Self-efficacy, coping, and difficulties interacting ... - Wiley Online Library

PSYCHO-ONCOLOGY

Psycho-Oncology 14: 901–912 (2005) Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.944

SELF-EFFICACY, COPING, AND DIFFICULTIES INTERACTING WITH HEALTH CARE PROFESSIONALS AMONG WOMEN LIVING WITH BREAST CANCER IN RURAL COMMUNITIES K. COLLIEa,*, P. WONGa, J. TILSTONb, L. D. BUTLERa, J. TURNER-COBBb, M. A. KRESHKAc, R. PARSONSd, K. GRADDYe, J. D. CHEASTYf and C. KOOPMANa a

Stanford University, USA University of Bath, USA c Sierra College, Grass Valley, CA, USA d Sierra Nevada Memorial Cancer Center, Grass Valley, CA, USA e Graddy Graphic Design and Illustration, San Francisco, CA, USA f Brown University, USA b

SUMMARY This study examined self-efficacy, coping, and social support in relation to difficulties interacting with physicians and nurses among women living with breast cancer. One hundred women living in rural, mountainous communities of northeastern California were recruited, with 89 providing complete data for this study. All women completed a battery of questionnaires that included the CARES}Medical Interaction Subscale and measures of self-efficacy, coping, satisfaction with social support, and demographic and medical characteristics. In a multiple regression analysis, difficulties interacting with medical professionals were found to be greater among women who were not married, who used more behavioral disengagement or less self-distraction to cope with breast cancer, and who reported less self-efficacy for affect regulation and for seeking and understanding medical information. Emotional venting and satisfaction with social support for dealing with cancer-related stress were not, however, significantly related to difficulties in interacting with the medical team. This model accounted for an adjusted value of 42% of the variance. Further research is needed to identify possible causal relationships related to these findings and to determine what interventions might be warranted to improve medical interactions for women with breast cancer living in rural areas. Copyright # 2005 John Wiley & Sons, Ltd. KEY WORDS: breast cancer; rural; doctor–patient interaction; self-efficacy; coping; cancer; oncology

INTRODUCTION It is now recognized that medical status is not the only contributing factor in determining disease course, prognosis, and quality of life. Viewed from a biopsychosocial perspective rather than a strictly biomedical model, it is acknowledged that psychosocial factors play a vital role. The quality of patients’ interactions with their health care providers is one such factor. In this community– *Correspondence to: Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA 94305-5718, USA. E-mail: [email protected]

Copyright # 2005 John Wiley & Sons, Ltd.

university partnership study, we examined patient characteristics and behaviors that could have a bearing on patient–provider interaction in a sample of 89 women residing in rural communities in northeastern California who were within three months of initial breast cancer diagnosis or within six months of ending treatment}two time periods during which there may be increased psychosocial distress and need for support and increased risk of post-traumatic-stress-like symptoms (Cordova et al., 1995). Effective patient–provider communication has been shown to be associated with more favorable medical outcomes for patients with chronic diseases (Kaplan et al., 1989), and also with lower Received 18 October 2004 Accepted 29 April 2005

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psychiatric morbidity (anxiety and depression) for people with cancer (e.g. Butow et al., 1996; Lerman et al., 1993), and treatment adherence in a range of patients (Bartlett et al., 1984; DiMatteo et al., 1993; DiMatteo, 2003; Golin et al., 1996; Ong et al., 1995; Stewart, 1984). Problematic patient–provider communication has been associated with poor role, social, and emotional functioning and with poor overall quality of life in patients with rectal cancer for at least 3 years (Kerr et al., 2003). Engel et al. (2003) found quality of communication with physicians to be the second greatest predictor of quality of life for 990 breast cancer patients surveyed over five years, and negative experiences in doctor–patient relationships have been associated with impaired adjustment and more problematic coping for women with breast cancer (Alder and Bitzer, 2003). Poor doctor– patient communication and problems interacting with medical providers have been associated with higher levels of distress, anxiety, depression, anger, confusion, and cancer-related traumatic stress and with lower emotional self-efficacy for cancer on the part of women with breast cancer (Han et al., 2005; Jones and Greenwood, 1994; Lerman et al., 1993). While early research about patient–provider interaction focused mainly on the effect of physicians’ communication styles, more recent research has taken a patient-centered approach and has examined factors pertaining to both patients and providers (e.g. Kidd et al., 2004; Tran et al., 2004), reflecting a move toward a model of greater patient involvement in medical decision-making (Gafni et al., 1998). Research has shown that many patients wish to be actively involved in their care and value information exchange (e.g. Dowsett et al., 2000; Koike et al., 1997). Women with breast cancer have a great need for information about such issues as treatment options, the possibility of recurrence, chances of cure, and impact on family members (Blanchard et al., 1988; Cassileth et al., 1980; Hall and Dornan, 1990; Harris and Templeton, 2001; Raupach and Hiller, 2002). Participatory interactions with physicians have been found to be preferable to most women with breast cancer (Degner et al., 1997; Rothenbacher et al., 1997) and to predict better adjustment with respect to work, attitudes towards the future, self-efficacy, and both physical and psychological functioning (Morris and Ingham, 1988).


