Biomedical subjects

Nancy K Janz

Publications and source records attributed to Nancy K Janz.

At least 19 recordsLinked to original sources

PubMed2006

Determinants of colorectal cancer screening use, attempts, and non-use.

BACKGROUND: Relatively little is known about the experiences and preferences of users and those who attempt colorectal cancer (CRC) screening. This study describes factors influencing CRC screening decisions among users, attempters, attempter users (individuals who both attempted and completed at least one screening procedure), and non-users; identifies factors interfering with test completion; and describes correlates of screening preferences. METHODS: A primarily stratified random sample of patients from the University of Michigan Health System clinics, Ann Arbor, Michigan, with oversampling of FOBT attempters, completed a mailed questionnaire in fall, 2003. Descriptive and multivariate approaches evaluated factors influencing screening use and preferences. RESULTS: "Accuracy of results" was reported most often as important when deciding about CRC screening regardless of screening status. The importance of psychological decisional factors differed significantly by screening status (P<0.05). Among factors interfering with test completion, 38.5% attempting FOBT reported they "forgot" whereas 29.8% attempting colonoscopy were "afraid of pain." Approximately 56.3% indicated a preference for a CRC test: respondents who considered "discomfort" important preferred FOBT (OR: 0.39, 95% CI: 0.17, 0.87); those with a prior colonoscopy preferred an invasive test (OR: 6.50, 95% CI: 2.90, 14.50). CONCLUSIONS: To improve adherence to CRC screening recommendations, physicians should tailor discussions to patients' prior experiences and test-specific concerns and elicit preferences for screening.

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PubMed2006

Factors associated with patient involvement in surgical treatment decision making for breast cancer.

OBJECTIVE: To evaluate factors associated with women's reported level of involvement in breast cancer surgical treatment decision making, and the factors associated with the match between actual and preferred involvement in this decision. METHODS: Survey data from breast cancer patients in Detroit and Los Angeles was merged with surgeon data for an analytic dataset of 1101 patients and 277 surgeons. Decisional involvement and the match between actual and preferred amount of involvement were analyzed as three-level dependent variables using multinomial logistic regression controlling for clustering within surgeons. Independent variables included patient demographic and clinical factors, surgeon demographic and practice factors, cancer program designation, and two measures of patient-surgeon communication. RESULTS: We found variation in women's actual decisional involvement and match between actual and preferred involvement. Women with a surgeon-based or patient-based (versus shared) decision were significantly (p < or = 0.05) younger. Women who had too little decisional involvement (versus the right amount) were younger, while women with too much involvement had less education. Patient-surgeon communication variables were significantly associated with both involvement and match, and higher surgeon volume as associated with too little involvement. CONCLUSION: Patient factors and patient-surgeon communication influence women's perception of their involvement in breast cancer surgical treatment decision making. PRACTICE IMPLICATIONS: Decision tools are needed across surgeons and practice settings to elicit patients' preferences for involvement in treatment decisions for breast cancer.

Adult↗

PubMed2006

The influence of race, ethnicity, and individual socioeconomic factors on breast cancer stage at diagnosis.

OBJECTIVES: Previous research has generally found that racial/ethnic differences in breast cancer stage at diagnosis attenuate when measures of socioeconomic status are included in the analysis, although most previous research measured socioeconomic status at the contextual level. This study investigated the relation between race/ethnicity, individual socioeconomic status, and breast cancer stage at diagnosis. METHODS: Women with stage 0 to III breast cancer were identified from population-based data from the Surveillance, Epidemiology, and End Results tumor registries in the Detroit and Los Angeles metropolitan areas. These data were combined with data from a mailed survey in a sample of White, Black, and Hispanic women (n=1700). Logistic regression identified factors associated with early-stage diagnosis. RESULTS: Black and Hispanic women were less likely to be diagnosed with early-stage breast cancer than were White women (P< .001). After control for study site, age, and individual socioeconomic factors, the odds of early detection were still significantly less for Hispanic women (odds ratio [OR]=0.45) and Black women (OR = 0.72) than for White women. After control for the method of disease detection, the White/Black disparity attenuated to insignificance; the decreased likelihood of early detection among Hispanic women remained significant (OR=0.59). CONCLUSION: The way in which racial/ethnic minority status and socioeconomic characteristics produce disparities in women's experiences with breast cancer deserves further research and policy attention.

