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UBC Theses and Dissertations

Continuity of care : a study of alternate forms of intervention Doll, Richard P. 1987

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CONTINUITY OF CARE: A STUDY OF ALTERNATE FORMS OF INTERVENTION By RICHARD P. DOLL M . S . W . , U n i v e r s i t y o f T o r o n t o , 1979 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE i n THE FACULTY OF GRADUATE STUDIES ( H e a l t h S e r v i c e s P l a n n i n g and A d m i n i s t r a t i o n ) We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA NOVEMBER 1987 R i c h a r d D o l l , 1987 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Af^JUi C/t^£. £/L^Q*«J*&&pf The University of British Columbia 1956 Main Mall Vancouver, Canada V6T 1 Y 3 Date QCrT*>^ S,f?0? A b s t r a c t The aim o f t h i s s t u d y i s t o d e t e r m i n e t h e e f f e c t o f two approaches o f s o c i a l work i n t e r v e n t i o n , a c o n t i n u i t y a p p r o a c h , and a team a p p r o a c h , upon t h e t h r e e dependent v a r i a b l e s o f s u b j e c t s a t i s f a c t i o n , c o n t r o l , and mood. In o r d e r t o d e t e r m i n e d i f f e r e n c e s i n outcome, s u b j e c t s were a d m i n i s t e r e d p s y c h o l o g i c a l t e s t s t o d e t e r m i n e changes i n t h e i r r e p o r t e d sense o f c o n t r o l and mood ( h o p e l e s s n e s s ) i n r e l a t i o n t o t h e i r r e s p o n s e t o t h e d i a g n o s i s and t r e a t m e n t o f c a n c e r . At f o l l o w - u p , s u b j e c t s a l s o c o m p l e t e d a q u e s t i o n n a i r e d e s i g n e d t o d e t e r m i n e t h e i r s a t i s f a c t i o n w i t h s o c i a l work s e r v i c e s r e c e i v e d . The amount o f t i m e s p e n t i n c o n t a c t w i t h s o c i a l w o r k e r s was a l s o a s s e s s e d at t h i s t i m e . The a n a l y s i s o f t h e r e l a t i o n s h i p between t h e s e v a r i a b l e s r e v e a l e d t h a t t h e r e were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between t h e s t u d y g r o u p s ; s u b j e c t s were e q u a l l y s a t i s f i e d w i t h t h e two approaches i n s o c i a l work i n t e r v e n t i o n , and t h e r e were no major d i f f e r e n c e s between t h e r e p o r t e d changes i n mood and c o n t r o l by t h e s u b j e c t s i n t h e s t u d y g r o u p s . i i TABLE OF CONTENTS Page A b s t r a c t i i T a b l e o f C o n t e n t s i i i L i s t o f T a b l e s v i Acknowledgements v i i C h a p t e r 1 : INTRODUCTION AND REVIEW OF CURRENT KNOWLEDGE Impact o f P s y c h o s o c i a l I s s u e s i n C a n c e r 1 C o n t i n u i t y o f Care 3 Team Approach t o Care . 7 P a t i e n t S a t i s f a c t i o n . . . . . . 8 H e a l t h Locus o f C o n t r o l 11 H o p e l e s s n e s s 13 i i i C h a p t e r 2 : METHODOLOGY O b j e c t i v e s 14 P r o t o c o l 14 C o n t r o l Group 15 Hypotheses 16 Study S e t t i n g 16 Study Sample 16 Data C o l l e c t i o n 18 E t h i c a l C o n s i d e r a t i o n s 19 Study I n s t r u m e n t s : H o p e l e s s n e s s S c a l e 20 H e a l t h Locus o f C o n t r o l 20 P a t i e n t S a t i s f a c t i o n 21 Data A n a l y s i s 21 I n t e r v e n t i o n 22 i v C h a p t e r 3 : PRESENTATION OF RESULTS I n t r o d u c t i o n 25 C o n t r o l V a r i a b l e s 31 M a j o r Study F i n d i n g s 33 A d d i t i o n a l A n a l y s i s 36 CHAPTER 4 D i s c u s s i o n 40 Recommendation f o r F u r t h e r S t u d y : A c c r u a l 42 I n s t r u m e n t s 43 Treatment I n t e r v e n t i o n 44 Summary 45 B i b l i o g r a p h y Appendix I L e t t e r o f Consent Appendix I I H o p e l e s s n e s s S c a l e Appendix I I I H e a l t h Locus o f C o n t r o l Appendix IV P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e v LIST OF TABLES TABLE 1 TABLE 2 TABLE 3 TABLE 4 TABLE 5 TABLE 6 TABLE 7 TABLE 8 TABLE 9 TABLE 10 TABLE 11 TABLE 12 Page C a t e g o r y o f Returned Q u e s t i o n n a i r e 26 C h a r a c t e r i s t i c s o f S u b j e c t s C o m p l e t i n g 27 Q u e s t i o n n a i r e s at Time 1 D i s t r i b u t i o n o f S u b j e c t s Among Treatment 28 Groups by Age, Gender, M a r i t a l S t a t u s and D i s e a s e S i t e D i f f e r e n c e s Among Age Groups on 29 Mood and C o n t r o l D i f f e r e n c e s Between Cancer S i t e s i n 30 Mood and C o n t r o l D i s t r i b u t i o n o f C h a r a c t e r i s t i c s A g e , Gender, 32 M a r i t a l S t a t u s , and D i s e a s e S i t e by C o m p l e t i o n S t a t u s D i f f e r e n c e Among Treatment Groups on S u b j e c t 33 S a t i s f a c t i o n D i f f e r e n c e s Among Treatment Groups Over Time 34 on Mood and C o n t r o l D i f f e r e n c e s Among Treatment Groups on Mood 36 and C o n t r o l D i f f e r e n c e Among Treatment Groups Over 37 Time on Mood D i f f e r e n c e Between M a r i t a l S t a t u s on 38 S u b j e c t S a t i s f a c t i o n D i f f e r e n c e Between M a r i t a l S t a t u s on 39 Mood and C o n t r o l vi ACKNOWLEDGEMENTS I g r a t e f u l l y acknowledge t h e a s s i s t a n c e p r o v i d e d t o me by a number o f i n d i v i d u a l s . I would l i k e t o r e c o g n i z e my committee c h a i r m a n , D r . Robert Modrow, f o r h i s d i r e c t i o n and s u p p o r t . My two o t h e r committee members a r e a l s o d e s e r v i n g o f s p e c i a l m e n t i o n . D r . D a v i d C r o c k e t t s p e n t c o n s i d e r a b l e t i m e p r o v i d i n g d i r e c t i o n i n t h e s t a t i s t i c a l and computer a n a l y s i s o f t h i s t h e s i s and D r . Greg H i s l o p , made i n v a l u a b l e c o n t r i b u t i o n s t o my u n d e r s t a n d i n g o f t h e c o n t e x t and t h e development o f t h e s t u d y . I would l i k e t o thank Ms. B a r b a r a F i d d l e r f o r her s k i l l and p a t i e n c e i n p r o d u c i n g t h i s m a n u s c r i p t . F i n a l l y , t o my p a r t n e r , A d e l e , and our c h i l d r e n Graham and E l l e n who have s u p p o r t e d me t h r o u g h o u t my s t u d i e s . v i i CHAPTER 1 INTRODUCTION AND REVIEW OF CURRENT KNOWLEDGE Impact o f P s y c h o s o c i a l I s s u e s i n Cancer Cancer remains as a major d i s e a s e a f f e c t i n g N o r t h A m e r i c a n s , and i n B r i t i s h C o l u m b i a i t i s t h e second l e a d i n g cause o f d e a t h . In Western Canada, t h e p r o b a b i l i t y o f d e v e l o p i n g c a n c e r i s now a p p r o x i m a t e l y one i n t h r e e and as many as one i n f i v e c o u l d d i e from t h e d i s e a s e . ( M c B r i d e and G a l l a g h e r , 1987). The p s y c h o s o c i a l m a n i f e s t a t i o n s o f c a n c e r have been e x h a u s t i v e l y s t u d i e d and i t i s c l e a r t h a t c a n c e r p a t i e n t s and t h e i r f a m i l i e s are s i g n i f i c a n t l y a f f e c t e d by t h i s d i s e a s e . T e l c h (1986) r e p o r t e d t h a t a h i g h p r o p o r t i o n o f c a n c e r p a t i e n t s e x p e r i e n c e d d i f f i c u l t y a d j u s t i n g t o t h e i r i l l n e s s , and both Maguire (1978) and G r e e r ( 1 9 8 0 ) , s u g g e s t e d t h a t many o f t h e s e d i f f i c u l t i e s were e n d u r i n g . E s t i m a t e s o f t h e p r e v a l e n c e and s i g n i f i c a n c e o f p s y c h o l o g i c a l and s o c i a l d i s r u p t i o n s t h a t r e s u l t from c a n c e r are u n e q u i v o c a l . For t h i s r e a s o n , most a u t h o r s s u g g e s t t h a t t h e need t o c o n d u c t f u r t h e r r e s e a r c h i n t h e s e i s s u e s i s e x t r e m e l y i m p o r t a n t . Yet i t i s not c l e a r how s o c i a l i n t e r v e n t i o n a f f e c t s t h e impact o f p s y c h o l o g i c a l and s o c i a l d i s r u p t i o n s . In s o c i a l work r e s e a r c h , t h e use o f s c i e n t i f i c methods i n o n c o l o g y s e t t i n g s d e a l i n g w i t h t h e outcome o f i n t e r v e n t i o n i s l a r g e l y absent i n t h e l i t e r a t u r e , w i t h s p e c i f i c s o c i a l work c o n t r i b u t i o n s b e i n g t y p i c a l l y 1 d e s c r i p t i v e ( F o b a i r , 1973; S m i t h , 1977; J o h n s o n , 1981). In h i s r e v i e w o f e v a l u a t i v e r e s e a r c h i n s o c i a l w o r k , M u l l e n (1972) o f f e r e d the o p i n i o n t h a t s o c i a l work had been d e r e l i c t i n p u r s u i n g r e s e a r c h , and c r i t i c i z e d t h e i m p l i c i t assumption t h a t s o c i a l w o r k e r s "know what the needs a r e , and a r e hampered i n e f f e c t i v e n e s s o n l y by s h o r t a g e s o f r e s o u r c e s " (page 4 8 ) . He emphasized t h a t v e r y l i t t l e outcome r e s e a r c h had been c o n d u c t e d , and t h a t i t was incumbent upon t h e s o c i a l work p r o f e s s i o n t o pursue r e s e a r c h a v e n u e s . S i n c e t h a t t i m e , t h e r e have been some e f f o r t s t o c o n d u c t s c i e n t i f i c r e s e a r c h . The work o f Raphael (1977) c e n t e r i n g on t h e e f f e c t i v e n e s s o f bereavement c o u n s e l l i n g p o i n t s t o t h e p o s i t i v e r e s u l t s o f i n t e r v e n t i o n by p r o f e s s i o n a l s i n Oncology s e t t i n g . F u r t h e r grounds f o r o p t i m i s m i n p s y c h o s o c i a l i n t e r v e n t i o n i s p r e s e n t e d by R e i d (1982) i n h i s r e v i e w o f t w e n t y - t w o s t u d i e s completed t o 1979 t h a t c e n t e r on p s y c h o s o c i a l i n t e r v e n t i o n s . Y e t , i n a r e c e n t p u b l i c a t i o n by P e t e r s o n (1984) a r e v i e w o f s o c i a l work r e s e a r c h s i n c e 1979 y i e l d e d a mere f i f t e e n a r t i c l e s c o n c e n t r a t i n g on t h e e f f e c t i v e n e s s o f i n t e r v e n t i o n i n h e a l t h c a r e r e l a t e d s e t t i n g s . A l t h o u g h some p r o g r e s s has been made, more a t t e n t i o n t o outcome i n t e r v e n t i o n a d d r e s s i n g p s y c h o s o c i a l i s s u e s i s needed. The m a t t e r o f e v a l u a t i n g s o c i a l work e f f e c t i v e n e s s i s c l e a r l y t o p i c a l s i n c e as Berkman (1980) s t a t e s : "The s p i r a l l i n g c o s t o f h e a l t h c a r e , and c o n c e r n s r e l a t e d t o t h e q u a l i t y o f c a r e , pose a c h a l l e n g e t o the 2 h e a l t h c a r e system i n t h e r e g u l a t i o n o f h e a l t h c a r e e x p e n d i t u r e s by the p u b l i c , and more r e s p o n s i b i l i t y assumed by p r o v i d e r s o f h e a l t h c a r e s e r v i c e s f o r c o s t c o n t a i n m e n t . S o c i a l Workers i n h e a l t h c a r e are now f a c i n g t h e s e i s s u e s " (page 3 7 3 ) . We now t u r n t o t h e c e n t r a l c o n s t r u c t t o be s t u d i e d , c o n t i n u i t y o f c a r e . CONTINUITY OF CARE C o n t i n u i t y o f c a r e has been i d e n t i f e d as one o f t h e most i m p o r t a n t c h a r a c t e r i s t i c s o f optimum p a t i e n t c a r e , ( S l o a n e , 1 9 8 3 ) . Some o t h e r s have c o n s i d e r e d t h a t t h e development o f a p e r s o n a l r e l a t i o n s h i p between t h e p h y s i c i a n and t h e p a t i e n t i s among t h e c h i e f g o a l s i n m e d i c i n e (McWhinney, 1 9 8 2 ) . A l t h o u g h many f e e l t h a t a c o n t i n u i t y r e l a t i o n s h i p between a p h y s i c i a n and p a t i e n t i s by d e f i n i t i o n a good t h i n g , the r e l a t i o n s h i p between c o n t i n u i t y o f c a r e and p e r s o n a l h e a l t h i s i n f a c t a c o n t r o v e r s i a l t o p i c . Most o f t h e r e s e a r c h c o n c e r n i n g c o n t i n u i t y o f c a r e and p a t i e n t s a t i s f a c t i o n i s found i n m e d i c a l p r a c t i c e and many o f t h e s e w r i t e r s have r e f e r r e d t o t h e extreme d i f f i c u l t y i n d e f i n i n g and i m p l e m e n t i n g c o n t i n u i t y o f c a r e measures i n t h e h e a l t h c a r e s e t t i n g ( D r i g g e r s , 1982; McWhinney, 1983; E r i k s o n , 1 9 8 3 ) . P a r t o f t h e r e a s o n f o r t h e d i f f i c u l t y i n d e f i n i n g c o n t i n u i t y o f c a r e r e l a t i o n s h i p s i s due t o t h e f a c t t h a t t h i s c o n s t r u c t means d i f f e r e n t t h i n g s f o r d i f f e r e n t i n d i v i d u a l s . 