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Scholars have adopted Street's (2003) ecological model of communication in medical encounters to investigate the factors promoting patient participation in health care. However, factors demonstrated in the ecological model were bounded in the context of medical care primarily focusing on health care providers and patients. Social factors, such as patients' relationships and supportive communication with others outside the context of health care remain relatively unexplored. To expand the purview of our understanding of factors that influence patient participation, this research integrated social support literature into the research on physician-patient communication and proposed a model which described a process through which social support can enhance patient participation in health care. The data analyzed in this study were a part of two larger clinical trials in which 661 women with breast cancer were recruited from three cancer institutions in the United States. The results from structural equation modeling analysis from cross-sectional and longitudinal data provided strong evidence for the hypotheses predicting that perceived social support was positively associated with health information competence, which in turn fully mediated the association between social support and patient participation in health care. Theoretical and practical implications are discussed.

Objective: This investigation explores how using different e-health interventions facilitates positive psychosocial changes and how these changes reduce cancer concerns and improve quality of life in breast cancer patients over time., Methods: A total of 326 breast cancer patients were randomly assigned to one of three e-health interventions: (a) Internet only, (b) the Comprehensive Health Enhancement Support System information and support services (CHESS-IS), or (c) CHESS with mentor. Proximal health outcomes such as information overload, emotional functioning, and social support were measured alongside distal outcomes like cancer concerns and quality of life. Participants completed surveys at four time points: pretest as a baseline, 6 weeks, 3 months, and 6 months., Results: Both interventions were effective in improving patient health beyond Internet only but they differed in type of change mechanism and clinical benefit. The CHESS-IS enhanced proximal outcomes at 3 months through improved information competence. The CHESS with mentor intervention reduced breast cancer concerns at 6 months, mediated mainly by emotional-social competence and emotional functioning., Conclusions: Using e-health interventions like CHESS can help patients improve cancer information management skills and emotional functioning, contributing to better short-term health outcomes. Adding a human mentor can enhance the benefits of CHESS use, extending the experience among breast cancer patients. Theoretical, practical, and clinical implications of the study results are discussed., (© 2020 John Wiley & Sons Ltd.)

This study examined the interplay of depression and different types of e-health interventions on breast cancer patients' perceived healthcare competence, emotional processing, and social well-being over time. The three e-health interventions--Internet Only as a control condition, CHESS (Comprehensive Health Enhancement Support System) Only, and CHESS with a Human Mentor, a cancer information specialist--provided varying degrees of interactivity and presence. A total of 328 women with breast cancer participated in one of the three interventions for a 6-month period. Women were further split into two groups based on reported levels of depression. For perceived healthcare competence and social well-being, results revealed significant interaction effects for intervention type by depression over time, such that breast cancer patients with higher levels of depression benefited most from the CHESS with Mentor intervention over the 6-month study period. For emotional processing, depressed cancer patients benefited more from the CHESS with Mentor than the other two interventions, regardless of time. These findings have (a) theoretical implications on how mental health factors can intersect with interactivity and presence to influence psychosocial outcomes, (b) conceptual implications for the role of human interaction within e-health systems, and (c) practical implications for the development of e-health interventions for cancer patients with depression.

Recent studies have devoted attention to the effects of both expression and reception in communication process. However, there remain both theoretical and methodological complexities concerning whether and under what condition message expression and reception play significant but different roles in explaining various psychosocial health outcomes. Relying on theoretical insights from the social support literature and methodological innovations offered by computational social science, this study aims to examine the effects of empathic exchanges on cancer patient's short- and long-term psychosocial health outcomes. Our findings suggest that both empathy expression and reception are crucial to attaining benefits for cancer patients, each predicting differential cognitive and affective health outcomes. Further, our finding supports the stress-buffering hypothesis such that empathy reception provides a beneficial effect for patients who experienced a higher degree of depression associated with their cancer diagnosis and follow-up treatments.

