"They don't care to study it": Trust, race, and health care experiences among patient-caregiver dyads with multiple myeloma

BACKGROUND

Medical mistrust, rooted in unethical research, is a barrier to cancer-related health care for Black/African American (AA) persons. Understanding trust, mistrust, and health care experiences is crucial, especially in multiple myeloma (MM), which disproportionately burdens Black/AA persons in incidence and survival.

STUDY PURPOSE

This study qualitatively examines the experiences of Black/AA and White dyads (patient with MM and adult caregiver) to gain insights into these phenomena.

METHODS

From November 2021 to April 2022, we recruited 21 dyads from the UNC Lineberger Comprehensive Cancer Center. Participants completed a sociodemographic survey and a 60-90 min semi-structured interview. We used ATLAS.ti v9 for project management and to facilitate data analysis using the Sort and Sift, Think and Shift approach (ResearchTalk Inc).

RESULTS

We interviewed 21 racially concordant dyads (11 Black/AA, 10 White) with mean patient ages of 70 (Black/AA) and 72 (White) at enrollment. Both Black/AA and White caregivers had a mean enrollment age of 68. The mean duration from MM diagnosis to enrollment for all patients was 5.5 years. Four key themes emerged: (1) knowledge and trust, (2) heightened emotions and discomfort, (3) differing mental constructs of health care experiences, and (4) mitigating mistrust, which varied by self-identified race. Black/AA participants had greater knowledge of historical events like the U.S. Public Health Service Untreated Syphilis Study at Tuskegee and carried the emotional burden longer. They also emphasized self-learning and self-guided research about MM for informed medical decision-making. Both Black/AA and White dyads emphasized the pivotal role of patient-provider relationships and effective communication in fostering trust and addressing concerns.

CONCLUSION

Our study offers contextual insights into the enduring challenges of medical mistrust, particularly within the Black/AA community, and its implications for patients and caregivers accessing and receiving MM-related care. Future studies should leverage these insights to guide the development of multilevel interventions addressing medical mistrust within the Black/AA community.

Translation, cross-cultural adaptation and validation of the sickle cell self-efficacy scale (SCSES)

OBJECTIVE

To translate, cross-culturally adapt and validate the Sickle Cell Self-Efficacy Scale for application in the Brazilian cultural context.

METHODS

This is a methodological study performed in 6 steps: 1- Forward translation; 2- Translation synthesis; 3- Back-translation; 4- Assessment by expert committee, with computation of the Content Validity Index (CVI); 5- Cultural adequacy (pre-test); 6- Reproducibility. A pre-test was performed with the participation of 10 adolescents/young adults with sickle cell disease through a telephone call and their responses were recorded on a form in a web platform. The instrument validation step was carried out with 55 adolescents/young adults with sickle cell disease, 43 of them having participated in the retest. The analysis of internal consistency and reproducibility was calculated using the Cronbach's alpha coefficient and the Intraclass Correlation Coefficient (ICC), in the R statistical programming environment.

RESULTS

The translated instrument had good acceptance among the experts, reaching an average CVI of 1.0. In assessing reliability, the scale showed acceptable internal consistency, with a Cronbach's alpha of 0.84. In the agreement analysis, the ICC was 0.923 (95% CI: 0.857 to 0.958), which indicates good temporal reproducibility.

CONCLUSIONS

Following the process of translation, cross-cultural adaptation and validation, we obtained the Brazilian version of the Sickle Cell Self-Efficacy Scale, considered valid and reliable to be applied to adolescents and young adults with sickle cell disease in Brazil.

Social ecological approach to factors influencing perinatal mental health service provision among providers in Bulloch County, GA

Perinatal mental illness pertains to pregnancy-related mental health complications, which could last as long as one year post-delivery. Despite the high prevalence of PMI, there remains a poor accessibility and utilization of mental health services, especially in the rural America. Hence, using the Social Ecological Model (SEM), we aim to identify factors influencing perinatal mental health service provision among providers in Bulloch County, GA. Using a random sampling method, we recruited 15 mental health providers in Bulloch County through professional networks who completed open-ended surveys between January 31 and March 5 of 2021. The open-ended survey was guided by the SEM constructs, which included Individual, Interpersonal, Organizational, Community, and Policy factors. The Qualitative thematic analysis was conducted using NVivo software. Major barriers among providers include lack of available resources and lack of rapport among patients and providers. Major facilitator themes included increase in mental health screening, rapport building, education, and awareness. This study suggests the introduction of group therapies in public communal areas is helpful. Findings from this study will be useful in developing tailored interventions to address barriers to perinatal mental health-care utilization experienced by both women and perinatal mental health-care providers.

