Barriers to mental health service use among distressed family caregivers of lung cancer patients

Although family caregivers of patients with lung and other cancers show high rates of psychological distress, they underuse mental health services. This qualitative study aimed to identify barriers to mental health service use among 21 distressed family caregivers of lung cancer patients. Caregivers had not received mental health services during the patient's initial months of care at a comprehensive cancer centre in New York City. Thematic analysis of interview data was framed by Andersen's model of health service use and Corrigan's stigma theory. Results of our analysis expand Andersen's model by providing a description of need variables (e.g. psychiatric symptoms), enabling factors (e.g. finances), and psychosocial factors associated with caregivers' non-use of mental health services. Regarding psychosocial factors, caregivers expressed negative perceptions of mental health professionals and a desire for independent management of emotional concerns. Additionally, caregivers perceived a conflict between mental health service use and the caregiving role (e.g. prioritising the patient's needs). Although caregivers denied stigma associated with service use, their anticipated negative self-perceptions if they were to use services suggest that stigma may have influenced their decision to not seek services. Findings suggest that interventions to improve caregivers' uptake of mental health services should address perceived barriers.

Primary malignant brain tumor incidence and Medicaid enrollment

BACKGROUND

The relationship between socioeconomic status and health care disparities in the incidence of brain tumors is unclear.

OBJECTIVE

To identify the associations between age, sex, and Medicaid enrollment and the incidence of primary malignant brain tumors in Michigan in 1996 and 1997.

METHODS

Records were obtained from the Michigan Cancer Surveillance Program on the 1,006 incident cases during this period and cross-checked with Medicaid enrollment files.

RESULTS

Persons enrolled in Medicaid were more likely than non-enrolled persons to develop a malignant brain tumor of any type, a glioblastoma multiforme, and an astrocytoma for certain subgroups. In addition, incidence rates for malignant brain tumors in persons enrolled in Medicaid peaked at a younger age.

CONCLUSION

Sociodemographic status may be associated with cerebral malignancy and should be considered when targeting treatment and educational interventions at persons at risk.

Research design and subject characteristics predicting nonparticipation in a panel survey of older families with cancer

BACKGROUND

While recognized that loss of subjects over time may introduce bias and complicate statistical analysis in panel studies, it is seldom acknowledged that sampling bias starts with subjects who are eligible but do not participate.

OBJECTIVES

Community-based recruiters identified 1,948 subjects as eligible to participate in a descriptive panel survey of older families with cancer. Focusing on the time between identification of eligible subjects until contact for the first interview for consenting subjects, the purpose of this study was to determine if subject or research design factors predicted who was more prone to nonparticipation.

METHOD

A multivariate model explored the simultaneous effects of subject and research design characteristics on nonparticipation. Demographic and cancer characteristics, as well as features of the study protocol, were used as predictors in a multinomial logit regression model to enable a three-way comparison between nonconsenters (n = 748), consenters who dropped out prior to data collection (n = 208), and consenters who participated in the intake interview (n = 992).

RESULTS

Age and cancer diagnosis played roles in whether consent was obtained, whereas race did not affect consent but raised odds of drop out after consent. Powerful evidence emerged that design features, such as if a caregiver participated, recruitment staff roles, and payment to recruiters, affected the probability of subjects not participating or dropping out before being interviewed.

CONCLUSIONS

Findings suggest that both subject and research design characteristics affect the likelihood of nonparticipation in a panel study of older cancer patients and family caregivers. Future research involving testing of strategies addressing access and accrual issues, research staff roles, reimbursements, and responsiveness to the needs of research personnel, ill participants, and family members is warranted.

Improving depressive symptoms among caregivers of patients with cancer: results of a randomized clinical trial

PURPOSE/OBJECTIVES

Determine the impact of a 16-week supportive nursing intervention on caregivers of patients with newly diagnosed cancer.

DESIGN

Randomized clinical trial.

SETTING

Two midwestern cancer treatment sites.

SAMPLE

Caregivers of newly diagnosed patients. Patients' mean age was 55.73 years; 55% had breast cancer, and 76% were female. Caregivers' mean age was 52.44 years, and 50% were female. 125 dyads consented to participate; 89 dyads completed the study.