It is important to understand what factors may promote or inhibit successful interactions with medical professionals for women with breast cancer. This issue has particular relevance for women living in rural areas, who may find it harder than their urban counterparts to get access to information they need because of social isolation, the risk of stigma in small communities, scarcity of providers, poverty, inadequate transportation, and geographic distances between patients and providers (DeLeon et al., 2003; Gray et al., 2004; Kenkel, 2003; Wilson et al., 2000). In rural northeastern California where this study was conducted, this problem is exacerbated by mountainous terrain, exceptionally sparse population, and severe winter weather. The parent study from which the data for the present study were drawn was a response to the lack of readily available psychosocial and informational support for women with breast cancer living in a remote and rural area (see description below). The study illustrates how members of rural communities may mobilize resources in innovative and creative ways to meet local needs and compensate for the lack of resources that are more available in urban areas. The present study was an effort to maximize the value of available resources and help women with breast cancer living in rural areas get the most out of their interactions with their healthcare providers. In this study, we explored the possibility that for women with breast cancer living in rural areas certain patient characteristics might be related to problems interacting with nurses and physicians. Specifically, we examined relationships between problems with medical interactions and selfefficacy for coping with cancer, coping strategies, and satisfaction with social support. Self-efficacy for coping with cancer We hypothesized that, with respect to selfefficacy for coping with cancer, affect regulation and seeking and understanding medical information would be the dimensions most likely to be related to problems with medical interactions for this sample. We predicted that women with higher self-efficacy in both these domains would report fewer problems in their interactions with their nurses and physicians. Good affect regulation (i.e. the ability to express both negative and positive emotions) is regarded

Psycho-Oncology 14: 901–912 (2005)

BREAST CANCER AND MEDICAL INTERACTIONS

as a positive characteristic for cancer patients (Giese-Davis et al., 2002). Emotional expression, an aspect of affect regulation, has been found to predict fewer medical appointments for cancerrelated morbidities, enhanced physical health and vigor, and decreased distress during the next 3 months for women with breast cancer compared with those low in emotional expression (Stanton et al., 2000). Women with higher selfefficacy for affect regulation may be more successful in expressing their feelings during medical encounters, and therefore find them more emotionally satisfying and associated with fewer difficulties. Within the informed treatment decision-making model (Gafni et al., 1998), patients’ seeking and understanding of medical information is a crucial part of information sharing between medical professionals and patients and is an aspect of self-efficacy that may be improved as a consequence of good patient–provider communication (Zachariae et al., 2003). Women who feel more confident about their ability to seek and understand medical information may be more successful at obtaining the information they need and may, therefore, describe their medical interactions as less problematic. Use of coping strategies Previous research has found associations between coping style and problems communicating with healthcare providers (Lerman et al., 1993). We predicted that coping with cancer by means of behavioral disengagement, self-distraction, or venting of emotions would be associated with more problems in medical interactions. Behavioral disengagement can result in a reduction of the effort a person invests in dealing with a stressor and can involve withdrawal and avoidance of contact with others. Avoidance of this type has been associated with negative medical outcomes longitudinally for men and women with cancer (Epping-Jordan et al., 1994). Because women who use the coping strategy of behavioral disengagement may put less effort into ensuring the success of their medical encounters, they are likely to have less successful encounters and report more problems. Mental disengagement in the form of selfdistraction is characterized by such things as daydreaming and sleeping to separate oneself from


