherited mutation. Fear of the adverse effects of surgical menopause, both physiological and psychosocial, was common. Women expressed interest in hearing from other women facing the same decision.

CONCLUSIONS

Women facing the decision to undergo risk-reducing salpingo-oophorectomy have several information gaps and unmet needs despite comprehensive counseling.

IMPLICATIONS FOR PRACTICE

Based on our findings, we make specific recommendations that will guide nursing practice and future research.

Canadian adolescents' perspectives of cancer risk: a qualitative study

Research examining adolescents' understandings of cancer and cancer risk is limited. Accordingly, we conducted an ethnographic study that sought to extend our limited understanding of Canadian adolescents' perspectives of cancer and cancer prevention including how adolescents conceptualize and understand cancer risk. This article addresses findings specific to adolescents' perspectives of cancer risk. Seventy-five adolescents (11–19 years old) took part in the study. Two individual open-ended interviews were planned for each adolescent with the second interview occurring 4 to 5 weeks after the first interview. The second interview was complemented by the use of photovoice. Four focus groups, composed of the adolescents who took part in the individual interviews, were also conducted. Data analysis involved both thematic and content analysis. Findings revealed that adolescents conceptualized cancer risk in terms of specific risk factors, with lifestyle factors (e.g., smoking, diet/nutrition and physical inactivity) dominating their discourse. Adolescents rationalized risky health behaviours through use of cognitive strategies that included questioning and evaluating risk information, considering the benefits costs of the cancer risk, and downplaying the impact of the cancer risk. Use of these cognitive strategies helped to make cancer risks more acceptable to adolescents. While adolescents felt that cancer could not always be prevented, they did feel it was possible for individuals to delay getting cancer by lowering the impact of cancer risks through making the right choices. Although more research in this area is needed, the findings from this study may help inform cancer prevention and risk communication programmes and policies.

Understanding the role of the volunteer in specialist palliative care: a systematic review and thematic synthesis of qualitative studies

BACKGROUND

Volunteers make a major contribution to palliative patient care, and qualitative studies have been undertaken to explore their involvement. With the aim of making connections between existing studies to derive enhanced meanings, we undertook a systematic review of these qualitative studies including synthesising the findings. We sought to uncover how the role of volunteers with direct contact with patients in specialist palliative care is understood by volunteers, patients, their families, and staff.

METHODS

We searched for relevant literature that explored the role of the volunteer including electronic citation databases and reference lists of included studies, and also undertook handsearches of selected journals to find studies which met inclusion criteria. We quality appraised included studies, and synthesised study findings using a novel synthesis method, thematic synthesis.

RESULTS

We found 12 relevant studies undertaken in both inpatient and home-care settings, with volunteers, volunteer coordinators, patients and families. Studies explored the role of general volunteers as opposed to those offering any professional skills. Three theme clusters were found: the distinctness of the volunteer role, the characteristics of the role, and the volunteer experience of the role. The first answers the question, is there a separate volunteer role? We found that to some extent the role was distinctive. The volunteer may act as a mediator between the patient and the staff. However, we also found some contradictions. Volunteers may take on temporary surrogate family-type relationship roles. They may also take on some of the characteristics of a paid professional. The second cluster helps to describe the essence of the role. Here, we found that the dominant feature was that the role is social in nature. The third helps to explain aspects of the role from the point of view of volunteers themselves. It highlighted that the role is seen by volunteers as flexible, informal and sometimes peripheral. These characteristics some volunteers find stressful.

CONCLUSIONS

This paper demonstrates how qualitative research can be sythnesised systematically, extending methodological techniques to help answer difficult research questions. It provides information that may help managers and service planners to support volunteers appropriately.

Can the theoretical domains framework account for the implementation of clinical quality interventions?

BACKGROUND

The health care quality improvement movement is a complex enterprise. Implementing clinical quality initiatives requires attitude and behaviour change on the part of clinicians, but this has proven to be difficult. In an attempt to solve this kind of behavioural challenge, the theoretical domains framework (TDF) has been developed. The TDF consists of 14 domains from psychological and organisational theory said to influence behaviour change. No systematic research has been conducted into the ways in which clinical quality initiatives map on to the domains of the framework. We therefore conducted a qualitative mapping experiment to determine to what extent, and in what ways, the TDF is relevant to the implementation of clinical quality interventions.

