Evidence of compensatory neural hyperactivity in a subgroup of chemotherapy-treated breast cancer survivors and its association with brain aging

Chemotherapy-related cognitive impairment (CRCI) remains poorly understood in terms of the mechanisms of cognitive decline. Neural hyperactivity has been reported on average in cancer survivors, but it is unclear which patients demonstrate this neurophenotype, limiting precision medicine in this population. We evaluated a retrospective sample of 80 breast cancer survivors and 80 non-cancer controls, age 35-73, for which we had previously identified and validated three data-driven, biological subgroups (biotypes) of CRCI. We measured neural activity using the z-normalized percent amplitude of fluctuation from resting state functional magnetic resonance imaging (MRI). We tested established, quantitative criteria to determine if hyperactivity can accurately be considered compensatory. We also calculated brain age gap by applying a previously validated algorithm to anatomic MRI. We found that neural activity differed across the three CRCI biotypes and controls (F = 13.5, p < 0.001), with Biotype 2 demonstrating significant hyperactivity compared to the other groups (p < 0.004, corrected), primarily in prefrontal regions. Alternatively, Biotypes 1 and 3 demonstrated significant hypoactivity (p < 0.02, corrected). Hyperactivity in Biotype 2 met several of the criteria to be considered compensatory. However, we also found a positive relationship between neural activity and brain age gap in these patients (r = 0.45, p = 0.042). Our results indicated that neural hyperactivity is specific to a subgroup of breast cancer survivors and, while it seems to support preserved cognitive function, it could also increase the risk of accelerated brain aging. These findings could inform future neuromodulatory interventions with respect to the risks and benefits of up or downregulation of neural activity.

Patterns and Correlates of Physical Symptoms among People with Peripheral Neuropathy

Background

As the population ages and more people are affected by multiple chronic conditions, the prevalence of Peripheral Neuropathy (PN) has also rapidly increased. This swift rise in PN leaves clinicians and patients challenged by a lack of consistent diagnosis and treatment guidelines.

Purpose

To assist those affected by PN, it is imperative to understand the breadth of symptoms, experiences, and factors related to the quality of life. The primary aims of this study are to (1) characterize the symptoms of PN in a nationwide sample; (2) discern differences in symptom clusters, given perceived causes of PN; and (3) identify significant physiological symptoms related to the quality of life for people with PN.

Methods

An online survey of people in online PN support groups. Participants were recruited primarily via an open request sent to recipients of web-based communications from nationally recognized online PN support groups. Inclusion criteria were as follows: Self-reported diagnosis of PN, ability to read English or Spanish, residence in the U.S., and age ≥ 18 years.

Results

A total of 608 individuals with PN were included in the analysis. This sample represents 49 U.S. states and the District of Colombia; 221 were male and 387 female. Their disease severity and etiology were similar to previously reported information on this population, with 53.3% of respondents suffering from PN without a known cause. Among known causes, diabetes was the most common (19.6%), followed by chemotherapy (6.9%) and autoimmune diseases (3.6%). Factors affecting the quality of life among people with PN included lower extremity mobility, upper extremity mobility, sleep disturbance, depressive symptoms, and patient activation.

Development and testing of a biobanking acceptability scale: A multistage effort to add a biobank to an existing longitudinal study

BACKGROUND

More biobanks linked to demographic, phenotypic, and clinical data are needed to advance multiple sclerosis (MS) research; however, little is known about biobanking attitudes among persons with MS, broadly, as well as willingness of participants in an existing longitudinal study to donate biospecimens, specifically.

METHODS

To assess biobanking attitudes in a cohort of MS patients in an ongoing longitudinal study, a new Biobanking Acceptability Scale (BAS) was developed, its reliability and predictive validity tested, and factors that influenced biobanking intent as well as behavior were explored. Analysis included descriptive statistics, factor analysis, Cronbach's α, and Pearson's bivariate correlation coefficients.

RESULTS

In 2018, 227 participants completed the 10-item BAS. Biobanking attitudes were generally positive (BAS total score, M = 38.8 out of 50; SD = 6.7), and most participants expressed willingness to donate hair (87%), saliva (85%), and/or blood (72%). In 2019, 143 participants consented to biobanking and were mailed supplies; 110 individuals provided at least one biospecimen, resulting in 110 saliva samples and 89 hair samples. The 10-item BAS displayed good internal consistency (α = 0.81). Demographic and clinical variables were not significantly associated with BAS score nor actual donation. Total BAS score was related to consent (r = 0.36, p < .001) and to actual donation of hair or saliva samples (r = 0.24, p < .01).

CONCLUSION

Overall, the participants had positive attitudes toward biobanking; the scale should be assessed in more diverse samples. The BAS predicted biobanking consent, and thus may be a useful measure to identify individuals most likely to donate biospecimens and/or identify potential barriers to biobanking that can be addressed through study design.

Comparing Health Promotion and Quality of Life in People with Progressive Versus Nonprogressive Multiple Sclerosis

Background

People with multiple sclerosis (MS) benefit from engaging in health promotion. Most studies have been conducted with those having relapsing-remitting MS; information about health promotion for those with progressive MS is more limited. In this study, health promotion and quality of life (QOL) for people with progressive versus nonprogressive MS were systematically examined and compared.

Methods

These data are from years 21 and 22 of an ongoing longitudinal study of persons with MS. Participants were compared on demographic, psychosocial, and health promotion factors and 36-item Short Form Health Survey (SF-36) QOL subscales. Based on the conceptual framework, barriers, symptom clusters, social supports, and health promotion activities were entered into hierarchical multivariate regressions to predict selected SF-36 subscale scores separately for those with progressive versus nonprogressive MS after controlling for variance associated with years of education and MS incapacity.

Results

Analyses included 72 respondents with progressive MS and 117 with nonprogressive MS. People with progressive MS reported significantly less frequent health promotion and lower scores on SF-36 physical role limitations and social functioning. Symptoms were a strong and significant predictor for all three SF-36 subscales in both groups. The explained variances in the hierarchical models differed significantly by MS course, with adjusted R ² scores ranging from 0.17 to 0.30 in progressive MS and 0.35 to 0.45 in nonprogressive MS.