College Students' Experiences of Race-Related Bias or Hatred in Their Lifetimes and COVID-19 Era

OBJECTIVE

The primary aim of this study was to investigate whether students in minority race categories are more likely to experience race-related bias and hatred in their lifetime and since the onset of COVID-19, after controlling the effect of demographic and other variables.

METHODS

This quantitative study used primary data from the survey of 1249 college students at one of the universities in Georgia during April and May 2020. We performed multinomial logistic regression, computing 2 models for the 2 ordinal dependent variables concerning students' experience of race-related bias and hatred-(a) during their lifetime and (b) since the onset of COVID-19 in March 2020-both measured as "never," "rarely," "sometimes," and "fairly often or very often."

RESULTS

During their lifetime, 47.5% of students had experienced some level of bias or hatred, ranging from "rarely" to "very often." Since the onset of COVID-19 on March 2 in Georgia, in a short period of 1 to 2 months, 17.6% of students reported experiencing race-related bias or hatred. Univariate statistics revealed substantial differences in race-related bias and hatred by race, experienced during students' lifetime as well as since the onset of COVID-19. Results of multinomial logistic regression showed that the odds of having experienced bias or hatred during their lifetime were significantly higher (P < .05) for the Black students than for White students (adjusted odds ratio [AOR] = 75.8, for very often or often vs never; AOR = 42 for sometimes vs never). Compared with White students, the odds of hatred and bias were also significantly higher for students who were Asian, multiple races, or another non-White race. The odds of having experienced race-related bias and hatred since the onset of COVID-19 were also higher for Black Asian, multiple races, and other non-White students.

CONCLUSIONS

This study adds critical scientific evidence about variation in the perception of bias and hatred that should draw policy attention to race-related issues experienced by college students in the United States.

Publication of data collection forms from NHLBI funded sickle cell disease implementation consortium (SCDIC) registry

BACKGROUND

Sickle cell disease (SCD) is an autosomal recessive blood disorder affecting approximately 100,000 Americans and 3.1 million people globally. The scarcity of relevant knowledge and experience with rare diseases creates a unique need for cooperation and infrastructure to overcome challenges in translating basic research advances into clinical advances. Despite registry initiatives in SCD, the unavailability of descriptions of the selection process and copies of final data collection tools, coupled with incomplete representation of the SCD population hampers further research progress. This manuscript describes the SCDIC (Sickle Cell Disease Implementation Consortium) Registry development and makes the SCDIC Registry baseline and first follow-up data collection forms available for other SCD research efforts.

RESULTS

Study data on 2400 enrolled patients across eight sites was stored and managed using Research Electronic Data Capture (REDCap). Standardized data collection instruments, recruitment and enrollment were refined through consensus of consortium sites. Data points included measures taken from a variety of validated sources (PHENX, PROMIS and others). Surveys were directly administered by research staff and longitudinal follow-up was coordinated through the DCC. Appended registry forms track medical records, event-related patient invalidation, pregnancy, lab reporting, cardiopulmonary and renal functions.

CONCLUSIONS

The SCDIC Registry strives to provide an accurate, updated characterization of the adult and adolescent SCD population as well as standardized, validated data collecting tools to guide evidence-based research and practice.

Development of a sickle cell disease readiness for transition assessment

BACKGROUND

Instrumentation with established reliability and validity is not yet routinely utilized to assess readiness for transition from pediatric to adult care for youth and young adults with chronic conditions, including sickle cell disease (SCD).

OBJECTIVE

The aim of this study was to develop a SCD specific readiness for transition assessment tool.

SUBJECTS

Fifty-seven youths with SCD, ages 15-21 years, completed the initial version of the Transition Intervention Program - Readiness for Transition (TIP-RFT) assessment; 113 youths/young adults with SCD, ages 14-26 years, at two distinct sites of care completed a refined version of the TIP-RFT.

METHODS

The TIP-RFT was constructed based on a literature review, provider and patient consensus and assessed domains including knowledge and skills in medical self-care, social support, health benefits and independent living and educational/vocational skills. We used principal components factor analysis to evaluate TIP-RFT responses and assessed differences in TIP-RFT scores in relation to age, gender, sickle cell diagnosis and site of care.

RESULTS

The original TIP-RFT, which had demonstrated face validity, was reduced from 56 to 22 items. The revised instrument consisting of four subscales demonstrated good internal consistency reliability and construct validity.

CONCLUSION

Our results support that the TIP-RFT is a valid and reliable tool for the assessment of transition readiness for youths with SCD. The TIP-RFT assessment can guide interventions to improve transition readiness and can provide a foundation for future research on other variables that might be associated with transition readiness.