METHODS

We conducted a thematic synthesis of the qualitative literature exploring clinicians' perceptions of various clinical quality interventions. We analysed and synthesised 50 studies in total, in five domains of clinical quality interventions: clinical quality interventions in general, structural interventions, audit-type interventions, interventions aimed at making practice more evidence-based, and risk management interventions. Data were analysed thematically, followed by synthesis of these themes into categories and concepts, which were then mapped to the domains of the TDF.

RESULTS

Our results suggest that the TDF is highly relevant to the implementation of clinical quality interventions. It can be used to map most, if not all, of the attitudinal and behavioural barriers and facilitators of uptake of clinical quality interventions. Each of these 14 domains appeared to be relevant to many different types of clinical quality interventions. One possible additional domain might relate to perceived trustworthiness of those instituting clinical quality interventions.

CONCLUSIONS

The TDF can be usefully applied to a wide range of clinical quality interventions. Because all 14 of the domains emerged as relevant, and we did not identify any obvious differences between different kinds of clinical quality interventions, our findings support an initially broad approach to identifying barriers and facilitators, followed by a "drilling down" to what is most contextually salient. In future, it may be possible to establish a model of clinical quality policy implementation using the TDF.

Ambivalence and its influence on participation in screening for colorectal cancer

Colorectal cancer (CRC) is one of the most prevalent cancers worldwide, and an ideal target for early detection and prevention through cancer screening. Unfortunately, rates of participation in screening are less than adequate. In this article we explore why people who were offered a fecal immunochemical test for CRC decided to participate or not, and for those who did participate, what influenced them to take action and complete the test. We conducted four focus groups and 30 telephone interviews with 63 people. The main reason people decided to screen was "wanting to know" their CRC status, which operated on a continuum ranging from wanting to know, through varying degrees of ambivalence, to not wanting to know. The majority of participants expressed ambivalence about CRC screening, and the main cue to action was the opportunity to screen without being too inconvenienced.

Support after the completion of cancer treatment: perspectives of Australian adolescents and their families

Young people recovering from cancer may lack adequate support post-treatment, yet little is known about the types of support and information young Australians and their families need. This study investigated adolescent/young adult cancer survivors' and their families' perceptions of care and support needs after completing cancer treatment. Seventy semi-structured interviews were conducted with 19 survivors (mean age 16.1 years), 21 mothers, 15 fathers and 15 siblings. Interviews were recorded, transcribed and analysed using the conceptual framework of Miles and Huberman. Post-treatment, participants regarded medical staff positively but were reluctant to ask for their help fearing it may deflect resources away from patients still receiving treatment. Appraisals of social workers' and psychologists' support post-treatment were mixed. Formal emotional support was rarely accessed and participants reported that any additional funds should be directed to greater psychological support in this period. Participants also reported the need for additional financial support post-treatment. Clinicians need to be aware that while young people and their families may not demand support post-treatment, they may 'suffer in silence' or burden family members and friends with the responsibility of providing emotional support, though they may be experiencing distress also.

A second chance: meanings of body weight, diet, and physical activity to women who have experienced cancer

OBJECTIVE

To understand the meanings of diet, physical activity, and body weight in the context of women's cancer experiences.

DESIGN

Grounded theory using 15 qualitative interviews and 3 focus groups.

SETTING

Grassroots community cancer organizations in the northeastern United States.

PARTICIPANTS

Thirty-six white women cancer survivors; 86% had experienced breast cancer.

MAIN OUTCOME MEASURES

Participants' views of the meanings of body weight, diet, and physical activity in the context of the cancer.

ANALYSIS

Procedures adapted from the constant comparative method of qualitative analysis using iterative open coding.

RESULTS

Themes emerged along 3 intersecting dimensions: vulnerability and control, stress and living well, and uncertainty and confidence. Diet and body weight were seen as sources of increased vulnerability and distress. Uncertainty about diet heightened distress and lack of control. Physical activity was seen as a way to regain control and reduce distress.