Adult↗

PubMed2006

An informed decision? Breast cancer patients and their knowledge about treatment.

OBJECTIVE: Although involving women in breast cancer treatment decisions is advocated, there is little understanding of whether women have the information they need to make informed decisions. The objective of the current study was to evaluate women's knowledge of survival and recurrence rates for mastectomy and breast conserving surgery (BCS) and the factors associated with this knowledge. METHODS: We used a population-based sample of women diagnosed with breast cancer in metropolitan Los Angeles and Detroit between December 2001 and January 2003. All women with ductal carcinoma in situ and a random sample of women with invasive disease were selected (N=2382), of which 1844 participated (77.4%). All participants were mailed surveys. The main outcome measures were knowledge of survival and recurrence rates by surgical treatment type. RESULTS: Only 16% of women knew that recurrence rates were different for mastectomy and BCS, and 48% knew that the survival rates were equivalent across treatment. Knowledge about survival and recurrence was improved by exposure to the Internet and health pamphlets (p<0.01). Women who had a female (versus male) surgeon, and/or a surgeon who explained both treatments (rather than just one treatment) demonstrated higher survival knowledge (p<0.01). The majority of women had inadequate knowledge with which to make informed decisions about breast cancer surgical treatment. CONCLUSION: Previous explanations for poor knowledge, such as irrelevance of knowledge to decision making and lack of access to information, were not shown to be plausible explanations for the low levels of knowledge observed in this sample. PRACTICE IMPLICATIONS: These results suggest a need for fundamental changes in patient education to ensure that women are able to make informed decisions about their breast cancer treatment. These changes may include an increase in the use of decision aids and in decreasing the speed at which treatment decisions are made.

Adult↗

PubMed2006

Cataract extraction in the collaborative initial glaucoma treatment study: incidence, risk factors, and the effect of cataract progression and extraction on clinical and quality-of-life outcomes.

OBJECTIVES: To study the incidence of and predictors for cataract extraction (CE) in patients with newly diagnosed glaucoma, the impact of CE on visual function, and changes in the time around CE. METHODS: Patients were randomized to medical or surgical treatments for glaucoma at 14 centers and followed up for a median of 7.7 years. Vision-specific quality of life (VS-QOL) data were collected by telephone interview during follow-up of 607 patients randomized to medical or surgical treatments for glaucoma. The occurrence of CE was the signal event. Risk factors were evaluated using survival analyses; changes from before to after CE were evaluated by paired t tests; and trends were estimated by loess regression. RESULTS: During follow-up of 607 patients, CE took place in 99 study eyes. Initial surgery, older age, a more negative spherical equivalent, and a diagnosis of pseudoexfoliative glaucoma conferred a higher risk of CE. Visual field testing before and after CE showed the mean deviation improved but the pattern standard deviation worsened. The VS-QOL improved on most subscales. CONCLUSIONS: Initial surgery places a patient with glaucoma at a higher risk of CE. The impact of CE on visual field indexes is mixed-the mean deviation improved but the pattern standard deviation worsened. Most, but not all, VS-QOL subscales were responsive to worsening of cataract prior to and acute improvement in vision after CE.

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PubMed2006

Correlates of between-surgeon variation in breast cancer treatments.

BACKGROUND: Determinants of between-surgeon variation in breast cancer treatment utilization are not well understood. OBJECTIVES: The objectives of this study were to evaluate variation in receipt of surgical treatment (ie, mastectomy or breast-conserving surgery with or without radiation) for women with stage I, II, or III breast cancer and receipt of breast reconstruction attributable to surgeons, and to assess factors associated with this between-surgeon variation. METHODS: We surveyed all attending surgeons (n = 456) of a population-based sample of patients with breast cancer diagnosed in Detroit and Los Angeles during 2002 (n = 1844). Our analytic dataset linked data from 1477 patients with that of 311 surgeons. We used random-effects modeling to account for the multilevel dataset and evaluated 2 outcomes: 1) primary surgical treatment (mastectomy vs. BCS); and 2) receipt of reconstruction before being surveyed (yes vs. no). Independent variables included patient-related factors (clinical and demographic), surgeon-related factors (breast procedure volume, practice setting, and demographics), surgeon treatment recommendation, and referral propensity. RESULTS: Surgeons explain some variation in use of both mastectomy and reconstruction (9.9% and 26%, respectively). Patient clinical factors and surgeon volume together explain approximately one-third of the between-surgeon variation in mastectomy. Patient factors and surgeon demographics explain approximately 60% of between-surgeon variation in reconstruction, and surgeon referral propensity explains an additional 15%. CONCLUSION: Our findings suggest that similar patients may get different treatment depending on their surgeon. Broader dissemination of guidelines coupled with increasing patient access to consultations before definitive surgery may reduce between-surgeon variation. Contributing factors such as patient-physician communication should be explored.

