Endocrine levels at the start of treatment are associated with subsequent psychological adjustment in cancer patients with metastatic disease

OBJECTIVE

This study examined the association between hormonal profiles at the start of cancer treatment and subsequent psychological symptomatology.

METHODS

Twenty-seven patients with metastatic renal cell carcinoma and 18 patients with metastatic melanoma completed three assessments during the course of treatment: at the start of treatment (baseline), at the end of treatment (3 weeks after baseline), and at a follow-up appointment 1 month later. Cortisol, norepinephrine, and epinephrine levels were measured at baseline using 15-hour urine samples. At each assessment, patients completed the Impact of Event Scale (IES) and the Brief Symptom Inventory (BSI).

RESULTS

Patients reported moderate levels of distress throughout treatment as measured by the IES and BSI. Norepinephrine levels at the start of treatment were positively associated with IES total scores at the end of treatment and at follow-up, and cortisol levels were positively associated with IES total scores at follow-up after adjusting for baseline IES and overall distress scores. Norepinephrine levels were also positively associated with depression scores at follow-up, and cortisol levels were positively associated with depression scores at the end of treatment and at follow-up after adjusting for baseline depression and overall distress scores.

CONCLUSIONS

Hormonal profiles at the start of cancer treatment are associated with subsequent psychological adjustment.

The association between treatment-specific optimism and depressive symptomatology in patients enrolled in a Phase I cancer clinical trial

BACKGROUND

Previous research has found that cancer patients often overestimate the likelihood that they will achieve a positive response in Phase I trials. However, maintaining optimistic expectations may help patients cope with a poor prognosis and uncertain outcome. The authors prospectively examined the association between treatment-specific optimism and mental health among patients participating in a Phase I/b trial.

METHODS

Twenty-four patients with metastatic renal cell carcinoma and 22 patients with metastatic melanoma completed an assessment battery at the beginning of treatment and 3 weeks later, on the final day of treatment. Patients completed measures of treatment-specific optimism (e.g., beliefs regarding the treatment working), depressive symptomatology, mood disturbance, and overall distress.

RESULTS

The majority of patients believed that the treatment would either cure them (87%) or stop cancer progression (85%). Regression analyses revealed that the level of treatment-specific optimism (e.g., "The treatment I am receiving may cure me") was associated negatively with baseline measures of depressive symptoms (P < 0.006), mood disturbance (P < 0.001), and symptoms of distress (P < 0.0001) after controlling for age, number of metastases, and time since diagnosis. Patients with symptoms of clinical depression at baseline reported significantly lower levels of treatment-specific optimism than patients without symptoms (P < 0.03). Treatment-specific optimism also was associated negatively with symptoms of depression at the end of treatment (P < 0.003), controlling for symptoms of depression at the beginning of treatment.

CONCLUSIONS

The results of the current study suggest that high levels of treatment-specific optimism are associated with better mental health outcomes at both the beginning and end of treatment.

Breaking bad news about cancer: patients' preferences for communication

PURPOSE

The goal of this study was to assess patients' preferences regarding the way in which physicians deliver news about their cancer diagnosis and management.

PATIENTS AND METHODS

A sample of 351 patients with a variety of cancers completed a measure assessing their preferences for how they would like to be told news about their cancer. Patients rated characteristics of the context and content of the conversation as well as physician characteristics.

RESULTS

Factor analysis indicated that patients' preferences for how they would like to be told news regarding their cancer can be grouped into the following three categories: (1) content (what and how much information is told); (2) facilitation (setting and context variables); and (3) support (emotional support during the interaction). Women (P =.02) and patients with higher education (P =.05) had significantly higher scores on the Content scale, women (P =.02) had higher scores on the Support scale, and younger patients (P =.001) and those with more education (P =.02) had higher scores on the Message Facilitation scale. Medical variables were not associated with patients' ratings of the importance of the three subscales.

CONCLUSION

Patients rated items addressing the message content as most important, though the supportive and facilitative dimensions were also rated highly. Understanding what is important to patients when told news about their cancer provides valuable information that may help refine how this challenging task is best performed.

Child-reported family and peer influences on fruit, juice and vegetable consumption: reliability and validity of measures

Family, peers and other environmental factors are likely to influence children's dietary behavior but few measures of these phenomena exist. Questionnaires to measure family and peer influences on children's fruit, juice and vegetable (FJV) consumption were developed and pilot tested with an ethnically diverse group of Grade 4-6 children. Principal components analyses revealed subscales with acceptable internal consistencies that measured parent and peer FJV modeling, normative beliefs, normative expectations, perceived peer FJV norms, supportive and permissive parenting practices, food rules, permissive eating, and child food preparation. Internal consistencies were adequate to high, but test-re-test correlations often were low. Children also completed questionnaires on FJV availability and accessibility in the home, and food records for 2 days in the classroom. Parental modeling, peer normative beliefs and FV availability were significantly correlated with FJV consumption. Further research with these scales is warranted.

