Neeraj K. Arora

How does communication heal? Pathways linking clinician–patient communication to health outcomes

OBJECTIVE Although prior research indicates that features of clinician-patient communication can predict health outcomes weeks and months after the consultation, the mechanisms accounting for these findings are poorly understood. While talk itself can be therapeutic (e.g., lessening the patients anxiety, providing comfort), more often clinician-patient communication influences health outcomes via a more indirect route. Proximal outcomes of the interaction include patient understanding, trust, and clinician-patient agreement. These affect intermediate outcomes (e.g., increased adherence, better self-care skills) which, in turn, affect health and well-being. Seven pathways through which communication can lead to better health include increased access to care, greater patient knowledge and shared understanding, higher quality medical decisions, enhanced therapeutic alliances, increased social support, patient agency and empowerment, and better management of emotions. CONCLUSION Future research should hypothesize pathways connecting communication to health outcomes and select measures specific to that pathway. PRACTICE IMPLICATIONS Clinicians and patients should maximize the therapeutic effects of communication by explicitly orienting communication to achieve intermediate outcomes (e.g., trust, mutual understanding, adherence, social support, self-efficacy) associated with improved health.

Effect of Computer Support on Younger Women with Breast Cancer

AbstractOBJECTIVE: Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved. DESIGN: Randomized controlled trial conducted between 1995 and 1998. SETTING: Five sites: two teaching hospitals (Madison, Wis, and Chicago, Ill), two nonteaching hospitals (Chicago, Ill), and a cancer resource center (Indianapolis, Ind). The latter three sites treat many underserved patients. PARTICIPANTS: Newly diagnosed breast cancer patients (N=246) under age 60. INTERVENTIONS: Experimental group received Comprehensive Health Enhancement Support System (CHESS), a home-based computer system providing information, decision-making, and emotional support. MEASUREMENTS AND MAIN RESULTS: Pretest and two posttest surveys (at two- and five-month follow-up) measured aspects of participation in care, social/information support, and quality of life. At two-month follow-up, the CHESS group was significantly more competent at seeking information, more comfortable participating in care, and had greater confidence in doctor(s). At five-month follow-up, the CHESS group had significantly better social support and also greater information competence. In addition, experimental assignment interacted with several indicators of medical underservice (race, education, and lack of insurance), such that CHESS benefits were greater for the disadvantaged than the advantaged group. CONCLUSIONS: Computer-based patient support systems such as CHESS may benefit patients by providing information and social support, and increasing their participation in health care. These benefits may be largest for currently underserved populations.

Measuring patient-centered communication in cancer care: A literature review and the development of a systematic approach

Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institutes Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.

Discrete and Continuous Representations of Unobserved Heterogeneity in Choice Modeling

We attempt to provide insights into how heterogeneity has been and can be addressed in choice modeling. In doing so, we deal with three topics: Models of heterogeneity, Methods of estimation and Substantive issues. In describing models we focus on discrete versus continuous representations of heterogeneity. With respect to estimation we contrast Markov Chain Monte Carlo methods and (simulated) likelihood methods. The substantive issues discussed deal with empirical tests of heterogeneity assumptions, the formation of empirical generalisations, the confounding of heterogeneity with state dependence and consideration sets, and normative segmentation.

Providing Health Messages to Hispanics/Latinos: Understanding the Importance of Language, Trust in Health Information Sources, and Media Use

Health communication is critical to promoting healthy lifestyles and preventing unhealthy behaviors. However, populations may differ in terms of their trust in and use of health information sources, including mass media, the Internet, and interpersonal channels. We used the 2005 Health Information National Trends Survey (HINTS) to test the hypothesis that Hispanics who are less comfortable speaking English would differ from Hispanics who are comfortable speaking English with respect to trust in health information sources and media use. Hispanics/Latinos comprised 9% of the 2005 HINTS sample (n = 496). Respondents not born in the United States regardless of race/ethnicity and all Hispanics were asked, “How comfortable do you feel speaking English?” Responses of “completely,” “very,” or “native speaker” were combined into “comfortable speaking English”: all other responses were categorized as “less comfortable speaking English.” Those comfortable speaking English reported higher trust for health information from newspapers (p < .05), magazines (p < .05), and the Internet (p < .01) compared with those less comfortable speaking English. They also reported more media exposure: daily hours listening to the radio and watching television (both p < .05) and days per week reading newspapers (p < .05). Hispanics comfortable speaking English reported much higher levels of Internet use (54% versus 14%, p < .0001). Hispanics who are not comfortable speaking English may be difficult to reach, not only because of language barriers and lower trust in media, but also because they report relatively little use of various media channels. These findings have important implications for health communications toward non-native speakers of English in general and Hispanics in particular.

Positive and negative life changes experienced by survivors of non-Hodgkin’s lymphoma

Background: The impact of cancer on adult survivors of aggressive non-Hodgkin’s Lymphoma (NHL) is understudied.Purpose: We examined positive and negative life changes (health behaviors, relationships, financial situation) experienced by survivors of NHL and their association with physical and mental function.Methods: Using the Los Angeles County Cancer Surveillance Program, 744 questionnaires were mailed to adult survivors of NHL: 308 provided complete data for analyses (M age=59.8, SD=14.9).Results: Perceptions of positive and negative life changes were common in our sample, with 77.9% of NHL survivors reporting at least one positive change and 78.6% reporting at least one negative change. Cancer had the greatest positive change on relationships and the most negative change on survivors’ financial situation. There was an equal distribution of survivors classified as having experienced positive change and negative change on health behaviors. Regardless of whether positive and negative life change were entered into separate regression models or the same model, an increase in negative life change in each of the domains was significantly associated with a decrease in physical and mental functioning. Positive change was significantly associated only with physical functioning when examining overall change (p=.018) and health behaviors (p=.013), and the inclusion of negative change attenuated these associations.Conclusions: In designing interventions to improve the mental and physical function of NHL survivors, the greatest benefit may likely be achieved by reducing the negative effects of cancer. Perhaps positive life change are related in more specific ways to other indexes of adjustment, but our findings failed to show a positive relationship with mental and physical function.

An exploratory study of predictors of participation in a computer support group for women with breast cancer.

This study examined what characteristics predict participation in online support groups for women with breast cancer when users are provided free training, computer hardware, and Internet service removing lack of access as a barrier to use. The only significant difference between active and inactive participants was that active users were more likely at pretest to consider themselves active participants in their healthcare. Among active participants, being white and having a higher energy level predicted higher volumes of writing. There were also trends toward the following characteristics predictive of a higher volume of words written, including having a more positive relationship with their doctors, fewer breast cancer concerns, higher perceived health competence, and greater social/family well-being. Implications for improving psychosocial interventions for women with breast cancer are discussed, and future research objectives are suggested.

Understanding the role of preference revision and concession in group decisions

In this article, the authors contend that member influence in a groups decision could be decomposed into two distinct elements of preference revision and concession. Using a hierarchical Bayes model of dyadic decision making, the authors show that the degree of preference revision and concession varies across product attributes, individuals, and product categories. The authors demonstrate that converging preferences affect a members concession, which in turn affects members’ satisfaction with the joint decision. More important, a members satisfaction is higher when his or her concession is reciprocated.

Promoting Brands Across Categories with a Social Cause: Implementing Effective Embedded Premium Programs.

Embedded premium (EP) promotions promise purchase-contingent donations to a social cause and are typically studied within a single category. However, EP programs spanning multiple product categories and brands are widespread. This research investigates fundamental questions regarding where and to what extent an EP promotion should be used in multicategory contexts. Using experimental choice data from more than 3500 people in two studies, the authors examine multicategory EP programs in two distinct branding environments: spanning a diverse house-of-brands portfolio or covering a multicategory product line that shares a common corporate brand name. For the corporate brand context, the results show that EP effects in one category carry over to adjacent categories that do not have an EP association. Greater multicategory EP prevalence does not enhance brand attractiveness beyond the effect of a single EP exposure. For the house-of-brands context, there is an inverse relationship between brand strength and incremental gain from EP. From a return-on-investment standpoint, EP promotions are more efficient than price promotions because they enhance brand preference and are relatively cheaper to deploy. The results make a strong case for a more discriminating implementation of EP programs across brands and categories.

Health-related quality of life among survivors of aggressive non-Hodgkin lymphoma.

Non‐Hodgkin lymphoma (NHL) is the fifth most common cancer among men and women. Patients with aggressive NHL receive intense medical treatments that can significantly compromise health‐related quality of life (HRQOL). However, knowledge of HRQOL and its correlates among survivors of aggressive NHL is limited.