stephanie gilbertson-white, phd, rn alexandra bursic paula sherwood, phd, rn, faan
DESCRIPTION
Symptom representations and coping efforts for pain and numbness/tingling in women with a history of ovarian cancer. Stephanie Gilbertson-White, PhD, RN Alexandra Bursic Paula Sherwood, PhD, RN, FAAN Heidi Donovan, PhD, RN [email protected]. School of Nursing - PowerPoint PPT PresentationTRANSCRIPT
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Symptom representations and coping efforts for pain and numbness/tingling in women with a history of ovarian cancerStephanie Gilbertson-White, PhD, RNAlexandra BursicPaula Sherwood, PhD, RN, FAANHeidi Donovan, PhD, [email protected]
School of NursingDepartment Acute and Tertiary Care
Funding Agencies: NIH/NINR F31 NR07556; ONS/Orthobiotech; NIH/NINR T32 NR011972
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Background
• Pain and numbness/tingling are two symptoms that are frequently reported as distressing by women with ovarian cancer. (Stavraka et al., 2012)
• Etiology and treatment strategies are significantly different for these two symptoms. (NCCN, 2012; APS, 2008)
• Cognitive representations have been found to be significantly associated with coping efforts across a variety of diseases. (Leventhal, 2011)
• Little is known about factors that influence patients’ symptom-related coping efforts.
• The relationships between individual dimensions of representations and symptom-related coping efforts have not been previously explored.
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Theoretical Framework
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Leventhal’s Common-Sense Model of Illness Representations
(Power, Swartzman, & Robinson, 2011)
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Leventhal’s Common-Sense Model of Illness Representations
Individuals have “common-sense understandings” (i.e., representations) of health problems (e.g., cancer related symptoms) that guide how they cope with a problem.
Representations consist of • Cognitions about:
– Identity – Cause(s)
– Timeline
– Consequences
– Cure or controllability
• Emotional responses
(Leventhal, H., Meyer, D. & Nerenz, D. 1980)
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Purpose and Specific Aims
The purpose of this study was to describe the relationships between symptom representations and coping in women with a history of ovarian cancer experiencing pain and/or numbness and tingling.
Specific aims
1. To describe coping efforts and symptom representations for pain and numbness/tingling.
2. To evaluate whether coping efforts are associated with symptom representations after controlling for disease and personal characteristics.
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Methods – Design and Sample
Secondary analysis of a cross-sectional, descriptive study (N=713) conducted via surveys mailed to women with ovarian cancer who were members of the National Ovarian Cancer Coalition (NOCC).
This analysis includes participants (n=266) identifying pain or numbness/tingling as one of their top three “most noticed” symptoms in past week.
•Pain (n=152)
•Numbness/tingling (n=144)
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Methods – Key Variables
Independent variables: Symptom Representations
Symptom Representation Questionnaire (Donovan et al, 2008):
– 15-item scale per symptom
– Response options of 0 (strongly disagree) to 4 (strongly agree)
– Identity (severity), cause, timeline, consequences, cure/control, emotional response (distress).
– Higher scores indicate more negative representations.
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Methods – Key Variables
Dependent variables: Coping Efforts
Daily Coping Inventory (DCI) (Stone, Kennedy-Moore, & Neale, 1995):
• 9-item yes/no inventory of categories of coping strategies.
• Factor analysis was used on the DCI resulting in a 2-factor solution (problem-focused and emotion-focused).
• Sum scores for problem-focused coping (0-6) and emotion-focused coping (0-3) used in analyses.
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Coping SubscalesLabel Daily Coping Inventory Item
Emotion- focused coping
Problem-focused coping
Distraction
Diverted attention away from the symptom by thinking about other things or engaging in some activity.
X
ReframingTried to see the symptom in a different light that made it seem more bearable.
X
Expressed emotion
Expressed emotions in response to the symptom to reduce tension, anxiety, or frustration.
X
Emotional support
Sought or found emotional support from loved ones, friends, or professionals.
X
Relaxation Did something to relax. X
Spiritual support
Sought or found spiritual comfort and support. X
PlanningThought about ways to manage the symptom, or gathered information about ways to manage it.
X
Manage symptom
Actually did something to manage the symptom. X
Acceptance
Accepted that the symptom had occurred, but that nothing could be done about it (reverse scored).