Conclusions

Findings underscore the importance of symptom severity in relation to health promotion and QOL in people with long-standing MS. Future research should explore additional contributors to QOL for those with progressive MS.

Experiences of African American Women with Multiple Sclerosis

Background

Despite growing understanding that African American patients may have a more aggressive course of multiple sclerosis (MS) and experience disparities in diagnosis and treatment, fewer studies have examined how African Americans experience MS and its effect on their lives. This study explored the experiences of African American women with MS to inform future research and practice.

Methods

Face-to-face semistructured interviews were conducted with 19 African American women. Inductive content analysis was used to identify major categories and subcategories.

Results

The analyses yielded three major categories: no one could believe I had MS, it is tough living with MS, and you have to keep going. Many women reported that the MS diagnosis was a surprise to them and their doctors because of the common belief that MS is a "Caucasian disease." For this reason, many women felt their diagnosis had been delayed while their physicians initially focused on other diseases considered more typical in African American individuals. Living with losses related to social and family activities, independence, and employment was especially challenging for them. Faith in God, coming to grips with the diagnosis, and health promotion behaviors were key strategies for dealing with their MS. Women also spoke of pushing forward, working through MS challenges, and taking care of themselves, thus preserving their identity as strong Black women, a culturally important construct in the African American community.

Conclusions

Future research should explore the interactions of culture with coping strategies and the development of useful and valued resources and supports for African American people with MS.

Functional and health promotion predictors of PROMIS® scores in people with multiple sclerosis

OBJECTIVE

The purpose of this study was to examine the impact of perceived functional abilities and health promotion activities on subsequent symptom experience among those who have lived with multiple sclerosis (MS) for many years.

METHODS

This longitudinal mailed survey study examined Health Promoting Lifestyle Profile II (HPLP) scores and MOS SF 36 scores as predictors of PROMIS® Pain Interference, Pain Intensity, Fatigue, Sleep Disturbance, and Applied Cognition Abilities Scores among 260 adults with MS. The community dwelling sample was initially recruited from the mailing list of the MS Society in a large southwestern state. Respondents were predominantly female, with an average age of 67 years. They had been diagnosed an average of 30 years. Forty percent reported relapsing remitting MS, and 41% have the more severe progressive form of the disease.

RESULTS

HPLP and SF 36 Role Physical, Role Emotional, and Social Function scores assessed in 2013 were moderately correlated (r > .30) with PROMIS® Fatigue and PROMIS® Cognitive Abilities scores measured in 2014 and were somewhat predictive of PROMIS® Pain and Sleep Disturbance scores (r > .20). These results were replicated in an analysis using data from Years 2016 and 2017.

CONCLUSIONS

Findings suggest that those who report higher levels of health promotion activities and greater functional ability may experience lower levels of fatigue, pain, and sleep disturbance and higher levels of cognitive abilities in the subsequent year. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Modifiable correlates of perceived cognitive function in breast cancer survivors up to 10 years after chemotherapy completion

BACKGROUND

Cognitive changes following breast cancer treatment are likely multifactorial and have been linked to emotional factors, biophysiological factors, and fatigue, among others. Little is known about the contributions of modifiable factors such as stress, loneliness, and sleep quality. The purpose of this study was to explore the direct and indirect effects of perceived stress, loneliness, and sleep quality on perceived cognitive function (PCF) in breast cancer survivors (BCS) after chemotherapy completion.

METHODS

In this observational study, BCS 6 months to 10 years post chemotherapy were recruited from the community. We measured perceived stress, loneliness, sleep quality, anxiety, depression, fatigue, and PCF. Data analyses included descriptive statistics, correlations, and mediation analyses utilizing ordinary least square regression.

RESULTS

Ninety women who were on average 3 years post chemotherapy completion participated in the study. Moderate to largely negative correlations were found between PCF and the psychosocial and sleep variables (r values ranged from - 0.31 to - 0.70, p values < .0009). Mediation analyses revealed that stress and daytime sleepiness both directly and indirectly impact PCF and that loneliness and sleep quality only have indirect effects (through anxiety and fatigue).

CONCLUSION

Our findings suggest that perceived cognitive changes following breast cancer treatment are multifactorial and that higher stress levels, loneliness, daytime sleepiness, and poorer sleep quality are linked to worse perceived cognitive functioning. Also, stress, loneliness, and sleep quality may affect cognitive functioning through a shared psychobiological pathway.

IMPLICATIONS FOR CANCER SURVIVORS

Interventions targeting stress, loneliness, and sleep quality may improve perceived cognitive functioning in breast cancer survivors.

Perceived cognitive deficits are associated with diabetes self-management in a multiethnic sample

Background

People with diabetes have almost twice the risk of developing cognitive impairment or dementia as do those without diabetes, and about half of older adults with diabetes will become functionally disabled or cognitively impaired. But diabetes requires complex self-management: patients must learn about the implications of their disease; manage their diets, physical activity, and medication; and monitor their blood glucose. Difficulties with cognition can hinder these activities.

Methods

The purpose of this study was to explore perceptions of cognitive ability in a multiethnic sample of persons with type 2 diabetes (T2DM). One hundred twenty participants completed surveys assessing perceived memory, executive function, diabetes self-management, and quality of life. Scores on the surveys were examined along with hemoglobin A1C levels and demographics.

Results

Scores for executive function were positively associated with self-reports of dietary adherence and blood glucose monitoring. Perceived memory ability was a significant predictor of quality of life, and executive function was a significant predictor of A1C.

Conclusions

Patients’ perceptions of their cognitive difficulties may assist health care providers in detection of patients’ deficiencies in performing diabetes self-management tasks. The relationships between cognitive difficulties and self-management found in this descriptive study suggest that research on the processes leading to cognitive changes in T2DM is needed, as are studies on how those processes affect diabetes self-management.

Low-Income Cancer Survivors' Use of Health-Promoting Behaviors

This cross-sectional correlation study examined use of health-promoting (HP) behaviors and self-efficacy for engaging in HP behaviors. Participants reported higher HP behavior scores for health responsibility, interpersonal relationships, and spiritual growth, and lower scores for physical activity/exercise, nutrition, and stress management. Low physical activity, stress management, and nutrition scores suggest nurses can implement strategies that encourage use of these HP behaviors and enhance self-efficacy.