CONCLUSIONS AND IMPLICATIONS

Emergent themes of vulnerability-control, stress-living well, and uncertainty-confidence may aid in understanding and promoting health behaviors in the growing population of cancer survivors. Messages that resonated with participants included taking ownership over one's body, physical activity as stress reduction, healthy eating for overall health and quality of life, and a second chance to get it right.

In search of the cancer candidate: can lay epidemiology help?

First published in 1991, the ideas embedded in 'Lay epidemiology and the prevention paradox' offered a novel and rational explanation for the lay public's failure to fully engage with the lifestyle messages offered by health educators. During the course of a large ethnographic study in South Wales, Davison and colleagues described the emergence of what they termed the coronary candidate. Candidacy provides a 'cultural mechanism' that facilitates the estimation of risk for coronary heart disease. The model has rarely been applied to other major illnesses. This article presents findings from a study that sought to explore the lay epidemiology model, candidacy and cancer. In a series of in-depth individual interviews, members of the lay public discussed their ideas about cancer, and what emerged was an explanatory hierarchy to account for cancer events. Yet the random and unpredictable nature of cancer was emphasised as well as a general reluctance to accept the idea of cancer candidacy.

Constructing a questionnaire for assessment of awareness and acceptance of diversity in healthcare institutions

Background

To develop a healthcare environment that is congruent with diversity among care providers and care recipients and to eliminate ethnic discrimination, it’s important to map out and assess caregivers’ awareness and acceptance of diversity. Because of a lack of standardized questionnaires in the Swedish context, this study designed and standardized a questionnaire: the Assessment of Awareness and Acceptance of Diversity in Healthcare Institutions (AAAD, for short).

Method

The questionnaire was developed in four phases: a comprehensive literature review, face and content validity, construct validity by factor analysis, and a reliability test by internal consistency and stability assessments.

Results

Results of different validity and reliability analyses suggest high face, content, and construct validity as well as good reliability in internal consistency (Cronbach’s alpha: 0.68 to 0.8) and stability (test-retest: Spearman rank correlation coefficient: 0.60 to 0.76). The result of the factor analysis identified six dimensions in the questionnaire: 1) Attitude toward discrimination, 2) Interaction between staff, 3) Stereotypic attitude toward working with a person with a Swedish background, 4) Attitude toward working with a patient with a different background, 5) Attitude toward communication with persons with different backgrounds, 6) Attitude toward interaction between patients and staff.

Conclusion

This study introduces a newly developed questionnaire with good reliability and validity values that can assess healthcare workers’ awareness and acceptance of diversity in the healthcare environment and healthcare delivery.

A cluster-randomised, parallel group, controlled intervention study of genetic prostate cancer risk assessment and use of PSA tests in general practice--the ProCaRis study: study protocol

INTRODUCTION

Unsystematic screening for prostate cancer (PCa) is common, causing a high number of false-positive results. Valid instruments for assessment of individual risk of PCa have been called for. A DNA-based genetic test has been tested retrospectively. The clinical use of this test needs further investigation. The primary objective is to evaluate the impact on the use of prostate-specific antigen (PSA) tests of introducing genetic PCa risk assessment in general practice. The secondary objectives are to evaluate PCa-related patient experiences, and to explore sociocultural aspects of genetic risk assessment in patients at high PCa risk.

METHODS AND ANALYSIS

The study is a cluster-randomised, controlled intervention study with practice as the unit of randomisation. We expect 140 practices to accept participation and include a total of 1244 patients in 4 months. Patients requesting a PSA test in the intervention group practices will be offered a genetic PCa risk assessment. Patients requesting a PSA test in the control group practices will be handled according to current guidelines. Data will be collected from registers, patient questionnaires and interviews. Quantitative data will be analysed according to intention-to-treat principles. Baseline characteristics will be compared between groups. Longitudinal analyses will include time in risk, and multivariable analysis will be conducted to evaluate the influence of general practitioner and patient-specific variables on future PSA testing. Interview data will be transcribed verbatim and analysed from a social-constructivist perspective.