METHODS

A nursing intervention was delivered to the experimental group that emphasized symptom monitoring/management, education, emotional support, coordination of services, and caregiver preparation to care. Nurses made a total of nine contacts, five in person and four by telephone, over 16 weeks. Centers for Epidemiological Studies-Depression (CES-D) and a symptom inventory were used. Medical record audits were conducted retrospectively.

MAIN RESEARCH VARIABLES

Patient and caregiver depression scores and patient symptom experience.

FINDINGS

Baseline caregiver depression and the number of patient symptoms at baseline, 9, and 24 weeks were significant predictors of caregiver depression at 9 and 24 weeks. However, no main effect of the experimental condition existed on caregiver depression. At the final observation, a nonsignificant inverse relationship was found between the number of interventions and depression scores for caregivers.

CONCLUSIONS

The intervention appeared to be more effective in slowing the rate of deterioration of depressive symptoms than in decreasing levels of depression in this sample of caregivers. Determining the effectiveness of this intervention in decreasing caregiver depression was difficult because caregivers with higher levels of depression were more likely to withdraw from the study.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be vigilant in monitoring caregivers for signs of depression and must intervene to provide emotional support and make appropriate referrals for follow-up care to promote positive outcomes for patients and caregivers.

Family support in advanced cancer

Changes in the health care system have resulted in a shift of cancer care from the in-patient arena to ambulatory and home settings. This shift has likewise translated into increased family involvement in the day-to-day care of the person with cancer. Cancer patients have multifaceted needs, including disease and treatment monitoring, symptom management, medication administration, emotional support, assistance with personal care, and assistance with instrument care. Family caregivers may be ill prepared to assume these tasks, requiring information on the disease and treatment, as well as instruction in technical and care skills. Moreover, caregiving must be balanced against already established roles and role responsibilities. In addition, family caregivers have their own emotional responses to the patients' diagnosis and prognosis, and may require coaching and emotional support themselves. The health care system can facilitate positive outcomes by embracing the family caregiver as a partner in the health care team, providing instruction and guidance to the caregiver as he/she assumes this role, and evaluating the home care situation. Research to date has only scratched the surface of testing interventions that meet the needs of the cancer caregiver. A research agenda is proposed to more fully elucidate the cancer caregiver's experience throughout the illness and treatment trajectory, and identify the means to effecting positive outcomes for the person with cancer, their family caregiver, and the health care system.

Access to Hospice: A Perspective from the Bereaved

Access to hospice care continues to be an enigma. Hospice has been available for nearly three decades in the United States, but the services continue to be underutilized. In an effort to better understand access barriers, a series of focus groups were held with recently bereaved caregivers (mean = 9.9 months since the death of the patient). During the process of the focus group discussions, participants relived their experience with hospice. Although the purpose of this research was to ascertain access recommendations, participants integrated their access comments into the overall richness of their hospice experience. The 12 participants were divided into two groups, and each group met twice with a 2-week interval between sessions. From the focus group discussions, six themes emerged. Two of the six themes related to access issues: (1) societal and health system issues related to delayed hospice access and (2) education and practice needs of health professionals that affect hospice access. Participants provided recommendations to address the concerns expressed through both of these access themes.

Symptomatology and loss of physical functioning among geriatric patients with lung cancer

In this study of 129 geriatric patients with lung cancer, we investigated how symptom severity varied according to treatment type, stage of disease, and gender; how change in physical functioning (prediagnosis versus post-hospital discharge) was predicted by symptomatology, prior physical functioning, comorbidity, and age; and whether differences exist according to stage of disease, treatment status, or gender. Data were gathered through patient interviews and audits of patient records. Analysis of variance (ANOVA) techniques revealed that there were no significant differences in average symptom severity scores by gender, treatment categories, or stages of disease. Significant predictors of loss of physical functioning were symptom severity, prior physical functioning and patient age. Characteristics of a profile for elderly lung cancer patients at high risk of suffering substantial losses in physical functioning include higher prior levels of physical functioning, higher levels of current symptomatology, and lower age.