Reliability and Validity of PROMIS Cognitive Abilities and Cognitive Concerns Scales Among People with Multiple Sclerosis

BACKGROUND

Cognitive impairment is among the most debilitating outcomes of multiple sclerosis (MS). Although several neuropsychological tests and self-report cognitive measures have been used to assess cognitive impairment, they may not be sensitive to change over time, or may not be feasible to administer in a clinical setting. The purpose of this study was to assess the reliability and validity of the 8-item PROMIS Cognitive Abilities and Cognitive Concerns Scales in a large community-based sample of people with MS. The PROMIS Cognitive Abilities and Cognitive Concerns Scales derive from the National Institutes of Health-funded Patient Reported Outcomes Measurement Information System (PROMIS), an item repository that capitalizes on recent psychometric advances to produce short, psychometrically sound health measures.

METHODS

Mailed survey data were collected from 322 individuals recruited from two National Multiple Sclerosis Society chapters in a southwestern state.

RESULTS

Both cognitive scales demonstrated high internal consistency reliability and were moderately correlated with self-reported depressive symptoms, self-efficacy, barriers to health promotion, health, and functional status (all correlation coefficients >0.35). In hierarchical regression analysis, the PROMIS Cognitive Concerns score added significant unique variance to the prediction of MS Incapacity Status after controlling for self-reported depressive symptoms, exercise, spiritual growth, and global health. Those who were unemployed owing to their disabilities had significantly lower PROMIS Cognitive Abilities scores and higher Cognitive Concerns scores than those who were working or those who were retired or not working for other reasons.

CONCLUSIONS

The PROMIS Cognitive Abilities and Cognitive Concerns Scales are short, psychometrically sound measures that assess an important dimension of functioning and health for people with MS.

Racial/ethnic differences in midlife women's attitudes toward physical activity

INTRODUCTION

Women's racial/ethnic-specific attitudes toward physical activity have been pointed out as a plausible reason for their low participation rates in physical activity. However, very little is actually known about racial/ethnic commonalities and differences in midlife women's attitudes toward physical activity. The purpose of this study was to explore commonalities and differences in midlife women's attitudes toward physical activity among 4 major racial/ethnic groups in the United States (whites, Hispanics, African Americans, and Asians).

METHODS

This was a secondary analysis of the qualitative data from a larger study that explored midlife women's attitudes toward physical activity. Qualitative data from 4 racial/ethnic-specific online forums among 90 midlife women were used for this study. The data were analyzed using thematic analysis, and themes reflecting commonalties and differences in the women's attitudes toward physical activity across the racial/ethnic groups were extracted.

RESULTS

The themes reflecting the commonalities were: 1) physical activity is good for health, 2) not as active as I could be, 3) physical activity was not encouraged, 4) inherited diseases motivated participation in physical activity, and 5) lack of accessibility to physical activity. The themes reflecting the differences were: 1) physical activity as necessity or luxury, 2) organized versus natural physical activity, 3) individual versus family-oriented physical activity, and 4) beauty ideal or culturally accepted physical appearance.

DISCUSSION

Developing an intervention that could change the social influences and environmental factors and address the women's racial/ethnic-specific attitudes would be a priority in increasing physical activity of racial/ethnic minority midlife women.

Health promotion for cancer survivors: adaptation and implementation of an intervention

Randomized control trial of a health promotion intervention was implemented for low-income cancer survivors. The majority of participants were female, older, divorced, educated, and unemployed or on disability leave. Findings indicate the health promotion intervention improved cancer survivors' self-efficacy and increased their use of health-promoting behaviors.

Asian American midlife women's attitudes toward physical activity

OBJECTIVES

To explore Asian American midlife women's attitudes toward physical activity using a feminist perspective.

DESIGN

A qualitative online forum study.

SETTINGS

Internet communities/groups for midlife women and ethnic minorities.

PARTICIPANTS

A total of 17 Asian American women recruited through the Internet using a convenience sampling method.

METHODS

A 6-month qualitative online forum was conducted using 17 online forum topics. The data were analyzed using thematic analysis.

RESULTS

Three major themes related to Asian American midlife women's attitudes toward physical activity were extracted from the data: keeping traditions, not a priority, and not for Asian girls. Because Asian American midlife women were busy in keeping their cultural traditions, they rarely found time for physical activity. The women gave the highest priority to their children, and physical activity was the lowest priority in their busy lives. Also, the women were rarely encouraged to participate in physical activity during their childhoods, and they perceived that their weak and small bodies were not appropriate for physical activity.

CONCLUSIONS

Several implications for future development of physical activity promotion programs for this specific population have been suggested based on the findings.

Promising New Approaches to Assess Cognitive Functioning in People with Multiple Sclerosis

Cognitive impairment has a major impact on the lives of people with Multiple Sclerosis (MS). Yet, it is often under-diagnosed, and more effective assessment methods are needed. In particular, brief measures that focus on cognitive functioning in daily life situations, are sensitive to modest change over time, and do not require a highly skilled assessor merit exploration. The purpose of this exploratory study was to investigate the performance of individuals with MS on three relatively new measures: the PROMIS Cognitive Concerns and Abilities Scales and the Everyday Problems Test (EPT), and to compare scores on these measures with scores on neurocognitive performance measures typically used to assess cognitive functioning in people with MS. Twenty-nine individuals with MS who reported cognitive concerns participated in the study. Most were non-Hispanic White women, with relapsing-remitting MS, diagnosed approximately 18 years ago. All three measures yielded reliability coefficients of .80 or above and also demonstrated sensitivity to change following an educational intervention. Scores on the revised EPT were moderately correlated with scores on five standard neuropsychological measures. Compared with the PROMIS Cognitive Concerns scale, scores on the self-reported PROMIS Cognitive Abilities scale tended to correlate more highly with the neurocognitive performance measures, although the correlations were generally small. While results of this exploratory study are promising, future research should be conducted with larger and more diverse samples of people with MS to determine the broader utility of these measures.

