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Psychosocial adjustment of Latina cervical cancer patients

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Psychosocial adjustment of Latina cervical cancer patients

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Content PSYCHOSOCIAL ADJUSTMENT OF LATINA CERVICAL CANCER PATIENTS by Lina M. D'Orazio A Thesis Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF ARTS (PSYCHOLOGY) May 2009 Copyright 2009 Lina M. D’Orazio ii Table of Contents List of Tables iii List of Figures iv Abstract v Chapter 1: Introduction 1 Chapter 2: Methods 13 Chapter 3: Analyses 21 Chapter 4: Results 25 Chapter 5: Discussion 43 References 56 Appendix 63 iii List of Tables Table 1: Patient Demographic Variables 27 Table 2: Medical Variables 28 Table 3: Descriptive Statistics for Outcome Variables 31 Table 4: Descriptive Statistics for Predictor Variables 35 Table 5: Correlations between Predictor and Dependent Variables 36 Table 6: Regression Analysis for Predictors of Depression 37 Table 7: Regression Analysis for Predictors of Positive and Negative Affect 39 Table 8: Regression Analysis for Predictors of Quality of Life 40 iv List of Figures Figure 1: Comparisons of Depression Scores with Community Samples and other Cancer Patients 29 Figure 2: Quality of Life for Current Sample as Compared to Normative Data (Brucker et al., 2005) 30 Figure 3: Methods of Coping 32 v Abstract Latinas have sustained the highest rates of cervical cancer throughout the past decade, yet, little is known about the experiences of these patients. In this study, 54 low-income, monolingual Spanish-speaking Latina cervical cancer patients were interviewed in order to describe their psychosocial experiences, identify predictors of psychosocial outcomes and explore the role of optimism in their adjustment. Cancer-related coping strategies, life stressors and social support were tested as predictors of depression, affect, and quality of life, and as mediators of the relation between optimism and the outcome variables. 67% of the sample reported symptoms similar to those of individuals with diagnosable levels of depression. Cancer-related and contextual variables significantly predicted all outcome variables. Approach coping mediated the relation between optimism and quality of life. The results of this study emphasize the need to consider the context within which patients live, in addition to cancer-related factors, when assessing adjustment to cancer. 1 Chapter 1: Introduction The diagnosis and treatment of cancer is often accompanied by psychological challenges including emotional distress, increased need for support, and fears about the future (Simon, Palmer, & Coyne, 2006). However, cancer patients are not a homogenous patient group—they do not all face this life-threatening illness with the same reserve of resources and support across demographic groups. The majority of research on the psychosocial adjustment of cancer patients has focused primarily on the experiences of middle-class, Caucasian patients, despite the fact that some cancers are much more prevalent among minority groups. Cervical cancer offers researchers an opportunity to learn about how cancer affects low-income ethnic minority patients, specifically, Latinas. Despite increased progress in cancer screening initiatives over the past decade, cervical cancer remains a serious problem for Latinas (De Alba, Ngo-Metzger, Sweningson, & Hubbell, 2005; Otero-Sabogal, Stewart, Sabogal, Brown, & Pérez-Stable, 2003). From year to year, these women continue to sustain the highest incidence of cervical cancer among women in the U.S. (American Cancer Society, 2005), with low-income Latinas being most affected (Howe, Delphino, Taylor, Anton-Culver, 1998). Great strides in the speed and quality of diagnoses and treatments have rendered cervical cancer as one of the most treatable cancers, resulting in thousands of patients becoming survivors with promising health outcomes. In spite of this, little is known about the psychosocial adjustment of Latina cervical cancer patients during and after their cancer treatment. The current study will be among the first to describe the adjustment of a sample of low-income Latina cervical 2 cancer patients, as well as to explore relationships between potential predictors of psychosocial well-being that may be most relevant to this specific patient group. There are several reasons to believe that the experiences of Latina cervical cancer patients would be different than the standard study samples. First, cancer can be a sizable burden to Latinas who may already be facing many obstacles in their lives including potential discrimination and decreased opportunities for education and employment (Hernandez, Plant, Sachs-Ericsson, & Joiner, 2004). Second, Latinas have been shown to have higher rates of depression (particularly dysthymia) than non-Latinas (Riolo, Nguyen, Greden, & King, 2005). Meyerowitz, Formenti, Ell, & Leedham (2000) found high rates of depression and non-cancer related stress among a sample of fifty low- income Latina cervical cancer patients receiving radiation therapy. Depression and fatigue have also been reported among gynecologic cancer patients treated with chemotherapy, though these studies have not included Latina patients (Klee, Thranov, & Machin; 2000; Lutgendorf, Anderson, Rothrock, Buller, Sood, & Sorosky, 2000). Therefore, treatments for cancer may amplify the risk for depression for Latinas patients who may already be vulnerable to depressive symptomology. Third, cervical cancer is often considered a sexually transmitted disease since the majority of cases are caused by infection with the human papilloma virus. The location of the cancer as well as the social implications of receiving a diagnosis of cervical cancer are potentially stigmatizing among Latinas from more conservative communities (Ashing-Giwa, Padilla, Bohórquez, Tejero, Garcia, & Meyers, 2006). Latina patients may, therefore, be at increased risk for 3 developing depressive symptomology for reasons that are both related and unrelated to the disease itself. The amount of research published specifically on the psychosocial adjustment of cervical cancer patients is remarkably small, even when including studies that group all gynecological cancers together (Ashing-Giwa et al., 2004; Bradley, Rose, Leath, Straughn, Kirby, Huggins, Partridge, & Parham, 2005; Chan et al., 2001; Eisemann & Lalos, 1999; Frumovitz et al., 2005; Greimel, Theil, Peintinger, Cegnar, & Pongratz, 2002; Klee et al.; Li, Samsioe, Iosif, 1999; Lutgendorf, Costanzo, & Anderson, 2006; Lutgendorf et al., 2001; Lutgendorf et al., 2000; Wenzel et al., 2005). The literature specifically on the experiences of Latina cervical cancer patients is even smaller (Ashing- Giwa et al., 2006; Meyerowitz et al.). Based on the available literature on non-Latina cancer patients, there appear to be some factors that consistently predict psychosocial well-being during and after receiving treatment for cancer, namely coping strategies, social support and dispositional optimism (Carver, Lehman, & Antoni, 2003; Scheier, Weintraub, & Carver, 1986; Scheier & Carver, 1992). However, there is very little evidence to suggest that these variables work in the same ways for Latina cervical cancer patients as they do with the more mainstream middle-class American cancer patients. Moreover, we now know that contextual factors, such as life stressors, are quite relevant to this patient group (Meyerowitz et al.), suggesting that it is possible that other factors not considered in the previous cancer literature may also be important to the psychosocial adjustment of Latina cervical cancer patients, such as the impact of bearing the financial responsibility of a family while battling cancer. 4 The goals of the current study were designed to test whether cancer-related and contextual variables that have been shown to predict psychosocial well-being in the recent literature, work in similar ways for a sample of low-income Latina cervical cancer patients and to examine potential relationships between these variables in predicting psychosocial outcomes. In order to accomplish these goals, the existing literature on cancer-related coping, life stress, general social support, and dispositional optimism was considered. The following sections will discuss the rationale for examining these variables with the present Latina cervical cancer patient sample. Predicting Psychosocial Adjustment: Cancer-related Coping Coping strategies—the methods used by individuals in dealing with challenges or stressors, such as cancer—have consistently been found to predict the psychosocial well- being of cancer patients (Culver, Arena, Antoni & Carver, 2002). Strategies of coping include approach coping (methods to cope with cancer by approaching the situation, such as seeking social support, acceptance, or positive reframing), and avoidant coping (coping by avoiding the situation, such as denial, emotional disengagement, or substance use) (Carver et al., 1993; Scheier et al.). Certain types of coping strategies have been associated with better adjustment to cancer, particularly approach coping (Carver et al. 1993). Conversely, individuals who use denial or disengagement in order to avoid dealing with the stressor altogether have been shown to report higher levels of distress (Carver, Antoni, Petronis, Weiss, & Derhagopian, 2005; Sheier et al. This trend has been consistent in numerous patient populations, including those with cervical cancer (Cuevas- Renaud et al., 2000; Lutgendorf et al., 2002; Wenzel et al.). In a study by Lutgendorf et 5 al. (2001), gynecologic cancer patients who used avoidant coping strategies, such as disengagement, reported higher levels of distress and poorer quality of life as compared to women who used approach coping strategies. Little is known about how Latinas cope with cancer, let alone cervical cancer. A qualitative study of a multiethnic sample of cervical cancer patients showed that numerous Latina participants reported using denial and emotional disengagement to deal with the disease (Ashing-Giwa et al., 2006). Among multiethnic sample of early stage breast cancer patients, Latinas were found to report higher levels of religious coping, venting, and self-distraction, (Culver et al.). The authors also found that Latinas’ levels of distress remained high from baseline to one year after treatment. The findings of this study are limited in that the sample of Latinas included bi-lingual and English speaking Latinas, suggesting there may have been a range of acculturation levels among these women, however, this variable was not accounted for. The sparse literature on the coping strategies used by Latina cancer patients does not provide enough information to distinguish between Latina patients tending to use more avoidant coping strategies than approach strategies or whether they are just as likely to use approach strategies, but do not benefit from them as other groups of cancer patients have demonstrated. Predicting Psychosocial Adjustment: Contextual Predictor Variables Life Stress. The amount of non-cancer related stress that women face while dealing with their cancer appears to be relevant to psychosocial wellbeing. Receiving a diagnosis of cervical cancer does not automatically relieve women of their work and/or familial responsibilities (Ashing-Giwa et al., 2004; Lutgendorf et al., 2000). In a study 6 by Bradley et al., greater depression and mood disturbance were found among endometrial and cervical cancer patients who were unemployed and unmarried after controlling for disease stage, length of time from diagnosis, and treatment type. The stress of providing for families and balancing caregiver and social roles can be a great burden for Latinas, given the high value of family responsibility within this group (Ashing-Giwa et al., 2004; Meyerowitz et al.; Mirowsky & Ross, 1984). Since the majority of studies published on the adjustment of cervical cancer patients include predominantly middle- to upper-class Caucasian and European women—some even living in nations where there is universal health care (Greimel et al., Li et al., 1999) — certain stressors faced not only by women in the US, but Latinas specifically, may not be reflected within these homogenous samples. Salgado de Snyder and team found that the stress incurred from balancing multiple responsibilities associated with being mothers, wives, and employees is associated with particularly high levels of stress among immigrant Latinas in the US—especially when considering the stress of navigating unfamiliar social, educational, and financial systems on top of the stress of daily living. Even more relevant, Meyerowitz and team found that stress was an independent predictor of depression among Latina cervical cancer patients. Thus, it is important to consider the level of non-caner related stress experienced by Latina cervical cancer patients when attempting develop theoretical models to predict the psychosocial wellbeing for this patient group. Social Support. In addition to coping strategies, social support has been frequently associated with adjustment among cancer patients, including those with cervical cancer 7 (Bradley et al.; Cuevas-Renaud et al.; Klee et al.; Lutgendorf et al., 2002; Wenzel et al.). In a study of 51 long-term cervical cancer survivors, Wenzel et al. found greater social support was associated with better quality of life as much as ten years after receiving a diagnosis. Moreover, there is evidence that among Latino immigrants, lack of social support has been associated with increased psychological distress (Salgado de Snyder, Cervantes, & Padilla, 1990). Latinas have also been shown to report finding the most effectual support for stress within their families (Mirowsky & Ross). Therefore, social support may be even more important to Latinas during difficult times, such as after receiving a diagnosis of cancer. This issue may also be particularly relevant to Latinas cancer patients who immigrated to the US alone for economic opportunities in order to financially support families in their native countries (Salgado de Snyder et al.,1990). Dispositional Optimism & Perceived Social Norms of Optimism While coping strategies, stress, and social support may predict the psychosocial outcomes of Latina cervical cancer patients, dispositional optimism may also be an influential variable in the adjustment process. Specifically, higher levels of dispositional optimism may promote more approach coping strategies and social support seeking. At the same time, they may also mitigate the perception of stress. However, different patterns of psychosocial adjustment may appear between patients who report levels of dispositional optimism that are dissimilar to the levels of optimism they perceive to be the norm among their community. Dispositional optimism, a non-cancer related personal characteristic, can be viewed as the stage upon which the cancer experience plays itself out and it may help to 8 explain how these cancer-related and contextual factors work with respect to predicting psychosocial wellbeing. Empirical evidence supports a predictive relationship between dispositional optimism—the belief that one will usually experience favorable outcomes in life (Scheier & Carver)—and subsequent psychosocial well-being (Carver et. al, 2005; Richman, Kubzansky, Maselko, Kawachi, Choo, & Baurer, 2005; Schnoll, Harlow, Stolbach, & Brant, 1998; Stanton & Snider, 1993). For example, in a longitudinal study of 161 women with breast cancer, women who reported higher levels of dispositional optimism during treatment tended to report better overall quality of life, including lower levels of distress, up to one year after their treatment had ended (Shou, Ekeberg, & Ruland, 2005). Similar results have been found among colorectal