Effect of a la carte and snack bar foods at school on children's lunchtime intake of fruits and vegetables

OBJECTIVES

To compare lunch fruit, juice, and vegetable (FJV) intake of fourth-grade students who receive only National School Lunch Program meals and fifth-grade students who also have access to a school snack bar and to compare FJV intake by meal source among fifth-grade students.

DESIGN

Cross-sectional study: students completed FJV preference questionnaires and 5 days of lunch food records in classrooms.

SUBJECTS/SETTING

312 fourth- and 282 fifth-grade students in south Texas.

MAIN OUTCOME MEASURES

Mean FJV consumption.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics, correlation analyses, analysis of variance, analysis of covariance.

RESULTS

Fourth-grade students (n = 312) consumed significantly more fruits, juices, and vegetables (0.80 serving) than fifth-grade students (n = 282) (0.60 serving). Students whose parents reported a high school education or less consumed more regular and total vegetables than students whose parents reported some college or higher education. There were no interaction effects among gender, grade, ethnic, or family education groups. Fifth-grade students who ate only snack bar meals consumed significantly less total fruits, juices, and vegetables (0.40 serving) than fifth-grade students who ate school lunch meals (0.82 serving). Controlling for FJV preferences did not change the main effect for grade level in the FJV consumption models.

APPLICATIONS/CONCLUSIONS

FJV consumption during school lunch is low. School foodservice staff should identify FJV items that middle school students prefer and increase availability of those items in middle school cafeterias and snack bars.

Depression, anxiety, and quality of life in patients with epithelial ovarian cancer

OBJECTIVE

The aims of this study were to evaluate psychological distress and quality of life (QOL) in patients with epithelial ovarian cancer (EOC) and to examine the relationship between these problems and health and demographic variables.

METHODS

Of 344 consecutive patients identified, 246 completed questionnaires. Four dimensions of QOL were assessed including physical, functional, emotional, and social/family well-being, as well as concerns specific to ovarian cancer patients. Depression was measured with the Center for Epidemiologic Studies-Depression (CES-D) scale and anxiety was measured by the State Anxiety Subscale of the Spielberger State-Trait Anxiety Inventory. Performance status was evaluated by the Zubrod score.

RESULTS

Sixty-five patients (26%) had early stage disease; 181 (74%) had advanced disease. One hundred twenty-one patients (49%) were under active treatment, while 124 (51%) were seen for posttherapy surveillance. Forty-eight (21%) met CES-D cutoff criteria for a clinical evaluation for depression, and 29% scored above the 75th percentile for anxiety. Performance status was related to depression, anxiety, and QOL problems, except in the domain of social well-being.

CONCLUSIONS

Clinically significant depression and anxiety may be more prevalent in patients with EOC than previously reported. Future studies of screening for and treating psychological distress are being designed to improve QOL in these women.

Socioenvironmental influences on children's fruit, juice and vegetable consumption as reported by parents: reliability and validity of measures

OBJECTIVE

To pilot test theory-based questionnaires to measure socioenvironmental influences on children's fruit, juice and vegetable (FJV) consumption as reported by parents.

DESIGN

Cross-sectional.

SETTING

Parents of fourth to sixth grade students completed socioenvironmental questionnaires. The students completed food records (FRs) for 2 days in the classroom.

SUBJECTS

Interviews were completed by 109 parents (17% African-American, 32% Hispanic-American and 51 Euro-American).

RESULTS

Student mean daily FJV intake was 2.1 servings. Principal components analyses revealed subscales measuring positive and negative parenting practices; self-efficacy for modelling and planning/encouraging FJV consumption, and making FJV available; encouraging, consequences and discouraging food socialization practices; negative home, cost and canned/frozen food barriers; meal planning; child shopping; mother food preparation; and child lunch and dinner FJV preparation practices. Internal consistencies were adequate to high. Negative parent practices and negative home FJV barriers were significantly negatively correlated with child FJV consumption variables. Planning/encouraging self-efficacy was positively associated with fruit consumption, and child dinner FJV preparation was significantly negatively correlated with child juice consumption.