Breast cancer screening barriers and disability

There is evidence that early detection from breast cancer screening is an effective means to reduce overall mortality from breast cancer. Findings from multiple research studies suggest that women with chronic disabling conditions are less likely to participate in breast cancer screening due to the multiple barriers they face. Barriers include those related to finances, environment, physical limitations, health carers' attitudes and lack of knowledge, and psychosocial issues. The purpose of this article is to provide an overview of the existing evidence of the barriers to breast cancer screening experienced by women with physical disabilities. Rehabilitation nurses that work with women who have chronic disabling conditions can be instrumental in eliminating these barriers to breast cancer screening through their efforts to promote health which is consistent with the philosophy of maximizing the health potential and quality of life of these women whose needs are often overlooked.

Predictors of quality of life for long-term cancer survivors with preexisting disabling conditions

PURPOSE/OBJECTIVES

To explore whether measures of resources, barriers, and health-promoting behaviors would add significantly to the prediction of health-related quality of life among survivors with disabilities that occurred prior to their cancer diagnosis once contextual factors were controlled for.

DESIGN

A descriptive correlational study.

SETTING

Adult cancer survivors with preexisting disabling conditions who had completed active treatment were recruited from throughout the United States.

SAMPLE

Most of the 145 respondents were breast cancer survivors with preexisting neuromuscular conditions such as polio and multiple sclerosis. The average time since cancer diagnosis was nine years.

METHODS

Respondents completed a mailed survey.

MAIN RESEARCH VARIABLES

Health-promoting behaviors, self-efficacy, barriers to health promotion, social support, functional limitations, cancer-related variables, depression, and quality of life.

FINDINGS

The sample reported poorer physical well-being than other cancer survivors without preexisting disabling conditions. Health-promoting behaviors and psychosocial factors, such as depressive symptoms and self-efficacy, added significantly to the prediction of physical, social, emotional, and functional components of health-related quality of life after contextual factors entered the equations.

CONCLUSIONS

The findings underscore the importance of providing this population with the means to promote their health to the greatest extent possible, given the multiple threats to their health status.

IMPLICATIONS FOR NURSING

Nurses may be able to help survivors with preexisting disabling conditions reduce the negative influence of poorer health status and functional limitations on quality of life by providing interventions that reduce depression and build perceived ability to engage in health-promoting behaviors.

Home-Based Computer-Assisted Cognitive Training: Feasibility and Perceptions of People with Multiple Sclerosis

Initial evidence suggests that computer-assisted cognitive rehabilitation may improve cognitive performance among people with multiple sclerosis (MS). Most studies of computer-assisted cognitive training have incorporated an individualized in-office/clinic approach for training. The purpose of this study was to explore the feasibility of home-based computer-assisted training and systematically examine the perceptions of people with MS regarding home use of the program. Qualitative data (written and verbal) obtained as part of a larger randomized clinical trial of a cognitive rehabilitation intervention were analyzed. The computer training component of the intervention included prescribed tracks and exercises on the Internet-based Neuropsychonline program. The majority of the participants used the program the recommended number of times per week and for the minimum number of minutes over the 8-week intervention. Although participants had notable negative perceptions and complaints about the program during the training experience, most of them acknowledged during training that use of the program helped them recognize cognitive limitations, create and practice strategies to increase cognitive function, and improve the quality of their daily life. Data from focus groups 3 months after the training included similar criticisms regarding lack of feedback and difficulties with the program as well as acknowledgment of the positive effects and a desire for continued access to the program. The findings suggest that while home training is feasible, careful preparation for use of the program is required.

Attitudes toward physical activity of white midlife women

OBJECTIVE

To explore attitudes toward physical activity of White midlife women in the United States using a feminist perspective.

DESIGN

A cross-sectional qualitative study using a thematic analysis.

SETTING

Internet communities for midlife women.

PARTICIPANTS

Twenty-nine White midlife women in the United States recruited using a convenience sampling method.

METHODS

We used 17 topics on attitudes toward physical activity and ethnic-specific contexts to administer an online forum. We analyzed the data using thematic analysis.

RESULTS

We found three themes: thinking without action, gendered and sedentary culture, and motivating myself. The women knew and understood the necessity of physical activity for their physical and mental health but in most cases had not been able to take action to increase their physical activities. Although the culture that circumscribed the women's physical activity was sedentary in nature, the women tried to motivate themselves to increase their physical activities through several creative strategies.

CONCLUSION

The findings strongly suggest that although women were doing their best, American culture itself needs to be changed to help women increase physical activity in their daily lives.

Barriers and Facilitators to Breast Cancer Screening: A Qualitative Study of Women with Multiple Sclerosis

PURPOSE: Recent literature indicates that women with various types of chronic disabling conditions are less likely to participate in routine breast cancer screening compared to those without disabling conditions. The purpose of this study is to identify the barriers and facilitators related to breast cancer screening among women with MS. METHODS: After receiving approval from the IRB, a semi-structured interview in a private setting was conducted with 36 women with MS, whose mean age was 55. Interviews were audio-taped and transcribed verbatim. The interview questions informed by the Health Belief Model, addressed knowledge, experience, barriers and facilitators related to breast cancer screening. Qualitative descriptive techniques were used to analyze the data. The majority of the women in the sample were White, 67% were married, 47% had at least a bachelor's degree and about 31% were unemployed due to their disability. FINDINGS: Findings show that 70% of these women had received annual mammograms and 50% had performed monthly breast self-exams. Of the women who had not received mammograms, most (80%) had mobility limitations. Some of the women in this study described various environmental and intrapersonal barriers to breast cancer screening. Among these were barriers related to transportation, difficulty in positioning for the exam, health care provider attitudes, not remembering, fear, discomfort, and "having enough to handle." Facilitators included annual reminders and helpful health care providers.

Health-promoting behaviors of low-income cancer survivors

PURPOSE/OBJECTIVES

The purpose of this study was to explore the health-promoting (HP) behaviors of low-income cancer survivors before and after their diagnosis of cancer.

DESIGN

This qualitative study used a purposive sampling strategy to identify low-income, ethnically diverse cancer survivors.

SETTING

Participants were recruited from an urban outpatient cancer clinic serving only low-income clients.

SAMPLE

Thirteen, ethnically diverse low-income cancer survivors participated in 60- to 90-minute interviews discussing their experience with HP behaviors before and after their diagnosis with cancer, their cancer experience, and their perspectives on being a cancer survivor.