3 In h i s r e v i e w o f s i x t e e n s t u d i e s c o n c e r n i n g c o n t i n u i t y o f c a r e , i n f a c t , D i e t r i c h (1982) found t h a t t h e major m e t h o d o l o g i c a l problem o f t h e s e s t u d i e s c o n c e r n t h e i n c o n s i s t e n c y i n t h e d e f i n i t i o n o f c o n t i n u i t y . C o n t i n u i t y can r e f e r t o an ongoing form o f c a r e p r o v i d e d by a person such as a p h y s i c i a n o r o t h e r h e a l t h c a r e p r o f e s s i o n a l , o r from an i n s t i t u t i o n such as a c a n c e r c l i n i c . Yet i t can a l s o r e f e r t o a p r o c e s s o f c a r e where a p a t i e n t moves t h r o u g h a d i a g n o s t i c t o a t r e a t m e n t phase i n t h e h e a l t h c a r e f a c i l i t y . Some a t t e m p t s have been made t o s t a n d a r d i z e t h e d e f i n i t i o n o f c o n t i n u i t y (Rogers and C u r t i s , 1980; S t a r f i e l d , 1980) by d e f i n i n g i t as a l o n g i t u d i n a l r e l a t i o n s h i p between t h e p r o v i d e r and p a t i e n t . T h i s d e f i n i t i o n i s w i d e l y r e g a r d e d as t h e most u s e f u l d e f i n i t i o n c o n c e r n i n g c o n t i n u i t y o f c a r e between p a t i e n t and c a r e g i v e r . D e s p i t e t h e s e d i f f e r e n c e s i n d e f i n i t i o n s , t h e r e i s some c o n s i s t e n c y i n t h e d e f i n i t i o n o f t h e outcome v a r i a b l e s . For e x a m p l e , s e v e r a l a u t h o r s have found a p o s i t i v e r e l a t i o n s h i p between c o n t i n u i t y o f c a r e and i n c r e a s e d c o m p l i a n c e w i t h t r e a t m e n t ( A l p e r t , 1964; B e c k e r , 1972; M i l l e r , 1973; P o l l a n d , 1976). The o t h e r v a r i a b l e most commonly l i n k e d w i t h c o n t i n u i t y o f c a r e i s p a t i e n t s a t i s f a c t i o n . A number o f r e s e a r c h e r s have found a p o s i t i v e r e l a t i o n s h i p between c o n t i n u i t y o f c a r e and i n c r e a s e d p a t i e n t 4 s a t i s f a c t i o n ( B e c k e r , 1974; S h o r t e n , 1977; W o o l l e y , 1978). However, o t h e r r e s e a r c h e r s have a l s o s t u d i e d t h e s a t i s f a c t i o n v a r i a b l e , a l b e i t , from t h e p o i n t o f v i e w o f t h e p r o v i d e r w i t h t h e f i n d i n g s s u p p o r t i n g t h e i m p o r t a n c e o f c o n t i n u i t y from t h e p o i n t o f view o f t h e p r o v i d e r (Caplan and Sussman, 1 9 6 6 ) . G e n e r a l l y , i n l o o k i n g a t t h e outcome measures f o r c o n t i n u i t y o f c a r e i t seems c l e a r t h a t p a t i e n t s a t i s f a c t i o n i s t h e most r e l i a b l y a s s o c i a t e d v a r i a b l e w i t h t h e c o n t i n u i t y v a r i a b l e . In t h i s r e g a r d , a s t u d y which examined c o n t i n u i t y i n r e l a t i o n s h i p s ( B e c k e r , Drachman, K i r s c h t , 1974) r e p o r t e d t h a t p h y s i c i a n s and mothers o f p a e d i a t r i c p a t i e n t s were more s a t i s f i e d i f subsequent c l i n i c v i s i t s were w i t h t h e same d o c t o r as seen a t t h e f i r s t v i s i t . These c o n c l u s i o n s were s u p p o r t e d i n a l a t e r r e s e a r c h s t u d y e x a m i n i n g d i f f e r e n t s a t i s f a c t i o n l e v e l s between f o u r c l i n i c s s p e c i a l i z i n g i n t h e t r e a t m e n t o f d i s a b l e d c h i d r e n ( B r e s l a u & M o r t i m e r , 1 9 8 2 ) . A m u l t i p l e r e g r e s s i o n a n a l y s i s u s i n g s o u r c e s o f c a r e , c o n t i n u i t y o f c a r e , w a i t i n g t i m e , and p a t i e n t and f a m i l y c h a r a c t e r i s t i c s as p r e d i c t o r s , and t h e l e v e l o f s a t i s f a c t i o n as t h e dependent v a r i a b l e , i n d i c a t e d t h a t c o n t i n u i t y o f c a r e a c c o u n t e d f o r a l a r g e p a r t o f s a t i s f a c t i o n e x p r e s s e d . T h i s was found t o be t r u e i n c l i n i c s where t h e p a t i e n t r e c e i v e d p r i m a r y c a r e ( g e n e r a l m e d i c i n e ) a n d , i n c l i n i c s where s p e c i a l i z e d c a r e was o f f e r e d . 5 In r e v i e w i n g t h e m e d i c a l l i t e r a t u r e , i t i s apparent t h a t not everyone a g r e e s t h a t c o n t i n u i t y o f c a r e i s p o s i t i v e . Some s u g g e s t t h a t f a m i l i a r i t y breeds c o n t e m p t , and c o n t i n u i t y encourages u n c r i t i c a l a c c e p t a n c e o f e s t a b l i s h e d d i a g n o s i s and t r e a t m e n t ( D i e t r i c h , 1 9 8 2 ) ; o t h e r s p o i n t t o t h e f i n d i n g s t h a t c o m p l i a n c e i s not i n c r e a s e d w i t h c o n t i n u i t y o f c a r e ( G o r d i s and M a r k o w i t z , 1971); and y e t o t h e r s s u g g e s t t h a t many consumers c o n s i d e r c o n t i n u i t y o f c a r e t o be a low p r i o r i t y w i t h r e s p e c t t o t h e i r g e n e r a l h e a l t h c o n c e r n s ( L e w i s , 1971). In a s t u d y by R o o s , Roos, G i l b e r t and N i c o l (1980) e x a m i n i n g t h e r e l a t i o n s h i p between c o n t i n u i t y and q u a l i t y o f c a r e , no d i f f e r e n c e s were found i n samples o f p a t i e n t s r e c e i v i n g t o n s i l l e c t o m i e s and a d e n o i d e c t o m i e s . A l t h o u g h t h e r e a r e some i n d i c a t i o n s t h a t a p o s i t i v e a s s o c i a t i o n between c o n t i n u i t y and q u a l i t y o f c a r e e x i s t s i n m e d i c a l p r a c t i c e , t h i s c o n c l u s i o n cannot be made i n p s y c h o s o c i a l i n t e r v e n t i o n i n h e a l t h s e t t i n g s . There i s no e v i d e n c e i n t h e l i t e r a t u r e t h a t h o s p i t a l p a t i e n t s v i e w t h a t c o n t i n u i t y o f c a r e i s d e s i r a b l e , nor indeed t h a t t h e a d m i n i s t r a t i v e o r g a n i z a t i o n o f p a t i e n t s e r v i c e s a f f e c t t h e i r adjustment t o t h e i r i l l n e s s . There a r e no r e p o r t e d s t u d i e s i n s o c i a l work u n d e r t a k e n t o date e x a m i n i n g t h e r e l a t i o n s h i p between t h e outcome o f p s y c h o s o c i a l i n t e r v e n t i o n and p a t i e n t s a t i s f a c t i o n . The s i n g l e a r t i c l e d e a l i n g w i t h c o n t i n u i t y i s s u e s ( B u f f u m , 1984) i s o l a t e s c o n t i n u i t y o f c a r e i n terms 6 o f t h e r e f e r r a l p r o c e s s , and t h i s i s u n d e r t a k e n o n l y from a d e s c r i p t i v e p o i n t o f v i e w . In c o n s i d e r i n g t h e r e v i e w o f t h e l i t e r a t u r e , i t i s c l e a r t h a t c o n t i n u i t y o f c a r e from a p s y c h o s o c i a l p o i n t o f v i e w has r e c e i v e d l i t t l e o r no a t t e n t i o n . At t h i s p o i n t , a v a r i a b l e t h a t i s t y p i c a l l y r e l a t e d t o c o n t i n u i t y , t h e team approach t o c a r e w i l l be r e v i e w e d . Team Approach t o Care In t h e l i t e r a t u r e t h e c o n c e p t o f team work i n c o n j u n c t i o n w i t h s o c i a l work p r a c t i c e c e n t e r s e x c l u s i v e l y upon t h e " i n t e r p r o f e s s i o n a l team" c o m p r i s e d o f p h y s i c i a n s , s o c i a l w o r k e r s , and o t h e r h e a l t h c a r e p r o f e s s i o n a l s (Lowe, and H e r r a n e n ) . A l t h o u g h t h e s e a r e r e l e v a n t o b s e r v a t i o n s i n terms o f s o c i a l work p r a c t i c e , f o r purposes o f t h i s s t u d y t h i s d e f i n i t i o n f o r a team approach i s not r e l e v a n t i n an attempt t o make c o m p a r i s o n s w i t h a c o n t i n u i t y approach t o c a r e . In f a c t , t h e r e a r e no r e p o r t e d s t u d i e s e x a m i n i n g t h e d i f f e r e n c e s between a c o n t i n u i t y approach i n t h e d e l i v e r y o f s o c i a l work s e r v i c e s i n c o m p a r i s o n w i t h a team a p p r o a c h . T h i s i s s u r p r i s i n g c o n s i d e r i n g t h a t t y p i c a l s o c i a l work s e r v i c e d e l i v e r y i n v o l v e s many s o c i a l w o r k e r s o v e r t i m e i n such a r e a s as c h i l d w e l f a r e , m e d i c a l , and p s y c h i a t r i c s o c i a l work s e t t i n g s . The c u r r e n t s t u d y t h e r e f o r e appears t o be unique i n t h a t i t examines t h e d i f f e r e n c e s i n outcome i n s o c i a l work p r a c t i c e by comparing a c o n t i n u i t y and team approach e x a m i n i n g o n l y t h e s o c i a l work 7 c o n t r i b u t i o n o f t h e team. Such an e x a m i n a t i o n o f t h i s n a t u r e i s i m p o r t a n t c o n s i d e r i n g t h e e t h i c a l , f i n a n c i a l , and s e r v i c e q u a l i t y i m p l i c a t i o n s i n t h e d e l i v e r y o f s e r v i c e . We now t u r n t o t h e v a r i a b l e o f p a t i e n t s a t i s f a c t i o n , which i s c o n s i s t e n t l y l i n k e d w i t h c o n t i n u i t y s t u d i e s i n t h e l i t e r a t u r e . P a t i e n t ( S u b j e c t ) S a t i s f a c t i o n In t h e h e a l t h c a r e s e t t i n g , p a t i e n t s a t i s f a c t i o n i s d e f i n e d as t h e h e a l t h c a r e r e c i p i e n t s ' r e a c t i o n t o key a s p e c t s o f c a r e p r o v i d e d w i t h r e s p e c t t o t h e p r o c e s s and outcome o f c a r e ( P a s c o e , 1 9 8 3 ) . Research c o n c e r n i n g p a t i e n t s a t i s f a c t i o n has r e c e i v e d a g r e a t d e a l o f a t t e n t i o n w i t h s e v e r a l r e v i e w s p u b l i s h e d i n r e c e n t y e a r s (Lebow, 1974; L o c k e r & Dunt, 1978; Swan & C a r r o l l , 1 9 8 0 ) . Two fundamental approaches have been used i n s t u d y i n g s a t i s f a c t i o n l e v e l s i n h e a l t h c a r e s e t t i n g s : t h e f i r s t i s based on f u l f i l l m e n t t h e o r i e s i n d e f i n i n g s a t i s f a c t i o n ( L a w l e r , 1973) which i s o l a t e s s a t i s f a c t i o n as a f u n c t i o n o f t h e amount o f c a r e r e c e i v e d by a consumer, whether o r not t h a t person w i s h e d t o r e c e i v e t h e s e r v i c e ; and t h e second i s based on d i s c r e p a n c y t h e o r y which uses t h e c o n s u m e r ' s p e r c e p t i o n o f what i s e x p e c t e d as t h e b a s e l i n e f o r comparing a c t u a l outcomes (Fox & S t o r m s , 1981). Most p a t i e n t s a t i s f a c t i o n r e s e a r c h u t i l i z e s t h e d i s c r e p a n c y approaches a l t h o u g h both s u f f e r from c e r t a i n e m p i r i c a l w e a k n e s s e s . In t h i s r e g a r d , f u l f i l l m e n t approaches t a k e i n 8 c o n s i d e r a t i o n o n l y t h e o b j e c t i v e outcome o f t h e p r o v i d e d c a r e which i n i t s e l f i s l i m i t i n g ; whereas d i s c r e p a n c y approaches do not p r o v i d e c o m p a r i s o n o f outcomes w i t h a p a r t i c u l a r s t a n d a r d ( f o r e x a m p l e , t h e r e i s t y p i c a l l y a l a c k o f a marker t h a t d i f f e r e n t i a t e s t h e p o i n t where t h e p a t i e n t i s e i t h e r s a t i s f i e d o r d i s s a t i s f i e d w i t h c a r e ) . There a r e a l s o a number o f m e t h o d o l o g i c a l i s s u e s t h a t a f f e c t p a t i e n t s a t i s f a c t i o n r e s e a r c h . F i r s t , t h e r e are c o n c e r n s o f t h e a m b i g u i t y o f e x p e c t a t i o n s o f c a r e by p a t i e n t s . S e c o n d , t h e r e are q u e s t i o n s about t h e domain o f t h e h e a l t h c a r e system f o r which i n q u i r i e s s h o u l d be made. F i n a l l y i t i s d i f f i c u l t t o d e t e r m i n e which o f t h e key f a c t o r s r e s e a r c h s h o u l d f o c u s upon. Compounding t h e problem i n p a t i e n t s a t i s f a c t i o n r e s e a r c h are c e r t a i n measurement i s s u e s . I n s t r u m e n t s d e v e l o p e d t o measure p a t i e n t s a t i s f a c t i o n a r e t y p i c a l l y s i m p l e , a d h o c , and u t i l i z e broad q u e s t i o n s t h a t a r e n o n s t a n d a r d i z e d (Westbrook & O l i v e r , 1981). D e s p i t e t h e s e m e t h o d o l o g i c a l f l a w s i n p a t i e n t s a t i s f a c t i o n r e s e a r c h , a number o f i n t e r e s t i n g f i n d i n g s can be h i g h l i g h t e d . A d i r e c t approach r a t h e r than an i n d i r e c t one t o q u e s t i o n i n g has met w i t h g r e a t e r s u c c e s s (Ware, S n y d e r , W r i g h t & D a v i e s , 1983). A d i r e c t approach i s f a v o u r e d s i n c e t h e e x p e r i e n c e o f t h e p a t i e n t i s sought i n r e l a t i o n t o t h e i r p e r s o n a l r e a c t i o n t o c a r e r e c e i v e d , i n c o m p a r i s o n w i t h a g e n e r a l l i n e o f q u e s t i o n i n g . For e x a m p l e , an i n d i r e c t approach would pose t h e q u e s t i o n " s o c i a l w o r k e r s always do t h e i r b e s t t o h e l p t h e p a t i e n t f e e l b e t t e r " , t h e p r e f e r r e d d i r e c t approach would r e a d " t h e s o c i a l worker I saw always d i d her b e s t t o h e l p me f e e l b e t t e r " . 