ETHICS AND DISSEMINATION

Consent will be obtained from patients who can withdraw from the study at any time. The study provides data to the ongoing conceptual and ethical discussions about genetic risk assessment and classification of low-risk and high-risk individuals. The intervention model might be applicable to other screening areas regarding risk of cancer with identified genetic components, for example, colon cancer. The study is registered at the ClinicalTrials.gov (Identifier: NCT01739062).

Genetic and lifestyle causal beliefs about obesity and associated diseases among ethnically diverse patients: a structured interview study

BACKGROUND

New genetic associations with obesity are rapidly being discovered. People's causal beliefs about obesity may influence their obesity-related behaviors. Little is known about genetic compared to lifestyle causal beliefs regarding obesity, and obesity-related diseases, among minority populations. This study examined genetic and lifestyle causal beliefs about obesity and 3 obesity-related diseases among a low-income, ethnically diverse patient sample.

METHODS

Structured interviews were conducted with patients attending an inner-city hospital outpatient clinic. Participants (n=205) were asked how much they agreed that genetics influence the risk of obesity, type 2 diabetes, heart disease, and cancer. Similar questions were asked regarding lifestyle causal beliefs (overeating, eating certain types of food, chemicals in food, not exercising, smoking). In this study, 48% of participants were non-Hispanic Black, 29% Hispanic and 10% non-Hispanic White.

RESULTS

Over two-thirds (69%) of participants believed genetics cause obesity 'some' or 'a lot', compared to 82% for type 2 diabetes, 79% for heart disease and 75% for cancer. Participants who held genetic causal beliefs about obesity held more lifestyle causal beliefs in total than those who did not hold genetic causal beliefs about obesity (4.0 vs. 3.7 lifestyle causal beliefs, respectively, possible range 0-5, p=0.025). There were few associations between causal beliefs and sociodemographic characteristics.

CONCLUSIONS

Higher beliefs in genetic causation of obesity and related diseases are not automatically associated with decreased lifestyle beliefs. Future research efforts are needed to determine whether public health messages aimed at reducing obesity and its consequences in racially and ethnically diverse urban communities may benefit from incorporating an acknowledgement of the role of genetics in these conditions.

Enhancing transparency in reporting the synthesis of qualitative research: ENTREQ

BACKGROUND

The syntheses of multiple qualitative studies can pull together data across different contexts, generate new theoretical or conceptual models, identify research gaps, and provide evidence for the development, implementation and evaluation of health interventions. This study aims to develop a framework for reporting the synthesis of qualitative health research.

METHODS

We conducted a comprehensive search for guidance and reviews relevant to the synthesis of qualitative research, methodology papers, and published syntheses of qualitative health research in MEDLINE, Embase, CINAHL and relevant organisational websites to May 2011. Initial items were generated inductively from guides to synthesizing qualitative health research. The preliminary checklist was piloted against forty published syntheses of qualitative research, purposively selected to capture a range of year of publication, methods and methodologies, and health topics. We removed items that were duplicated, impractical to assess, and rephrased items for clarity.

RESULTS

The Enhancing transparency in reporting the synthesis of qualitative research (ENTREQ) statement consists of 21 items grouped into five main domains: introduction, methods and methodology, literature search and selection, appraisal, and synthesis of findings.

CONCLUSIONS

The ENTREQ statement can help researchers to report the stages most commonly associated with the synthesis of qualitative health research: searching and selecting qualitative research, quality appraisal, and methods for synthesising qualitative findings. The synthesis of qualitative research is an expanding and evolving methodological area and we would value feedback from all stakeholders for the continued development and extension of the ENTREQ statement.

Children's experiences of living with juvenile idiopathic arthritis: a thematic synthesis of qualitative studies

OBJECTIVE

To describe the experiences and perspectives of children and adolescents living with juvenile idiopathic arthritis (JIA).

METHODS

We conducted a systematic review of qualitative studies that explored the experiences of children living with JIA. We searched electronic databases (to week 2 of July 2011) and reference lists of relevant articles.

