Australian behavioural research in cancer


Behavioural Research and Evaluation Unit (BREU), Cancer Council SA

Use of the distress thermometer in the context of a telephone-based cancer information and support service. An exploratory study.

While the validity of the distress thermometer (DT) for the measurement of psychological distress has been examined in several cancer settings, little is known about user experience of the DT and its utility and acceptability in telephone-based cancer support services. Using a mixed-methods design, eligible callers (individuals diagnosed with cancer and family/friends, N=100) responded to a questionnaire that included DT ratings and the Depression Anxiety and Stress Scale-21 (DASS-21). Comfort in asking about and responding to the DT was assessed for both nurse operators and callers.

A purposively selected subgroup was then interviewed (n=20) and content analysis was used to thematically categorise responses. Analysis of variance indicated distress reduced significantly over the course of the call, regardless of caller type or gender. Caller DT scores correlated with DASS-21 depression (r=.45, p=.000), anxiety (r=.56, p=.000) and stress (r =.64, p =.000) subscales. Both callers and nurses reported comfort in using the DT. Qualitatively, some callers reported the DT as easy to answer and conversational, while others expressed difficulty responding to the scale.

Future research could explore the impact of methods of DT delivery (e.g. point in call, methods of introduction) on caller distress, psychosocial outcomes and uptake of referral to other support services.

Exploring patterns in sun-related behaviour in adolescents and triathletes
Australia has one of the highest rates of skin cancer, which is largely preventable by adopting sun protection practices. Research indicates that regular adoption of multiple sun protection behaviours (i.e. protective clothing, sunscreen, hat, shade, sunglasses) is uncommon and people adopt different behaviours in different contexts. This suggests that these behaviours may not have the same underlying motivations and may require tailored strategies to improve uptake. This report describes the findings of two studies that explored patterns in sun-related behaviours. The first study investigated sun protection practices in adolescents and the second study investigated sun protection among triathletes.  

Data for the investigation of adolescent sun protection behaviour were collected via the Australian Secondary Schools Alcohol and Drug Survey (ASSAD), which is tri-annual survey of students’ health behaviours. Analyses were based on data collected from students in South Australia in 2011. In total, data were available for 2875 students aged 12 to 17 years. Participants were asked to indicate how often they participated in seven sun-related behaviours between 11am and 3pm in summer on a five point scale – 1 (never), 2 (rarely), 3 (sometimes), 4 (usually) or 5 (always). Participants also reported skin tone dissatisfaction, tanning intentions, and agreement with several statements addressing beliefs about the desirability and risks of tanning.

A principal components analysis was run to identify underlying factors. Sun-related behaviours could be reduced to three components. Items that loaded on component 1 were wearing a hat, wearing sunscreen and wearing protective clothing. This was labelled ‘sun protection’. Items that loaded on component 2 were wearing sunglasses and deliberately wearing briefer clothing. This was labelled ‘appearance-enhancement’. Items that loaded on component 3 were seeking shade and time indoors. This was labelled ‘shade behaviour’.

Appearance-enhancement was associated with higher skin tone dissatisfaction, stronger intentions to tan, stronger beliefs about the attractiveness of a tan, and perceived peer norms in support of tanning. These measures were associated with sun protection and shade behaviour but in the opposite direction. In general, misperceptions about the risks of tanning were more likely to be associated with shade behaviour (lower misperceptions) than with sun protection and appearance-enhancement, however the patterns of associations with sun protection behaviours varied depending on the specific question and gender.

This work has been reported in Hutchinson A, Prichard I, Ettridge K & Wilson C. Int J Behav Med. 2014 and Corsini N, Hutchinson A, Prichard I, Sharplin G, & Wilson C. E-poster presentation. World Cancer Congress, Melbourne. Dec 2014.

The second study investigated motivations underlying sun protection practices in a sample of triathletes in clubs from around Australia. In total, 101 triathletes were recruited (47 female, average age was 37.51±10.99 years). Participants completed an online survey which included questions about sun protection, including how often they participated in sun protection behaviours at triathlon competitions in the past season on a five point scale – 1 (never), 2 (a few), 3 (half), 4 (most) or 5 (every competition). Sun protection behaviours included: wearing sunscreen; wearing a hat/visor (run and bike leg); wearing a top that covered the shoulders; wearing sunglasses (run and bike leg); and seeking shade after the event. Participants also completed a range of other questions, including whether or not their club had a sun protection policy and their susceptibility to sunburn.

A principle components analysis revealed a similar pattern of results to those described in the adolescent sample. Items that loaded on component 1 were wearing a shoulder-covering top and wearing sunglasses (Appearance-enhancement). Wearing sunglasses loaded negatively on the appearance-enhancement component, meaning that triathletes who wore sunglasses were less likely to wear a shoulder-covering top and vice versa. Items that loaded on component 2 were wearing sunscreen and wearing a hat (sun protection). Seeking shade loaded on component 3 (shade behaviour).

Appearance-enhancement was lower among triathletes who reported belonging to a club with a sun protection policy, compared with triathletes who did not have or did not know whether their club had a policy. There were no differences in sun protection or shade behaviour by policy status. Sun protection and shade behaviour were significantly associated with greater reported susceptibility to sunburn. Appearance-enhancement was not associated with reported susceptibility to sunburn.

These findings indicate that sun-related behaviours can be understood in terms of a smaller number of themes. The traditional ‘slip, slop, slap’ sun protection behaviours group together and are likely to be motivated by sun protection concerns. Wearing sunglasses however, appears to be motivated more by appearance-based concerns and is associated with sun exposure behaviours. Seeking shade does not group with traditional sun protection behaviours. This may reflect the fact that shade behaviour is affected by environmental factors such as the availability of shade structures. The similarity in patterns of behavioural groupings seen in both an adolescents and an adult population suggest that these groupings may be robust. Strategies to engage people in sun protection should consider the possible motivations underlying different sun protection behaviours. Interventions to address appearance-based concerns should be considered a priority.