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PubMed2005

Correlates of breast reconstruction: results from a population-based study.

BACKGROUND: Immediate or early postmastectomy breast reconstruction is performed infrequently. To the authors' knowledge, little is known regarding surgeon or patient perspectives on reconstruction treatment decisions. The purpose of the current study was to identify patient attitudes and preferences associated with breast reconstruction, and whether these differed by race. METHODS: A sample of women age < or = 79 years who were diagnosed with ductal carcinoma in situ and invasive breast carcinoma between December 2001 and January 2003 was identified from the Surveillance, Epidemiology, and End Results (SEER) registries of Detroit and Los Angeles. Eligible subjects completed a questionnaire at a mean of 7 months after diagnosis. The Wald chi-square test and logistic regression were used for data analysis. RESULTS: Of the 1844 respondents, 646 underwent a mastectomy (35.0% of the total sample) and 245 of these patients received breast reconstruction (38.0%; of the mastectomy group). On multivariate analysis, younger patient age, higher educational levels, and earlier stage of disease were found to be significantly associated with breast reconstruction. Although 78.2% of women reported that breast reconstruction was discussed, only 11.2% correctly answered 3 basic knowledge questions regarding the procedure. The desire to avoid more surgery was the most common reason for not undergoing breast reconstruction. CONCLUSIONS: The results of the current study found that the majority of women were aware of breast reconstruction but choose not to undergo the procedure. Lack of knowledge and a greater perception of barriers to the procedure were more common among African-American patients and women with a lower education level, suggesting a need for improved educational strategies.

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PubMed2005

Surgeon perspectives about local therapy for breast carcinoma.

BACKGROUND: Geographic variations in the use of mastectomy and the use of radiation therapy (RT) after breast-conserving surgery (BCS) have motivated concerns that surgeons are not uniformly adhering to treatment standards. METHODS: The authors surveyed attending surgeons of a population-based sample of patients with breast carcinoma diagnosed in Detroit and Los Angeles from December 2001 to January 2003 (n = 365; response rate, 80.0%). Clinical scenarios were used to evaluate opinions about local therapy. RESULTS: On average, surgeons reported that they devoted 31.3% of their total practice to breast carcinoma. Approximately one-half of surgeons practiced in a community hospital setting, whereas 18.8% practiced in a cancer center. Compared to low volume surgeons, high volume surgeons were more likely to favor BCS with RT for invasive breast carcinoma (60.8%, 74.0%, and 87.2% for low, moderate, and high volume surgeons, respectively, P < 0.001). Surgeons who favored BCS were more likely to perceive greater quality of life (QOL) benefits for BCS than mastectomy (85.9%) compared with surgeons who favored mastectomy (28.6%) and those who did not favor 1 procedure over the other (60.0%, P < 0.001). In a ductal carcinoma in situ scenario, 35.0% of surgeons favored BCS without RT and 61.0% favored BCS with RT. Opinions regarding the role of RT after BCS varied by geographic site, surgeon volume, and patient age. CONCLUSIONS: Variation in surgeon opinion concerning local therapy reflected clinical uncertainty about the benefits of alternative treatments. High volume surgeons more frequently endorsed current clinical guidelines that favor BCS compared with mastectomy. This may partly be explained by the greater belief that BCS confers a better patient QOL than mastectomy.

Adult↗

PubMed2005

Breast cancer treatment experiences of Latinas in Los Angeles County.

OBJECTIVE: We examined breast cancer treatment experiences of and outcomes for Latinas in Los Angeles County. METHODS: We conducted a population-based survey of women who were diagnosed with breast cancer between December 2001 and November 2002 (n=910) to evaluate the types of treatments received, communication with clinicians, and satisfaction. RESULTS: About two thirds were non-Latina White, 18.8% were African American, and 18.9% were Latina (with 11.0% preferring English and 7.9% preferring Spanish). The rest indicated other ethnic groups. Latinas who preferred Spanish were more likely to experience a delay of 3 months or more from diagnosis to surgical treatment (36.4% vs 9.1% for non-Latina Whites, 18.6% for African Americans, and 12.7%, for other Latinas, P<.001). African Americans and Latinas who preferred Spanish had very low rates of reconstruction (13.8% and 9.2%, respectively, compared with 42.1% for Whites and 34.5% for Latinas who preferred English, P=.009). Latinas who preferred Spanish had the highest odds ratio for low satisfaction. CONCLUSION: Latinas who preferred Spanish received different treatments and perceived a different treatment experience than did other cultural groups.

Adult↗

PubMed2005

Patient involvement in surgery treatment decisions for breast cancer.

PURPOSE: High rates of mastectomy and marked regional variations have motivated lingering concerns about overtreatment and failure to involve women in treatment decisions. We examined the relationship between patient involvement in decision making and type of surgical treatment for women with breast cancer. METHODS: All women with ductal carcinoma-in-situ and a 20% random sample of women with invasive breast cancer aged 79 years and younger who were diagnosed in 2002 and reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results registries were identified and surveyed shortly after receipt of surgical treatment (response rate, 77.4%; n = 1,844). RESULTS: Mean age was 60.1 years; 70.2% of the women were white, 18.0% were African American, and 11.8% were from other ethnic groups. Overall, 30.2% of women received mastectomy as initial treatment. Most women reported that they made the surgical decision (41.0%) or that the decision was shared (37.1%); 21.9% of patients reported that their surgeon made the decision with or without their input. Among white women, only 5.3% of patients whose surgeon made the decision received mastectomy compared with 16.8% of women who shared the decision and 27.0% of women who made the decision (P < .001, adjusted for clinical factors, predisposing factors, and number of surgeons visited). However, this association was not observed for African American women (Wald test 10.0, P = .041). CONCLUSION: Most women reported that they made or shared the decision about surgical treatment. More patient involvement in decision making was associated with greater use of mastectomy. Racial differences in the association of involvement with receipt of treatment suggest that the decision-making process varies by racial groups.

Adult↗

PubMed2005

Patterns and correlates of local therapy for women with ductal carcinoma-in-situ.

PURPOSE: Concerns have been raised about the quality of treatment for women with ductal carcinoma-in-situ (DCIS) because persistent high rates of mastectomy suggest overtreatment, whereas lower than expected rates of radiation therapy after breast-conserving surgery (BCS) suggest undertreatment. PATIENTS AND METHODS: All women with DCIS diagnosed in 2002 and who reported to the Detroit and Los Angeles Surveillance, Epidemiology, and End Results (SEER) registries were identified and surveyed shortly after receipt of surgery (response rate, 79.7%; n = 817). Analyses were restricted to patients with DCIS (n = 659) indicated by SEER stage data. RESULTS: Only 14.0% of patients at lowest risk of recurrence (based on tumor size and histologic grade) received a mastectomy compared with 22.8% and 52.6% of patients at intermediate and highest risk (P < .001). Only 13.1% of patients who were not influenced or slightly influenced by concerns about recurrence received mastectomy compared with 48.8% of women who were greatly influenced by this concern (P < .001). A between-geographic site difference in receipt of radiation after BCS was observed for the lowest risk group (38.9% in Los Angeles v 70.5% in Detroit) but not for the highest risk group (80.2% in Los Angeles v 85.9% in Detroit, P = .006 for site and risk group differences). Between-site differences in receipt of radiation after BCS were consistent with patient recall of surgeon discussions about treatment. CONCLUSION: Surgeons are tailoring their recommendations for local therapy options for DCIS based on important clinical factors. Patient attitudes also play an important role in treatment decisions. The substantial influence of both surgeon opinion and patient attitudes should temper concerns about the quality of treatment for women with DCIS.

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PubMed2005

Taking CHARGE: A self-management program for women following breast cancer treatment.

The purpose of the study was to develop and evaluate Taking CHARGE, a self-management intervention designed to facilitate successful transitions to survivorship after breast cancer treatment. The Taking CHARGE intervention involves a two-pronged approach building on self-regulation principles to (1) equip women with self-management skills to address concerns following breast cancer treatment, and (2) provide information about common survivorship topics. The program involved four intervention contacts, two small group meetings and two individualized telephone sessions, delivered by nurse/health educators. This paper focuses on the process evaluation findings from a preliminary test of the Taking CHARGE intervention conducted with 25 women, aged 34-66 years, completing breast cancer treatment, who were randomly assigned to the intervention group. The process evaluation was conducted to obtain systematic information about the relevance and usefulness of the self-regulation approach, informational aspects, and program delivery. The findings indicated that intervention group participants found the Taking CHARGE program to be timely, relevant, and to have high utility in dealing with concerns that exist following breast cancer treatment. The process evaluation findings provide early evidence of the usefulness of the Taking CHARGE intervention for successful transition to survivorship following breast cancer treatment.

Adaptation, Psychological↗

PubMed2005

Population-based study of the relationship of treatment and sociodemographics on quality of life for early stage breast cancer.

OBJECTIVE: To examine the relationship between cancer stage, surgical treatment and chemotherapy on quality of life (QOL) after breast cancer and determine if sociodemographic characteristics modify the observed relationships. METHODS: A population-based sample of women with Stages 0-II breast cancer in the United States (N = 1357) completed surveys including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), and the Breast Cancer-Specific Quality of Life Questionnaire (QLQ BR-23). Regression models calculated mean QOL scores across primary surgical treatment and chemotherapy. Clinically significant differences in QOL were defined as > or = 10 point difference (out of 100) between groups. RESULTS: Meaningful differences in QOL by surgical treatment were limited to body image with women receiving mastectomy with reconstruction reporting lower scores than women receiving breast conserving surgery (p < 0.001). Chemotherapy lowered QOL scores overall across four QOL dimensions (p values < 0.001), with a disproportionately greater impact on those with lower levels of education. Younger women reported lower QOL scores for seven of nine QOL dimensions (p values < 0.001). CONCLUSIONS: Women should be reassured that few QOL differences exist based on surgical treatment, however, clinicians should recognize that the impact of treatment on QOL does vary by a woman's age and educational level.

Adult↗

PubMed2005

Reliability of health-related quality-of-life measures 1 year after surgical procedures for pelvic floor disorders.

OBJECTIVE: The purpose of this study was to assess the reliability and validity of condition-specific health-related quality-of-life measures in women who are treated surgically for pelvic organ prolapse and urinary incontinence. STUDY DESIGN: The study used the cross-sectional telephone interview-based administration of a health-related quality-of-life measure, with a 2-week follow-up interview for test-retest reliability. RESULTS: Initial and follow-up interviews were completed by 88 women (mean age, 65.7 +/- 11.6 years) approximately 1 year after surgical procedures. Condition-specific measures demonstrated acceptable reliability with test-retest correlation coefficients that approached or exceeded 0.6 and Cronbach's alpha that exceeded 0.8 in most domains. Validity was demonstrated with significant correlations of the urinary domains of the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire, with continence defined by the medical, epidemiologic, and social aspects of aging and Hunskaar severity measures (all P < .001). CONCLUSION: The condition-specific health-related quality-of-life assessment is reliable and valid in women after surgical procedures for pelvic floor disorders. These findings support the inclusion of condition-specific health-related quality-of-life measures in clinical trials for women with pelvic floor disorders.

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PubMed2005

Satisfaction with surgery outcomes and the decision process in a population-based sample of women with breast cancer.

OBJECTIVE: To better understand medical decision making in the context of "preference sensitive care," we investigated factors associated with breast cancer patients' satisfaction with the type of surgery received and with the decision process. DATA SOURCES/DATA COLLECTION: For a population-based sample of recently diagnosed breast cancer patients in the Detroit and Los Angeles metropolitan areas (N=1,633), demographic and clinical data were obtained from the Surveillance, Epidemiology, and End Results tumor registry, and self-reported psychosocial and satisfaction data were obtained through a mailed survey (78.4 percent response rate). STUDY DESIGN: Cross-sectional design in which multivariable logistic regression was used to identify sociodemographic and clinical factors associated with three satisfaction measures: low satisfaction with surgery type, low satisfaction with the decision process, and decision regret. PRINCIPAL FINDINGS: Overall, there were high levels of satisfaction with both surgery and the decision process, and low rates of decision regret. Ethnic minority women and those with low incomes were more likely to have low satisfaction or decision regret. In addition, the match between patient preferences regarding decision involvement and their actual level of involvement was a strong indicator of satisfaction and decision regret/ambivalence. While having less involvement than preferred was a significant indicator of low satisfaction and regret, having more involvement than preferred was also a risk factor. Women who received mastectomy without reconstruction were more likely to report low satisfaction with surgery (odds ratio [OR]=1.54, p<.05), low satisfaction with the process (OR=1.37, p<.05), and decision regret (OR=1.55, p<.05) compared with those receiving breast conserving surgery (BCS). An additional finding was that as patients' level of involvement in the decision process increased, the rate of mastectomy also increased (p<.001). CONCLUSIONS: A significant proportion of breast cancer patients experience a decision process that matches their preferences for participation, and report satisfaction with both the process and the outcome. However, women who report more involvement in the decision process are significantly less likely to receive a lumpectomy. Thus, increasing patient involvement in the decision process will not necessarily increase use of BCS or lead to greater satisfaction. The most salient aspect for satisfaction with the decision making process is the match between patients' preferences and experiences regarding participation.

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PubMed2004

Patient-physician concordance: preferences, perceptions, and factors influencing the breast cancer surgical decision.

PURPOSE: This study explored patient preferences for involvement in the breast cancer treatment decision and concordance between patients' and physicians' views on decisional role. The impact of demographic and psychosocial characteristics on patients' decisional role was also examined. PATIENTS AND METHODS: Women with stage I or II breast cancer who were candidates for either mastectomy or lumpectomy were recruited from a university breast cancer treatment center. Patient interviews were obtained before meeting the surgical oncologist and again after the treatment decision was made but before surgical intervention. Clinician responses were obtained after the consultation. RESULTS: The 101 participants were generally white (97%), married (80%), and well-educated. They reported moderate levels of depression and anxiety but good social support and self-efficacy in communicating with their physician. Before the consultation, 47% of women reported a preference for shared decision making; afterwards, 61% felt they had primary responsibility for the decision. Only 38% of patients agreed with the physician's assessment of how the treatment decision was made. In regression analyses, higher education was significantly associated with patients' preferred level of control (P = .01). There was a trend toward women with greater self-efficacy desiring more active decisional roles (P = .08). Patient preference for decision making did not impact time in the patient-physician encounter, but more influence did increase satisfaction. CONCLUSION: Limited concordance between patient preference and patient perception and between patient and physician perception in how the treatment decision was made suggests the need for better communication between patient and clinician during a critical treatment encounter for breast cancer patients.

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PubMed2004

Understanding and reducing stress and psychological distress in older women with heart disease.

Stress and psychological distress were assessed in 457 older women who were subsequently randomized to a six-week heart disease management program ("Women take PRIDE") or to a "usual care" control group. Baseline distress was significantly associated with age, symptoms, physical functioning, social support, optimism, and self-esteem (p < .05). Only 20% of women reported their physician had recommended reducing stress. At four months follow-up, intervention women compared to controls were significantly more likely to report reductions in stress levels (p = 0.02) and also showed improvement in emotional behavior (p = 0.09).

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PubMed2004

Longitudinal effects of social support on the health and functioning of older women with heart disease.

This study examined the effects of: 1) four dimensions of social support, 2) the number of close social ties, and 3) marital status on the physical and psychological health and functioning of 471 women aged 60 years and over with heart disease. Linear mixed models were used to assess the impact of each baseline social relations predictor on health outcomes at four-, 12-, and 18-month follow-up intervals. A second set of models examined the association between change in support variables over time with concomitant change in health outcomes. Results indicated that baseline emotional/ informational support, positive social interaction, affectionate support, tangible support, number of close friends and relatives, and marital status all significantly predicted (p < .05) one or more health outcomes over time. Increases in positive social interaction and emotional support over time were significantly associated with concurrent improvement in all self-reported physical and psychological health outcomes. Interventions that enhance the availability of emotional/informational support and promote social interaction are needed for this population.

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