Alice E. Simon

Stress and dietary practices in adolescents

Baseline data from the Health and Behavior in Teenagers Study (HABITS) were used to investigate associations between stress and dietary practices in a socioeconomically and ethnically diverse sample of 4,320 schoolchildren (mean age = 11.83 years). Male (n = 2,578) and female (n = 1,742) pupils completed questionnaire measures of stress and 4 aspects of dietary practice (fatty food intake, fruit and vegetable intake, snacking, and breakfast consumption) and also provided demographic and anthropometric data. Multivariate analyses revealed that greater stress was associated with more fatty food intake, less fruit and vegetable intake, more snacking, and a reduced likelihood of daily breakfast consumption. These effects were independent of individual (gender, weight) and social (socioeconomic status, ethnicity) factors. Stress may contribute to long-term disease risk by steering the diet in a more unhealthy direction.

Socioeconomic disparities in cancer-risk behaviors in adolescence: baseline results from the Health and Behaviour in Teenagers Study (HABITS).

BACKGROUND This study explores the association between socioeconomic deprivation and five factors associated with long-term risk of cancer, in adolescents. METHODS BMI, fat intake, fruit and vegetable intake, smoking, and exercise were assessed in 4320 students ages 11 to 12, from 36 schools, in the first year of a 5-year longitudinal study of the development of health behaviors (HABITS study). Neighborhood socioeconomic deprivation for each students area of residence was matched to their postcode (zip code). We used multiple logistic regression analyses to investigate the relationship between risky behaviors and socioeconomic circumstances. RESULTS Univariate analyses showed boys and girls from more deprived neighborhoods were more likely to have tried smoking, to eat a high fat diet, and to be overweight. Girls living in more deprived areas were also less likely to eat five servings of fruit and vegetables or to exercise at the weekend. Most differences persisted after controlling for ethnicity. A clear deprivation gradient emerged for each risk factor, indicating the linear nature of the relationship. CONCLUSIONS This study demonstrates the influence of deprivation on engaging in cancer-risk health behaviors. These patterns may set young people from more socioeconomically deprived social environments on a trajectory leading to increased cancer mortality in adult life.

Patient delay in presentation of possible cancer symptoms: the contribution of knowledge and attitudes in a population sample from the United kingdom.

Background: Qualitative studies implicate knowledge of cancer symptoms and attitudes towards help-seeking as important factors in patient delay. The present study uses quantitative data from a population-based survey to test the hypotheses that (a) a greater knowledge of early cancer symptoms is associated with a higher likelihood of having appraised a symptom as possibly due to cancer, and (b) more negative attitudes towards help-seeking are associated with a lower likelihood of having sought medical advice for that symptom. Methods: Two thousand and seventy-one adults were asked whether they had experienced a symptom that they worried might be cancer in the past 3 months, and if so, whether they had seen a doctor. Respondents also completed the Cancer Awareness Measure (CAM) assessing symptom knowledge and barriers to help-seeking. Results: Two hundred and thirty-six (11.4%) respondents reported having experienced a possible cancer symptom. In logistic regression analyses controlling for age, sex, and self-rated health, higher CAM symptom knowledge scores were associated with a greater likelihood of having experienced a possible cancer symptom (odds ratio = 1.09; 95% confidence interval, 1.01-1.17). Of those who had experienced a symptom, 75% (177/236) had seen a doctor. Higher scores on the CAM barriers scale were associated with being less likely to have seen a doctor (odds ratio, 0.74; 95% confidence interval, 0.63-0.87). Conclusions: Better knowledge of the signs and symptoms of cancer might help people recognize possible cancer symptoms and therefore reduce appraisal delay, whereas more positive attitudes towards help-seeking might reduce behavioral delay. Impact: Campaigns to educate the public about cancer symptoms and reduce help-seeking barriers could play a role in promoting early diagnosis. Cancer Epidemiol Biomarkers Prev; 19(9); 2272–7. ©2010 AACR.

Cancer Fatalism: Deterring Early Presentation and Increasing Social Inequalities?