RESULTS

Twenty-seven studies that reported the experiences of more than 542 participants were included. Six major themes were identified: aversion to being different (unrelenting and unpredictable pain, disablement, internal disfigurement, differential treatment, and forced dependency on others); striving for normality (preserving social identity, resourcefulness, sense of community, focus on remission, and mastery over body and pain); stigma and misunderstanding (trivialization of disease, invisible pain, and discrimination); suspension in uncertainty (control versus powerlessness, hope versus disappointment); managing treatment (benefits of taking medicines, respect and involvement in health care, and motivation for physical therapy); and desire for knowledge (medical treatment and advances, lifestyle management).

CONCLUSION

JIA disrupts a child's sense of normality and impairs his or her capacity for social participation. Children with JIA have a sense of being misunderstood and stigmatized, and they feel perpetually caught between having hope and control over their bodies and overwhelming pain and despair. To increase their confidence, the ability to manage pain, and their resourcefulness for self-management, children need ongoing information about treatments and lifestyle management, strong social support, community advocacy, and active involvement in their own health decision making.

When the risks are high: psychological adjustment among melanoma survivors at high risk of developing new primary disease

In this study we explored the psychosocial experiences of melanoma survivors at high risk of developing new primary disease. A total of 20 survivors (9 men, 11 women, mean age 57.6 years) completed a semistructured telephone interview, exploring melanoma-related beliefs and experiences, psychological adjustment to melanoma risk, and supportive care needs. Participants perceived melanoma as potentially terminal and reported persistent worries about the possibility of developing new or metastatic disease. Fear of developing a new melanoma endured for years after treatment completion and, for some, created a pervasive sense of uncertainty. Still, not a single participant sought formal emotional support to address his or her melanoma-related concerns. Belief in the benefits of early intervention, including self- and clinical skin examination, provided a sense of control and a recommended course of action in an otherwise uncontrollable situation. The expertise of the High Risk Clinic physicians was perceived as instrumental in creating a sense of reassurance.

Family information needs at childhood cancer treatment completion

BACKGROUND

Despite the recognized importance of information provision across the cancer trajectory, little research has investigated family information needs recently after childhood cancer. This mixed-methods, multiperspective, study explored the information needs of families of childhood cancer survivors in the first year post-treatment.

PROCEDURE

In total, 112 semi-structured telephone interviews were conducted with 19 survivors (mean age 16.2 years, off treatment for ≤36 months), 44 mothers, 34 fathers, and 15 siblings. Interviews were analyzed inductively, line-by-line, using the framework of Miles and Huberman. Emergent themes were cross-tabulated by sample characteristics using QSR NVivo8.

RESULTS

Participant views were mixed regarding the need for a "finishing treatment review" with their oncologist (the primary information source for most families); however, many mothers (29/44) and fathers (17/34) and most siblings (14/15) reported receiving insufficient information post-treatment. Information regarding fertility and how to prepare for likely post-treatment challenges were the most cited unmet needs. Online support was ranked highest by survivors (mean score: 7/2/10) and siblings (7.4/10), whilst parents preferred an information booklet (often due to concerns about accessing accurate and relevant information from the Internet). While many participants reported feelings of isolation/loneliness, many were reluctant to attend face-to-face support groups/seminars.

CONCLUSIONS

Family members of survivors may experience the most acute unmet needs for information about fertility and in preparation for post-treatment challenges. However, provision of the correct amount of information at the right time for each family member during a highly stressful period remains clinically challenging.

The salience of existential concerns across the cancer control continuum

Despite significant improvement in cancer survival, the fear of death still remains rooted in individuals' beliefs about cancer. Existential fears pertaining to cancer cut across the cancer control continuum and taint decisions related to prevention, screening, surveillance, and follow-up recommendations, as well as the overall management of cancer-related issues. However, individuals are innately predisposed to cope with their cancer-related fears through mechanisms such as reliance on the process of meaning making. To better appreciate the potential impact of existential concerns across the cancer control continuum, the Temporal Existential Awareness and Meaning Making (TEAMM) model is proposed. This tripartite model depicts three types of perceived threats to life related to cancer including a “social awareness” (i.e., cancer signals death), “personalized awareness” (i.e., I could die from cancer), and the “lived experience” (i.e., It feels like I am dying from cancer). This construal aims to enhance our understanding of the personal and contextual resources that can be mobilized to manage existential concerns and optimize cancer control efforts. As such, existential discussions should be considered in any cancer-related supportive approach whether preventive, curative, or palliative, and not be deferred only until the advanced stages of cancer or at end of life. Further delineation and validation of the model is needed to explicitly recognize and depict how different levels of existential awareness might unfold as individuals grapple with a potential, actual, or recurrent cancer.