A profile of bereaved caregivers following provision of terminal care

Caregivers are often overwhelmed by the strain of terminal caregiving. We wished to better understand the needs of terminal caregivers and to supply a basis for tailoring interventions to them during caregiving and early bereavement. This report provides a profile of 124 bereaved caregivers interviewed within three months of their patient's death. Three quarters were female and married to the patient. Four major areas were assessed: psycho-spiritual, personal-social, health status, and financial status. Caregivers reported higher than average depressive symptomatology (mean CES-D = 17.6), moderate levels of positive outlook, low negative reactions to caring, and relatively high levels of spirituality. Caregivers were highly involved in their patient's activities of daily living, providing an average of 10.8 hours/day of direct care and 8.9 hours/day of companionship. Caregivers reported low utilization of health services and relatively high personal health status. 45% of the sample reported lower income since the patient's death and 44% reported out-of-pocket expenses not covered by insurance. Suggestions for interventions that target emotional, physical, and financial concerns are discussed.

Complementary Therapy Use Among Older Cancer Patients

PURPOSE

The purpose of this study was to assess the use of complementary therapies among older cancer patients, to report patterns of use, and to understand who is more likely to use complementary therapies.

DESCRIPTION OF STUDY

A survey was conducted of 699 older cancer patients at 4 weeks and 6 weeks into cancer treatment. All participants were 64 years of age or older, had received a diagnosis of breast, colorectal, prostate, or lung cancer, and were recruited from community cancer treatment centers throughout Michigan. Measures of interest included self-reported physical symptoms, depressive symptomatology, optimism, spirituality, and use of conventional and complementary health services.

RESULTS

Approximately 33% of older cancer patients reported using complementary therapies. These individuals were more likely to be women, to be breast cancer patients, and to have a higher level of education. The three most frequently used therapies were exercise, herbal therapy, and spiritual healing. Complementary therapy users were significantly more optimistic than nonusers. Also, there were significant differences between users and nonusers on types of physical symptoms experienced, but no differences on reported depressive symptomatology or spirituality.

CLINICAL IMPLICATIONS

Oncology providers need to be aware that one third of their older patients are likely to supplement conventional care with complementary therapies. Therefore, providers should be knowledgeable about the safety and efficacy, in particular, of various exercise programs, herbal and vitamin therapies, and spiritual healing. It would be beneficial to develop a system within cancer centers by which patients could easily report on their use of complementary therapies, allowing providers to work in partnership with their patients.

Breast cancer screening in rural populations: a pilot study

This report describes the development and implementation of a pilot intervention project designed to determine the economic, logistic, behavioral, and attitudinal variables that influence rural women's participation in a community-based breast cancer screening program. This paper reports on survey responses of women who registered for this pilot breast cancer screening program. It includes information on all women who registered for the project--both those who received breast cancer screening and those who did not. The study is a pilot intervention project, the overall goal of which was to develop a network of community providers, organizations, and volunteers to facilitate breast cancer screening among rural women. Of the 159 women registered for this pilot program, 101 (63.5%) were screened (receiving both a clinical breast examination and mammogram). The attitudes of women surveyed through the project confirm the importance of a physician recommendation for breast cancer screening. More than 90 percent of both the screened and unscreened groups of women stated that a doctor's recommendation to have breast cancer screening is important. Further, nearly 42 percent of the unscreened group had never had a physician recommend breast cancer screening. Despite existing barriers to screening, this pilot study demonstrated that health care professionals and regional organizations that have not traditionally been associated with delivering health care in this particular community setting can successfully work together to implement breast cancer screening programs.

The impact of new demands for assistance on caregiver depression: tests using an inception cohort

Family caregivers of patients facing high numbers of new demands for assistance following hospital discharge were more likely to experience increased levels of depression in the following six months compared with caregivers facing similar overall demands but few new demands for assistance following hospital discharge. New demands for assistance had a significant independent effect upon the levels of depression and were independent of family relationship (spouse vs nonspouse) and caregiver gender. These findings provide insight into theories of caregiver stress, begin to specify the interaction of time following the onset of a stressful event and caregivers' subsequent reactions, and suggest which caregivers may require some assistance following discharge of their patients.