Background: Fatalistic beliefs about cancer have been implicated in low uptake of screening and delay in presentation particularly in low socioeconomic status (SES) groups, but no studies have systematically evaluated interrelationships between SES, fatalism, and early detection behaviors. We explored whether (i) fatalism is associated with negative attitudes toward early detection, (ii) lower SES groups are more fatalistic, and (iii) SES differences in fatalism partly explain SES differences in attitudes toward early detection. Methods: In a population-representative sample of adults in Britain using computer-based interviews in the home setting, respondents (N = 2,018) answered two questions to index fatalism (expectations of cancer survival and cure) and two items on early detection attitudes (the perceived value of early detection and fear of symptom reporting). SES was indexed with a social grade classification. Results: Fatalism was associated with being less positive about early detection (β = −0.40, P < 0.001) and more fearful about seeking help for a suspicious symptom (β = 0.24, P < 0.001). Lower SES groups were more fatalistic (β = −0.21, P < 0.001). Path analyses suggest that SES differences in fatalism might explain SES differences in attitudes about early detection. Conclusions: In this population sample, SES differences in fatalism partly explained SES differences in the perceived value of early detection and fear of symptom presentation. Impact: Fatalistic beliefs about cancer should be targeted to promote early presentation of cancer and this may be particularly important for lower SES groups. Cancer Epidemiol Biomarkers Prev; 20(10); 2127–31. ©2011 AACR.

Persistent impact of pubertal timing on trends in smoking, food choice, activity, and stress in adolescence.

Objectives: a) To replicate the established association between early puberty and smoking; b) to see whether differences between early and late maturers narrowed with increasing age and differed by gender; and c) to determine whether other health behaviors (food choice, physical activity, sedentary behavior) and stress showed the same association with pubertal timing. Methods: The Health and Behaviour in Teenagers Study (HABITS) followed a cohort of 5863 adolescents from ages 11 to 12 years (UK year 7; US grade 6) for 5 years. Puberty was assessed with the Pubertal Development Scale. Three pubertal timing groups were created by identifying adolescents who reached midpuberty relatively early, average, or late, compared with their peers. Longitudinal trends in health behaviors and stress were compared between the three groups. Results: Smoking rates were higher throughout adolescence among early-maturing students, with no evidence that late-maturers “caught up” when they reached puberty, although group differences narrowed over time. Early-maturing students had higher rates of sedentary behaviors but also reported higher rates of vigorous activity than their “on-time” developing counterparts. Patterns in dietary behaviors and stress showed lower rates of daily breakfast and higher stress among early-maturing girls, but not boys. Overall, the effects were largest in early adolescence (ages 11–13 years) and became smaller at older ages (ages 14–16 years). Conclusion: Early-maturing adolescents are at increased risk for unhealthy behaviors, especially smoking, and although differences attenuate during adolescence, they remain significant at age 16 years. This suggests that early maturation may be a cause of, or is at least a marker for, differences in lifestyle. HABITS = Health and Behaviour in Teenagers Study; OR = odds ratio; CI = confidence interval.

Recognition of cancer warning signs and anticipated delay in help-seeking in a population sample of adults in the UK

Background:Not recognising a symptom as suspicious is a common reason given by cancer patients for delayed help-seeking; but inevitably this is retrospective. We therefore investigated associations between recognition of warning signs for breast, colorectal and lung cancer and anticipated time to help-seeking for symptoms of each cancer.Methods:Computer-assisted telephone interviews were conducted with a population-representative sample (N=6965) of UK adults age ⩾50 years, using the Awareness and Beliefs about Cancer scale. Anticipated time to help-seeking for persistent cough, rectal bleeding and breast changes was categorised as >2 vs ⩽2 weeks. Recognition of persistent cough, unexplained bleeding and unexplained lump as cancer warning signs was assessed (yes/no). Associations between recognition and help-seeking were examined for each symptom controlling for demographics and perceived ease of health-care access.Results:For each symptom, the odds of waiting for >2 weeks were significantly increased in those who did not recognise the related warning sign: breast changes: OR=2.45, 95% CI 1.47–4.08; rectal bleeding: OR=1.77, 1.36–2.30; persistent cough: OR=1.30, 1.17–1.46, independent of demographics and health-care access.Conclusion:Recognition of warning signs was associated with anticipating faster help-seeking for potential symptoms of cancer. Strategies to improve recognition are likely to facilitate earlier diagnosis.

Disease stage and psychosocial outcomes in colorectal cancer.

Objective  Disease stage is a strong predictor of cancer survival and is therefore assumed to influence psychosocial outcomes. However, existing findings are inconsistent, perhaps reflecting limited sample sizes, especially among patients with advanced disease. There has also been an emphasis on breast cancer, resulting in a focus on outcomes among women. The present study investigated associations between disease stage and psychosocial wellbeing in 128 patients (52% male, 48% female) diagnosed with colorectal cancer.

Examining the relationship between pubertal stage, adolescent health behaviours and stress.