African American Adolescents with Sickle Cell Disease: Support Groups and Psychological Well-Being

There has been little systematic study of the impact of support groups on the psychological well-being (PWB) of adolescents with sickle cell disease (SCD). Questionnaires, administered by group leaders of 12 SCD support groups, were completed and returned from 79 (80%) of the 99 African American adolescent SCD support group members recruited into this study. Multiple regression analysis revealed that PWB was best predicted by fewer physical symptoms and greater satisfaction with the group. To test a buffering hypothesis of social support, two 2 2 analyses of variance (ANOVAs) were computed to test the interaction of group satisfaction and (a) physical symptoms and (b) pain on PWB. Group satisfaction showed a main effect for each ANOVA. An interaction effect between pain and group satisfaction was detected, supporting a buffering hypothesis. This suggests that adolescents with SCD associate pain, but not physical symptoms, as high stressors. Professionals can enhance their effectiveness as providers of social and mental health services by understanding the role support groups play in the overall well-being of adolescents with SCD.

Transition and sickle cell disease

Sickle cell disease (SCD), the most common genetic disease screened for in the newborn period, occurs in ~1 in 2400 newborns in the general population and 1 in 400 individuals of African descent in the United States. Despite the relative high prevalence and low pediatric mortality rate of SCD when compared with other genetic diseases or chronic diseases in pediatrics, few evidence-based guidelines have been developed to facilitate the transition from pediatrics to an internal medicine or family practice environment. As with any pediatric transition program, common educational, social, and health systems themes exist to prepare for the next phase of health care; however, unique features characterizing the experience of adolescents with SCD must also be addressed. These challenges include, but are not limited to, a higher proportion of SCD adolescents receiving public health insurance when compared with any other pediatric genetic or chronic diseases; the high proportion of overt strokes or silent cerebral infarcts (~30%) affecting cognition; risk of low high school graduation; and a high rate of comorbid disease, including asthma. Young adults with SCD are living longer; consequently, the importance of transitioning from a pediatric primary care provider to adult primary care physician has become a critical step in the health care management plan. We identify how the primary care physicians in tandem with the pediatric specialist can enhance transition interventions for children and adolescents with SCD.

Knowledge and perceptions of couples' voluntary counseling and testing in urban Rwanda and Zambia: a cross-sectional household survey

Background

Most incident HIV infections in sub-Saharan Africa occur between cohabiting, discordant, heterosexual couples. Though couples' voluntary HIV counseling and testing (CVCT) is an effective, well-studied intervention in Africa, <1% of couples have been jointly tested.

Methods

We conducted cross-sectional household surveys in Kigali, Rwanda (n = 600) and Lusaka, Zambia (n = 603) to ascertain knowledge, perceptions, and barriers to use of CVCT.

Results

Compared to Lusaka, Kigali respondents were significantly more aware of HIV testing sites (79% vs. 56%); had greater knowledge of HIV serodiscordance between couples (83% vs. 43%); believed CVCT is good (96% vs. 72%); and were willing to test jointly (91% vs. 47%). Stigma, fear of partner reaction, and distance/cost/logistics were CVCT barriers.

Conclusions

Though most respondents had positive attitudes toward CVCT, the majority were unaware that serodiscordance between cohabiting couples is possible. Future messages should target gaps in knowledge about serodiscordance, provide logistical information about CVCT services, and aim to reduce stigma and fear.

Findings from a community education needs assessment to facilitate the integration of genomic medicine into primary care

PURPOSE

To assess the lay public's knowledge of, and beliefs about, genetics and genetic testing to create an educational initiative that promotes acceptance and utilization of genomic medicine in primary health care.

METHODS

A telephone survey of English-speaking adults in Guilford County, North Carolina was conducted in 2006 to identify community members' educational needs regarding genetics and genetic testing.

RESULTS

Most respondents recognized the connection between family history and disease risk. A majority did not appear to know about: (1) basic principles of inheritance, (2) laws prohibiting genetic discrimination, and (3) the availability and limitations of genetic tests. About 25% thought that they could not reduce their risk if they have a genetic predisposition for disease. Knowledge level was affected by education, experience, age, and race.

CONCLUSION

If primary care providers use family history as a risk assessment tool, community education programs must address (1) the collection of family health history, (2) legislation regarding genetic nondiscrimination, (3) benefits and limitations of existing genetic tests, and (4) genetic determinism. Programs emphasizing practical, "how to" information can be targeted to individuals likely to collect family history information and address misperceptions about discrimination, testing, and determinism.