METHODS

Conventional content analysis of transcripts and field notes by 2 coders identified words, context, frequency, emphasis, and consistency of participants' comments. Statements were further examined to identify patterns and main themes and to interpret the meaning of what was said.

FINDINGS

Participants described their use of various HP behaviors primarily walking, maintaining a positive mental attitude, and changing their diet. Participants discussed their perspectives on having a diagnosis of cancer as well as the meaning of being a cancer survivor. They described spiritual growth through prayer, renewing their faith, maintaining a hopeful outlook, and expressing thankfulness toward God. Participants expressed interested in learning about effective physical exercises, healthy eating, and stress management strategies.

CONCLUSIONS

Results suggest that low-income cancer survivors engage in various HP behaviors and want to learn more behaviors to use after cancer treatment.

IMPLICATIONS FOR PRACTICE

Findings provide useful information for clinical nurse specialists when providing information about HP behaviors for use during and after cancer treatment as well as the meaning of cancer survivor for low-income cancer survivors.

"Physical activity as a luxury": African American women's attitudes toward physical activity

The purpose of this study was to explore African American midlife women's attitudes toward physical activity. Using a feminist perspective, a 6-month online forum was conducted with 21 African American midlife women recruited on the Internet. The data were analyzed using thematic analysis. Four themes emerged: (a) culturally acceptable body, (b) missed opportunity to learn, (c) physical activity as a luxury, and (d) want to do by myself. The women had positive body images regardless of their actual weight. The women considered physical activity "a luxury" in their busy lives and thought that they had already missed opportunities to learn. The women wanted to participate in physical activities alone because of their bad childhood experiences and hesitance to go out in public with sweaty, messy hair. The findings suggested that unique programs that promote physical activity should be developed that consider the women's ethnic-specific attitudes.

The meaning of gender while aging with paralytic polio

The purpose of this article is to report the influence of gender on aging with childhood onset paralytic polio. The hermeneutic phenomenological exploration of gender was done using multiple qualitative interviews with 25 women, age 55 to 75 years of age, who had polio since before 14 years of age. We noted three themes: (a) the movement of her body, (b) integrating body and gender, and (c) gender discrepancies. Findings are discussed in the context of gendered expectations and the women's bodies.

"A waste of time": Hispanic women's attitudes toward physical activity

Despite a lack of studies on Hispanic midlife women's physical activity, the existing studies have indicated that Hispanics' ethnic-specific attitudes toward physical activity contributed to their lack of physical activity. However, little is still clearly known about Hispanic midlife women's attitudes toward physical activity. The purpose of this study was to explore Hispanic midlife women's attitudes toward physical activity using a feminist perspective. The study was a 6-month qualitative online forum among 23 Hispanic women who were recruited through Internet communities/groups. The data were collected using 17 online forum topics on attitudes toward physical activity and ethnic-specific contexts. The data were analyzed using thematic analysis. Three major themes emerged from the data analysis process: (a) "family first, no time for myself," (b) "little exercise, but naturally healthy," and (c) "dad died of a heart attack." Although some of the women perceived the importance of physical activity due to their family history of chronic diseases, the study participants thought that physical activity would be a waste of time in their busy daily schedules. These findings provided directions for future health care practice and research to increase physical activity among Hispanic midlife women.

The use of goal attainment scaling to facilitate and assess individualized change in a wellness intervention for women with fibromyalgia syndrome

PURPOSE

The authors examined goal achievement over an 8-month period in women with fibromyalgia participating in a holistic health promotion intervention using Goal Attainment Scaling.

DESIGN

Descriptive.

METHODS

Goal attainment was assessed by interviews at five points: baseline (retrospectively), immediately after the 8-week classes, at the middle and end of the telephone support period, and 3 months later.

FINDINGS

The percentage of women who attained or exceeded their goals in the four health promotion areas of Lifestyle Adjustment, Physical Activity, Nutrition, and Stress Management increased from between 15% and 26% at the end of the classes to between 58% and 76% at the end of the telephone support period. Although scores declined somewhat in the following 3 months, at least 60% of the women continued to report behaviors at or above their goal level in all areas except Physical Activity.

CONCLUSIONS

Goal Attainment Scaling, an individually determined measure of change, can effectively capture behavioral changes associated with a holistic health promotion intervention. A nurse facilitator, who not only understood the need for specific, measurable GAS but was also able to encourage and support women's identification of goals that were meaningful to them, was key to the positive findings observed here.

Women's experiences as members of attention control and experimental intervention groups in a randomized controlled trial

Attention control groups are often used in research testing the efficacy of psychosocial and behavioural interventions in order to control for placebo effects. The authors conducted a descriptive qualitative study to investigate how participants viewed their experiences in attention control and experimental intervention groups following a randomized controlled trial for women with fibromyalgia syndrome. Moderately structured interviews were conducted with 18 women (12 from the experimental intervention group and 6 from the attention control group). Members of the control group reported some benefits but few behavioural changes as a result of participating in the RCT, and some participants expressed disappointment at not receiving the intervention. Perceptions of changes in attitudes towards fibromyalgia syndrome and behaviours reported by the intervention group appear to be consistent with the theory underlying the intervention. Possible placebo effects identified in both groups include negative and positive social interactions with other participants.

Longitudinal predictors of attitudes toward aging among women with multiple sclerosis

The purpose of the study was to explore the impact of change in functional limitation (FL), controlling for social support (SS), on attitudes toward aging using longitudinal survey data collected over a 7-year period. The 503 women with multiple sclerosis (MS; age, M=57 years, SD=10.25) were mostly Anglo (93%) and married (69%). First, the authors identified a quadratic growth model as the best for describing change in FL. Next, they considered SS as a time-varying covariate of FL to assess both within- and between-individual effects of SS on FL over time. Within individuals, higher FL levels were associated with lower SS levels. Between individuals, level of but not change in FL was associated with average SS level. Finally, average SS and response level and change in FL were studied as predictors of attitudes toward aging, accounting for 38% of the variance. Women with higher FL and lower SS scores had more negative views of aging. Negative views of aging among women with MS may have long-term consequences for their health outcomes as well as for the quality of their later years.