Computerized documentation for a rural nursing intervention project

The Rural Partnership Linkage for Cancer Care project is a program of advanced practice nursing care made available to rural cancer patients to provide education, symptom management, referral, and support within their communities. The advanced practice nurses used a computerized clinical information system (CCIS) to record care. In this article the CCIS is described, the software and hardware requirements are discussed, and the outcomes and value of the system are discussed. The CCIS is a relational database run on laptop computers that includes screens for standard recording of demographics, physical exam, symptoms, and treatments. The advanced practice nurses track patient symptoms over time, noting which treatments are successful in resolving or reducing the problems. Information from patient visits is selected by help menus for inclusion into referral forms, reports of patient care, and discharge summaries. Reports can be faxed or mailed to distant sites. The research team uses the combined data set to examine symptom patterns, nursing diagnosis, and treatments that result in improved physical and psychological functioning and symptom resolution. Rural cancer patients and their families benefit from care management, participation in research, and communication of patient health status in an integrated and timely fashion made possible by the CCIS.

Health promotion for family caregivers of chronically ill elders

Previous research has focused almost exclusively on the burden and the negative effects of caregiving on the primary caregivers of the chronically ill. This prior research has provided a backdrop for understanding the psychological and physical challenges that caregiving incurs. Missing from past research, however, is any focus on the health promotion strategies of this caregiving population. Although some literature focuses on the psychological well-being, few articles deal with the physical health status of caregivers. Fewer yet describe the health promotion strategies that caregivers use to maintain their health. The chapter reviews existing literature regarding health promotion activities of primary caregivers in the context of articles focused on the psychological and physical health status of caregivers. Health promotion strategies will be discussed, as will recommendations for future research in this topic area.

Determinants of family care giver reaction. New and recurrent cancer

PURPOSE

The authors examined the interaction of patient and care giver variables and identified whether changes in new and recurrent patients' levels of symptoms, functioning, and depression were related to changes in care givers' reactions to providing care.

DESCRIPTION OF STUDY

During a 6-month observation period, the psychosocial status and burden of a matched sample of patients with either new or recurrent cancer and their family care givers were assessed and compared.

RESULTS

Care givers of patients with recurrent disease experienced a marginally significantly different impact on depression over time. The type of disease (new or recurrent) did not impact care givers reactions to the care they were providing for patients. Instead, patients' symptoms and symptom experience incurred a greater impact on care giver depression.

CLINICAL IMPLICATIONS

The impact of cancer on patients and family care givers must be evaluated carefully and thoroughly, regardless of whether the diagnosis is new or recurrent. Patients' symptoms and symptom experience, mobility, and dependencies in instrumental activities of daily living are primary influences in creating emotional burden and depression in the family care giver of the patient diagnosed with new and with recurrent cancer.

Establishing a collaborative practice in a comprehensive breast clinic

BREAST CANCER IN women is a major health concern due to the high prevalence of subtle changes in breast tissue that are difficult to diagnose. Consequently, women require information about benign and malignant breast changes. Nurse practitioners (NPs) can play an important role in helping women with breast concerns by incorporating clinical expertise with teaching and counseling skills. Establishing clinics in which information, screening, and diagnosis of breast cancer are readily available will help decrease women's anxiety and enhance their ability to act as self-advocates within the healthcare system. A comprehensive breast clinic was developed, incorporating NP and physicians in a collaborative model of care. Defining roles within the model was an ongoing process as each provider developed areas of expertise and interest. The NP role emerged as an integral part of the practice, increasing the efficiency, availability, and effectiveness of clinic services.

The advanced practice nurse: meeting the information needs of the rural cancer patient

BACKGROUND

The goal of the Rural Cancer Care Project is to assist patients and families residing in rural areas to receive the highest-quality cancer care in their own communities.

METHODS

An advanced practice nursing clinic, serving as an adjunct service to specialty cancer care, is the core of the intervention model demonstrated by the "Rural Partnership Linkage for Cancer Care", a National Cancer Institute grant awarded to Michigan State University in 1990. The nursing intervention is directed to meeting patient and family needs.

RESULTS

One hundred seventy patients enrolled in the study beginning in January 1993 through September 1995. Knowledge deficit proved to be one of the most frequently identified problems (in 78% of the 170 patients evaluated), although the patient and family had often received care at a community oncology center with specialist health care professionals. Teaching was a major nursing intervention employed in patient care to address patient problems and needs as presented (e.g., chronic pain, fatigue). The data also demonstrated that the patients had more knowledge needs in the later stages of disease when they had cancers in all sites but the breast, where patients with Stage I and II disease had the greater learning needs.

CONCLUSIONS

Nursing interventions were directed primarily at education regarding cancer as a disease or the understanding of chemotherapy. The advanced practice nurse, by providing direct patient and family education in a community setting, does improve patient knowledge and subsequent outcomes.