X
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Analysis
• Descriptive statistics • Separate multiple linear regression
analyses for pain and numbness/tingling to determine the relationship between symptom representations and each coping style– Co-variates: optimism, depression, total
number of symptoms, survivorship status
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Results
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Sample (n=266)Mean (SD)
Mean age in years 54.7 (11.5)
n (%)
Pain as “most noticed symptom” 152 (57%)*
Numbness/tingling as “most noticed symptom” 144 (54%)*
Race
White 252 (95.1%)
Other 13 (4.9%)
Education
Some high school/high school graduate 44 (16.6%)
Some college 96 (36.2%)
College graduate/postgraduate training 125 (47.2%)
*30 participants selected both pain and n/t
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Descriptive Statistics for C0-variates
Mean (SD)
Optimism (0-24) 16.5 (4.3)
Depression severity (0 to10 NRS) 2.4 (2.5)
Number of symptoms (0 to 22) 11.2 (4.5)
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Percentage of patients in each survivorship status category
14%
36%
10%
40%
Survivorship Status
No evidence of dis-ease, no recurrence >5 yr.
No evidence of dis-ease, no recurrence <5 yr.
No evidence of dis-ease with recurrence < 5 yr.
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Mean identity representation scores
Pain Numbness/Tingling0
2
4
6
8
10
Symptom Severity
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Mean representation subscale scores
Treat
men
t Cau
se
Cance
r Cau
se
Cure/
Contr
ol
Conse
quen
ces
Timel
ine
Emot
iona
l 0
0.5
1
1.5
2
2.5
3
3.5
4
Pain Numbness/Tingling
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Mean coping sub-scale scores
Pain Numbness/Tingling
0
1
2
3
4
5
6
Emotion-focused coping
Pain Numbness/Tingling0
0.5
1
1.5
2
2.5
3Problem-focused coping
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Percentage of patients reporting use of each coping strategy
Distra
ctio
n
Refra
min
g
Expre
ssed
em
otio
n
Emot
iona
l sup
port
Relax
atio
n
Spirit
ual s
uppo
rt
Plann
ing
Man
age sy
mpt
om
Accep
tanc
e0
10
20
30
40
50
60
70
80
90
100
Pain Numbness/tinglingCoping strategy
Perc
en
tag
e (
%)
Emotion-focused coping
Problem-focused coping
Multiple linear regression analyses of predictors of coping efforts Emotion-focused coping Problem-focused coping
PainNumbness/
TinglingPain
Numbness/Tingling
PredictorOverall Model
R2
p.219.003
.346<.001
.273<.001
.231
.002
Disease & Personal Characteristics*
Survivorship statusbetaR2p
.025
.003
.807
.049
.002
.596
-.076.004.438
-.044.002.642
Number of symptomsbetaR2p
.310
.050
.009
-.061.002.592
.202
.021
.068
.124
.008
.290
Depression severitybetaR2p
-.098.005.384
.000<.001.999
-.182.032.085
-.096.006.366
OptimismbetaR2p
.065
.003
.508
.163
.020
.092
.163
.020
.079
.108
.009
.260
Representations
Representation BlockR2p
.069
.214.247
<.001.190
<.001.170.002
Symptom severity (Identity representation)
betaR2p
-.006<.001.958
.304
.038
.022
.114
.007
.291
.010<.001.937
Treatment cause representationbetaR2p
-.047.002.612
.238
.043
.015
-.157.020.080
-.059.003.542
Cancer cause representationbetaR2p
.092
.005
.413
-.002<.001.983
-.114.007.290
.007<.001.938
Cure/control representationbetaR2p
.034<.001.721
-.221.037.023
-.188.027.043
-.201.032.034
Consequences representationbetaR2p
.228
.019
.106
.245
.017
.122
.345
.043
.010
.199
.010
.227
Timeline representationbetaR2p
-.077.004.479
.004<.001.964
-.192.023.061
-.096.006.355
Emotional representationbetaR2p
.110
.005
.411
.002<.001.991
-.028<.001.823
.224
.014
.165
Block 1 was significant in all models except for problem-focused coping for numbness/tingling.
Multiple linear regression analyses of predictors of coping efforts Emotion-focused coping Problem-focused coping
PainNumbness/
TinglingPain
Numbness/Tingling
PredictorOverall Model
R2
p.219.003
.346<.001
.273<.001
.231
.002
Disease & Personal Characteristics*
Survivorship statusbetaR2p
.025
.003
.807
.049
.002
.596
-.076.004.438
-.044.002.642
Number of symptomsbetaR2p
.310
.050
.009
-.061.002.592
.202
.021
.068
.124
.008
.290
Depression severitybetaR2p
-.098.005.384
.000<.001.999
-.182.032.085
-.096.006.366
OptimismbetaR2p
.065
.003
.508
.163
.020
.092
.163
.020
.079
.108
.009
.260
Representations
Representation BlockR2p
.069
.214.247
<.001.190
<.001.170.002
Symptom severity (Identity representation)
betaR2p
-.006<.001.958
.304
.038
.022
.114
.007
.291
.010<.001.937
Treatment cause representationbetaR2p
-.047.002.612
.238
.043
.015
-.157.020.080
-.059.003.542
Cancer cause representationbetaR2p
.092
.005
.413
-.002<.001.983
-.114.007.290
.007<.001.938
Cure/control representationbetaR2p
.034<.001.721
-.221.037.023
-.188.027.043
-.201.032.034
Consequences representationbetaR2p
.228
.019
.106
.245
.017
.122
.345
.043
.010
.199
.010
.227
Timeline representationbetaR2p
-.077.004.479
.004<.001.964
-.192.023.061
-.096.006.355
Emotional representationbetaR2p
.110
.005
.411
.002<.001.991
-.028<.001.823
.224
.014
.165
Block 1 was significant in all models except for problem-focused coping for numbness/tingling.