9 Other r e s e a r c h e r s have found t h a t t h e t i m i n g o f a d m i n i s t e r i n g p a t i e n t s a t i s f a c t i o n q u e s t i o n n a i r e s can i n f l u e n c e t h e r e s u l t s ( L a r s e n , 1979). For e x a m p l e , s a m p l i n g soon a f t e r t h e p a t i e n t has r e c e i v e d t h e s e r v i c e t e n d s t o r e s u l t i n h i g h e r s a t i s f a c t i o n s c o r e s . From a s o c i o d e m o g r a p h i c p e r s p e c t i v e , h i g h s a t i s f a c t i o n l e v e l s are a l s o r e l a t e d t o t h e age and gender o f t h e p a t i e n t . Younger p a t i e n t s have been found t o r e p o r t s i g n i f i c a n t l y h i g h e r l e v e l s o f s a t i s f a c t i o n than more e l d e r l y p a t i e n t s ( H u l k a & Z y z a n s k i , 1 9 8 2 ) . A n o t h e r i m p o r t a n t f i n d i n g i n t h e f a m i l y p r a c t i c e l i t e r a t u r e c o n c e r n s t h e l i n k a g e between c o n t i n u i t y o f c a r e and p a t i e n t s a t i s f a c t i o n ; where i t has been shown t h a t p a t i e n t s a t i s f a c t i o n r e p o r t s a r e l o w e r where a r o t a t i o n o f t h e p h y s i c i a n w i t h a n o t h e r d o c t o r unknown t o t h e p a t i e n t o c c u r s . ( G r e e n e , G i l l i n g s , & S a l b e r , 1979). A l t h o u g h t h e r e are a number o f m e t h o d o l o g i c a l problems c o n c e r n i n g p a t i e n t s a t i s f a c t i o n s t u d i e s , a summary o f t h e a v a i l a b l e e v i d e n c e s u g g e s t s t h a t enhanced p a t i e n t s a t i s f a c t i o n i s c o r r e l a t e d w i t h p r o v i d e r competency and i n t e r p e r s o n a l s k i l l s . ( S t e w a r t & W a n k l i n , 1978). F u r t h e r m o r e , t h e l e n g t h o f c o n t a c t between t h e p r o v i d e r and t h e consumer i s i n c o n s i s t e n t l y r e l a t e d t o measurable p a t i e n t s a t i s f a c t i o n l e v e l s ( K o r s c h , G o z z i , & F r a n c i s , 1 9 6 8 ) . F u r t h e r r e f e r e n c e s i n t h i s r e p o r t t o c o n t i n u i t y o f c a r e s h a l l be c o n s i d e r e d i n r e l a t i o n t o t h e d e f i n i t i o n p r o v i d e d by S t a r f i e l d (1980) i n r e f e r e n c e t o t h e l o n g i t u d i n a l r e l a t i o n s h i p between a s i n g l e p r o v i d e r and a p a t i e n t . 10 In c o n c l u d i n g t h e d i s c u s s i o n o f two o f t h e key c o n s t r u c t s , we now t u r n t o an e x a m i n a t i o n o f two p s y c h o l o g i c a l v a r i a b l e s t h a t w i l l be u t i l i z e d i n t h e measurement o f t h e c o n t i n u i t y and team approaches t o c a r e , the H e a l t h Locus o f C o n t r o l , and t h e H o p e l e s s n e s s v a r i a b l e . H e a l t h Locus o f C o n t r o l With t h e i n c r e a s e d s o p h i s t i c a t i o n i n m e d i c a l t r e a t m e n t o f c a n c e r , which b r i n g s w i t h i t c o m p l i c a t e d t r e a t m e n t p r o t o c o l s t o t r e a t t h e d i s e a s e , c a n c e r p a t i e n t s can become b e w i l d e r e d and o f t e n f e e l a l o s s o f c o n t r o l i n t h e i r a b i l i t y t o cope w i t h t h e d i s e a s e and t r e a t m e n t p r o c e s s ( D e r o g a t i s , 1979). At t h e CCABC, s o c i a l w o r k e r s have n o t i c e d t h a t many p a t i e n t s w i s h t o become b e t t e r i n f o r m e d about t h e r a m i f i c a t i o n s o f t r e a t m e n t and t o g a i n more c o n t r o l o v e r c i r c u m s t a n c e s a f f e c t i n g t h e i r w e l l - b e i n g . Yet i r o n i c a l l y , a t CCABC i t has been noted t h a t p l a c i n g p a t i e n t s i n a s i t u a t i o n o f g r e a t e r c o n t r o l may r e s u l t i n more q u e s t i o n i n g o f p h y s i c i a n s by p a t i e n t s r e g a r d i n g t h e p r o c e d u r e s recommended and t h i s can have a n e g a t i v e a f f e c t on c o m p l i a n c e and p o t e n t i a l l y p l a c e t h e s o c i a l w o r k e r a t odds w i t h t h e d o c t o r . The c o n c e p t o f l o c u s o f c o n t r o l r e f e r s t o t h e e x t e n t t o which p e r s o n s have a p e r c e p t i o n t h a t c o n t i n g e n c y r e l a t i o n s h i p s e x i s t between t h e i r a c t i o n s and t h e i r outcomes (Dua, 1970). Locus o f c o n t r o l i s e x p r e s s e d i n terms o f i n t e r n a l o r e x t e r n a l c o n t r o l . " I n t e r n a l s " are d e s c r i b e d as 11 t h o s e who b e l i e v e t h a t t h e y have a t l e a s t some c o n t r o l o v e r c i r c u m s t a n c e s w h i c h a f f e c t them. In c o n t r a s t , " e x t e r n a l s " b e l i e v e t h a t t h e i r outcomes a r e d e t e r m i n e d by f a c t o r s w h i c h a r e e x t r i n s i c t o t h e m s e l v e s w h i c h are u s u a l l y m a n i f e s t e d by f a t e , l u c k , chance o r o t h e r s i n t h e i r e n v i r o m e n t . The h e a l t h l o c u s o f c o n t r o l c o n s t r u c t r e f e r s d i r e c t l y t o t h e s e v a r i a b l e s i n r e l a t i o n t o o n e ' s h e a l t h : t h e " i n t e r n a l s " would t e n d t o b e l e i v e t h a t t h e y would have a degree o f d i s c r e t i o n o v e r t h e i r f a t e w i t h r e s p e c t t o t h e i r p e r s o n a l h e a l t h , and t h e " e x t e r n a l s " would n o t . The l o c u s o f c o n t r o l c o n s t r u c t i s c o n s i d e r e d t o be i m p o r t a n t i n s t u d y i n g a p a t i e n t ' s c o p i n g r e s p o n s e ( G r e e r , 1979). O t h e r r e s e a r c h on t h i s s u b j e c t has demonstrated t h a t p e o p l e a r e g e n e r a l l y handicapped where t h e y a r e c o n s i d e r e d t o be s t r o n g " e x t e r n a l s " . ( R e i m a n i s and S c h a e f e r , 1970) D e s p i t e t h e f a c t t h a t t h e c o n c e p t o f l o c u s o f c o n t r o l i s an i m p o r t a n t v a r i a b l e i n t h e c l i n i c i a n ' s approach t o p a t i e n t and f a m i l y c a r e i n t h e o n c o l o g y s e t t i n g , t h e r e has been an absence o f r e s e a r c h c o n d u c t e d i n t h i s a r e a . D e s p i t e t h i s f a c t , f o r purposes o f my s t u d y , t h e i n t e r r e l a t i o n s h i p between c o n t i n u i t y o f c a r e , and t h e p a t i e n t ' s r e p o r t e d f e e l i n g s o f c o n t r o l a r e c o n s i d e r e d t o be an i m p o r t a n t a r e a f o r e x a m i n a t i o n . 12 H o p e l e s s n e s s A t t e m p t s t o l i n k h o p e l e s s n e s s w i t h v a r i o u s t y p e s o f c a n c e r as a p r e d i c t o r f o r t h e o n s e t o f t h e d i s e a s e are w e l l documented ( K i s s e n , 1 9 6 3 ) ; ( S c h m a l e , 1958, 1 9 6 4 ) ; ( H a g n e l l , 1 9 6 6 ) . In Oncology s e t t i n g s t h o s e i n d i v i d u a l s c h a r a c t e r i z e d as h o p e l e s s are seen as " g i v i n g u p " , f r u s t r a t e d , s e l f - b l a m i n g and p e s s i m i s t i c about t h e r e s o l u t i o n o f problems ( S c h m a l e , 1 9 6 6 ) . These b e h a v i o u r p a t t e r n s were l i n k e d w i t h low s e l f - e s t e e m , a d e s i r e f o r p e r f e c t i o n and a p r e - o c c u p a t i o n w i t h p l e a s i n g o t h e r s . The c o n c e p t o f h o p e l e s s n e s s has r e c e i v e d a good d e a l o f a t t e n t i o n i n p r o g n o s t i c s t u d i e s ( M o r r i s , 1 9 8 0 ) ; ( D e r o g a t i s , 1979) as i t has been h y p o t h e s i z e d t h a t t h o s e p s y c h o l o g i c a l s c o r e s r e f l e c t i n g an a t t i t u d e o f h o p e l e s s n e s s a r e l e s s l i k e l y t o s u r v i v e . A l t h o u g h t h e r e s e a r c h f i n d i n g s have been e q u i v o c a l , t h e c l i n i c a l i n t e r e s t i n h o p e l e s s n e s s r e m a i n s v e r y s t r o n g , p a r t i c u l a r l y s i n c e p a t i e n t s who p r e s e n t as h o p e l e s s can o f t e n be e a s i l y d e t e c t e d . Yet t h e h o p e l e s s n e s s v a r i a b l e has a h i g h degree o f r e l e v a n c y t o c l i n i c a l p r a c t i c e i n o n c o l o g y d e s p i t e t h e f a c t t h a t t h e r e have been no a t t e m p t s t o l i n k t h i s v a r i a b l e w i t h c o n t i n u i t y o f c a r e . C o n s e q u e n t l y , t h i s s t u d y would be one o f t h e f i r s t e f f o r t s t o examine t h e l i n k a g e s between t h e s e two i m p o r t a n t v a r i a b l e s i n c l i n i c a l p r a c t i c e . 13 CHAPTER 2 METHODOLOGY O b j e c t i v e s The aim o f t h i s s t u d y i s t o d e t e r m i n e t h e e f f e c t o f two approaches o f s o c i a l work i n t e r v e n t i o n , a c o n t i n u i t y a p p r o a c h , and a team a p p r o a c h , upon t h r e e dependent v a r i a b l e s . These v a r i a b l e s a r e : 1) The degree o f s u b j e c t s a t i s f a c t i o n w i t h s o c i a l work s e r v i c e s i n c o n s i d e r a t i o n o f d i r e c t t i m e spent by s o c i a l w o r k e r s w i t h s u b j e c t s . 2) The degree o f c o n t r o l p e r c e i v e d by t h e s u b j e c t s o v e r t h e i r h e a l t h s i t u a t i o n . 3) The degree o f h o p e l e s s n e s s (mood) which t h e s u b j e c t f e e l s c o n c e r n i n g h i s / h e r h e a l t h p r e d i c a m e n t . P r o t o c o l Two models o f s o c i a l work i n t e r v e n t i o n o f f e r i n g a c o n t i n u i t y and a team approach t o c a r e w i l l be e v a l u a t e d . C o n t i n u i t y M o d e l : One s o c i a l worker w i l l p r o v i d e s e r v i c e s t o t h e p a t i e n t t h r o u g h o u t t h e i r c o n t a c t w i t h t h e Cancer C o n t r o l Agency o f B . C . (CCABC). T h i s i n c l u d e s t h e new p a t i e n t p h a s e , t h e t r e a t m e n t p h a s e , and t h e f o l l o w -up o r t e r m i n a l phase where a p p l i c a b l e . 14 Team M o d e l : Two s o c i a l w o r k e r s w o r k i n g as a team w i l l p r o v i d e p s y c h o s o c i a l i n t e r v e n t i o n t o t h e p a t i e n t . A l t h o u g h t h e p a t i e n t w i l l be f o l l o w e d t h r o u g h t h e same c o u r s e as i n t h e c o n t i n u i t y m o d e l , both s o c i a l w o r k e r s w i l l be i n v o l v e d i n assessment and p s y c h o s o c i a l i n t e r -v e n t i o n . C o n t r o l Group In o r d e r t o e v a l u a t e t h e e f f e c t o f s o c i a l work i n t e r v e n t i o n , a c o n t r o l group was i n c l u d e d t h a t d i f f e r e d w i t h t h e o t h e r two groups i n t h a t s u b j e c t s d i d not r e c e i v e s o c i a l work s e r v i c e s from CCABC. P a t i e n t s w i t h d i a g n o s e s o f G a s t r o i n t e s t i n a l ( G . I . ) and G e n i t o - u r i n a r y ( G . U . ) c a n c e r s but who d i d not r e c e i v e t r e a t m e n t a t t h e CCABC were asked t o c o m p l e t e a m a i l - o u t q u e s t i o n n a i r e w i t h i n t h r e e months from t h e t i m e o f t h e i r new p a t i e n t appointment a t CCABC. There were a v a r i e t y o f r e a s o n s f o r t h e s e p a t i e n t s not r e c e i v i n g t r e a t m e n t a t CCABC i n c l u d i n g t h e e s t a b l i s h m e n t o f t r e a t m e n t f a c i l i t i e s i n a l o c a t i o n near t h e i r home, t h e tumour was not c o n s i d e r e d t r e a t a b l e , t h e p a t i e n t was i n r e m i s s i o n , o r o t h e r f a c t o r s . Those p a t i e n t s who were not c o n s i d e r e d t o be t r e a t a b l e , and who were not e x p e c t e d t o s u r v i v e f o r at l e a s t t h r e e months were not i n c l u d e d i n t h e c o n t r o l g r o u p . Those p a t i e n t s who are i n c l u d e d , were asked t o c o m p l e t e t h e same p s y c h o l o g i c a l i n s t r u m e n t s t h a t were completed by p a t i e n t s r e c e i v i n g s o c i a l work i n t e r v e n t i o n . 15 Hypotheses I t i s e x p e c t e d t h a t both models o f s o c i a l work i n t e r v e n t i o n w i l l f a c i l i t a t e q u a l i t y s o c i a l work s e r v i c e . C o n s e q u e n t l y , t h e f o l l o w i n g n u l l h y p o t h e s e s a r e o f f e r e d : 1) There w i l l be no d i f f e r e n c e i n t h e degree o f r e p o r t e d s a t i s f a c t i o n w i t h r e s p e c t t o s o c i a l work s e r v i c e s . 2) There w i l l be no d i f f e r e n c e s i n t h e degree o f change i n p e r c e i v e d c o n t r o l . 3) There w i l l be no d i f f e r e n c e i n t h e degree o f change i n r e p o r t e d mood. Study S e t t i n g The s t u d y s e t t i n g i s t h e Cancer C o n t r o l Agency o f B r i t i s h C o l u m b i a , (CCABC) l o c a t e d i n V a n c o u v e r , B r i t i s h C o l u m b i a . T h i s t e r t i a r y c a r e c e n t e r i s t h e p r i m a r y t r e a t m e n t f a c i l i t y i n t h e p r o v i n c e f o r r a d i o t h e r a p y and chemotherapy s e r v i c e s . There are o v e r f i v e thousand new p a t i e n t s d i a g n o s e d each y e a r which r e p r e s e n t s about f o r t y p e r c e n t o f a l l new p a t i e n t s d i a g n o s e d w i t h c a n c e r i n B r i t i s h Columbia ( M c B r i d e and G a l l a g h e r , 1987). Study Sample A l l p a t i e n t s e n r o l l e d i n t h e s t u d y were r e g i s t e r e d at t h e CCABC as new p a t i e n t s . A new p a t i e n t i s any i n d i v i d u a l r e f e r r e d t o t h e CCABC f o r e i t h e r t r e a t m e n t o r c o n s u l t a t i o n p u r p o s e s . P a t i e n t s who were r e f e r r e d t o t h i s Agency p r i o r t o May 1986 were not e n r o l l e d i n t h i s s t u d y . 