The Common-Sense Model of Self-Regulation (CSM): a dynamic framework for understanding illness self-management

Illness perceptions are a potential predictor of psychological distress in patients with non-muscle-invasive bladder cancer: a 12-month prospective, longitudinal, observational study

Depressive and anxiety symptoms are common psychiatric disorders among cancer patients. Among the 137 patients with NMIBC (Non-Muscle-Invasive Bladder cancer), 101 patients who provided answers to the Hospital Anxiety and Depression Scale (HADS) and the Brief Illness Perception Questionnaire (B-IPQ) completed the 12-month longitudinal study. Hierarchical regression analyses were conducted to evaluate the interactions between psychiatric problems and illness perceptions (IPs). Patients with NMIBC displayed less positive IPs and more negative IPs. IPs have explained 42.0% and 39.5% of the variance in anxiety at 3 and 12 months of follow-up. IPs have explained 41.4% and 45.5% of the variance in depressive symptoms at 3 and 12 months of follow-up. The results demonstrated IPs are significantly associated with psychological distress and taken as the potential predictor of psychological distress in patients with NIMBC. Interventions focusing on the modification of poor IPs may be feasible and effective in improving psychiatric disorders and quality of life among patients with NIMBC.

Acquisition and generalization of cough trigger beliefs in allergic rhinitis

In allergic conditions, trigger identification is often inaccurate, and may be influenced by pre-existing beliefs. In this study, we investigated the acquisition and generalization of symptom trigger beliefs in individuals with allergic rhinitis (n = 24) and control participants (n = 24). In a lab-based trigger acquisition task, unique exemplars of two trigger categories were either paired with saline inhalation (CS- category) or citric acid inhalation (CS+ category). The next day, we tested recognition and symptom expectancy for CS category exemplars and exemplars of novel trigger categories. Participants acquired differential symptom expectancies for CS+ compared to CS- exemplars, with faster acquisition in participants with rhinitis. Differential symptom expectancies persisted the next day, and generalized to novel trigger categories, with stronger generalization in rhinitis vs. control participants. These patterns of acquisition and generalization suggest that overgeneralization of trigger beliefs may complicate trigger identification in participants with allergic conditions.

THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer

Background

Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence.

Methods

In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an “App” group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an “App+Feedback” group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a “Usual Care” group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence.

Discussion

A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the “Triple Aim” – reduce costs while improving health outcomes and the patient care experience.

Trial registration

NCT03592771. Prospectively registered on July 19, 2018.

Home health monitoring around the time of surgery: qualitative study of patients' experiences before and after joint replacement

OBJECTIVES

Hip and knee replacements are common major elective surgical interventions with over 200 000 performed annually in the UK. Not all patients achieve optimal outcomes or experience problems or delays in recovery. The number of patients needing these operations is set to increase, and routine clinical monitoring is time-consuming and resource-consuming for patients and healthcare providers; therefore, innovative evaluation of surgical outcomes is needed. The aim of this qualitative study was to capture the patient experience of living with a novel home monitoring sensing system during the period around joint replacement.

SETTING

One secondary care hospital in the South West, UK.

PARTICIPANTS

13 patients (8 female, 63-89 years) undergoing total hip or knee replacement enrolled into the study.

DESIGN

Qualitative study with thematic analysis. The system remained in situ for up to 12 weeks after their surgery and comprised a group of low-powered sensors monitoring the environment (temperature, light and humidity) and activity of people within the home. Patients were interviewed at two timepoints: before and after surgery. Interviews explored views about living with the technology, its acceptability, as well as attitudes towards health technology.

RESULTS

Three main themes emerged: installation of home-sensing technology on the journey to surgery, the home space and defining unobtrusiveness and pivotal role of social support networks.

CONCLUSIONS

Patients who agreed to the technology found living with it acceptable. A home-sensing system that monitors the environment and activity of the people in the home could provide an innovative way of assessing patients' surgical outcomes. At a time characterised by reduced mobility, functional limitations and increased pain, patients in this study relied on informal and formal supportive networks to help maintain the system through the busy trajectory of the perioperative period.

Assessing Informal and Formal Diabetes Knowledge in African American Older Adults With Uncontrolled Diabetes

Some researchers attribute the excess rates of diabetes complications among African American older adults compared to other racial/ethnic subgroups to low diabetes knowledge. Diabetes knowledge measures have a biomedical orientation, including knowledge of glycemic control and using diet and exercise to control blood sugar. Measures do not assess informal knowledge that patients obtain outside of the clinical environment. The distinction between formal and informal knowledge is meaningful for cultural groups such as African American individuals who have historically transferred knowledge about maintaining their health "through the grapevine." A qualitative approach was used to understand participants' informal diabetes knowledge. Three major themes identified addressed the threat that participants perceived when diagnosed, the social construction of diabetes knowledge through their lived and observed experiences, and the limited role that clinicians played in participants' diabetes knowledge acquisition. Findings reveal ways nurses can individualize the diabetes education they provide to African American older adults based on their experiential understanding. [Journal of Gerontological Nursing, 45(2), 35-41.].

An observational mixed-methods approach to investigate the fear of cancer recurrence cognitive and emotional model by Lee-Jones et al with women with breast cancer during radiotherapy treatment

There is minimal qualitative research on fear of cancer recurrence (FCR) in patients who are still undergoing treatment. This study explored how breast cancer patients' illness beliefs changed during radiotherapy treatment, so as to provide their longitudinal perspective across sessions. These beliefs were mapped to Lee-Jones et al FCR model to assess its applicability to patients during this key treatment phase. A framework qualitative analysis was employed for verbatim interactions between patients (n = 8) and their radiographer (n = 2) over a minimum of three weekly review sessions (26 review consultations in total). Results proved suggested evolution and repetition of themes within and across sessions. Most themes were consistent with the early stages of the Lee-Jones et al model (antecedents and FCR) such as internal and external cues, cognitions and emotions. The crucial observation was that somatic stimuli were interpreted as side effects of radiotherapy treatment rather than cancer symptoms. Patients were still undergoing their last phase of major treatment, whereas the Lee-Jones et al model has been constructed to explain patients' past treatment experience. New themes emerged, including current exercise, concurrent illnesses/problems, cancer treatment as a constant reminder (of diagnosis) and associated sleeping difficulties. Decatastrophising of symptoms and experiences relating to cancer and its treatment was also a prominent theme indicating a possible coping mechanism to reduce worries about treatment side effects and associated experiences. Finally, some evidence was found from failure of emotional/fear processing in patients due to early surface reassurance by health professionals - a possible explanation of how FCR might arise. Early detection of FCR and promoting support while patients are still undergoing treatment might prevent patients from developing FCR after treatment.

Short-term integrated rehabilitation for people with newly diagnosed thoracic cancer: a multi-centre randomized controlled feasibility trial

OBJECTIVES

The main objective of this study is to determine the feasibility of recruiting and retaining patients recently diagnosed with thoracic cancer to a trial of short-term integrated rehabilitation; evaluate uptake of theoretically informed components targeting physical function, symptom self-management and participation; estimate sample size requirements for an efficacy trial.

DESIGN

Parallel group randomized controlled feasibility trial.

SETTING

Three U.K. hospitals.

PARTICIPANTS

Patients ⩽eight weeks of thoracic cancer diagnosis, Eastern Cooperative Oncology Group Performance Status 0-3, any cancer stage and treatment plan.

INTERVENTIONS

Participants randomly allocated (1:1) to short-term integrated rehabilitation and standard care or standard care alone over 30 days.

MAIN MEASURES

Primary: participant recruitment and retention, targeting ⩾30% of eligible patients enrolling and ⩾50% of participants reporting outcomes at 30 days. Secondary: intervention fidelity; missing data and performance of outcome measures for self-efficacy, symptoms, physical activity and health-related quality of life.

RESULTS

Of 159 eligible patients approached, 54 (34%) were recruited. A total of 44 (82%) and 39 (72%) participants reported outcomes at 30 and 60 days, respectively. Intervention fidelity was high. Rehabilitation was delivered across 3 (1-3) sessions over 32 (22-45) days (median (range)). Changes in clinical outcomes were modest but most apparent at 60 days for health-related quality of life: Functional Assessment of Cancer Therapy Lung Cancer score median (interquartile range) change 9.7 (-12.0 to 16.0) rehabilitation versus 2.3 (-15.0 to 14.5) standard care.

CONCLUSION

A trial to examine efficacy of short-term integrated rehabilitation for people newly diagnosed with thoracic cancer is feasible. A sample of 336 participants could detect a meaningful effect on health-related quality of life as the primary outcome.