'Worse than HIV' or 'not as serious as other diseases'? Conceptualization of cervical cancer among newly screened women in Zambia

Invasive cervical cancer is the second most common cancer among women worldwide, with approximately 85% of the disease burden occurring in developing countries. To date, there have been few systematic efforts to document African women's conceptualization of cervical cancer after participation in a visual inspection with acetic acid (VIA)-based "see and treat" cervical cancer prevention program. In this study, conducted between September, 2009-July, 2010, focus groups and in-depth interviews were conducted with 60 women who had recently undergone cervical cancer screening at a government-operated primary health care clinic in Lusaka, Zambia. Interviewers elicited participants' causal representations of cervical cancer, associated physical signs and symptoms, perceived physical and psychological effects, and social norms regarding the disease. The lay model of illness causation portrayed by participants after recent exposure to program promotion messages departed in several ways from causal models described in other parts of the world. However, causal conceptualizations included both lay and biomedical elements, suggesting a possible shift from a purely traditional causal model to one that incorporates both traditional concepts and recently promoted biomedical concepts. Most, but not all, women still equated cervical cancer with death, and perceived it to be a highly stigmatized disease in Zambia because of its anatomic location, dire natural course, connections to socially-condemned behaviors, and association with HIV/AIDS. No substantive differences of disease conceptualization existed according to HIV serostatus, though HIV positive women acknowledged that their immune status makes them more aware of their health and more likely to seek medical attention. Further attention should be dedicated to the processes by which women incorporate new knowledge into their representations of cervical cancer.

Life after cancer: living with risk

BACKGROUND

Recent research shows that cancer survivors are at greater risk of developing cancer than the general population. Although recommended, many cancer survivors receive no regular cancer screening. Cancer survivors' perceptions of their second cancer risk are, in part, suspected to influence their participation in cancer screening.

OBJECTIVE

This study was conducted to explore how cancer survivors define and interpret second cancer risk.

METHODS

An interpretive descriptive approach was taken whereby semistructured interviews were conducted with 22 cancer survivors (16 women and 6 men) drawn from a provincial cancer registry. The sample ranged in age from 19 to 87 years. The cancer history of the participants varied. Data were analyzed using the constant comparative method of data analysis.

RESULTS

The overall theme, "life after cancer-living with risk," described cancer survivors' sense that risk is now a part of their everyday lives. Two themes emerged from the data that speak to how cancer survivors lived with second cancer risk: (1) thinking about second risk and (2) living with risk: a family affair.

CONCLUSIONS

Effective risk communication to support the decisions made by cancer survivors with respect to cancer screening is warranted.

IMPLICATIONS FOR PRACTICE

Study results provide foundational knowledge about the nature of second cancer risk that may be used to develop and refine standards for survivorship care including how second cancer risk can be best managed.

Lifestyle risk management--a qualitative analysis of women's descriptions of taking hormone therapy following surgically induced menopause

AIM

This article is a report of a study that examined how women describe their decisions in relation to the use of menopausal hormone therapy following surgical menopause.

BACKGROUND

Women who have had a surgically induced menopause generally experience more intense menopausal symptoms than natural menopause and are regularly prescribed menopausal hormone therapy. Since 2002 the risks associated with this therapy have been widely reported.

METHOD

This study is a qualitative analysis of semi-structured interviews between March and May 2009 with 30 participants who had experienced surgical menopause and were, or had in the past, taken menopausal hormone therapy. This was a community sample recruited in Christchurch, New Zealand. A risk management theoretical approach underpinned the analysis.