Transition from pediatric to adult care in sickle cell disease: establishing evidence-based practice and directions for research

Transition of young adults with sickle cell disease (SCD) from pediatric to adult medical care is an important priority, given medical advances that have transformed SCD into a lifelong chronic condition, rather than a disease of childhood. Successful transfer from pediatric to adult care has its foundation in collaboration among the young adult, the family, and the health care system to support building skills in positive disease management and independent living. Systemic issues in transition from pediatric to adult care for individuals with SCD include limited access to adult providers with the skills and/or interest in caring for people with SCD; poor communication and follow-up between pediatric and adult providers; and insurance coverage and reimbursement for care coordination. Family and patient issues in transition include lack of skill development for successful transition into adulthood; absence of financial independence; fear of the unknown; and increasing morbidity with age. The design and evaluation of successful transition programming in SCD requires clarity in conceptual frameworks and consistent measurement, both before and after transfer to adult care. Strategies used by three SCD transition programs and future directions for research and program development are presented.

Implementation of culturally and linguistically competent policies by state Title V Children with Special Health Care Needs (CSHCN) programs

OBJECTIVE

This descriptive study was intended to identify actual actions, steps and processes of Children with Special Health Care Needs (CSHCN) programs to develop, implement, sustain and assess culturally and linguistically competent policies, structures and practices.

METHODS

An online 52-item mixed format survey of Maternal and Child Health (MCH) CSHCN directors was conducted. In April 2003 and May 2004, 59 directors were solicited to participate in the survey and 42 (86%) responded. Standard quantitative and qualitative analyses of the data were conducted to address key questions linked to the study's overall objective.

RESULTS

Findings indicated that almost all respondents are implementing some actions to provide culturally and linguistically competent services including adapting service practices, addressing workforce diversity, providing language access, engaging communities and including requirements in contracts. These individual actions were less often supported by processes such as self-assessment and creating an ongoing structure to systematically address cultural and linguistic competence. Programs are challenged to implement cultural and linguistic competence by state agency organization and budget restrictions.

CONCLUSIONS

The results of the study indicate a continued need for support within state MCH CSHCN programs in order to maintain or enhance the systematic incorporation of culturally and linguistically competent efforts.

The influence of motivational messages on future planning behaviors among HIV concordant positive and discordant couples in Lusaka, Zambia

In Zambia the HIV/AIDS epidemic has resulted in many single female-headed households. Strong patriarchal laws and customs prevent widows and children from maintaining economic assets. This study examines the impact of a video-based motivational intervention promoting future planning in 1,504 HIV-infected couples in Lusaka, Zambia. Following a group video session, couples randomized to the motivational arm could choose to write a will, identify a guardian for their children and make financial plans. Desirable behaviours modelled in the motivational video were measured at quarterly intervals for a year and compared in intervention and control arms. Demographic measures including age, income and educational status were not associated with planning behaviours. Participation in the intervention was associated with will writing (23% versus 5%) and naming a guardian (32% versus 17%) but not with other planning behaviours. The study demonstrates the ability of motivational messages integrated into HIV VCT to encourage future planning behaviour and points to the need to expand existing HIV and VCT services to meet other non-health needs of those living with HIV.

Promotion of couples' voluntary counselling and testing for HIV through influential networks in two African capital cities

BACKGROUND

Most new HIV infections in Africa are acquired from cohabiting heterosexual partners. Couples' Voluntary Counselling and Testing (CVCT) is an effective prevention strategy for this group. We present our experience with a community-based program for the promotion of CVCT in Kigali, Rwanda and Lusaka, Zambia.

METHODS

Influence Network Agents (INAs) from the health, religious, non-governmental, and private sectors were trained to invite couples for CVCT. Predictors of successful promotion were identified using a multi-level hierarchical analysis.

RESULTS

In 4 months, 9,900 invitations were distributed by 61 INAs, with 1,411 (14.3%) couples requesting CVCT. INAs in Rwanda distributed fewer invitations (2,680 vs. 7,220) and had higher response rates (26.9% vs. 9.6%), than INAs in Zambia. Context of the invitation event, including a discreet location such as the INA's home (OR 3.3-3.4), delivery of the invitation to both partners in the couple (OR 1.6-1.7) or to someone known to the INA (OR 1.7-1.8), and use of public endorsement (OR 1.7-1.8) were stronger predictors of success than INA or couple-level characteristics.

CONCLUSION

Predictors of successful CVCT promotion included strategies that can be easily implemented in Africa. As new resources become available for Africans with HIV, CVCT should be broadly implemented as a point of entry for prevention, care and support.