and prostate cancer patients (Deimling, Bowman, Sterns, Wagner, Kahana, 2006; Lee, Cohen, Edgar, Laizner, & Gagnon 2005). Additionally, studies have shown dispositional optimism to be associated with more approach coping strategies and social support seeking. In another study of breast cancer patients (Carver et al., 1993), coping strategies were found to mediate the relationship between optimism and responses to stress. Optimists (or individuals scoring high on optimism measures) have been shown to use approach coping strategies aimed at directly resolving stress-inducing events, especially when it appeared that they had some control over said events (Shou et al.; Carver et al., 1993; Scheier & Carver). Trunzo & Pinto (2003) found that social support mediated the relationship between optimism and distress in a sample of 61 early stage breast cancer patients up to six months after completing treatment, though this did not hold at the 12 month point. The authors 9 suggested that individuals with higher levels of dispositional optimism tend to place less emotional demand on those who support them. Consequently, the supportive others experience less distress which decreases the chance of social withdrawal from the patient. Currently, whether a relationship between optimism and non-cancer related stress exists in predicting the psychosocial adjustment of cancer patients has yet to be demonstrated. The amount of stress one perceives may be influenced by levels of dispositional optimism. It may be the case that Latinas with high levels of optimism may not perceive as many challenges in their lives as stressful. Alternatively, they may believe that the problems in life tend to work themselves out in positive ways, making stress about their outcomes unnecessary. Exploring the role of Perceived Social Norms of Optimism. Despite the consistent evidence for the predictive power of optimism in predicting psychosocial wellbeing, would it be a cultural bias on the part of American researchers to assume that optimism is universally valued and encouraged in times of distress? It is possible that some ethnic minority groups come from communities where optimism simply is not relevant to dealing with life’s challenges—it may even been seen as unrealistic. There is little evidence, if any, that optimism functions similarly among ethnic minority groups—most likely due to an assumption that everyone benefits from having a positive outlook on life. However, Meyerowitz et al. found that having positive attitudes specifically towards cancer, sometimes referred to as cancer-related optimism, did not relate to any variable of psychosocial adjustment for Latina cervical cancer patients. Perhaps, optimism only works in the ways that they have been documented among non-Latina American cancer 10 samples because this construct is an intrinsic part of the American medical culture. The question is, how does optimism work for Latina cervical cancer patients living and receiving medical treatment in the US? One anthropological theory that may be relevant to this issue is the concept of cultural consonance (Dressler, 1996). Cultural consonance is a measure of correlation between one’s beliefs and behaviors and one’s cultural ideal (Chavez, Mc Mullan, Mishra, & Hubbell, 2001; Dressler)—more simply, how alike one is to her culture’s norms. It may be that optimism works differently for individuals who demonstrate consonance between their level of dispositional optimism and their perceived level of optimism of their community as compared to individuals who perceive themselves as either more or less optimistic than their community. The evidence of the benefits of optimism imply that in environments that value and promote optimism in the face of misfortune, having low levels of optimism could be detrimental to one’s psychosocial wellbeing. However, what would the psychosocial outcomes look like for the situation where a mismatch exists between one’s level of dispositional optimism and the level of optimism among one’s community in cultures where it is not clear that optimism is a valued norm? It is possible that there may be an interaction between one’s perceived social norm of optimism and one’s own level of dispositional optimism that influences the predictive value of dispositional optimism for adjustment. The predictive value of optimism in this latter case is unclear because optimism has rarely, if ever, been investigated within a social context, only individually as a dispositional trait. 11 The Present Study In the present study, a group of low-income, immigrant Latina cervical cancer patients receiving medical care at an urban county hospital were interviewed with a preliminary aim of gaining descriptive information about their cancer experiences. Additional goals included testing the relationships between cancer-related and contextual variables as predictors of depression, affect, and quality of life. First, the relationship between coping strategy, life stress, and social support was examined with respect to the prediction of depression, affect, and quality of life. Second, the relationship between optimism and depression, affect, and quality of life was examined considering coping strategy, life stress, and social support as potential mediators. Third, perceived social norm of optimism was tested as a potential moderator of the relation between dispositional optimism and depression, affect, and quality of life. Specific hypotheses tested in this study include: 1. Coping strategies, stress, and social support will, as a group, predict depression, affect, and quality of life. More approach coping strategies, increased social support, less avoidant coping strategies, and lower levels of stress will be positively associated with quality of life and positive affect and negatively associated with depression and negative affect. 2. There will be a main effect of optimism in predicting the outcome variables. Specifically, higher levels of optimism will predict lower levels of depression and negative affect and higher levels of quality of life and positive affect. 12 3. Higher levels of optimism will be significantly associated with more approach coping, higher levels of social support, less avoidant coping, and lower levels of stress. Additionally, coping strategy, stress, and social support will also mediate the relation between dispositional optimism and each of the outcome variables. 4. The relation ship between optimism and depression, affect, and quality of life will be moderated by the perceived social norm of optimism. Specifically, levels of depression and negative affect will be higher, while levels of quality of life and positive affect will be lower for patients where there is a mismatch between their reported level of optimism and the level of optimism they perceive to exist in their community, as compared to patients who have similar levels of optimisms as their perception of levels of optimism existing in their community. 13 Chapter 2: Method Participants Fifty-four women were recruited over a 6-month period from the University of Southern California Gynecological Oncology Clinic of the Keck School of Medicine Women and Children’s Hospital. This clinic is affiliated with the Los Angeles County Hospital and serves predominantly low-income patients from racial and ethnic minority groups. Patients were included in the study if they (1) received a cervical cancer diagnosis for the first time within the past five years, (2) identified themselves as a Latina, Latina-American, Chicana, or Hispanic, and (3) were not already taking part in any other quality of life study. Procedures Patients were recruited before scheduled appointments at the clinic after they had checked in at the nurses’ station. The intake nurse, who takes vital signs of all patients prior to patient appointments with physicians, asked all cervical cancer patients if they were interested in hearing about the present study. None of the patients refused to meet with the interviewer for more information about the study after meeting with the nurse. After the patient expressed interest, the interviewer was introduced to the patient and escorted her to a private location to provide more information about the study and consent procedures. Patients usually had approximately between an hour and a half to three hours to wait to see their doctor or a nurse, allowing time to conduct the study without interfering with medical care. If the patient expressed interest in participating in the study after it was described to her, consent was obtained, including permission for 14 access to medical records. The interview began upon completion of the consent procedures. If the patient refused to participate after hearing about the study from the interviewer, no further information was obtained. Five women chose not to participate in the study after meeting with the interviewer and receiving a brief description the study. Two of these women stated that they did not have time to participate in the study and the other three did not report reasons for refusal. Of the women who agreed to participate, none chose to discontinue their participation after consent was obtained nor did any decide to stop the interview once it was started. If the interview was interrupted because the patient was called in to see the nurse or her doctor, the interviewer asked if the interview could be continued once the patient is finished with her appointment. Instruments The current study measured the following variables: (1) cancer-related variables including medical characteristics and coping strategies, (2) contextual variables including, demographic characteristics, life stressors, social support and dispositional optimism, (3) psychosocial outcome variables including depression, affect, and quality of life. An interview packet that included both standardized scales and some modified scales specifically adjusted for this study was designed for use during face-to-face interviews with participants. The standardized scales have all demonstrated adequate reliability and validity, in both English and Spanish. Participants chose the language of administration of the interview. The appendix of this paper includes the English versions of all of the instruments that were used in this study. An 8 x 11 inch card was made for each instrument that used a Likert-type response scale that listed the possible responses 15 for each item. For example, one card had numbers from 0 to 4 and under the number 0 it read “Never”, under 1 it read “Almost never” and so on. Symbols, such as happy or sad faces, were included to aid participants who were unable to read the labels. The study investigator, who is both bi-lingual and bi-cultural, conducted all of the interviews in Spanish. Demographics and Medical information Demographic information was gathered from each consenting participant on age, education, living situation, marital status, and medical information including diagnosis, cancer stage, type of treatment, time since diagnosis or treatment, and pertinent medical information. Medical chart information was used to corroborate self-reported medical data. Acculturation Since the majority of patients being seen at the clinic were considered low- acculturated, an acculturation scale was administered to confirm this assumption. Level of acculturation was measured using the Acculturation Rating Scale for Mexican Americans-II (Brief Version) (ARSMA-II; Cuellar, Arnold & Maldonado, 1995; Dawson, Crano, & Burgoon, 1996). The brief version of the ARSMA-II is a 12-item scale which measures acculturation among three domains: language, ethnic identity, and ethnic interaction. Responses are based on a 5-point scale, ranging from 1 (Not at all) to 5 (Almost always/Extremely often). This scale is made up of two subscales, a Mexican Orientation Subscale (MOS) and an Anglo Orientation Subscale (AOS). Scores are based on the average of responses to items for each subscale and a total acculturation score is 16 derived from subtracting the MOS mean from the AOS mean. Positive scores indicate more Anglo orientation and negative scores indicate more Mexican orientation. The authors reported a coefficient alpha of .85 for the total acculturation scale, reflecting adequate internal consistency. This scale has been used with non-Mexican Latino samples (Raffaelli, Zamboanga, & Carlo, 2005). Psychosocial Adjustment Outcomes Depressed Mood. The Center for Epidemiologic Studies Depression Scale (CES- D, Radloff, 1977) was used to measure depressive symptoms among this patient sample. The CES-D is made up of twenty self-report items and scores range from 0 to 60. Responses are based on 5-point scales. Scores of 16 or above indicate depressive symptoms comparable to patients with depressive disorders. This scale has been shown to be reliable among Spanish-speaking populations, with high internal reliability (>.90) (Roberts, 1980). Further, the CES-D has been shown to have cross-cultural construct and factorial validity (Roberts, 1980, Liang et al., 1989). Affect. The Spanish version of the Positive and Negative Affect Scale (SPANAS; Watson, Clark, & Tellegen, 1988; Joiner, Sandìn, Chorot, Lostao, & Marquina, 1997) was used to measure affect. This scale is an adjective checklist in which mood states assess 10 positive affect (PA) and 10 negative affect (NA) statuses. Participants were asked to rate the extent to which they had experienced these emotions on 5-point scales, ranging from 1 (“Very slightly or Not at all”) to 5 (“Extremely”). Higher total scores indicate higher levels of either type of affect. Reported coefficient alphas for this scale ranged from .88 for PA to .92 for NA indicating good internal consistency. The SPANAS 17 was translated into Castilian Spanish; however, it has been used with Mexican samples with Cronbach’s alphas of .80 for the PA and .87 for NA (Goodman & Silverstein, 2005). Quality of life. The quality of life of participants was measured with the Functional Assessment of Cancer Treatment—Cervical Cancer (Version 4) (FACT-G; Cella et al., 1993), a combination of the FACT-G scale and items specific to cervical cancer. This 42 item scale consists of five subscales assessing physical, social, emotional and functional well-being and fifteen items specific to potential experiences of cervical cancer patients. Participants respond to items based on a 5-point scale that indicates the experience of each statement in the previous seven days, from 0 (Not at all) to 4 (Very much), therefore higher scores indicate better quality of life. Reported coefficient alpha for the FACT-G indicate that this scale has good internal reliability (alphas>.80). Cancer-related Predictor Variable: Cancer-related Coping Coping strategies of participants were assessed using the brief version of the Coping Orientation to Problems Experienced Scale (Brief COPE; Carver, 1997). This 28-item scale measures the use of different coping strategies specific to the experience of having cervical cancer within fourteen domains including active coping, denial, behavioral disengagement, positive reframing, humor, acceptance, and religion, for example. Each item is based on a 4-point scale ranging from 1 (“I haven’t been doing this at all”) to 4 (“I’ve been doing this a lot”). Scores are based on total sums within specific domains of coping. Higher scores are indicative of greater use of the type of coping style. Approach coping was defined by the following subscales: active coping, use of emotional and instrumental support, positive reframing, planning, acceptance, 18 humor, and religion. Avoidant coping was made up of the following subscales: self- distraction, denial, behavioral disengagement, and venting. None of the participants endorsed substance use as a method of coping; therefore this scale was excluded from the final analyses. Carver does not provide coefficient alphas for this scale since it is offered as a series of subscales from which researchers can choose. Contextual Predictor Variables Stress. Hispanic Stress Inventory (HSI; Cervantes et al., 1991) was used to measure non-cancer related stress 1 . There are two versions of this inventory, one for immigrants (HSI-I; 73 items) and another for non-immigrants (HSI-NI; 59 items), however, since this sample is made up of non-native participants, only the immigrant version of this scale was used here. Participants respond to level of distress on a 5-point scale. Participants would first respond “Yes” or “No” as to whether they have experienced the situation depicted in the item since their diagnosis and if so, they rate the level of distress it has caused from 1 (“Not at all worried/tense”) to 5 (Extremely worried/tense). If the participant’s response was “No”, as in the situation described in the item had not happened since her diagnosis, the response recorded was 0. Domains of stress include marital, occupational/economic, parental, family/cultural conflict, and immigrant-specific stress. Higher scores indicate higher levels of stress. Cronbach’s alphas for this scale have ranged from .77 and 91 (Cervantes et al.). Social Support. Social Support was measured by the Medical Outcomes Study (MOS) Social Support Survey (Scherbourne & Stewart, 1991). This 20-item survey 1 Four participants were unable to complete the interview due to time restraints, in which case an entire scale was omitted to save time (3 participants did not complete the stress measure, HIS; one participant did not complete the affect measure, SPANAS). 