Deciphering programs for optimal self-management of persistent musculoskeletal-related pain and disability - Clinical implications for PTs

The prolonged disability associated with musculoskeletal (MSK) pain represents an enormous health burden, for individuals as well as society. Promoting pain and disability management for patients with persistent MSK-related conditions can be very challenging for rehabilitation professionals. These often-complex conditions require the adoption of a biopsychosocial perspective in order to assess and address a vast array of potential factors affecting the patient. Fortunately, a self-management (SM) approach has been deemed effective in enhancing patients' control over their symptoms and disabilities. However, given the many different existing SM approaches, rehabilitation professionals would benefit from a clearer definition of SM and a better understanding of the basics of a SM program in order to facilitate their patients' development of SM skills, as this can lead to better outcomes. This narrative review explores the various components of an intervention program intended to facilitate patients' SM of their symptoms and disabilities resulting from a persistent MSK condition. It does so by drawing on a body of published work on pain and disability management, conceptual frameworks underlying SM programs, essential skills associated with optimal SM, and examples from the persistent low back pain (LBP) literature.

A pilot study of decision factors influencing over-the-counter medication selection and use by older adults

BACKGROUND AND OBJECTIVES

Despite their availability without prescription, OTC medications pose a risk for significant harm for older adults due to higher likelihood of polypharmacy, drug interactions, and age-related physiological changes. The purpose of this study is to identify the individual decision factors that influence how older adults select and use over-the-counter medications.

METHODS

A pilot study was conducted with 20 community-dwelling older adults. Older adults met the interviewer at a regional mass merchandise store where they were given both pain and insomnia standardized scenarios. Participants described how they would select and then hypothetically use a given medication to treat the problem described in the scenario.

RESULTS

OTC medication selection and reported use were influenced by several person-level decision-making factors including: personal beliefs/knowledge about OTCs, assessment of the ailment, and medical constraints.

CONCLUSION

The findings from this investigation provide direction for interventions to address unsafe OTC medication selection by older adults.

The associations among illness perceptions, resilient coping, and medication adherence in young adult hypertensive black women

Hypertension, a modifiable risk factor of cardiovascular disease, is largely responsible for the disproportionate morbidity and mortality in black women. Black women 20 years of age and older have a higher prevalence of HTN compared to white women (44% vs 28%). Poor adherence and non-adherence to hypertensive medications have been strongly indicated as a primary contributor to the early onset of disparity in cardiovascular disease morbidity and mortality experienced by black people. The purpose of this study was to examine medication adherence in black women relative to sociodemographic, clinical, cultural context, psychosocial, cognitive, and behavioral factors. This was a prospective, descriptive cross-sectional study of N = 85, hypertensive black women, with mean age of 39 ± 5.4 years, 18-45 years of age. Variables and measures included: sociodemographic characteristics, clinical, adverse social stressors, psychosocial, cognitive-behavioral factors, and medication adherence. Descriptive statistics, correlations, multivariate logistic regressions, and moderation analysis were tested. 81.2% (n = 69) of the sample was categorized as non-adherent. SBP was the only clinical covariate associated with HTN medication adherence. HTN illness perceptions, composite score, resilient coping, depressive symptoms, exposure to lifetime gender, and racial stressors, were not associated with HTN medication adherence. Using multivariate logistic regression, decreased SBP and lower scores on the "Consequence" dimension of the HTN illness perception scale were associated with medication adherence (χ2  = 10.53, P = .001). Adherence was associated with both the "Consequence" and "Identity" dimensions of the HTN illness perception scale indicating the need and importance for clinicians to have open and honest communication regarding HTN and its treatment in facilitating adherence.

Controlling the Uncontrollable: Perceptions of Balance in People With Parkinson Disease

BACKGROUND

Exercise improves balance in Parkinson disease (PD), yet the majority of people with the diagnosis are physically inactive. Insights gained from understanding how people with PD (PwPD) make sense of their symptoms and their ability to control them may inform the communication strategies and motivational approaches adopted by physical therapists. To our knowledge, no previous study has qualitatively explored how PwPD perceive the concept of balance and the beliefs they hold concerning their ability to affect balance.

OBJECTIVE

This study aimed to explore the meaning of balance for PwPD and the beliefs they hold regarding their ability to influence their balance in everyday life.

DESIGN

The design was a qualitative study with an inductive approach.

METHODS

In-depth interviews were conducted with 18 participants with PD (age range 46-83 years, Hoehn and Yahr range 1-4), and transcripts were analyzed using qualitative content analysis.

RESULTS

Five main themes emerged from the analysis: remaining in control over the body, adapting behavior to deal with uncertainty, directing focus to stay 1 step ahead, resilience as a defense, and exercise beliefs and reservations. Interpretation of the underlying patterns in the main themes yielded the overarching theme of focus and determination to regain control over shifting balance.

CONCLUSIONS

The concept of balance was perceived as both bodily equilibrium and mind-body interplay and was described in the context of remaining in control over one's body and everyday life. Cognitive resources were utilized to direct focus and attention during balance-challenging situations in a process involving internal dialogue. Even participants who did not express beliefs in their ability to affect balance through exercise used psychological resilience to counter the challenges of impaired balance.

Understanding sciatica: illness and treatment beliefs in a lumbar radicular pain population. A qualitative interview study

BACKGROUND

Several pathological processes contribute to lumbar radicular pain (LRP), commonly known as sciatica. It is not known how patients rationalise the experience of sciatica or understand the diagnosis. Providing clinicians with a better understanding of how patients conceptualise sciatica will help them to tailor information for patients on the management and treatment of the condition.

AIM

To understand patients' beliefs regarding their illness following a diagnosis of LRP, how these beliefs were developed, and the impact of illness beliefs on treatment beliefs.

DESIGN & SETTING

Qualitative interview study from a single NHS musculoskeletal interface service (in Wales, UK).

METHOD

Thirteen patients recently diagnosed with LRP were consecutively recruited. Individual semi-structured interviews were recorded and transcribed. Data were analysed using a thematic approach.

RESULTS

Four main themes were generated: (1) the illness experience (2) the concept of sciatica, (3) treatment beliefs, and (4) the desire for credible information.

CONCLUSION

The diagnosis of LRP is often communicated and understood within a compressive conceptual illness identity. Explaining symptoms with a compressive pathological model is easily understood by patients but may not accurately reflect the spectrum of pathological processes known to contribute to radicular pain. This model appears to inform patient beliefs about treatments. Clinicians should take care to fully explain the pathology prior to shared decision-making with patients.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

Illness beliefs and emotional responses in mildly disabled stroke survivors: A qualitative study

Background

As acute stroke services improve, more persons experience mild stroke and need to cope daily with hidden disabilities, which may be influenced by how they perceive stroke, cognitively and emotionally.

Objective

To investigate cognitive illness beliefs and emotional responses in persons with mild stroke and their possible influences on daily coping.

Methods

Semi-structured interviews were conducted with 24 persons with mild stroke, on average 7.5 months (±0.89) after stroke occurrence. A thematic analysis on verbatim transcripts was guided by the Common-Sense Model of Self-Regulation.

Results

All participants experienced difficulties constructing an illness identity at both acute and chronic phase. Behavioral risk factors were less accepted as causes of stroke. Lack (or inappropriate timing) of information from healthcare providers led to limited medication knowledge and low perceived control of stroke recurrence which generated anxiety, fear, and low involvement in coping. Participants who considered stroke a chronic condition experienced more difficulties. Perceived support from relatives and healthcare providers was beneficial for participation in recovery and health behaviour change.

Conclusion

Despite having mildly disabilities, participants reported difficulties developing illness beliefs conducive to coping, and dealing with their emotional responses. These elements should be considered in tailored programs to improve coping with hidden disabilities post-stroke.

Facebook Groups on Chronic Obstructive Pulmonary Disease: Social Media Content Analysis

Facebook Groups facilitate information exchange and engagement for patients with chronic conditions, including those living with Chronic Obstructive Pulmonary Disease (COPD); however, little is known about how knowledge is diffused throughout these communities. This study aimed to evaluate the content that is available on COPD-related Facebook Groups, as well as the communication (self-disclosures, social support) and engagement (agreement, emotional reaction) strategies used by members to facilitate these resources. Two researchers independently searched the "Groups" category using the terms "COPD", "emphysema", and "chronic bronchitis". Twenty-six closed (n = 23) and public (n = 3) COPD Facebook Groups were identified with 87,082 total members. The vast majority of Group members belonged to closed (n = 84,684; 97.25%) as compared to open (n = 2398; 2.75%) groups. Medications were the most commonly addressed self-management topic (n = 48; 26.7%). While overall engagement with wall posts was low, the number of "likes" (an indicator of agreement) was significantly greater for wall posts that demonstrated social support as compared to posts that did not (p < 0.001). Findings from this study showed that COPD Facebook group members share specific disease-related experiences and request information about select self-management topics. This information can be used to improve the quality of self-management support provided to members of popular COPD Facebook groups.