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a stressor (Carver, 1997) and has been shown to be related to increased risk of traumatic stress (e.g. Silver et al., 2002). Women with breast cancer who use this coping strategy may find it difficult to focus their attention during medical encounters or to be proactive in asking for the information and help they need. Consequently, they may perceive their medical encounters as more problematic. Although affect regulation and the expression of a range of emotions are considered to be beneficial for women with breast cancer, excessive negative emotional expression, or venting, has not been associated with positive outcomes in previous cancer research (Culver et al., 2002). In fact, venting has been associated with higher distress for women with breast cancer (Angell et al., 2003). Venting may impede both communication and relationship development, and therefore women who use this coping strategy may have difficulties communicating with their nurses and physicians and find their medical interactions to be more problematic. Social support The literature connecting greater social support to better physical and psychosocial health outcomes is extensive (e.g. Berkman and Syme, 1979; Cobb, 1976; Cohen, 1988; Koopman et al., 2001; Levy et al., 1990; Moyer and Salovey, 1999; Neuling and Winefield, 1988; Sormanti and Kayser, 2000; Turner-Cobb et al., 2000; Wallston et al., 1983). In rural areas, geographical distance and the possibility of stigma within the community may severely limit the availability of social support following a breast cancer diagnosis. Nurses and physicians may be more important sources of social support than for women with breast cancer living in urban areas. Women who experience less satisfying social support from their families and friends for stressors pertaining to breast cancer may be particularly sensitive to the quality of social support they receive from medical professionals. Therefore, we predicted that women who rated themselves as having more satisfactory social support for coping with the stresses of breast cancer would be less likely to report difficulties in their medical interactions because they would be less concerned about receiving social support from their nurses and physicians.


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METHODS Participants Data for this study come from a larger study investigating the effectiveness of a workbookjournal intervention to help women in rural northeastern California (USA) cope with living with breast cancer (Angell et al., 2003; Koopman et al., 1999). The idea for the intervention emerged from discussions in a local breast cancer support group, in response to the lack of psychosocial services available to women with breast cancer in this sparsely populated mountainous region. The workbook-journal was created by one breast cancer survivor working in close consultation with other breast cancer survivors, a graphic artist, and psychosocial oncology researchers at a major medical research center. The participants in the parent study were 100 women with biopsy-confirmed primary breast cancer (Stage 0–III, including ductal carcinoma in situ [DCIS]) residing in seven rural counties in northeastern California. Participants were included in the study if they met the following criteria: (1) they did not have any other lifethreatening illness, (2) they were over the age of 18, (3) they gave informed consent, and (4) they were either within 3 months of initial diagnosis or within 3 months of ending treatment (this last inclusion criterion was changed during recruitment to within 3 months of diagnosis or within 6 months of ending treatment based on feedback from community members of the research team). Inclusion in the current study required that participants complete all measures. Consequently, 11 of the original 100 participants were excluded from the present analyses due to missing data, resulting in 89 participants. There were no systematic differences between the 89 women who were included and the 11 women who were excluded. The women ranged in age from 31 to 82 (M ¼ 58:2, S:D: ¼ 11:7). The sample was predominantly European American (89%), with 5% Native American, 2% Asian American, 1% African American, 1% Latina/Hispanic, and 1% other ethnicity. Additional demographic and medical characteristics of the 89 women are presented in Table 1. About one quarter of the sample (26.1%) lived in rural towns or cities (i.e. with populations of less than 10 000); 10.2% within 1 mile of a town or city, 31.8% within 5


Table 1. Characteristics of the sample: women with breast cancer (N=89) Characteristic

%

Sociodemographics Marriage Yes Employment status Not employed Part time Full time Educational level High school or less Some college or higher Total household income before taxes Less than $20 000 $20 000–$39 999 $40 000–$79 999 $80 000 and above Don’t know or refuse to answer Medical factors Had reconstructive surgery Treatments received Mastectomy Chemotherapy Hormone therapy Radiation