This study investigates how social support and family relationship perceptions influence breast cancer patients' online communication networks in a computer-mediated social support (CMSS) group. To examine social interactions in the CMSS group, we identified two types of online social networks: open and targeted communication networks. The open communication network reflects group communication behaviors (i.e., one-to-many or "broadcast" communication) in which the intended audience is not specified; in contrast, the targeted communication network reflects interpersonal discourses (i.e., one-to-one or directed communication) in which the audience for the message is specified. The communication networks were constructed by tracking CMSS group usage data of 237 breast cancer patients who participated in one of two National Cancer Institute-funded randomized clinical trials. Eligible subjects were within 2 months of a diagnosis of primary breast cancer or recurrence at the time of recruitment. Findings reveal that breast cancer patients who perceived less availability of offline social support had a larger social network size in the open communication network. In contrast, those who perceived less family cohesion had a larger targeted communication network in the CMSS group, meaning they were inclined to use the CMSS group for developing interpersonal relationships.

Despite the mounting evidence of efficacy of eHealth interventions, their mechanisms of action remain unknown. The current study analyzed patient log data as each patient engaged in an eHealth system called the Comprehensive Health Enhancement Support System (CHESS) and reports on how patients engage with different combinations of eHealth services over time. Newly diagnosed breast cancer patients (N = 443) were given access for 6 months to one of four different configurations of CHESS: (1) Information, (2) Information and Support, (3) Information, Support, and Coaching (Full CHESS), and (4) Full CHESS and Mentor. Besides a baseline survey, three follow-up posttests were administered. Action log data on how patients engaged with the CHESS were also collected and merged with surveys to examine how patients benefit during the cancer experience. The findings suggest that usage patterns were not competitive, implying that cancer patients' access to more complex tools generates more use with their time spreading out over the diverse services. Despite overall decline in usage rates, it was less severe in Full CHESS and Mentor condition, suggesting that communication functions drive long-term engagement with the system. Notably, the strongest relation between use and cancer information competence appeared late in the follow-up period.

A breast cancer diagnosis typically results in dramatic and negative effects on an individual's quality of life. Web-based interactive support systems such as the Comprehensive Health Enhancement Support System (CHESS) offer one avenue for mitigating these negative effects. While evidence supports the efficacy of such systems, evaluations typically fail to provide a true test of the theorized model of effects, treating self-determination theory's constructs of competence, relatedness, and autonomy as outcomes rather than mediators. Using path analysis, this study tests the nature of the proposed mediated relationship between system engagement and quality-of-life indicators utilizing data collected from women (N = 90) who participated in the treatment condition of a CHESS randomized controlled trial. Findings support a latent model, indicating that system effects are mediated through an intertwined measure of autonomy, competence, and relatedness.

Despite existing research identifying psychological benefits of patients' interpersonal competence in various contexts, little longitudinal research has addressed underlying mechanism(s). To address this limitation, we examined both the cross-sectional and longitudinal associations between cancer patients' communication competence in close relationships and psychological well-being, as well as the mediating role of coping efforts. Data came from a larger project with women with breast cancer (N = 661), recruited from April 2005 to May 2007 at three large university-affiliated cancer centers in the U.S. to study the effects of an Internet-based system providing patients and families with a range of services. The present study focused on survey data at baseline, 6 weeks, and 12 weeks after the intervention (controlling for the possible effects of the intervention). Results from both cross-sectional and longitudinal analyses indicated that competence in open communication between patients and their close support persons had a positive association with patients' psychological well-being and that approach coping efforts partially mediated this association. We discussed the implications and limitations of the study.

