July 2007, Volume 34, Number 4
A Test of the Self-Help Model and Use of Complementary and Alternative Medicine Among Hispanic Women During Treatment for Breast Cancer
Barbara Owens, PhD, RN, OCN®
To describe the relationships
in Braden’s Self-Help Model of side-effect burden to uncertainty,
complementary and alternative medicine (
Design: Descriptive, correlational; convenience sample; cross-sectional design.
oncology clinic in a public setting of a metropolitan community in southern
Sample: 137 Hispanic women receiving or completing treatment for breast cancer.
Methods: Participants completed a comprehensive set of instruments. Analyses included a correlation of variables and multiple regressions to examine variables for potential theoretical relationships.
The study results
provide valuable information about understanding
for Nursing: The
findings further inform the concept development of
· Braden’s Self-Help Model is an excellent framework for testing hypotheses regarding self-care and side-effect burden.
relationship between side-effect burden and uncertainty is not affected by the
use of complementary and alternative medicine (
· Complementary therapy scales should be tailored to the local areas where they are being used.
and alternative medicine (
medicine is defined as methods used in the diagnosis, treatment, or prevention
of disease that supplement Western medicine. In contrast, alternative medicine
is used as a substitute for Western medicine (Cassileth,
1999). The construct, CAM, includes two concepts: the amount and types of CAM
used and the perceived efficacy of
life events, including chronic stressors and major traumatic experiences, such
as breast cancer, increase consumer interest in and need for
attribute their selection of self-help and
studies have examined the phenomenon of the use of CAM among women with breast
cancer; however, few studies have provided a theoretical framework to
demonstrate the network of interrelated concepts of
Braden’s Self-Help Model has five stages. The first stage is the side-effect burden or level of perceived debility (i.e., physical and psychological complaints or problems) attributable to side effects of therapy or disease course (Braden, 1990; Longman, Braden, & Mishel, 1999).
The second stage is uncertainty that occurs as a result of the disease and treatment side effects. Braden (1986) discussed the conditions that lead to uncertainty in chronic illness as cues for reinforcement because of uncertainty for events that are likely to occur. Mishel (1981) defined uncertainty as the extent to which patients are unable to derive meaning from illness and treatment experiences.
The third stage is related to patients’ perceived coping or perceived enabling skills. Enabling skills are defined as the level of problem solving or cognitive reframing used to eliminate or modify effects of adversities to reach desired goals.
The fourth stage uses four adaptation activities that are considered instrumental in carrying out adult role functions (Braden, 1990). Psychological adjustment is defined as patients’ psychological and social adjustment to illness. The self-help variable represents an outcome that is defined as patients’ perceived levels of adult role performance. Self-care denotes the activities that are devoted to enhancing or maintaining health.
additional variable of
The fifth stage is overall well-being or the degree of perceived satisfaction with QOL. QOL is a subjective phenomenon that includes physical, psychological, and social domains (Aaronson, 1990). The fifth stage is defined as patients’ perceptions of their positions in life in the context of the culture and value systems in which they live and in relation to goals, expectations, standards, and concerns (Orley, 1996). The relevance of exploration of the responses in the context of the culture of Hispanic women is crucial to understand the salient characteristics among women who respond differently to similar situations.
descriptive, correlational research design in a
cross-sectional sample was used to examine the relationship between
Setting and Sample
researchers selected a convenience sample of women receiving treatment for
breast cancer at an outpatient clinic located in a southern
Table 1 summarizes the study concepts, conceptual definitions, and instruments used to measure each concept. Table 2 provides the published reliability estimates for the instruments. The studies on which the reliability information was based were among women who were in a similar stage of breast cancer treatment. All instruments were translated into Spanish to facilitate the enrollment of Spanish- and English-speaking subjects. The instruments were translated into Spanish and back translated into English to verify that word use was correct for the constructs being measured. The translation of the English form to the Spanish form was done initially by one person and then checked for local word use by two independent bilingual translators. The second phase was back translation of the questions read aloud and recorded, for the meaning as it sounded when read quickly, as patients would do. The resulting back-translated version was compared with the original. Translation probes (Marin & Marin, 1991) were used to test the accuracy of the translation by comparing how closely the target Spanish language version was related to the English.