Parent caregivers: a comparison of employed and not employed daughters

A major task for social workers is sorting out the kinds of assistance needed by families who care for an elderly parent. In particular, information is needed about the differential effects of employment on daughters who care for their elderly parent. This study describes parental caregiving among three groups: daughters who were employed, daughters who were never employed while caregivers, and daughters who ended their employment to continue caregiving. The effects of caregiving on these three groups, as well as the daughters' involvement with care tasks and use of formal and informal assistance, are examined.

The impact of age, treatment, and symptoms on the physical and mental health of cancer patients. A longitudinal perspective

BACKGROUND

To describe continuing care and rehabilitation needs of cancer patients, a longitudinal design (6 months) was performed among patients 50 years of age and older with solid tumors. The study examined how age, type of treatment, site of cancer, and symptom experience affect physical functioning and their mental health; age, site of cancer and the interval of time out of treatment influence changes in their symptom experience; and age, site of cancer, the interval of time out of treatment, and changes in symptom experience influence changes in physical and mental health.

METHODS

Patients (n = 111) who completed an intake and a 6-month self-administered questionnaire were included. Treatment included chemotherapy, radiation, or hormonal treatment at intake and for 6 months. Scales of nine symptoms and physical health using activities of daily living and measures of vigorous function were composed. Mental health was measured by the Center for Epidemiological Studies--Depression Scale.

RESULTS

The analyses yielded the following findings: (1) Primary site may have had an impact on symptom experience, limitations in functioning, and mental health if more patients with lung cancer had survived to 6 months. (2) Age, gender, treatment, or change in treatment had no impact on symptoms, functioning, or mental health at intake or changes in these variables. (3) Symptom experience at intake and the changes in symptoms predicted physical functioning and mental health at intake and the changes in these variables over time. (4) Gender differences were important in predicting mental health.

CONCLUSIONS

Strategies for continuing care and rehabilitation need to focus on symptom management, and strategies need to be different for male and female patients.

Social vulnerability and reactions to caregiving in daughters and daughters-in-law caring for disabled aging parents

Variables that have been conceptually linked with social vulnerability--income, educational level, employment, cessation of work to provide care, marital status, social support, and health--were used to predict four categories of reaction to caregiving in 159 daughters and daughters-in-law caring for their disabled aging parents. Social support, income, and health best predicted negative reactions to caregiving; social support alone best predicted negative reactions to caregiving; social support alone best predicted feelings of family abandonment, impact on health, and impact on schedule. Compared with daughters and daughters-in-law who had not quit work to provide care, those who had quit work were significantly older, had lower incomes and fewer social supports, and were more involved in care. The results suggest that quitting work may be a precursor to social isolation that places the caregiver at increased risk for social vulnerability and negative reaction to caregiving. The implications of the findings for health care policy are discussed.

Predictors of use of secondary carers used by the elderly following hospital discharge

This research examines how caregiver-patient relationship (female spouses, and adult daughters and daughters-in-law) when cross classified with patient coresidence patterns explains the level of secondary carers' involvement among patients with newly added needs for assistance at home following hospital discharge. Among 196 primary caregivers (104 spouses, 92 daughters and daughters-in-law), patient needs were divided into ADL and mobility limitations, and medical tasks. Secondary carer involvement was categorized into levels differing at two observations: one following discharge and a second 3 months later. Analyses focused on explaining the levels of involvement of secondary carers following hospital discharge and the changes in secondary carers' involvement between the two observations. The baseline and change analyses revealed that caregiver-patient relationship was more important than coresidence patterns or patients' demands in explaining assistance from secondary carers. The implications of these findings on caregivers' reactions and policies regarding home care are explored.

Strategies to meet the needs of the rural poor

Demographic, geographic, and economic forces have influenced the treatment and supportive care of patients with cancer and their families who reside in rural areas. The trends that limit access to cancer care include an aging population, lower income, less comprehensive insurance coverage, ill-equipped and poorly staffed health care facilities, and geographic isolation from health care services. It is important to develop strategies that can be used to overcome the barriers to rural cancer care.