CONCLUSIONS

These questionnaires may provide important insights about the relationship between parent-reported socioenvironmental influences and children's FJV consumption. Future work should test these questionnaires with larger groups of parents and youths, with more reliable estimates of usual FJV intake, e.g. 7-day food records, to obtain a detailed understanding of how parents influence what children eat. Tests of models of relationships among these variables are warranted, but should control for possible confounding variables, e.g. socioeconomic status, gender of the child, etc.

The effects of type of surgery and time on psychological adjustment in women after breast cancer treatment

BACKGROUND

The aim of the present study was to examine whether type of surgery, age, and time since surgery influenced psychological distress and quality of life (QOL) in women treated for breast cancer.

METHODS

We surveyed 183 women who had undergone surgery for breast cancer. Psychological distress was measured with the Mental Health Inventory and QOL was measured with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire.

RESULTS

After controlling for stage of disease, radiation treatment, and age, there was a statistically significant interaction between type of surgery and time since surgery for the Mental Health Inventory total score, and a marginal interaction between type of surgery and time since surgery for the Global health status/QOL score. Women who had breast conservation surgery experienced significantly greater levels of psychological distress and marginally worse QOL from 40 months after surgery onward than did women who received a mastectomy.

CONCLUSIONS

The effects of different surgical treatments for breast cancer on psychological distress and QOL become apparent only after a period of several years. Women, therefore, need counseling on the potentially positive and negative psychological implications of different surgical treatments for breast cancer.

Aerobic fitness and leisure physical activity as moderators of the stress-illness relation

Exercise as a moderator of the stress-illness relation was examined by exploring leisure physical activity and aerobic fitness as potential "buffers" of the association between minor stress on physical and psychological symptoms in a sample of 135 college students. The goal was to gather information regarding the mechanisms by which exercise exhibits its buffering effects. Researchers have examined both physical activity and physical fitness in an attempt to demonstrate this effect; however, whether both of these components are necessary to achieve the protective effects against stress is unknown. This study examined engaging in leisure physical activity and having high aerobic fitness to determine if both were necessary for the stress-buffering effects or if one factor was more important than the other. Findings suggested a buffering effect for leisure physical activity against physical symptoms and anxiety associated with minor stress. This effect was not found with depression. Additionally, there was no moderating effect for aerobic fitness on physical or psychological symptoms. Collectively, the data suggested that participation in leisure physical activity as opposed to level of aerobic fitness is important to the stress-buffering effect of exercise. Implications for exercise prescription are discussed.

Intraindividual variability and reliability in a 7-day exercise record

PURPOSE

High levels of day-to-day or intraindividual variability implies unreliability of a measure of physical activity. Unreliability in a measure leads to attenuation of correlations with other variables. As intraindividual variability increases, the number of days necessary to assess physical activity to achieve the desired level of reliability increases. The use of an intraclass correlation to assess day-to-day reliability in a measure assumes compound symmetry.

METHODS

This study reports on these issues in a sample of 165 elementary school teachers who maintained a 7-d record of physical activity each year for 3 yr. Analyses were conduced with physical activity measured as minutes, MET minutes, and kcal. Analyses were conducted with PROC MIXED in SAS controlling for the clustering effect by school.

RESULTS

Compound symmetry could not be supported across 7 d of the record. The weekdays tended to intercorrelate, Saturday correlated at very low levels, and Sunday correlated with Monday only. Compound symmetry was supported across the three weeks.

CONCLUSIONS

To achieve a reliability of 0.8 using a 7-d activity record requires 2 wk of assessment. The reliability of measures of physical activity require more careful attention, and likely require more points of assessment to achieve desired levels.

Pilot study of the validity and reliability of brief fruit, juice and vegetable screeners among inner city African-American boys and 17 to 20 year old adults

OBJECTIVE

Compare the validity and reliability of a one-week fruit, juice and vegetable (FJV) food frequency questionnaire (FFQ) that does not require averaging in response categories and one-week food recognition form (FRF) against three to four 24-hour dietary recalls (24hdr) among mostly African-American boys and 17 to 20 year-old adults for possible use in subsequent intervention studies.

DESIGN

In Study One, the FFQ was administered to 40 boys in four Boy Scout (BS) troops on two occasions separated by two weeks. The FRF was administered to 36 boys in four other BS troops after school on six school days, covering seven consecutive days. All these boys completed four 24hdr, including one Sunday. In Study Two, 56 17 to 20 year-old adults completed the FFQ during telephone interviews on two occasions two weeks apart. In between, they completed three 24hdr by telephone interview on one weekend and two weekdays.