The role of stigma and trauma in hepatitis C virus treatment in veterans: Applying the common-sense model

Hepatitis C Virus (HCV), a blood borne pathogen capable of causing severe liver disease, disproportionately affects veterans in the United States. While there are antiviral medications to treat HCV, stigma and trauma in this population may lead to avoidance of care. Those veterans who do undergo treatment have certain illness representations about HCV and its treatment. They undergo treatment even while facing stigma and trauma. The Common-Sense Model may be useful in elucidating how such representations, when matched to an appropriate illness prototype, may inform an action plan of how to respond to HCV. An exploration of the illness representations among veterans with HCV, and the effects of stigma and trauma on these representations, may help to explain how they exercise the choice to undergo treatment and may inform interventions to encourage treatment in veterans who have yet to do so.

The role of illness schemata in self-care behaviors and glycemic control among patients with type 2 diabetes in Iran

AIMS

The diabetes illness perception domains outlined by Leventhal's common-sense model may be weakly associated with hemoglobin A1c (HbA1c) and adherence to diabetes self-care behaviors. However, type 2 diabetes patients' illness schemata identified by clustering the illness perception domains remain to be explained. This study aimed to describe type 2 diabetes patients' illness schemata and to examine their association with self-care behaviors and glycemic control in Iran.

METHODS

A cross-sectional survey was conducted with 200 patients (mean age 59.5±10.3; 70% female) who attended self-management classes at the Iranian Diabetes Society in Tehran. Illness perceptions and self-care behaviors were assessed using the Persian version of the Illness Perception Questionnaire Revised and the Summary of Diabetes Self-Care Activity.

RESULTS

Three clusters of diabetes illness beliefs were identified: "empowered," "self-condemned," and "powerless." "Empowered" participants adhered most rigorously to general diet, fruit and vegetable intake, and exercise, and had the best glycemic control (HbA1c=7.2%, SD=0.2), followed by "self-condemned" and then "powerless" participants, who had the lowest adherence and the worst glycemic control (p<0.0001).

CONCLUSIONS

The clustering method for identifying type 2 diabetes patients' illness schemata is useful for selecting patients who need further care and assistance with adhering to self-care behaviors and glycemic control.

Patient Prototypes

Abstract. Despite large bodies of research examining perceptions of illnesses and perceptions of people who engage in various health behaviors, very little research has examined perceptions of people who have a specific illness. The aims of this research were to create a measure of “patient prototypes,” mental representations of the type of person who has a specific illness, and to examine their associations with other health cognitions and behaviors. Two survey studies (Study 1: N = 208 and Study 2: N = 246) assessed patient prototype favorability for three illnesses (skin cancer, Human papillomavirus (HPV), and type 2 diabetes) as well as constructs from the common-sense model and prototype willingness model. Patient prototypes for the three illnesses were distinct in terms of specific traits and overall favorability. Generally, patient prototype favorability was unrelated to illness representation dimensions in the common-sense model but was positively associated with some constructs in the prototype/willingness model. All three prototypes were positively correlated with perceived vulnerability. The skin cancer prototype was positively correlated with measures of behavioral willingness, behavioral intention, and actual health behavior (UV exposure). Limitations include the use of young adult participants who have relatively little experience with the illnesses examined. Measures of patient prototype favorability and health behaviors need to be further examined and refined. The novel construct of patient prototype favorability provides a foundation for future inquiry into the role that patient perceptions play in health behavior and the implications for the prototype/willingness model and the common-sense model.

Experience of living with knee osteoarthritis: a systematic review of qualitative studies

OBJECTIVES

Systematically review the qualitative literature on living with knee osteoarthritis from patient and carer perspectives.

DESIGN

Systematic review of qualitative studies. Five electronic databases (CINAHL, Embase, MEDLINE, PsycINFO, SPORTDiscus) were searched from inception until October 2018. Data were synthesised using thematic and content analysis.

PARTICIPANTS

Studies exploring the experiences of people living with knee osteoarthritis, and their carers were included. Studies exploring experiences of patients having participated in specific interventions, including surgery, or their attitudes about the decision to proceed to knee replacement were excluded.

RESULTS

Twenty-six articles reporting data from 21 studies about the patient (n=665) and carer (n=28) experience of living with knee osteoarthritis were included. Seven themes emerged: (i) Perceived causes of knee osteoarthritis are multifactorial and lead to structural damage to the knee and deterioration over time (n=13 studies), (ii) Pain and how to manage it predominates the lived experience (n=19 studies), (iii) Knee osteoarthritis impacts activity and participation (n=16 studies), (iv) Knee osteoarthritis has a social impact (n=10 studies), (v) Knee osteoarthritis has an emotional impact (n=13 studies), (vi) Interactions with health professionals can be positive or negative (n=11 studies), (vii) Knee osteoarthritis leads to life adjustments (n=14 studies). A single study reporting the perspectives of carers reported similar themes. Psychosocial impact of knee osteoarthritis emerged as a key factor in the lived experience of people with knee osteoarthritis.

CONCLUSIONS

This review highlights the value of considering patient attitudes and experiences including psychosocial factors when planning and implementing management options for people with knee osteoarthritis. Trial registrationnumber CRD42018108962.

Evaluation of implicit associations between back posture and safety of bending and lifting in people without pain

Background and aims Despite lack of support from recent in vivo studies, bending and lifting (especially with a round-back posture) are perceived as dangerous to the back. In light of this view, it has been proposed that pain-free people may hold a common implicit belief that is congruent with the idea that bending and lifting with a round-back represents danger to a person's back, however this has not been evaluated. The aims of this study were: (1) to evaluate implicit associations between back posture and safety related to bending and lifting in pain-free people; (2) to explore correlations between the implicit measure and explicit measures of back beliefs, fear of movement and safety of bending; (3) to investigate self-reported qualitative appraisal of safe lifting. Methods Exploratory cross-sectional study including 67 pain-free participants (no pain, or average pain ≤3/10 for less than one week over the previous 12 months) (52% male), who completed an online survey containing demographic data and self-reported measures of: fear of movement (Tampa Scale for Kinesiophobia for General population - TSK-G), back beliefs (Back Pain Attitudes Questionnaire BackPAQ), and bending beliefs (Bending Safety Belief - BSB - a pictorial scale with images of a person bending/lifting with round and straight back postures). Implicit associations between back posture and safety related to bending and lifting were evaluated with the Implicit Association Test (IAT). A qualitative assessment of descriptions of safe lifting was performed. Results An implicit association between "danger" and "round-back" bending/lifting was evident in all participants (IATD-score=0.65 (SD=0.45; 95% CI [0.54, 0.76]). Participants' profile indicated high fear of movement, unhelpful back beliefs, and perceived danger to round-back bending and lifting (BSBThermometer: 5.2 (SD=3.8; 95% CI [4.26, 6.13] range -10 to 10; t(67)=11.09, p<0.001). There was a moderate correlation between IAT and BSBThermometer (r=0.38, 95% CI [0.16, 0.62]). There were weaker and non-statistically significant correlations between IAT and TSK-G (r=0.28, 95% CI [-0.02, 0.47]), and between IAT and BackPAQDanger (r=0.21, 95% CI [-0.03, 0.45]). Qualitative assessment of safe lifting descriptions indicated that keeping a "straight back" and "squatting" when lifting were the most common themes. Conclusions Pain-free people displayed an implicit bias towards bending and lifting with a "round-back" as dangerous. Our findings support the idea that pain-free people may have a pre-existing belief about lifting, that the back is in danger when rounded. Research to evaluate the relationship between this implicit bias and lifting behaviour is indicated. Implications The findings of this study may have implications for ergonomic guidelines and public health information related to bending and lifting back postures. Additionally, clinicians may need to be aware of this common belief, as this may be reflected in how a person responds when they experience pain.