19 measures overall social support as defined by the total sum score from items measuring the amount of support that participants perceive is available to them. Responses are based on a 5-point scale and range from 1 (None of the time) to 5 (All of the time). Higher scores indicate higher levels of social support. The coefficient alphas reported for the Spanish version of this scale is .92, indicating strong internal consistency (Shalowitz et al., 2006). Optimism. Dispositional optimism was measured with the Life Orientation Test— Revised (LOT-R; Scheier, Carver & Bridges, 1994). The scale includes six items each rated on a 5-point scale (0=”I Disagree a Lot” to 4=”I Agree a Lot”) with a maximum total score of 24 indicating highest levels of optimism. Four filler items are included making up a total of ten items. Validated Spanish translation of this scale was used with Spanish-speakers (Perczek, Carver & Price, 2000). Despite Scheier, Carver, & Bridges reports of adequate reliability and both convergent and divergent validity among Latino undergraduates, the Cronbach alphas for this scale among Latina breast cancer patients was reported to be .65 (C. S. Carver, personal communication, September 10, 2007). Perceived social norm of optimism (PSNO). Perceived social norms of optimistic beliefs were assessed using the LOT-R and instructing patients to respond to the items the way they believe their family, friends or other Latinas in their community would respond. The scale includes six items each rated on a 5-point scale (0=”Latinas would disagree a lot” to 4=”Latinas would agree a Lot”) with a maximum total score of 24 indicating highest levels of optimism. Four filler items are included making up a total of ten items. After completing the scale, participants were asked who they had in mind when 20 responding to items. Responses were coded as 1 (family), 2 (friends), 3 (family and friends), 4 (other). This questionnaire was not administered directly after the LOT-R for self-rated optimism so as not to be affected by responses given previously pertaining to the patient’s individual level of optimism. 21 Chapter 3: Analyses Prior to interviewing participants, it was decided that if a participant could not finish a scale within the interview, the entire scale would be omitted. This occurred with five participants (three missing the HSI and two missing the SPANAS). These participants were omitted from analyses that included the HSI or the SPANAS, respectively. For the purposes of comparison, means scores for key variables were compared to community norms or reported means from studies using identical measures. For example, quality of life scores were compared to published norms available for the FACT-G (Brucker, Yost, Cashy, Webster, & Cella, 2005) whereas depression and stress score means for this sample were compared to those reported by Meyerowitz et al (2000), since the authors used the CES-D and the HSI. In order to better understand the relative difference (not statistical differences) between means of this sample and those of established norms or means reported in previous studies, z-scale scores were calculated by taking the score for this sample and subtracting the mean reported for other samples and dividing this difference by the standard deviation reported by the authors of the norms or of the previous studies. Positive z-scores indicate that the sample mean is higher than the comparison mean by whatever standard deviation was found for the z- scores, while negative z-scores indicate that the current sample scored below the means reported by others. Again, the purpose of these z-scores are purely descriptive and used to better understand where the present sample stood on key variables compared to scores that are typical among the literature. 22 Multiple regression analyses were used to test coping strategies, stress, and social support as predictors of depression, affect and quality of life (Hypothesis 1). Optimism was also tested as a predictor of the outcome variables in this way (Hypothesis 2) in order to include it in the mediation analyses (Hypothesis 3). Demographic (age, years in the US, country or origin, years of education, marital status, number of people living with patient, living situation (apartment or house), financially responsible for home (self or other), number of children, caring for an elder (yes or no), and employment status (current and pre-diagnosis status)) and medical variables (cancer stage, time since diagnosis, treatment type, time since treatment, family history of cervical cancer) were tested as potential covariates prior to the regression analyses in order to determine which variables would subsequently need to be controlled for. First, using a correlation matrix, potential covariates were identified (variables significantly correlated to outcomes with p- values <.05). Second, potential covariates identified in the previous step were entered into linear regression equations for each relevant outcome variable and significant associations are noted in the following sections for predictors of each outcome variable. To test Hypothesis 1 and 2, multiple regression analyses were conducted in SPSS for each outcome variable where covariates were entered in the first block and predictors were entered into the second block. Specific details on these equations are provided with each variable in the results section. In order to test potential mediators of optimism in predicting the outcome variables (Hypothesis 3), a bootstrap method program designed for SPSS was used that incorporates the Sobel test after the regression analysis to test the significance of 23 potential mediation relationships (Preacher & Hayes, 2004). This bootstrap sampling method (with replacement) was used to address the problems associated with performing regression analyses with small sample sizes and non-normal distributions. The number of bootstrap samples generated for the analyses of the current data was set to 3,000 (z). The analysis to test perceived social norm of optimism (PSN) as a moderator of optimism in predicting outcomes (Hypothesis 4) involved a multiple regression analysis in SPSS. First the optimism and PSN variables were centered and a cross-product was calculated into a separate variable. The first block contained covariates, the second block contained the two centered variables and the third block contained the cross-product of the centered variables. Multicollinearity, which can cause problems in regression analyses, was assessed in two ways. First, inter-correlations among key variables were examined for significant relationships. Second, for each regression equation, variation inflation factors (VIFs) were generated and examined. VIFs of less than 0.1 were indicative of multicollinearity (Brace, Kemp, & Snelgar, 2006). The stress and social support measures of the predictor variables include subscales. When either of these variables is found to independently predict an outcome variable, an exploratory regression analysis was conducted including its subscales in order to tease apart the active element in the variable. Since including subscales increases the number of predictors in any given regression equations, caution should be taken with the results of these analyses—they are only intended for descriptive purposes. 24 In addition to using bootstrap regression analyses in testing potential mediations as a way of avoiding problems associated with small samples sizes and non-normal distributions, confirmatory analyses were conducted using a quantile regression method in R. Quantile regression, a robust statistical method, was used to confirm the findings from the first set of analyses used to test Hypothesis 1. Traditional linear regression methods are based on minimizing sums of squared residuals to enable one to estimate models for conditional mean functions, whereas quantile regression methods estimate models for the conditional median function, and the full range of other conditional quantile functions (Koenker, 2006). Medians are less sensitive to extreme values (outliers), as compared to means, and this method is also less sensitive to even small departures from normality problems associated with small sample sizes (Koenker). Quantile regressions were run for the 20 th , 50 th (median), and 80 th quantile of each outcome variable. 25 Chapter 4: Results Patient Characteristics Table 1 includes a summary of patient demographic characteristics. The patients included in this study ranged in age from 30 to 75 years old (mean= 50.5). All of the patients immigrated to the United States from either Mexico, Central America, or South America between 6 months and 38 years prior to the interview (mean=16.2 years). All of the patients were monolingual Spanish-speakers, with the exception of one bi-lingual speaker who chose to complete the interview in Spanish. All patients reported Spanish as their preferred language. The majority of patients identified themselves as “Latinas” (93%) with a minority identifying as “Latina-American” (7 %). Results of the Brief ARSMA confirm the assumption that this sample is low acculturated with respect to the American mainstream (M= -2.71 (0.73)). Since the clinic where recruitment and interviews took place is a county-run facility designed for low-income patients on Medical, all of the participants in this study came from low-income backgrounds. As Table 1 shows, just over half of patients were in the labor force prior to their diagnosis; however, few patients were working at the time of the interview. Additionally, this is a generally low educated group of patients, with several women never receiving any kind of formal education. Half of the patients were currently married or partnered. Among the non-partnered patients, 48% were single, 15% were widowed, and 37% were separated or divorced. Most patients reported coming from large families with women having approximately 4 children on average and with 35% of the sample having 5 or more children. Over half of patients reported bearing the 26 financial responsibility for their living situation (i.e. paying rent or a mortgage) themselves (or contributing the majority of rent or mortgage), with 57% renting apartments and 43% renting or owning houses. Table 2 includes a summary of medical characteristics for this sample. Since the majority of patients (73%) did not know the stage of their cancer, diagnostic information was corroborated by medical records. Most patients were either currently receiving treatment for cervical cancer (17%) or had completed treatment within the past 5 years (78%), with an average time since treatment completion of 23.2 months, for those who had completed treatment. Most patients (69%) fell within a good prognostic category of having Stage 2A or less cervical cancer, with a majority of patients having been diagnosed with early stage cancer (IB). Most patients also reported receiving a combination of surgery, radiation and chemotherapy to treat their cancer. 27 Table 1 Patient Demographic Variables n %* Mean (SD) Range Age 54 50.48 (12.00) 30 - 75 Years in the United States 54 16.19 (10.80) Country of Origin Mexico 35 64% Central America 18 33% South America 1 2% Education No schooling 9 16 % <High school 28 52% Some high school 4 7% High school graduate 11 20% Some college 1 2% Bachelor degree 1 2% Current Relationship status Married/Partnered 27 50% Single 13 24% Widowed 4 7% Divorced/Separated 10 19% Current Occupational Status Not in labor force 42 76 % Working 12 22% Pre-Diagnosis Occupational Status Not in labor force 23 42% Working 31 57% Note. Due to rounding, percentages may not equal 100% 28 Table 2 Medical Variables n %* Mean (SD) Range Cancer Stage Good Prognosis Stage 1A 7 13% Stage 1B 26 47% Stage 2A 5 9% Stage 2B 5 9% Stage 3A 1 2% Stage 3B 8 15% Stage 4A 0 0 Stage 4B 2 4% Treatment Not yet started treatment 3 6% Surgery (S) only 13 24% Radiation (R) only 0 0 Chemotherapy (C) only 3 6% S/R 3 6% S/C 0 0 R/C 10 19% S/R/C 22 41% Time since treatment completion (in months) 54 19.19(18.74) 0 - 60 Note. Due to rounding, percentages may not equal 100% Psychosocial Outcome Variables Descriptive Data The descriptive statistics, including means, score ranges, and Cronbach alphas for depressed mood, affect, and quality of life are provided in Table 3. Depression. CES-D scores indicated that patients in this sample were experiencing high levels of depression. Just over 67% of participants scored at or above the cut-off score of 16, which is typically used to identify individuals at risk for depressive disorders. Figure 1 shows how this sample compared to a healthy female sample and other cancer patient samples with respect to depression. The mean score for 29 these patients (24.5) appears to be over one standard deviation higher than reported means of non-Latina (z= 1.56) or Latina cancer patients (z= 1.22) (Hann, Winter, & Jacobsen, 1999; Culver, Arena, Antoni, Carver, 2002), non-Latina cervical cancer survivors (Carter et al., 2005). A sample of Latina cervical cancer patients previously studied through a radiation oncology clinic (Meyerowitz et al., 2000) reported means on the CES-D just below those reported for this sample (z score <0.5). Figure 1 Comparisons of Depression Scores with Community Samples and other Cancer Patients 0 5 10 15 20 25 30 Non-Latina Breast Ca (Hann et al., 1999) Latina Breast CA (Culver et al., 2002) non-Latina Cervical CA (Carter et al., 2005) Latina Cervical CA (Meyerowitz et al., 2000) Current Sample CES-D Mean 30 Affect. Affect scores for this sample indicated that this group was experiencing elevated levels of negative affect. Negative affect scores for this sample appeared to be higher than those reported by a community sample of Latina-Americans (z= .83) (Bartholomew, Laffrey, Kilpatrick, & Spina, 2004). Positive affect for this sample was over one standard deviation lower than scores reported in this community sample (z=- 1.63) and relatively lower than a mixed sample of breast cancer patients (z=- 1.47) (Andrykowski et al., 1996). Quality of Life. Patients’ scores on quality of life measures (FACT-Cx scales) were comparable to those of community samples of healthy non-Latinas, Latinos, and female cancer patients (z