Evaluation of a Disease-Specific Self-Efficacy Instrument in Adolescents with Sickle Cell Disease and its Relationship to Adjustment

The psychometric properties of a disease-specific instrument used to assess self-efficacy in adolescents with sickle cell disease, the Sickle Cell Self-Efficacy Scale, were evaluated in a sample of 131 adolescents ranging from 11 to 19 years of age. This nine-item instrument was associated with a one-item, general self-efficacy question and an item of self-control. After controlling for age, gender, highest grade of education completed, and the number of individuals in the household, high levels of self-efficacy were related to fewer physical, psychological, and total symptoms. Using the stress process framework to examine the relationship between self-efficacy and self-reported symptoms in adolescents may lead to the initiation of effective intervention programs capable of increasing levels of self-efficacy in adolescents. These interventions could lead to better outcomes for adolescents with sickle cell disease. Additional longitudinal investigations are needed to evaluate the ability of self-efficacy to predict adolescent adjustment over time.

Demonstrating excellence in practice-based research for public health

This document explores the opportunity for scholarship to enhance the evidence base for academic public health practice and practice-based research. Demonstrating Excellence in Practice-Based Research for Public Health defines practice-based research; describes its various approaches, models, and methods; explores ways to overcome its challenges; and recommends actions for its stakeholders in both academic and practice communities. It is hoped that this document will lead to new partnership opportunities between public health researchers and public health practitioners to strengthen the infrastructure of public health and add new dimensions to the science of public health practice. Demonstrating Excellence in Practice-Based Research for Public Health is intended for those who produce, participate in, and use practice-based research. This includes academic researchers and educators, public health administrators and field staff, clinical health professionals, community-based organizations and professionals, and interested members of the public.

The impact of SCHIP enrollment on adolescent-provider communication

PURPOSE

Effective communication between physicians and adolescents is critical to convey health information, provide counseling and identify emerging health problems. This article addressed two questions: (a) After an adolescent enrolls in a State Children's Health Insurance Program (SCHIP), is there a change reported in communication between the adolescent and his/her health care provider; and (b) Is there a relationship between respondent's characteristics and change observed within specific content areas?

METHODS

Adolescent preventive care guidelines developed by national organizations provided the study framework. Surveys were mailed to 3472 12-19-year-olds in a SCHIP; 1689 responded (response rate = 49%). Frequencies described the study population, chi-square analysis explored differences in adolescent-provider communication before and after enrollment, and multiple linear regressions were used to determine relationships between respondents' characteristics and provider communication topics.

RESULTS

There were substantial increases after enrollment in SCHIP in the general area of communication between adolescents and their health care providers. Specifically, the presence of a special health care need had a significant influence on most communication areas. Further, females were more likely than males to talk about sexual health (p = .049) and diet and exercise (p < or = .001); older more likely than younger to discuss sexual health (p = .026) and mental health feelings (p = .023); and white more likely than nonwhite to have better overall communication with the provider after enrollment (p = .029) but Whites also were more likely to experience more negative mental health feelings after enrollment in SCHIP (p = .029).

CONCLUSIONS

Practice guidelines define the content of preventive services; but, it appears that many adolescents do not receive adequate guidance from their physicians. For the group of adolescents in this study who had recently enrolled in SCHIP, there was a reported increase in their communication with their health care provider. The positive changes in communication suggest that encouraging providers and adolescents to discuss risky behaviors is a feasible, achievable goal.

The Association of Child Condition Severity with Family Functioning and Relationship with Health Care Providers Among Children and Youth with Special Health Care Needs in Alabama

OBJECTIVE

The purpose of the present study is to assess how the severity of a child's condition affects family functioning and the relationship with health care providers among children with special health care needs in Alabama.

METHODS

Using the data from the National Survey of Children with Special Health Care Needs (CSHCN), three variables were used as measures of condition severity: responses to the CSHCN screener questions, whether condition affected the ability to do things for children and youth with special health care needs (CYSHCN), and the level of severity of CYSHCN's condition. The dependent variables included family functioning and provider relationship.

RESULTS

CYSHCN who only take prescription medicine for their chronic condition (MO) had lower condition severity from those who have other needs (NMO). In NMO CYSHCN, higher condition severity was associated with increased strain on family functioning outcomes and higher unmet needs in provider relationship outcomes, adjusted for demographic and insurance variables. Families of NMO CYSHCN with a more severe condition spent more temporal and financial resources and had a higher need for professional care coordination, and were less likely to have sensitive providers.

CONCLUSIONS

Severity of condition is an important factor increasing strain on family resources and relationship with the provider. Our results indicate the need for professional care coordination and family support, particularly among those families in which there is a NMO CYSHCN with a more severe condition. This finding supports the mandate that all CYSHCN should have their health care coordinated and provided in the context of a medical home.