Family home care for individuals with cancer

Cancer care has, to a great extent, shifted to outpatient and home settings, placing more responsibility for such care on the family members. Home care encompasses a wide range of patient needs, including symptom management, monitoring and use of equipment, medical care tasks related to surgery, coordination of care, and monitoring and evaluation of key health status parameters, as well as assistance with self-care and instrumental activities. Different families organize care tasks in different ways. By understanding how a particular family responds and organizes to fulfill patient care needs, health-care professionals will have a basis upon which to construct a plan of care in partnership with the patient and family members. This article describes home care issues from the perspectives of the patient and family members, and proposes strategies that health-care professionals can use to improve the outcomes of supportive care for the patient and family.

Family and out-of-pocket costs for women with breast cancer

Other than loss of income to family members, little attention has been given to costs incurred by women with breast cancer and their families. Informal costs, such as the family labor for patient care and nonreimbursed out-of-pocket expenditures to care for the patient with breast cancer, need to be considered. Informal costs of women who survived for at least 3 months after the observation are compared with informal costs of a group of patients who died during the subsequent 3 months. Data for this longitudinal descriptive study were obtained from a convenience sample of 62 women with new or recurrent breast cancer. Data were collected at intake and at 3-month intervals across the 6-month observation. Data are presented for the out-of-pocket costs, primary family care-giver and "other" family labor costs, and total costs. Considering all costs, the 3-month average was $2,720 (SD, $3314) for the survivors and $7905 (SD, $5448) for the decedents. Regressions of costs on predictors were performed; survivors' status and patient dependencies in activities of daily living were the only significant predictors. Family care costs need to be considered along with the formal and direct reimbursable medical costs as an essential component of breast cancer care cost.

The costs of family contributions to the care of persons with dementia

This study focuses on the costs of dementia care incurred by families. Cost components operationalized include: costs of unpaid caregiver labor services, paid and unpaid family labor, paid and unpaid services of nonfamily persons, and cash outlays for equipment and services. Among 182 families of dementia patients, average care costs for a 3-month period amount to $4,564. Cash expenditures average only 29% of total care costs, with unpaid labor accounting for 71% of the family care costs. Total care costs rise by $1,158 for each additional dependency in an activity of daily living (ADL), while reliance on paid services is 5% higher for each additional $10,000 household income and drops by 25% if the patient lives in the caregiver's household.

Interventions with family caregivers of persons with Alzheimer's disease

The types of assistance that are most often needed by family caregivers of persons with Alzheimer's disease are described. The results of experimental studies of clinical interventions with dementia are reviewed, and recommendations are made for clinical practice and research.

Gender bias in the measurement properties of the Center for Epidemiologic Studies Depression Scale (CES-D)

Confirmatory factor-analytic models are used to examine gender biases of individual items of the Center for Epidemiologic Studies Depression (CES-D) Scale. In samples containing 708 cancer patients and 504 caregivers of the chronically ill elderly, two CES-D items are identified as producing biased responses in comparisons of male and female respondents. Three additional CES-D items are excluded on the basis of other psychometric problems, yielding a subset of 15 CES-D items that capture almost all the information of the original 20-item CES-D scale but are free of any gender bias. Gender differences in mean levels of depressive symptomatology are significantly reduced, but not eliminated, when the 15-item scale is used.

The cost of cancer home care to families

BACKGROUND

For the most part, previous research on costs of cancer care has focused on the formal medical care costs. Research on home care for patients with cancer has emphasized direct care costs (expenditures). Among indirect costs, only loss of income to family members has been studied. However, a major component of indirect costs, the family labor expended to care for the patient with cancer, needs to be included for a more realistic appreciation of home care costs.

METHODS

The costs of family labor are estimated by imputing monetary values for the time spent caring for the patient with cancer. The assigned monetary cost either is equated with income losses of the helper in question or is based on a putative market value of the expended labor time. In addition, out-of-pocket expenditures examined in this study cover all cancer care-related expenses for which the patient was not reimbursed by third parties. Data were obtained from a convenience sample of 192 patients with cancer and their families in lower Michigan.

RESULTS

When family labor is included in the cost calculations, average cancer home care costs for a 3-month period ($4563) are not much lower than the costs of nursing home care. The substantial variation in home care costs (standard deviation [SD] = $4313) appears to be unrelated to the type of cancer diagnosis, type of treatment, or time since diagnosis but seems to be driven by the functional status of the patient and the family living arrangements.