16 F u r t h e r m o r e , p a t i e n t s who were r e f e r r e d t o t h e Agency w i t h a p r i o r c a n c e r d i a g n o s i s and r e t u r n e d w i t h a second s i t e were not e n r o l l e d i n t h i s s t u d y . P a t i e n t s were asked f o r t h e i r i n f o r m e d c o n s e n t t o p a r t i c i p a t e i n t h i s s t u d y , and were not r e s t r i c t e d f o r i n c l u s i o n by age o r g e n d e r . A l l s u b j e c t s were i n c l u d e d o n l y i f t h e y were a b l e t o communicate v e r b a l l y and i n w r i t t e n form i n t h e E n g l i s h l a n g u a g e . P a t i e n t s w i t h a d i a g n o s i s o f G . I . and G . U . c a n c e r s were i n c l u d e d f o r s t u d y as t h e e x p e r i e n c e at CCABC s u g g e s t e d t h a t t h e s e s i t e s would a l l o w f o r a good d i s t r i b u t i o n by age and g e n d e r . There were no r e s t r i c t i o n s r e l a t e d t o t h e d a t e o f the d i a g n o s i s o f c a n c e r , o r i n terms o f t h e t i m e l a p s e between i n i t i a l d i a g n o s i s and r e f e r r a l t o CCABC. S e v e n t y - t w o p a t i e n t s were e n r o l l e d i n t h e s t u d y from May 1986 t o J a n u a r y 1987. Of t h i s number, twenty s u b j e c t s c o m p l e t e d t h e f i r s t q u e s t i o n n a i r e but not t h e second (27%), t h i r t y - e i g h t completed both the f i r s t and second q u e s t i o n n a i r e (53%), f i v e were deceased p r i o r t o c o m p l e t i n g t h e second q u e s t i o n n a i r e (6%), and n i n e s u b j e c t s were e n r o l l e d as p a r t o f t h e c o n t r o l group (13%). T h e r e f o r e , s i x t y - s e v e n c a s e s r e t u r n e d a t l e a s t t h e f i r s t q u e s t i o n n a i r e , and t h i r t y - e i g h t p a t i e n t s c o m p r i s e d t h e main s t u d y g r o u p . S u b j e c t s were randomly a s s i g n e d t o e i t h e r t h e c o n t i n u i t y o r team g r o u p s . C o n t r o l s were s e l e c t e d on t h e b a s i s o f h a v i n g not b e i n g t r e a t e d a t t h e CCABC. They were s e l e c t e d at t h e t i m e o f t h e new p a t i e n t p r o c e s s when i t was not e x p e c t e d t h a t t h e y would r e t u r n f o r t r e a t m e n t and t h e r e f o r e would not r e c e i v e s o c i a l work i n t e r v e n t i o n . 17 Data C o l l e c t i o n S u b j e c t s f o r t h e s t u d y were i d e n t i f i e d a t t h e t i m e o f t h e i r f i r s t appointment a t t h e CCABC (new p a t i e n t appointment) and were randomly a s s i g n e d t o e i t h e r t h e c o n t i n u i t y o r team g r o u p s . S o c i a l work i n t e r v e n t i o n then commenced at t h e next v i s i t . Q u e s t i o n n a i r e s were m a i l e d t o t h e p a t i e n t f o l l o w i n g t h e f i r s t v i s i t , and w i t h i n t h r e e months t h e second q u e s t i o n n a i r e was m a i l e d t o t h e p a t i e n t t o be c o m p l e t e d . In o r d e r t o improve t h e r a t e o f r e t u r n o f q u e s t i o n n a i r e s , p a t i e n t s were t e l e p h o n e d w i t h i n two weeks from t h e t i m e o f t h e o r i g i n a l q u e s t i o n n a i r e m a i l o u t t o d e t e r m i n e i f t h e y r e c e i v e d t h e q u e s t i o n n a i r e , i f t h e y had any d i f f i c u l t y w i t h i t ( c o m p r e h e n s i o n , an e m o t i o n a l r e a c t i o n t o t h e q u e s t i o n s and so on) and t o encourage them t o complete t h e q u e s t i o n n a i r e and r e t u r n i t . In t h e event t h a t i t was l a t e r d e t e r m i n e d t h a t t h e s u b j e c t who had p r e v i o u s l y been a s s i g n e d t o t h e team group d i d not r e c e i v e c o n t a c t by two s o c i a l w o r k e r s , t h e y were r e -a s s i g n e d t o t h e c o n t i n u i t y g r o u p . S i x s u b j e c t s were r e - a s s i g n e d under t h e s e c i r c u m s t a n c e s . The e n t i r e q u e s t i o n n a i r e was seven pages i n l e n g t h and t o o k a p p r o x i m a t e l y t h i r t y minutes t o complete ( f o r a l l i n s t r u m e n t s ) . At t h e c o n c l u s i o n o f t h e s t u d y , p a t i e n t s r e c e i v e d a l e t t e r from t h e p r i n c i p l e i n v e s t i g a t o r a d v i s i n g them t h a t t h e s t u d y had ended and thanked them f o r t h e i r p a r t i c i p a t i o n . 18 The H e a l t h Locus o f C o n t r o l S c a l e , and t h e H o p e l e s s n e s s S c a l e were a d m i n i s t e r e d t o t h e p a t i e n t a t t h e t i m e o f t h e f i r s t assessment by t h e s o c i a l w o r k e r , w i t h t h e p a t i e n t s a t i s f a c t i o n q u e s t i o n n a i r e b e i n g a d m i n i s t e r e d a l o n g w i t h t h e s e i n s t r u m e n t s on t h e second m a i l i n g . E t h i c a l C o n s i d e r a t i o n s P r i o r t o a p p r o a c h i n g t h e p a t i e n t , p h y s i c i a n s p r o v i d e d t h e i r p e r m i s s i o n t o e n r o l l t h e i r p a t i e n t s i n t h e s t u d y t h r o u g h d i s c u s s i o n s o f t h e s t u d y p r o t o c o l . P a t i e n t s were i n f o r m e d o f t h e i r o p t i o n not t o p a r t i c i p a t e i n t h e s t u d y t h r o u g h t h e p r e s e n t a t i o n o f a d e s c r i p t i o n o f t h e s t u d y a t t a c h e d t o t h e s t u d y i n s t r u m e n t s (Appendix I ) . T h i s l e t t e r o f i n t r o d u c t i o n s t r e s s e d t h a t t h e p a t i e n t ' s d e c i s i o n t o p a r t i c i p a t e was o p t i o n a l and t h a t t h e i r d e c i s i o n t o d e c l i n e t h i s o p p o r t u n i t y would i n no way a f f e c t t h e i r t r e a t m e n t by t h e i r p h y s i c i a n , s o c i a l worker o r o t h e r t r e a t m e n t s t a f f . The d e c i s i o n t o randomly a s s i g n p a t i e n t s t o e i t h e r t h e c o n t i n u i t y o r team group was not e x p e c t e d t o have had d e l e t e r i o u s e t h i c a l i m p l i c a t i o n s s i n c e t h e r e i s no e v i d e n c e t o d a t e t h a t e i t h e r form o f i n t e r v e n t i o n by s o c i a l w o r k e r s o r o t h e r h e a l t h p r o f e s s i o n a l s a f f e c t t h e management and outcome o f c a n c e r t r e a t m e n t . A l l a s p e c t s r e l a t e d t o t h i s r e s e a r c h s t u d y conformed t o t h e CCABC s t a n d a r d o f p a t i e n t c o n f i d e n t i a l i t y . Q u e s t i o n n a i r e s completed by s u b j e c t s were r e t a i n e d by t h e s t u d y ' s p r i n c i p a l i n v e s t i g a t o r i n a l o c k e d f i l e c a b i n e t . W r i t t e n r e s u l t s o f f i n d i n g s have been completed i n a manner t h a t i n no way i d e n t i f i e d i n d i v i d u a l s u b j e c t s . 19 Study I n s t r u m e n t s The c h a r a c t e r i s t i c s o f t h e i n s t r u m e n t s a d m i n i s t e r e d t o t h e s e s u b j e c t s a r e as f o l l o w s : H o p e l e s s n e s s S c a l e (HOPE) T h i s s c a l e d e v e l o p e d by Beck (1974) i s c o m p r i s e d o f t w e n t y - t w o items w i t h t r u e and f a l s e r e s p o n s e s which r e f l e c t t h e degree o f p e s s i m i s m e x p r e s s e d by s u b j e c t s (Appendix I I ) . The s c o r e s range from z e r o t o twenty w i t h z e r o r e f l e c t i n g low p e s s i m i s m on b e h a l f o f t h e s u b j e c t . T h i s s c a l e has been a d m i n i s t e r e d t o a v a r i e t y o f samples but has been used p r i m a r i l y i n mental h e a l t h s e t t i n g s . The i n t e r n a l c o n s i s t e n c y o f t h i s s c a l e was a n a l y z e d by means o f a c o - e f f i c i e n t a l p h a which y i e l d e d a r e l i a b i l i t y c o - e f f i c i e n t o f 0 . 9 3 i n a s t u d y i . e . (KR - 20) o f two hundred and n i n e t y - f o u r h o s p i t a l i z e d p a t i e n t s . T h i s sample o f p a t i e n t s a l s o showed h i g h l y s i g n i f i c a n t c o r r e l a t i o n s between each i t e m and t h e t o t a l H o p e l e s s n e s s S c a l e S c o r e ( B e c k , 1974). H e a l t h Locus o f C o n t r o l S c a l e (HLOC) T h i s s c a l e d e v e l o p e d by W a l l s t o n (1976) c o n s i s t s o f e l e v e n q u e s t i o n s w i t h a numbered r e s p o n s e r a t e r a n g i n g from one t o s i x w i t h s e l e c t i o n s o f s t r o n g l y d i s a g r e e t o s t r o n g l y agree r e s p e c t i v e l y (Appendix I I I ) . The s c a l e measures t h i r t y - f o u r i t e m s w h i c h are c o n s i d e r e d t o have f a c e v a l i d i t y w i t h r e g a r d t o e x p e c t a n c i e s c o n c e r n i n g l o c u s o f c o n t r o l , ( W a l l s t o n ) . The e l e v e n i t e m s c a l e has a p o t e n t i a l s c o r e range o f e l e v e n t o s i x t y - s i x w i t h t h e h i g h e r s c o r e r e l a t e d t o g r e a t e r p e r c e p t i o n o f c o n t r o l . 20 The s c a l e i s an a r e a - s p e c i f i c measure o f e x p e c t a n c i e s r e g a r d i n g l o c u s o f c o n t r o l d e v e l o p e d f o r t h e p r e d i c t i o n o f h e a l t h r e l a t e d b e h a v i o u r . A l p h a r e l i a b i l i t y o f t h e e l e v e n i t e m s was 0 . 7 2 . The H e a l t h Locus o f C o n t r o l S c a l e does not r e f l e c t a s o c i a l d e s i r a b i l i t y b i a s , as e v i d e n c e d by a .01 c o r r e l a t i o n w i t h a Marlowe - Crowne S o c i a l D e s i r a b i l i t y s c a l e ( W a l l s t o n , 1976) . P a t i e n t S a t i s f a c t i o n (PSQ) T h i s s c a l e was d e v e l o p e d by L a r s e n e t . a l , (1979) and c o m p r i s e s e i g h t q u e s t i o n s w i t h f o u r p o s s i b l e r e s p o n s e s f o r each q u e s t i o n (Appendix I V ) . The s c o r e s range from one t o f o u r w i t h t h e h i g h e s t s c o r e b e i n g a s s o c i a t e d w i t h h i g h e r s a t i s f a c t i o n o f s e r v i c e s r e c e i v e d . T h e r e f o r e , t h e minimum s c o r e a t t a i n a b l e i s e i g h t w i t h a maximum b e i n g t h i r t y - t w o . The p r e l i m i n a r y s c a l e was a d m i n i s t e r e d t o two hundred f o r t y - e i g h t mental h e a l t h p a t i e n t s i n f i v e s e r v i c e s e t t i n g s . C o - e f f i c i e n t a l p h a r e c o r d e d was . 9 3 , which i n d i c a t e d t h a t i t p o s s e s s e d a h i g h degree o f i n t e r n a l c o n s i s t e n c y w i t h t h e sample p o p u l a t i o n s ( L a r s e n e t . a l . , 1979). Data A n a l y s i s A l l s t a t i s t i c a l c a l c u l a t i o n s were performed u s i n g t h e S t a t i s t i c a l Package f o r t h e S o c i a l S c i e n c e s - X (SPSS-X, 1 9 8 3 ) . In o r d e r t o d e t e r m i n e t h e c o m p a r a b i l i t y o f groups by a g e , g e n d e r , m a r i t a l s t a t u s , and d i s e a s e s i t e , f r e q u e n c i e s were measured u s i n g t h e n o n p a r a m e t r i c t e s t , Chi S q u a r e . Changes i n t h e d i s t r i b u t i o n o f t h e s c o r e s f o r 21 r e p o r t e d mood and c o n t r o l were compared u s i n g a M u l t i v a r i a t e A n a l y s i s o f V a r i a n c e (MANOVA) u s i n g a between-group and w i t h i n - g r o u p d e s i g n and t h e w i t h i n - f a c t o r was t r i a l s . The b e t w e e n - f a c t o r was group membership. The t e s t f o r u n i v a r i a t e d i f f e r e n c e s i n A n a l y s i s o f V a r i a n c e (ANOVA) used t h e same f a c t o r s . F r e q u e n c i e s were computed u s i n g t h e c r o s s t a b u l a t i o n o p t i o n o f t h e SPSS. I n t e r v e n t i o n P s y c h o s o c i a l needs o f c a n c e r p a t i e n t s have been e x h a u s t i v e l y s t u d i e d w i t h t y p i c a l needs o f c a n c e r p a t i e n t s i d e n t i f i e d . These i n c l u d e t h e c a n c e r p a t i e n t s need f o r h o n e s t y , f o r more i n f o r m a t i o n , f o r e m o t i o n a l e x p r e s s i o n , f o r d i s c u s s i o n o f i s s u e s r e l a t e d t o d e a t h and d y i n g , a n d , f o r some, t h e need t o m a i n t a i n a degree o f c o n t r o l i n t h e i r c a r e . ( Y o u n g - B r o c k o p p , 1982; K l a g s b u r n , 1971; D e r o g a t i s , 1 9 7 9 ) . Two o f t h e s e i d e n t i f i e d needs have been s e l e c t e d f o r t h e s t u d y , t h e degree o f p a t i e n t h o p e l e s s n e s s , and t h e degree o f c o n t r o l . At t h e CCABC, t h e s