scores < 0.4) (Brucker et al., 2005). However, scores on emotional well-being appeared to be consistently below the norms for healthy women (z= -2.73), female cancer patients (z=-1.37), and general Latino populations (z= -1.49) (Figure 2). Scores on the physical-wellbeing subscale suggest that patients were experiencing similar levels of physical symptoms than those reported among comparison samples (z scores < 1). Figure 2 Quality of Life for Current Sample as Compared to Normative Data (Brucker et al., 2005) 0 10 20 30 40 50 60 70 80 90 100 Physical Well-being Social Well-being Emotional Well-being Functional Well-being Overall Quality of Life Current Sample Healthy Female Norm Cancer Patient Norm Hispanic Norm 31 Table 3 Descriptive Statistics for Outcome Variables (N=54) Scale Subscale α Possible Range Mean (SD) Actual Range Quality of Life (FACT-Cx a ) .87 0 to 168 118 (27.4) 49 - 165 FACT-G .93 0 to 108 75.1 (20.6) 17 - 108 Physical Well-being .74 0 to 28 22.2 (5.08) 7 – 28 Social Well-being .85 0 to 28 18.4 (6.72) 0 - 29 Emotional Well-being .88 0 to 24 12.5 (5.76) 1 - 20 Functional Well-being .87 0 to 28 19.2 (6.84) 4 - 28 Cx CA Specific Problems N/A c 0 to 60 43.8 (8.15) 24 - 59 Depression (CES_D) .80 0 to 64 24.5 (14.1) 1 - 55 under 16 cutoff (32.7%) At or over 16 cutoff (67.3%) Affect (SPANAS b ) Positive Affect .89 10 to 50 26.8 (8.00) 13 - 43 Negative Affect .92 10 to 50 21.1 (9.27) 10 - 44 a The FACT-CX is made up of the general FACT-G that is used with any disease and the section on cervical cancer specific problems. b One participant did not finish this scale due to time limitations. c Cervical Cancer Specific Problems is not a true scale measure of a construct but rather a check list of common symptoms among these patients, therefore, no coefficient alpha was calculated as it would not truly represent internal reliability. Key: FACT = Functional Assessment of Cancer Treatment (Cx = Cervical Cancer Supplement, G= General), Cx Ca= Cervical Cancer Specific Problems, CES-D Center for Epidemiologic Studies Depression Scale, SPANAS= Spanish Positive and Negative Affect Schedule, Predictor Variables Descriptive Data: Cancer-related Coping The majority of patients endorsed the use of approach coping strategies in response to their cervical cancer diagnosis (Table 4). Endorsement of each of the different types of coping strategies is provided in Figure 2, with religious forms of coping being utilized the most, followed by active coping. 32 Figure 3 Methods of Coping 0 1 2 3 4 5 6 7 8 Self-Distraction Active Coping Denial Substance Use Seeking Emotional Support Behavioral Disengagement Venting Positive Reframing Planning Humor Acceptance Religious Methods of Coping Mean Predictor Variables Descriptive Data: Contextual Variables Table 4 contains a summary of the descriptive data for the predictor variables of stress, and social support, including means, ranges, and coefficient alphas. Levels of stress among this sample were generally low. HSI scores were over one and half standard deviations below those reported by another Latina cervical cancer sample (Meyerowitz et al., 2000) and those reported by Cervantes and team (1992). Patients in this sample reported high levels of general social support (Table 4), with scores similar to those reported by other Latina cervical caner patients (z= .24) (Meyerowitz et al., 2000). 33 Scores on the social support subscales indicate that the most support they perceive to have available is affectionate support, followed by positive social interactions. Dispositional & Perceived Social Norm of Optimism Descriptive Data Table 4 also includes the means and ranges for measures of optimism and perceived social norm of optimism. The internal reliability of the LOT-R for this sample was rather poor (alpha= .15), therefore, a factor analysis was conducted to identify items within the scale that could be used as an alternate measure of optimism. Item 1 (“ In uncertain times, I usually expect the best.”), item 4 (“I am always optimistic about the future”), and item 10 (“In general, I think that more good things will happen to me than bad.” all loaded strongly onto the same factor and had the most face validity, with participants appearing to understand them more than other items. Some of the other items that used negative wording also loaded onto a second factor; however, these items did not reach an adequate reliability alpha and did not appear to be well understood by participants. A sum score for items 1 and 4 of the full LOT-R (for the purposes of clarity, this score will be referred to as LOT14) was used as the measure of optimism, which resulted in a Cronbach alpha of .63. Item 10 was not included in the final LOT-R alternative measure as the reliability coefficient of the three items came to .50. The reliability coefficient for the LOT14 is comparable to the one found for the LOT-R by Carver and team when used with a Latina breast cancer sample (personal communication, September 10, 2007). Since the whole scale score is not being used, it is not possible to compare the optimism scores for this group to others who have been administered the full LOT-R. Updegraff and Marshall (2005) used a similar factor method to create three two- 34 item subscales for the LOT-R for their study on predictors of perceived growth following exposure to community violence, only the factor loading for their study was slightly different to the one conducted here so different items were grouped together (such as item 1 and 10). The same measures were taken with the perceived social norm of optimism (PSN) measure, where items 1 (“ In uncertain times, Latinas usually expect the best.”) and item 4 (“Latinas are always optimistic about the future.”) were used as an alternate measure of PSN (PSN14). The coefficient alpha did not reach an acceptable level for this measure (.40), however, since the intention of this measure was purely exploratory, it was still included in the regression analysis for Hypothesis 4 in testing the interaction between LOT14 and PSN14. With regards to who patients had in mind when answering PSN items, approximately 30% of patients reported that they had family in mind, 24% reported having friends in mind, 20% reported having both family and friends in mind, 24% reported having Latinas in general in mind. One patient had herself in mind and was, therefore, not included in the analyses involving PSN14. Regardless, the results of a paired t-test comparing the scores of the LOT14 and the PSN14 indicate that this group of participants rated themselves as more optimistic than other Latinas in their communities (mean difference (LOT 1 and PSN 1) =.83, t=4.08, p<.001; mean difference (LOT 4 and PSN 4) = .46, t=2.23, p<.05). 35 Table 4 Descriptive Statistics for Predictor Variables (N=54) Scale Subscale α Possible Range Actual Range Mean (SD) Optimism (LOT-R) .15 0 to 24 6-22 14.6 (3.50) Perceived Social Norm of Optimism (PSN LOT-R) .13 0 to 24 2-20 12.7(4.10) LOT14 a Items 1 and 4 .63 0 to 8 1 - 8 6.26 (1.91) PSN14 b Items 1 and 4 .40 0 to 8 0 - 8 4.96 (1.98) Social Support (MOS) .99 1 to 5 1.26-5 4.03 (1.13) Emotional Support .96 1 to 5 1.13-5 3.90 (1.33) Tangible Support .87 1 to 5 1.00-5 3.87 (1.26) Affectionate Support .94 1 to 5 1.00-5 4.56 (1.03) Positive Social Interaction .90 1 to 5 1.00-5 4.10 (1.24) Coping Strategy (Brief COPE) Approach coping d .83 0 to 56 26-56 43.6 (7.92) Avoidant Coping d .68 0 to 40 10-32 19.7 (4.47) Stress (HSI_SC) c .93 0 to 355 0-188 44.7 (37.2) Occupational (total) .73 0 to 65 0-28 5.51 (6.99) Parental (parents only) .86 0 to 65 0-43 9.67(10.8) Marital (partnered only) .85 0 to 75 0-43 8.35 (10.6) Immigration .84 0 to 85 0-81 18.1 (13.6) Culture/Family Conflict .89 0 to 65 0-52 6.65 (10.1) a, b LOT-R and PSN-LOT-R include only items 1 and 4 from each scale. See Results section for the rationale. c Three participants did not complete this scale due to time limitations (n=51). d The coping scales were not designed as a whole scale, but of individual subscales. For the purposes of this study, the subscales are grouped into two variables; therefore, the internal reliability statistic may not relevant. Key: LOT-R= Life Orientation Test-Revised; PSN LOT-R= Perceived Social Norm of Optimism; MOS= Medical Outcomes Study; COPE= a measure of coping strategy; HSI= Hispanic Stress Inventory. 36 Predicting Psychosocial Outcome Variables (Testing Hypothesis 1) In order to test Hypothesis 1, multiple regression analyses were used to test coping strategies, stress, and social support as predictors of each of the outcome variables, while controlling for covariates. Covariates were identified in a preliminary analysis described in the analyses section. Covariates found for depression include living situation (living in an apartment or house), treatment stage (not in treatment, currently in treatment or completed treatment), and the number of elderly under the patient’s care. Living in a house (rather than an apartment), the more elderly being cared for by the patient, and the earlier in treatment patients were predicted higher depression scores. Whether the patient was financially responsible for her living situation was the only covariate found for positive affect indicating that patients who were responsible for their living situation had more positive affect. The number of elderly under the patient’s care was the only variable significantly related to negative affect, predicting higher levels of negative affect. No covariates were identified for quality of life. Inter-correlations of predictor variables and outcome variables are presented in Table 5. Table 5 Correlations between Predictor and Dependent Variables (N=54) Variable 1 2 3 4 5 6 7 8 1. Active COPE --- -.045 -.096 .498** -.445** .505** .494** -.390** 2. Avoidant COPE --- .557** -.188 .425** -.286* -.065 .369** 3. HSI --- -.364** .495** -.374** -.018 .458** 4. MOS Social Support --- -.283* .536** .132 -.337* 5. CES-D ---- .662** -.405** .680** 6. FACT-Cx -.568** .509** 7. SPANAS PA ---- -.209 8. SPANAS NA ---- *p<.05, **p<.01 37 Predicting Depression. In the preliminary covariate analysis, living situation, treatment stage, and caring for an elder were entered into the first block of the analyses. Coping strategy (approach and avoidant), stress, and social support were then entered simultaneously into the second block. The approach coping, avoidant coping, stress, and social support model significantly accounted for 49.7% of variance (Table 6). As hypothesized, less approach coping, more avoidant coping, and higher levels of stress independently predicted more depression, however social support was not a significant independent predictor of depression. The results of a quantile regression analysis were somewhat different, where more avoidant coping significantly predicted more depression at the 50 th and 80 th quantile, however, both avoidant and approach coping significantly predicted depression at the 20 th quantile. Stress was not found to significantly predict depression in these analyses. Exploratory analyses were run to determine if the stress subscales were predictors of depression, when included in models with each of the coping strategies. None of the subscales for stress was found to independently predict depression. Though it appears that the stress scale predicts depression as a whole scale and not when broken down into subscales, the power for this analysis was .34—which is too low to interpret these findings. Table 6 Regression Analysis for Predictors of Depression Variable β Adjusted R 2 Change R 2 F (df) Block 1: .231** 6.01 (3, 47) Living Situation .290* Treatment Stage -.303* 38 Table 6 (continued) Charge of Elderly .358** Block 2: .497** .290 8.048 (7, 43) Living Situation .164 Treatment Stage -.180 Charge of Elderly .347** Approach coping -.260* Avoidant Coping .259* Stress .315* Social Support .046 * p<.05 **p<.01 Predicting Affect. Coping strategies, stress, and social support were tested as predictors of positive and negative affect in the same manner as they were tested for predicting depression. The only covariate identified for positive affect was whether the patient was financially responsible for her living situation; therefore, this was entered into the first block of the regression analysis. When approach coping, avoidant coping, stress, and social support were entered together (second block), they accounted for 23.4% of the variance for positive affect (Table 7). Approach coping was the only independent predictor of positive affect, with more approach coping significantly predicting more positive affect. It was hypothesized that more approach coping and social support and less avoidant coping and stress would predict positive affect, however, only one of these predictions was confirmed. In the quantile regression analysis, approach coping was the only significant predictor of positive affect at each quantile level. The number of elders under the patient’s care was found to be a covariate for negative affect; therefore, it was entered into the first block of the regression equation. 39 Approach coping, avoidant coping, stress, and social support together accounted for 37.6% of the variance for negative affect (Table 7). Here, more avoidant coping was found to predict more negative affect, confirming one of the hypothesized predictions of negative affect. The results of the quantile regression analysis indicated that both less approach coping and more avoidant coping predicted more negative affect, but only at 50 th quantile. Table 7 Regression Analysis for Predictors of Positive and Negative Affect Positive Affect Variable β Adjusted R 2 Change R 2 F (df) Block 1: .091* 6.00 (1,49) Financial Responsibility .330* Block 2: .234** .202 4.06 (5, 45) Financial Responsibility .185 Approach coping .517** Avoidant Coping -.119 Stress .089 Social Support -.151 Negative Affect Variable β Adjusted R 2 Change R 2 F (df) Block 1: .055 3.89 (1,49) Charge of Elder .271 Block 2: .376** .365 7.03 (5, 45) Charge of Elder .282* Approach coping -.254 Avoidant Coping .287* Stress .245 Social Support -.099 * p<.05 **p<.01 40 Predicting Quality of Life. Regression analyses were conducted to test coping strategies, stress, and social support as predictors of total quality of life (Table 9). No covariates were identified in the preliminary analyses, therefore, approach coping, avoidant coping, stress, and social support were entered into the first block of the regression analysis. It was hypothesized that more approach coping and social support and less avoidant coping and stress would predict better quality of life only. The resulting model accounted for 34.4% of the variance for quality of life. More approach coping was found to independently predict better quality of life. Quantile regression analysis confirmed this finding, where approach coping was also found to significantly predict quality of life at the 20 th and 50 th quantile. However, at the 80 th quantile, avoidant coping was the only variable to significantly predict quality of life. Table 8 Regression Analysis for Predictors of Quality of Life Variable β Adjusted R 2 F (df) .344** 7.56 (4, 46) Approach coping .323* Avoidant Coping -.122 Stress -.175 Social Support .275 * p<.05 **p<.01 Separate exploratory analyses were conducted to identify predictors of the quality of life subscales for physical, social, emotional, and functional well-being and cervical cancer specific outcomes. Models containing approach coping, avoidant coping, stress, and social support significantly predicted all of the quality of life subscales domains. In 41 these models, more approach coping significantly predicted better functional wellbeing ( β=.514, p<.001) and more social support independently predicted better social wellbeing ( β=.584, p<.001). Main effect of Optimism (Testing Hypothesis 2) Using a multiple regression analysis, optimism was tested as a predictor of the outcome variables in order to include it in the mediation analyses (Hypothesis 3). Optimism significantly predicted depression ( β= -3.69, t(50)=-3.16, p<.001), positive affect ( β= .42, t(51)=3.30, p<.01), negative affect ( β= -.49, t(51)=-4.00, p<.001), and quality of life ( β= .56, t(53)=4.84, p<.001). Mediators of the Relation between Optimism and Psychosocial Outcomes (Testing Hypothesis 3) It was hypothesized that coping strategies, stress, and social support would significantly mediate the relation between optimism and the outcome variables. Again, bootstrap regression analyses (using 3000 bootstrap samples) were conducted to test these variables as potential mediators. The only significant relationship found included approach coping mediating the relation between optimism and quality of life (p<.05). Approach coping almost reached significance as a mediator on the relation between optimism and positive affect (p=.05). When testing each of the potential mediators on the relationship between optimism and the quality of life subscales, approach coping was again the only significant mediator, acting on the relation between optimism and functional wellbeing (p=.032). Stress and 42 social support subscales were also tested as potential mediators, however, none were found to reach significance in these analyses. Moderating the Relation between Optimism and Psychosocial Outcomes (Testing Hypothesis 4) In order to test whether one’s level of optimism predicts psychosocial wellbeing differently at different levels of perceived social norms of optimism (PSN). An interaction term (which was simply the cross-product of the centered optimism and PSN measures) was tested as a significant predictor of depression, affect, or quality of life. A regression analysis was used with centered optimism and PSN variables. The first block of the analyses included covariates, the second block contained the optimism measure (LOT14) and the PSN measure (PSN14), and the final block contained the interaction term. The moderation hypothesis for PSN was not supported as the interaction term did not significantly predict depression, affect, or quality of life (p’s F-change > .05). 