Multiple linear regression analyses of predictors of coping efforts Emotion-focused coping Problem-focused coping
PainNumbness/
TinglingPain
Numbness/Tingling
PredictorOverall Model
R2
p.219.003
.346<.001
.273<.001
.231
.002
Disease & Personal Characteristics*
Survivorship statusbetaR2p
.025
.003
.807
.049
.002
.596
-.076.004.438
-.044.002.642
Number of symptomsbetaR2p
.310
.050
.009
-.061.002.592
.202
.021
.068
.124
.008
.290
Depression severitybetaR2p
-.098.005.384
.000<.001.999
-.182.032.085
-.096.006.366
OptimismbetaR2p
.065
.003
.508
.163
.020
.092
.163
.020
.079
.108
.009
.260
Representations
Representation BlockR2p
.069
.214.247
<.001.190
<.001.170.002
Symptom severity (Identity representation)
betaR2p
-.006<.001.958
.304
.038
.022
.114
.007
.291
.010<.001.937
Treatment cause representationbetaR2p
-.047.002.612
.238
.043
.015
-.157.020.080
-.059.003.542
Cancer cause representationbetaR2p
.092
.005
.413
-.002<.001.983
-.114.007.290
.007<.001.938
Cure/control representationbetaR2p
.034<.001.721
-.221.037.023
-.188.027.043
-.201.032.034
Consequences representationbetaR2p
.228
.019
.106
.245
.017
.122
.345
.043
.010
.199
.010
.227
Timeline representationbetaR2p
-.077.004.479
.004<.001.964
-.192.023.061
-.096.006.355
Emotional representationbetaR2p
.110
.005
.411
.002<.001.991
-.028<.001.823
.224
.014
.165
Block 1 was significant in all models except for problem-focused coping for numbness/tingling.
Multiple linear regression analyses of predictors of coping efforts Emotion-focused coping Problem-focused coping
PainNumbness/
TinglingPain
Numbness/Tingling
PredictorOverall Model
R2
p.219.003
.346<.001
.273<.001
.231
.002
Disease & Personal Characteristics*
Survivorship statusbetaR2p
.025
.003
.807
.049
.002
.596
-.076.004.438
-.044.002.642
Number of symptomsbetaR2p
.310
.050
.009
-.061.002.592
.202
.021
.068
.124
.008
.290
Depression severitybetaR2p
-.098.005.384
.000<.001.999
-.182.032.085
-.096.006.366
OptimismbetaR2p
.065
.003
.508
.163
.020
.092
.163
.020
.079
.108
.009
.260
Representations
Representation BlockR2p
.069
.214.247
<.001.190
<.001.170.002
Symptom severity (Identity representation)
betaR2p
-.006<.001.958
.304
.038
.022
.114
.007
.291
.010<.001.937
Treatment cause representationbetaR2p
-.047.002.612
.238
.043
.015
-.157.020.080
-.059.003.542
Cancer cause representationbetaR2p
.092
.005
.413
-.002<.001.983
-.114.007.290
.007<.001.938
Cure/control representationbetaR2p
.034<.001.721
-.221.037.023
-.188.027.043
-.201.032.034
Consequences representationbetaR2p
.228
.019
.106
.245
.017
.122
.345
.043
.010
.199
.010
.227
Timeline representationbetaR2p
-.077.004.479
.004<.001.964
-.192.023.061
-.096.006.355
Emotional representationbetaR2p
.110
.005
.411
.002<.001.991
-.028<.001.823
.224
.014
.165
Block 1 was significant in all models except for problem-focused coping for numbness/tingling.