o c i a l w o r k e r s are p a r t i c u l a r l y i n t e r e s t e d i n h a v i n g an impact on t h e s e n e e d s ; and a t t e m p t s are made t o a s s i s t t h e p a t i e n t t o become more h o p e f u l i n t h e f a c e o f t r e a t m e n t , and t o attempt t o g a i n more c o n t r o l o v e r t h e i r m e d i c a l s i t u a t i o n . I t i s g e n e r a l l y b e l i e v e d t h a t t h e more h o p e f u l a p e r s o n i s , t h e more l i k e l y t h e y are t o cope e f f e c t i v e l y w i t h t h e t r e a t m e n t p r o c e s s . Most o f t h e r e s e a r c h p e r t a i n i n g t o c o n t r o l s u g g e s t s t h a t i t i s d e s i r a b l e t o change p e o p l e , e s p e c i a l l y when such i n d i v i d u a l s a r e not p e r c e i v e d as d o i n g w e l l i n 22 s o c i e t y . E f f o r t s are then made t o change t h e d i r e c t i o n from an e x t e r n a l (low c o n t r o l ) t o an i n t e r n a l ( h i g h c o n t r o l ) v i e w o f l i f e (Dua, 1970; Coven, 1970). Documentation o f s t r a t e g i e s t o a l t e r mood and c o n t r o l o f c a n c e r p a t i e n t s i s a b s e n t i n t h e l i t e r a t u r e . Most d e s c r i p t i o n s o f s o c i a l work i n o n c o l o g y s e t t i n g s emphasize t h e l i s t e n i n g s k i l l s r e q u i r e d o f p r o f e s s i o n a l s , t h e need t o b r i d g e communication g a p s , ( F o b a i r , 1973) and t h e need t o r e l a t e t o p a t i e n t s , and t o u n d e r s t a n d t h e i r e m o t i o n s . ( J o h n s o n , 1977) In u n d e r t a k i n g t h i s s t u d y , a l l s o c i a l w o r k e r s a t t h e Cancer C o n t r o l Agency were p o l l e d t o d e t e r m i n e t h e i r g o a l s w i t h c a n c e r p a t i e n t s beyond t h e g e n e r i c d e s c r i p t i o n s o f p r o v i d i n g c o u n s e l l i n g , s u p p o r t , and p r a c t i c a l s e r v i c e s . F o l l o w i n g t h e s e i n t e r v i e w s , two v a r i a b l e s were i d e n t i f i e d as a g o a l by a l l s o c i a l w o r k e r s , i n c l u d i n g t h e need t o a s s i s t t h e p a t i e n t t o have more c o n t r o l o v e r t h e v a r i o u s p e r i m e t e r s o f m e d i c a l t r e a t m e n t , and t h e need f o r hope. A l t h o u g h t h e s e g o a l s were i d e n t i f i e d by a l l s o c i a l w o r k e r s , t h e r e i s no s p e c i f i c i d e n t i f i a b l e s t r a t e g y t h a t was employed t o e n s u r e an impact on t h e s e v a r i a b l e s , but r a t h e r , t h e methods u t i l i z e d were p r i m a r i l y summarized where s o c i a l w o r k e r s p r o v i d e i n f o r m a t i o n , c o u n s e l l i n g , and r e f e r r a l . In a l l c a s e s , s o c i a l w o r k e r s p r o v i d e d s u p p o r t , c o u n s e l l i n g and p r a c t i c a l s e r v i c e s t o p a t i e n t s w i t h i n t h e c o n f i n e s o f t h e CCABC. 23 P a t i e n t s were g e n e r a l l y c o n t a c t e d i n t h e c o u r s e o f c l i n i c s , where p a t i e n t s r e c e i v e d t r e a t m e n t and f o l l o w - u p . Through t h e c o u r s e o f i n t e r v e n t i o n , s o c i a l w o r k e r s completed s o c i a l work i n f o r m a t i o n forms which h i g h l i g h t t h e p a t i e n t ' s c i r c u m s t a n c e s i n c l u d i n g how t h e y were i d e n t i f i e d as " a t r i s k " , t h e p e r c e i v e d problems i d e n t i f i e d by the p a t i e n t , t h e p e r c e p t i o n s o f t h e s o c i a l worker w i t h r e s p e c t t o the p a t i e n t ' s e x p e c t e d c o p i n g r e s p o n s e , and s t a t e m e n t o f g o a l s f o r f u t u r e c o n t a c t s . Length o f t i m e spent by t h e s o c i a l w o r k e r w i t h t h e p a t i e n t v a r i e d depending on t h e i d e n t i f i e d problem and t h e s e t t i n g o f t h e i n t e r v i e w , but t h e minimum s t a n d a r d was a twenty minute i n t e r v i e w . 24 CHAPTER 3 PRESENTATION OF RESULTS I n t r o d u c t i o n The p r e s e n t a t i o n o f r e s u l t s w i l l be o r g a n i z e d i n t o f o u r s e c t i o n s . The f i r s t s e c t i o n w i l l p r o v i d e i n f o r m a t i o n c o n c e r n i n g t h e s t u d y g r o u p i n g s , t h e second w i l l h i g h l i g h t t h e major s o c i o d e m o g r a p h i c v a r i a b l e s ( i e . c o n t r o l v a r i a b l e s ) which c o u l d have a major impact on t h e dependent v a r i a b l e s ; t h e t h i r d w i l l h i g h l i g h t t h e major s t u d y f i n d i n g s ; and f i n a l l y , t h e f o u r t h w i l l p r e s e n t a d d i t i o n a l a n a l y s i s s e c o n d a r y t o t h e major f i n d i n g s . The f i r s t s e c t i o n i n c l u d e s a d e s c r i p t i o n o f t h e s t u d y g r o u p i n g s and t h e r e s p o n s e r a t e s f o r t h o s e who r e f u s e d t o p a r t i c i p a t e by not c o m p l e t i n g a q u e s t i o n n a i r e , t h o s e who completed t h e f i r s t q u e s t i o n n a i r e but not t h e second and t h o s e who c o m p l e t e d t h e f i r s t and t h e second q u e s t i o n n a i r e . These d a t a are summarized i n T a b l e One. 25 T a b l e 1 C a t e g o r y o f Returned Q u e s t i o n n a i r e s CATEGORY FREQUENCY REFUSAL 45 COMPLETED 1 20 COMPLETED 1 & 2 38 TOTAL 103 T h i r t y - e i g h t s u b j e c t s completed both q u e s t i o n n a i r e s and a r e t h e r e f o r e t h e major group t o be s t u d i e d . T h i s r e f l e c t s s u b j e c t s who completed t h e q u e s t i o n n a i r e s h o r t l y a f t e r t h e new p a t i e n t p r o c e s s , and a g a i n w i t h i n t h r e e months from t h a t t i m e . These t h i r t y - e i g h t s u b j e c t s r e p r e s e n t t h i r t y - s e v e n p e r c e n t o f a l l s u b j e c t s e l i g i b l e ( o v e r a l l r e s p o n s e r a t e ) t o p a r t i c i p a t e i n t h e s t u d y . Of t h e s e s u b j e c t s , t w e n t y -s i x (68%) r e c e i v e d s o c i a l work i n t e r v e n t i o n as p a r t o f t h e c o n t i n u i t y g r o u p . Twelve s u b j e c t s (60%) r e c e i v e d s o c i a l work s e r v i c e s by two o r more s o c i a l w o r k e r s . A summary o f t h e c h a r a c t e r i s t i c s o f t h e s u b j e c t s c o m p l e t i n g t h e q u e s t i o n n a i r e s at Time 1 i s p r e s e n t e d i n T a b l e 2 . 26 T a b l e 2 C h a r a c t e r i s t i c s o f S u b j e c t s C o m p l e t i n g Q u e s t i o n n a i r e s at Time 1 GENDER AGE MARITAL STATUS TUMOUR SITE Male Female Mean ( y r s ) P a r t n e r No P a r t n e r GI GU 53 (79%) 14 (21%) 6 4 . 5 52 (78%) 15 (22%) 30 (45%) 37(55%) A l t h o u g h t h e t r e a t m e n t groups were not o f equal s i z e , and t h e r a n d o m i z a t i o n p r o c e s s was b r o k e n , t h e d i s t r i b u t i o n s o f s u b j e c t s by a g e , g e n d e r , m a r i t a l s t a t u s and tumour s i t e s were s i m i l a r f o r t h e t r e a t m e n t g r o u p s . The randomized assignment was broken when s u b j e c t s were o r i g i n a l l y a s s i g n e d t o t h e team group and s u b s e q u e n t l y o n l y saw one s o c i a l w o r k e r ; t h e y were t h e r e f o r e r e - a s s i g n e d t o t h e c o n t i n u i t y g r o u p . The sample was then compared w i t h t h e n o n - r e s p o n d e n t s and i t was d e t e r m i n e d t h a t t h e n o n - r e s p o n d e n t s compared f a v o u r a b l y t o t h e sample w i t h t h e mean age b e i n g 6 4 . 1 y e a r s , 75% m a l e s , 25% f e m a l e s , and a 50 -50 s p l i t f o r t h o s e who had and d i d not have m a r i t a l p a r t n e r s . A f t e r t h e p a t i e n t s were randomly a s s i g n e d t o t h e i r t r e a t m e n t g r o u p , t h e i r t r e a t m e n t s t a t u s was compared t o t h e i r a g e , g e n d e r , m a r i t a l s t a t u s , t h e s i t e o f t h e i r c a n c e r , and t h e r a t e o f c o m p l e t i o n o f t h e i r q u e s t i o n n a i r e s . The d i s t r i b u t i o n o f s u b j e c t s among t r e a t m e n t groups i n c o n s i d e r a t i o n o f t h e s e f a c t o r s i s c o n t a i n e d i n T a b l e 3 . 27 T a b l e 3 D i s t r i b u t i o n o f S u b j e c t s Among Treatment Groups by Age, Gender, M a r i t a l S t a t u s and D i s e a s e S i t e FACTOR CATEGORY NUMBER AND % WITHIN GROUPS BY TREATMENT C o n t i n u i t y Team C o n t r o l Age under 60 10 (26%) 7 (35%) 2 (22%) 60 - 67 12 (32%) 4 (20%) - ( 0%) 68 - 72 10 (26%) 4 (20%) 2 (22%) o v e r 73 6 (16%) 5 (25%) 5 (56%) Gender Male 31 (82%) 14 (70%) 8 (89%) Female 7 (18%) 6 (30%) 1 (11%) M a r i t a l P a r t n e r 29 (76%) 15 (75%) 8 (89%) S t a t u s No P a r t n e r 9 (24%) 5 (25%) 1 (11%) D i s e a s e G . I . 18 (47%) 11 (55%) 1 (11%) S i t e G . U . 20 (53%) 9 (45%) 8 (89%) 100% 100% 100% In o r d e r t o o b t a i n groups o f p a t i e n t s at d i f f e r e n t age l e v e l s w i t h comparable f r e q u e n c i e s , t h e s u b j e c t s ' age were recoded i n terms o f f o u r c a t e g o r i e s : under t h e age o f 5 9 ; 60 - 67; 68 - 72; and o v e r t h e age o f 72. These age g r o u p i n g s were made i n an a r b i t r a r y f a s h i o n . I t can be seen from t h e d a t a t h a t t h e d i s t r i b u t i o n o f s u b j e c t s amongst t h e t h r e e t r e a t m e n t groups f o r t h e above c h a r a c t e r i s t i c s i s r o u g h l y comparable w i t h any d i f f e r e n c e s not b e i n g s t a t i s t i c a l l y s i g n i f i c a n t . 28 The sample was d i v i d e d w i t h r e s p e c t t o whether o r not t h e s u b j e c t s c u r r e n t l y had a p a r t n e r . In t h i s s t u d y , m a r i t a l p a r t n e r s were t a k e n as i n c l u d i n g common-law r e l a t i o n s h i p s . The f r e q u e n c y o f t h e s u b j e c t s h a v i n g p a r t n e r s o r not w i t h r e s p e c t t o t h e i r t r e a t m e n t group membership r e v e a l e d no s y s t e m a t i c d i f f e r e n c e s between t h e s e g r o u p s . The s u b j e c t s ' s i t e o f c a n c e r was then compared t o t h e i r membership i n the t r e a t m e n t g r o u p s . I t can be seen from T a b l e 3 t h a t t h e r a t e o f c a n c e r i d e n t i f i e d i n d i f f e r e n t s i t e s was found t o be a p p r o x i m a t e l y comparable a c r o s s t h e t h r e e t r e a t m e n t g r o u p s . N e x t , an a n a l y s i s was c o n d u c t e d t o d e t e r m i n e t h e d i f f e r e n c e s among the f o u r age c a t e g o r i e s i n r e l a t i o n t o changes i n mood (HOPE) and c o n t r o l (HLOC). These d a t a are p r e s e n t e d i n T a b l e 4 T a b l e 4 D i f f e r e n c e s Among Age Groups on Mood and C o n t r o l AGE OF HOPE HOPE HLOC HLOC SUBJECT NUMBER TIME 1 TIME 2 TIME 1 TIME 2 22-59 11 MEAN 2 . 8 2 3 . 3 6 3 7 . 3 6 3 6 . 2 7 SD 2.14 2 . 6 9 8 . 9 0 6 . 6 5 60-67 13 MEAN 2 . 6 9 3 . 2 3 4 0 . 0 0 4 1 . 2 3 SD 3 . 0 4 4 . 2 3 9 . 0 4 1 0 . 0 8 68-72 10 MEAN 2 . 2 8 1 .73 3 7 . 7 3 3 6 . 7 3 SD 1.73 1.27 9 . 8 4 8 . 8 6 73 + 12 MEAN 4 . 8 3 3 . 5 8 4 0 . 0 8 3 6 . 0 0 SD 2 . 7 9 3 . 0 9 6 . 5 7 10.92 OVERALL 46 MEAN 3 . 2 1 3 . 0 4 3 9 . 0 0 3 7 . 9 3 SD 2 . 6 4 3 . 0 8 8 . 5 0 9 . 1 9 29 C o n s i s t e n t w i t h t h e f i n d i n g s p r e s e n t e d t h u s f a r , t h e r e were no s i g n i f i c a n t d i f f e r e n c e s among age groups on t h e s e v a r i a b l e s . The f i n a l a n a l y s i s u n d e r t a k e n examines t h e r e l a t i o n s h i p between the s i t e o f t h e c a n c e r and t h e dependent v a r i a b l e s o f mood and c o n t r o l . T h i s a n a l y s i s was u n d e r t a k e n i n o r d e r t o d e t e r m i n e i f t h e r e was c o m p a r a b i l i t y between s i t e s o f c a n c e r f o r change i n mood and c o n t r o l . A g a i n , both mood and c o n t r o l were a s s e s s e d by comparing s c o r e s from the f i r s t t o t h e second assessment o c c a s i o n . These d a t a a r e p r e s e n t e d i n T a b l e 5 . T a b l e 5 D i f f e r e n c e s Between Cancer S i t e s i n Mood and C o n t r o l MOOD CONTROL SITE OF HOPE HOPE HLOC HLOC CANCER NUMBER TIME 1 TIME 2 TIME 1 TIME 2 G . I . 21 MEAN 4 . 1 0 3 . 5 7 3 8 . 8 3 3 8 . 5 3 SD 3 . 3 2 3.77 9 . 3 3 10.37 G . U . 25 MEAN 3 . 2 9 2 . 5 3 3 9 . 2 9 3 7 . 0 6 SD 3 . 7 4 2 . 3 2 8 . 5 1 8 . 3 9 OVERALL 46 MEAN 3.17 3 . 0 0 3 8 . 8 7 3 7 . 6 8 SD 2 . 6 3 3 . 0 6 8 . 4 6 9 . 2 5 T h i s a n a l y s i s r e v e a l e d t h a t t h e s i t e o f t h e s u b j e c t s ' c a n c e r was not r e l a t e d t o changes i n h o p e l e s s n e s s and h e a l t h l o c u s o f c o n t r o l as t h e r e were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between t h e s e g r o u p s . 