Predictors and moderators of the disablement process in persons with multiple sclerosis

The purpose of this study is to explore how selected behavioral and psychological factors may influence the disablement process in persons with multiple sclerosis. Specifically, we explored what contextual factors (age, length of diagnosis, comorbidities), resources (social support, adequacy of assistive devices), barriers, and health behaviors predict functional limitations, disability, and quality of life and what factors might moderate the relationship between functional limitation and disability and disability and quality of life. A sample of 442 persons with multiple sclerosis (371 females, 71 males; mean age 56, mean time since diagnosis 19 years) completed measures of demographic and disease-related variables, barriers, social support, health behaviors, functional limitations, disability and perceived quality of life. Using regression analyses, the predictors explained significant amounts of variance in functional limitations (R2 = 0.37), disability (R2 = 0.36) and quality of life (R2 = 0.68), but there were no significant moderators of the relationship between functional limitations and disability and disability and quality of life. A model testing the indirect effects of functional limitations and direct effects of disability and the proposed moderators explained 66% of the variance in quality of life (CFI = 0.95, TLI = 0.89, RMSEA = 0.10). Barriers, social support and health behaviors were consistent predictors of the outcome variables.

Perceptions of Health and Relationships to Disability Measures Among People with Multiple Sclerosis

Researchers use various measures to assess health status, impairment, functional limitations, and disability among people with multiple sclerosis (MS). Conceptual and empirical associations among measures are not always clear, however. The purpose of this study was to examine the relationships among measures of impairment, disability, functional status, and health-related outcomes in a sample of 443 individuals with MS. A secondary purpose was to compare the self-reported health status of this sample with that of a population-based sample of individuals with and without disabilities. Although both the MS sample and a population-based sample of individuals with activity limitations indicated poorer health than did their nondisabled counterparts, the MS sample reported more days in the preceding month when their physical and mental health were not good and more days when poor health kept them from usual activities than the population-based sample of individuals with disabilities. Most measures were moderately intercorrelated, but the pattern suggests that issues such as the time frame specified may affect the relationships. Researchers should carefully consider operational as well as conceptual definitions, length of proposed measures, and appropriate time frame, in addition to the more traditional criteria of reliability and validity, when selecting study measures.

Conceptualization and development of the Acceptance of Chronic Health Conditions Scale

Acceptance of chronic conditions often has been studied from the perspective of grief and loss. This paper presents a new conceptualization of acceptance of chronic conditions that is grounded in the perspective of those living with a chronic condition and focuses on adaptation to and acceptance of change in one's life. Data obtained from a sample of 822 persons with multiple sclerosis and a sample of more than 2,000 polio survivors support the reliability and validity of the new Acceptance of Chronic Health Conditions Scale.

Leisure-time physical activity among midlife Korean immigrant women in the US

The purpose of the study was to investigate the level of leisure-time physical activity (LTPA) among midlife Korean American women and to determine the relationships of LTPA with individual characteristics and behavior-specific cognition and affects. A cross-sectional descriptive study of 152 middle-aged Korean American women in Central Texas was conducted using a health-promotion model of physical activity adapted from Pender's Health Promotion Model. The results showed that 32% of the participants were not engaged in any form of exercise. The level of acculturation was not significantly related to the amount of physical activity. After age, level of acculturation, education, income, and marital status were controlled, LTPA was significantly associated with perceived benefits and barriers and social support. Physical inactivity, which was common in this group of immigrant women, warrants further rigorous investigation to determine the dynamics of the women's involvement in more physical activity.

Loneliness in women with multiple sclerosis

Loneliness is an underrecognized component of the experience of chronic illness and disability. Women with multiple sclerosis (MS) may be at risk for loneliness due to social network changes that occur in the course of chronic illness. The purpose of this secondary analysis was to assess the extent of loneliness in a sample of 659 women with MS and examine the relationship of loneliness, social support, functional limitation, self-rated health status, social demands of illness, and marital status. More than half of the women in this sample reported feeling lonely. A significant association was found between loneliness and lower levels of social support, greater social demands of illness, greater functional limitation, lower self-rated health status, and marital status. These findings suggest that rehabilitation nurses and other health professionals should be aware that loneliness may be a common occurrence for women with MS and point to the need for screening procedures to identify loneliness in this population.

Satisfaction with mental health care among people with multiple sclerosis in urban and rural areas

OBJECTIVES

This study explored urban and rural differences in mental health needs and treatments among people with multiple sclerosis, as well as their satisfaction with access to and quality of mental health care.

METHODS

Data were collected in a nationwide survey of 1,518 people with multiple sclerosis.

RESULTS

More than 40 percent of people with multiple sclerosis in each urban or rural area had received a diagnosis of depression, and more than 90 percent of them received mental health services, regardless of location of residence. However, rural residents were significantly less likely than their urban counterparts to receive the recommended combined medication and psychotherapy for treatment of depression.

CONCLUSIONS

Current mental health care systems, even in rural areas, are capable of reaching out to patients with neuromedical illnesses, such as multiple sclerosis. Patients perceive some limitations in quality and accessibility, and recommended treatment differs between urban and rural areas.

Health Promotion in Heart Failure—A Paradigm Shift

For people living with heart failure, levels of health exist along a continuum in correlation with the illness experience. A focus on health promotion rather than only disease or symptom management expands opportunities for self-care and presents an emerging paradigm shift in the care of people with heart failure. Results from 2 studies revealed that few health-promoting behaviors were reported by patients with heart failure until a focused intervention that emphasized health promotion as part of self-care was implemented.

Demographic and Disease Characteristics of People With Multiple Sclerosis Living in Urban and Rural Areas

This study compares demographic and disease-related characteristics of people with multiple sclerosis (MS) living in urban and rural areas. The data analyzed for this study were collected from a survey of 1518 people with MS living throughout the United States from October 2004 through January 2005. We found significant urban-rural differences in various MS characteristics, including type of MS. A significantly larger proportion of people with MS in remote rural areas than their urban counterparts responded that they had primary progressive MS. People with MS in rural areas were significantly more likely than those in urban areas to report that MS symptoms interfered with their independence. A significantly larger proportion of people with MS in remote rural areas than in urban areas were not receiving disease-modifying medications. Our results suggest that MS disease expression varies across urban-rural gradients. Although the findings are not definitive, we hope that other investigative groups will build on these results and work toward confirming and understanding them.