Objectives: To determine whether an online support tool can impact anxiety in women experiencing an abnormal mammogram., Materials and Methods: We developed an online support system using the Comprehensive Health Enhancement Support System (CHESS) designed for women experiencing an abnormal mammogram as a model. Our trial randomized 130 of these women to online support (the intervention group) or to a list of five commonly used Internet sites (the comparison group). Surveys assessed anxiety and breast cancer worry, and patient satisfaction at three important clinical time points: when women were notified of their abnormal mammogram, at the time of diagnostic imaging, and at the time of biopsy (if biopsy was recommended)., Results: Study participants in the intervention group showed a significant decrease in anxiety at the time of biopsy compared to the comparison group (p = 0.017). However, there was no significant difference in anxiety between the intervention group and the comparison group at the time of diagnostic work-up. We discontinued assessment of patient satisfaction after finding that many women had substantial difficulty answering the questions that referenced their physician, because they did not understand who their physician was for this process of care., Conclusion: The combination of the inability to identify the physician providing care during the mammography work-up and anxiety effects seen only after an interaction with the breast imaging team may indicate that online support only decreases the anxiety of women in concert with direct interpersonal support from the healthcare team., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Despite the importance of family environment and computer-mediated social support (CMSS) for women with breast cancer, little is known about the interplay of these sources of care and assistance on patients' coping strategies. To understand this relation, the authors examined the effect of family environment as a predictor of the use of CMSS groups as well as a moderator of the relation between group participation and forms of coping. Data were collected from 111 patients in CMSS groups in the Comprehensive Health Enhancement Support System "Living with Breast Cancer" intervention. Results indicate that family environment plays a crucial role in (a) predicting breast cancer patient's participation in CMSS groups and (b) moderating the effects of use of CMSS groups on breast cancer patients' coping strategies such as problem-focused coping and emotion-focused coping.

To better understand participation in computer-mediated social support (CMSS) groups for breast cancer patients, this study examines two overarching questions of (1) who are posters, lurkers, or nonusers and (2) what role do these different types of engagement play in explaining psychosocial health outcomes? This study incorporates the comprehensive model of information seeking and two competing models of social enhancement and social compensation, as well as the literature on lurking and posting behaviors in online groups to answer research questions. Our findings suggest that patterns of engagement in a CMSS group differed according to patients' sociodemographic characteristics and psychosocial factors. In addition, we found that lurkers had a higher level of perceived functional well-being than posters at 3 months post baseline. Theoretical and practical implications for effective online cancer support group campaigns are discussed.

Background: Emotional support has traditionally been conceived as something a breast cancer patient receives. However, this framework may obscure a more complex process, facilitated by the emerging social media environment, which includes the effects of composing and sending messages to others. Accordingly, this study explores the effects of expression and reception of emotional support messages in online groups and the importance of bonding as a mediator influencing the coping strategies of breast cancer patients., Methods: Data were collected as part of two National Cancer Institute-funded randomized clinical trials. Eligible subjects were within 2 months of diagnosis of primary breast cancer or recurrence. Expression and reception of emotionally supportive messages were tracked and coded for 237 breast cancer patients. Analysis resulted from merging 1) computer-aided content analysis of discussion posts, 2) action log analysis of system use, and 3) longitudinal survey data., Results: As expected, perceived bonding was positively related to all four coping strategies (active coping: β = 0.251, P = .000; positive reframing: β = 0.288, P = .000; planning: β = 0.213, P = .006; humor: β = 0.159, P = .009). More importantly, expression (γ = 0.138, P = .027), but not reception (γ = -0.018, P = .741), of emotional support increases perceived bonding, which in turn mediates the effects on patients' positive coping strategies., Conclusions: There is increasing importance for scholars to distinguish the effects of expression from reception to understand the processes involved in producing psychosocial benefits. This study shows that emotional support is more than something cancer patients receive; it is part of an active, complex process that can be facilitated by social media.

Background: Using available communication technologies, clinicians may offer timely support to family caregivers in managing symptoms in patients with advanced cancer at home., Aim: To assess the effects of an online symptom reporting system on caregiver preparedness, physical burden, and negative mood., Design: A pooled analysis of two randomized trials (NCT00214162 and NCT00365963) was conducted to compare caregiver outcomes at 6 and 12 months after intervention between two randomized, unblinded groups using General Linear Mixed Modeling. Caregivers in one group (Comprehensive Health Enhancement Support System-Only) were given access to an interactive cancer communication system, the Comprehensive Health Enhancement Support System. Those in the other group (Comprehensive Health Enhancement Support System + Clinician Report) received access to Comprehensive Health Enhancement Support System plus an online symptom reporting system called the Clinician Report. Clinicians of patients in the Comprehensive Health Enhancement Support System + Clinician Report group received e-mail alerts notifying them when a symptom distress was reported over a predetermined threshold., Setting/participants: Dyads (n = 235) of advanced-stage lung, breast, and prostate cancer patients and their adult caregivers were recruited at five outpatient oncology clinics in the United States., Results: Caregivers in the Comprehensive Health Enhancement Support System + Clinician Report group reported less negative mood than those in the Comprehensive Health Enhancement Support System-Only group at both 6 months (p = 0.009) and 12 months (p = 0.004). Groups were not significantly different on caregiver preparedness or physical burden at either time point., Conclusions: This study provides new evidence that by using an online symptom reporting system, caregivers may experience less emotional distress due to the Clinician Report's timely communication of caregiving needs in symptom management to clinicians.