43 Chapter 5: Discussion The goals of this study were to describe the experiences of Latina cervical cancer patients with respect to cancer-related and contextual variables, to identify predictors of depression, affect, and quality of life, and to explore the relationship of optimism and psychosocial wellbeing, including identifying potential mediators or moderators. The results of this study suggest that Latina cervical cancer patients experience and adjust to their disease in several similar and some dissimilar ways as what has typically been reported in the current psychosocial cancer literature. Though elevated depression scores were expected for this sample, the levels reported here were uncommonly high, even for Latino cancer patients. Proportions of middle- class non-Hispanic White cancer samples meeting criteria for depression are typically lower than 30% (Simon, Palmer, & Coyne). In the present sample, 67% of the patients scored at or above the CES-D cut-off score indicating symptomology similar to individuals diagnosed with depression. Further, positive affect was low when compared to community and cancer patient samples. Without pre-diagnostic baseline data, it is difficult to determine the extent to which the depression scores reported here can be attributed to the experience of being diagnosed and treated for cancer. Although previous research suggests that patients coming into the study may have had elevated levels of depression (Salgado de Snyder et al., 1990), physical symptoms of cervical cancer (e.g. vaginal discharge, and pain) were significantly correlated with depression (r= .32, p=.018 and r=.35, p=.011). This suggests that the depression levels reported by patients were, in part, associated with experiences specific to their cancer, and therefore are unlikely to be 44 solely attributable to pre-diagnostic depression. The levels of affect among the patients in this study were consistent with the high levels of depression, where they reported higher levels of negative affect and lower levels of positive affect relative to means reported by community samples of Latina-Americans and breast cancer patients (Bartholemew et al., 2004; Andrykowski et al.). An area of particular concern for these patients appeared to be their sexual functioning. The majority of patients reported feeling afraid to engage in sexual intercourse, in addition to experiencing physical changes typically related to discomfort during sex, such as vaginal shrinkage and dryness. Aside from pain and discomfort, patients shared they feared that that sex would give them cervical cancer again. Moreover, not feeling sexually attractive was associated with depression levels (r=-.48, p<.001), though it is unclear if negative body image was specific to their cancer. Alternatively, it is possible that depression could increase the risk of sexual dysfunction or decreased interest in sex, making conclusions about directionality difficult. The quality of life of patients in this sample was comparable to norms for healthy non-Latinas, Latinos, and female cancer patients (Brucker et al., 2005). Upon examining the domains of wellbeing included in the quality of life measure, patients consistently reported poorer emotional well-being than the groups mentioned previously. This finding was consistent with the general pattern of depressive symptomology among patients in this sample. However, scores on physical wellbeing were comparable to the scores reported in the normative data by Brucker and team . This finding is not consistent with findings of higher rates of somatic symptoms among Latinos as compared to Caucasian 45 Americans and other ethnic minorities (Mio, Barker-Hackett, & Tumambing, 2006). Moreover, Mexican-Americans have been shown to have higher rates of somatic symptoms accompanying depression, especially among less acculturated groups (Kaplan & Marks, 1990). However, the results of this study suggest that it was unlikely that the Latinas in this sample were expressing their emotional distress through reports of physical symptoms. Predicting outcome variables Together, coping strategies, contextual stress and general social support consistently predicted depression, affect, and quality of life, not unlike previous studies of non-Latina cancer patients. However, the pattern of independent predictors found within these regression analyses is not typical of the current literature in some notable ways. Approach coping was constantly predictive of the outcome variables, with the exception of negative affect (which was predicted by avoidant coping)—this is consistent with the current non-Latina cancer literature and contradicts previous findings of higher rates of avoidance coping among Latinas (Culver et al.). However, social support was not found to independently predict depression, affect, or quality of life—with the only exception being the social wellbeing subscale of the quality of life measure (which tested similar constructs). Social support has regularly been shown to be predictive of psychosocial well-being, where Wenzel and team found this to be true for long-term cervical cancer patients upwards of ten years after receiving their diagnosis. Meyerowitz and team, in testing contextual and cancer-related variables as predictors of depression among a comparable sample of low-income Latina cervical cancer patients, found that 46 general social support was a significant independent predictor of depression, as well as non-cancer related stress, while cancer-related social support did not significantly predict depression. In the present study, it appears that approach coping—which includes a seeking support subscale—accounts for so much of the variance in depression, affect, and quality of life, that social support simply loses its predictive power when entered into the same equation with this variable. The modest but significant inter-correlation between approach coping and social support (r=.50, p<.01) suggests that approach coping did take up the variance otherwise accounted for by social support. It would have been informative to include a measure of cancer-related social support. It may have been the case that patients in this sample felt that they had a lot of access to general social support, but if questions relating specifically to cancer-related social support were asked, outcomes may have been different. Despite living in an environment where general support is readily available, it remains unclear how Latina social networks react to a diagnosis of cancer—especially since qualitative data exists suggesting that some Latinas choose not to disclose their diagnosis with family members (Ashing-Giwa et al., 2006). Seeking cancer-related social support could be inhibited among this sample for several reasons, including feeling like a burden on family or friends or feeling ashamed or embarrassed. Ashing-Giwa and team (2006) found that among a sample of Latina cervical cancer patients, feelings of shame, fear of becoming dependent on others, and fear of losing the matriarchal role in the family were prevalent. Furthermore, the range in social support scores was limited (with most patients scoring in the upper range), and it may be that this variable could not predict the outcome variables independently since it 47 lacked the diversity in responses to adequately test such a relationship, despite efforts to use robust statistical methods to address issues related to skewed distributions. The findings on the role of stress in the lives of the current sample were somewhat consistent with the current literature on how this variable affects psychosocial adjustment among both Latina and non-Latina cancer patients. Meyerowitz and team found that stress independently predicted depression and this was replicated in the current study. However, what was not expected was the generally low level of stress reported by this group, especially since the depression scores were as high as they were. It seems that for this sample, even low levels of stress are associated with high levels of depression. It may be the case that low levels of chronic stress may be associated with more psychosocial distress than acute moments of stress that dissipate with time. The implication of this finding is grim when considering what it would have been like for these patients had they been experiencing moderate to high levels of stress. Stress was not an independent predictor of either affect or quality of life. It appears that for this sample, stress and depression have a unique relationship, even after controlling for medical variables such as treatment type (i.e. chemotherapy or radiation, both of which are associated with higher levels of depression). It may be that the measure of quality of life taps into a wide range of domains, some that may not be as strongly associated with non-cancer related stress. For example, levels of physical wellbeing and functional wellbeing may not be as heavily influenced by stress levels as emotional or social wellbeing. 48 As for stress not independently predicting affect, one issue that may be involved is the difference in the face validity of the items in the CES-D and the SPANAS. The SPANAS asks about the frequency of experiencing a list of emotions (or adjective describing emotions), such as fear or inspiration, which can be rather abstract and difficult to answer, particularly among low-educated individuals. The CES-D, on the other hand, is relatively more concrete using detailed statements, like “I felt sad” or “I have spent some time crying”. Additionally, it may be that stress is dealt with through coping strategies, which were shown to independently predict both positive (approach coping) and negative affect (avoidant coping). In this case, affect is apparently influenced by cancer-related coping strategies, and not general stress. This suggests that patients’ mood may be more sensitive to their cancer experience, while their perceived level of non-cancer related stress acts as a constant backdrop to their lives and contributes more to depression than cancer-specific mood. Of note was the direction of the relationship between positive affect and whether the patient was financially responsible for her living situation (its only covariate). It appears that bearing this financial responsibility predicted more positive affect. This may reflect a need for independence during a time when patients may be forced to depend on others for emotional and instrumental support (i.e. taking the patient to doctor’s appointments). Optimism While cancer-related and contextual variables were shown to be associated with adjustment, the salience of dispositional optimism for Latina patients remains unclear primarily due to unexpected measurement challenges. The LOT-R Spanish translation 49 demonstrated poor internal consistency. The low reliability of this scale could have been due to cross-cultural differences in the definition of optimism, resulting in reduced construct validity. Researchers working with Chinese participants found that optimism was defined as possessing the ability to accept the condition of one’s life, rather than expecting favorable future outcomes (Lai and Yue, 2000). Similarly, the Spanish LOT-R uses phrasing that suggests optimism is synonymous to hopefulness. For example, the translation of the item “I hardly expect things to go my way,” includes the word espero, which in Spanish can mean both “I expect” and “I hope”. Most patients said that they believed everyone hoped good things would happen to them. This nuance in meaning could have resulted in a measurement of hope for favorable outcomes in life, rather than expectations. We also found that participants it difficult to answers items that were worded with double negatives. Ultimately, the two items chosen as the measure of dispositional optimism had the most face validity and were the most directly worded, yet, it remains unclear if we measured optimism or hopefulness. These issues aside, whatever was assessed appeared to be relevant to patients’ psychosocial adjustment in this study, mainly in predicting positive psychosocial outcomes (i.e. positive affect and quality of life) and depression. More work is needed to define this factor as either dispositional optimism, hopefulness, or a combination of the two. Expectations about specific events, such as cancer outcomes and life stress, should also be considered to distinguish them from generic optimism, as they may have independent relationships with the psychosocial outcomes of low-income immigrant patients. 