CONCLUSIONS

Outpatient care for patients with cancer coupled with greater reliance on home care appear to be economically attractive because costs to families usually are underestimated.

Fatigue affecting family caregivers of cancer patients

Fatigue, a universally reported symptom, may be one of the most prevalent feelings of people suffering physical or mental diseases. An understanding of the factors leading to fatigue in the caregiving population can contribute to better care and support of both the cancer patient and caregiver. The purpose of this article is to investigate and describe the experience of fatigue among caregivers of cancer patients, in relation to caregiver age, employment status, number of hours of care provided daily, duration of caregiving, and the impact upon the caregiver's schedule. A sample of 248 caregivers of cancer patients, participating in the Family Homecare Cancer Study, were surveyed regarding fatigue related to their caregiving roles. No relationship was found between severity of fatigue experienced by the caregiver of the cancer patient and caregiver age, employment status, the number of hours of daily caregiving, or the duration of caregiving. However, a significant relationship was found between fatigue and the impact of care on the daily schedule. This finding has strong implications for the oncology nurse, because the more the caregiver's schedule is a burden, the greater will be the fatigue experienced.

Compliance among patients with cancer

Although there has been substantial progress in the effectiveness of cancer treatment and more patients experience longer-lasting remissions or cure, a substantial number of individuals still fail to respond to treatment. Healthcare professionals now are investigating patient behaviors which may result in ineffective response to potentially curative regimens. Patient perceptions, disease and treatment factors, sociodemographic characteristics, and social support systems influence the patient's decision to comply with a treatment regimen.

Sources of stress among families caring for relatives with Alzheimer's disease

We have described the different sources of stress and burden that are imposed by caring for a family member with AD. We have provided an approach to assessing each of these possible sources of stress and burden and have indicated how such assessments must take a family-based approach and consider the broader social roles and family dynamics that may color the way in which family members view and carry out their caregiving roles.

Prediction of patient attrition from experimental behavioral interventions

Attrition of patients in treatment and control was compared for loss from the study and loss from care. Previously diagnosed hypertensive patients who were under treatment but out of control (diastolic blood pressure greater than 90 and systolic blood pressure greater than 140 mm Hg) were assigned to conventional care or to an experimental nursing intervention group. The intervention involved eight visits covering a 6-month period. Attrition from the study for the experimental group was defined as completion of four or fewer experimental sessions; for the control group it was defined as making no visits to a treatment center during a 6-month posttest observation period. Attrition from care by the facilities where the study was conducted was defined as no visits to these sources of care during a 1 1/2-year follow-up period. More controls than experimentals were lost from the study. No differences could be found between patients lost from the study and those lost from both the study and care. A logistic regression was used to predict attrition. The four significant predictor variables were: perceived difficulty in following a diet, knowledge of disease, perceived severity of symptoms, and the experimental condition. The study showed: social psychological variables, important predictors of attrition, should be used to identify patients at risk of leaving care for their chronic diseases.

The effects of patient characteristics and beliefs on responses to behavioral interventions for control of chronic diseases

Tests of behavioral interventions seldom examine changes in health beliefs and behaviors thought to be prerequisites of improved outcome health states and they do not attempt to specify how patient characteristics or pretest measures influence responses to the intervention. In this study an experimental nursing intervention, its impact on hypertensive patients' beliefs about their disease, efficacy of medications and diet, as well as blood pressure and weight are described. Among patients from the experimental group, the ability of selected pretest variables to predict clinical outcomes and changes in clinical health states was evaluated. The intervention was successful in lowering diastolic blood pressure and altering certain beliefs held by the patients. The pretest characteristics were not successful in explaining hypertensive patients' responses to the intervention. Explanations for this are pursued through remarks from the content analysis of the intervention protocol. From these observations, the original health belief model was revised. The discussion concludes with a set of research questions that may prove promising for future research.

Development of Scales to Measure Beliefs of Diabetic Patients

In this article health belief concepts are identified and previous attempts to construct scales for measuring these concepts are critiqued. Using an initial sample of 156 diabetic patients, factor analytic techniques were used to develop measures of the basic concepts of the Health Belief Model. The derived scales from this sample were cross-validated on a second sample of 92 diabetic patients. The scales were tested for unidimensionality, internal and external consistency, and stability across both samples. The application of these scales to nursing research and practice are discussed.