SUBJECTS/SETTING

Participants in Study One were members of eight urban BS troops, and in Study Two were high school (HS) seniors and recent HS graduates. BS data were collected at times scheduled for troop meetings or immediately after school. The young adult group completed telephone interviews in the evenings and on weekends.

MAIN MEASURES

This research compared a FJV FFQ and a FJV FRF (incorporating the same 24 foods) against three to four 24hdr conducted using NDS software from the University of Minnesota.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics, intraclass correlations, Spearman correlations, corrections for attenuation.

RESULTS

The first FFQ provided substantially higher mean consumption estimates for both groups. The FFQ had moderate reliability across assessments and moderate validity coefficients for fruit and total FJV combined for the BS sample. The FRF had higher validity coefficients for juice. The FFQ had moderate reliability and poor validity among the young adult group. Correction for measurement error in the 24hdr substantially increased validity coefficients to high levels for BS fruit and total FJV and to moderate levels for the HS groups, with some exceptions.

APPLICATIONS/CONCLUSIONS

FFQ more validly assessed fruit and combined FJV consumption for the nine to 14 year-old BS but overestimated mean values. FRF means were closer to those of the 24hdr and were more valid for assessing juice consumption. The FFQ had moderate validity among the young adult group but overestimated consumption. Further research is needed on simpler methods of reporting diet in these age groups.

Factors related to adiposity among children aged 3 to 7 years

OBJECTIVE

To compare diet and physical activity between a group of children aged 4 to 7 years who had increased their sum of 7 skinfolds by 1.5 standard deviations or more since the previous year and those who had not.

SUBJECTS/DESIGN

A longitudinal design was used wherein children had their body composition assessed at 4 annual intervals. Fifteen study subjects were identified from a larger study on the development of cardiovascular risk factors in children. Three matched control subjects were identified for all but 4 study subjects. Children were included if they were 3 or 4 years old at the time of the first of 4 annual clinics to collect data. Children were volunteers from a mid-sized city.

MEASURES

Seven skinfold sites were assessed, each 3 times. An average was taken of the mean at each site. Diet and physical activity were assessed using observational methods for up to 4 days for each of 3 years between the 4 annual clinics (held in the summers of 1986, 1987, 1988, and 1989).

RESULTS

Children consumed significantly (P = .02) more fat grams and suggestively higher percentages of energy from fat (P = .06), total energy (P = .08), and percentage energy from protein (P = .10). No differences were detected for percent energy from carbohydrate, physical activity, or height.

CONCLUSIONS

Programs to prevent childhood obesity might have success by targeting dietary fat consumption among children as young as 4 years old, but further research is needed.

First year after head and neck cancer: quality of life

PURPOSE

Treatment regimens for head and neck cancer patients profoundly affect several quality-of-life domains. Rehabilitative needs have been identified through cross-sectional analyses; however, few studies have prospectively assessed quality of life, included assessment of psychosocial variables, and identified predictors of long-term follow-up.

PARTICIPANTS AND METHODS

The present study addresses these limitations through a prospective assessment of 105 patients with a newly diagnosed first primary squamous cell carcinoma of the oral cavity, pharynx, or larynx. Participants were enrolled onto a larger randomized controlled trial comparing a provider-delivered smoking cessation intervention with a usual-care-advice control condition. Participants completed a battery of self-report measures after diagnosis and before treatment and additional quality-of-life instruments at 1 and 12 months after initial smoking cessation advice.

RESULTS

Participants displayed improvements at 12 months in functional status (P = .006) and in the areas of eating, diet, and speech; however, the latter three represent areas of continued dysfunction, and the changes were not statistically significant. Despite these improvements, patients reported a decline in certain quality-of-life domains, including marital (P = .002) and sexual functioning (P = .017), as well as an increase in alcohol use (P < .001). Predictors of quality of life at 12 months included treatment type, the Vigor subscale of the Profile of Mood States instrument, and quality-of-life scores obtained 1 month after initial smoking cessation advice.

CONCLUSION

Results reinforce the need for rehabilitation management through the integration of psychologic and behavioral interventions in medical follow-up.

Radiation therapy and survival in breast cancer patients with 10 or more positive axillary lymph nodes treated with mastectomy

PURPOSE

Adjuvant loco-regional radiation (XRT) frequently is recommended after mastectomy and adjuvant systemic therapy in patients with 10 or more positive axillary lymph nodes (ALN) to reduce the high loco-regional failure rate observed in this subset. In this study, we explored the possibility that adjuvant loco-regional radiation therapy (LR-XRT) also could decrease distant failure and improve overall survival (OS) in this subset of poor-prognosis patients.