Hierarchy of hair loss stigma: media portrayals of cancer, alopecia areata, and cancer in Israeli newspapers

BACKGROUND

Over 300,000 people in Israel cope with temporary or permanent hair loss (alopecia) that results from diseases and medical treatments. For women, hair loss can be a highly traumatic event that may lead to adverse psychosocial consequences and health outcomes. Nevertheless, this phenomenon has been mostly ignored by health professionals as it is primarily considered an aesthetic-rather than as a health-related issue. Only recently the Healthcare Basket Committee approved financial assistance for the purchase of wigs by patients coping with hair loss. Given the important role that the media plays in shaping health policies related to diagnoses, treatment and support services, the current study sought to enrich our understanding of how the media portrays disease-related hair-loss.

METHODS

Using framing and agenda-setting theories, this study examined the media portrayals of hair loss associated with three diseases-cancer, alopecia areata, and ringworm, depicted in Israeli newspapers in 1994-2016. The sample consisted of 470 articles about the three diseases: 306 on cancer, 36 on AA, and 128 on ringworm.

RESULTS

Textual and visual analysis revealed the ways media marginalize this physical flaw. Cancer was framed in medical terms, and patients were portrayed as older Israeli-born people whose hair loss was absent from their experience. Ringworm was framed as a fear-inducing disease; patients were portrayed as faceless, unidentified immigrants that coped with visible hair loss. Articles on AA provided the greatest focus on the patient's experience of hair loss, but patients were portrayed as young foreign people.

CONCLUSIONS

Our results revealed a hierarchy of stigmas against hair loss, in which the media coverage marginalized this experience. The omission of hair loss by the media may explain, at least in part, why health professionals often ignore the psychosocial needs of these patients. Health insurance funding of wigs is a helpful but nevertheless insufficient solution to coping with feminine hair loss. Our findings may encourage media leaders to conduct planned media interventions to increase awareness of clinicians and health policymakers about the unique challenges faced by women coping with hair loss and promote health policy-making aimed at the well-being of these women.

Psychological correlates of adherence to photoprotection in a rare disease: International survey of people with Xeroderma Pigmentosum

OBJECTIVES

Xeroderma pigmentosum (XP) is an extremely rare genetic disorder (approximately 100 known cases in the United Kingdom), where DNA damage caused by ultraviolet radiation in daylight cannot be repaired. Adherence to photoprotection is essential to prevent skin cancer. We investigated psychological correlates of photoprotection in the XP population of Western Europe and the United States.

DESIGN

Cross-sectional survey of adults with XP and caregivers of patients <16 years and those with cognitive impairment in the United Kingdom, Germany, the United States, and France (n = 156).

METHODS

Photoprotection activities to protect the face and body when outdoors; avoidance of going outside during daylight hours; intention; self-efficacy; and social support were assessed using measures developed for this study. Participants answered questions about their illness representations of XP (BIPQ); beliefs about photoprotection (BMQ); automaticity (i.e., without conscious effort) (SRBAI); clinical and demographic characteristics. Ordinal logistic regressions determined factors associated with photoprotection.

RESULTS

One third did not achieve optimal face photoprotection. After controlling for demographic and clinical factors, modifiable correlates of higher photoprotection included greater perceived control of XP, stronger beliefs in necessity and effectiveness of photoprotection, and higher intention. Avoidance of going outside was associated with greater photoprotection concerns, more serious illness consequences, and higher XP-related distress. Greater automaticity and higher self-efficacy were associated with better protection across all outcomes.

CONCLUSIONS

Approximately half of all known cases across three European countries participated. Identified modifiable predictors of photoprotection may be targeted by interventions to reduce the incidence of skin cancers in the immediate future, when a treatment breakthrough is unlikely. Statement of contribution What is already known on this subject? Adherence to photoprotection in other populations at elevated risk from skin cancer is poor; however, the level in XP is unknown. Research across chronic conditions shows that adherence to treatment and lifestyle recommendations are influenced by illness perceptions, self-efficacy, and treatment beliefs. Studies on photoprotection conducted with the general population have found that perceived risk, perceptions of ultraviolet radiation (UVR) protection, self-efficacy for the behaviour, and automaticity (behaviours that are enacted with little conscious awareness) are related to better photoprotection. What does this study add? This is the first international survey to examine adherence and its correlates in people with XP (an under-researched group at very high risk of fatal skin cancer). Adherence varies and at least one third have potential for improvement. Perceptions about XP, photoprotection beliefs, self-efficacy, intention, and automaticity were associated with photoprotection of the face and body when outdoors. Negative emotional representations of XP were associated with avoidance of going outside during daylight hours.

Misconceptions and the Acceptance of Evidence-based Nonsurgical Interventions for Knee Osteoarthritis. A Qualitative Study

BACKGROUND

In contrast to best practice guidelines for knee osteoarthritis (OA), findings from several different healthcare settings have identified that nonsurgical treatments are underused and TKA is overused. Empirical evidence and qualitative observations suggest that patients' willingness to accept nonsurgical interventions for knee OA is low. A qualitative investigation of why patients may feel that such interventions are of little value may be an important step toward increasing their use in the treatment of knee OA QUESTIONS/PURPOSES: This qualitative study was embedded in a larger study investigating patient-related factors (beliefs/attitudes toward knee OA and its treatment) and health-system related factors (access, referral pathways) known to influence patients' decisions to seek medical care. In this paper we focus on the patient-related factors with the aim of exploring why patients may feel that nonsurgical interventions are of little value in the treatment of knee OA.

METHODS

A cross-sectional qualitative study was conducted in a single tertiary hospital in Australia. Patients with endstage knee OA on the waiting list for TKA were approached during their preadmission appointment and invited to participate in one-to-one interviews. As prescribed by the qualitative approach, data collection and data analysis were performed in parallel and recruitment continued until the authors agreed that the themes identified would not change through interviews with subsequent participants, at which point, recruitment stopped. Thirty-seven patients were approached and 27 participated. Participants were 48% female; mean age was 67 years. Participants' beliefs about knee OA and its treatment were identified in the interview transcripts. Beliefs were grouped into five belief dimensions: identity beliefs (what knee OA is), causal beliefs (what causes knee OA), consequence beliefs (what the consequences of knee OA are), timeline beliefs (how long knee OA lasts) and treatment beliefs (how knee OA can be controlled).

RESULTS

All participants believed that their knee OA was "bone on bone" (identity beliefs) and most (> 14 participants) believed it was caused by "wear and tear" (causal beliefs). Most (> 14 participants) believed that loading the knee could further damage their "vulnerable" joint (consequence beliefs) and all believed that their pain would deteriorate over time (timeline beliefs). Many (>20 participants) believed that physiotherapy and exercise interventions would increase pain and could not replace lost knee cartilage. They preferred experimental and surgical treatments which they believed would replace lost cartilage and cure their knee pain (treatment beliefs).

CONCLUSIONS

Common misconceptions about knee OA appear to influence patients' acceptance of nonsurgical, evidence-based treatments such as exercise and weight loss. Once the participants in this study had been "diagnosed" with "bone-on-bone" changes, many disregarded exercise-based interventions which they believed would damage their joint, in favor of alternative and experimental treatments, which they believed would regenerate lost knee cartilage. Future research involving larger, more representative samples are needed to understand how widespread these beliefs are and if/how they influence treatment decisions. In the meantime, clinicians seeking to encourage acceptance of nonsurgical interventions may consider exploring and targeting misconceptions that patients hold about the identity, causes, consequences, timeline, and treatment of knee OA.

LEVEL OF EVIDENCE

Level II, prognostic study.

Adolescents' experiences of being diagnosed with attention deficit hyperactivity disorder: a phenomenological study conducted in Sweden

OBJECTIVES

To explore adolescents' experiences of being diagnosed with Attention deficit hyperactivity disorder (ADHD).

DESIGN

Qualitative interview study, using a phenomenological framework and analysis.

SETTING

The children's clinic of a specialised out-care hospital located in a multicultural area of a Swedish city.

PARTICIPANTS

13 adolescents, 7 boys and 6 girls between 14 and 19 years old, who had been diagnosed with ADHD.

RESULTS

The participants' experience of being diagnosed with ADHD was interpreted as a process of understanding oneself as being different, for better or worse, like many others. The participants sought acceptance and a sense of normality, while developing an understanding of both the positive and the negative sides of their ADHD traits. These two sides of a coin were inter-related parts of themselves and were shared by many others, which increased their acceptance. Three themes described phases of the process: struggling with vulnerability, responding to a label and manoeuvring social life.

CONCLUSION

The results add to previous research, illuminating that the adolescents tried to make sense of both the uniqueness and the vulnerability of the ADHD diagnosis. The findings can be useful for healthcare professionals, in reflecting on the complexity of ADHD and on the adolescents' expectations.