67.4 55.2 19.5 25.3 18.0 72.0 16.9 20.4 31.3 15.6 15.6

6.7 44.9 51.8 48.7 65.4

miles, 19.3% within 10 miles, 10.2% within 20 miles, and 2.3% within 50 miles of a town or city. The distances the women had to travel to reach an oncologist/surgeon were as follows: more than 51 miles 11.9%, 21–51 miles 21.4%, 6–20 miles 29.8%, 5 miles or less 36.9%. Most of the women (83.0%) reported having at least one child. They received a variety of breast cancer treatments: 44.9% had mastectomies, 51.8% had chemotherapy, 65.4% had radiation, and 48.7% had hormone therapy. Procedure The participants for the parent study were recruited from Sierra Nevada Cancer Center (SNCC); rural community-based support groups; and medical, surgical, and radiation oncology private practices in the Sierra Foothills of California. Each eligible woman treated at SNCC was contacted in person by a clinical social worker who routinely visited breast cancer patients to assess their needs for services. She explained the study to each woman and invited each one to participate.



Women who were undecided were asked for their permission to be contacted again later. Ninety percent of those approached agreed to participate ðn ¼ 68Þ. Recruitment from breast cancer support groups was done in person by community members of the research team. All the women who were invited this way agreed to participate ðn ¼ 9Þ. Recruitment through private practices was initiated by the clinical social worker, a registered nurse, or a local breast cancer advocate, who gave presentations outlining the study to physicians and staff members and asked for referrals. Physicians and staff at all the practices that were approached agreed to refer women to the study and to display recruitment materials. Sixty-four percent of the women who were referred through private practices were enrolled in the study ðn ¼ 23Þ. Informed consent was obtained at the time of enrollment. Baseline data were collected from questionnaires the women filled out either in private rooms in the cancer treatment center or in their homes. Only baseline data were used in this study to preclude any effects of the intervention that was the focus of the parent study. (For a complete description of the parent study procedures see Angell et al., 2003.) Measures: dependent variable The CARES}Medical Interaction Subscale was used to assess participants’ problems interacting and communicating with their doctors and nurses. This is an 11-item subscale of the Cancer Rehabilitation Evaluation System (CARES) (Schag and Heinrich, 1989), which was derived from the Cancer Inventory of Problem Situations (Heinrich et al., 1984). This measure was chosen because it specifically assesses whether or not patients experience problems in their interactions with their nurses and doctors, including problems related to information seeking. Participants were asked to rate on a 5-point Likert scale (a) the degree to which they felt they had problems obtaining information from their doctors and nurses, (b) difficulty communicating with the medical team, and (c) control of the medical team. The specific items were: ‘I find that the medical team withholds information from me about the cancer,’ ‘I find that doctors (nurses) don’t explain what they are doing to me,’ ‘I have difficulty asking doctors (nurses) questions,’ ‘I have difficulty expressing my feelings to doctors


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and nurses,’ ‘I have difficulty telling my doctor about new symptoms,’ ‘I have difficulty understanding what the doctors (nurses) tell me about the cancer or its treatments,’ and ‘I would like to have more control over what the doctors (nurses) do to me.’ When the scores are summed, higher scores indicate more problems. The CARES}Medical Interaction Scale is widely used in clinical and research settings because it is cost-effective and easy to use. It has been shown to be a reliable, valid, and internally consistent instrument (Schag and Heinrich, 1990). It assesses problems specific to medical interactions and reflects cancer patients’ actual experiences in a patient-sensitive way. This measure showed adequate internal consistency with the current study sample, Cronbach’s alpha=0.70. Measures: independent variables The Cancer Behavior Inventory (CBI) is a 51item self-report scale that measures self-efficacy for coping with cancer (Merluzzi and Martinez Sanchez, 1997). Self-efficacy refers to confidence about one’s ability to meet the challenges of a particular stressor, regardless of actual skills or previous experiences. Those low in self-efficacy may feel overwhelmed by the stressor (Bandura, 1982). Although the CBI contains 6 subscales, the present study focused on the two that we hypothesized would be related to difficulties in interacting with physicians and nurses: self-efficacy for seeking and understanding medical information and self-efficacy for affect regulation, each of which was measured with 7 items. Self-efficacy for seeking and understanding medical information includes confidence about seeking information about cancer or cancer treatment and actively participating in treatment decisions. Self-efficacy for affect regulation includes confidence about expressing negative feelings about cancer and about denying, escaping, and ignoring strong negative psychological states. It measures flexibility to deny and escape or to express negative emotions, depending on the situation. The participants designated confidence levels for each item on a scale from 1 (‘Not confident at all’) to 9 (‘Totally confident’). For each subscale, the total score was computed by summing the responses to the items comprising the subscale. This measure has demonstrated good internal consistency and validity. In a sample of cancer patients, the