50 Mediators of Optimism Contrary to what was predicted, only approach coping mediated the relation between optimism and quality of life. Therefore, it appears that more dispositional optimism predicts more approach coping, which in turn, predicts better quality of life. Neither stress nor social support mediated optimism and this effect was limited to the relationship between optimism and quality of life. Therefore, the findings from this study do not support a mediating effect of stress or social support on the relation between optimism and the outcome variables, nor does it support the mediating effect of approach coping on the relation between optimism and depression or affect. Again, given the complications associated with the measure of optimism, any interpretations of this finding should be made with caution. Moderators of the Relation between Optimism and Outcome variables The exploratory question in this study asked whether one’s perception of the level of optimism among people in her community affects the manner in which dispositional optimism predicts psychosocial wellbeing. Therefore, this analysis attempted to address the impact of the social context of optimism by considering the level of perceived level of optimism of one’s community as moderating the relation between dispositional optimism and outcome variables. If a patient perceived her community to be generally optimistic, would this affect how her own level of optimism related to her psychosocial wellbeing? However, the results of the analysis of the interaction term never reached significance in predicting the outcome variables. There are several possible reasons for this. First, the problems with measuring optimism discussed in the previous section could be part of the 51 issue. Second, the measure of perceived social norm of optimism may not have been a valid measure of assessing a social context of optimism, especially considering the range of responses of who patients had in mind while responding to these items. The rationale behind this was that cultural norms may shape how individuals view their worlds and that one’s perception of this norm would be more relevant to an individual than a community norm established through anthropological field studies. Perhaps, the community norm would have been more appropriate for use since it lacks any personal biases, such as tendencies to rate oneself in a more favorable light than others. This was the first attempt to examine optimism within a social context, therefore, more work needs to be done to develop methods to test the relevance of optimism for groups outside the American mainstream as well as to test the validity of the scales being used to measure this construct among non-English speakers. The literature suggests that the recipe for better psychosocial outcomes includes using more approach coping, perceiving less levels of stress, and having access to more social support. The results presented here indicate that the current sample of Latina cervical cancer patients were doing just that, using approach coping, reporting generally low levels of stress, and reporting high levels of social support—yet, they still reported high levels of depression. In an attempt to tease apart reasons for this inconsistency, demographic and medical variables were explored to see if there were differences between patients who scored at or above the CES-D cutoff and those who scored below it for these variables. A two-tailed t-test indicated that the only variables that were significantly different for patients above the depression cutoff as compared to those 52 below it were the number of elderly under the patient’s care and whether they lived in an apartment or a house. Patients who scored above the CES-D cutoff were more likely to care for an elder and more likely to live in a house, as opposed to an apartment (t(36)=2.09, p<.05, t(35)=2.07, p<.05, respectively and without assuming equal variances). Caring for elders, who may themselves be ill, while being treated for cancer may be an additional burden for patients who’s own self-care may be compromised by side-effects of cancer treatments, such as fatigue and nausea (NCI, 2006). However, the impact of living in a house versus an apartment is not entirely clear. It may be that low- income patients living in houses may face more financial burden than those living in apartments. A two-tailed t-test was also conducted between patients above and below the depression cutoff with respect to the stress subscales to see if there was a difference in occupational/economic stress across this threshold. The only significant finding in this test was that patients above the depression cutoff reported significantly higher levels of immigration stress than those below the cutoff (t (46)=2.80, p<.01). Clearly, more research is necessary to understand what factors contribute to the high rates of depression among this sample of Latina cervical cancer patients. Limits and Suggestions for Future Research This study has shown that despite using adaptation methods that would typically predict better psychosocial outcomes for cancer patients, the Latina cervical cancer patients in this sample continued to report high levels of depression. However, limitations of this study should be acknowledged. 53 First, the number of participants recruited in the study (n=54) was just over half of the proposed sample size (n=100). The original sample size was proposed based on power analyses for a medium effect size. The power for the analyses conducted here were 0.44, 0.51, and .56 when predicting depression, affect, and quality of life, respectively. Had the proposed sample size (n=100) been recruited the power would have ranged from 0.78 to 0.87. However, to address this issue, robust measures were introduced that are designed to work well with relatively small sample sizes. Second, the in-person interview design of this study is vulnerable to certain response limitations including over or under reporting and socially desirable responding. It is possible that participants’ responses may have been different if a more anonymous questionnaire method was used. However, the in-person interview can also be considered strength of this study in that it allowed for maximal engagement of participants in the study procedures as well as offering opportunities for clarification of interview items. The fact that the interviewer was bi-lingual and bi-cultural may have facilitated the interview process as conversations with the medical staff suggested that patients disclosed more information about their psychological experiences with the interviewer than when the doctors inquired about those experiences. Additionally, if socially desirable responding was taking place, it must have been limited or else the depressive symptomology across the different outcome variables (i.e. depression scores, negative affect, and low emotional wellbeing) would not have appeared as significant as they were. 54 A third limitation of this study is that the interviewer was not blind to the hypotheses proposed. The use of standardized instruments minimized the potential effect of knowing outcome predictions; however, since the items were read by the interviewer to participants, there remains the potential for bias. Fourth, a limitation of this study was its cross-sectional design. All of the results obtained can only provide information on the experiences of participants at the time of the interview. As the time from diagnosis increases, the concerns expressed during the interview may not be as salient to the participants. A strength of this study is the focused attention to an understudied patient population. The low-income, low-acculturated Latina cervical cancer patient sample was designed to maximize on the potential homogeneity of this group to target the patients at most risk for distress. This strategy allows for more control over extraneous confounds and for the study of targeted variables that are likely to be most relevant to this specific population. Issues with generalizability should not cause much concern given that the majority of the cervical cancer patient population looks very much like this sample (ACS, 2006). Conclusion and Future Research The goal of this study was to provide a description of the psychosocial experiences of Latina cervical cancer patients and to identify non-cancer related and contextual variables that predict depression, affect, and quality of life. An additional goal was to explore the role of optimism in the psychosocial adjustment process of Latina cancer patients. These results suggest that despite efforts to adjust to cancer, such as 55 approach coping and seeking social support, the Latina patients in this study remained highly depressed. These findings have the potential to benefit patients, medical staff, and clinicians by identifying predictors for post-diagnosis psychosocial wellbeing for a traditionally understudied patient group. 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Gynecologic Oncology, 97, 310-317. 63 APPENDIX INTERVIEW PACKET Demographic Information 1. Have you ever participated in the ADAPT study (with Maria Cordova)? YES NO 2. DOB:___/___/____ 3. Where were you born?___________________________________ 4. Where were you raised?__________________________________ 5. How many years have you spent in the US?_________ 6. Number of years of education completed:_____________________ 7. Marital Status/History:______________________________________________ 8. Who do you live with?____________________________________ 9. Where do you live (apt, house, etc.)?_________________________ a. Whose home is it?__________________________________ 10. Number of people currently in household?______________________ 11. Number of children: biological____________ other_______________ 12. For how many people are you the primary caregiver?______________ a. # children______ b. #elderly________ c. other__________ 13. Occupation:____________________________________ 14. Has there been any changes since your current diagnosis in your: a. Marital Status? YES NO Details:_________________________________________ b. Household/Family? YES NO Details:____________________________________________ c. Occupation/ Work status? YES NO Details:_________________________________________ 64 MEDICAL INFORMATION 1. What is your diagnosis?______________________ a. What is the stage of your cancer?___________________ 2. When were you diagnosed?____________________ 3. Have you started treatment? YES NO 4. How long are you into treatment or how long has it been since you completed treatment?______________________________________________________ 5. What kind of treatment are/ have you received?_____________________________ a. If YES, what date did you start each treatment?______________________________________________ 6. Has any one in your family had cervical cancer?_________________________ 7. What do you believe are the causes of cervical cancer?____________________________________________________________________________ _______________________________________________________ 8. Have you heard of a vaccine that could prevent cervical cancer?______________________________________________________________ d. What have you heard?__________________________________________ _______________________________________________________________ 9. Has your doctor spoken to you about sexuality before your treatment was completed? YES NO a. If yes, who spoke to you about this? __________________________________ b. When did they speak to you about this?________________________________ 10. Has your doctor discussed his or her expectations of your recovery or survival with you? YES NO a. If YES, when did they speak to you about this?: Before Tx During Tx After Tx 11. ECOG: 0 Fully active, able to carry on all pre-disease performance without restriction 1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours 3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours 4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair 5 Dead 65 Brief ARSMA-II Please tell me to what extent you do each of these items. Not at all Very little/Not very much Moderately Much/ Very often Almost always/ Extremely often 1. I speak Spanish 1 2 3 4 5 2. I speak English 1 2 3 4 5 3. I enjoy speaking Spanish 1 2 3 4 5 4. I associate with Anglos 1 2 3 4 5 5. I enjoy listening to English language music 1 2 3 4 5 6. I enjoy Spanish language TV 1 2 3 4 5 7. I enjoy Spanish language movies 1 2 3 4 5 8. I enjoy reading books in Spanish 1 2 3 4 5 9. I write letters in English 1 2 3 4 5 10. My thinking is done in the English language 1 2 3 4 5 11. My thinking is done in the Spanish language 1 2 3 4 5 12. My friends are of Anglo origin 1 2 3 4 5 1995, Cuéllar, Arnold & Maldonado 66 FACT-Cx Below is a list of statements that other people with cervical cancer have said are important. Please tell me how true each statement has been for you since your cancer diagnosis PHYSICAL WELL-BEING Not at all A little bit Some- what Quite a bit Very much I have a lack of energy ....................................................... 0 1 2 3 4 I have nausea ...................................................................... 0 1 2 3 4 Because of my physical condition, I have trouble meeting the needs of my family ......................................... 0 1 2 3 4 I have pain .......................................................................... 0 1 2 3 4 I am bothered by side effects of treatment ......................... 0 1 2 3 4 I feel ill ............................................................................... 0 1 2 3 4 I am forced to spend time in bed ........................................ 0 1 2 3 4 SOCIAL/FAMILY WELL-BEING Not at all A little bit Some- what Quit e a bit Very much I feel close to my friends .................................................... 0 1 2 3 4 I get emotional support from my family ............................ 0 1 2 3 4 I get support from my friends ............................................ 0 1 2 3 4 My family has accepted my illness .................................... 0 1 2 3 4 I am satisfied with family communication about my illness ................................................................................. 0 1 2 3 4 I feel close to my partner (or the person who is my main support) .............................................................................. 0 1 2 3 4 Regardless of your current level of sexual activity, please answer the following question. If you prefer not to answer it, please check this box and go to the next section. I am satisfied with my sex life ...........................................0 1 2 3 4 67 EMOTIONAL WELL-BEING Not at all A little bit Some- what Quite a bit Very much I feel sad ........................................................................... 0 1 2 3 4 I am satisfied with how I am coping with my illness ....... 0 1 2 3 4 I am losing hope in the fight against my illness ............... 0 1 2 3 4 I feel nervous ................................................................... 0 1 2 3 4 I worry about dying .......................................................... 0 1 2 3 4 I worry that my condition will get worse ......................... 0 1 2 3 4 FUNCTIONAL WELL-BEING Not at all A little bit Some- what Quite a bit Very much I am able to work (include work at home) ....................... 0 1 2 3 4 My work (include work at home) is fulfilling .................. 0 1 2 3 4 I am able to enjoy life ...................................................... 0 1 2 3 4 I have accepted my illness ............................................... 0 1 2 3 4 I am sleeping well ............................................................ 0 1 2 3 4 I am enjoying the things I usually do for fun ................... 0 1 2 3 4 I am content with the quality of my life right now ........... 0 1 2 3 4 ADDITIONAL CONCERNS Not at all A little bit Some- what Quite a bit Very much I am bothered by discharge or bleeding from my vagina ............................................................................... 0 1 2 3 4 I am bothered by odor coming from my vagina ............... 0 1 2 3 4 I am afraid to have sex ..................................................... 0 1 2 3 4 I feel sexually attractive ................................................... 0 1 2 3 4 My vagina feels too narrow or short ................................ 0 1 2 3 4 68 I have concerns about my ability to have children ........... 0 1 2 3 4 I am afraid the treatment may harm my body .................. 0 1 2 3 4 I am interested in sex ....................................................... 0 1 2 3 4 I like the appearance of my body ..................................... 0 1 2 3 4 I am bothered by constipation .......................................... 0 1 2 3 4 I have a good appetite ...................................................... 0 1 2 3 4 I have trouble controlling my urine .................................. 