Illness Perceptions in Chronic Lymphocytic Leukemia: Testing Leventhal's Self-regulatory Model

BACKGROUND

Leventhal's Self-regulatory Model proposes that somatic characteristics of a health threat (e.g., symptom severity), and prior experience with the threat (e.g., unsuccessful treatment), are determinants of illness perceptions. Chronic lymphocytic leukemia (CLL) is appropriate for test of these postulates, having three phases differing in symptom severity and prior treatment experiences: indolent disease requiring no treatment (active surveillance; AS), symptomatic disease requiring a first treatment (FT), and highly symptomatic disease in those who have relapsed and/or failed to respond to prior treatments (relapsed/refractory; RR).

PURPOSE

To test symptom severity and prior treatment experiences as determinants of illness perceptions, illness perceptions were characterized and contrasted between CLL groups.

METHODS

Three hundred and thirty CLL patients (AS, n = 100; FT, n = 78; RR, n = 152) provided illness perception data on one occasion during a surveillance visit (AS) or prior to beginning treatment (FT, RR).

RESULTS

Analysis of variance with planned comparisons revealed that consequences, identity, and concern were least favorable among RR patients, followed by FT, then AS (ps < .01). AS patients endorsed the lowest levels of coherence (ps < .01), and the most chronic illness timeline (ps < .01). FT patients endorsed the highest levels of personal and treatment control (ps < .01).

CONCLUSIONS

Data provide preliminary empirical support for Self-regulatory Model postulates that symptom severity and prior disease experiences influence illness perceptions. Unique knowledge needs for AS patients and elevated psychological/physical symptoms for later-stage CLL patients may warrant clinical attention.

Home remedy use and influenza vaccination among African American and white adults: An exploratory study

Racial disparities in influenza vaccination persist between African American and White adults. It is critical to explore the reasons behind this disparity, which may be linked to the use of "folk" or home remedies for illness prevention and treatment. For this study, The GfK Group was contracted to conduct a nationally-representative survey (n = 819 African American and 838 White respondents). Respondents were asked about behaviors, attitudes, and risk perception related to the influenza vaccine, as well as frequency of home remedy use. Results were analyzed using adjusted logistic regression with 95% confidence intervals. In comparison to those who never use home remedies, those who use home remedies often or almost always were less likely to get vaccinated for influenza (respectively, OR = 0.70, CI 0.49, 0.99; OR = 0.27, CI 0.15, 0.49), less likely to be in favor of the vaccine (OR = 0.47, CI 0.33, 0.67; OR = 0.19, CI 0.10, 0.34), less likely to trust the vaccine (OR = 0.42, CI 0.29, 0.61; OR = 0.34, CI 0.20, 0.61), and more likely to perceive higher risk of vaccine side effects (OR = 1.79, CI 1.19, 2.68; OR = 4.00, CI 2.38, 6.73). These associations did not vary by race. Home remedy users may hold negative views toward the influenza vaccine, such that a combination of little trust in the vaccine process, and overestimation of risk associated with the vaccine itself, may contribute to vaccine refusal. Health care professionals can use these findings to tailor advice toward individuals with a preference for home remedy use to allay fears and correct misconceptions surrounding influenza and its vaccine.

Are Walking Treatment Beliefs and Illness Perceptions Associated With Walking Intention and 6-Min Walk Distance in People With Intermittent Claudication? A Cross-Sectional Study

Intermittent claudication is debilitating leg pain affecting older people with peripheral arterial disease, which is improved by regular walking. This study evaluated associations between psychosocial variables and 6-min walk distance (6MWD) to identify factors that motivate walking. A total of 142 individuals with intermittent claudication (116 males; M_age = 66.9 years [SD = 10.2]) completed cross-sectional assessments of sociodemographics, walking treatment beliefs and intention (Theory of Planned Behaviour), illness perceptions (Revised Illness Perceptions Questionnaire), and 6MWD. Multiple linear regression was used to evaluate relationships among psychosocial variables (treatment beliefs and illness perceptions) and outcomes (walking intention and 6MWD). Theory of planned behavior constructs were associated with intention (R = .72, p < .001) and 6MWD (R = .08, p < .001). Illness perceptions were associated with 6MWD only (R = .27, p < .001). Intention (β = 0.26), treatment control (β = -0.27), personal control (β = 0.32), coherence (β = 0.18), and risk factor attributions (β = 0.22; all ps < .05) were independently associated with 6MWD. Treatment beliefs and illness perceptions associated with intention and 6MWD in people with intermittent claudication are potential intervention targets.

Dutch Translation and Adaptation of the Treatment Beliefs Questionnaire for Chronic Pain Rehabilitation

Background

The Treatment Beliefs Questionnaire has been developed to measure patients' beliefs of necessity of and concerns about rehabilitation. Preliminary evidence suggests that these beliefs may be associated with attendance of rehabilitation. The aim of this study was to translate and adapt the Treatment Beliefs Questionnaire for interdisciplinary pain rehabilitation and to examine the measurement properties of the Dutch translation including the predictive validity for dropout.

Methods

The questionnaire was translated in 4 steps: forward translation from English into Dutch, achieving consensus, back translation into English, and pretesting on providers and patients. In order to establish structural validity, internal consistency, construct validity, and predictive validity of the questionnaire, 188 participants referred to a rehabilitation centre for outpatient interdisciplinary pain rehabilitation completed the questionnaire at the baseline. Dropout was measured as the number of patients starting, but not completing the programme. For reproducibility, 51 participants were recruited at another rehabilitation centre to complete the questionnaire at the baseline and one week later.

Results

We confirmed the structural validity of the Treatment beliefs Questionnaire in the Dutch translation with three subscales, necessity, concerns, and perceived barriers. internal consistency was acceptable with ordinal alphas ranging from 0.66–0.87. Reproducibility was acceptable with ICC_{2,1 agreement} ranging from 0.67–0.81. Hypotheses testing confirmed construct validity, similar to the original questionnaire. Predictive validity showed the questionnaire was unable to predict dropouts.

Conclusion

Cross-cultural translation was successfully completed, and the Dutch Treatment Beliefs Questionnaire demonstrates similar psychometric properties as the original English version.

Illness perceptions and perceived stress in patients with advanced gastrointestinal cancer

OBJECTIVE

According to the Common-Sense Model of Self-Regulation, when faced with a health threat, we make cognitive and emotional assumptions about the illness. The aims of this study were to (a) examine the role of sociodemographic and disease-specific factors on illness perception and perceived stress and (b) test the association between perceived stress and illness perception in participants diagnosed with gastrointestinal cancer.

METHODS

Participants completed a battery of questionnaires including a Sociodemographic and Disease-Specific Questionnaire, the Illness Perception Questionnaire, Brief Version (Brief-IPQ), and the Perceived Stress Scale (PSS-14). Descriptive statistics, Pearson correlations, analysis of variance (ANOVA), and linear regression were performed to test the hypotheses.

RESULTS

Of the 627 participants, the mean age was 62 years (SD = 11); the majority were male (63.3%) and Caucasian (90.9%). Younger (F3,625 = 5.80, P < .01) and divorced or never married participants reported higher levels of perceived stress when compared with older and married participants (F4,618 = 3.52, P < .01). Younger participants (18-74 years old) reported more negative illness perceptions than older participants (75 years and older) (F3,511 = 4.08, P < .01). A weak, positive relationship between perceived stress and illness perceptions was observed (r = 0.22, P < .01), and illness perceptions predicted 36.1% of the variance of perceived stress.

CONCLUSIONS

Our findings suggest that participants who negatively perceived their illness experienced greater levels of perceived stress. Interventions that aim to adjust patients' illness perceptions in order to facilitate a reduction of stress and improvement in quality of life are needed.

"I keep hearing reports on the news that it's a real problem at the moment": Public health nurses' understandings of sexting practices among young people

Over the past decade, the potential harms regarding young people's use of technology have attracted mounting political, media and research attention worldwide. One practice engaged in by many young people is that of "sexting" and the sharing of partially, or complete nude images ("selfies"). Such images are not always retained within private spaces and are prone to be shared, with significant psychosocial consequences for young people involved. A significant risk is the hidden nature of some online interactions, with potential for grooming and child sexual exploitation. As key professionals working with young people, public health nurses have potential to educate and explore the risks with them. Yet to date, to our knowledge there has been no research in relation to public health nurses' understandings of the practices involved or their potential harms. A qualitative study was undertaken drawing theoretically on the common-sense model (CSM) to frame the analysis. Eighteen semi-structured interviews were conducted with public health nurses in a region of England in 2016. Data were analysed through thematic analysis, and mapped to the five domains of CSM. Public health nurses' understandings of young people's sexting practices were shaped largely by media reports, rather than scientific, disciplinary knowledge. Sexting did not resonate with many public health nurses' own experiences of being a young person and was therefore difficult to understand. All were able to express an opinion about the causes and consequences of sexting and we present these as a "perceived hierarchy of risk". All public health nurses acknowledged the importance of their role in dealing with harm reduction associated with sexting among young people, but they need education and support to do this effectively and confidently. Findings can be transferred carefully to many contexts and countries because sexting is a practice among young people that transcends geographical boundaries.