Equivalency of reliability between the Spanish and English versions of all instruments is reported in Table 3. Rogers, Howard, and Vessey (1993) introduced the concept to determine whether groups are sufficiently similar to be considered equivalent. They used the same method typically used by biostatisticians to determine whether two drugs have an equivalent effect. The a priori decision of 0.1 for tolerance, or less than 10% difference between the English and Spanish versions, is considered sufficiently similar to be considered equivalent. An equivalency check demonstrated a small nonzero difference in reliability between the English and Spanish versions of all instruments except the Index of Well-Being and the Effectiveness Rating Subscale. Therefore, results of the study were reported with the Spanish and English language versions combined into one statistical value. The scale items were written at a sixth-grade reading level.
The Side-Effects Burden Scale (Longman, Braden, & Mishel, 1997) measured the perceived levels of physical and psychological complaints or problems. The specific side effects included nausea, change in appetite, difficulty sleeping, pain, fatigue, bowel pattern, difficulty concentrating, appearance, breathing, skin changes, arm weakness or swelling, hair loss, depression, hot flashes, and weight gain. The side effects are evaluated according to frequency, participants’ lives, and how effectively they can be managed.
The Uncertainty in Illness Scale (Mishel, 1983) was used to measure uncertainty. The instrument has four subscales: ambiguity, complexity, lack of information, and unpredictability. Items are scored in a positive direction for uncertainty on a five-point Likert scale from “strongly agree” to “strongly disagree.” The total possible range is 26–130, with a high score indicating a great amount of uncertainty.
The Self-Control Schedule (Rosenbaum, 1980) was used to measure enabling skills, which were defined as the level of problem solving and cognitive reframing available to eliminate or modify effects of adversities to reach desired goals. A 10 mm horizontal line visual analog scale response format that ranged from 1 (not true about me) to 10 (true about me) was used. Scores can range from 0–200, with a higher score indicating a greater amount of enabling skills. The 20-item measure covers use of cognitions and self-instructions to cope with stressors, application of problem-solving strategies, ability to delay immediate gratification, and a general belief regarding the ability to control stressors.
The Psychosocial Adjustment to Illness Scale is an assessment of how patients have adjusted to their illnesses (Derogatis, 1986). A four-point Likert response format is used. Scores range from 4–20, with higher scores indicating excellent adjustment and lower scores indicating poorer adjustment to changes in their lives.
The Inventory of Adult Role Behavior (IARB) (Braden, 1993) represents the self-help variable. This outcome variable is defined as patients’ perceived levels of adult role performance. Items from the IARB address maintenance of involvement in social events, community activities, routine errands and household activities, work activities, recreational activities, and visiting with friends. A visual analog scale is used, with a rating from 1–10 of the amount of change in activities since cancer was diagnosed. Total scores can range from 0–60, with higher scores indicating more involvement in adult self-help behaviors.
The wellness promotion aspects of self-care were measured with 15 items from the Self-Care Inventory–Wellness Promotion Subscale (Pardine, Napoli, & Dytell, 1983). Items addressed were eating the right amount of healthful foods, receving the basics of good nutrition, avoiding junk foods, pacing self at work and play, making time for relaxation, practicing relaxation exercises, taking time to exercise, reducing negative self-talk, and increasing positive self-talk. The scale is scored in a four-point Likert response format, with higher scores indicating higher levels of self-care and wellness promotion behavior.