0 1 2 3 4 It burns when I urinate ..................................................... 0 1 2 3 4 I have discomfort when I urinate ..................................... 0 1 2 3 4 I am able to eat the foods that I like ................................. 0 1 2 3 4 69 LOT-R Now I’m going to read to you some statements and I want you to tell me how much you either agree or disagree with each one. Please be as honest and accurate as you can throughout. Try not to let your response to one statement influence your responses to other statements. There are no "correct" or "incorrect" answers. Answer according to your own feelings, rather than how you think "most people" would answer. I DISagree a lot I DISagree a little I neither agree nor disagree I agree a little I agree a lot 1. In uncertain times, I usually expect the best. 0 1 2 3 4 2. It's easy for me to relax. 0 1 2 3 4 3. If something can go wrong for me, it will. 0 1 2 3 4 4. I'm always optimistic about my future. 0 1 2 3 4 5. I enjoy my friends a lot. 0 1 2 3 4 6. It's important for me to keep busy. 0 1 2 3 4 7. I hardly ever expect things to go my way. 0 1 2 3 4 8. I don't get upset too easily. 0 1 2 3 4 9. I rarely count on good things happening to me. 0 1 2 3 4 10. Overall, I expect more good things to happen to me than bad. 0 1 2 3 4 70 Hispanic Stress Inventory (Version I: Immigrant) Instructions: Please tell me whether the following situations have occurred to you during the last 3 months. Then if it did occur to you, let me know how worried or tense the situation made you feel. If the situation did not happen to you, just say so and we will move on to the next item. Remember there is no right or wrong answer so try and be as honest as you can. Example 1: It has been difficult for me to find medical care. Has this occurred to you in the past 3 months? __Yes __No 1 Not at all worried/tense 2 A little worried/tense 3 Moderately worried/tense 4 Very worried/tense 5 Extremely worried/tense Example 2: I have been criticized about my work. Has this occurred to you in the past 3 months? __Yes __No 1 2 3 4 5 1. I’ve seen my daughter/son behave delinquently. 2. I have questioned the idea that marriage is forever. 3. I have felt unaccepted by others due to my Latino culture. 4. Because I do not know enough English, it has been difficult for me to interact with others. 5. My children have been influence by bad friends. 6. Others have been too worried about the amount and quality of the work I do. 7. I have not been able to forget the last few months in my home country. 8. My spouse has been drinking too much alcohol. 9. I have thought that my children used illegal drugs. 10. My children have been drinking alcohol. 11. I have been discriminated against. 12. My spouse expected me to be more traditional in our relationship. 13. My spouse and I have disagreed on how to bring up our children. 14. My spouse and I have disagreed on the importance of religion within our family 15. I have been criticized about my work. 16. My spouse and I have had disagreements about who should control the household money. 17. I have thought a lot about my son (daughter) who left home to live independently. 18. Because of American ideas about the children it has been difficult for me to decide how strict to be with my children. 19. Because of my poor English people have treated me badly. 20. I have felt that being to close to my family interfered with my own goals. 21. I have thought that my children want their independence before they are ready. 22. I have felt that members of my family are losing their religion. 23. My children have not respected my authority the way they should. 24. Because we have different customs, I have had arguments with other members of my family. 25. Members of my family have considered divorce as a solution to their marital problems. 26. Because of the lack of family unity, I have felt lonely and isolated 27. Because I am Latino, I have been expected to work harder. 28. It has been difficult for me to understand why my spouse wishes to be more Americanized. 29. My spouse and I have disagreed on which language is spoken by our children at home. 30. Due to problems in understanding English, I have had difficulties in school. 31. My spouse has not helped with household chores. 71 32. My income has not been sufficient to support my family or myself. 33. I feared the consequences of deportation. 34. I have thought that my children were not receiving a good education. 35. My legal status has been a problem in getting a good job. 36. There have been cultural conflicts in my marriage. 37. I have felt that my children’s ideas about sexuality are too liberal. 38. There has been physical violence among members of my family. 39. I did not get the job I wanted because I didn’t have the proper skills. 40. Because I am Latino I have had difficulty finding the type of work I want. 41. My spouse has expected me to be less traditional in our relationship. 42. The pressures to achieve economic success have made me stop going to church. 43. My children have talked about leaving home. 44. My legal status has limited my contact with family and friends. 45. I have felt that I would never regain the status and respect that I had in my home country. 46. I have felt that family relationships are becoming less important for people who I’m close to. 47. My children have received bad school reports (or grades). 48. It has been difficult for my spouse and I to combine Latino and American cultures. 49. My boss has thought of me as being too passive. 50. I have had to watch the quality of my work so others do not think I am lazy. 51. Because I am Latino it has been hard to get promotions or salary raises. 52. Because of money problems, I have had to work away from my family. 53. I have had serious arguments with members of my family. 54. I have been around too much violence. 55. I have avoided immigration officials. 56. I have thought that if I went to a social or government agency, I would be deported. 57. My personal goals have been in conflict with family goals. 58. Both my spouse and I have had to work. 59. Because I do not know enough English, it has been difficult to deal with day-to-day situations. 60. I have not been able to forget about the war related deaths which happened to friends or family members. 61. My spouse and I have had disagreements on the use of contraceptives. 62. My children have seen too much sex on television or at the movies. 63. I have noticed that religion is less important to me now than before. 64. I have felt guilty about leaving family and friends in my home country. 65. My spouse has not been adapting to American life. 66. I have been forced to accept low paying jobs. 67. There have been conflicts among members of my family. 68. I have been questioned about my legal status. 69. I have had difficulty finding legal services. 70. I have felt that I might lose my job to newly arriving immigrants. 71. I have felt pressured to learn English. 72. Some members of my family have become too individualistic. 73. I have felt that my spouse and I have not been able to communicate. 72 MOS Social Support Survey 1. About how many close friends and close relatives do you have—people you feel at ease with and can talk to about what is on your mind? # of relatives/close friends_____ a. How many of these people are here in the Los Angeles area?____ People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it? Circle one number on each line. None of the time A little of the time Some of the time Most of the time All of the time I Don’t know 2. Someone to help you if you were confined to bed. 1 2 3 4 5 9 3. Someone you can count on to listen to you when you need to talk. 1 2 3 4 5 9 4. Someone to give you good advice about a crisis. 1 2 3 4 5 9 5. Someone to take you to the doctor if you needed it. 1 2 3 4 5 9 6.Someone who shows you love and affection. 1 2 3 4 5 9 7. Someone to have a good time with. 1 2 3 4 5 9 8. Someone to give you information to help you understand a situation. 1 2 3 4 5 9 9. Someone to confide in or talk about yourself or your problems 1 2 3 4 5 9 10. Someone who hugs you. 1 2 3 4 5 9 11. Someone to get together with for relaxation. 1 2 3 4 5 9 12. Someone to prepare your meals if you were unable to do it yourself. 1 2 3 4 5 9 13. Someone whose advice you really want. 1 2 3 4 5 9 14. Someone to do things with to help you get your mind off things. 1 2 3 4 5 9 15. Someone to help with daily chores if you were sick. 1 2 3 4 5 9 16. Someone to share your most private worries and fears with. 1 2 3 4 5 9 17.Someone to turn to for suggestions about how to deal with a personal problem. 1 2 3 4 5 9 18. Someone to do something 1 2 3 4 5 9 73 enjoyable with. 19. Someone who understands your problems. 1 2 3 4 5 9 20. Someone to love and make you feel wanted. 1 2 3 4 5 9 21. Regarding your current health situation, how much support are you getting? 1 Less than I usually get. 2 3 The same amount as I usually get. 4 5 More than I usually get about other things. 22. Is there anyone from whom you wish you got more support? Yes____ No____ 23. To what extent are you satisfied with the support that you are receiving in relation to your current illness and treatment? 1 2 3 4 5 Complete unsatisfied Completely satisfied 74 Brief COPE I am going read to you some statements that deal with ways you've been coping with your diagnosis of cervical cancer. There are many ways to try to deal with problems. These items ask what you've been doing to cope with this one. Obviously, different people deal with things in different ways, but I'm interested in how you've tried to deal with cervical cancer. Each item says something about a particular way of coping. I want to know to what extent you've been doing what the item says. How much or how frequently. Don't answer on the basis of whether it seems to be working or not—just whether or not you're doing it. Use these response choices. Try to rate each item separately in your mind from the others. Make your answers as true FOR YOU as you can. I haven’t been doing this at all I’ve been doing this a little bit. I’ve been doing this a medium amount I’ve been doing this a lot 1. I've been turning to work or other activities to take my mind off things. 1 2 3 4 2. I've been concentrating my efforts on doing something about the situation I'm in. 1 2 3 4 3. I've been saying to myself "this isn't real". 1 2 3 4 4. I've been using alcohol or other drugs to make myself feel better. 1 2 3 4 5. I've been getting emotional support from others. 1 2 3 4 6. I've been giving up trying to deal with it. 1 2 3 4 7. I've been taking action to try to make the situation better. 1 2 3 4 8. I've been refusing to believe that it has happened. 1 2 3 4 9. I've been saying things to let my unpleasant feelings escape. 1 2 3 4 10. I’ve been getting help and advice from other people. 1 2 3 4 11. I've been using alcohol or other drugs to help me get through it. 1 2 3 4 12. I've been trying to see it in a different light, to make it seem more positive. 1 2 3 4 13. I’ve been criticizing myself. 1 2 3 4 14. I've been trying to come up with a strategy about what to do. 1 2 3 4 15. I've been getting comfort and understanding from someone. 1 2 3 4 16. I've been giving up the attempt to cope. 1 2 3 4 17. I've been looking for something good in what is happening. 1 2 3 4 18. I've been making jokes about it. 1 2 3 4 19. I've been doing something to think about it less, such as going to movies, watching TV, reading, daydreaming, sleeping, or shopping. 1 2 3 4 75 20. I've been accepting the reality of the fact that it has happened. 1 2 3 4 21. I've been expressing my negative feelings. 1 2 3 4 22. I've been trying to find comfort in my religion or spiritual beliefs. 1 2 3 4 23. I’ve been trying to get advice or help from other people about what to do. 1 2 3 4 24. I've been learning to live with it. 1 2 3 4 25. I've been thinking hard about what steps to take. 1 2 3 4 26. I’ve been blaming myself for things that happened. 1 2 3 4 27. I've been praying or meditating. 1 2 3 4 28. I've been making fun of the situation. 1 2 3 4 76 PSN LOT-R Now I am going to ask you some questions about how people around you, like your family, friends or other Latinas, think about their lives. I am going to read you some statements, and I would like for you to tell me how the people around you would answer. Please be as honest and accurate as you can throughout. Try not to let your response to one statement influence your responses to other statements. There are no "correct" or "incorrect" answers. Please remember to answer according to how you believe your friends, family, or other Latinas, would answer. They would DISagree a lot They would DISagree a little They would neither agree nor disagree They would agree a little They would agree a lot In uncertain times, my family, friends or other Latinas usually expect the best. 0 1 2 3 4 It's easy my friends, family, and other Latinas to relax. 0 1 2 3 4 If something can go wrong, it will. 0 1 2 3 4 My family, friends, or other Latinas are always optimistic about the future. 0 1 2 3 4 My family, friends, or other Latinas hardly ever expect things to go their way. 0 1 2 3 4 My family, friends, or other Latinas enjoy their friends a lot. 0 1 2 3 4 It's important for people to keep busy. 0 1 2 3 4 My family, friends, or other Latinas don't get upset too easily. 0 1 2 3 4 My family, friends, or other Latinas rarely count on good things happening to them. 0 1 2 3 4 Overall, they expect more good things to happen to them than bad. 0 1 2 3 4 Who did you have in mind when you were answering these questions?______________ 77 CES-D Now I am going to read some statements about some ways people act and feel. Please look at this sheet (hand subject Card I with response list) and tell me the number which best describes how often you felt or behaved this way since your cancer diagnosis. Rarely/ None of the time Some of the time/ A little Occasionally/ Moderate Amount of Time Most/ All of the Time Not Applicable I don’t know 1. I was bothered by things that usually don't bother me. 1 2 3 4 7 8 2. I did not feel like eating; my appetite was poor. 1 2 3 4 7 8 3. I felt that I could not shake off the blues even with help from my family or friends. 1 2 3 4 7 8 4. I had trouble keeping my mind on what I was doing. 1 2 3 4 7 8 5. I felt that I was just as good as other people. 1 2 3 4 7 8 6. I felt depressed. 1 2 3 4 7 8 7. I felt that everything I did was an effort. 1 2 3 4 7 8 8. I felt hopeful about the future. 1 2 3 4 7 8 9. I thought my life had been a failure. 1 2 3 4 7 8 10. I felt fearful. 1 2 3 4 7 8 11. My sleep was restless. 1 2 3 4 7 8 12. I was happy. 1 2 3 4 7 8 13. I talked less than usual. 1 2 3 4 7 8 14. I felt lonely. 1 2 3 4 7 8 15. People were unfriendly. 1 2 3 4 7 8 16. I enjoyed life. 1 2 3 4 7 8 17. I had crying spells. 1 2 3 4 7 8 18. I felt sad. 1 2 3 4 7 8 19. I felt that people disliked me. 1 2 3 4 7 8 20. I could not get "going." 1 2 3 4 7 8 78 PANAS This scale consists of a number of words that describe different feelings and emotions. Read each item and then circle the appropriate answer next to that word. Indicate to what extent you have felt this way since your cancer diagnosis. Use the following scale to record your answers. (1) = Very slightly or not at all (2) = A little (3) = Moderately (4) = Quite a bit (5) = Extremely Very slightly or not at all A little Moderately Quite a bit Extremely 29. Interested 1 2 3 4 5 30. Distressed 1 2 3 4 5 31. Excited 1 2 3 4 5 32. Upset 1 2 3 4 5 33. Strong 1 2 3 4 5 34. Guilty 1 2 3 4 5 35. Scared 1 2 3 4 5 36. Hostile 1 2 3 4 5 37. Enthusiastic 1 2 3 4 5 38. Proud 1 2 3 4 5 39. Irritable 1 2 3 4 5 40. Alert 1 2 3 4 5 41. Ashamed 1 2 3 4 5 42. Inspired 1 2 3 4 5 43. Nervous 1 2 3 4 5 44. Determined 1 2 3 4 5 45. Attentive 1 2 3 4 5 46. Jittery 1 2 3 4 5 47. Active 1 2 3 4 5 48. Afraid 1 2 3 4 5