PATIENTS AND METHODS

Retrospectively, 618 breast patients with 10 or more positive ALN were studied. The median follow-up time was 7.5 years. All patients received systemic adjuvant therapy and 35% also received adjuvant radiation therapy. Loco-regional failure, distant failure, and OS analyses were adjusted for age, tumor size, number of positive ALN, and estrogen receptor (ER) status using Cox regression model.

RESULTS

As expected, patients had a very high risk of loco-regional and distant failure. At 5 years, 30% of patients had loco-regional failure as a first event and 54% had distant failure. Radiation dramatically reduced loco-regional failure (hazards rate ratios [RR]=0.29; 95% confidence interval [CI], 0.19 to 0.45). The adjusted 5-year loco-regional failure rate was 13% with radiation and 38% without radiation (P=.0001). Radiation also was associated with improved distant control (RR=0.75; 95% CI, 0.58 to 0.96). The adjusted 5-year distant failure rate was 48% with radiation and 58% without radiation (P=.02). OS also improved with radiation (RR=0.68; 95% CI, 0.53 to 0.85). The adjusted 5-year OS was 56% with radiation and 42% without radiation (P=.001).

CONCLUSION

In this cohort of high-risk breast cancer patients, XRT was associated with less loco-regional and distant failure and improved OS. This suggests that improved loco-regional control might decrease secondary systemic spread and improve survival.

bcl-2 and apoptosis in lymph node positive breast carcinoma

BACKGROUND

Because bcl-2 can block apoptosis in vitro, and because lower levels of apoptosis might lead to malignant cell accumulation and therefore to a more aggressive clinical course, the authors tested the hypothesis that high bcl-2 and low apoptosis would result in a worse prognosis for breast carcinoma patients.

METHODS

Primary breast tumor specimens from 979 patients with positive axillary lymph nodes were evaluated for bcl-2 protein expression by immunohistochemistry (IHC). Apoptosis was evaluated by using IHC to detect 3' DNA fragments end-labeled with biotinylated uridine. Results were analyzed with respect to patient characteristics, prognostic factors, and clinical outcome. Median follow-up was 61 months.

RESULTS

High bcl-2 expression was significantly associated with a number of favorable prognostic factors, including a lower number of positive lymph nodes, absence of p53 protein accumulation, estrogen receptor (ER) and progesterone receptor (PR) positivity, diploidy, and a lower proliferative rate. However, although bcl-2 is generally considered a negative regulator of apoptosis, in these tumors there was no significant association between bcl-2 and apoptosis. Patients with high bcl-2 expression had significantly improved disease free survival (DFS) (P < 0.0001) and overall survival (OS) (P < 0.0001). In a multivariate analysis, bcl-2 expression was independently associated with better DFS (P = 0.004). Regarding apoptosis, the presence of > or = 1% apoptotic cells was significantly associated with a greater number of positive lymph nodes, p53 protein expression, ER and PR negativity, aneuploidy, and a higher proliferation rate, although there was no significant association with a worse clinical outcome when this dichotomized cutoff was used.

CONCLUSIONS

For lymph node positive breast carcinoma patients, high bcl-2 expression is associated with a number of good prognostic factors and is independently associated with better clinical outcome. Apoptosis is associated with a number of poor prognostic factors but not with a significantly worse outcome.

"5 A Day" achievement badge for urban boy scouts: formative evaluation results

BACKGROUND

Certain cancers are more common among African Americans (AA). Fruit and vegetables (F&V) reduce cancer risk, but Americans, and African Americans in particular, do not meet the "5 A Day" goal. Scouting organizations, particularly urban Boy Scout groups that target inner-city youth, provide promising channels for nutritional behavioral change programs.

METHODS

Focus groups were conducted with urban Boy Scouts and their parents to identify factors influencing F&V consumption and evaluate potential intervention activities. Twenty-four-hour dietary recalls were collected from 85 area Boy Scouts. A national data set was used to obtain values for F&V consumption by African American and European American (boys age 0-16).

RESULTS

Vegetable preferences were low and a negative peer influence for vegetables was reported. The group has limited food-preparation skills, but both parents and scouts reported that F&V were available in their homes. Use of goal setting and use of problem-solving techniques were limited. The local scouts' mean F&V intake was 3.2 servings per day. Ethnic differences in F&V consumption were identified in the national data.

CONCLUSIONS

Based on these results and previous interventions in schools, an overall structure for the intervention was developed to include eight weekly troop sessions and two camping sessions, parent newsletters, seven weekly home badge assignments, and ten comic books.