The Complementary Therapy Rating Scale (Bennett & Lengacher, 1998) collects demographic information and rates the complementary therapies patients with cancer use or intend to use and their effectiveness. The scale includes two subscales: the Use and Intent Subscale and the Effectiveness Rating Subscale. The Use and Intent Subscale measures 14 complementary therapies on a five-point Likert scale ranging from 0 (I am currently doing this) to 4 (definitely would not try this). The items include exercise, humor, hypnosis, massage, chiropractor, acupuncture, relaxation therapies and groups, prayer, vitamins, herbs, health foods, and support groups. The Effectiveness Rating Subscale rates how effective a complementary therapy is on a three-point Likert scale ranging from 1 (very helpful) to 3 (not helpful). The Effectiveness Rating Subscale allows patients to list the complementary therapy they are using, as well as describe one therapy and provide any additional information.
measured by two questions using Cantril’s
ladder, a single-item visual analog response format that has a potential
score range from 0 (the worst possible life) to 10 (the best possible
life). The first question asked, “Where are you on this ladder?” The second
question asked, “Where would you be on the ladder if you did not use
The Side-Effects Burden Scale listed depression as a side effect. A second measure of depression burden as a side effect associated with breast cancer diagnosis and treatment was indexed using the Center for Epidemiologic Studies–Depression Scale (Radloff, 1977), which measures a range of cognitive, affective, motivational, and somatic symptoms of depression. Twenty questions are scored from 0–3 on a scale of frequency of occurrence, ranging from rarely or none of the time (less than one day) to most or all of the time (five to seven days). The possible range of scores is 0–60, with higher scores indicating more symptomatology.
11.0 (SPSS, Inc.) was used to summarize demographic data and perform
statistical procedures. Correlation statistics, including Pearson’s correlation
coefficient, were calculated for all study variables using an alpha less than
0.05 as the significance level. Multiple regression
was used to analyze the effects of the mediator variables on the relationships
between predictor and outcome variables. The t tests for independent samples
were calculated for selected demographics (i.e., age, education, and parity)
and analyzed for differences in
relationships between the concepts in Braden’s Self-Help Model with
Data for the analysis were provided by 140 Hispanic women who ranged in age from 33–80 years (—X = 54, SD = 10.22). Thirty-four (25%) chose to complete the instrument in Spanish. Fifty percent were married or partnered, and 50% were not partnered. Nine percent were working full- or part-time, and 29% were on medical leave from their jobs. The remaining 62% were retired (19%) or homemakers (43%). Seventy-four percent earned less than $20,000 per year, and the average education was 10 years. Thirty-six percent had a high school degree or its equivalent, and 13% had some college.
Twenty-six percent of the women had stage I disease, 36% had stage II disease, 13% had stage III disease, and 25% had stage IV disease. Twenty-seven percent had recurrent disease, and 43% had positive nodes. Sixty percent underwent modified radical or partial mastectomy, 32% had lumpectomies, and 7% had no surgery. Eighty-one percent of the women received chemotherapy, 58% received radiation therapy, and 26% received hormone therapy. Thirty-five percent were premenopausal, 9% perimenopausal, and 56% postmenopausal.
Three surveys were excluded from the data because they had greater than 25% missing data, making the final number of participants 137. Reasons for not participating in the study were being too ill, not having time, being busy with the Christmas season, and not being able to read very well. In addition, healthcare providers did not refer some women whom they perceived as incapable of completing the instruments, either because of a psychological condition or because of the large amount of information being given to them during the appointment.