30 In summary, a l t h o u g h t h e r e were d i f f e r e n c e s i n t h e s i z e o f t h e t r e a t m e n t groups as a r e s u l t o f t h e break i n t h e r a n d o m i z a t i o n p r o c e s s , t h e a n a l y s i s u n d e r t a k e n r e v e a l e d t h a t t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between t h e t r e a t m e n t groups i n r e l a t i o n t o t h e d i s t r i b u t i o n o f s u b j e c t s by a g e , g e n d e r , m a r i t a l s t a t u s and tumour s i t e . T h e r e f o r e , t h e r e s e a r c h e r proceeded w i t h c o n f i d e n c e t h a t f u r t h e r a n a l y s i s would not be n e c e s s a r i l y c o n t a m i n a t e d by i n i t i a l d i f f e r e n c e s i n t h e t r e a t m e n t groups f o r t h e s e f o u r f a c t o r s . C o n t r o l V a r i a b l e s Of g r e a t c o n c e r n was t h e r a t e o f c o m p l e t i o n o f q u e s t i o n n a i r e s amongst t h e s u b j e c t s . T h i s " N u i s a n c e " v a r i a b l e was compared t o t h e t r e a t m e n t g r o u p , a g e , g e n d e r , m a r i t a l s t a t u s , and s i t e o f c a n c e r i n o r d e r t o d e t e r m i n e whether t h e r e were s y s t e m a t i c d i f f e r e n c e s among t h e t r e a t m e n t groups which might have o b s c u r e d o r i n t e r f e r e d w i t h t h e r e s u l t s o f t h e s t a t i s t i c a l a n a l y s i s . S u b j e c t s a s s i g n e d t o t h e c o n t r o l g r o u p , n e c e s s a r i l y had completed both s e t s o f q u e s t i o n n a i r e s and d i d not r e c e i v e t r e a t m e n t . T h e r e f o r e , t h e r a t e o f c o m p l e t i o n o f the q u e s t i o n n a i r e was compared o n l y f o r s u b j e c t s f o l l o w i n g w i t h i n t h e team and c o n t i n u i t y g r o u p s . These d a t a are p r e s e n t e d i n T a b l e 6 . 31 T a b l e 6 D i s t r i b u t i o n o f C h a r a c t e r i s t i c s Age, Gender, M a r i t a l S t a t u s , and D i s e a s e S i t e by C o m p l e t i o n S t a t u s FACTOR CATEGORY NUMBER AND % BY QUESTIONNAIRE COMPLETION F i r s t F i r s t & Second Age under 60 8 (40%) 9 (24%) 60 - 67 3 (15%) 13 (34%) 68-72 5 (25%) 9 (24%) o v e r 73 4 (20%) 7 (18%) Gender Male 19 (95%) 26 (68%) Female 1 ( 5%) 12 (32%) M a r i t a l P a r t n e r 16 (80%) 28 (74%) S t a t u s No P a r t n e r 4 (20%) 10 (26%) D i s e a s e G . I . 9 (45%) 20 (53%) S i t e G . U . 11 (55%) 18 (47%) 100% 100% The a n a l y s i s o f t h e c o n t r o l v a r i a b l e s ; a g e , g e n d e r , m a r i t a l s t a t u s , and d i s e a s e s i t e , r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s between s u b j e c t s c o n c e r n i n g t h e s e f a c t o r s . A g a i n , t h e r e s e a r c h e r was a b l e t o proceed w i t h some c o n f i d e n c e t h a t t h e s e f a c t o r s would not unduly i n f l u e n c e the major t r e a t m e n t e f f e c t s t o be s t u d i e d . 32 M a j o r Study F i n d i n g s The t h r e e major hypotheses were s t a t e d i n t h e methodology s e c t i o n o f t h i s r e p o r t . The f i r s t n u l l h y p o t h e s i s c i t e d s t a t e d t h a t " t h e r e w i l l be no d i f f e r e n c e s i n t h e degree o f r e p o r t e d s a t i s f a c t i o n w i t h r e s p e c t t o s o c i a l work s e r v i c e s . " In o r d e r t o a s c e r t a i n i f t h i s was t h e c a s e , the r e s p o n s e s o f s u b j e c t s i n r e l a t i o n t o t h e i r r e p o r t e d s a t i s f a c t i o n w i t h s e r v i c e was d e t e r m i n e d by a d m i n i s t e r i n g t h e s a t i s f a c t i o n q u e s t i o n n a i r e t o t h e c o n t i n u i t y and t h e t r e a t m e n t g r o u p s . When asked t o r a t e t h e i r consumer s a t i s f a c t i o n on a t h i r t y - t w o p o i n t s c a l e , w i t h t h i r t y - t w o b e i n g e q u i v a l e n t t o t h e g r e a t e s t amount o f s a t i s f a c t i o n , s u b j e c t s i n t h e c o n t i n u i t y group r a t e d t h e i r s a t i s f a c t i o n l e v e l s as s l i g h t l y h i g h e r than t h o s e s u b j e c t s i n t h e team a p p r o a c h . However, t h e s e d i f f e r e n c e s were not s t a t i s t i c a l l y s i g n i f i c a n t . These d a t a a r e r e p o r t e d i n T a b l e 7. T a b l e 7 D i f f e r e n c e s Among Treatment Groups on S u b j e c t S a t i s f a c t i o n TREATMENT GROUP NUMBER SUBJECT SATISFACTION TIME SPENT IN MINUTES CONTINUITY 26 MEAN SD 2 9 . 2 7 5 . 2 3 8 5 . 7 7 5 4 . 2 7 TEAM 12 MEAN SD 2 8 . 8 3 2 . 9 7 110.00 7 0 . 0 8 33 There were l a r g e r a p p a r e n t d i f f e r e n c e s between t h e amount o f t i m e spent by t h e s o c i a l w o r k e r w i t h s u b j e c t s a s s i g n e d t o t h e c o n t i n u i t y v e r s u s t h e team approach groups but a g a i n t h e a n a l y s i s o f t h e d i f f e r e n c e s i n t i m e spent r e v e a l e d t h a t t h e mean t i m e spent w i t h s u b j e c t s was not s t a t i s t i c a l l y s i g n i f i c a n t . I t i s t h e r e f o r e a p p a r e n t , t h a t f o r t h i s s a m p l e , t h e o r g a n i z a t i o n o f s o c i a l work s e r v i c e s by v i r t u e o f e i t h e r a c o n t i n u i t y o r team approach t o c a r e makes no d i f f e r e n c e t o t h e p a t i e n t i n terms o f t h e i r l e v e l o f s a t i s f a c t i o n f o r c a r e r e c e i v e d from s o c i a l w o r k e r s . The major q u e s t i o n s t o be answered i n t h i s s t u d y c o n c e r n t h e o v e r a l l e f f e c t o f s o c i a l work i n t e r v e n t i o n on t h e changes o f t h e s u b j e c t s ' r e p o r t i n t h e i r sense o f c o n t r o l and mood o v e r t i m e . These d a t a are r e p r e s e n t e d i n T a b l e 8 . T a b l e 8 D i f f e r e n c e s Among Treatment Groups Over Time on Mood and C o n t r o l TREATMENT HOPE HOPE HLOC HLOC GROUP NUMBER TIME 1 TIME 2 TIME 1 TIME 2 CONTINUITY 26 MEAN 3 . 4 6 3 . 1 2 3 9 . 6 5 4 0 . 5 0 SD 2 . 5 6 3 . 4 8 9 . 3 5 8 . 9 5 TEAM 12 MEAN 2 . 5 5 2.91 3 8 . 2 7 3 7 . 0 0 SD 2 . 7 3 1.87 8 . 2 6 9 . 9 1 CONTROL 9 MEAN 3 . 3 3 3 . 0 0 3 8 . 0 0 3 1 . 6 7 SD 2 . 9 2 3 . 3 5 6 . 7 0 5.87 OVERALL 47 MEAN 3 . 2 2 3 . 0 4 3 9 . 0 0 3 7 . 9 4 SD 2 . 6 4 3 . 0 8 8 . 5 0 9 . 1 9 34 When t h e t h r e e t r e a t m e n t groups were compared u s i n g a MANOVA m o d e l , t h e W i l k ' s Lamda was n o n s i g n i f i c a n t ( W i l k ' s Lamda = 1 . 1 2 , d f = 4 / 8 4 , £ > 0 . 3 5 ) . The ANOVA t e s t o f t h e d i f f e r e n c e s o f t h e t h r e e t r e a t m e n t groups was l i k e w i s e n o n s i g n i f i c a n t (F- HOPE = 0 . 3 2 , d f = 2 / 4 1 , £ > . 7 3 ; F - HLOC = 1 . 7 7 , d f = 2 / 4 1 , £ > 0 . 1 8 ) . The next a n a l y s i s examined t h e t r i a l s e f f e c t among t h e t r e a t m e n t g r o u p s . When t h e t r e a t m e n t groups were compared u s i n g a MANOVA model t h e W i l k ' s Lamda was n o n s i g n i f i c a n t ( W i l k ' s Lamda = 1 . 8 5 , d f = 4 / 8 4 , p _ > 0 . 1 7 ) . The ANOVA t e s t o f t h e d i f f e r e n c e s among t h e t h r e e t r e a t m e n t groups was a l s o n o n s i g n i f i c a n t (F - HOPE = 0 . 1 7 , d f = 2 / 4 3 , p_ > 0 . 8 4 ; F - HLOC = 1 . 7 9 , d f = 2 / 4 3 , £ > 0 . 1 8 ) . The l a s t e f f e c t t o be examined i s t h a t a s s o c i a t e d w i t h t h e changes o f t h e c o n t r o l groups o v e r t r i a l s . The MANOVA o f t h e changes o v e r t r i a l s was n o n s i g n i f i c a n t ( W i l k ' s Lamda = 0 . 4 0 , d f = 2 / 4 2 , £ > 0 . 6 7 ) . C o n s i s t e n t w i t h t h i s n o n s i g n i f i c a n t o v e r a l l e f f e c t , t h e u n i v a r i a t e ANOVAs a s s o c i a t e d w i t h t h e d i f f e r e n c e s o v e r t i m e f o r t h e s u b j e c t s ' r e p o r t o f f e e l i n g s o f h o p e l e s s n e s s (F -HOPE = 0 . 2 3 , d f = 1 / 4 3 , £ > 0 . 6 3 ) and t h e s u b j e c t s ' p e r c e p t i o n o f c o n t r o l (F - HLOC = 0 . 6 1 , d f = 1/43, £ > 0 . 4 4 ) were n o n s i g n i f i c a n t . In o r d e r t o r u l e out t h e p o s s i b l e e f f e c t o f t h e " n u i s a n c e v a r i a b l e s " , a second a n a l y s i s was done u s i n g a g e , g e n d e r , m a r i t a l s t a t u s and d i s e a s e s i t e as c o - v a r i a t e s i n a m u l t i v a r i a t e a n a l y s i s o f c o - v a r i a n c e d e s i g n . Once a g a i n , none o f t h e m u l t i v a r i a t e o r u n i v a r i a t e d i f f e r e n c e s were s i g n i f i c a n t . 35 A d d i t i o n a l A n a l y s i s The e x a m i n a t i o n o f t h e d a t a from t h e p r e v i o u s s e c t i o n s u g g e s t s t h a t t h e s u b j e c t s r e p o r t e d changes i n mood, c o n t r o l , and s a t i s f a c t i o n w i t h s o c i a l work c a r e was not s i g n i f i c a n t l y d i f f e r e n t by v i r t u e o f t h e model o f s o c i a l work c a r e p r o v i d e d . In o r d e r t o d e t e r m i n e i f o t h e r t r e a t m e n t e f f e c t s were p r e s e n t , a n a l y s i s c o n c e r n i n g t h e i n t e r a c t i o n o f t h e major v a r i a b l e s was c o n d u c t e d . The f i r s t a n a l y s i s examined t h e d i f f e r e n c e among t h e t r e a t m e n t groups on mood and c o n t r o l i n r e l a t i o n t o t h e t r e a t m e n t o f f e r e d , and i n c o m p a r i s o n t o t h e c o n t r o l g r o u p . I t s h o u l d be noted t h a t t h i s a n a l y s i s i n c l u d e s a l l s u b j e c t s who completed t h e f i r s t q u e s t i o n n a i r e whether o r not t h e y c o m p l e t e d t h i s on t h e second o c c a s i o n . These d a t a are p r e s e n t e d i n T a b l e 9 . T a b l e 9 D i f f e r e n c e Among Treatment Groups on Mood and C o n t r o l TREATMENT HOPE HLOC GROUP NUMBER TIME 1 TIME 1 CONTINUITY 38 MEAN 3 . 5 5 3 9 . 2 4 SD 2 . 7 0 9 . 2 4 TEAM 20 MEAN 4 . 0 0 3 9 . 3 0 SD 5 . 0 8 9.17 CONTROL 9 MEAN 3 . 3 3 3 8 . 0 0 SD 2 . 9 2 6 . 7 0 36 From t h e d a t a p r e s e n t e d i n T a b l e 9 , i t can be seen t h a t t h e range o f means f o r t h e H o p e l e s s n e s s s c a l e among t h e t h r e e t r e a t m e n t groups i s v e r y s i m i l a r and i s not s t a t i s t i c a l l y s i g n i f i c a n t . These non-s i g n i f i c a n t d i f f e r e n c e s i n d i c a t e t h a t t h e a t t e m p t s t o equate t h e groups w i t h r e s p e c t t o t h e i r p r e - t r e a t m e n t s t a t u s w i t h r e s p e c t t o mood and p e r c e i v e d d e g r e e s o f c o n t r o l were s u c c e s s f u l . The n e x t s e t o f a n a l y s e s i n v o l v e d comparing t h e t h r e e t r e a t m e n t groups a f t e r t h e s u b j e c t s i n t h e c o n t i n u i t y and team t r e a t m e n t groups had been exposed t o a t l e a s t twenty minutes o f i n t e r v e n t i o n . These d a t a are p r e s e n t e d i n T a b l e 10. T a b l e 10 D i f f e r e n c e s Among Treatment Groups Over Time on Mood TREATMENT HOPE HLOC GROUP NUMBER TIME 2 TIME 2 CONTINUITY 26 MEAN 3 , .12 40. .50 SD 3. .48 8. ,95 TEAM 12 MEAN 2, .75 3 6 . .08 SD 1, .86 9. .97 CONTROL 9 MEAN 3, .00 31. .67 SD 3, .35 5. .87 OVERALL MEAN 3 . 0 0 37. . 6 8 SD 3 .06 9, .25 37 T h i s r e p r e s e n t s t h e d a t a o b t a i n e d a t t h e second assessment o c c a s i o n which was t h e e x p e r i m e n t a l i n t e r v e n t i o n a t t h e end o f t h e s t u d y . The c o m p a r i s o n o f t h e s e groups r e v e a l e d no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s . The e f f e c t o f t h e s u b j e c t s ' m a r i t a l s t a t u s on t h e i r s a t i s f a c t i o n was t h e n e x t a n a l y s i s c o n d u c t e d . The r e s u l t s o f t h i s a n a l y s i s c o n t a i n e d i n T a b l e 11 r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s between t h e s e g r o u p s . T a b l e 11 D i f f e r e n c e between M a r i t a l S t a t u s on S u b j e c t S a t i s f a c t i o n MARITAL SUBJECT STATIS NUMBER SATISFACTION PARTNER 28 MEAN 2 8 . 3 9 SD 4 . 4 9 NO PARTNER 10 MEAN 2 8 . 5 4 SD 4 . 5 2 The n e x t a n a l y s i s d e t e r m i n e d i f t h e s u b j e c t s ' m a r i t a l s t a t u s was a s i g n i f i c a n t i n f l u e n c i n g f a c t o r on r e p o r t e d mood and c o n t r o l . The a n a l y s i s c o n s i d e r e d m a r i t a l s t a t u s by e x a m i n i n g two c a t e g o r i e s , t h o s e who had p a r t n e r s and t h o s e who d i d n o t . These d a t a are p r e s e n t e d i n T a b l e 12. 38 T a b l e 12 D i f f e r e n c e Between M a r i t a l S t a t u s on Mood and C o n t r o l HOPE HOPE HLOC HLOC NUMBER TIME 1 TIME 2 TIME 1 TIME 2 PARTNER 28 MEAN 3 . 0 3 2 . 6 4 3 8 . 7 2 3 6 . 5 8 SD 2 . 5 0 2 . 3 3 8 . 2 5 7 . 9 8 NO PARTNER 10 MEAN 3 . 6 4 4 . 1 8 3 9 . 3 6 41 .27 SD 3.11 3 . 7 0 9 . 5 1 12.32 A g a i n t h e s e s l i g h t d i f f e r e n c e s i n means f o r both mood and c o n t r o l were not s t a t i s t i c a l l y s i g n i f i c a n t . T h i s c o n c l u d e s t h e a n a l y s i s o f t h e r e s u l t s o f t h e s t u d y and we now t u r n t o some o f t h e i m p l i c a t i o n s and e x p l a n a t i o n s f o r t h e f i n d i n g s . 