Urban/rural differences in the use of physician services by people with multiple sclerosis

OBJECTIVE

to identify any urban/rural differences among people with multiple sclerosis (MS) in the utilization of physician services and MS-focused care, as well as differences in patient perceptions of access and quality.

METHOD

data were collected by surveying 1,518 people with MS throughout the United States, equally divided among urban, urban-adjacent rural areas, and more remote rural areas. Standard SAS procedures were used to analyze the results.

RESULTS

significantly larger proportions of people with MS in rural areas had a family or general practitioner as their primary physician while a significantly larger proportion of people with MS in urban areas had a neurologist as their primary physician. Rural residents traveled significantly greater distances to receive MS-focused care than their urban counterparts. People with MS living in more remote rural areas averaged less satisfaction with their access to a neurologist and to MS-focused care, and less satisfaction with the quality of care received, than people with MS in urban areas.

CONCLUSION

limited availability of MS specialists in rural areas, and greater travel time and distance required to receive care from these providers, present future challenges to providing appropriate and high quality MS-focused care to people living with MS in rural areas.

Urban/rural differences in access and barriers to health care for people with multiple sclerosis

CONTEXT

People living in rural areas face barriers when seeking health care, often experiencing difficulties accessing health providers or facilities. Little is known about barriers to the use of health care confronting people with multiple sclerosis (MS) in rural areas.

PURPOSE

To identify any rural/urban differences in access and barriers to health services, including MS-focused care, among people with MS.

METHODS

The data were collected in a survey of 1,518 people with MS living in all 50 States. The study included three geographic subgroups: urban areas; adjacent rural areas; and more remote rural areas.

FINDINGS

We found significant rural/urban differences in access and barriers to care among people with MS, especially for MS-focused care. Significantly smaller proportions of people with MS from adjacent and more remote rural areas reported no difficulty getting MS-related care than their urban counterparts.

CONCLUSIONS

Greater difficulty accessing MS-related care experienced by people with MS in rural areas has negative implications for the quality of the MS care they receive.

A Hermeneutic Phenomenological Analysis of Aging with a Childhood Onset Disability

In this qualitative study, we combined multiple interviews, field notes, life history review charts, and demographic questions to explore the life course experiences of 25 women, ages 55 to 65 years, who developed impairments due to paralytic polio during childhood. Based on a hermeneutic phenomenological methodology using thematic analysis, multiple themes emerged that traced their lives from childhood to later adulthood. The women described how they pushed their bodies and dismissed their physical decline as long as possible. The women's early experiences combined with the culturally defined role expectations for women to influence their perceptions of how to react to changing physical abilities with age.

Weight and behavioral and psychosocial factors among ethnically diverse, low-income women after childbirth: II. Trends and correlates

OBJECTIVE

This paper presents a longitudinal analysis of behavioral and psychosocial correlates of weight trends during the first postpartum year. Data are derived from the Austin New Mothers Study (ANMS), a longitudinal study of a low-income, tri-ethnic sample of postpartum women that incorporated serial assessment of weight and behavioral and psychosocial variables.

METHOD

Postpartum body mass index (BMI) was measured prospectively (post-delivery, 6 weeks, and 3, 6, and 12 months postpartum). The analytic sample consisted of 382 White, African American, and Hispanic women receiving maternity care funded by Medicaid who had at least three measured postpartum weights. Behavioral and psychosocial variables included energy intakes, fat intakes, physical activity, health related lifestyle, smoking, breastfeeding, contraception, depressive symptoms, emotional eating, body image, and weight-related distress.

RESULTS

Using hierarchical linear modeling to incorporate baseline only and time-varying effects, significant associations with postpartum BMI were found for the following variables: ethnicity (p = .001), time of weight measurement (p < .001), the interaction of ethnicity and time (p = .005), pre-pregnant BMI (p < .001), gestational weight gain (p < .001), weight-related distress (p < .001), and energy intakes (p = .005). After adjusting for covariates, ethnic groups displayed differing trends in postpartum BMI resulting in White women having significantly lower BMIs at 12 months postpartum compared to ethnic minority women (p's < .01).

CONCLUSION

Behavioral and psychosocial variables contribute to a fuller understanding of BMI status of low-income women during the first postpartum year.

Weight and behavioral and psychosocial factors among ethnically diverse, low-income women after childbirth: I. Methods and context

OBJECTIVE

In this paper, we present the background, hypotheses, methods, and descriptive findings from the Austin New Mothers Study, a longitudinal series measuring weight and contextual variables across the first postpartum year. Among the distinguishing features of this study are its tri-ethnic sample of low-income women and its serial measurement of the behavioral and psychosocial context of postpartum weight changes post-delivery and at 6 weeks, and 3, 6, and 12 months postpartum.

METHOD

A prospective longitudinal design was used to assess body mass index (BMI), energy intake, fat intake, physical activity, health-related lifestyle, depressive symptoms, body image, and weight-related distress at each observation.

SAMPLE

The analytic sample consisted of 382 White, African American, and Hispanic women.

FINDINGS

For BMI, effects for ethnicity (p < .001), time (p < .001), and their interaction (p = .005) were significant. All ethnic groups had significant declines in BMI from delivery to 6 weeks postpartum. Thereafter, BMIs of White women declined during the second 6 months, whereas those of Hispanic and African American women either displayed small gains or plateaus between adjacent observations. Time-related effects were significant for behavioral and psychosocial variables except for body image and weight-related distress, whereas effects for ethnicity were significant on fat intake, depressive symptoms, and body image. Despite declines in depressive symptoms, women remained at risk of depression across the first postpartum year.

CONCLUSIONS

Low-income ethnic minority women have a higher vulnerability to postpartum weight gains or plateaus. High depressive symptoms occurred in all ethnic groups examined.