Abstract (if available)

Abstract Latinas have sustained the highest rates of cervical cancer throughout the past decade, yet, little is known about the experiences of these patients. In this study, 54 low-income, monolingual Spanish-speaking Latina cervical cancer patients were interviewed in order to describe their psychosocial experiences, identify predictors of psychosocial outcomes and explore the role of optimism in their adjustment. Cancer-related coping strategies, life stressors and social support were tested as predictors of depression, affect, and quality of life, and as mediators of the relation between optimism and the outcome variables. 67% of the sample reported symptoms similar to those of individuals with diagnosable levels of depression. Cancer-related and contextual variables significantly predicted all outcome variables. Approach coping mediated the relation between optimism and quality of life. The results of this study emphasize the need to consider the context within which patients live, in addition to cancer-related factors, when assessing adjustment to cancer.

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University of Southern California Dissertations and Theses

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Asset Metadata

Creator D'Orazio, Lina M. (author)

Core Title Psychosocial adjustment of Latina cervical cancer patients

School College of Letters, Arts and Sciences

Degree Master of Arts

Degree Program Psychology

Publication Date 05/08/2009

Defense Date 10/09/2007

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag cancer,coping,Depression,Latinas,OAI-PMH Harvest,Optimism,Stress

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Meyerowitz, Beth E. (committee chair), Huey, Stanley J., Jr. (committee member), Wilcox, Rand R. (committee member)

Creator Email ldorazio@usc.edu,lina.dorazio@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m2221

Unique identifier UC1107165

Identifier etd-DOrazio-2032 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-236900 (legacy record id),usctheses-m2221 (legacy record id)

Legacy Identifier etd-DOrazio-2032.pdf

Dmrecord 236900

Document Type Thesis

Rights D'Orazio, Lina M.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu