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This is to certify that the
thesis entitled

THE INFLUENCE OF SOCIOECONOMIC STATUS ON THE
UTILIZATION OF COMMUNITY HEALTH SERVICES OF
INDIVIDUALS DIAGNOSED WITH LUNG CANCER.

presented by

JANE LERMONT. SMALLWOOD

has been accepted towards fulfillment
of the requirements for

M.S,N, Jegreeinm

with

Major professor

8/3/75

0-7639 MS U is an Affirmative Action/Equal Opportunity Institution

 

 

LIBRARY

Michigan State
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PLACE IN RETURN BOX
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ma mm“

THE INFLUENCE OF SOCIOECONOMIC STATUS ON
THE UTILIZATION OF COMMUNITY HEALTH SERVICES OF INDIVIDUALS
DIAGNOSED WITH LUNG CANCER
BY

JANE LERMONT SMALLWOOD

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
of the degree of

MASTERS OF SCIENCE
College of Nursing

1998

ABSTRACT
THE INFLUENCE OF SOCIOECONOMIC STATUS ON THE

UTILIZATION OF FORMAL COMMUNITY HEALTH SERVICES
OF INDIVIDUALS DIAGNOSED WITH LUNG CANCER

BY

Jane Lermont Smallwood

The purpose of this study was to examine the influence
of socioeconomic status on the utilization of formal
community health services of individuals diagnosed with lung
cancer. This was a correlational study, using secondary data
analysis of the Community Based Cancer Study. A connivance
sample of 196 individuals, ages 66-90 with a recent
diagnosis of lung cancer were enlisted from participating
cancer sites in Michigan. Data was obtained by telephone
interviews at six and twelve weeks post diagnosis. The
framework for this study focused on predisposing, enabling,
and need factors which influence the use of formal community
health services. Implication for APNs in primary care who
care for cancer patients, as well as, implications for

further research were identified.

ACKNOWLEDGMENTS

I would like to thank my Thesis Chair, Barbara A.
Given, RN, Ph.D., FAAN and the members of my thesis
committee Clare Collins, RN, CS, Ph.D. and Patricia Peek RN,
CS for their guidance and constructive assistance in this
research project. Also, I am indebted to Susan Ratwick,
Ph.D. whose expert knowledge of SPSS and willingness to help
were critical to my statistical analysis. I also, would
like to thank my husband Paul and family for all of their

encouragement, love, and patience through this project.

iii

TABLE OF CONTENT

page

LIST OF TABLES .......................................... iv
LIST OF FIGURES .......................................... V
CHAPTER I: Introduction .................................. 1
Problem Statement ....................................... 2
Purpose of Research Question ............................. 4
CHAPTER II: CONCEPTUAL FRAMEWORK ......................... 6
Conceptual Definitions of the Variables .................. 6
Formal Community Services ........................... 6
Socioeconomic Status ................................ 6
Functional Status ................................... 7

Lung Cancer ......................................... 9
Theoretical Framework .................................... 9
CHAPTER III: REVIEW OF LITERATURE ....................... 16
Overview ................................................ 16
Socioeconomic Status ............................... 16
Functional Status .................................. 19

Use of Services .................................... 20
CHAPTER IV: METHODS ..................................... 27
Study Design ............................................ 27

iv

page
Sample Selection ........................................ 27
Data Collection ......................................... 28

Operational Definitions, Instrumentation, and Scoring...29

Analysis ................................................ 33
CHAPTER V: RESULTS ...................................... 35
Sociodemographic Characteristics ........................ 37
Socioeconomic Factors and Community service use ......... 37
Functional Status .................................. 37
Education .......................................... 39
Income ............................................. 41
Insurance Coverage ................................. 44
Interpretation Of Findings and Discussion ............... 47
Other Interesting Findings .............................. 50
Limitations of The Study ................................ 52
CHAPTER VI: IMPLICATIONS FOR ADVANCED
NURSING PRACTICE ............................ 55
Implications for Further Research ....................... 62
Bibliography ............................................ 66
Appendix A: Functional Status Questionnaire ............. 71
Appendix B: Subject Consent Form ........................ 74

Appendix C: University Committee on Research Involving
Human Subjects Approval of the Family Home
Care for Cancer——A Community Based Model
Study ....................................... 78

Appendix D: University Committe on Research Involving
Human subjects Approval of This
study ....................................... 80

Table

Table

Table

Table

Table

Table

Table

LIST OF TABLES
Proposed Variables of the Study ............. Page
Sociodemographic Variables .................. Page

Formal Community Health Service Use By
Frequency and Percent ....................... Page

Functional Status and Use of Formal Community
Health Services by Number, Percent, and
Significance ................................ Page

Educational Level and Use of Formal Community
Health Service By Number, Percent, and
Significance ................................ Page

Income Level and Use of Formal Community
Health Services By Number, Percent, and
Significance ................................ Page

Insurance Coverage and Use of Formal Community

Health Services By Number, Percent, and
Significance ................................ Page

vi

35

38

4O

42

45

46

LIST OF FIGURES

Page
Figure 1: The Initial Behavior Model of Families Use
of Health Services B Andersen ............... 13
Figure 2: Model of Health Service Use ................. 15

vii

Chapter I

INTRODUCTION

According to the American Cancer Society (1997) eight
million Americans alive today have been diagnosed with
cancer, and it is estimated that an additional 1,382,400 new
cases of invasive cancer will be diagnosed in 1997.
Statistics have proven that one of ever five deaths in the
United States is due to cancer. Predictions suggest that
roughly 560,000 people may die of Cancer this year, this
equals more than 1,500 people each day. Lung cancer is
reported to be the leading cause of cancer deaths among both
women and men. Even though the number of people being
diagnosed with lung cancer is increasing, the available
resources to help meet the needs of these individuals may
not be.

Individuals diagnosed with cancer have many needs. In a
hospital setting these needs are readily met by
professionals aware of how to access available resources.
Once the individual is out of the acute care setting and
into the community it can be very difficult to meet some of
their most basic needs (Reddall, 1994). Several

characteristics of the health care system including

accessibility, availability, affordability may have a
tremendous influence on whether an individual with the
diagnosis of cancer is able to have their needs met. Failure
of formal as well as informal support systems to meet cancer
patients needs can lead to decline in outlook and
functioning as well as unfavorable decisions regarding
treatment (Goudagnoli, Rice, & Mor, 1991). The use of
community health services is one way in which cancer
patients can attempt to help get their needs met.

Formal community health services can play a vital role
in meeting the needs of cancer patients, unfortunately they
are not always available to all persons diagnosed with
cancer. A large percentage of individuals diagnosed with
cancer are elderly, less economically advantaged and have a
lower level of education, which may lead to difficulties in
access to formal community health services (Given, Given &
Harlan 1994). The socioeconomically disadvantaged may be the
population with the greatest need for community services,
yet have the least means in obtaining such assistance.
Therefore, it is crucial to determine what factors influence
the use of formal community health services in order to help
facilitate access by the persons with the greatest needs.

Problem Statement
The social and economic environment in which

individuals diagnosed with cancer reside has a great impact

on survival duration as well as quality of survival
(Randall, 1994). The socioeconomically disadvantage have a
high level of ineffective coping with their physical and
social environment, secondary to ignorance and poverty
(Freeman, 1989). Data has concluded that persons living
below the poverty level have a much greater rate of death
from cancer than do persons who are above the poverty level
(Underwood, & Hoskins, 1994). According to Freeman (1989)
the 5 year survival rate for poor individuals diagnosed with
cancer, is estimated to be 10% to 15% lower then middle and
upper class individuals.

According to the United States Department of Commerce,
Bureau of Census in (1993) there were 39.3 million persons
living below the official government poverty level. These
statistics indicate that the poverty level in the United
States is worsening. The United States Department of
Education (1994) reports that only 71.8 percent of persons
60-65 years of age have attained a high school diploma.
Given these statistics it may be accurate to assume there
are a significant number of individuals who have been
diagnosed with cancer that are under educated and living in
poverty.

In order to promote more favorable outcomes, health
care professionals must develop the expertise needed, to

assist socioeconomically disadvantaged individuals with

cancer to access and utilize formal community health
services available to them. Formal community health services
play a vital link in meeting the needs of individuals who
are in the chronic stages of the cancer. Such services help
to meet the physical and psychological needs of individuals
that social support systems may be unable to fulfill.

In order for individuals to utilize community services
they must be aware of the services available to them, and
the way in which to access such services. Therefore, it is
imperative that Advanced Practice Nurses in primary care,
educate individuals and develop interventions that encourage
the use of community health services by cancer patients, in
order to promote more favorable outcomes.

Purpose and Research Question

There is a great need for more insight into why and
when cancer patients do, or do not utilize formal community
health services. It is also important to determine whether
socioeconomic factors influence the use of such services,
since the socioeconomically disadvantaged appear to be at
greatest risk for poor outcomes of cancer. The purpose of
this study is to determine if differences in socioeconomic
status and functional status have an influences the use of
community health services by individuals diagnosed with lung
cancer. Therefore the questions to be answered in this

study are:

Is there a difference in socioeconomic status of
individuals diagnosed with lung cancer that utilize
formal community health services and those who do not
use services?

Is there a difference in functional status of
individuals diagnosed with lung cancer that utilize
formal community health services and those who do not

use services?

Chapter II
Conceptual Framework
Conceptual Definitions of the variables
The variables identified for this study are: 1) use of
formal community services as the dependent variable; 2)
socioeconomic factors as the independent variable; 3)
functional status of an individual as the control variable.

Formal community services

 

Formal community health services are service available
by formally organized agencies in local communities,
designed to help meet the needs of individuals diagnosed
with cancer. Formal community services are designed to help
decrease the physical and psychological distress of an
individual. Such services may provide an Opportunity to meet
needs that the social support system of an individual is
unable to fulfill (James, 1994). Services that are
identified for the current study include: Visiting Nurses,
home health aides, home companions, sitters, case management
services, chore or housekeeping services, and meals on
wheels.

Socioeconomic status

 

Socioeconomic status can be measured by variables that
determine the status of an individual within their
community, the ability to utilize resources to deal with

problems, and how healthy the physical environment is

 

(Andersen, 1995). Andersen(1995) found that measures to
determine social structure include occupation, ethnicity and
level of education. Economic status can be determined by
assessing an individuals household income according to the
governmental poverty level. Governmental standards are in
accordance with the minimum income to maintain an adequate
food budget.

Household income and educational level are only two of
the many factors that play a role in determining an
individuals socioeconomic status. When looking at
socioeconomic status one must also take into consideration
type of, or lack of insurance, as well. The socioeconomic
factors which will be included in this study are level of
education, level of household income, and insurance
coverage.

Functional Status

 

Functional status is the ability to perform biological,
psychological, and social activities that individuals do
throughout their lives to meet their basic needs. These
activities are necessary to carry out expectations
associated with individuals roles in life. Such activities
are thought to preserve, regain, or achieve well-being.
Individuals are said to have limitations in functional
status if they are unable to perform biological,

psychological, or social activities in a normal manner

Table 1.

Proposed Variables for this study

 

 

DEPENDENT VARIABLES - FORMAL COMMUNITY SERVICES

1. Visiting Nurses Services

2. Home Health Aides or Home Companion Services
3. Home Case Management

4. Chore or Housekeeping Services

5. Meals on Wheels

INDEPENDENT VARIABLES - SOCIOECONOMIC FACTORS

1. Level of Household Income
2. Level of Education
3. Insurance Coverage

CONTROL VARIABLE - NEEDS

1. Current Functional Status

 

(Fawcett, Tulman, & Samarel, 1995). Functional status
was selected as a control variable for the study since it
has been identified as a powerful predictor of the use or
non—use of formal community services in previous research
(Andersen, 1995; Guadagnoli, Rice, & Mor, 1991; Given,
Given, & Harlan, 1994). For the current study functional
status of an individual will be determined by determining
deficits in their physical functioning alone.

Lung cancer

 

Lung cancer is defined as carcinoma of the lung, which
may include the bronchus, peribronchial lymph nodes,
intrapulmonary lymph nodes, mediastinal lymph nodes and
chest wall (American Cancer Society, 1995). Individuals with
all four stages of lung cancer are eligible for inclusion in
this study.

Theoretical Framework

The Behavior Model of Health Service Use was developed
in 1968 by Ronald M. Andersen (1995) to gain a better
understanding of why families utilize health services, as
well as to define, measure and promote equitable access to
health care. Andersen’s (1968) original work is based on a
three stage model consisting of predisposing, enabling, and
need components. The model suggests that a sequence of
conditions contribute to health service utilization by

families (See Figure 1).

Predisposing factors are described as family
characteristics which influence the likelihood of service
use. The predisposing component of Andersen’s (1968) model
is further broken down into subcomponents of family
composition, social structure, and health beliefs. The
family composition variables chosen for the original study
included: age, sex, marital status of the head of the
family, family size, as well as the age of youngest and
oldest family member. Each variable in itself is not a
reason to seek health care, although considering them
together can help to predict patterns of health care needs
within a family.

Social structure reflects the location of a family
within society as measured by characteristics of the
families main wage earner. These characteristics include
employment status, occupation, social class, educational
level, race, and ethnicity of the main earner. Such
variables help to determine the physical as well as the
social environment of a family and behavior patterns which
may be reflected in the families use of health services.

Health Beliefs is the third subcomponent of
predisposing characteristics, which takes into consideration
beliefs about disease, health care, and persons who provide
care. What a family believes about health care, plays a

vital role in determining whether health services are

10

utilized or not. Andersen(1968) used seven scales to
determine the beliefs of the family concerning health care.
These scales included: value of health, physicians, and
health services; attitudes toward service use, and physician
use; and lastly knowledge of disease.

The second component of Andersen’s (1968) model is the
enabling resources. Health care systems characteristics of
accessibility, availability and affordability would be
considered enabling factors within the Anderson (1968)
model. Although families may be predisposed to use health
services, resources must be available to make this possible.
Andersen (1968) defines enabling as “a condition which
permits a family to act upon a value or satisfy a need
regarding health service use” (p. 16). Both, family means to
attain services and geographic accessibility of services
must be present before services can be utilized.

Family resources are considered the families ability to
obtain health services for its members. Assessment of family
resources includes the family; income, savings, health
insurance, welfare care, and sources of primary care.
Community resources includes characteristics of the
community in which a family lives that can enable service
use. The most important characteristic is availability of

services. Included in the community resource characteristics

11

is; physician-population ratio, hospital size—population
ratio, region, and residence.

The third component of Andersen's(1968) model is the
need component, which represents the most likely determinant
of health service use. Illness or the possibility of it,
must be perceived in order for health service utilization to
take place. Need is measure by perceived illness by the

family, as well as, how they respond to such perceptions.

PREDISPOSING ----- > ENABLING ------ > NEED----> USE OF

CHARACTERISTICS RESOURCES FORMAL COMMUNITY
| I HEALTH SERVICES
I I I
I I I
I I |

Family composition Family Illness
Resources
| | I
l I I
| | I
Social Structure Community Response
Resources

I
Health Beliefs

Figure 1: The Initial Behavior Model of Families Use of

Health Services By Andersen (1968)

The final component of the model is the utilization of

health services. The use of health services is considered to

be either discretionary or non—discretionary. Discretionary
use of health services involves considerable choice, whereas
non-discretionary use of services is usually dictated either
by the physical condition itself or by service providers
such as physicians.

Andersen’s (1968) model for health service use is
modified for the current study. Predisposing character—
istics, enabling resources and needs are the components
which are included in this study as well. Each of the
components are further divided into additional
subcomponents, which include level of education, level of
income, and insurance coverage as indicators of health
service use. Since need has been identified as having such a
strong influence on health service utilization, it will be
included as a control variable. For the purpose of this
study functional status of an individual, as determined by
deficits in physical functioning, will be examined to
determine that individuals level of need (See Figure 2).

Predisposing characteristics are factors that predict
the use of community health services prior to an episode of
illness or the onset of disease. Level of education is one
predisposing characteristic that can influence the use of
community health services in a positive way. Individuals
with higher education levels, many times have the knowledge

needed to accessing available resources within the

community. Also, social skills obtained in higher education
can serve as a great asset when attempting to secure formal
community services. To the contrary, individuals with lower
levels of education may have a difficult time in accessing
services due to poor social skills and difficulty under-
standing information that is available to them.

Enabling resources are economic means available which
make utilization of community health services feasible.
Level of income and insurance coverage are two enabling
resources that may have the greatest impact on whether an
individual uses services or not. Individuals with insurance
coverage that assists with the cost of formal community
health services and those individuals who have a higher
income to pay for services may be more likely to use them ,
persons who have low income levels and pay out of pocket.

Needs are present when an individual must seek
assistance in performing their physical functions of daily
living. Individuals with the greatest number of deficits in
physical functioning have greater needs and therefore, are
more likely to use the most formal community services. In
order to determine an individuals deficits in physical
functioning, limits in moderate and vigorous activities are
examined. Also, limitations in lifting, climbing, bending,
and walking are important determinants when considering

deficits in physical functioning.

l4

 

PREDISPOSING CHARACTERISTICS

Patients level of education

 

 

 

 

 

ENABLING RESOURCES

Level of Household Income

Patients Insurance Coverage

 

 

 

 

 

 

NEEDS

Current Physical Functional Status

 

 

 

USE OF FORMAL COMMUNITY

HEALTH SERVICES AT WAVE II

 

Figure 2: Study model adapted from The Behavioral Model of
Families Use of Health Services developed by Andersen(1968).

 

CHAPTER III
REVIEW OF LITERATURE

There is a great paucity in the literature regarding
the influence of socioeconomic factors on the utilization of
formal community services by cancer patients. Most of the
available literature focuses on the utilization of formal
health care services such as hospitals and physicians
offices, rather than community services. Also a great
percentage of the literature regarding utilization of
services deals with the acute or terminal phase of the
disease instead of the chronic phase of cancer (Mor,
Masterson, Houts, & Siegel, 1992); Siegel, Raveis, Houts, &
Mor (1991). The focus of this review will be to examine what
is known about use of formal community health services by
individuals with and without the diagnosis of cancer, and
how socioeconomic status might influence use.

Socioeconomic status

 

What has been determined by the small amount of current
literature is the fact that socioeconomic status have a
crucial impact on the outcome of individuals diagnosed with
cancer. Schrijver and Mackenbach (1994), Kagawa-Singer
(1995), Michielutte, Bahnson, and Beal (1990), as well as
Boquet, Horm, Gibbs, and Greenwald (1991) found there to be
higher mortality rates of individuals diagnosed with cancer

in the low socioeconomic group. Freeman (1989) as well found

the social, physical, political, and economic environment in
which an individual resides largely determines the morbidity
and mortality of the disease. Freeman (1989) identifies the
five year survival rate for the socioeconomically
disadvantaged with cancer as being approximately 15 percent
lower than persons in the middle and upper classes,
regardless of their race. The higher mortality rates of
under privileged individuals may in part be a result of the
fatalistic attitude and struggle for day-to-day survival of
the socioeconomically disadvantaged.

Freeman(1989) identified late detection of cancer to be
one of the main determinants of higher mortality rates among
the socioeconomically disadvantaged. Several reasons of late
detection, delayed treatment and lower survival rates
include; unemployment, inadequate education, substandard
living conditions, chronic malnutrition, and diminished
access to health care primarily due to lack of insurance
coverage.

In a study conducted by Mandelblatt, Andrews, Kerner,
Zauber, and Burnett(1991) it was determined that low income
and lack of education were positively correlated to late
detection of breast and cervical cancer. Lack of access to
health care, forces disadvantaged individuals to use
emergency rooms as their primary source of health care.

Subsequently, individuals are often triaged negatively back

17

into the community and seek help only after their cancer
becomes incurable (Freeman, 1989; Given, Given, & Harlan,
1994).

Given, Given and Harlan (1994) found that the rural
poor are diagnosed after their cancer has progressed to late
stages of the disease. Poverty as well as lack of education
contribute to the late diagnosis of cancer among the rural
population, due to the limited knowledge of early signs and
symptoms of the disease. The combination of poverty and late
diagnosis may limit the treatment choices available for
these individuals. Baldiwn (1994) found lack of education
and poverty as well as increasing age contributed to late
diagnosis of cancer. It is estimated that fifty-seven
percent of all cancer is diagnosed in those over the age of
65.

Freeman (1989) as well as Baldwin (1994) found poverty
to be a proxy for other circumstances of living such as
unemployment, poor education, poor living situations, high
risk behaviors and lifestyles, and lack of access to health
care. In explaining the differences in incidences and
mortality rates of cancer among racial/ethnic populations,
Kagawa-Singer(1995) found socioeconomic status to have a
tremendous impact on outcomes, irregardless of race. Given,
Given, & Harlan (1994) found poverty to be a significant

barrier to cancer care among the rural population. The rural

poor have less access to cancer treatment centers as well as
more difficulty paying for health care services, therefore
leading to the higher mortality and morbidity seen among
poverty stricken rural cancer patients. Baldwin (1994)
identified there to be 35.7 million Americans suffering from
poverty and 35.4 million Americans who are uninsured. There
are 50 million Americans who have inadequate insurance
coverage for major medical expenses. If insurance is
available it may be to costly for the working poor, also
these individuals many times do not qualify for public
assistance.

Baldwin (1994) also found that since 1965 when Medicare
and Medicaid were initiated access for the elderly and poor
have improved. Although in the last several years the
percentage of individuals eligible for Medicaid has
dramatically declined. In 1985 only 41 percent of poor were
eligible for Medicaid. Although lack of insurance seems to
be prevalent among the poor there is a significant number of
Americans in the mid to upper socio-economic status that are
uninsured as well. Improved access to health care coverage
for individuals of all economic backgrounds may
significantly improve the outcomes of lung cancer patients.

Functional Status

 

The definition of an individuals functioning is defined

by Fawcett, Tulman, and Samarel (1995) as a term that

includes biological, psychological and social activities
which one does to meet their basic needs. These activities
help individuals to fulfill their roles in life and maintain
well-being. Functional status, refers to the individuals
actual performance of such biological, psychological, and
social activities. When there is a incongruiency in the
individuals performance from that which is expected, a
deficit in functional status is identified (Fawcett, Tulman,
& Samarel, 1995).

Sarna and McCorkle (1996) identified individuals to
have deficits in physical functioning when there was a
disruption in their capacity to engage in a variety of
activities of daily living. They concluded that individuals
with physical compromise can become a significant burden to
themselves as well as their families.

Use of Services

 

According to Andersen (1995) needs of an individual, is
the strongest determinant of health service utilization.
Needs are determined by how an individual views their own
general health and functional status. How an individual
experiences symptoms of illness, discomforts of illness, and
worries about their health all influences their perception
of need. Perceived needs are social circumstances which can
be explained not only by social structure, but health

beliefs as well. Needs are biological imperatives that

20

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explain individuals help-seeking behaviors and use of health
services. Guadagnoli, Rice, and Mor (1991) found, although
socioeconomic status influenced the use of community service
by cancer patients, the greatest determinant of utilization
was need.

Guadagnoli, Rice, and Mor (1991); determined, among the
socioeconomic factors which influenced utilization of
services, education and income seemed to be the strongest
predictors. They found that better educated individuals and
those in the higher SES classification were more aware of
available services than persons with less education and
lower income. Individuals with a bachelors or masters level
education were nine times more likely to utilize available
service than persons with no high school diploma.

Varricchio (1994) identified several socioeconomic
factors which influence the availability and use of
community support services as well. The socioeconomic
factors which are felt to have the greatest impact on the
use of service include: income, educational level, type of
insurance coverage, location in which a individual lives
rural vs. urban, family resources, and financial and social
resources. The presence of anxiety, depression, guilt,
denial, and anger were also identified as factors which

influence use of community health services.

21

According to Given, Given, and Harlan (1994)individuals
with lower levels of education often lack the social skills
needed to access the resources available to them. A large
number of rural poor are unaware of the needed care of
individuals diagnosed with cancer, therefore community
health services that are available are not utilized. Also
many individuals have no expectations of assistance with
care so they are not willing to ask for help from community
resources. Families as well as individuals afflicted by
cancer would benefit from use of community health services
to assist with coping of physical as well as emotional
needs.

Guadagnoli, Rice, and Mor (1991) found that persons in
the low to middle SES were five times more likely to use
services than individuals in the poverty category. Although,
persons in the high SES group were just as likely to use
services as their poverty level counterparts. Several
sources report that among those most likely to use formal
community services were, women, older patients, well
educated individuals, persons living alone, and persons with
the greatest number of needs (Given, Given, & Harlen, 1994;
Guadagnoli, Rice, & Mor, 1991). Individuals who reach a
critical level of need are more willing to utilize formal

community services independent of socioeconomic status.

22

In another study conducted by Andersen, Giachello, and
Aday (1986) which investigated access of Hispanics with any
medical diagnosis to health care, it was determined that
education was a strong factor which influenced utilization
of health services. The proposed reason for lesser educated
individuals in not using services, was correlated to these
persons having high levels of distrust, set beliefs about
health practices and lack of information about available
services. Kagawa-Singer (1995), identified the fatalistic
attitude that often accompanies low educational attainment
and lower socioeconomic status, a reason for lack of health
service use among the ethnic populations.

Guadagnoli, Rice, and Mor (1991) conducted a study on
the utilization of agency—based services and found, access
and knowledge to be two of the main deterrents to the use of
such services. Of the 596 subjects that participated in the
study, two—thirds had never used a community resource, and
nearly half were unaware of available resources. This study
concluded that cancer patients are unaware of resources
available to them or are not clear about how to access
services. It is suggested that health care professionals
must gain a better understanding of patients awareness of
available services and their willingness to use such
services. The acquisition of knowledge of services does not

insure that individuals will utilize them, therefore it is

23

of great importance to also determine factors which
influence the decision to use services. Also, the individual
must View services as acceptable before they may be willing
to use them.

Andersen and Newman (1973) identified several societal
and individual determinants that influence the use of
community health services. Technology and norms were
considered societal determinants of health service
utilization. Predisposing factors, enabling factors and
illness level are the individual determinants of health
service use.

The structure of the health care system itself is
identified by Andersen and Newman (1973) as a strong
determinant of health service use. The health service system
is responsible for the distribution of resources of goods
and services. Andersen and Newman (1973) determined that if
the resource/population ratio is not equitable then under
utilization of health services may occur due to lack of
access.

There is sparse literature available which discusses
the relationship between insurance coverage and service use
by cancer patients. Andersen and Newman (1973) however,
found health insurance coverage to have a strong influence
on health service utilization in general. Medicare and

Medicaid coverage facilitate the utilization of community

24

health services by decreasing the out of pocket expenditures
and increasing access to health services for the elderly and
socioeconomically disadvantaged. Although Medicare and
Medicaid cover portions of out patient services, many
private insurance’s do not. Therefore, many individuals with
private insurance are unable or unwilling to use service
available to them.

Anderson and Bartkus (1973) in another study found
persons with insurance coverage that pays for outpatient
services much more likely to utilize such services then
those without. Unfortunately, all of the available
literature regarding insurance coverage and services use is
old and may not be a true representation of influence on
service use today.

In summarizing the literature, there appears to be a
strong correlation between socioeconomic status and health
service utilization among patients in general, irregardless
of their diagnosis. Education level and level of household
income were identified as the socioeconomic factors having
the greatest impact on utilization. Individuals in the
middle socioeconomic level, and those with insurance that
covered services were felt to utilize services the most.

Therefore, this and other studies are needed to obtain
a greater understanding of how socioeconomic status

influences the use of formal community health services by

25

individuals diagnosed with lung cancer. Understanding the
influence that socioeconomic status has on service use will
assist health care professionals to help improve access to
services in order to achieve more favorable outcomes for

their patients.

26

CHAPTER IV
Methods
Study Design

A correlational study design will be used to examine
the differences Socioeconomic status, and functional
deficits in their regard to formal community health service
utilization. This study design will make it possible to
determine whether there is a difference between
socioeconomic status and the use of formal community health
services, by individuals diagnosed with lung cancer. Also,
differences in functional status will be determined in
regard to service use.

Sample selection

To address the research question, the following
analyses are based on secondary data analysis from a sample
of 196 patients who participated in waves I and II of the
(R01 NR/CA01915) “ Family Home Care for Cancer - A Community
Based Model” study. The study was funded by the National
Institute of Nursing Research and the National Cancer
Institute. Co-Principal Investigators of the study were
Barbara A. Given, PhD, RN, FAAN, and Charles W. Given, PhD.
The eligibility requirements for participation in this study
included:

1) age 65 or older

27

2) newly diagnosed with lung cancer, of any stage.

Participants in the study were recruited through
community hospitals affiliated with the College of Human
Medicine, College of Nursing, and the Cancer Consortium of
Michigan State University. Information on the original
study’s human subjects' protection and approval of UCRIHS is
included (see Appendix c). To ensure further protection of
the subjects in this study, data provided to the author will
not include names or address of the individuals who
participated.

Data Collection

Demographic data which will include the individuals
sex, age, race, living arrangements, household income,
education, insurance coverage and caregiver status will be
collected by completing wave I of the study. All other data
will be obtained from wave II of the study with the patient
as the respondent. The data was collected by completing the
“ Patient With and Without Caregiver Telephone Interviews”
which was administered by a trained interviewer. In order to
insure accuracy of the data collection the interviewers were
required to complete a formal training session. After
completing the training session the interviewer completed a
mock interview as well as participated in a taped interview
with a subject in order that feedback from the training

staff could be offered. To insure quality assurance

28

throughout the study each interviewer is required to have a
taped interview on a monthly basis to be critiqued and ten
percent of the records are audited for quality.

Operational Definitions, Instrumentation, and Scoring
The instruments used for collection of data in this
study are wave I—II of the “Patient With Caregiver Telephone

Interview” and “Patient Without Caregiver Telephone
Interview”. Wave I of the study collected data six weeks
post-discharge and wave II data was collected at week 12.
For the purpose of the current study selected questions from
the original instruments will be included in the data.
Psychometric testing of all scales will be completed to
determine reliability and validity, if the scale can be
improved by item deletion this will be done and reported.

Although the original study included twelve items under
community health service utilization category, only five
items will be included for this study. The five items that
will be operationalized for this study are identified in
Table 1. The operational definitions of these five items are
listed below:

1. Visiting Nurse Services are services provided by a
R.N. or L.P.N. hired through an agency to come into the home
and provide skilled nursing care to an individual.

2. Home health aides or companions are services hired

through an agency or privately, for the purpose of assisting

29

in personal care, and non skilled health care services. Such
services may assist in housekeeping tasks and meal
preparation.

3. Case management services are services that a nurse
or social worker provide to assist an individual to access
available resources to provide care.

4. Chore or housekeeping services are services provided
by a paid individual, which may include family or friends to
assist in housekeeping duties.

5. Meals on Wheels is a service which provides prepared
meals to the home with minimal cost to the recipient.

Each of the above five items were given a score of
either zero or one. If the respondent indicated that a
service was utilized, a score of one was given to that
particular item. If the respondent indicated that a service
was not utilized no score was given. A score of one or
greater will indicate that a service or services were
utilized. Frequency of use and number of services used is
beyond the scope of this study and will not be included.

The independent variables operationalized in the
current study are socioeconomic factors that may influence
the use of community health services. A list of the
independent variables is also found in Table 1. The
operational definitions and scoring of the independent

variables within this study are described below.

30

Level of income can be operationalized as all sources
of combined income of all household members. Item # 5 under
the category of “Finances” is used to measure the level of
income of a combined household. Income levels will be
combined to make three categories for more accurate

analysis. The scoring for this item includes:

Level of income Score
0- 14,999 1
15,000— 29,999 2
30,000+ 3

Level of education is determined by the highest level
of education completed by the individual. Item # 3 under the
category of “Sociodemographic Information” is used to assess
this variable. Respondents are asked to indicate the highest
level of education completed. For the current study levels
of were combined to make only four categories of education.

The scoring for their responses are as follows:

Score
Some high school or below 0
High School Graduate 1
Some College 2
College degree or greater 3

The third independent variable is insurance coverage
which includes what type of insurance coverage an individual

has. Insurance will be scored as three mutually exclusive

3]

categories and will be given a 0 if the individual doesn’t
carry this type of insurance or a 1 if they do. Medicare
part B, Medigap or private insurance, Champus, Indian health
services, and Blue Cross/Blue Shield are combined and are
included in the other category. Items # 9a thru 9h under the
category of “Finances” is used to determine the current

insurance coverage .

Type of insurance Scoring
Medicare A O or 1
Medicaid 0 or 1
Other 0 or 1

For the purpose of this study need is identified as a
control variable and will be determined by the functional
status of an individual. Instrumentation used to assess the
functional status of individuals in the original study, is
the MOS 36-Item Short Form Survey (SF-36). This instrument
was developed by John E. Ware and was designed to assess
health status of individuals in a study on medical outcomes
(Ware & Sherbourne, 1992). Eight health concepts were
assessed using this instrument and include: physical
functioning, role limitations due to physical problems,
social functioning, body pain, general mental health, role
limitations due to emotional problems, vitality, and general
health perceptions. Individuals included in this study will

be assessed for limitations in physical functioning only, in

32

order to determine their functional status. Ten items that
address physical functioning have been identified from the
FS 36 functional status tool (Ware & Sherbourne, 1992). This
scale is found in wave II interview booklets and includes
items # 1a thru lj under the category of “instrumental
activities of daily living for the patient”. Reliability and
validity of the original thirty-six item scale was reported
by Ware, Kosinski, Bayliss, Mchorney, Rogers, and Raczek
(1995).

Each item of the functional status tool will be scored
using a unidirectional scale with lower scores indicating
less defects in functioning and higher scores indicating
greater levels of functional defects. The scores will be
totaled and divided by the number of items asked.
Individuals with higher scores are those with greater levels
of functional defects. Individuals with score of 1 or less
will be placed in the category of minimal functional
deficits, scores of 1.0-1.99 will be in a category of
moderate functional deficits, and 2.0 -3.0 is the category
for maximum functional deficits. Refer to Appendix A for the
questions that form this scale and the scoring of items.

Analysis

Although there are 196 participants in the study the N:

may be significantly different in the findings, due to the

subjects not providing complete data on all items.

33

SPSS software will be used in this analysis (Norusis,
1993). Frequencies will be run on all sociodemographic data.
Crosstabulations will be run on the sociodemographic data to
determine the relationship between socioeconomic status and
service use. Chi-Square analysis will be run on the
variables with an established level of significance of 0.05
to determine the relationship between variables. Pearsons
Chi—Square analysis will be used to determine the
relationship between the independent variables of the study:
level of income, level of education, insurance coverage, and
functional status and formal community health service
utilization by lung cancer patients.

With the knowledge of previous research indicating the
high degree of influence that need has on service
utilization, deficits in physical functioning will be
analyzed to determine needs in this population. Analysis
will determine how much service utilization is due to

deficits in physical functioning.

34

 

CHAPTER V
Results
The findings described in this section are compiled
from the 196 subjects who were eligible for the study.
Tables showing sociodemographic characteristics of the
sample and the results of the data analysis are included.
Table 2.

Sociodemographic Variables in this patient Population (N =
196)

 

 

 

Characteristics n %

Sex

Male 122 (62%)

Female 74 (37%)
Race

Caucasian 177 (90%)

African American 14 (7%)

Native American 2 (1%)
Age

60-69 44 (22%)

70-79 122 (62%)

80-90 30 (16%)
Education Completed

Some High School or less 60 (36%)

High School graduate 51 (26%)

35

Table 2. (Cont.)

Sochxmmogmqmic Variables In This Patient Population

(N

 

196)

 

 

Characteristics n %
Some College 32 (16%)
College Degree or more 11 (6%)
Living Arrangement
Lives Alone 55 (29%)
Lives With Spouse 114 (59%)
Lives With Children 24 (12%)
Household Income
O—14,999 48 (29%)
15,000-29,999 78 (47%)
30,000+ 39 (24%)
Insurance Coverage
Medicare A 180 (99%)
Medicaid 15 (8%)
Other 176 (92%)

 

36

Sociodemogggphic Characteristics

'Thee sannple from which the results were drawn was

predominantly mutelk=177

(90.3%), males N: 122 (62.2%).

“Thezrnearieage of the sample was 74, SD 5.15 the youngest

Stflxject.vwas 66 years old and the oldest was 99.

Forty eight
percent (N= 94)

of the sample held a high school diploma or
greater.

'The mean household income was $20,000 to $25,000.
Fiftg/tjine percent (N: 144) of the population lived with a

spouse, twenty nine percent (N

— 55) lived alone,

and twelve
percent (N: 24)

lived with children. The majority of the

sample were insured by Medicare and secondary insurance.
Among the 196 subjects that fit the criteria for the

current study few utilized formal community health services.

A significant amount of individuals did not provide data on

use of services therefore N=166 responded to visiting nurses

services and N=165 responded to all other services.

Table 3.
provides frequency,

and percent of usage.

Socioeconomic Factors and Community Service Use
The independent variables of: level of education,
household income,

insurance coverage, and functional status

are emMMIed to determine influence of socioeconomic factors

(wiusecfifformal community health services.

Functional status

Theihnctional status of individuals prior to the

(flamumisci cancer was not considered for the current

37

Table 3.

Iflornual Ckmnmunity Health Service Use by Frequency and Percent
(N: 165)

 

 

‘Jaritflole Used No. (%) Not Used No. (%)
‘Jisithug Nurses 38 (23) 128 (77)
Home Health.Aides 7 (4) 158 (96)
Case Management 7 (4) 158 (96)
Chore/Housekeeping 12 (7) 153 (93)
Meals on Wheels 10 (6) 155 (93)

 

study. Therefore, the functional status presented reflects

deficits in physical functioning of the individual at the
time data was collected for Wave II of the original study.
Level of functioning ranged from 0 to 3 with the lower
scoring representing individuals with the least deficits in
function to higher scores indicating those with the most
deficits. Scores ranging for 0-.99 indicated individuals
wininunimal functional deficits and were placed into
flnmxional category 1, those with scores of 1.0-1.99 are in

catayny 2, and the remainder of scores 2.0—3.0 are in

catayny 3. The mean score for functional status was 1.78.

Thermfiority of the study population fell into the moderate

finmthxml deficit category or level 2, this included fifty

38

eight percent (N: 112) of the population. Thirty nine

percent (N=74) were found to have maximum functional

deficits, and only three percent (N=6) had minimal

functional deficits.
Functional status of an individual did not appear to
have an influence on the use of any of the five formal

community health services. Visiting Nurses Services was the

services that was utilized the most although statistical
analysis did not indicate an influence from functional
deficits on use (Chi-Square 4.1; df 2; p= .128). It is
surprising that functional deficits did not have a greater
influence on community services use since there were a

significant amount of individuals who fell within the

category of maximum deficit category. Table 4. shows a

representation of functional deficits and use of community

health services.

Education

Level of education within the sample group included

individuals who completed grade school to one individual who

completed graduate education. The majority, 62% (N=111), of

individuals obtained a high school diploma or less. Of the
196 subjects only N=141 provided information on their

educational level. Visiting Nurses services was utilized

the most among individuals who provided information on

educational level. Thirty subjects reported using Visiting

39

Table 4.

Ehnctnxml Status and Use of Formal Community Health

 

 

 

 

Sendeestw Number, Percent, and Significance Level
Used Not Used
Variable No. (%) No. (%) p value
Visiting Nurses N=38 N=127
Functional Category
1 l (33) 2 (67) n/s
2 28 (28 72 (72) .13
3 9 (15) 53 (85)
Home Health Aides N= 7 N=157
Functional category
1 0 (OO) 3 (100) n/s
2 6 (.06) 94 (94) .39
3 1 (.01) 6O (98)
Case Management N= 7 N=157
Functional Category
1 O (00) 3 (100) n/s
2 5 (5) 95 (95) .81
3 2 (3) 59 (97)
Chore/Housekeeping N=10 N=154
Functional Category
1 0 (00) 3 (100) n/s
2 8 (8) 92 (92) .43
3 2 (3) 59 (97)
Meals on Wheels N=11 N=153
Functional Category
1 0 (00) 3 (100) n/s
2 6 (6) 94 (94) 77
3 5 (8) 56 (92)

 

SignificancejMwel

p 5 0.05

40

Musessmrvices (21%), seventy nine percent (N: 111) did not

twiliuathis service. The greatest percentage of individuals

LRiliLUQ Visiting Nurses services were those that had less

thenraingh school diploma (29%), or persons who had a

college degree or more (30%).

One hundred and forty individuals of the sample (N=196)

provhfixiinformation on educational level and the remaining

services. Only 4 individuals (3%) reported using home health

aides. Individuals with the highest level of education
demonstrated the greatest use of home health aides. Six
individuals reported using case management services, the

greatest percentage of which were in the lowest educational

level (12%). Eight percent (N=12) reported using chore or
housekeeping services, with the highest usage among those
having some college educational. Six percent (N= 8), of

individuals reported use of meals on wheels with the highest

percent falling in the college or more category. See Table 5

for listing of use and significance values.

INCOME
ZXLthough the majority of the sample 47% (N: 78) fell
withiri‘the $15,000 to $29,999 range, twenty nine percent (N:

48) ivereztvithin the lowest income category of $0 to $14,999.

41

Table 5.

meatuxml Level and Use of Formal Community Health

 

Servnxm by Number, Percent, and Significance Level

 

 

Used Not Used
Variable No. (%) No. (%) p value
Visiting Nurses N=30 N=111
some high school 5 (30) 12 (71)
high school 5 (12) 36 (88) n/s
some college 8 (19) 35 (81) .19
college or more 12 (30) 28 (70)
Home Health Aide N=4 N=136
some high school 0 17 (100)
high school 1 (2) 40 (98) n/s
some college 1 (2) 42 (98) .73
college or more 2 (5) 37 (95)
Case Management N=6 N=134
some high school 2 (12) 15 (88)
high school 2 (5) 39 (95) n/s
some college 0 (0) 43 (100) .23
college or more 2 (5) 37 (95)
Chore/Housekeeping N=12 N=128
some high school 1 (6) 16 (94)
high school 2 (5) 39 (95) n/s
some college 5 (12) 38 (88) .68
college or more 4 (10) 35 (90)
Mealjscni Wheels N=8 N=132
sonmaliigh school 1 (6) 16 (94)
high school 3 (7) 38 (93) n/s
some college 1 (2) 42 (98) .71
college or more 3 (8) 36 (92)

 

Significance level = p 5 0.05

42

Thereefimears to be a substantial number of individuals who

partkflrmted in the study that are considered to be in
povemun When using the US Bureau of the Census poverty
levelcfi $14,335 there may be inaccuracy in the significance
oftxwerty within this study. All individuals with an income

range of $0-$14,999 were considered to have an income equal

to or less than poverty level, although there might have

been individuals whose income was above $14,335 but below

$14,999. Therefore, it is possible that the true number of

individuals with an income level below $14,335 is over

estimated.

Income did appear to have a significant influence on

the use of home health aides services (Chi-Square 6.2; df 2;

.04). There was no other significance found in the influence

of income level on the use of formal community health

services other then home health aides. Although, Visiting

Nurses services was found to be closest to significance with
Pearson Chi—Square vales of 5.3; df 2; p= .06.

Individuals in the lowest income category utilized
fornutl community health services over all more than persons
IJI anyrcyther income category. The exception to this was in
.regartks to case management services which was utilized most
by'ijuiividuals in the middle income category. As with

echucatirmaal level there were a many subjects who did not

repxirt chata on both services use and income both. The

43

rMsshm'mNa may be do to individuals reluctance to share

infinmatum on income. See Table 6.

Insurance Coverage
sump the population in the study included only

indivunmls over the age of sixty—five it is not surprising

tint 99%vere covered by Medicare. In addition to Medicare

cpveray384% of individuals also had additional insurance
(Knerageiduch fell into the category of other. Medicaid
two who were covered |

 

15) of the sample group,

covered 8% (N:
the other thirteen had Medicare coverage

only by Medicaid,
as well. When examining the relationship between insurance

coverage and use of formal community services Medicare,
Medicaid or other insurance coverage were found not to have
for insurance coverage

a significant influence. See Table 7.

and use of service significance level.

44

Table 6.
hmpmelevel and Use of Formal Community Health Services by

IMmber,E%rcent, and Significance Level

 

 

Used Not Used
variable No. (%) No. (%) p value
Visiting Nurses N=35 N=117
$0-14,999 16 (35) 30 (65) n/s
$15,000—29,999 12 (17) 60 (84) .06
$30,000 > 7 (21) 27 (79)
Home Health Aides N=7 N=144
$0-14,999 5 (11) 41 (89) Sig
$15,000-29,999 2 (3) 70 (97) .04
$30,000 > 0 (0) 33 (100)
Case Management N=6 N=145
$0-14,999 2 (4) 44 (96) n/s
$15,000—29,999 4 (6) 68 (94) .39
$30,000 > 0 (0) 33 (100)
Chore/Housekeeping N=11 N=140
$O-14,999 4 (9) 42 (91) n/s
$15,000-29,999 3 (4) 69 (96) .31
$30,000 > 4 (12) 29 (88)
Meals on Wheels N=10 N=141
$0-14,999 6 (13) 40 (87) n/s
$15,000-29,999 2 (3) 70 (97) .09
$30,000 > 2 (6) 31 (94)

 

Significance level==g>§ 0.05

45

Table 7.

jhmurmue Coverage and Use of Formal Community Health

 

Semflcestw Number, Percent and Significance Level

 

 

 

Used Not Used
Variable No. (%) No. (%) p value
Visiting Nurses
Medicare A 37 (23) 125 (77) n/s.58
Medicaid 3 (23) 10 (77) n/s.99
other 9 (17) 45 (83) n/s.16
Home Health Aides
Medicare A 7 (4) 154 (96) n/s.83
Medicaid l (7) 12 (92) n/s.52
other 1 (2) 53 (98) n/s.27
Case Management
Medicare A 7 (4) 154 (96) n/s.83
Medicaid 1 (7) 12 (92) n/s.52
other 2 (4) 52 (96) n/s.79
Chore/Housekeeping
Medicare A 11 (7) 150 (93) n/s.78
Medicaid 1 (7) 12 (92) n/s.88
other 3 (6) 51 (94) n/s.66
Meals on Wheels
Medicare A 10 (6) 151 (94) n/s.79
Medicaid 1 (7) 12 (92) n/s.80
other 1 (2) 53 (98) n/s.10

 

Significanceilevel==g>§_0.05

46

Interpretation of Findings and Discussion

Thecnmstion studied by this researcher was: Does the

socimaxmomic status of individuals diagnosed with lung
cancer,influence their use of formal community health
servhxm? After statistical analysis was completed it

appeamxithat socioeconomic status did not have a great

influence on the use of any of the five services identified
for the study. Although ninety seven percent (N: 186) of
to have

individuals in the current study were determined

moderate to high deficits in physical functioning,
functional status was also found not to have a significance

From the literature review, need was

on use of services.

determined to be the strongest predictor of health service
use. The current study found no significance between
functional deficits and the use of formal community health

services. This may be do to the fact that the majority of

subjects who participated in the study did not live alone

and likely received assistance from family members.
thdividuals living with a spouse or child likely have help
in nmaating there activity of daily living needs therefore,
.requirdng less assistance from out of the home.

Wheni considering education’s influence on the use of
fornuil cxxmnunity health services it is important to note the
greatest percentage of the sample had less than a high

scfluool. ditaloma. According to Freeman(1989) and Mandelblatt

47

etal.,(1991) individuals with less education may not have

'Um mxfiaL or problem solving skills needed to seek health
these individuals have a higher

care services therefore,
The current study however found

peraauege of poor outcomes.
that hxflviduals with less than a high school diploma were
amongtflmme who utilized services most. It was found that

indivmmmfls who had a college degree or more were the most

likely to use services followed very closely by those with
the least education. Individuals in the high school diploma
and some college categories were much less likely to utilize

services.
When looking at the current study income, may have the
most influence on service use of all of the variables. When

using Chi-Square analysis, the influence that income had on

home health aides showed the only true significance with p <
- .06 and meals

Visiting Nurses had significance of p

.05.
= .09. Even though the p

on wheels a significance of p

valtmas of Meals on Wheels and Visiting Nurses did not meet

the cnztteria for significance, there values were the closest

to sitfliificant of all the variables other than Visiting
Inccme however may not be a good indicator of

nurses.
serWfiice Lnse due to the fact that Medicare and Medicaid cover

tflae cxast (of Visiting Nurses and home health aides when
irujivdxiualus qualify for services. When individuals covered

by Medicare and Medicaid utilize Visiting Nurses services

48

andimmelmalth aides there is no out of pocket expenditure

iftheyneet criteria, therefore income may have no
infhkmcecm use. Individuals that do not qualify for
sendcesexmording to Medicare and Medicaid requirements

willimvecnm.of pocket expenditures. Level of income would

likelyzumluence the use of services by these individuals

with expenditures.
The significance in use of Meal on Wheels among the

lower income may be due to the fact that most counties have
Elderly

financial subsidy programs that cover this service.

individuals in the low income level that meet the criteria

can receive meals at little or no cost.

The lack of significance that insurance coverage had on

service use is not surprising since almost the entire
population was covered by Medicare. Medicare and Medicaid,

as well as, nwst private insurance’s cover Visiting Nurse
servicxms and home health aides. A more diversified coverage

of iJHMIrance’s or a greater representation of individuals
.beltnv time age of sixty five who did not have Medicare

coverage may present very different statistics on

tatilrizatitnu. Much less significance may be found among
.inciivithialrs covered by insurance’s other than Medicare

chJe tub time fact most do not cover formal community health

fThe failure of insurance companies to cover formal

services.
(conunuruity'lnealth.services, means out of pocket expenditure

49

forimfivkhals and their families, therefore decreasing the

1Umlfimmiof use by these individuals.

Other Interest ing Findings

not part of the formal study, the influence

Although,

thatageanm gender had on service use was of interest. Age

has fmnmlto have a significant influence on the use of Meal

The significance indicated that

on Wheels with a PF: .02.

indivhmufls over the age of seventy eight were more likely
to usermmls on wheels then those younger. This significance

may bechxato speculation that with increasing age the more

co-morbid conditions one might have or the likelihood of
being widowed increases as well. It was surprising that use

of services other than Meals on Wheels did not increase with

It seems as individuals age, the need

age of the individual.
for services that provide more physical assistance such as

lumne health aides or chore/housekeeping services would

increase.
Wheu1.looking at gender, there was a significance in the
use; of'laonma health aides and housekeeping services for

individuals reported using home health

females. Seven M%)

aixdes; aruj cxf those that utilized the service six were
(df 1); .01 for

CtLi—Square analysis revealed 6.5;
.hcnne laeatltri aide use. Twelve individuals reported using
ten were female

females.

chore or housekeeping services and of those,
The significance of these findings may be

cgixrirng ea E>== .001.

50

due to the fact that females usually assume the roles that
these two services can provide, therefore if she is unable
to fulfill the role outside assistance is needed.

Sixty two percent of the subjects in the study were
male and thirty seven were female, therefore it would seem
likely that more men than women would require assistance.
This may reflect that many of the men are married and that
their wives are continuing to fulfill the roles that home
health aides and chore or housekeeping services would
provide.

In summarizing the results of this study, socioeconomic
status of an individual was not found to have much
significance on the use of formal community health services.
The population in this study which included individuals
diagnosed with lung cancer within twelve weeks of their
participation, who were over the age of sixty five were not
frequent users of formal community health services. Although
the literature supported that need was a significant factor
in health service utilization the current studies findings
did not support this fact. The lack of use of formal
community health services may be explained in many ways,
including diagnosis and staging of cancer although it is

beyond the scope of this study.

51

Limitations of This Study
The following limitations to the current study are
identified:
The first limitation to the study is the sample
population which was a nonprobability, convenience sample.

The sample is fairly homogeneous in that all participants

are elderly, recently diagnosed with lung cancer and living

in Michigan. The sample population was perdominantly

Caucasian individuals, therefore it is a poor prediction of
service utilization by all races. The results of this study
may not be generalized to a larger population which includes
younger patients or those with other types of malignancies.
The results as well may not be generalized to individuals
living in other geographical areas due to availability of
services within each state.

There was no control or examination for stage of cancer,
comorbid conditions or treatment modality, such as
chemotherapy, surgery, or radiation or a combination of
these. Stage and comorbid conditions would likely be a
strong predictor of formal community health service

utilization, with the persons in more advanced stages or
with more comorbid conditions requiring more assistance. Not
all treatment modalities carry the same risk for side
effects, therefore it would seem more likely that an

individual receiving chemotherapy would be sicker and

52

requhe more assistance than someone undergoing radiation

alone.
Ahflmugh functional status of the individual could be

contnflled after their diagnosis of cancer, it is important

to control for the functional status of an individual prior

to diagnosis of cancer to determine an accurate influence on

use. Previous deficits in functional status as well as

continued decline may significantly influence use of formal

community health services.

In the current study each socioeconomic variable is

looked at separately which does not give a true
To determine a more

representation of socioeconomic status.
aCINJrate estimate of socioeconomic status it would be

education, and insurance

rmacessary to combine income,

cxyverage. In order to assess the difference in socioeconomic

stxitus and its influence on formal community service

utiflization, the independent variables must be combined. The

Curzrent study can determine only if difference in each
inctividual variable has a influence on service use.

The nmst significant limitation of the study is the

iHchxrtance placed on insurance coverage and type of

lrlstarznace. Insurance may be a very poor predictor of formal

COHumunityhealth service use because few formal community
hELaILtII services are actually covered. Visiting Nurses and

INDDHEE rmaalth aides are covered by Medicare and Medicaid for a

53

thtedtime, only if a skilled nursing care need is

idmujfied. Therefore, it is not possible to know from the

datainthin this study which individuals have skilled needs

thatcnmlify for coverage of formal community health

servhxm. A more accurate prediction of service use is not

havhxginsurance coverage, but whether the service needed

withe covered by the type of insurance the individual has.
The last limitation identified for this study is the lack

of information regarding pattern of use of community health

services previous to this study. If an individual has

utilized services prior to the diagnosis of lung cancer and
had a good experience there likelihood of utilizing services

again would be higher. Individuals who have never used

formal community health services or those who had a bad

experience with service use may be less willing to attempt

use again.

54

CHAPTER VI
Implications for Advanced Nursing Practice

Given the statistical findings of the current study it
appears that few elderly individuals diagnosed with lung
cancer utilized formal community health services. Advanced
Practice Nurses (APN’s) in primary care, as well as,
geriatrics could influence the way elderly patients
diagnosed with lung cancer utilize community health
services. APN’s can help in achieving more favorable
outcomes for lung cancer patients by facilitating the use of
services available to help meet individuals needs. Since 78
percent (N=152) of the individuals in this study were
between the ages of 70 and 90 it is understandable that many
elderly individuals diagnosed with lung cancer have
considerable deficits in their functional status. APN’s have
the ability to assist individuals with the greatest needs to
benefit from formal community health services.

Advanced Practice Nurses are well known as highly
effective practitioners with a holistic focus on the health
care they provide. Holistic care is very important for the
individuals in this study who have a recent diagnosis of
lung cancer. As a practitioner the APN provides care for
patients diagnosed with lung cancer based on sound theory
and advanced clinical judgment therefore, assisting

individuals in securing formal community health services to

55

Ihelp cope with health care problems and prevent
complications.

First and foremost, it is imperative for the APN
functioning as a assessor to determine what needs each
individual diagnosed with lung cancer may have. The majority
of the current sample appeared to have at least a moderate
amount of need since, 186 individuals fell into the
categories of 2 or 3 on the functional deficits scale.
Individuals with greater deficits in functional status would
likely require more assistance with their mobility and
activities of daily living. After determining what needs an
individual has, it is important to determine if the
resources they are currently using to meet their needs are
adequate. If the current resources are not adequate to meet
the individuals needs the APN must assess what access they
may have to community health services. In order to determine
accessibility the APN must take into consideration
acceptability, attainability, accommodation, affordability,
and availability.

Affordability and availability are just two reasons
individuals in this study may not have utilized services.
Although the majority of individuals in the study have
Medicare, this is no indication that there need for services
will be met, do to strict requirements for coverage of

services. Access to formal community health services may be

56

 

limited to many of the individuals in this study due to low
incomes that could not sustain much out of the pocket
expenditures. As an advocate and case manager the APN can
assist individuals to limit their out of pocket expenditures
and attempt to get service use covered by their insurance
carrier. If the individual is hospitalized, it is important
for the APN to assess the needs of the individual so that a
skilled nursing need is not overlooked prior to discharge.
If the individual is not hospitalized though has, or
develops a skilled nursing need the APN must advocate for
the individual, so that formal community services that
qualify for payment will be covered.

When considering services that insurance does not
cover, many individuals may not be aware that each county
has services available to elderly individuals in need
through the Commission on Aging. Service availability is
dependent on the funding within each county, therefore all
counties do not offer the same services. Services may have
different requirements for eligibility or individuals may
need referrals to receive assistance. Some services such as
meals on wheels are accessible to low income individuals at
no cost, but only available to others at a fee. The APN
working with lung cancer patients must be well versed on the

availability and affordability of such services.

57

Meals on Wheels and chore or housekeeping services are
not covered by any health insurance agency. However, these
services are available, at minimal cost for those who
qualify. Even though the cost of many services is minimal
many individuals may view this as unaffordable or
unacceptable and choose not to utilize certain services as
an option to assist in meeting their needs. For these
reasons it is important as new health care systems are
developed under national health care reform, that APN's
utilize their knowledge and abilities as a change agents,
leaders, and patient advocates to help identify and
eliminate barriers to formal community health services for
lung cancer patients.

A large portion of the Advanced Practice Nurses role
when working with lung cancer patients focuses around
education of patients and families. When dealing with
elderly individuals diagnosed with lung cancer the APN uses
the roles of assessor, educator, counselor, and change agent
to influence the use of community health services by cancer
patients. Although each individual has the common diagnosis
of lung cancer their situations may be very different.
Thirty percent of the current population live alone, and may
have very different situations and needs than those who live

with a spouse or child. Therefore, each individual situation

58

requires a thorough assessment by the APN to determine the
appropriate educational and counseling needs.

If an individual has needs that are not being met, it
is the role of the APN to educate and counsel regarding the
available resources so they may make an educated decision on
service use. If the individual currently requires no formal
community health services the APN should educate on
availability of resources in case the need arises in the

future.

The elderly individuals in this study demonstrated that

the majority seventy one percent (N 138) of lung cancer

patients do not live alone, but live with a spouse or
children. Because the majority of individuals lived with
someone this could account for the low frequency of use of
formal community health service among this population.
Twenty nine percent (N: 55) of the sample population live
alone, and would likely benefit from formal community health
services the most due to less family support services.
Regardless of living arrangement, both individuals that do
and do not live alone may benefit form services that formal
community health agencies can provide. APN's in the role of
change agent should encourage both individuals to utilize

services in order to increase the likelihood of a more

favorable outcome.

59

The current study population indicates that many
individuals diagnosed with cancer have a minimal level of
education. Therefore, education materials provided by the
APN regarding use of community health services must include
accurate and easy to understand information not only on
available services but what types of activities each service
provides. Education materials must be easy to read as well
as understandable, for those individuals with limited
education. The APN in primary care can assist the individual
diagnosed with lung cancer, to make appropriate decisions on
which services would best meet their needs.

When functioning in a collaborative role the APN can
utilize the knowledge of other disciplines in obtaining
accurate information on available services as well as
financial reimbursement. Medical Social Workers are very
knowledgeable about community services as well as financial
issues regarding such service use. Social services is one
resource in which to obtain information on available
services within the area that an individual client lives.

While collaborating with other health care disciplines
the APN must assume the role of case manager in order to
ensure continuity and advocacy of care for lung cancer
patients. As a case manager for the population within this
study the APN would help determine services needed and

assure that the appropriate plan of care provided by formal

60

community health services was being carried out. APN’s
functioning in the role of case manager, as well as change
agent facilitate the identification of service needs and
implement a therapeutic plan in collaboration with other
members of the health care team. In order to meet the needs
of individuals diagnosed with lung cancer a collaborative
approach must be taken to bring about positive changes in
service use behavior.

The APN as a researcher and evaluator can study the
frequency, health status and demographic characteristics of
individuals diagnosed with lung cancer who utilize formal
community health services. Individuals with low functional
status, the socioeconomically disadvantaged and those living
alone need closer follow up by the APN to ensure that the
services used are meeting their needs. Quality of formal
community services needs to be assessed through regularly
scheduled evaluations. Quality assurance programs to study
the effectiveness of formal community health services when
used by individuals diagnosed with lung cancer need to be
developed to determine patient satisfaction.

There are many ways in which the APN can influence the
use of formal community health services by individuals
diagnosed with lung cancer. By providing comprehensive,
continuous, and coordinated care the APN in primary care can

utilize the various role characteristics to assist

61

individuals diagnosed with lung cancer in meeting their
needs.
Implications For Further Research

A secondary analysis was used to complete this research
study, and was a beginning attempt in identifying
differences in socioeconomic factors and functional status
that influence the use of formal community health services,
by individuals diagnosed with lung cancer. There is a great
need for further investigation into why individuals
diagnosed with lung cancer may or may not use the assistance
of formal community health services. There are several ways
in which further research could improve and expand this
subject.

Research that would include a less homogenous sample,
which included equal men and women and more racial
diversity, may be helpful in determining the influence
socioeconomic status had on service use by lung cancer
patients. Since all individuals in the current study were
over the age of 65, living in Michigan and diagnosed within
the last twelve weeks with cancer these findings cannot be
generalized to all individuals diagnoses with lung cancer.

A broader study of individuals from many different
geographical regions, and timing since diagnosis might be
helpful in predicting a more accurate assessment of use by

lung cancer patients. Waiting until six months form the

62

initial diagnosis may have very different findings then the
current population. It may be beneficial to examine
different age groups as well, although most individuals
diagnosed with lung cancer are over 50.

Although this study included only lung cancer patients
further research which included a sample of individuals with
any cancer diagnosis might provide us with better
understanding of service use on a broader basis. Individuals
diagnosed with breast cancer would likely not need as much
assistance as others with lung, or stomach cancer due to the
severity of the location. Although, individuals diagnosed
with metistatic cancer of any origin may require significant
assistance dependent on staging.

In the current study there was no way to indicate the
stage of lung cancer the individual was diagnosed with, if
further research were to be done using only lung cancer
patients, controlling for stage could prove beneficial. The
staging of lung cancer is important when considering use of
formal community health services. Individuals in the more
advanced stages of cancer would more likely need the
assistance of formal community health services more than
those with early staging.

Research that controlled for co-morbid conditions,
functional status prior to diagnosis, treatment modality

such as surgery vs. chemotherapy or radiation, and prior use

63

of formal community health services would also provide a
more accurate picture of service use. Individuals with other
co-morbid conditions, or deficits in functional status prior
to diagnosis may be more apt to use formal community
services because they may have greater needs. Those
individuals with prior formal community health service use
that had a positive experience would likely be more apt to
use these services again.

The influence that differing modalities of treatment
such as surgical intervention, radiation, chemotherapy, has
on formal community health service use is vital. The overall
prognosis of lung cancer is poor. Some individuals
diagnosed in the early stage of lung cancer that are treated
with surgical intervention may however be asymptomatic for
many years, never requiring the need for use of formal
community health services. Individuals such as these would
make it inaccurate to predict service use by diagnosis of
lung cancer alone. Controlling for prior service use would
help to determine the effects of the current cancer
diagnosis on use.

Lastly, a follow-up study using these same 196 subjects
would be helpful to determine any changes in patterns of
formal community health service use. The question of while
controlling for functional status, does socioeconomic status

of individuals diagnosed with lung cancer, influences their

64

use of formal community health services could be addressed.
Length of time since diagnosis, closeness to death and the
stage of lung cancer at diagnosis would give a more accurate
assessment of formal community health service use by these
individuals. It is very likely that the further out in time
from diagnosis, the closer to death, and the higher the
staging the more apt the individual would be to use
services.

Since the cost of most formal community services
identified in the current study were not covered by
insurance without meeting strict criteria, it may be helpful
to delete this as an influence. In further research all
variables could be combined to determine socioeconomic
status rather than looking at individual socioeconomic
variables.

In summary, the current study did not indicate
significant use of formal community health services
although, further research may. It is important then to
continue research on the factors that influence use of
formal community health services not only by lung cancer
patients but those with all types of chronic disease
processes. Further research on service utilization could
prove beneficial in more readily meeting the needs of

patient to help facilitate improved outcomes of care.

65

BIBLIOGRAPHY

66

Bibliography
Andersen, R., Giachello, A., & Aday, L. (1986). Access
of Hispanics to Health Care and Cuts in Services: A State-

of—the-art Overview. Public Health Reports, 101(3), 238—248.

 

Andersen, R. (1995). Revisiting the Behavioral Model

And Access to Medical Care: Does It Matter? Journal of

 

Health and Social Behavior, 6(3), 1-10.

 

Andersen, R. & Newman, J.F. (1973). Societal and
Individual Determinants of Medical Care Utilization in the

United States. Milbank Memorial Fund Quarterly Health and

 

Society, _1(l), 95-124.
Anderson, J. & Bartkus, D. (1973). Choice of Medical

Care: A Behavioral Model of Health and Illness Behavior.

Journal of Health & Social Behavior, 4(2), 348-362.

 

Baldwin, P. (1994). Caring For the Indigent Patient:

Resources to improve Care. Seminars in Oncology Nursing,

 

1 (2), 130-138.

Baquet, C., Horm,J., Gibbs,T.,& Greenwald,P. (1991).

Socioeconomic Factors and Cancer Incidence Among Blacks and

Whites. Journal of National Cancer Institute, 8 (5), 551—

 

557.
Fawcett, J., Tulman, L., & Samarel, N. (1995).
Enhancing Function in Life Transitions and Serious Illness.

Advanced Practice Nursing Quarterly, 1(3), 50—57.

 

67

Freeman, H. (1989). Cancer in the Socioeconomically

Disadvantaged. CA-A Cancer Journal for Clinicians, 3 (5),

 

266-288.
Given, B., Given, C., & Harlan, A. (1994). Strategies

to Meet the Need of the Rural Poor. Seminars in Oncology

 

Nursing, l_(2), 114—122.

Guadagnoli, E., Rice, C., & Mor, V. (1991). Cancer
Patients’ Knowledge of and willingness to Use Agency-Based
Services: Toward Application of a Model of Behavioral

Change. Journal of Psychosocial Oncology, 9(3), 1-21.

 

James, J. (1994). The Effects of Cues To Action On The

 

Use of Formal Community Services By Family Caregivers of

 

Physically Dependent Elders. (Master’s Thesis). East

 

Lansing, MI.
Kagawa-Singer, M. (1995). Socioeconomic and Cultural

Influences on Cancer Care of Women. Seminars in Oncology

 

Nursing, _1(2), 109-119.

Mandelblatt, J., Andrews, H., Kerner, J., Zauber, A., &
Burnett, W. (1991). Determinants of Late Stage Diagnosis of
Breast and Cervical Cancer: The Impact of Age, Race, Social

Class, and Hospital Type. American Journal of Public Health,

 

1(5), 646-649.

68

Michielutte, R., Bahnson, J., & Beal, P. (1990).
Readability of The Public Education Literature on Cancer

Prevention and Detection. Journal of Cancer Education, 5(1),

 

55-61.
Mor, V., Fleishman, J., Dresser, M., & Piette, J.
(1992). Variation in Health Service Use Among HIV-Infected

Patients. Medical Care, 0(1), 17-29.

 

Mor, V., Masterson-Allen, S., Houts, P., & Siegel, K.
(1992). The Changing Needs of Patients With Cancer at Home.
Cancer, 69(3), 829—838.

Reddall, C. (1994). People with cancer have the right
to expect the best possible treatment and care. European

Journal of Cancer Care, 3(3), 39—43.

 

Sarna, L., & McCorkle, R. (1996). Burden of Care and

Lung Cancer. Cancer Practice, 4(5), 245-250.

 

Schrijvers, C., & Mackenbach, J. (1994). Cancer Patient
Survival by Socioeconomic Status in The Netherlands: A

Review For Six Common Cancer Sites. Journal of Epidemiology

 

and Community Health, 1 441-446.

 

Siegel, K., Raveis, V., Houts, P., & Mor, V. (1991).
Caregiver Burden and Unmet Patient Needs. Cancer, 68(5),
1131-1140.

Smith, T., Rogers, G., Alsalam, N., Perie, M., Mahoney,
R., & Martin, V., (1994). The Condition of Education 1994.

National Center For Education Statistics, 67-69.

 

69

Underwood, S. & Hoskins, D. (1994). Increasing Nursing
Involvement in Cancer Prevention and Control Among the
Economically Disadvantaged: The Nursing Challenge. Seminars

in Oncology Nursing, 1 (2), 89-95.

 

United State Department of Commerce (1994). Income,
Poverty and Valuation of Non cash Benefits: 1993. Current
Population Reports, Consumer Income Series p60-188.

Wares, J., & Sherbourne, C. (1992). The MOS 36-Item

Short-Form Health Survey (SF-36). Medical Care, 0(6), 473-

 

483.

Ware, J., Kosinski, M., Bayless, M., Mchorney, C.,
Rogers, W., & Raczek, A. (1995). Comparison of Methods for
the Scoring and Statistical Analysis of SF-36 Health Profile
and Summary Measures: Summary of Results from the Medical

Outcomes Study. Medical Care, 33(4), 264-279.

 

7O

APPENDIX A
QUESTIONNAIRE

7l

Are you currently limited in . . . because of your health? (We are interested In your
ability to do these activities.)

a. Moderate activities, such as moving a table, bowling or playing golf?

Score
No, not limited at all 1
Yes, limited a little 2
Yes, limited a lot 3

b. Vigorous activities, such as lifting heavy objects or participating in strenuous sports?

 

Score
No, not limited at all 1
Yes, limited a little 2
Yes, limited a lot 3
c. Lifting or carrying groceries?
_ Score
No, not limited at all 1
Yes, limited 3 little 2
Yes, limited a lot 3
d. Climbing several flights of stairs?
Score
No, not limited at all 1
Yes, limited a little 2
Yes, limited a lot 3
e. Climbing one flight of stairs?
Score
No, not limited at all 1
Yes, limited a little 2
Yes, limited a lot 3
f. Bending, kneeling or stooplng?
Score
No, not limited at all 1
Yes, limited a little 2
Yes, limited a lot 3
9. Walking one block?
Score
No, not limited at all 1
Yes, limited a little 2
Yes. limited a lot 3

72

h. Walking several blocks?

No, not limited at all
Yes, limited a little
Yes, limited 3 lot

 

 

i. Walking more than one mile?

No, not limited at all
Yes. limited 3 little
Yes, limited a lot

 

 

 

j. Bathing or dressing yourself?

No, not limited at all
Yes, limited 8 little
Yes, limited a lot

 

 

 

Score

73

APPENDIX B
CONSENT

74

this pic-“3Q EXPIRI.

JUN 0 5 1998

andmuslberencw - ' -
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tr months to contineahm

gag... sue University 9195

MSU FAMILY HOME CARE CANCER STUDY

CAREQIXER CONSENT FOR RESEARCH

Introduction

You are being asked to participate in a research project to study the costs associated with cancer and
the effects of cancer on the lives of patients and their families or caregivers. The purpose of this
research study is to determine how age. preexisting health conditions, the site and extent of the cancer,
and the type of treatment affects the patient's mental status and ability to perform usual daily activities.
In addition, information concerning the involvement of and effect on patient's families or caregivers will
be collected.

This study is being conducted by Drs. Barbara and Charles Given who are professors in the College
of Nursing and the Department of Family Practice at Michigan State University. This research study
is being sponsored by Michigan State University and also involves other hospitals or medical center.
This study‘will involve 1,235 patients 65 years of age and older who have breast. colon, lung or
prostate cancer.

Description of Procedures

Should you decide to participate you will be contacted by telephone four times over the next 12 months;
at approximately 4, 12, 24 and 52 weeks following your friend or family member’s diagnosis. The
trained interviewer who will call you will ask a number of questions about your health, how you are
feeling, the types of activities you help your friend or family member perform} and the amount of time
and money you spend in caring for this person. It will take about 45-60 minutes to complete each
interview. In addition, a written questionnaire will be sent to you with a stamped return enveIOpe. This
questionnaire will ask questions regarding the assistance you provide to your friend or relative and will
take about 15- minutes to complete.

Risks and Discomforts

It is not expected that you or your friend or family member will be placed at any physical, financial or
legal risk as a result of participation in this study. Regardless of whether or not you choose to
participate in this study, you and your friend or family member will continue to receive medical care
under the direction of his/her personal physician(s). All information collected for this study including
that obtained from your friend or family member will be kept strictly confidential.

It is recognized that the diagnosis and treatment of cancer is stressful. In over 400 cancer patients, the

up: \CO-MSU

75

Michigan Stu: Unite-Ii, ”S

investigators have found no patient to date who experienced additional stress as a result of responding
to similar interview questions or written questionnaires. All interviewers for this study will be trained
by the investigators. and will be able to assist you if you should find any aspect of this study upsetting.
In addition, you are free to withdraw from this study at any time for any reason without penalty or
change in the quality of medical care which you receive. lf you have any questions or wish to withdraw
from the study you may call either the project coordinator or Charles W. Given. the Co-Principal
Investigator. at the research office: (517) 353-3843 or toll free, l-800—654-8219.

Benefits

It is not expected that you or your friend or family member will experience any direct benefit from
participation in this study. information from- this study may provide useful information concerning the
personal and financial impact of the diagnosis and treatment of four common cancers among the elderly.
Neither you nor your friend or family member will be paid or receive any other form of compensation
for participating in this study.

Alternatives -

If you decide not to participate in this study your friend or family member will continue to receive all
medical care and other standard forms of support. Neither you nor your friend or family member will
be contacted for telephone interviews or asked to complete questionnaires.

Rights and Responsibilities

To take part in this study, you must choose to do so and sign this form on the line below. Only
volunteers will be used in this study. If you choose to be in the study now, you may withdraw later
on by calling Dr. Charles W. Given at (517) 353-3843 or toll free, 1-800-654-8219. If you choose not

to take part in this study, or if you withdraw after you have started, you will not be penalized in any
way.

A record of your progress while on the study will be kept in a confidential file at College of Nursing
at Michigan State University. Only a few pe0ple who work on-the study will have access to records
that could directly or indirectly identify you. Information about your participation in this study will be
combined with that of all other patients who participate in the study and may be shared with others in
the research field, but no names will .be used. There will be no names or other patient identification
used in any study reports published later'on.

In the unlikely event of any injury from the research. no reimbursement, compensation or free medical
treatment is offered by Michigan State University.

up: \CG-MSU

76

Should you have any questions about your rights as a subject or should you sustain any
injury related to the research. you may contact Dr. David Wright, Chair. University
committee on Research Involving Human Subjects. at (517) 355-2180.

I have had an opportunity to ask questions about the study and was given sufficient time

to consider my participation. i have received a copy of this form and agree to
participate.

Caregivers Signature Date

Please print:

name

 

address

 

phone

 

Name of Patient

Investigators Signature Date

Wrtness' Signature Date

77

APPENDIX C
HUMAN SUBJECT APPROVAL

78

 

RESEARCH
AND
GRADUATE
STUDIES

University mutter—anlcerel

Research involving
Human Subjects
(UCRlliS)

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(Wilda.

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MICHIGAN STATE
U N l v f; a s l T it

May 7, 1996

 

10: Barbara A. Given
A230 Life Sciences

RE: IRBI: 92-280
TITLE: FMIB‘! HOME CARE FOR CANCSR- -A COMMUNITY-BASED
MODE
REVISION REQUESTED: 04/22/96
CATEGORY: FULL REVIEW
APPROVAL DATE: 05/06/96

The University Comittee on Research Involving Human Subjects' (UCRIHS)
review of this project is complete. I am pleased .to adVise that the
rights and welfare of the human subjects appear to be adequately
p‘r‘otected and methods to obtain informed conse are appropriate.
bgrefore, the UCRIHS approved this project an any reVisions listed
a ve.

RENEWAL: UCRIHS approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek it te certification. There is a

maxmum of four such expedite renewals possible. Investigators

wishin to continue a project beyond tha time need to submit it
again or complete review.

 

REVISIONS: UCRIHS must review any changes in cgrocedures involving human
subJects, rior to initiation of e change. If this is done at
the time o- renewal, please use the green renewal form. To
revise an approved protocol at an other time during the year
send your written request to the CRIBS Chair, requesting revised
approval and referencing the project's IRB ii and title. Include
in your request a description of- the change and any revised
ins ruments. consent forms or advertisements that are applicable.

PROBLEMS]

camcss: Should either of the following arise during the course of the
work. investigators must noti UCRIHS promptly: (l) robleras
(unexpected side effects comp aints. e c.) involving urnan
subgects or (2) changes in the research environment or new
information indicating greater risk to the human suba'ects than

existed when the protocol was previously reviewed an approved.

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517“ 2- 171.

    
 

   

avid E. Hright, Ph.D.
CRIBS Chair

new:bed

cc: Charles Given

79

APPENDIX D
HUMAN SUBJECT

80

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
Research involving
HumanSubnct

(UCRIHS) .

Michigan State University
246 Adm-nutrition Budding
Easx Lansing Michigan

48824-1046
sums-2180
FAX 5l7/432-ll7i

be A! ' :2" Start- U'vvvrrsdy
13!; . warm.” Gummy

inwlwy on Mon

USU - - - Aflrl'lu'n.‘ xhan
Mu! .‘NNlr-vln'. "$l-lulm

MICHIGAN STATE

 

U l4 l V E.l{ S I T Y
July 9. 1997
TO: Barbara A. Given

A230

RE: IRE”:

TITLE:

Life Sciences

97-462

TNE INFLUENCE OF SOCIOECONOMIC STATUS ON THE USE
OF FORMAL COMMUNITY HEALTH SERVICES BY LUNG
CANCER PATIENTS. WHILE CONTROLLING FOR
FUNCTIONAL STATUS

REVISION REQUESTED: N/A
CATEGORY: l-E
APPROVAL DATE: 07/07/97

The University Committee on Research Involving Human Subjects'IUCRIHS)

review of this project is complete.

rights and

protected a

herefore,
above.

RENEWAL:

REVISIONS:

Pnonnsns/
CHANGES :

. I am pleased to adVise that the
welfare of the human subjects appear to be adequately
nd methods to obtain informed consent are appropriate.

the UCRIHS approved this project and any reVisions listed

UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond ene year must use the green renewal
form (enclosed with t e original agproval letter or when a
project is renewed) to seek u date certification. There is a
maXimum of four such expedite renewals ossible. Investigators

wishing to continue a project beyond tha time need to submit it
again or complete reView.

UCRIHS must review eny changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
reVise an approved protocol at any other time during the year.
send your written request to the CRIHS Chair, requesting revised
approval and referenCing the project's IRB B and title. Include
in our request a description of the change and any revised

ins ruments. consent forms or advertisements that are applicable.

Should either of the followin arise during the course of the
work, investigators must noti UCRIHS promptly: (l) roblems
(unexpected Side effects, comp aints, etc.) involving uman
subjects.or (2) changes in the research environment or new
information indicating greater risk to the human sub'ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future hel

at

Sincerely,

 
 
  
 
  

DEW:bed

cci/;§;e L.

(517)355-2180 or FAX

avid E. Wright.
CRIHS Chair

p, please do not hesitate to contact us
ISl7i4 2- 171.

Ph.

Smallwood

81

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