Objectives: To explore how the expression of emotional support in an online breast cancer support group changes over time, and what factors predict this pattern of change., Methods: We conducted growth curve modeling with data collected from 192 participants in an online breast cancer support group within the Comprehensive Health Enhancement Support System (CHESS) during a 24-week intervention period., Results: Individual expression of emotional support tends to increase over time for the first 12 weeks of the intervention, but then decrease slightly with time after that. In addition, we found that age, living situation, comfort level with computer and the Internet, coping strategies were important factors in predicting the changing pattern of expressing emotional support., Conclusions: Expressing emotional support changed in a quadratic trajectory, with a range of factors predicting the changing pattern of expression., Practical Implications: These results can provide important information for e-health researchers and physicians in determining the benefits individuals can gain from participation in should CMSS groups as the purpose of cancer treatment., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objective: To better understand the process and effect of social support exchanges within computer-mediated social support (CMSS) groups for breast cancer patients, this study examines (1) the dynamic interplay between emotional support giving and receiving and (2) the relative effects of emotional support giving and receiving on patients' psychosocial health outcomes., Methods: Data was collected from 177 patients who participated in online cancer support groups within the Comprehensive Health Enhancement Support System (CHESS) during the 4-month intervention. Data included (1) pretest and/or post-test survey scores of demographic, disease-related, and psychosocial factors, (2) automatically collected CHESS usage data, and (3) computer-aided content analysis of social support messages posts., Results: Hierarchical regression analyses revealed that those who receive higher levels of support from others have fewer breast cancer-related concerns (β = - 0.15, p<0.05), while those who give higher levels of support to others reframe their own problems in a positive light and adopt more positive strategies for coping (β = 0.16, p<0.05). In addition to these positive effects, partial correlation analysis indicated that these two supportive behaviors are reciprocal., Conclusions: We concluded that supportive exchanges of receiving and giving play positive, but different, roles in predicting psychosocial health outcomes. Moreover, emotional support giving and receiving tend to reinforce each other. Our findings help practitioners, health-care providers, and health system designers make sense of diverse social support processes among cancer patients participating within CMSS groups., (Copyright © 2011 John Wiley & Sons, Ltd.)

Despite the benefits and growing availability of online cancer support groups, many breast cancer patients still do not actively participate in them. To better understand cancer patients' online information- and support-seeking behaviors, this study explores how various social and psychological characteristics predict different levels of engagement with an online breast cancer support group: posters, lurkers, and nonusers. The study sample included 231 recently diagnosed breast cancer patients. Data included baseline survey scores of demographic, disease-related, and psychosocial factors and automatically collected discussion group use data over the 4-month intervention. Patterns of engagement with the cancer support group differed according to the patients' characteristics, suggesting that (a) cancer patients have very different orientations to and engagement with an online support group, and (b) deficits in social and psychological resources may not be barriers to participation in a cancer support group, but rather motivators to interact with other patients. The authors discuss the theoretical and practical implications of their findings.

