Kathleen E. Grady

Quality of social support and associated social and psychological functioning in women with rheumatoid arthritis.

Using a cross-sectional interview study of 194 women with rheumatoid arthritis, investigated the relationship between health status, social integration, qualitative aspects of social support, and social and psychological functioning in the presence of a chronic, disabling disease. Even after controlling for the influences of current physical limitations and social integration, qualitative dimensions of social support as measured by the Quality of Social Support Scale, a scale developed for this study, explained a significant proportion of the variance in home and family functioning and in depression.

The importance of physician encouragement in breast cancer screening of older women

METHODS The relationship between physician encouragement and breast cancer screening is examined with a population-based survey of 630 women between the ages of 45 and 75. Although the women interviewed were selected on the basis of their noncompliance with mammography guidelines, nearly half had previously had at least one mammogram. RESULTS Women reported having received more physician encouragement of breast self-examination than of mammography. Older women reported less encouragement of both screening modalities than younger women. Multivariate analyses revealed physician encouragement to be more strongly associated with screening mammography than with health status, health care utilization, attitudes, and sociodemographic characteristics: those who reported having received physician encouragement were nearly four times more likely to have ever had screening mammography. CONCLUSIONS These and related findings are used to highlight the critical importance of physician behavior in the secondary prevention of breast cancer in older women and to identify types of patients whose needs for screening are most likely to be overlooked by physicians.

The impact of rheumatoid arthritis on the homemaker

Few current studies of the effects of chronic conditions on social functioning examine the effects of disease on the role of homemaker. A major problem confronting researchers in this area is the difficulty in operationalizing dysfunction in social roles other than work roles. In this study we have developed a measure of homemaker functioning based on conceptualizing the homemaker role on two dimensions: the instrumental functions associated with meeting the physical needs of the household and the nurturant dimension concerned with meeting the expressive needs of the household. We used our measure of homemaker functioning to study the effects of rheumatoid arthritis on 142 women, whether employed outside the home or not, between the ages of 21 and 65, all living with husband and/or children at the time of disease onset. The disease significantly limited both instrumental and nurturing functions associated with managing a household. The more strenuous instrumental functions were more likely to be limited, although women in our study experienced serious limitations in nurturant role functions, as well. Limitations in functioning along the nurturant dimension were surprisingly high and previously undocumented. Comparisons between women employed outside the home and those not employed found few differences between the groups in social functioning on either dimension of the homemaker role. Employed women were somewhat less physically disabled than the unemployed, but both groups of homemakers continued to assume major responsibility for homemaking. Assessing functioning in social roles other than work, and functioning in nurturant as well as instrumental areas, is especially important in evaluating the effects on women of a chronic disease such as rheumatoid arthritis.

Work disability and the experience of pain and depression in rheumatoid arthritis

People with rheumatoid arthritis (RA) who are work disabled report more pain and depression than do those who are able to continue in paid employment. This paper explores the connections between work ability, clinical disease factors and symptom reports among people with this chronic disease. Using the expanded Biopsychosocial model of disease and illness it is shown that both work ability and clinical factors have independent, additive effects on pain and depression. The paid work effect is found even after controlling for the large and significant effect of pain on depression and depression on pain. This suggests that the pain and depression experience associated with RA is a function of both the underlying disease and the structural barriers that prevent continued participation in the workplace. It also suggests that contrary to popular notions of how disease severity affects symptoms, one does not have to be in the highest categories of disease severity to be in the highest levels of depression and/or pain.

Cue enhancement and the long-term practice of breast self-examination

This study investigates the stimulus control of breast self-examination (BSE) using two methods of cue enhancement: self-managed use of calendars with sticker reminders and monthly reminder postcards. One hundred eighty-nine women patient volunteers with or without menstrual cycles (“cyclic” or “noncyclic”) were randomly assigned to experimental conditions after an initial interview and teaching session. Their monthly BSE records, returned by mail during the 6-month experimental period, constituted the major dependent measure of the study. Results indicate an overall positive effect of postcard reminders and a positive effect for self-management for the cyclic women only. In addition, noncyclic women practiced BSE at a higher rate than cyclic women. A subsequent analysis clarified these results substantially by showing that timing of the postcard and use of self-management account for these group differences. Thus, the interventions seem to be extraordinarily effective in obtaining high rates of BSE over 6 months provided only that they can be appropriately instituted. During the postexperimental period, the rate of BSE practice declined, especially in the postcard conditions. Results are discussed in terms of the applicability of behavioral analysis to intractable problems of patient compliance.

The effect of reward on compliance with breast self-examination

Based on a behavioral analysis of compliance with breast self-examination (BSE), this study replicates a previously successful stimulus control intervention and tests the effectiveness of two types of reward for increasing compliance: external reward and self-reward. Patient volunteers (N=153) were randomly assigned to experimental conditions and followed for 1 year, equally divided into experimental and postexperimental periods. Compliance was measured by the monthly return of BSE records, with self-reports used as a secondary measure. The results indicate that external reward was most effective; self-reward was used by only half the participants but was effective when used. In the postexperimental period, all rates of record return declined, especially in the external reward group. A cycle-by-cycle analysis indicates that the decline was gradual except for a sharp drop when the external reward was withdrawn. The results are discussed in terms of the acceptability of both interventions and contingencies.

Who Volunteers for a Breast Self-Examination Program? Evaluating the Bases for Self-Selection

Interest in a free breast self-examination (BSE) teaching program offered to a patient population (n=1590) was assessed, and a follow-up survey of refusers undertaken to determine difference between participants and refusers. Fifty-one percent of the known, eligible women patients expressed interest in the program and 24% ultimately had the teaching. Participants differed from refusers most notably in terms of less previous experience with BSE, more family history of cancer, a longer relationship with their physicians, and different health beliefs. They state more confidence in the effectiveness of breast cancer detection and treatment, less fear and embarrassment, and more personal and physician responsibility for health outcomes, as measured by the Health Locus of Control Scales. Self-selection thus seems rationally based on the kind of program and the needs of the women. Such self-selection can be cost- effective in delivering health education to the people most in need of it and most likely to benefit from it.

Older Women and the Practice of Breast Self-Examination.

Breast self-examination (BSE) for breast cancer is used by only a fraction of the women who might benefit from it, and some studies show that older women who are more at risk for breast cancer are less likely to use it. This article reports a community study of women (n = 528) who were trained in BSE in womens group meetings, provided a behavioral management intervention, and followed for two years. The intervention consisted of monthly postcard cues for BSE and lottery ticket rewards whenever a BSE record was returned indicating a BSE had been done. During the second year, the intervention was withdrawn. Results show that although women over 50 are no more likely to report having done more BSEs than women under 50 prior to entering the study, they did tend to do more BSEs during the intervention year and were significantly more compliant during the follow-up year. A more detailed analysis by age decade showed the highest rates of compliance in both years were for women ages 60–69 and 70–87. An analysis of attitudinal, history, and sociodemographic factors indicated that the only consistent predictor of BSE practice other than age and the intervention was the womans confidence in BSE.