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Cronbach’s alphas for affect regulation and for seeking and understanding medical information and were 0.75 and 0.88, respectively (Merluzzi and Martinez Sanchez, 1997). The COPE (Carver et al., 1989) is a 60-item measure that examines a variety of conceptually distinct coping strategies. For the present study only subscales assessing the following three types of potentially dysfunctional coping were used: venting of emotions (e.g. ‘I’ve been expressing my negative feelings’), behavioral disengagement (e.g. ‘I’ve been giving up the attempt to cope’), and selfdistraction (e.g. ‘I’ve been doing something to think less about it, such as going to the movies, watching TV, reading, daydreaming, sleeping, or shopping’). Responses were given on a Likert scale ranging from 1 (‘I don’t usually do this at all’) to 4 (‘I usually do this a lot’). Each was measured with four items. The internal consistency for this sample was adequate with Cronbach’s alphas as follows: Venting=0.61; Behavioral Disengagement=0.55; Self-distraction=0.47. The UCLA Social Support Inventory (Schwarzer et al., 1994) was used to assess availability of and satisfaction with three types of social support (information and advice, instrumental assistance, and encouragement and reassurance) from four sources (friends, relatives, partner, and groups or organizations). This instrument measures the quality of social support with regard to a particular stressful situation, in this case cancer. A sample item reads: ‘In general, how satisfied or dissatisfied have you been with all the information and advice you have received about your cancerrelated stress?’ Satisfaction is rated on a scale ranging from 1 (‘Very Dissatisfied’) to 7 (‘Very Satisfied’). This measure has demonstrated good test-retest reliability, and validity across differentiated dimensions of social support (Schwarzer et al., 1994). It showed good internal consistency with the current sample, Cronbach’s alpha=0.82. Data analysis Descriptive statistics for the dependent variable (difficulties interacting with nurses and physicians) and 6 independent variables (self-efficacy for seeking and understanding medical information, self-efficacy for affect regulation, use of behavioral disengagement, use of self-distraction, use of venting, and satisfaction with social support) were compiled. We explored demographic and medical


characteristics in relation to the CARES scores to see whether we needed to include any of them in our model. The demographic characteristics that were explored were age, current marital status, number of children, ethnicity, religion, sexual orientation, education, employment status, total household income, distance from nearest town/ city, and distance from oncologist/surgeon. The medical characteristics were stage of disease, number of months since diagnosis, and type of treatment. Pearson’s product–moment correlations were computed to examine the relationships between the demographic/medical variables that were continuously distributed and the dependent variable (e.g. the relationship of age to the CARES}Medical Interaction Subscale score), to explore which demographic and medical variables should be included in the regression analysis to test the hypotheses. Marital status (married or not) was the only demographic or medical variable that was significantly related to the CARES scores ðr ¼ 0:25; p50:05Þ, so it was entered in the first block of a hierarchical multiple regression analysis to statistically control for it in the regression model with the CARES}Medical Interaction Subscale total score as the dependent variable. Scores on the measures of the independent variables hypothesized to be related to the CARES}Medical Interaction Subscale score were included in a second block, with simultaneous entry of variables.

RESULTS Predictors of perceived difficulties in medical interactions Table 2 shows the means and standard deviations of the psychosocial characteristics of the sample. As shown by the ranges of scores and standard deviations, these measures elicited sufficient variance to address the hypotheses. Table 3 presents the zero-order correlation coefficients among the self-efficacy, coping, and social support variables. Although a number of the variables were moderately correlated with one another, no strong correlations were found among these variables, further supporting the inclusion of these variables in the regression model. Table 4 presents the results of the multiple regression analysis. As indicated in the first block,