Social support in computer-mediated settings is an important variable in health communication research, yet little is known about the factors that influence the amount of social support one gives and receives in online support groups. To shed some light on this issue, the authors examined demographics, disease-related factors, psychosocial factors, and strategies for coping with breast cancer as potential determinants of which patients provide support to others and which ones consume it. Data collected from 177 participants in the Comprehensive Health Enhancement Support System "Living With Breast Cancer" program revealed that individuals who are younger, have higher levels of positive reframing, and lower levels of self-blame are more likely to provide emotional support in online settings. In contrast, individuals who are more educated, have less perceived availability of social support, and have lower levels of religious coping are more likely to receive emotional support from others. The authors discuss the theoretical and practical implications for providing effective psychosocial support for women with breast cancer.

Purpose: To examine how psychosocial variables predicted use of an online health consultation service among low-income breast cancer patients and in turn how using this service affected these same psychosocial outcomes., Method: This retrospective study included 231 recently diagnosed, low-income (at or below 250% of the federal poverty level) breast cancer patients provided a free computer with 16 weeks of access to the Internet-based 'Ask an Expert' service offered as part of the Comprehensive Health Enhancement Support System (CHESS) "Living with Breast Cancer" program. The use activity included a total of 502 messages submitted to the online health consultation service. The data included five psychosocial variables: information seeking, social support, health self efficacy, participation in health care, and doctor-patient relationship, were collected at both the pre-test and 16-week post-test after using the service. Correlation tests were conducted to examine the relationship between pre- and post-test, and use activity. A multiple regression model was formed for each of five psychosocial variables to examine how use activity of the consultation service was associated with various psychosocial measurements., Results: In total, 865 distinct consulting queries from 502 messages were identified as measurement of patients' use activities (3.74 consulting queries per participant). Use activity had significant negative relationships with pre-test scores across all five psychosocial variables. The regression models found significant positive main effects (use activity) associated with three of these psychosocial variables: health self efficacy, participation in health care and doctor-patient relationship. Use activity of the online consultation service did not have significant relationships with the dependent variables of information seeking and perceived social support., Conclusion: Low-income breast cancer patients sought out information from an online cancer information expert. Patients with more negative perceptions at pre-test tended to use the service more. Greater use of the service was associated with improvement in patients' perception of health self-efficacy, participation in health care and doctor-patient relationship. Moreover, use of online health consultation appears to level the differences, narrowing the gaps between those who were worse and better off at pre-test. These findings suggest that online health consultation can serve as an effective complement to other resources, which help low-income, breast cancer patients feel more confident to participate more actively in their health care, become more actively involved in making decisions about their treatments and enhance the relationship with their doctors., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Past studies on the efficacy of participation in online cancer support groups have primarily focused on the role of expression in the accrual of health benefits for participants. Unfortunately, few steps have been taken to determine whether this observed effect arises solely from the internal mental processes underlying the act of expressing or, perhaps, owes something to a nuanced, multidimensional understanding of expression that includes reception of responses to what is expressed. To test for the multilayered effect, we attend to one of the key concepts in the online support community scholarship: empathy. Our findings suggest that it is a combination of empathy expression and reception that is crucial to attaining optimal benefits for cancer patients. Further, our finding supports the buffering hypothesis that empathic expression provides a salutary effect for patients who experienced a higher degree of concern associated with their cancer diagnosis and follow-up treatments.