Facts and Fears in Public Reporting: Patients' Information Needs and Priorities When Selecting a Hospital for Cancer Care

Objective. Public reporting on the quality of provider care has the potential to empower patients to make evidence-based decisions. Yet patients seldom consult resources such as provider report cards in part because they perceive the information as irrelevant. To inform more effective public reporting, we investigated patients' information priorities when selecting a hospital for cancer treatment. We hypothesized that patients would be most interested in data on clinical outcomes. Methods. An experienced moderator led a series of focus groups using a semistructured discussion guide. Separate sessions were held with patients aged 18 to 54 years and those older than 54 years in Philadelphia, Pennsylvania; Phoenix, Arizona; and Indianapolis, Indiana, in 2017. All 38 participants had received treatment for cancer within the past 2 years and had a choice of hospitals. Results. In selecting hospitals for cancer treatment, many participants reported that they considered factors such as reputation, quality of the facilities, and experiences of other patients. For most, however, decisions were guided by trusted advisors, with the majority agreeing that a physician's opinion would sway them to disregard objective data about hospital quality. Nonetheless, nearly all expressed interest in having comparative data. Participants varied in selecting from a hypothetical list, "the top 3 things you would want to know when choosing a hospital for cancer care." The most commonly preferred items were overall care quality, timeliness, and patient satisfaction. Contrary to our hypothesis, many preferred to avoid viewing comparative clinical outcomes, particularly survival. Conclusions. Patients' information preferences are diverse. Fear or other emotional responses might deter patients from viewing outcomes data such as survival. Additional research should explore optimal ways to help patients incorporate comparative data on the components of quality they value into decision making.

[Understanding lower gynaecological cancer consultation delay and help-seeking behavior in patients over 65]

INTRODUCTION

Delays for consultation of more than six months exist for uterine cancer. Delays in diagnosis of more than five years exist for vulvar cancer. The peak incidence of these neoplasms appear after the age of 65 years. Patient's symptoms are characteristically swelling, vaginal bleeding or itching. This study aims to understand what is happening during this period for women over 65 years old. It also tries to identify triggers during the help-seeking period.

METHODS

Qualitative studies using semi-structured interviews with dual analyses (semio-pragmatic and psychodynamic) have been conducted on a population of older (65+) gynaecologic cancer patients, recruited from a French oncology centre.

RESULTS

Twelve patients were interviewed. Patients' courses of action were determined by the characteristics of their symptoms, their feelings and their emotions. Representations, subjective beliefs and past experiences were employed to make sense of their symptoms. The patient's friend and family circle had an important role in incentivizing the patient to seek consultation. Multiple factors affected the path towards consulting the doctor. The initial medical contact included several challenges. The patient would consult a doctor earlier if he had more information about his illness and if his relationship with the doctor was better.

CONCLUSION

Our findings are similar to those of other cancers. The peculiarity for this population appears to be the different representations of age-related changes in the reproductive system, and the taboo associated with this issue when facing friends and family.

How to prevent, minimize, or extinguish nocebo effects in pain: a narrative review on mechanisms, predictors, and interventions

Possible factors that contribute to nocebo effects on pain are explored. Strategies that can prevent, minimize, or extinguish nocebo effects in clinical settings are suggested.

Nocebo effects, such as side effects due to negative expectations regarding the pain treatment, are a concern for health care providers and come with significant costs. This narrative review focuses on underlying mechanisms and possible factors that contribute to the susceptibility to the nocebo effect on pain and related outcomes and suggests strategies that can prevent, minimize, or extinguish nocebo effects in clinical settings. Nocebo effects are the result of psychological (eg, conditioning, verbal suggestions, and observational learning) and neurobiological (eg, cholecystokinin and dopamine regulation) mechanisms. Evidence from clinical and experimental studies lead to various recommendations and strategies to alter the nocebo effect in order to optimize pain treatments, such as providing patients with enhanced information, optimizing patient–physician communication and relationships, and offering psychoeducation on coping skills in order to manage patient expectations. The current literature from both clinical and experimental studies provides a better understanding of the nocebo effect and possible factors that modulate its strength on treatment outcomes. This allows for the development of evidence-based strategies aimed at the prevention, minimization, and treatment of the nocebo effect in pain conditions and possible other somatic disorders.

Representations of cancer recurrence risk, recurrence worry, and health-protective behaviours: an elaborated, systematic review

An expanded Common-Sense Model (CSM) contextualised to the self-regulation of cancer recurrence risk identifies risk representational attributes and recurrence worry as primary processes motivating protective behaviours in cancer survivors. A systematic review examined evidence for CSM hypotheses regarding how these processes influence diet and physical activity (PA) among survivors. A research agenda is outlined and used to evaluate the evidence base. Common databases were searched for eligible, peer-reviewed, English language reports, yielding 18 studies quantitatively testing hypothesised relationships among representations of prior cancer, recurrence risk representations, recurrence worry, and diet and PA. The findings provide promising, but mixed and limited evidence for some of the hypothesised associations of specific risk recurrence attributes with recurrence worry, and risk recurrence attributes and recurrence worry with diet and PA. Findings support the distinction of recurrence risk representations and illness representations of the prior cancer, with each showing different relationships with recurrence worry and behaviours. We discuss the status of the evidence base in relation to assessment, design, and analysis priorities and propose strategies that can yield more sensitive, rigorous tests of the CSM for cancer recurrence risk as applied to diet and PA.

Helping Patients With Head and Neck Cancer Understand Dysphagia: Exploring the Use of Video-Animation

Purpose Patients newly diagnosed with head and neck cancer should be informed of the ramifications of cancer treatment on swallowing function during their pretreatment consultation. The purpose of this study was to explore (a) the usefulness and (b) the acceptability of video-animation in helping patients to understand the basics of the swallowing mechanism and dysphagia. Method Thirteen patients treated for head and neck cancer participated in this study. Think-aloud, a type of qualitative methodology, was used to encourage patients to verbalize their thoughts while watching two short video-animations showing the process of normal/abnormal swallowing. Transcripts were analyzed using thematic analysis. Results Four main themes were identified as follows: (a) patient interest and engagement, (b) acceptability of visual imagery and narration, (c) information provision and learning, and (d) personal relevance and intended action. Patients appeared interested and engaged in the video-animations, asking several spontaneous questions about how to maintain or improve swallowing function. Learning was evident from patients' recognition and verbalizations of grossly disordered swallowing patterns. Most patients reported the images to be visually acceptable and could often relate what they were seeing to their own swallowing experience. Many patients also verbalized recognition of the need to keep muscles active through exercises. Conclusions These results suggest that the video-animations of swallowing were acceptable, interesting, informative, and relevant for most patients. It was therefore useful not only as an education tool, but also showed potential to influence patients' intentions to undertake preventative interventions that may preserve better swallowing function after cancer treatment.

A qualitative comparison of high and low adherers with apparent treatment-resistant hypertension

Poor adherence is a leading cause of apparent resistance to antihypertensive treatment. Recent empirical research has investigated predictors of adherence for primary care patients who are apparently resistant to treatment; however, questions remain regarding the variability in adherence behaviour among this group. This study aimed to investigate factors that may elucidate medication adherence among patients with apparent treatment-resistant hypertension (aTRH) using qualitative methods. Fourteen semi-structured interviews were conducted with patients undergoing treatment for aTRH in primary care in the West of Ireland. Patients who self-reported both high and low adherence in a previous quantitative study were purposively sampled. Data were analysed using thematic analysis. A public and patient involvement research group were active partners in developing the study protocol and interview topic guide. Three major themes were identified: beliefs about treatment, habits and routine, and health and health systems. High adherers reported favourable beliefs about antihypertensive treatment that had been validated by experience with taking the treatment over time, described strong medication-taking habits and stable routines, and positive relations with their GP. Low adherers expressed less coherence in their beliefs and used less effective strategies to support their medication-taking in daily life. The current findings are consistent with qualitative studies of adherence in other chronic conditions. Results reflect the difficulty for healthcare practitioners in identifying adherent versus non-adherent patients via conversation, and highlight the importance of accurate adherence assessment. Inception studies may provide an opportunity to better understand adherence behaviour across the illness trajectory.