BACKGROUND This paper examines the associations between puberty and three important health behaviours (smoking, food intake and exercise) and explores whether these associations are mediated by pubertys relationship to stress and psychological difficulties. METHOD Data were taken from the first year of the ongoing, 5-year, Health and Behaviours in Teenagers Study (HABITS). This is a school-based study set in 36 schools in London. In the first year of the study, 4320 students (2578 boys, 1742 girls) in their first year of secondary education took part. RESULTS Among girls, being more pubertally advanced was associated with a greater likelihood of having tried smoking. Among boys, being more pubertally advanced was associated with a greater likelihood of having tried smoking, a higher intake of high-fat food and higher levels of exercise. More pubertally advanced girls experienced more stress but not more psychological difficulties. There were no associations between puberty and either stress or psychological difficulties in boys. Stress and psychological difficulties were associated with health behaviours in girls and boys, but neither of these factors mediated the relationship between pubertal stage and health behaviours found in girls. CONCLUSIONS These results suggest that the onset of puberty has a marked effect on the development of health behaviours. Puberty was related to an acceleration of the development of unhealthy behaviours, except for exercise behaviour in boys, where advanced puberty was associated with more exercise. These changes were unrelated to adolescent issues of stress and a causal explanation for these associations must be sought elsewhere.

An international measure of awareness and beliefs about cancer: development and testing of the ABC

Objectives To develop an internationally validated measure of cancer awareness and beliefs; the awareness and beliefs about cancer (ABC) measure. Design and setting Items modified from existing measures were assessed by a working group in six countries (Australia, Canada, Denmark, Norway, Sweden and the UK). Validation studies were completed in the UK, and cross-sectional surveys of the general population were carried out in the six participating countries. Participants Testing in UK English included cognitive interviewing for face validity (N=10), calculation of content validity indexes (six assessors), and assessment of test–retest reliability (N=97). Conceptual and cultural equivalence of modified (Canadian and Australian) and translated (Danish, Norwegian, Swedish and Canadian French) ABC versions were tested quantitatively for equivalence of meaning (≥4 assessors per country) and in bilingual cognitive interviews (three interviews per translation). Response patterns were assessed in surveys of adults aged 50+ years (N≥2000) in each country. Main outcomes Psychometric properties were evaluated through tests of validity and reliability, conceptual and cultural equivalence and systematic item analysis. Test–retest reliability used weighted-κ and intraclass correlations. Construction and validation of aggregate scores was by factor analysis for (1) beliefs about cancer outcomes, (2) beliefs about barriers to symptomatic presentation, and item summation for (3) awareness of cancer symptoms and (4) awareness of cancer risk factors. Results The English ABC had acceptable test–retest reliability and content validity. International assessments of equivalence identified a small number of items where wording needed adjustment. Survey response patterns showed that items performed well in terms of difficulty and discrimination across countries except for awareness of cancer outcomes in Australia. Aggregate scores had consistent factor structures across countries. Conclusions The ABC is a reliable and valid international measure of cancer awareness and beliefs. The methods used to validate and harmonise the ABC may serve as a methodological guide in international survey research.

Knowledge of lung cancer symptoms and risk factors in the UK: development of a measure and results from a population-based survey

Objectives To develop and validate a Lung Cancer Awareness Measure (Lung CAM) and explore the demographical and social predictors of lung cancer awareness in the general population. Methods study 1 Symptoms and risk factors for lung cancer were identified from the medical literature and health professional expertise in an iterative process. Test–retest reliability, internal reliability, item analyses, construct validity and sensitivity to changes in awareness of the Lung CAM were assessed in three samples (total N=191). Results study 1 The Lung CAM demonstrated good internal (Cronbachs α=0.88) and test–retest reliability (r=0.81, p<0.001). Validity was supported by lung cancer experts scoring higher than equally educated controls (t(106)=8.7, p<0.001), and volunteers randomised to read lung cancer information scoring higher than those reading a control leaflet (t(81)=3.66, p<0.001). Methods study 2 A population-based sample of 1484 adults completed the Lung CAM in a face-to-face, computer-assisted interview. Results study 2 Symptom awareness was low (average recall of one symptom) and there was little awareness of risk factors other than smoking. Familiarity with cancer, and being from a higher socioeconomic group, were associated with greater awareness. Conclusions Using a valid and reliable tool for assessing awareness showed the UK population to have low awareness of lung cancer symptoms and risk factors. Interventions to increase lung cancer awareness are needed to improve early detection behaviour.