The influence of resources on perceived functional limitations among women with multiple sclerosis

The purpose of this longitudinal investigation was to identify the effects of external resources (i.e., education, marriage, employment, social support, economic status) on the trajectory of perceived functional limitation among women with multiple sclerosis (MS). We hypothesized that these resources would have a long-term influence upon MS-related functional limitation. As part of a longitudinal study of health promotion and quality of life among persons with MS, we tested hypothesized relationships using data obtained at five time points, using repeated-measures MANOVA. We found that functional limitation scores increased over time for all participants. In general, women who were unemployed as a result of MS consistently had higher functional limitation scores, and employed women consistently had lower functional limitation scores. Women with lower social support scores consistently perceived greater functional limitation than those with higher social support scores. Women with lower perceived-economic-adequacy scores consistently had higher functional limitation scores than women with higher perceived-economic-adequacy scores. Nurses and other healthcare professionals are in an optimum position to observe and assess the resources of women with MS. They can use presence, listening, and observational skills to identify verbal and nonverbal cues of resource depletion. In addition, they can act as advocates for women with MS and speak out on policy issues and legislation at the local and national levels. Healthcare professionals can thus influence the presence of resources for those who are particularly vulnerable to resource loss, so they can participate successfully in work, recreational, and home environments.

Marriage, impairment, and acceptance in persons with multiple sclerosis

The purpose of this study was to investigate the relationship between marital status, marital concern, perceived impairment, health-promoting behaviors, and acceptance of disability using cross-sectional and longitudinal data from a sample of persons with multiple sclerosis (MS). We hypothesized that the quality and stability of the marital relationship would influence people's ability to accept their disability and protect from accumulation of impairment over time. Furthermore, men and women would receive dissimilar benefits from marriage. These hypotheses were considered with repeated measures analysis, Pearson correlations, and independent sample t tests of data obtained from a longitudinal study of persons with MS. The findings indicate that acceptance of disability and perceived impairment increase significantly over time for men and women. For men, being married was associated with a greater acceptance of disability and less perceived impairment. Men were more concerned than the women about how MS affected their sexual relationships.

What makes it so hard? Barriers to health promotion experienced by people with multiple sclerosis and polio

Perceptions of barriers to health promotion were examined in three groups of individuals with disabilities: (1) those with multiple sclerosis, (2) those with postpolio syndrome, and (3) polio survivors without postpolio syndrome. While there were small statistically significant differences among the three groups, all rated fatigue and impairment as their most frequent problems. For all groups, financial and interpersonal resources contributed significantly to the prediction of barriers, after accounting for perceived impairment. The findings suggest that health professionals should explore thoroughly the nature of individuals' perceived barriers to staying healthy, so that they can target their health-promoting interventions most effectively.

Disability, social support, and concern for children: depression in mothers with multiple sclerosis

OBJECTIVE

To investigate the relationship between disability, concern for children, social support, and depressive symptoms in a group of mothers with multiple sclerosis (MS).

DESIGN

An exploratory secondary analysis using correlation and multiple regression techniques.

SETTING AND PARTICIPANTS

Two hundred one women with MS responded to a survey as part of a cohort participating in a longitudinal study of health promotion and quality of life.

OUTCOME MEASURES

Depressive symptoms were measured using the CESD-10.

RESULTS

The results indicate that disability and concern for children are independent predictors of depressive symptoms, and social support can partially mediate the effect of concern for children on depressive symptoms.

CONCLUSION

Appropriate support should be identified and provided by nurses caring for mothers with disabilities such as MS to decrease the depressive symptoms related to the concern they have for their children.

Barriers that further disablement: a study of survivors of polio

This exploratory study of polio survivors was undertaken to clarify current level of function, comorbidity, and secondary conditions and to discover the relationships between perceived barriers to health, functional limitation, comorbidity, secondary conditions, and disability in a small convenience sample. Given the underrepresentation of research in the literature explaining the health status, perceived function, and barriers to health in this disabled population, a descriptive study with correlation was conducted. Thirty-one individuals living with the effects of polio were surveyed. Disability was correlated with perceived barriers to health but not with functional limitations, comorbidity, or secondary conditions. Secondary conditions were correlated with the number of years living with the illness. The findings support a model of disablement and allostatic load. Further research is needed to test these models and to provide direction for nurses caring for those aging with the effects of polio.

Answers to unasked questions: writing in the margins

This qualitative study is a secondary analysis of comments spontaneously provided by participants in a quantitative survey. Narrative comments were written by 25% (n = 205) of the adults with multiple sclerosis who responded to the survey. Forms of unsolicited written comments included responses to questions written in the margins of the questionnaires and narratives on blank booklet pages. The purpose of this study was to apprehend what participants were telling us, particularly in the responses that they had written in the margins. Qualitative methods were used to identify and explore major categories in the participants' comments. Those who wrote unsolicited comments perceived their economic resources as less adequate, were experiencing greater family and social demands related to their illness, and were more likely to live in a nonmetropolitan county than other respondents. Secondary analysis of this rich qualitative data enhances the depth of our understanding of the person's experience with chronic illness.

Promoting wellness for women with multiple sclerosis

There is increasing interest in wellness programs among health care providers and consumers. A unique intervention program was developed to promote wellness for women with multiple sclerosis (MS). Key processes include: provision of accurate knowledge that is specific to health promotion within the context of MS; enhancement of self-efficacy for health behaviors and individualized goal setting and monitoring. Participants have reported positive changes as a result of this two-phase (knowledge/skill building classes and telephone follow-up) intervention.

Reproductive health care experiences of women with physical disabilities: a qualitative study

OBJECTIVE

To explore the reproductive health care experiences of women with physical disabilities and how reproductive health care experiences could be improved.

DESIGN

A qualitative interview study was conducted.

PARTICIPANTS

Ten women, ages 28 to 47 years, with physical disabilities, including multiple sclerosis, cerebral palsy, and paralysis, were recruited through the investigators' contacts with local disability groups.

RESULTS

Interviewees encountered numerous barriers to quality reproductive health care services, including inaccessible equipment and facilities, limited contraceptive options, health care providers' insensitivity and lack of knowledge about disabilities, and limited information tailored to their needs. Providers sometimes appeared surprised that they would be sexually active, and did not ask about contraceptive use or assess for sexually transmitted diseases. Although most interviewees had private health insurance, some had problems seeing preferred providers. Accessing reproductive health care services is so difficult that some women avoid regular gynecologic visits. Suggestions for improving services included involving women with disabilities in teaching health care providers about their special needs and self-advocacy training to help disabled women become more knowledgeable partners in their own health care.

CONCLUSIONS

Additional research should address the gaps in knowledge about the reproductive health care needs of women with disabilities.