College Age Female Smokers and the Efficacy of Smoking Cessation on College Campuses

Young females are smoking on campuses in increasing rates in the last two decades. This thesis is secondary data analysis of a primary study with data from 472 female respondents, ages 18 to 24, enrolled or registered for classes at Minnesota State University, Mankato in the Spring, Summer and Fall semester of 2011. This sample included current smokers, former smokers, and nonsmokers. This research study will discuss the relationship between the age one starts smoking and any association with participation in unprotected intercourse and the concomitant use of estrogen containing oral contraceptives. Among the respondents a majority started smoking between the ages 14 to 19. Among current and former smokers, there was positive association among females, ages 14 to 15, and participation in unprotected intercourse. Among current and former smokers, there was no association or preference to use estrogen containing oral contraceptives. Using Pearson\u27s chi-square analysis, there was no statistically significant relationship among age one starts smoking and (a) participation in unprotected intercourse and (b) use of estrogen containing oral contraceptives. The percentage of females receiving smoking cessation advice from providers ranged from 26% among current smokers to 29% among former smokers. However, not all young female smokers disclosed their current smoking status to their providers. Future research should capture a more diverse dataset to improve interventions based on prevalence in various ethnic groups

QUEER HEALTH EQUITY AND CERVICAL CANCER: IDENTIFYING SOCIAL DETERMINANTS OF PAPANICOLAOU TEST UPTAKE IN A SAMPLE OF SEXUAL MINORITY WOMEN AND GENDER NONBINARY INDIVIDUALS

Sexual minority women (SMW) demonstrate lower rates of cervical cancer screening than heterosexual women. This is concerning as lesbian and bisexual women tend to engage in higher rates of substance-related cancer risk behaviors, unprotected sex, and tend to have higher body mass indices, all of which are risk factors for cancer development. Another major risk factor, screening avoidance, places SMW at increased risk for the development of high grade cervical lesions in the absence of early detection practices, which is likely to impact overall cervical cancer morbidity in this population. The aim of the present study was to utilize the Health Equity Promotion Model in order to investigate the interplay of medical heterosexism, social and community, behavioral, biological, and social identity/position factors on cervical cancer screening rates in a sample of SMW from a large metro area in the southeastern United States. 145 women who identify as sexual minorities were recruited from local LGBT-friendly venues, events, community organizations, email LISTSERVs, and related social media accounts and were asked to complete a fifteen-minute survey. A series of bivariate correlation, t-test, and multivariate regression analyses were run. Findings from mediation analyses demonstrated that health communication factors mediated the relationship between perceived medical heterosexism and cervical cancer screening outcomes. Further, after accounting for demographic factors, greater provider communication quality, provider trust, eHealth literacy, and ever having an HIV test significantly and differentially predicted cervical cancer screening outcomes in the multivariate models (ps \u3c .05). Findings suggest that health communication factors play an important role in facilitating cervical cancer screenings for SMW, and provider training interventions and policy that focus on reducing medical heterosexism may aid in improving patient-provider relationships in this population

Psychological Adjustment to the Onset of Rheumatoid Arthritis: a Longitudinal Evaluation of Perceptions of and Adherence to Medication

Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease causing inflammation of the synovium resulting in severe pain, joint disfigurement and disability as well as malaise, fatigue and a depressed immune system. Treatment consists of three broad phases; firstly, following diagnosis treatment is focussed on rapid reduction of pain and inflammation. Secondly, maintenance of quiescence is sought through medication. Finally, if disease activity remains high despite medication, escalation to anti-TNF α therapy is required to prevent permanent joint damage and disability. The primary course of treatment is prescription of disease modifying anti-rheumatic drugs (DMARDs) within 3 months of onset of symptoms. However, DMARDs can take 8-12 weeks to exhibit a noticeable benefit whereas unpleasant side effects can occur shortly after initiation. Also, DMARDs do not alleviate pain; therefore it is difficult for patients to attribute recovery to this medication. For these reasons, although it is imperative for future health and functioning to take DMARDs as prescribed, non-adherence is common at 30-50%. Non-adherence to treatment can be intentional, where a decision is made not to conform to the prescription, or unintentional which is often due to forgetting. To measure intentional non-adherence, a validated measure of adherence for rheumatoid arthritis was reduced through exploratory factor analysis from 19 items to 5 items by removing items that did not add to the explained variance of adherence. The CQR5 explained 53% of the variance in adherence and was shown to have a good fit to the data through confirmatory factor analysis. A discriminant function equation was generated that correctly identifies 88.5% of patients as high or low adherers and has high clinical utility due to the brevity for patients and unidimensionality for easy interpretation. The CQR5 was used throughout the programme of research to measure intentional non-adherence along with a separate measure of unintentional non-adherence. Four commonly used social cognition models of illness were measured in 227 RA patients to determine which had the best utility for predicting non-adherence to DMARDs. Patients were recruited to represent the three stages of illness including newly diagnosed, established on DMARD therapy and established with concurrent anti-TNF α therapy. Logistic regression analysis showed that the Self Regulatory Model best predicted intentional non-adherence as patients with perceptions of worse consequences of RA and longer disease duration were more likely to be highly adherent to DMARDs in cross-sectional analysis. In contrast, the Theory of Planned Behaviour better predicted patients who self-reported forgetting their DMARDs with patients with more confidence in being able to take their medications (Perceived Behavioural Control) being less likely to forget. 171 patients were successfully followed-up six months after baseline recruitment. The longitudinal results showed that the social cognition models differed for patients at different stages of the illness suggesting that their experience of living with rheumatoid arthritis influenced perceptions of their illness and medications. Newly diagnosed patients scored lower on factors measuring perceptions of disease chronicity and seriousness whereas patients that had escalated to anti-TNF α therapy scored higher on these factors. The newly diagnosed patients also showed more variability in the social cognition scores whereas the more established patients demonstrated stable models of illness. This supports Leventhal’s (1992) theory that illness representations will be regulated through integration of knowledge and experience of an illness. Structural equation modelling was used to establish the best predictors of intentional non-adherence at six month follow-up. In support of research in other chronic illnesses (Horne & Weinman, 2002; Niklas, Dunbar & Wild, 2010), the effect of perceptions of the consequences and chronicity of the illness on adherence are mediated by perceptions of the necessity of the medication. In addition, the impact of the emotional reaction to the illness on adherence to DMARDs is mediated by concerns about the medication. In addition, this study incorporated factors from the Theory of Planned Behaviour to explain medication adherence and found that the influence of friends and family impacts on the patient’s confidence to follow the prescription accurately which in turn as an effect on adherence to DMARDs. This large longitudinal study found that by combining factors from a number of social cognition models, it is possible to explain and predict intentional non-adherence and provides some evidence for best ways to intervene to improve adherence and prognosis. To provide a more comprehensive and clinically useful picture of non-adherence, a Cost of Illness study was carried which found that patients self-reporting low adherence to DMARDs also had significantly higher costs for this medication. This was caused by an increased incidence of Leflunamide prescribing for patients who often forget their medication and was maintained longitudinally. This association has not been previously reported in the literature and provides some evidence that non-adherence to DMARDs is having a concrete effect on the clinical management of patients. Finally, an SMS text message based reminder service designed to remind patients who self-report forgetting their medications was tested through a simulation study for the cost and likely benefit in health related quality of life using the health economic analysis of the longitudinal study and the results of a survey establishing the feasibility of implementing such a service in the rheumatology clinic. A sensitivity analysis testing the number of messages sent and the cost per message found that a reminder service for the sample of patients in this programme of research would cost between £1387.00 and £142.27 per year. This would equate to a cost per Quality Adjusted Life Year (QALY) gain of between £2889.58 and £296.40 by enabling patients to adhere more rigorously to their DMARD regimen. This programme of research is the first to test four commonly used social cognition models to predict adherence to DMARDs in a large, multi-centre longitudinal study of rheumatoid arthritis patients. Perceptions of the likely duration and consequences of the illness, as measured by the Illness Perceptions Questionnaire and the necessity of medications (measured by the Beliefs about Medications Questionnaire) along with self-efficacy (measured by the Theory of Planned Behaviour) explained 24% of the variance in intentional adherence over six months. The results show the importance of considering intentional and unintentional non-adherence separately as they appear to have different underlying mechanisms as well as patients in different phases of the illness as their experience influences their social cognition models of illness. A simple SMS based reminder service could act as a cue to action to reduce unintentional non-adherence whereas addressing issues surrounding maladaptive perceptions about the illness and the treatment could improve intentional non-adherence which has the potential to improve the prognosis and quality of life for patients as well as safe costs for the NHS.ESR

“It’s Not If I Get Cancer, It’s When I Get Cancer”: Exploring Previvors’ Management of Uncertainty for Hereditary Cancer in Clinical Encounters