Multi-site study of transition in adolescents with sickle cell disease in the United Kingdom and the United States

Adolescents with sickle cell disease may have problems of adjustment during the phase of transition from pediatric to adult health care. It is important to identify factors that may help in the development of appropriate interventions. We were interested in possible similarities, in terms of adjustment to transition in two countries where health service provision is quite different. The study employed a cross-sectional survey design, with a sample of adolescents (still in pediatric care) drawn from a U.S.A national sample and a single U.K. site. A battery of validated disease-specific measures was used to assess adolescent perceptions of physical and psychological symptoms, self-efficacy, self-management skills, and gather demographic data. There were no significant demographic differences between the samples of adolescents in the two countries. Taken together, the two populations indicate that adolescent age and educational level were associated with symptoms (physical and psychological). Self-efficacy is not associated with demographic factors, but is predicted by physical symptoms, while different aspects of self-management are predicted by age (responsibility with care), educational level (independence and confidence with care) and psychological symptoms (knowledge about SCD and confidence with care). This study highlights the importance of gathering disease-specific transitional information from adolescents with sickle cell disease in the U.K. and U.S.A. It also shows that demographic variables have to be considered in the development of any intervention programme.

Quality health care for adolescents with special health-care needs: issues and clinical implications

Assuring quality health care for the diverse U.S. adolescent population is a subject of growing concern among health-care providers and policy makers. Health-care services and policies must appreciate that experiences of adolescents with special health-care needs include challenges that stretch beyond those unique to their conditions to include relationships with family, friends, and professionals as well as their ability to function in school, clinics, and other settings. This review explores those issues while building upon the six core outcomes delineated in the draft 10-year action plan offered as an accompaniment to the U.S. Department of Health and Human Services' Healthy People 2010 guidelines.

Providers' perspectives and beliefs regarding transition to adult care for adolescents with sickle cell disease

Until recently, few children with chronic illnesses such as sickle cell disease (SCD) lived past late adolescence. Substantial reductions in mortality mean a growing number of adolescents with SCD reach adulthood. Consensus among researchers and health care providers (HCP) from multiple disciplines is that critical attention to and more empirical research on the transition from pediatric to adult care is needed. We address the following questions: (1) How do pediatric and adult providers demonstrate involvement in transition? (2) What is expected of adolescents when they move to adult care? and (3) Do providers think there is a need for a systematic transition program? A cross-sectional, multi-format survey research study utilizing open-ended and forced-choice questions was conducted to compare responses between pediatric and adult providers from multiple disciplines. Data were collected from 227 HCP in three waves. Significant bivariate results (p < 0.05) reflected differing opinions regarding transition expectations and program need, especially among female providers, those practicing in urban areas, and providers who treat both adolescent and adult clients in comparison with their counterparts. Discussion includes implications for program development, social service and public health practice, and future research.

Transition to adult care for adolescents with sickle cell disease: results of a national survey

The objective was to present the 'voice' of adolescents with sickle cell disease (SCD) as part of the discussion of transition issues by identifying and documenting their expressed concerns and expectations, as well as what program priorities they perceive would facilitate a smooth transition to adult care. Cross-sectional data were collected by means of structured questionnaire interviews, using standard instruments. A volunteer sample of 172 adolescents with SCD aged 14 years and older still in pediatric care within community-based and medical center SCD programs across the United States was recruited. Statistically significant results indicated the top concerns of adolescents were: lack of information relating to their transition to adult care; fear of leaving the healthcare provider with whom they were already familiar, fear that adult care providers might not understand their needs; belief that an SCD transition program was needed and that it should focus on provider support; information provision about adult care programs; ways to meet adult care providers; and ways to help healthcare providers understand their needs. We conclude that many adolescents with SCD have concerns and fears about their transition to adult care. Based on findings from this study, it is recommended that transition programs address structural and interpersonal issues of adolescents and providers if they are to be successful. Strategies by which this can be achieved are recommended, including the need to encourage, support and provide assistance for peer education, outreach programs and peer-led instructions, since these hold great promise as approaches that are adolescent-centered and adolescent-delivered.

Rural/urban differences in access to and utilization of services among people in Alabama with sickle cell disease

OBJECTIVE

This study examined relationships between socioeconomic factors and the geographic distribution of 662 cases of sickle cell disease in Alabama in 1999-2001.

METHODS

Measures of community distress, physical functioning, and medical problems were used in analyzing utilization differences between individuals with sickle cell disease living in urban and rural areas.

RESULTS

Utilization of comprehensive sickle cells disease services was lower for individuals with sickle cell disease living in rural areas than for those living in urban areas. Rural clients reported significantly more limitations than urban clients on several measures of physical functioning. The results also suggest that utilization of services was higher for those with more medical problems and those who lived in high distress areas, although these findings did not meet the criterion for statistical significance.

CONCLUSIONS

Conclusions based on statistical evidence that geographic location and socioeconomic factors relate to significantly different health care service experience bear important implications for medical and health care support systems, especially on the community level.

Self-care in adults with sickle cell disease

This article summarizes the psychometric evaluation of the Chronic Illness Assessment Interview for Sickle Cell Disease (CIAI-SCD), an instrument based on a model of self-care for adult patients with chronic medical conditions. The CIAI-SCD was administered to 104 adults with sickle cell disease. A factor analysis identified three factors that reflected the psychological constructs of Personal Satisfaction and Perceived Control (Factor 1), Feeling Concerned and Worried (Factor 2), and Feeling Supported (Factor 3). Preliminary evidence for the internal consistency, test-retest reliability content validity, and construct validity of the CIAI-SCD was obtained. After further refinement and validation, the CIAI-SCD may be a useful tool for assessing factors related to self-care skills among adults with sickle cell disease.

Self-efficacy as a predictor of adult adjustment to sickle cell disease: one-year outcomes

OBJECTIVE

The present study prospectively investigated the role of self-efficacy in predicting disease symptomatology and health services utilization for adult patients with sickle cell disease.

METHODS

These data are derived from a 12-month prospective cohort study of African American adults with sickle cell disease. Disease-specific perceptions of coping self-efficacy and indices of disease severity, health care utilization, and psychosocial adjustment were assessed by use of standardized questionnaires administered by trained clinicians.

RESULTS

Perceptions of self-efficacy for coping with sickle cell disease were moderately stable across the 12-month study period. At baseline (N = 147), significant inverse relationships, measured with Pearson correlations, were noted between self-efficacy and the following variables: physical symptoms, psychological symptoms, pain severity, and number of physician visits over the preceding 12 months (p <.01). Similar relationships with self-efficacy were noted at the 1-year follow-up (N = 104) period for measures of physical symptoms, psychological symptoms, and pain severity (p <.01). In multiple-regression models, baseline self-efficacy scores predicted changes over the 1-year study period in physical and psychological sickle cell disease symptomatology. Moreover, changes in self-efficacy from baseline to 1-year follow-up were significantly and independently related to changes in physical symptoms, psychological symptoms, and pain ratings from baseline to 1-year follow-up.

CONCLUSIONS

Self-efficacy beliefs among African American adults with sickle cell disease are inversely related to reported disease symptomatology, and these relationships persist across time. Future investigations should examine the mechanisms through which relationships between self-efficacy and adjustment to sickle cell disease are effected, as well as the feasibility and effectiveness of enhancing self-efficacy beliefs as a means of improving adjustment to sickle cell disease.

Socioeconomic distress and health status: the urban-rural dichotomy of services utilization for people with sickle cell disorder in North Carolina

Research on sickle cell disorder has not focused attention on the socioeconomic background and geographic distribution of people with the disease. This study examines 1,189 persons with sickle cell disorder in North Carolina during 1991 to 1995. Three indices were developed using clients' medical, psychosocial and socioeconomic characteristics for the purpose of analyzing the urban-rural difference in treatment for sickle cell disease. The study observed a wide disparity in these indices between urban and rural population groups. Also, differences were observed in the utilization of services and clients' health status. The findings suggest that utilization of services is directly related to socioeconomic condition facing clients and clinic distance from clients. They further suggest that people in rural areas who have high distress levels and are far from clinics have limited access to health care. The limited availability of medical and health care in rural areas, as well as other support systems calls for an increase in community based healthcare services. These findings should be of particular interest to the state level sickle cell disorder program in North Carolina and other areas with a large rural population. Enhanced support for all persons with sickle cell disorder in North Carolina, particularly those in rural areas, is critical.

Reliability and validity of a self-efficacy instrument specific to sickle cell disease

The psychometric properties of a new, 9-item scale measuring disease-specific perceptions of self-efficacy were investigated in a community-based sample of adults (N = 83) with sickle cell disease (SCD). The Sickle Cell Self-Efficacy Scale (SCSES) was comprised of nine questions relating to participants' perceptions of their ability to function on a day-to-day basis and to manage SCD symptomatology (e.g. episodes of pain). The SCSES demonstrated good internal consistency, discriminant validity, and convergent and predictive validity, both with previously validated measures of related constructs as well as with reported SCD symptomatology. Overall, the instrument appears to be reliable and valid for assessing clients' self-efficacy for engaging successfully in day-to-day activities despite having SCD. Future investigators may wish to examine temporal and causal links between alterations in self-efficacy and changes in adjustment to sickle cell disease; the SCSES provides a psychometrically sound tool with which to investigate these phenomena.