An evaluation of mammography beliefs using a decision model

The purpose of this study was to identify factors that contribute to a group of working women's decision related to mammography. The study was guided by a decision model called the Multiattribute Utility Model. Exploratory interviews were conducted among 36 women to identify positive and negative factors associated with the mammography decision. Eighteen factors emerged and were categorized into three broad areas: Knowledge and Attitudes (Confidence in Efficacy, Personal Risk, Other Means of Knowing, Fear of Cancer/Treatment, Belief in Fate, Embarrassment), Issues Related to Participation (Accessibility and Convenience, Difficulty Arranging, Time, Cost, Pain, Radiation), and Social Concerns (Role Model, Responsibility to Self, Responsibility to Others, Family/Friends' Influence, Societal Influences, Health Care Providers' Influence). This information served as the basis of a survey among 87 women to determine the importance of these factors. Seven factors emerged as significantly different between compliers and noncompliers. In order of significance, they were Difficulty Arranging, Fear of Cancer/Treatment, Cost, Accessibility and Convenience, Time, Other Means of Knowing, and Influence of Health Care Provider. The predictive validity of this analysis was 85%. Implications of findings are discussed.

Effects of health facilitator performance and attendance at training sessions on the acquisition of tobacco refusal skills among multi-ethnic, high-risk adolescents

The study examined the effectiveness of a psycho-social tobacco use prevention intervention with a refusal skills training component on the refusal skills of high-risk adolescents, and investigated skill acquisition as related to subject demographics, performance of health facilitators and attendance at skills training sessions. Tobacco refusal skills were assessed for a group (n = 389) of high-risk, seventh-grade students participating as intervention and control subjects in Project SHOUT, a large tobacco use prevention program in the San Diego area. In addition, subject demographics, ratings of health facilitator performance and information about subjects' attendance at skills training sessions were collected. Subjects' responses to audiotaped peer offers of cigarettes and smokeless tobacco were coded for content and quality. Greater tobacco refusal skills among intervention subjects was hypothesized. Further health facilitator performance, attendance at training sessions and subject demographics were thought to be related to skill acquisition. High-risk intervention subjects gave significantly higher quality tobacco-refusal responses than did controls, although the differences between means were small. Results suggested that Hispanic adolescents were particularly receptive to the refusal skills training. The association between health facilitator performance and skill acquisition varied by subject ethnicity, as did the relationship between attendance at training sessions and skill acquisition.

Patterns and correlates of smoking and smokeless tobacco use among continuation high school students

Students attending continuation high schools in San Diego, California were surveyed on their smoking and smokeless tobacco (SLT) use. The students are assigned to continuation high schools because of credit deficiencies, usually resulting from absenteeism, poor grades, and delinquency. Results indicated that smoking was higher than national prevalence rates for these adolescents, with the prevalence of weekly and daily smoking at 50.4% and 43.9%, respectively. Among weekly smokers, 43.7% reported smoking at least half a pack of cigarettes per day. Stepwise logistic regression analysis revealed that Anglo ethnicity, having a friend who smokes, weekly use of marijuana and alcohol, and having adults in the home who smoke were significantly associated with weekly smoking. The prevalence of SLT was very low, with only 5.7% reporting monthly use, 2.9% weekly use, and 1.8% daily use. With respect to monthly SLT use, increased risk was found among males, students whose friends used SLT, weekly alcohol users, students who intended on enrolling in college, and those with an adult in the home who used SLT. Comparison to a population of students attending regular public high schools in the same region showed that the prevalence of daily use of cigarettes, alcohol, marijuana and other illicit substances were 3.9, 2.7, 3.7, and 2.2 times higher, respectively, among the continuation high school students than the public school students. Daily use of SLT among the continuation high school students was, however, only 0.4 times as high as the regular public school students.

Parental influences to smoke in Latino youth

BACKGROUND

Latino youth have been found to have a higher prevalence of tobacco use than do other ethnic groups, possibly due to cultural factors and parental influences.

METHODS

Seventh-grade students (N = 589) were surveyed in San Diego, California, and Tijuana, Mexico, to assess parental influences to smoke. These parental influence variables were studied with logistic regression, adjusting for age, sex, and number of parents who smoke.