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married women were less likely to experience difficulties interacting with health care professionals, with this variable explaining 5% of the variance in difficulties in communicating with health care professionals, Fð1; 88Þ ¼ 5:74; p50:05. Adding the psychosocial variables to marital status created a model that explained 42% of the variance in scores on the CARES}Medical Interaction Subscale, Fð7; 88Þ ¼ 10:20; p50:001. Thus, adding the psychosocial variables to the model explained an additional 37% of the variance in these scores after accounting for marital status. As hypothesized, women who reported greater difficulties in their medical interactions reported more frequent use of behavioral disengagement to cope with their breast cancer, lower self-efficacy for seeking and understanding medical information, and lower self-efficacy for affect regulation. Contrary to our hypothesis, women who made greater use of self-distraction to cope with their cancer were significantly less likely to report difficulties with their medical interactions. Venting

Table 2. Means and standard deviations of self-efficacy, coping, and social support variables (N=89) Psychosocial variable

Mean S.D. Min Max

Cancer Behavior Inventory (CBI) 1. Self-efficacy for seeking and 41.1 understanding medical information 2. Self-efficacy for affect regulation 34.1 Brief COPE 1. Behavioral disengagement 2. Self-distraction 3. Venting emotions UCLA Social Support Inventory Satisfaction with social support

emotions and satisfaction with social support were not significantly related to women’s reports of difficulties in interacting with their medical team in this sample. DISCUSSION The association between higher self-efficacy for seeking and understanding medical information and fewer problems with medical interactions is consistent with self-efficacy theory, which posits that a higher expectation of oneself increases the

Table 4. Psychosocial variables examined in relation to difficulties communicating with doctors and nurses (N=89) Difficulties communicating with health care professionals Variable Model 1 Marriage status Model 2 Marriage status

B

SEB

0.24

0.10

0.25

0.30

0.08

0.31

Cancer Behavior Inventory (CBI) Seeking and understanding 0.13 medical information Affect regulation 0.08

0.04

0.33

0.02

0.32

5.7

12.5 45.0

9.1

5.0 45.0

Brief COPE Behavioral disengagement Self-distraction Venting emotions

0.06 0.04 0.02

0.02 0.02 0.02

0.24 0.21 0.12

5.2 7.8 7.8

1.8 2.5 2.2

4 4 4

UCLA Social Support Inventory 0.01

0.04

0.03

5.7

1.2

1.0

12 15 14 7.0

2

Note: Adjusted R =0.05 for Model 1 and adjusted R2=0.42 for Model 2. p50.05. p40.001.

Table 3. Pearson’s correlation coefficients among the self-efficacy, coping, and social support variables (N=89) Variable

1

2

3

4

5

1. 2. 3. 4. 5. 6.

} 0.36 0.17 0.15 0.08 0.36

} 0.09 0.02 0.15 0.29

} 0.22 0.41 0.25

} 0.29 0.14

} 0.01

Seeking and understanding medical information Affect regulation Behavioral disengagement Self-distraction Venting emotions Satisfaction with social support

p5 0.05. p5 0.01.



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chance that a desired goal will be attained (Bandura, 1982). The women who felt confident about seeking and understanding medical information probably were more successful at getting the information they wanted and therefore could report their medical interactions as being less problematic. However, because the measures were administered at the same time, interpretations of causality between self-efficacy and difficulty in medical interactions cannot be made with confidence. Problematic medical interactions may have decreased efficacy expectations. Additionally, it is possible that health professionals with better communication skills facilitated and reinforced better communication in their patients resulting in both less problematic medical encounters and greater self-efficacy. Nonetheless, patients’ ability to seek and understand medical information is an aspect of medical communication that clinicians can readily improve by encouraging questions and double-checking understanding. Higher self-efficacy for affect regulation was also associated with less problematic medical encounters. Women who rated themselves as confidently being able to express or manage negative feelings reported fewer problems in their interactions with their nurses and physicians. This is in keeping with previous research that has found that those high in self-efficacy for affect regulation are less likely to be resigned and therefore more likely to be proactive (Merluzzi and Martinez Sanchez, 1997). Again, causality cannot be assumed. It is possible that unproblematic medical encounters favor emotional self-efficacy for breast cancer. As hypothesized, behavioral disengagement was associated with more problematic interactions with health care professionals. It is likely that the women who were using avoidant coping responses, such as ‘giving up dealing with it’ and ‘giving up attempts to cope’ did not put much effort into ensuring the success of their medical interactions. It is also possible that problematic medical encounters fostered behavioral disengagement on the part of the participants. Given that avoidant coping has been related to poorer disease status longitudinally (Epping-Jordan et al., 1994), as well as to problematic medical encounters, both possible causal directions should be examined in future research. In the meantime, clinicians should consider the lack of active engagement during medical encounters as a possible indication of problems in the patient–provider relationship.