Factors that influence adolescent adaptation to sickle cell disease

OBJECTIVE

To examine whether psychosocial factors play a more important role than biomedical risk factors in predicting adolescent adaptation to sickle cell disease (SCD); to determine whether psychosocial factors moderate the relationship between biomedical risk factors and adaptation.

METHODS

Ninety African American adolescents from the multisite Cooperative Study of Sickle Cell Disease were recruited to complete a battery that included measures of psychosocial status and psychological adaptation. Data regarding their health status were collected from medical records.

RESULTS

The findings revealed that intrapersonal (self-esteem, social assertiveness), stress-processing (use of social support), and social ecological factors (family relations) were significant predictors of adaptation; however, biomedical factors did not predict adaptation. There was no evidence that psychosocial factors moderated the relationship between biomedical risk factors and adaptation.

CONCLUSIONS

Psychosocial factors proved to be better predictors of adaptation than biomedical risk factors. Additional research is needed to better understand the nature of the interrelationships among biomedical risk factors, psychosocial factors, and adaptation.

Adolescents with sickle cell disease: determinants of support group attendance and satisfaction

Support groups have the potential to mitigate some of the developmental and condition-specific psychological and social issues common to sickle cell disease (SCD), yet little is known about how adolescents with SCD view and use these groups. As part of a larger study, 79 adolescents with SCD completed questionnaires assessing reasons for attending or not attending support groups, level and type of help received from group participation, group satisfaction, and attendance. This article reports on findings descriptively. Professionals can enhance their effectiveness as providers of social and mental health services by understanding the role that support groups play in the overall well-being of adolescents with SCD.

Does race influence the provision of care to persons with sickle cell disease? Perceptions of multidisciplinary providers

This study examined whether multidisciplinary health care providers (HCPs) perceived race of persons with sickle cell disease (SCD) as an influence in the delivery of health care. A total of 227 multidisciplinary HCPs completed the three-item Influence of Patient Race on Provision of Health Care Services Index (Cronbach's alpha = 0.77). Results suggest that African American HCPs were more likely to perceive race as an influence along all scale items, whereas Caucasian and other race HCPs did not. Female HCPs and those who serve adults were more likely than male HCPs and those who serve children to perceive race as having an influence on the quality of health care. Findings suggest a need for the examination of the health care delivery systems in which persons with SCD receive care to determine if race does, in fact, affect the delivery of health care and to explain the discrepancies in the perceptions of the HCPs.

Transfer as a component of the transition of adolescents with sickle cell disease to adult care: adolescent, adult, and parent perspectives

PURPOSE

There are no empirical studies which access the transfer needs/concerns of adolescents and young adults with sickle cell disease (SCD) and their primary caretakers. The overall purpose of this research was to determine the issues, concerns, and expectations of adolescents, young adults and primary caretakers with regard to transfer to adult care.

METHODS

Participants were recruited from clinics and programs participating in the Duke/UNC Comprehensive Sickle Cell Program. Using a cross-sectional survey design, young adults (n = 60), adolescents (n = 36) and primary caretakers (n = 25) were administered the Sickle Cell Transfer Questionnaire (SCTQ).

RESULTS

Adolescents and young adults with SCD were primarily concerned about how they would pay for medical care and how they would be treated by adult providers. Caretakers were concerned about their teens leaving pediatric care and assuming responsibility for medical care. All three groups reported mixed emotions about leaving pediatric care. There was consensus among the respondents regarding the need for transfer programs and what they should offer. Bivariate analysis revealed that age, education level, and disease severity were statistically significant co-factors influencing the feelings, concerns and opinions of the study participants.

CONCLUSION

Future longitudinal experimental research is needed to corroborate the results of this study and to assess the effectiveness of transition-related intervention programs for adolescents with SCD and their families.

Factors in the long term adjustment of children and adolescents with sickle cell disease: conceptualizations and review of the literature

This paper focuses on the psychological and social factors that influence the adjustment process of children and adolescents with chronic conditions, primarily sickle cell disease. A review of the literature will reveal that psychological variables, such as anxiety and depression affecting adjustment, are the most studied. However, it will be pointed out that social variables such as family, school, and peers, also play a major role in this process. Furthermore, in keeping with the approach of this special collection, these psychological issues will be discussed within a developmental context. Clinical teams and practitioners are encouraged to take a longitudinal-biopsychosocial approach in addressing the needs of these children and their families. By doing so, they will be able to meet the present and long term psychological, social, educational, as well as medical needs of children and adolescents with sickle cell disease and other chronic conditions, and their families. This approach will also allow professionals to recognize and utilize the strengths of this population in the promotion of their overall well-being.