RESULTS

Among those whose parents smoke, Mexican students were asked to strike a match to light their parents' cigarettes significantly more often (57%) than Mexican-American students (37%) and U.S. Others (37%) (P < 0.05). Seventeen percent of the Mexican students reported having lit a cigarette in their own mouth for their parents, compared to 18% of Mexican-Americans and only 3% of U.S. Others (P < 0.01). Mexicans reported buying cigarettes for their parents more often (62%), compared with 36% for Mexican-Americans and 30% for U.S. Others (P < 0.01). Child smoking was only associated with friend offers of tobacco and parental prompts to light cigarettes in their mouths.

CONCLUSION

Latino parents are inadvertently prompting their children to smoke. Smoking prevention programs targeting Latino youth may need to include a parental tobacco education component.

The long-term prevention of tobacco use among junior high school students: classroom and telephone interventions

OBJECTIVES

The purpose of this study was to implement and evaluate the effectiveness of a long-term tobacco use prevention program for junior high school students that used college undergraduate change agents and telephone boosters.

METHODS

A psychosocial intervention combining refusal skills training, contingency management, and other tobacco use prevention methodologies such as telephone and mail boosters was implemented in 11 junior high schools in San Diego County, California. Eleven other junior high schools served as controls. Of the 2668 participants, 57% were White/non-Hispanic, 24% were Hispanic, and 19% were of other racial/ethnic groups. College undergraduates served as change agents for both the classroom and booster interventions, the latter of which was delivered in the third (ninth-grade) year of the program.

RESULTS

At the end of the third year, the prevalence of tobacco use within the past month was 14.2% among the intervention students and 22.5% among the controls, yielding an odds ratio of 0.71 for analysis at the school level.

CONCLUSIONS

Both college undergraduate change agents and direct one-to-one telephone interventions appear to provide cost-effective tobacco-related behavior modification.

The use of diarrhoeal management counselling cards for community health volunteer training in Indonesia: the HealthCom Project

The Indonesian Ministry of Health relies on a network of over a million kader (community health volunteers) to bring primary health care to the village level. In West Java, the Department of Health's Control of Diarrhoeal Disease (CDD) Program recently carried out an extensive research and development effort to produce effective job aids for the kader in CDD and a training programme to teach their use. A set of counselling cards was produced to provide kader with a tool to diagnose and treat diarrhoea and teach the proper use of ORS. Researchers conducted a controlled evaluation in which they measured the cards' effectiveness through observations of kader performance and interviews with mothers they had counselled. In the intervention group, 15 kader underwent two days training in the use of the cards when diagnosing and advising treatment for cases of diarrhoea in their villages. The 16 control kader received comparable CDD training without the cards. Each group provided lists of local mothers they pledged to counsel during the coming weeks. Follow-up interviews were held with these mothers to test their level of knowledge on CDD and to observe their ability to mix ORS properly. Significant performance differences between the intervention kader and mothers, and the control kader and mothers, were demonstrated. The intervention kader were consistently more accurate in their diagnoses and recommendations for treatment with a mean of 83% accuracy vs 68% for the control kader. Mothers counselled by the intervention kader also prepared ORS significantly better than the mothers counselled by the control kader, with 97 vs 74% accuracy.

Predictors of participation in a school-based anti-tobacco activism program

This study investigated the predictors of participation in a school-based, anti-tobacco activism program. Subjects in this study consisted of 7th grade students participating in the intervention component of Project S.H.O.U.T., a tobacco use prevention program in San Diego County, California. In the activism component, a newsletter containing an activism contest was distributed to each student. Small prizes were awarded to contest winners at each school. "Activism" included letter and petition writing, anti-tobacco poster contests, merchant education, peer surveys and magazine subscription cards. A total of 170 students participated in the activities, with 81.1 percent participating two or more times. Of those who participated, 59 percent were female and 60 percent were White, non-Hispanic. Two sets of logistic analyses were conducted. Variables such as SES, gender, ethnicity, friends' tobacco use and parental tobacco use were used to predict participation in activism activities. The choice of variables was intended to provide information regarding activism participation in reference to known tobacco risk factors. Results of the first analysis indicated that students with a higher SES, and in an urban vs. rural location were more likely to participate in the activism activities. The second analysis used the same set of characteristics to predict "ever-use" of tobacco. Results of this analysis indicated that male gender, low grades, White, non-Hispanic ethnicity, friends' and parents' tobacco use were positively associated with tobacco experimentation.