Contrary to our hypothesis, women who scored higher on the self-distraction subscale of the coping measure were less likely to report difficulties interacting with their health care providers. It may be that the women who were adept at selfdistraction were less subject to intrusive or upsetting thoughts during their medical encounters and more able to both give their full attention and avoid getting upset while discussing potentially upsetting topics. Interestingly, in the correlational analyses, self-distraction was not found to be related to women’s self-efficacy to regulate their affect, suggesting that self-distraction may have been helpful in ways that are not tapped by selfefficacy for regulating affect. Although self-distraction is frequently regarded as a maladaptive coping strategy with regard to chronic illness (Culver et al., 2002; Koopman et al., 2000), it may sometimes function as an active and constructive coping strategy. Whether self-distraction is an adaptive or maladaptive strategy may depend on context and prognosis. It may be a positive strategy in the short term when affective states could be overwhelming. Culver et al. (2002) found self-distraction to be positively related to distress in women with cancer following surgery but not pre-surgery. The women in this study were experiencing a primary incidence of breast cancer rather than a chronic or terminal prognosis. Previous research with more minor, acute illness has found cognitive avoidance coping styles to be linked to more favorable health outcomes (e.g. Turner-Cobb and Steptoe, 1996). It is also possible that problematic medical encounters prevent women from using self-distraction as a coping strategy. Our analyses failed to demonstrate two hypothesized relationships. In this sample, the use of venting of emotions as a strategy for coping with the stresses of cancer was not significantly related to problems in medical interactions. Venting of emotions has been associated with higher levels of distress in past cancer research, but only at certain time points (Culver et al., 2002), which suggests that further exploration of venting as a coping strategy at different time points is warranted. Satisfaction with social support also was not associated with problems in medical interactions. Two possible explanations for this should be considered. First, it is possible that women who lack adequate support from their social environments do not in turn seek it from their health care providers. Although physicians and nurses are a



potential source of social support for women with breast cancer, women may not expect to receive certain types of social support from medical professionals. They may expect to receive informational support from nurses and physicians and other kinds of support from other sources such as community organizations and clergy. Previous research has shown that people with cancer may have specific expectations about what kinds of support (e.g. emotional, instrumental, informational) they would like to receive from healthcare providers versus friends and family (e.g. Dakof and Taylor, 1990; Dunkel-Schetter, 1984). Future research could investigate whether these expectations differ in rural and urban settings. Another possible explanation for the lack of an association between satisfaction with social support and difficulties in medical interactions in our analyses is that because social support is a complex construct, involving specific unsupportive and supportive elements, our assessment did not tap into women’s true experiences of their support network. Unsupportive interactions have been associated with decreased social functioning for women with breast cancer (Figueiredo et al., 2004). If friends and family continually minimize the patient’s experience, she may feel inhibited in voicing her concerns to health care professionals or in evaluating the quality of such interactions. Future research should focus on the relationship between more specific aspects of the quality of social support and problems in medical interactions for this population. Although general satisfaction with social support was not found to be related to difficulties interacting with health care professionals, we did find that a related variable}marital status}was, with those who were married reporting fewer difficulties. This suggests that interactions between married women and their medical providers in rural areas may benefit from the women’s interdependence with their partners. Partners may assist women in their communication with health care professionals by providing a back up when being provided with information or by providing emotional support that reduces the anxiety women may experience in hospital environments. This is consistent with previous research in which being married has been associated with positive health outcomes for older women with breast cancer (Silliman et al., 1998). This study makes an important contribution to the understanding and the improvement of psy-