Relationship of Side-Effect Burden to Uncertainty, Self-Care, and Quality of Life
describe the relationship of side-effect burden to uncertainty, self-care, and
QOL in Hispanic women undergoing breast cancer treatment, the variables were
correlated and multiple regression analyses were conducted to examine the
variables for valid theoretical relationships. Next, the empirical
relationships between measures of concepts were examined. The determining
factor was the amount of explained variance in uncertainty (R2 =
0.14) resulting from the interaction effect of complementary therapy use with
side-effect burden (ß = 0.32), which was evidenced by a similar direct positive
relationship between side effects and uncertainty (ß = 0.33; R2 =
Self-Help Model with
national survey by Eisenberg et al. (1998), the estimated out-of-pocket
expenditure for CAM was a conservative $12.2 billion, which exceeded the
out-of-pocket expenditure for all
Few data exist specifying that variables
associated with the use of CAM correlate with QOL for Hispanic women during
breast cancer treatment in southern
Theory testing of Braden’s Self-Help Model has shown how a given range of enabling skills helps women meet situational and psychological challenges of uncertainty that are associated with breast cancer (Braden et al., 1998; Longman et al., 1997). Enabling skills such as problem solving, cognitive reframing, and belief in self mediate adversive situations that accompany breast cancer experiences relative to fulfillment of desired goals (Braden, 1990; Rosenbaum & Jaffe, 1983). The essential constructs in and the predictive power of Braden’s Self-Help Model appeared stable and robust in study participants.
study included patients receiving different treatments for breast cancer, which
may have influenced which and how much
Implications for Research and Practice
recommendations for future research can be suggested based on the study
findings, such as further concept development of
of a longitudinal design would allow the testing of the manner in which
results of the study provided valuable feedback about the role of
The author gratefully acknowledges Carrie Jo Braden, PhD, RN, FAAN, for her assistance in the completion of this dissertation study and Mickey Parsons, PhD, MHA, RN, for reviewing this article.
Aaronson, N.K. (1990). Quality-of-life research in cancer clinical trials: A need for common rules and language. Oncology, 4, 59–66.
Adler, S.R. (1999). Complementary and alternative medicine use among women with breast cancer. Medical Anthropology Quarterly, 13, 214–222.
Bennett, M., & Lengacher, C. (1998). Design and testing of the complementary therapy rating scale. Alternative Health Care Practitioner, 4, 179–198.
Braden, C. (1986). Self-help as a learned response to chronic illness experience: A test of four alternative theories. Dissertation Abstracts International, 47(09), 3704. (UMI No. 8623869)
Braden, C. (1990). A test of the Self-Help Model: Learned response to chronic illness experience. Nursing Research, 39, 42–47.
Braden, C., Mishel,
M., & Longman, A. (1993, November). Quality of life in treatment
for breast cancer. Paper presented at the American Nurses
Association Council of Nurse Researchers,
Braden, C.J. (1993). Final report: Learned self-help
response to chronic illness experience.
Braden, C.J. (2002). Final report: Breast cancer management
in younger minority women. “Promoting self-help: Underserved women with breast
cancer” (1 Rol CA64706).
Braden, C.J., Mishel, M.H., & Longman, A.J. (1998). Self-Help Intervention Project: Women receiving breast cancer treatment. Cancer Practice, 6, 87–98.
Burstein, H.J., Gelber, S., Guadagnoli, E., & Weeks, J.C. (1999). Use of alternative medicine by women with early-stage breast
Campbell, A. (1976). Subjective measures of well-being. American Psychologist, 31, 117–124.
Cantril, H. (1965). The
patterns of human concerns.
Cassileth, B.R. (1999). Complementary therapies: Overview and state of the art. Cancer Nursing, 22, 85–90.
Cassileth, B.R., & Vickers, A.J. (2005). High prevalence of complementary and alternative medicine use among cancer patients: Implications for research and clinical care. Journal of Clinical Oncology, 23, 2590–2592.
Chou, J.C., Horng,
P., Tolmos, J., & Vargus,
H.I. (2000). Alternative therapy use by breast cancer patients. Medicine
Derogatis, L.R. (1986). The Psychosocial Adjustment to Illness Scale (PAIS). Journal of Psychosomatic Research, 30, 77–91.
DiGianni, L.M., Garber, J.E., & Winer, E.P. (2002). Complementary and alternative medicine use among women with breast cancer. Journal of Clinical Oncology, 20(18, Suppl.), 34S–38S.
Dirksen, S.R. (2000). Predicting well-being among breast cancer survivors. Journal of Advanced Nursing, 32, 937–943.
Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rompay, M., et al. (1998). Trends in alternative medicine use in the United States, 1990–1997: Results of a follow-up national survey. JAMA, 280, 1569–1575.
Gray, R.E., Fitch, M., Goel, V., Franssen, E., & Labrecque, M. (2003). Utilization of complementary/alternative services by women with breast cancer. Journal of Health and Social Policy, 16(4), 75–84.
Hann, D., Baker, F., Denniston, M., &
Lee, M.M., Lin, S.S., Wrensch, M.R., Adler, S.R., & Eisenberg, D. (2000). Alternative therapies used by women with breast cancer in four ethnic populations. Journal of the National Cancer Institute, 9, 42–47.
LeFort, S.M. (2000). A test of Braden’s Self-Help Model in adults with chronic pain. Journal of Nursing Scholarship, 32, 153–160.
Lengacher, C., Bennett, M., Kip, K., Gonzalez, L., Jacobsen, P., & Cox, C. (2006). Relief of symptoms, side effects, and psychological distress through use of complementary and alternative medicine in women with breast cancer. Oncology Nursing Forum, 33, 97–104.
Longman, A.J., Braden, C.J., & Mishel, M.H. (1996). Side effects burden in women with breast cancer. Cancer Practice: A Multidisciplinary Journal of Cancer Care, 4, 274–280.
Longman, A.J., Braden, C.J., & Mishel, M.H. (1997). Pattern of association over time of side-effects burden, self-help, and self-care in women with breast cancer. Oncology Nursing Forum, 24, 1555–1560.
Longman, A.J., Braden, C.J., & Mishel, M.H. (1999). Side-effects burden, psychological adjustment, and life quality in women with breast cancer: Pattern of association over time. Oncology Nursing Forum, 26, 909–915.
Marin, B., & Marin, G. (1991). Research with
Maskarinec, G. (2000). Breast cancer—Interaction between ethnicity and environment. In Vivo, 14, 115–123.
Mishel, M. (1983). Adjusting the fit: Development of uncertainty scales for specific clinical populations. Western Journal of Nursing Research, 5, 355–370.
Mishel, M.H. (1981). The measurement of uncertainty in illness. Nursing Research, 30, 258–263.
Morris, K.T., Johnson, N., Homer, L., & Walts, D. (2000). A comparison of complementary therapy use between breast cancer patients and patients with other primary tumor sites. American Journal of Surgery, 179, 407–411.
O’Brien, K. (2004). Complementary and alternative medicine: The move into mainstream health care. Clinical and Experimental Optometry, 87, 110–120.
Orley, J. (1996). The WHO program on mental health behavioral science learning modules. International Journal of Psychiatry in Medicine, 26, 107–108.
Owens, B. (2002). Pilot study: Self-care and
complementary therapies used by women experiencing side effects of breast
Radloff, L.S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401.
Rees, C.E., &
Rosenbaum, M. (1980). A schedule for assessing self-control behaviors: Preliminary findings. Behavior Therapy, 11, 109–121.
Rosenbaum, M., & Jaffe, Y. (1983). Learned helplessness: The role of individual differences in learned resourcefulness. British Journal of Social Psychology, 22(Pt. 3), 215–225.
Sollner, W., Maislinger, S., DeVries, A., Steixner, E., Rumpold, G., & Lukas, P. (2000). Use of complementary and alternative medicine by cancer patients is not associated with perceived distress or poor compliance with standard treatment but with active coping behavior. Cancer, 89, 873–880.
Sparber, A., Bauer, L., Curt, G., Eisenberg, D., Levin, T., Parks, S., et al. (2000). Use of complementary medicine by adult patients participating in cancer clinical trials. Oncology Nursing Forum, 27, 623–630.
Owens, PhD, RN, OCN®, is an assistant
clinical professor in the
Digital Object Identifier: 10.1188/07.ONF.E42-E50