The purpose of this dissertation study was to identify previvors’ sources of uncertainty and strategies for managing uncertainty and understand how previvors’ uncertainty influence what type of preventative health decisions they make and how those decisions affect their subsequent sense of uncertainty. A previvor is an individual who is highly predisposed to breast and ovarian cancer due to a genetic mutation called BRCA1/2. Previvors have a 44 to 87 percent risk of developing cancer during their lifetime. Consequently, previvors live in a constant state of uncertainty—wondering not if they might get cancer but when—and must make certain preventative health decisions to reduce their cancer risk. To understand previvors’ health experiences, thirty-four, semi-structured interviews were conducted with female previvors. Participants were recruited through Facing Our Risk of Cancer Empowered’s (FORCE) social media pages. Interviews were recorded and transcribed. The constant comparison method was employed to code the interview transcriptions, and the interview transcripts’ themes served as the units of analysis. First, analysis revealed two main uncertainty sources for previvors—medical uncertainty and familial uncertainty. Medical uncertainty types include the unknown future, peaks and valleys associated with medical consultations, and personal cancer scares. Familial uncertainty encompasses traumatic family cancer experiences and being a mother and being present in children’s lives. Second, four uncertainty management strategies—seeking clinicians as an informational source, seeking clinicians as a partner for decision-making, seeking clinicians as an emotional support, and seeking referrals from clinicians for emotional support—were identified as ways previvors try to manage their uncertainties. Ultimately, previvors’ uncertainty sources and uncertainty management strategies impacted their health decision-making with preventative surgeries as the most common health decision. Overall, the purpose of this research was to gain insight into previvors’ uncertain health experiences in order to improve patient-centered communication between previvors and clinicians and ultimately better previvors’ health and well-being. This research contributes to the literature by extending the exploration of uncertainty management to a new population, reinforcing the belief that chronic uncertainty should be managed not reduced, supporting health and illness uncertainty theories, and providing practical recommendations for clinician-patient communication

Young people's beliefs about the health effects of different alcoholic beverages : an exploratory comparison of the UK and France

Different kinds of alcoholic drink have different connotations for drinkers in terms of their potential to produce intoxication and their effects on health. These connotations are likely to be important influences on drinking behaviour. This mixed methods study examined how young people (18 to 24 years old) in two countries with different drinking cultures (France and the UK) perceive the costs and benefits of consuming particular kinds of alcoholic beverage, specifically contrasting beers (blonde and dark), wines (red and white) and spirits (clear and dark). More broadly, the project evaluated young peoples beliefs about the different beverage types, and the factors that influence their choices of beverage, including, peer influence, beliefs about drink-specific effects and how different kinds of drink affect body weight. A pilot study of online drinking diaries was conducted to establish drinking trends among young adults in the two countries. A number of key difference were found between the two countries which informed areas of discussion in the focus groups, including beverage preferences, the difference in levels of preloading and mixing drinks, as well as the relationship between alcohol and food. The qualitative part consisted of sixteen structured focus groups (8 in each country), which examined participants’ understanding and beliefs about the health consequences of consuming different kinds of alcoholic beverage. They also explored how different drinks are related to drinking styles. In both countries, participants highlighted ‘getting drunk’ as a reason for drinking, and they adopted similar justifications for their drinking behaviours. UK participants tended to view all drinks (except wine) as equally problematic for health, whereas French participants had more diverse beliefs about the health effects of different beverages. The quantitative phase consisted of a large survey distributed across the two countries (UK= 555 participants and France= 401), which looked further into people’s health beliefs about different beverage types. The notion that wine is healthier than other beverages was widely held in both countries, but was stronger in France than the UK and it had different determinants in the two countries. Also, in France, spirits were identified as particularly problematic for health, much more so than in the UK. In the UK, apart from wine, all beverages were considered to have a similar potential for causing health problems. Liver damage was identified as a key problem linked to chronic alcohol consumption; in France, it was most strongly associated with drinking dark spirits, whereas in the UK it was not linked to any particular beverage type(s). In both countries, the acute effects on health were more salient than the chronic effects, and the primary concern relating to long-term consumption was addiction rather than damage to physical health. Lastly, 14 semi-structured interviews were conducted in the two countries (7 in each country) exploring the impacts of public information, media reports and peer influence on beliefs about different beverage types. Across the two countries the participants believed that there was a lack of information about the long-term health effects of alcohol, and expressed a lack of trust in the media (i.e. newspapers and television advertising). They believed that information should be more accessible through the internet, i.e. social media sites, and they also suggested the use of images to illustrate the major health impacts of alcohol consumption. To conclude: drinking practices and views about alcohol’s health effects appear to be converging across the two countries. Participants showed a limited understanding of (and concern about) long-term health problems associated with different drinks, and their views were confounded with stereotypes about typical consumers and beliefs about the “naturalness” or “authenticity” of different drink types