Centre for Behavioural Research in Cancer (CBRC), Victoria

Non-smokers, smokers and former smokers respond to various electronic cigarette advertisements
Internationally, electronic cigarette (e-cigarette) advertising and promotion is increasing rapidly, with widespread promotion on television, YouTube and retail websites. These ads commonly portray the hand-to-mouth action of ‘vaping’ in a very glamorous manner, and include claims of advantages over regular cigarettes and increased social status. CBRC is conducting a study to assess responses to e-cigarette ads among non-smokers, former smokers and smokers using an adaption of a standard ad pre-testing protocol.

Six groups were conducted (n=6-8 per group), two of which included 18-24 year-old non-smokers, two 25-55 year-old former smokers, and two 25-55 year old smokers. Each group viewed and rated one of two sets of eight ads and participated in a group discussion about each ad. All groups included two to three participants who had previously tried e-cigarettes but excluded regular e-cigarette users. Preliminary analyses from the qualitative discussions indicate glamorous ads with few references to product advantages were most appealing to non-smokers, whereas those detailing product advantages were most appealing to smokers. Few ads appealed to former smokers, who were especially concerned that a smoking-like behaviour could be promoted as glamorous. Quantitative analyses will examine the extent to which different e-cigarette ads may potentially promote ‘vaping’ and tobacco smoking.

With Australian authorities yet to decide on regulatory measures for e-cigarette production and promotion, this study will provide some indication of the potential effects of different e-cigarette advertising in Australia. 

Patterns of care in adolescents and young adults with cancer
Each year, about 900 Australian adolescents and young adults (AYAs, aged 15-24 years) are diagnosed with cancer. Research shows that AYA patients have had the smallest improvement in survival over the last 20 years of any age group. Also, for cancers that occur in both children and AYAs, survival is worse among AYA patients. The reasons for this are not well understood. A National Health and Medical Research Council project grant ($645,000) will fund a study to examine these issues in Victoria, Queensland and New South Wales. Additional funding ($100,000) was obtained from CanTeen and The Kid’s Cancer Fund to extend the study to the remaining Australian states and territories. The project is a retrospective review of hospital medical records. It aims to collect treatment and outcome data for all AYAs diagnosed with leukaemia, soft tissue sarcoma, bone cancer and central nervous system tumours between 2007 and 2012. These diagnoses account for about 20 per cent of AYA cancers and were selected for their relatively poor outcomes.

Data collection is now complete for all Eastern states, with 870 patients’ files reviewed. It will be completed nationally by mid-2015. The results will be used to identify the modifiable health-system factors and practices that influence patterns of care for AYAs with cancer so that clinical outcomes can be improved. The study is complemented by a patient survey that examines how to improve AYA experiences of cancer care.

Newcastle Cancer Control Collaborative (New-3C), NSW

Life expectancy discussions in a multi-site sample of Australian medical oncology outpatients
Patient-centred cancer care requires that patients receive the information they want about their life expectancy. A multi-site study of 1431 medical oncology outpatients across 11 Australian cancer treatment centres identified the proportion of patients who received their preferred level of information about life expectancy, and the socio-demographic, clinical and psychological factors associated with patients’ perceptions.

Patients completed a cross-sectional survey indicating the extent to which the information they received about their life expectancy aligned with their preferences for this information. Almost one quarter (24%) of patients perceived they received too little information, 4% received too much information, 22% neither wanted nor received any information, and 50% received all the information that they wanted about their life expectancy. Patients had greater odds of receiving too little information (rather than all the information they wanted) if they were not in remission, did not know their cancer stage at diagnosis, or were anxious or depressed. Patients had greater odds of receiving too much information if they were younger, had a more advanced cancer and did not know their cancer stage at diagnosis. Patients had greater odds of not wanting or receiving information if they were older and did not know their cancer stage at diagnosis. A majority of outpatients perceive that they receive the amount of life expectancy information that they prefer. However, there is room for improvement.

Health care providers should routinely assess whether patients have received preferred information regarding their life expectancy.

Prevalence and correlates of current smoking among medical oncology outpatients
Smoking after being diagnosed with cancer can have detrimental impacts on treatments and increases the risk of additional cancers. Smoking cessation interventions for patients with cancer show mixed results, thus data on prevalence and correlates of smoking are needed to better target at risk patients. This study explored: (a) the prevalence of self-reported current smoking; and (b) the demographic and psychosocial factors associated with self-reported smoking among outpatients attending a medical oncology clinic.

A heterogeneous sample of cancer patients aged 18 years or over was recruited from 11 medical oncology treatment centres across Australia. Patients completed a survey assessing: smoking status; socio-demographic, disease/treatment characteristics; time since diagnosis; anxiety; and depression. Univariate and multivariate mixed-effects logistic regression was used to explore patient characteristics associated with self-reported continued smoking.

A total of 1379 patients returned surveys (1338 included in analysis). Current smoking prevalence was 10.9% (n=146). After adjusting for treatment centre, patients aged 65 years and older and those without health concession cards were significantly less likely to smoke. Patients diagnosed with lung cancer and those without private health insurance were more likely to smoke. A minority of cancer patients reported continued smoking at an average time of 13 months post-diagnosis. Younger patients, patients with lung cancer, and patients with lower socioeconomic status appear to be the groups most at-risk of continued smoking following diagnosis, and represent key targets for smoking cessation intervention.

Cost-benefit analyses should be undertaken to examine the impact of such smoking cessation interventions in this sub-group.

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