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chosocial dimensions of breast cancer care because of its focus on the experiences of women with breast cancer who live in rural areas. The most significant limitation of this study is that the sample was primarily white European American in ethnicity, which reduces the generalizability to other rural populations. Different ethnicities may be faced with different challenges with respect to medical interactions. For example, one study found that Hispanic (non-rural) women reported the highest levels of self-distraction and venting compared to rural African Americans, Hispanic, and non-Hispanic white women during treatment for early stage breast cancer (Culver et al., 2002). Research is needed that addresses the isolation and the more general communication difficulties (language as well as cultural) that women with breast cancer of different ethnicities who move to a rural area are likely to experience, and that may have an impact on their medical interactions. Other limitations are the lack of an urban comparison sample and the lack of information about the health care providers’ views of the medical interactions in question. The results of this study pertain to women with breast cancer living in rural areas, but without a comparison with a similar sample of women with breast cancer living in urban areas, we cannot say that the results are specific to women living in rural areas. Further research is needed to determine to what extent the associations found in this study would also apply to women with breast cancer who live in urban areas. Although it is of utmost importance to hear directly from women with breast cancer about their medical interactions, efforts to improve the quality of these interactions require the perspectives of both patients and providers as well as information about the nature and style of the interactions. Further research is needed to obtain a more comprehensive picture of medical interactions involving women with breast cancer who live in rural areas. In the present study, interactions with nurses and physicians were considered together and no differentiation was made between different types of medical teams (e.g. surgical or oncological) or between different types of medical setting (e.g. primary care provider, hospital, specialist service, community nursing service). The associations between patient characteristics and problems with medical interactions that were revealed in this study could be clarified by asking women with breast cancer to report on their interactions with


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specific members of their medical teams or on interactions in a specific setting. For example, they could be asked to fill out separate CARES}Medical Interaction Subscales for their oncology team and their surgical team and/or for their nurses and their physicians and/or for different settings where they had received treatment. It would be useful to know if the quality of patient–provider interactions varied according to treatment setting (e.g. cancer center or private practice clinic); if procedural and structural differences between settings (e.g. average amount of waiting time, physical characteristics of the facility) are likely to be associated with problems with medical interactions; and if the distance a woman travels to receive care has a bearing on whether or not she is likely to have problems with her medical interactions. Although we collected data about proximity to specialist care, it was beyond the scope of this study to investigate whether access to medical services was related to problems interacting with nurses and physicians. Another limitation of this study was that because we examined six psychosocial variables in the statistical regression model}as well as the additional demographic characteristic of whether or not women were married, it is possible that the sample size of 89 women did not provide sufficient statistical power to detect some significant relationships. For example, if there was a small but real relationship between venting emotions and the difficulties in interacting with health care professionals, this sample size may not have been adequate to detect it. The response rate for this study was very high so it is not likely that the results of the analysis were strongly affected by sample bias. However, it is possible that women who did not participate in the study would have reported different types and levels of problems with their medical interactions than those who participated or that there would have been differences in non-participants’ selfefficacy, coping styles, and satisfaction with social support that could have affected the results. Future research is needed to uncover causal relationships implied by the results of this study. For example, an intervention to enhance positive coping strategies among rural women with breast cancer could be developed and tested with problems in medical interactions as an outcome. A longitudinal study could extend the results of the present study by examining if and how patient characteristics might affect medical interactions


over time. Additionally, future research could examine whether and how the qualities of the health care professionals themselves, such as communication skills and self-efficacy, interact with patient characteristics to contribute to difficulties in medical interactions. In sum, we found in this cross-sectional study that self-efficacy for seeking and understanding medical information, self-efficacy for affective regulation, self-distraction, and being married were each negatively related to problems in medical interactions, while behavioral disengagement showed the opposite relationship. Care for women with cancer in rural areas would benefit from further research into whether these relationships exist causally, in order to develop effective interventions. Future research should include women from minority groups, as they may have the most to gain from interventions aimed at improving self-efficacy, coping, and the quality of medical interactions in rural settings.

ACKNOWLEDGEMENTS This project was supported by a Community-Initiated Research Collaboration award from the California Breast Cancer Research Program #3AB-1301 to Ms Kreshka and Dr Koopman. We also wish to express our appreciation to the Sierra Nevada Memorial Cancer Center, to Drs William A. Newsom, Jr, David Campbell, Steven Wahlen, Janine Giese-Davis, Karyn Angell, Cristiane Bertuol, and David Spiegel, and to the women who participated in the study, Xin-Hua Chen, Patricia Donnelly, Ayse Turkseven, the La Loba breast cancer support group, and three anonymous reviewers.

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