Psychometric Characteristics of the Revised Illness Perception Questionnaire (IPQ-R) in People Undergoing Weight Loss Surgery

The Illness Perception Questionnaire-Revised (IPQ-R) has been used extensively across many health conditions to measure patient illness and treatment perceptions. The constructs have an association with treatment adaptation and adherence which, in turn, are considered core factors involved in bariatric surgery outcome. This study examines the factorial validity and internal reliability of a modified (IPQ-R) in bariatric surgery candidates. After wording modifications, participants (N = 310) completed the IPQ-R as part of standard pre-surgery assessments. After removal of two items, confirmatory factor analysis (CFA) supported the original 7-factor solution of the Beliefs scale, with good to marginal subscale internal consistency. Exploratory factor analysis (EFA), with two items removed only partially supported the original 5-factor Causal Attributions scale. Internal consistency was unacceptably low for two subscales. Further research is needed to generate new items which better fit the IPQ-R to this population before research can explore the relevance of illness perceptions.

Contextualizing Experiences of Diabetes-Related Stress in Rural Dominican Republic

Type 2 diabetes (T2D) is changing the burden of disease across Latin America. In this formative, qualitative study, we explored experiences of T2D diagnosis and management among adults in rural Dominican Republic. We conducted 28 in-depth interviews (12 men, 16 women) and used inductive analysis to explore the emotional burden of T2D and identify coping strategies. We found that stress relating to T2D began at diagnosis and persisted throughout management. Stress was produced by concerns about healthy food and medication access, fears about illness-induced injury, and the cyclical process of experiencing stress. Participants identified diabetes care and free medication services as external stress-reducers. Internally, participants' mitigated stress by not thinking about diabetes (" no dar mente"). Our study highlights the importance of a contextualized understanding of diabetes-related stress and the need for individual, clinic, and community-level interventions to reduce stressors and improve health outcomes among adults with T2D.

Supporting the Process of Help-Seeking by Caregivers of Functionally Dependent Older Persons Through Electronic Health: Protocol for a Multicenter Co-Design

BACKGROUND

It is often only when the initial signs of exhaustion appear that caregivers first may engage in help-seeking behavior, but it is difficult for them to know which is the most appropriate formal service in their situation. Electronic health (eHealth) can support caregivers in keeping the older person they are caring for at home, but few eHealth tools designed for supporting the process of help-seeking by caregivers of functionally impaired older persons have been developed using a co-design approach.

OBJECTIVE

This paper aims to describe the protocol of a project that tries to assist caregivers to target their needs and those of the older person they support early in their help-seeking process, and guide them effectively to the formal service most appropriate for their situation. This project aims to answer the following questions: (1) What type of tool can better support caregivers to identify their needs and those of the older person they are caring for and then refer them to an appropriate formal service? and (2) What information should be found in such a tool?

METHODS

This study presents a description of the process of an ongoing multicenter research project based on a co-design approach, which includes 3 phases (1) identification of caregivers' needs in terms of tools to support their help-seeking behavior, (2) development of a tool, and (3) evaluation of its usability.

RESULTS

The project began in January 2016 with the ethics application for the 3 phases of the project. For phase 1, recruitment began in December 2016 and ended in September 2017. Phase 2 began in the spring of 2017 and ended in June 2018. All the co-design sessions have been completed. Phase 3 of the project will begin in September 2018.

CONCLUSIONS

Although there are some challenges associated with this type of methodology, the methodology still remains relevant, as it involves future users in the development of a tool, which increases the chances that the tool will meet the users' needs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/11634.

Impact of caller's degree-of-worry on triage response in out-of-hours telephone consultations: a randomized controlled trial

BACKGROUND

Telephone triage entails assessment of urgency and direction of flow in out-of-hours (OOH) services, while visual cues are inherently lacking. Triage tools are recommended but current tools fail to provide systematic assessment of the caller's perspective. Research demonstrated that callers can scale their degree-of-worry (DOW) in a telephone contact with OOH services, but its impact on triage response is undetermined. The aim of this study was to investigate the association between call-handlers' awareness of the caller's DOW and the telephone triage response.

METHODS

A randomized controlled trial at a Danish OOH service using telephone triage with quantitative analyses and qualitative process evaluation. Prior to contact with a call-handler, callers were asked to rate their DOW on a five-point scale. Calls were randomized to show or not show DOW on the call-handlers' screens. Triage response (telephone consultation or face-to-face consultation) was analysed using Chi-square tests. Process evaluation incorporated a quantitative and qualitative assessment of intervention implementation and fidelity.

RESULTS

Of 11,413 calls, 5705 were allocated to the intervention and 5708 to the control group. No difference in number of face-to-face consultations was detected between the two groups (OR 1.05, 95% CI 0.98 to 1.14, p = 0.17). The process evaluation showed that call-handlers did not use the DOW systematically and were reluctant to use DOW.

CONCLUSION

Awareness of DOW did not affect the triage response, but this finding could reflect a weak implementation strategy. Future studies should emphasise the implementation strategy to determine the effect of DOW on triage response.

TRIAL REGISTRATION

Registration number, Clinicaltrials.gov NCT02979457 .

The psychometric properties of a new oral health illness perception measure for adults aged 62 years and older

BACKGROUND

Based on the Common-Sense Model of Self-Regulation (CSM), a new integrated Illness Perception Questionnaire Revised for Dental Use in Older/Elder Adults (IPQ-RDE) was developed for single and multiple dental conditions. This study describes psychometric properties of the IPQ-RDE for adults 62 years and older.

METHODS

Participants (n = 198) living in 16 subsidized housing facilities completed the IPQ-RDE and a questionnaire assessing their socio-demographics, frequency of dental visits, perceived condition of teeth/gums, depression, social support, and oral health quality of life (OHQOL). Participants received dental screening for presence/absence of teeth, coronal and root caries, and periodontitis. The 43-item IPQ-RDE was tested for internal (construct, discriminant) and external validity (concurrent, construct, discriminant, predictive) and reliability (internal consistency).

RESULTS

Confirmatory factor analysis demonstrated that a ten-factor model in accordance with the CSM framework (identity, consequences, control, timeline, illness coherence, treatment burden, prioritization, causal relationship, activity restriction, emotional representations) had good construct validity based on significant factor loadings and acceptable model fit (RMSEA = 0.065, CFI = 0.902). Edentulous participants had significantly higher mean factor scores (inaccurate perception) for overall IPQ-RDE and four constructs indicating concurrent validity. Discriminant validity was suggested by non-relationship with external measures (education, dental visit frequency). Predictive validity was indicated by the negative correlation of most constructs with OHQOL suggesting that inaccurate perception was related to lower quality of life. Internal consistency of eight IPQ-RDE constructs was excellent (Cronbach's alpha > 0.73).

CONCLUSIONS

The IPQ-RDE is a valid and reliable new measure for assessing older adult's perception of dental conditions. It can be an important tool for oral health behavioral research to restructure older adult's perception of dental conditions, and subsequently prevent tooth loss and improve oral health quality of life.

Patient and family-initiated escalation of care: a qualitative systematic review protocol

BACKGROUND

Despite the introduction of rapid response systems and early warning scores, clinical deterioration that is not recognised or responded to early enough prevails in acute care areas. One intervention that aims to address this issue and that is gaining increased attention is patient- and family-initiated escalation of care schemes. Existing systematic review evidence to date has tended to focus on identifying the impact or effectiveness of these schemes in practice. However, they have not tended to focus on qualitative evidence to consider the experience of deterioration and the factors that may promote or hinder engagement with these schemes in the practice setting. This systematic review will address this gap. The aim of this review is to explore patients', relatives' and healthcare professionals' experiences of deterioration and their perceptions of the barriers or facilitators to patient and family-initiated escalation of care in acute adult hospital wards.

METHODS

We will search Medline, CINAHL, Embase and PsycINFO databases using free-text and MESH terms relating to deterioration, family-initiated rapid response, families, patients, healthcare staff, hospital and experiences. We will search grey literature and reference lists of included studies for further published and unpublished literature. All studies with a qualitative design or method will be included. Two reviewers will independently assess studies for eligibility, extract data and appraise the quality of included studies. Data will be synthesised using a thematic synthesis approach, and findings will be presented narratively.