Multiple linear regression analyses of predictors of coping efforts Emotion-focused coping Problem-focused coping
PainNumbness/
TinglingPain
Numbness/Tingling
PredictorOverall Model
R2
p.219.003
.346<.001
.273<.001
.231
.002
Disease & Personal Characteristics*
Survivorship statusbetaR2p
.025
.003
.807
.049
.002
.596
-.076.004.438
-.044.002.642
Number of symptomsbetaR2p
.310
.050
.009
-.061.002.592
.202
.021
.068
.124
.008
.290
Depression severitybetaR2p
-.098.005.384
.000<.001.999
-.182.032.085
-.096.006.366
OptimismbetaR2p
.065
.003
.508
.163
.020
.092
.163
.020
.079
.108
.009
.260
Representations
Representation BlockR2p
.069
.214.247
<.001.190
<.001.170.002
Symptom severity (Identity representation)
betaR2p
-.006<.001.958
.304
.038
.022
.114
.007
.291
.010<.001.937
Treatment cause representationbetaR2p
-.047.002.612
.238
.043
.015
-.157.020.080
-.059.003.542
Cancer cause representationbetaR2p
.092
.005
.413
-.002<.001.983
-.114.007.290
.007<.001.938
Cure/control representationbetaR2p
.034<.001.721
-.221.037.023
-.188.027.043
-.201.032.034
Consequences representationbetaR2p
.228
.019
.106
.245
.017
.122
.345
.043
.010
.199
.010
.227
Timeline representationbetaR2p
-.077.004.479
.004<.001.964
-.192.023.061
-.096.006.355
Emotional representationbetaR2p
.110
.005
.411
.002<.001.991
-.028<.001.823
.224
.014
.165
Block 1 was significant in all models except for problem-focused coping for numbness/tingling.
Multiple linear regression analyses of predictors of coping efforts Emotion-focused coping Problem-focused coping
PainNumbness/
TinglingPain
Numbness/Tingling
PredictorOverall Model
R2
p.219.003
.346<.001
.273<.001
.231
.002
Disease & Personal Characteristics*
Survivorship statusbetaR2p
.025
.003
.807
.049
.002
.596
-.076.004.438
-.044.002.642
Number of symptomsbetaR2p
.310
.050
.009
-.061.002.592
.202
.021
.068
.124
.008
.290
Depression severitybetaR2p
-.098.005.384
.000<.001.999
-.182.032.085
-.096.006.366
OptimismbetaR2p
.065
.003
.508
.163
.020
.092
.163
.020
.079
.108
.009
.260
Representations
Representation BlockR2p
.069
.214.247
<.001.190
<.001.170.002
Symptom severity (Identity representation)
betaR2p
-.006<.001.958
.304
.038
.022
.114
.007
.291
.010<.001.937
Treatment cause representationbetaR2p
-.047.002.612
.238
.043
.015
-.157.020.080
-.059.003.542
Cancer cause representationbetaR2p
.092
.005
.413
-.002<.001.983
-.114.007.290
.007<.001.938
Cure/control representationbetaR2p
.034<.001.721
-.221.037.023
-.188.027.043
-.201.032.034
Consequences representationbetaR2p
.228
.019
.106
.245
.017
.122
.345
.043
.010
.199
.010
.227
Timeline representationbetaR2p
-.077.004.479
.004<.001.964
-.192.023.061
-.096.006.355
Emotional representationbetaR2p
.110
.005
.411
.002<.001.991
-.028<.001.823
.224
.014
.165
Block 1 was significant in all models except for problem-focused coping for numbness/tingling.
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SummaryRepresentations
• Scores for treatment as cause, cure/control, and timeline were higher (worse) for numbness/tingling than for pain.
• Scores for consequences and emotional response were higher (worse) for pain than for numbness tingling.
Coping
• Managing symptom, planning, seeking emotional support, and expressing emotions were more frequently used for pain than for numbness/tingling,
• Acceptance was the most common strategy used for numbness/tingling.
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Conclusions
•In general, more coping strategies (both emotion- and problem-focused) were used for pain compared to numbness/tingling. •Representations explained more of the variance in coping than disease and personal characteristics. •Perceived control of the symptom was a significant predictor in three of the four models. However, the level of contribution of the other representations varied across models.
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Limitations
• Sample comes from members of an advocacy organization who may differ from the general population.
• Secondary analysis from a 10 year-old dataset.
• Scoring of DCI may not capture the full scope of coping efforts or represent “adaptive” coping.
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Implications• Acceptance, or the belief that nothing can be done
about the symptom, was pervasive for numbness/tingling.
• Assessment of symptom representations may help practitioners identify patients’ concerns about symptoms that may interfere with productive coping efforts.
• Interventions that include efforts to enhance patients’ sense of control over symptoms may improve patients’ coping and ultimately improve other important outcomes.
• Further research is needed to better understand how symptom representations, and their underlying meaning, influence the selection of different types of coping efforts.