39 CHAPTER IV D i s c u s s i o n The aim o f t h i s s t u d y was t o d e t e r m i n e t h e e f f e c t o f two approaches o f s o c i a l work i n t e r v e n t i o n , t h e c o n t i n u i t y a p p r o a c h , and a team a p p r o a c h , upon t h e t h r e e dependent v a r i a b l e s o f s u b j e c t s a t i s f a c t i o n , c o n t r o l , and mood. The a n a l y s i s o f t h e r e l a t i o n s h i p between t h e s e v a r i a b l e s r e v e a l e d t h a t t h e r e were no s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e s between t h e s e g r o u p s ; s u b j e c t s were e q u a l l y s a t i s f i e d w i t h t h e two approaches i n s o c i a l work i n t e r v e n t i o n , and t h e r e were no major d i f f e r e n c e s between t h e r e p o r t e d changes i n mood and c o n t r o l by t h e s u b j e c t s i n t h e s e two g r o u p s . There a r e a number o f p o s s i b l e e x p l a n a t i o n s which s u p p o r t t h e s e f i n d i n g s . S u b j e c t s p e r c e i v e t h a t t h e s e r v i c e r e c e i v e d from s o c i a l w o r k e r s whether by t h e c o n t i n u i t y o r t h e team model was v e r y g o o d , t h e r e f o r e , what was i m p o r t a n t perhaps was not whether c o n t i n u i t y was p r o v i d e d but i n s t e a d t h a t t h e r e be an a s s u r a n c e o f good q u a l i t y s e r v i c e . In v i e w o f t h e r e l a t i v e s i m i l a r i t y o f s c o r e s f o r t h e c o n t i n u i t y and team g r o u p s , i t i s c o n c e i v a b l e t h a t t h e s u b j e c t s d i d not p e r c e i v e a l o s s o f c o n t i n u i t y ; t h e y may have viewed t h a t t h e r e c e i p t o f s o c i a l work i n t e r v e n t i o n whether by one s o c i a l worker o r two s o c i a l w o r k e r s 40 were e s s e n t i a l l y t h e same and were viewed as e q u a l l y as g o o d . P e r h a p s , t h e communication between s o c i a l w o r k e r s p r o v i d i n g c a r e i n t h e team i n t e r v e n t i o n was s a t i s f a c t o r y t o t h e p o i n t t h a t t h e s u b j e c t d i d not f e e l t h a t t h e y needed t o " t e l l t h e i r s t o r y " r e p e a t e d l y i n o r d e r t o r e c e i v e t h e needed s e r v i c e , o r t h a t t e l l i n g t h e i r s t o r i e s was not c o n s i d e r e d a p r o b l e m . L i t t l e i s known about t h e impact o f t h e t r e a t m e n t by s o c i a l w o r k e r s i n o n c o l o g y s e t t i n g s c o n c e r n i n g t h e i n t e r v e n t i o n on p s y c h o s o c i a l f a c t o r s . I t i s p o s s i b l e , t h a t t h e t r e a t m e n t i n t e r v e n t i o n s p r o v i d e d i n t h e m s e l v e s had an impact on a n o t h e r f a c t o r and not on t h e p a t i e n t ' s sense o f c o n t r o l and t h e i r mood. S i n c e p a t i e n t s were s a t i s f i e d w i t h t h e s e r v i c e s r e c e i v e d , what i s t h e r e f o r e needed perhaps i s t o d e t e r m i n e what f a c t o r s were p a r t i c u l a r l y i m p o r t a n t t o t h e s u b j e c t s w h i c h r e s u l t e d i n t h e i r r a t i n g o f s o c i a l work s e r v i c e s t o be h i g h . Some o f t h e p r e v i o u s l i t e r a t u r e r e p o r t e d r e s e a r c h i n o t h e r s e t t i n g s s u g g e s t i n g t h a t t h e r e are b e t t e r c l i n i c a l outcomes i n c o n t i n u i t y m o d e l s , however, s u b j e c t s i n t h e s e s t u d i e s were i n f a m i l y p r a c t i c e s e t t i n g s and t h e r e i s no i n d i c a t i o n t h a t any o f t h e s e i n d i v i d u a l s were c a n c e r p a t i e n t s . F u r t h e r m o r e , i t i s p o s s i b l e t h a t t h e l e n g t h o f t h e r e l a t i o n s h i p between t h e p a t i e n t and t h e p h y s i c i a n was o f l o n g e r d u r a t i o n i n c o m p a r i s o n w i t h t h e c u r r e n t s t u d y . A n o t h e r p o s s i b i l i t y i s t h a t t h e s u b j e c t may have c o n s i d e r e d t h e CCABC as a s e l f - c o n t a i n e d c o n t i n u i t y model where p h y s i c i a n s , n u r s e s and s o c i a l w o r k e r s work as a team t o p r o v i d e t h e needed c a r e f o r t h e c a n c e r p a t i e n t , and t h e s u b j e c t s i n t h i s s t u d y may not p e r c e i v e t h e d i f f e r e n c e i n c a r e between t h e team and t h e c a r e p r o v i d e d by t h e s o c i a l w o r k e r . 41 A l t h o u g h t h e two i n t e r v e n t i o n groups were r o u g h l y t h e same w i t h r e s p e c t t o t h e amount o f t i m e spent by s o c i a l w o r k e r s w i t h s u b j e c t s , a c o n c e r n i n t h e d e s i g n o f t h e s t u d y r e l a t e s t o t h e o v e r a l l t i m e and t h e number o f c o n t a c t s between s o c i a l w o r k e r s and s u b j e c t s . Perhaps both t i m e and number o f c o n t a c t s have been o f i n s u f f i c i e n t d u r a t i o n and number t o r e s u l t i n r e s p e c t a b l e d i f f e r e n c e s between t h e t r e a t m e n t g r o u p s . I t i s q u i t e p o s s i b l e t h a t t h e v a l u e o f c o n t i n u i t y o f s e r v i c e s i s o v e r -r a t e d by r e s e a r c h e r s a n d , i n f a c t , i t i s t h e p r a c t i o n e r who p l a c e s g r e a t e r v a l u e on c o n t i n u i t y r e l a t i o n s h i p s w i t h t h e i r p a t i e n t s i n o r d e r t o meet some o f t h e i r p e r s o n a l needs and t h e i r p r o f e s s i o n a l r e l a t i o n s h i p w i t h t h e i r p a t i e n t . Recommendation f o r F u r t h e r Study Much can be g a i n e d i n u n d e r t a k i n g r e s e a r c h i n an a r e a t h a t has r e c e i v e d l i t t l e s t u d y . In t h i s p r o j e c t , a number o f c o n c e r n s were uncovered and t h e s e a r e summarized by c a t e g o r y . A c c r u a l A major d i f f i c u l t y i n u n d e r t a k i n g t h i s s t u d y c o n c e r n s t h e problem o f o b t a i n i n g a s u f f i c i e n t number o f s u b j e c t s t o u n d e r t a k e t h i s s t u d y . G a s t r o i n t e s t i n a l c a n c e r p a t i e n t s i n p a r t i c u l a r were found t o be f r e q u e n t l y i l l due t o t h e s i d e e f f e c t s o f t r e a t m e n t . C o n s e q u e n t l y , t h e s o c i a l w o r k e r s p r o v i d i n g c a r e were o f t e n r e l u c t a n t t o approach p a t i e n t s when t h e y were i l l and t h i s n a t u r a l l y i n f l u e n c e d t h e amount o f t i m e and 42 t h e number o f c o n t a c t s t h e y had w i t h t h e s u b j e c t s . Assuming f u t u r e r e s e a r c h was c o n d u c t e d , i t would be recommended t h a t o t h e r d i s e a s e s i t e s be c o n s i d e r e d and t h a t t h e s t u d y a c c r u a l c o n t i n u e f o r a t l e a s t a t w e l v e month p e r i o d i n o r d e r t o accumulate a g r e a t e r number o f p a t i e n t s . A l t h o u g h t h i s would not n e c e s s a r i l y s o l v e t h e problem o f r e p r e s e n t a t i v e n e s s o f t h e s a m p l e , t h i s c o u l d a d d r e s s t h e i s s u e o f not d e t e c t i n g i m p o r t a n t c l i n i c a l d i f f e r e n c e s due t o s m a l l sample s i z e s . I n s t r u m e n t s The m a t t e r o f t h e i n s t r u m e n t s s e l e c t e d f o r t h i s s t u d y was one o f t h e few s u b j e c t a r e a s were d i r e c t feedback from p a t i e n t s was r e c e i v e d . The r e p o r t s o f s u b j e c t s r e g a r d i n g t h e i n s t r u m e n t s were o f t e n c o l l e c t e d on an i n f o r m a l b a s i s , a l t h o u g h some s u b j e c t s p r o v i d e d comments on t h e i r r e t u r n e d q u e s t i o n n a i r e s . The H o p e l e s s n e s s S c a l e posed v e r y few problems f o r s u b j e c t s and were g e n e r a l l y v e r y w e l l c o m p l e t e d . Yet p a r a d o x i c a l l y , some s u b j e c t s r e v e a l e d t h a t t h e y had d i f f i c u l t y i n g e t t i n g t h r o u g h " t h e s c a l e " h a v i n g j u s t r e c e i v e d news o f t h e i r d i a g n o s i s and t r e a t m e n t p l a n . T h i s would l e a d one t o b e l i e v e t h e n t h a t t h e t i m i n g o f a d m i n i s t r a t i o n o f t h e q u e s t i o n n a i r e c o u l d be c r i t i c a l . The Locus o f C o n t r o l q u e s t i o n n a i r e was s i m i l a r l y w e l l completed w i t h many o f t h e s u b j e c t s commenting t h a t t h e q u e s t i o n s were i n t e r e s t i n g and t h o u g h t p r o v o k i n g . 43 The major d i f f i c u l t y c o n c e r n i n g i n s t r u m e n t s i s t h a t v e r y few s c a l e s have been d e v e l o p e d t h a t a d d r e s s t h e s p e c i f i c problems and e x p e r i e n c e s o f c a n c e r p a t i e n t s . F u r t h e r m o r e , t h e o r d e r i n g o f t h e i n s t r u m e n t s f o r s t u d y r e q u i r e s c o n s i d e r a b l e thought s i n c e some s u b j e c t s r e p o r t e d d i f f i c u l t i e s h e r e . For e x a m p l e , t h e H o p e l e s s n e s s q u e s t i o n n a i r e was a d m i n i s t e r e d t o s u b j e c t s f i r s t , f o l l o w e d by t h e H e a l t h Locus o f C o n t r o l and t h e P a t i e n t S a t i s f a c t i o n q u e s t i o n n a i r e (where a p p r o p r i a t e ) . Some s u b j e c t s r e p o r t e d (by a t t a c h i n g comments t o t h e q u e s t i o n n a i r e ) t h a t t h e y found t h e s e q u e s t i o n s t o be d e p r e s s i n g and t h a t i t was d i f f i c u l t t o c o n t i n u e t o respond t o f u r t h e r q u e s t i o n s . Treatment I n t e r v e n t i o n Perhaps t h e key a r e a t h a t r e q u i r e s f u r t h e r s t u d y c o n c e r n s t h e a c t u a l t r e a t m e n t i n t e r v e n t i o n p r o v i d e d by s o c i a l w o r k e r s i n a d d r e s s i n g t h e p s y c h o s o c i a l c o n c e r n s o f c a n c e r p a t i e n t s . Much has been w r i t t e n about t h e impact o f c a n c e r from a p s y c h o s o c i a l p o i n t o f v i e w , but t h e r e has been l i t t l e e x a m i n a t i o n o f what t e c h n i q u e s work b e s t i n a d d r e s s i n g t h e s e n e e d s . At t h e CCABC, s o c i a l w o r k e r s have commonly d e s c r i b e d t h e i r r o l e as one o f c o u n s e l l i n g , s u p p o r t , and p r o v i d e r s o f i n s t r u m e n t a l c a r e . I t i s recommended t h a t more s p e c i f i c approaches be u n d e r t a k e n i n o r d e r t o t e s t t h e e f f e c t i v e n e s s o f d i f f e r e n t t y p e s o f i n t e r v e n t i o n . For e x a m p l e , many s o c i a l w o r k e r s a t CCABC c o n s i d e r e d t h a t a f a m i l y approach 44 t o c a r e i s i m p o r t a n t which t a k e s i n t o c o n s i d e r a t i o n t h e impact o f t h e d i s e a s e on i n d i v i d u a l members w i t h i n t h e f a m i l y u n i t . L i t t l e i s known about t h e a c t u a l impact o f t h e d i s e a s e on f a m i l y members, and i n d e e d w h i c h t y p e s o f s o c i a l work c a r e work b e s t t o a l l e v i a t e t h e s e c o n c e r n s . More w i d e s p r e a d i n t r o d u c t i o n o f r e l a x a t i o n and s t r e s s r e d u c t i o n t e c h n i q u e s a r e o t h e r examples o f c l i n i c a l a r e a s t h a t r e q u i r e a t t e n t i o n . A l t h o u g h many h e a l t h c a r e p r a c t i t i o n e r s may c r i t i c i z e t h e c o n c e p t o f t h e development o f a t r e a t m e n t manual i n t h e c a r e o f c a n c e r p a t i e n t s and t h e i r f a m i l i e s , i t does seem r e a s o n a b l e t h a t g r e a t e r s p e c i f i c i t y o f t e c h n i q u e s f o r improved c a r e , and a l l o w i n g f o r g r e a t e r f e a s i b i l i t y f o r a more e x a c t e v a l u a t i o n a r e i n o r d e r . Summary T h i s r e p o r t has examined i n d e t a i l an i m p o r t a n t c o n s t r u c t i n t h e d e l i v e r y o f h e a l t h c a r e s e r v i c e s i n s o c i a l w o r k , c o n t i n u i t y o f c a r e . A l t h o u g h i t i s c l e a r t h a t no d i f f e r e n c e s between t h e c o n t i n u i t y and team models were r e v e a l e d i n t h i s s t u d y , c o n s i d e r i n g t h e i m p o r t a n t c l i n i c a l and f i n a n c i a l c o n s i d e r a t i o n s i n t h e d e l i v e r y o f h e a l t h c a r e a t CCABC, c o n t i n u e d s t u d y o f t h e worth o f c o n t i n u i t y programs r e q u i r e s f u r t h e r a t t e n t i o n . 45 B i b l i o g r a p h y ALPERT, J . J . , Broken a p p o i n t m e n t s . J o u r n a l o f P e d i a t r i c s , 1964; 3 4 : 127. BECK, A . T . , and Weissman, A . , Measurement o f p e s s i m i s m : The h o p e l e s s n e s s s c a l e . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1974; 4 2 ( 6 ) : 6 8 1 - 6 8 5 . BECKER, M . H . , Drachman, R . H . , and K i r s c h t , J . P . , C o n t i n u i t y o f p e d i a t r i c i a n , new s u p p o r t f o r an o l d s h i b b o l e t h . J o u r n a l o f P e d i a t r i c s , 1974; 8 4 ( 4 ) : 5 9 9 - 6 0 5 . BECKER, M . H . , Drachman, R . H . , and K i r s c h t , J . P . , P r e d i c t i n g m o t h e r s ' c o m p l i a n c e w i t h p e d i a t r i c m e d i c a l r e g i m e n s . J o u r n a l o f P e d i a t r i c s , 1972; 8 1 : 8 4 3 . BERKMAN, B . , R e h r , H . , and R o s e n b e r g , G . , A s o c i a l work department d e v e l o p s and t e s t s a s c r e e n i n g mechanism t o i d e n t i f y h i g h r i s k s i t u a t i o n s . S o c i a l Work, 1980; 5 ( 4 ) : 3 7 3 - 3 8 5 . BRESLAU, N . , S t a r u c h , J . S . , and M o r t i m e r , E .A. J r . , P s y c h o l o g i c a l d i s t r e s s i n mothers o f d i s a b l e d c h i l d r e n . American J o u r n a l o f D i s e a s e i n C h i l d r e n , 1982; 1 3 6 ( 8 ) : 6 8 2 - 6 8 6 . BUFFUM, V . , P r o v i d i n g f o r c o n t i n u i t y o f c a r e : t h e r e f e r r a l p r o c e s s . J o u r n a l o f t h e American O p t o m e t r i c A s s o c i a t i o n , 1984; 5 5 : 519. DEROGATIS, L . R . , A b e l o f f , M . , and M e l i s a r a t o s , N . , P s y c h o l o g i c a l c o p i n g mechanisms and s u r v i v a l t i m e i n m e t a s t a t i c b r e a s t c a n c e r . J o u r n a l o f American M e d i c a l A s s o c i a t i o n , 1979; 2 4 2 ( 1 4 ) : 1504-1508. DIETRICH, A . J . , and M a r t o n , K . I . , Does c o n t i n u o u s c a r e from a p h y s i c i a n make a d i f f e r e n c e ? J o u r n a l o f F a m i l y P r a c t i c e , 1982; 1 5 ( 5 ) : 9 2 9 - 9 3 7 . DRIGGERS, D . , The f a m i l y c o n t i n u i t y o f c a r e c o n t r a c t . J o u r n a l o f F a m i l y P r a c t i c e , 1982; 1 5 ( 3 ) : 471-473. DUA, P, Comparison o f t h e e f f e c t s o f b e h a v i o r a l l y o r i e n t e d a c t i o n and p s y c h o t h e r a p y r e e d u c a t i o n on i n t r o v e r s i o n - e x t r a v e r s i o n , e m o t i o n a l i t y , and i n t e r n a l - e x t e r n a l c o n t r o l . J o u r n a l o f C o u n s e l i n g P s y c h o l o g y , 1970; 17: 5 6 7 - 5 7 2 . ERIKSSON, E . A . , Q u a n t i t a t i v e measurement o f c o n t i n u i t y o f c a r e , M e d i c a l  C a r e . 1983; 2 1 ( 9 ) : 8 5 8 - 8 7 5 . 46 FOBAIR, P . , S o c i a l work i n t h e c a n c e r c e n t e r . F r o n t i e r s o f R a d i a t i o n O n c o l o g y , 1973; 8 : 109-111. FOX, J . G . , and S t o r m s , D . 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ROGERS, J . , and C u r t i s , P . , The c o n c e p t and measurement o f c o n t i n u i t y i n p r i m a r y c a r e . American J o u r n a l o f P u b l i c h H e a l t h , 1980; 70: 122. R00S, L . L . , Roos, N . P . , G i l b e r t , P . , and N i c o l , J . P . , C o n t i n u i t y o f c a r e : does i t c o n t r i b u t e t o q u a l i t y o f c a r e ? M e d i c a l C a r e , 1980; 18: 3 7 6 - 3 8 7 . SARASON, I . , L e v i n e , H . , Basham, R . , S a r a s o n , B . , A s s e s s i n g s o c i a l s u p p o r t : q u e s t i o n n a i r e . J o u r n a l o f P e r s o n a l i t y and S o c i a l P s y c h o l o g y 1983; 4 4 : ( 1 ) : 127-139. SCHMALE, A . , R e l a t i o n s h i p o f s e p a r a t i o n and d e p r e s s i o n t o d i s e a s e . P s y c h o s o m a t i c M e d i c i n e , 1958; 2 0 : 2 5 9 . SCHMALE, A . , A g e n e t i c view o f a f f e c t s : w i t h s p e c i a l r e f e r e n c e t o t h e g e n e s i s o f h e l p l e s s n e s s and h o p e l e s s n e s s . P s y c h o a n a l y s i s i n t h e  Study o f C h i l d r e n , 1964; 19: 287. SCHMALE, A. and I k e r , H . , The e f f e c t o f h o p e l e s s n e s s i n t h e development o f c a n c e r - I . The p r e d i c t i o n o f u t e r i n e c e r v i c a l c a n c e r i n women w i t h a t y p i c a l c y t o l o g y . P s y c h o s o m a t i c M e d i c i n e , 1966; 28: 714. SHEPARDSON, J . , Team approach t o t h e p a t i e n t w i t h c a n c e r . American J o u r n a l o f N u r s i n g , March 1972; 4 8 8 - 4 9 1 . SHORTELL, S . M . , The r e l a t i o n s h i p s among d i m e n s i o n s o f h e a l t h s e r v i c e s i n two p r o v i d e r s y s t e m s : a c a s u a l model a p p r o a c h . J o u r n a l o f H e a l t h  and S o c i a l B e h a v i o u r , 1977; 18: 139. SLOANE, P . , and E g e l h o f f , C , The r e l a t i o n s h i p o f c o n t i n u i t y o f c a r e t o a g e , s e x , and r a c e . J o u r n a l o f F a m i l y P r a c t i c e , 1983; 16: 4 0 2 - 4 0 5 . SMITH, L . L . , S o c i a l work s e r v i c e s f o r r a d i a t i o n t h e r a p y p a t i e n t s and t h e i r f a m i l i e s . H o s p i t a l and Community P s y c h i a t r y , O c t o b e r 1977; 2 8 ( 1 0 ) : 7 5 2 - 7 5 4 . SPSS - X. ( 1 9 8 3 ) . S t a t i s t i c a l Packages f o r t h e S o c i a l S c i e n c e s - u s e r ' s g u i d e . New Y o r k : A u t h o r . 49 STARFIELD, B . H . , S i m b o r g , D . W . , H o r n , S . D . , and Y o u r t e e , S . A . , C o n t i n u i t y and c o o r d i n a t i o n i n p r i m a r y c a r e : T h e i r achievement and u t i l i t y , M e d i c a l C a r e , 1976; 14: 6 2 5 . STEWART, M . A . , and WANKLIN, J . , D i r e c t and i n d i r e c t measures o f p a t i e n t s a t i s f a c t i o n w i t h p h y s i c i a n s ' s e r v i c e s . J o u r n a l o f  Community H e a l t h , 1978; 3 : 195-204. SWAN, J . E . , and C a r r o l l , M . 6 . P a t i e n t s a t i s f a c t i o n : An o v e r v i e w o f r e s e a r c h - 1965 t o 1978. In H.K. Hunt & R . L . Day ( E d s . ) , R e f i n i n g c o n c e p t s and measures o f consumer s a t i s f a c t i o n and c o m p l a i n i n g  b e h a v i o u r . B l o o m i n g t o n , IN: I n d i a n a U n i v e r s i t y P r e s s , 1980. TELCH, C , and T e l c h , M. Group c o p i n g s k i l l s i n s t r u c t i o n and s u p p o r t i v e group t h e r a p y f o r c a n c e r p a t i e n t s : a c o m p a r i s o n o f s t r a t e g i e s . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1986; 54: 8 0 2 - 8 0 8 . WALLSTON, B . S . , W a l l s t o n , K . A . , K a p l a n , G . D . , and M a i d e s , S . A . , Development and v a l i d a t i o n o f t h e h e a l t h l o c u s o f c o n t r o l (HLC) s c a l e . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1976; 4 4 ( 4 ) : 5 8 0 - 5 8 5 . WARE, J . E . , S n y d e r , M . K . , W r i g h t , W . R . , and D a v i e s , A . R . D e f i n i n g and m e a s u r i n g p a t i e n t s a t i s f a c t i o n w i t h m e d i c a l c a r e . E v a l u a t i o n and  Program P l a n n i n g , 1983; 6 : 2 4 7 - 2 6 3 . WESTBR00K, R . A . , and O l i v e r , R . L . , D e v e l o p i n g b e t t e r measures o f consumer s a t i s f a c t i o n : some p r e l i m i n a r y r e s u l t s . In K . B . Munroe ( E d . ) , Advances i n consumer r e s e a r c h ( V o l . 8 ) . Ann A r b o r , MI: A s s o c i a t i o n f o r Consumer R e s e a r c h , 1981. W00LLEY, F . R . , Kane, R . L . , Hughes, C C . , and W r i g h t , D . D . , The e f f e c t s o f d o c t o r - p a t i e n t communication on s a t i s f a c t i o n and outcome o f c a r e . S o c i a l S c i e n c e s and M e d i c i n e , 1978; 12: 123-128. Y0UNG-BR0CK0PP, D . , Cancer p a t i e n t s ' p e r c e p t i o n s o f f i v e p s y c h o s o c i a l n e e d s . Oncology N u r s i n g Forum, 1982; 9 : 3 4 - 3 5 . 50 APPENDIX II Please indicate your feelings about these questions (1-20) by marking true i f you agree or false i f you disagree with the statments as they apply to you. TRUE FALSE 1. I look forward to the future with hope and enthusiasm. 2. I might as well give up because I can't make things better for myself. 3. When things are going badly, I am helped by knowing they can't stay that way forever. 4. I can't imagine what my l i f e would be lik e in 10 years. 5. I have enough time to accomplish the things I most want to do. 6. In the future, I expect to succeed in what concerns me most. 7. My future seems dark to me. 8. I expect to get more of the good things in l i f e than the average person. 9. I just don't get the breaks, and there's no reason to believe I will in the future. 10. My past experiences have prepared me well for my future. 11. A l l I can see ahead of me is unpleasant rather than pleasantness. 12. I don't expect to get what I really want. 13. When I look ahead to the future, I expect I will be happier than I am now. 52 TRUE FALSE 14. Things just won't work out the way I want them to. 15. I have great faith 1n the future. 16. I never get what I want so It's foolish to want anything. 17. It is very unlikely that I will get any real satisfaction 1n the future. 18. The future seems vague and uncertain to me. 19. I can look forward to more good times than bad times. 20. There's no use 1n really trying to get something I want because I probably won't get i t . 53 Appendix I I I Below a r e a number o f s t a t e m e n t s about v a r i o u s a t t i t u d e s about h e a l t h . There a r e no r i g h t o r wrong answers t o t h e s e q u e s t i o n s ; f o r e v e r y s t a t e m e n t t h e r e are a l a r g e number o f p e o p l e who agree and d i s a g r e e . P l e a s e i n d i c a t e whether you agree o r d i s a g r e e w i t h each s t a t e m e n t as f o l l o w s by c i r c l i n g t h e number; Example: 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 1 . I f I t a k e c a r e o f m y s e l f , I can a v o i d i l l n e s s . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 2 . Whenever I g e t s i c k i t i s because o f something I ' v e done o r not d o n e . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 3 . Good h e a l t h i s l a r g e l y a m a t t e r o f good f o r t u n e . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 4 . No m a t t e r what I d o , i f I'm g o i n g t o g e t s i c k I w i l l g e t s i c k . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 5 . Most p e o p l e do not r e a l i z e t h e e x t e n t t o which t h e i r i l l n e s s e s a r e c o n t r o l l e d by a c c i d e n t a l h a p p e n i n g s . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 54 2 6 . I can o n l y do what my d o c t o r t e l l s me t o d o . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 27. There a r e so many s t r a n g e d i s e a s e s around t h a t you can never know how o r when you might p i c k one up. 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 8 . When I f e e l i l l I know i t i s because I have not been g e t t i n g t h e p r o p e r e x e r c i s e o r e a t i n g r i g h t . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 2 9 . P e o p l e who never g e t s i c k a r e j u s t p l a i n l u c k y . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 3 0 . P e o p l e ' s i l l h e a l t h r e s u l t s from t h e i r own c a r e l e s s n e s s . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 3 1 . I am d i r e c t l y r e s p o n s i b l e f o r my own h e a l t h . 1 2 3 4 5 6 STRONGLY STRONGLY DISAGREE AGREE 55 A P P E N D I X I V Please help us improve our program by answering some questions about the services you have received at the Cancer Control Agency's Social Work Department. We are interested in your honest opinions, whether they are positive or negative. Please answer all of the questions. We also welcome your comments and suggestions. Thank you very much, we appreciate your help. CIRCLE YOUR ANSWER: 1. How would you rate the quality of service you receive from the Social Work Department? 4 3 2 1 Excellent Good Fair Poor 2. Did you get the kind of service you wanted? 1 2 3 4 No definitely No, not Yes, generally Yes, definitely not really 3. To what extent have our social work services met your needs? 4 3 2 1 Almost all of Most of my Only a few of None of my my needs have needs have my needs have needs have been met been met been met been met 4. If a friend were In need of similar help, would you recommend our Department to him/her? 1 2 3 4 No, definitely No, I don't Yes, I think so Yes, definitely not think so 56 5. How satisfied are you with the amount of help you received? 1 2 3 4 Quite Indifferent or Mostly Very dissatisfied mildy satisfied satisfied dissatisfied 6. Have the services you received helped you deal more effectively with your concerns? 4 3 2 1 Yes, they Yes, they No, they really No, they seemed helped a great helped didn't help to make things deal somewhat worse 7. In an overall, general sense, how satisfied are you with the service you received? 4 3 2 1 Very satisfied Mostly Indifferent or Quite satisfied mildy d i s s a t i s f i e d 8. If you were to seek help again, would you come back to our Social Work Department? No, defi n i t e l y No, I don't _ Yes, I think so Yes, de f i n i t e l y not think so WRITE COMMENTS BELOW: 57 

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