DISCUSSION

Patient- and family-initiated escalation of care schemes have been developed and implemented in several countries including the United States, the United Kingdom and Australia, but there is limited evidence regarding patients' or families' perceptions of deterioration or the barriers and facilitators to using these schemes in practice, particularly in acute adult areas. This systematic review will provide evidence for the development of a patient and family escalation of care scheme that can be tested in a feasibility study.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018106952.

Self-management behaviors in World Trade Center rescue and recovery workers with asthma

BACKGROUND

Asthma is a major source of morbidity among World Trade Center (WTC) rescue and recovery workers. While physical and mental health comorbidities have been associated with poor asthma control, the potential role and determinants of adherence to self-management behaviors (SMB) among WTC rescue and recovery workers is unknown.

OBJECTIVES

To identify modifiable determinants of adherence to asthma self-management behaviors in WTC rescue and recovery worker that could be potential targets for future interventions.

METHODS

We enrolled a cohort of 381 WTC rescue and recovery workers with asthma. Sociodemographic data and asthma history were collected during in-person interviews. Based on the framework of the Model of Self-regulation, we measured beliefs about asthma and controller medications. Outcomes included medication adherence, inhaler technique, use of action plans, and trigger avoidance.

RESULTS

Medication adherence, adequate inhaler technique, use of action plans, and trigger avoidance were reported by 44%, 78%, 83%, and 47% of participants, respectively. Adjusted analyses showed that WTC rescue and recovery workers who believe that they had asthma all the time (odds ratio [OR]: 2.37; 95% confidence interval [CI]: 1.38-4.08), that WTC-related asthma is more severe (OR: 1.73; 95% CI: 1.02-2.93), that medications are important (OR: 12.76; 95% CI: 5.51-29.53), and that present health depends on medications (OR: 2.39; 95% CI: 1.39-4.13) were more likely to be adherent to their asthma medications. Illness beliefs were also associated with higher adherence to other SMB.

CONCLUSIONS

Low adherence to SMB likely contributes to uncontrolled asthma in WTC rescue and recovery workers. Specific modifiable beliefs about asthma chronicity, the importance of controller medications, and the severity of WTC-related asthma are independent predictors of SMB in this population. Cognitive behavioral interventions targeting these beliefs may improve asthma self-management and outcomes in WTC rescue and recovery workers. Key message: This study identified modifiable beliefs associated with low adherence to self-management behaviors among World Trade Center rescue and recovery rescue and recovery workers with asthma which could be the target for future interventions.

CAPSULE SUMMARY

Improving World Trade Center-related asthma outcomes will require multifactorial approaches such as supporting adherence to controller medications and other self-management behaviors. This study identified several modifiable beliefs that may be the target of future efforts to support self-management in this patient population.

Systematic screening and assessment of psychosocial well-being and care needs of people with cancer

BACKGROUND

Receiving a diagnosis of cancer and the subsequent related treatments can have a significant impact on an individual's physical and psychosocial well-being. To ensure that cancer care addresses all aspects of well-being, systematic screening for distress and supportive care needs is recommended. Appropriate screening could help support the integration of psychosocial approaches in daily routines in order to achieve holistic cancer care and ensure that the specific care needs of people with cancer are met and that the organisation of such care is optimised.

OBJECTIVES

To examine the effectiveness and safety of screening of psychosocial well-being and care needs of people with cancer. To explore the intervention characteristics that contribute to the effectiveness of these screening interventions.

SEARCH METHODS

We searched five electronic databases in January 2018: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, and CINAHL. We also searched five trial registers and screened the contents of relevant journals, citations, and references to find published and unpublished trials.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised controlled trials (NRCTs) that studied the effect of screening interventions addressing the psychosocial well-being and care needs of people with cancer compared to usual care. These screening interventions could involve self-reporting of people with a patient-reported outcome measures (PROMs) or a semi-structured interview with a screening interventionist, and comprise a solitary screening intervention or screening with guided actions. We excluded studies that evaluated screening integrated as an element in more complex interventions (e.g. therapy, coaching, full care pathways, or care programmes).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed methodological quality for each included study using the Cochrane tool for RCTs and the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool for NRCTs. Due to the high level of heterogeneity in the included studies, only three were included in meta-analysis. Results of the remaining 23 studies were analysed narratively.

MAIN RESULTS

We included 26 studies (18 RCTs and 8 NRCTs) with sample sizes of 41 to 1012 participants, involving a total of 7654 adults with cancer. Two studies included only men or women; all other studies included both sexes. For most studies people with breast, lung, head and neck, colorectal, prostate cancer, or several of these diagnoses were included; some studies included people with a broader range of cancer diagnosis. Ten studies focused on a solitary screening intervention, while the remaining 16 studies evaluated a screening intervention combined with guided actions. A broad range of intervention instruments was used, and were described by study authors as a screening of health-related quality of life (HRQoL), distress screening, needs assessment, or assessment of biopsychosocial symptoms or overall well-being. In 13 studies, the screening was a self-reported questionnaire, while in the remaining 13 studies an interventionist conducted the screening by interview or paper-pencil assessment. The interventional screenings in the studies were applied 1 to 12 times, without follow-up or from 4 weeks to 18 months after the first interventional screening. We assessed risk of bias as high for eight RCTs, low for five RCTs, and unclear for the five remaining RCTs. There were further concerns about the NRCTs (1 = critical risk study; 6 = serious risk studies; 1 = risk unclear).Due to considerable heterogeneity in several intervention and study characteristics, we have reported the results narratively for the majority of the evidence.In the narrative synthesis of all included studies, we found very low-certainty evidence for the effect of screening on HRQoL (20 studies). Of these studies, eight found beneficial effects of screening for several subdomains of HRQoL, and 10 found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We found very low-certainty evidence for the effect of screening on distress (16 studies). Of these studies, two found beneficial effects of screening, and 14 found no effects of screening. We judged the overall certainty of the evidence for the effect of screening on HRQoL to be very low. We found very low-certainty evidence for the effect of screening on care needs (seven studies). Of these studies, three found beneficial effects of screening for several subdomains of care needs, and two found no effects of screening. One study found adverse effects, and the last study did not report quantitative results. We judged the overall level of evidence for the effect of screening on HRQoL to be very low. None of the studies specifically evaluated or reported adverse effects of screening. However, three studies reported unfavourable effects of screening, including lower QoL, more unmet needs, and lower satisfaction.Three studies could be included in a meta-analysis. The meta-analysis revealed no beneficial effect of the screening intervention on people with cancer HRQoL (mean difference (MD) 1.65, 95% confidence interval (CI) -4.83 to 8.12, 2 RCTs, 6 months follow-up); distress (MD 0.0, 95% CI -0.36 to 0.36, 1 RCT, 3 months follow-up); or care needs (MD 2.32, 95% CI -7.49 to 12.14, 2 RCTs, 3 months follow-up). However, these studies all evaluated one specific screening intervention (CONNECT) in people with colorectal cancer.In the studies where some effects could be identified, no recurring relationships were found between intervention characteristics and the effectiveness of screening interventions.

AUTHORS' CONCLUSIONS

We found low-certainty evidence that does not support the effectiveness of screening of psychosocial well-being and care needs in people with cancer. Studies were heterogeneous in population, intervention, and outcome assessment.The results of this review suggest a need for more uniformity in outcomes and reporting; for the use of intervention description guidelines; for further improvement of methodological certainty in studies and for combining subjective patient-reported outcomes with objective outcomes.

Caring for young people with moderate to severe psoriasis: an interpretive description of parental perspectives

Introduction: Psoriasis often sets on during childhood or adolescence, when parents have great importance for the young people's self-management, well-being, and quality of life. The aim of this study was to understand parents' perspectives on young people's daily life with psoriasis in order to improve adolescents' self-management.Method: Adopting interpretive, description methodology (ID), focus group discussion, and interviews were conducted with eight parents of adolescents with psoriasis. The analysis was inductive with an iterative comparative approach. Main themes conveying participants' perceptions were identified for constructing a coherent narrative of parents' perspectives on their young people's transition with psoriasis through adolescence.Results: Parents initially perceived psoriasis mainly a physical and treatment-related burden and not until late realized its socio-emotional impact. They eventually found themselves balancing between declining treatment due to fear of side effects and acknowledging the impact on their young people's quality of life and their desire for effective treatment.Conclusions: Caring for young people with psoriasis is a stressful process involving experimental learning to understand and manage the complexity of psoriasis and its impact on adolescents' emotional and social life. Future research should consider integration of shared decision-making and self-management support interventions in routine daily care as focus points.