FINDINGS

The womens' descriptions of managing the risks associated with menopausal therapy fell into two main themes: Life has to go on and Waiting for someone to tell me. All these women had either made an active decision to continue on treatment because of the impact of menopausal symptoms or took their doctor's advice to continue. A less dominant theme but one that was also evident was Relying on my body to get me through in which the women had decided to discontinue treatment because they regarded it as unnatural.

CONCLUSION

The study provided insights into how women utilize an experiential reasoning process to manage the health and lifestyle risks associated with taking menopausal hormone therapy. Nurses need to be aware of how this process influences women's reasoning processes when working with women following surgical menopause.

Examining risk perception among men with a family history of prostate cancer

OBJECTIVE

This paper explores factors that influence the formulation of risk perception among men with a family history of prostate cancer who are currently attending a prostate cancer screening clinic.

METHODS

Semi-structured interviews were conducted with fifteen participants. Interview transcripts were analyzed using interpretative phenomenological analysis.

RESULTS

The following themes were identified: Risk Information Pathways, Experience with Other Prostate Disease, Exposure to Prostate Cancer Screening, Exposure to Affected Relatives, Lifestyle Factors, Illness Beliefs, and Health-Based Risk Comparisons.

CONCLUSION

Understanding the contributors to risk perception and applying this knowledge during screening visits and genetic counselling may help to reduce risk distortion and result in increased adherence to screening programs and reduced psychological distress.

PRACTICE IMPLICATIONS

Prostate cancer screening should incorporate counselling to address patient-specific risk concepts in order to increase the accuracy and maintain the stability of risk perceptions.

How do women at increased, but unexplained, familial risk of breast cancer perceive and manage their risk? A qualitative interview study

Background

The perception of breast cancer risk held by women who have not had breast cancer, and who are at increased, but unexplained, familial risk of breast cancer is poorly described. This study aims to describe risk perception and how it is related to screening behaviour for these women.

Methods

Participants were recruited from a population-based sample (the Australian Breast Cancer Family Study - ABCFS). The ABCFS includes women diagnosed with breast cancer and their relatives. For this study, women without breast cancer with at least one first- or second-degree relative diagnosed with breast cancer before age 50 were eligible unless a BRCA1 or BRCA2 mutation had been identified in their family. Data collection consisted of an audio recorded, semi-structured interview on the topic of breast cancer risk and screening decision-making. Data was analysed thematically.

Results

A total of 24 interviews were conducted, and saturation of the main themes was achieved. Women were classified into one of five groups: don't worry about cancer risk, but do screening; concerned about cancer risk, so do something; concerned about cancer risk, so why don't I do anything?; cancer inevitable; cancer unlikely.

Conclusions

The language and framework women use to describe their risk of breast cancer must be the starting point in attempts to enhance women's understanding of risk and their prevention behaviour.

What factors do cancer patients believe contribute to the development of their cancer? (New South Wales, Australia)

OBJECTIVE

To analyze Australian cancer patients' beliefs about factors contributing to the development of their cancer.

METHODS

As part of a case-control study (The Cancer Council NSW Cancer, Lifestyle and Evaluation of Risk Study), a total of 2,857 cancer patients (open to all types of cancer) were surveyed and via an open-ended question, were asked to specify factors they think contributed to the development of their cancer. Qualitative analysis and categorical techniques were used to analyze the data.

RESULTS

About half, 53%, of patients specified at least one contributing factor. The odds of a person specifying a contributing factor increased with time period since diagnosis (p = 0.0006). Patients most frequently specified, respectively: "Stress" (15.4%), "Genetics/hereditary" (10.9%) and "Smoking" (6.2%). Among factors specified the largest proportion (24.1%) was perceived to be "Non-modifiable."

CONCLUSION

Cancer patients specified a broad range of factors and agents to which their disease may be attributed. Some of these were poorly correlated with epidemiological rankings of attributable risk factors. The role of psychosocial and genetic factors was overstated. Misconceptions regarding the causes of cancer are a key consideration of health professionals when devising communication strategies around cancer prevention.