Differences in cancer-risk-related behaviors in Latino and Anglo adults

METHODS. Latino (n = 358) and Anglo (n = 113) adults living in the San Diego area were surveyed on nutrition, smoking, and cancer screening behaviors. The Latino respondents were dichotomized into a low (L-Latino) or high (H-Latino) acculturation group according to a median split of an acculturation index. RESULTS. After controlling for age, years of education, gender, marital status, and income, significant cross-cultural differences were found in saturated fat/cholesterol avoidance, and fiber and high calorie food consumption. L-Latino respondents had the lowest degree of saturated fat/cholesterol avoidance, followed by H-Latinos and Anglos. A pattern of decreasing consumption with increasing acculturation was observed for fiber and high calorie foods. Significant differences were found among women in the prevalence of Pap smear exams, with L-Latinas having the lowest prevalence of ever and in the past year having had a Pap smear, followed by H-Latinas and Anglos. A similar significant pattern was observed among women 50 years of age or older with respect to the prevalence of ever having had a mammogram.

Depression late after combat: a follow-up of Finnish World War Two veterans from the seven countries east-west cohort

An analysis from the Finnish East and West Cohort of the Seven Countries Study tested the hypothesis that front line service during modern warfare is associated with depression later in life. World War Two-era Finnish combat veterans were compared to Finnish veterans who were non-combatants. Both groups were followed from 1959 to 1984. Dependent variables were the Zung depression scale and other measures of psychosocial adaptation and mental health. Analysis of variance of Zung scores by combat exposure was close to statistical significance (p = 0.0501). Even if statistical significance had been reached, it is felt that the absolute magnitude of the differences between the populations appear quite trivial. A significant association was found for those who had participated in over nine battles and when grouping depression, sleeplessness, paranoia, hallucinations, schizophrenia, and other mental illness into the general category of any mental illness (O.R. = 4.414; 95% C.I. = 1.113, 17.503). This seems to support the residual stress hypothesis pertaining to modern combat exposure.

Assessing skills for refusing cigarettes and smokeless tobacco

Hops and colleagues developed an audiotaped refusals skills test in which students respond to cigarette offers and their responses are scored for content. The present study employed a modified analogue skills test. Modifications included adding a separate subscale for smokeless tobacco, emphasizing repeated offers and group pressure, and rating the quality of responses (good, fair, poor). The test was evaluated in four seventh-grade classrooms (N = 78). Half had participated in a refusals skills training program; the others were controls. Intervention subjects provided more "good" responses and fewer "poor" responses than controls. In a multiple regression, repeated and group offers were associated with the quality of response, while offerer's gender and type of tobacco variables were not associated. In a second regression, experimental condition was associated with quality of the responses, while gender, ethnicity, exposure to tobacco, use of tobacco, and attitudes toward the test were not associated.

Preventive attitudes, beliefs, and practices of physicians in fee-for-service and health maintenance organization settings

To identify the self-reported differences in preventive practices, attitudes, and beliefs of physicians practicing in fee-for-service (FFS) and health maintenance organization (HMO) settings, we surveyed a 100% sample of primary care physicians practicing in a large, urban, closed-panel HMO and a random sample of physicians, in the same county, who were in an FFS practice. The FFS physicians were more likely to consider behavioral risk factors important than were HMO physicians, and they were more likely to ask their patients about behavioral risk factors. Fee-for-service physicians were more likely than HMO physicians to use continuing medical education courses to upgrade their skills in modifying behavioral risk factors. There was little difference in the self-reported proportion of patients with specific behavioral risks in the FFS and HMO practices. Also, both groups were comparable in their perception of their ability to do behavioral counseling and their perceived success in such counseling. We conclude that FFS physicians are more likely to have positive preventive beliefs, attitudes, and practices than are HMO physicians.

Prevention of tobacco use among adolescents in public schools in San Diego County, U.S.A

Project S.H.O.U.T. (which stands for "Students Helping Others Understand Tobacco") is a tobacco-use prevention project funded by the United States National Cancer Institute for preventing the use of cigarettes and smokeless tobacco (snuff and chewing tobacco) in public schools in San Diego County, California. Based on principles of behavior modification, Project S.H.O.U.T. teaches students how to anticipate and overcome negative peer pressure to use tobacco and reinforces them for having done so. Preliminary results indicate that the prevalence of tobacco use among students receiving peer pressure resistance skills training was somewhat but not statistically significantly lower than the control group after one year of intervention. In addition, students in a third lottery condition, who were reinforced for simply not using tobacco, showed lower prevalence rates compared to controls. Additional support for the efficacy of the intervention program was provided by the refusal skills assessment test, which indicated that students exposed to the intervention were able to refuse tobacco offers more effectively than the control students. Our results indicate that tobacco use prevention experts should do more than provide decision-making and behavioral skills for resisting tobacco use, but should also reinforce the non-use of tobacco.