Objectives: To examine the effects of exchanging treatment information within computer-mediated breast cancer support groups on emotional well-being, and to explore whether this relationship is moderated by health self-efficacy., Sample: 177 breast cancer patients using an electronic Health (eHealth) program with discussion group., Measure: expression and reception of treatment information; emotional well-being scale (0, 4 months)., Analyses: hierarchical regression., Results: Effects of expression and reception of treatment information on emotional well-being were significantly greater for those who have higher health self-efficacy., Conclusions: Results conditionally support prior research finding positive effects of treatment information exchanges among breast cancer patients. Such exchanges had a positive impact on emotional well-being for those with higher health self-efficacy, but they had a negative influence for those with lower health self-efficacy., Practice Implications: Given that the association between emotional well-being and exchanging treatment information was moderated by health self-efficacy, clinicians should explain the role of health self-efficacy before encouraging patients to use eHealth systems for treatment exchanges., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Objective: We evaluated the association between physicians' communication behavior and breast cancer patients' trust in their physicians., Design: Longitudinal survey conducted at baseline, 2-month, and 5-month follow-up during first year of diagnosis., Participants: Newly diagnosed breast cancer patients (N = 246)., Measurements: We collected data on patient perceptions of the helpfulness of informational, emotional, and decision-making support provided by physicians and patients' trust. Linear regression models evaluated the association of concurrent and prior levels of physician support with patients' trust., Results: At baseline, patients who received helpful informational, emotional, and decision-making support from physicians reported greater trust (p < 0.05, p < 0.001, and p < 0.01, respectively). At the 2-month assessment, baseline informational support and informational and emotional support at 2-months were associated with greater trust (p < 0.05, p < 0.01, and p < 0.05, respectively). At the 5-month assessment, only helpful emotional support from physicians at 5 months was associated with greater trust (p < 0.01). Interestingly, while perceived helpfulness of all three types of physician support decreased significantly over time, patient trust remained high and unchanged., Conclusions: Findings suggest that while informational and decision-making support may be more important to patient trust early in the course of treatment, emotional support from physicians may be important to maintain trust throughout the initial year of diagnosis.

Based upon Fredrickson's Broaden-and-Build Theory of Positive Emotions, this study examined the role of expressing positive emotions in online support groups for women with breast cancer. Underserved women with breast cancer in rural Wisconsin and Detroit, Michigan were recruited from 2001 to 2003, and they were given access to online support groups. Both pretest and four-month posttest surveys were conducted with a sample of 231 women. Messages from 96 active participants were analyzed using a computerized text analysis program. Psychological benefits that occurred following the expression of positive emotions were greater among those who expressed more negative emotions.

Research suggests communicating too much about one's self within an online support group may amplify breast cancer patients' focus on their own problems and exacerbate negative emotions while focusing on others may have the opposite effects. This study explored how pronoun usage within an online support group was associated with subsequent mental health outcomes. There were 286 patients recruited into the study who filled out the pre-test and 231 completed post-tests four months later with survey measures including breast cancer-related concerns and negative emotions. Messages were analyzed using a program counting first person and relational pronouns. A positive relationship was found between use of first person pronouns and negative emotions.

Objectives: To determine the effects of online narrative and didactic information on breast cancer patients' healthcare participation and the interaction effects of race., Sample: 353 breast cancer patients (111 African Americans) using an eHealth program with narratives (audiovisual and text) and didactic information (text only)., Measures: healthcare participation scale (0, 4 months), online information use., Analyses: hierarchical regression., Results: Narrative (beta=0.123, p<0.01) and didactic (beta=0.104, p<0.05) information use had independent and positive effects on healthcare participation. Effects of both were significantly greater for African Americans., Conclusions: Findings are consistent with and advance prior research on online learning processes and outcomes for breast cancer patients: (1) benefits accrue with using a variety of online learning tools; (2) African Americans use and benefit more from online narrative and didactic information than do Caucasians., Practice Implications: eHealth programs should provide both didactic and narrative information-especially for African Americans and might consider making greater use of interactive and audiovisual formats. As patients increasingly use of the web for cancer information, clinicians should provide lists of web high quality resources that provide both narrative and didactic information.

We evaluated the helpfulness of informational, emotional, and decision-making support received by women newly diagnosed with breast cancer from their family, friends, and health care providers. Data were collected at two time points via patient surveys: baseline on an average 2 months post-diagnosis and follow-up at 5 months post-baseline. In the period closer to diagnosis, majority of the women received helpful informational support from health care providers (84.0%); helpful emotional support from family (85%), friends (80.4%), and providers (67.1%); and helpful decision-making support from providers (75.2%) and family (71.0%). Emotional support at baseline and emotional and informational support at 5-month follow-up were significantly associated with patients' health-related quality of life and self-efficacy outcomes (p<0.01). Perceived helpfulness of informational, emotional, and decision-making support provided by family, friends, and providers however significantly decreased over time (p<0.001). Cancer patients' desire significant amount of support throughout their cancer journey. Our results show that while patients receive a lot of support during the period closer to diagnosis, receipt of helpful support drops significantly within the first year itself. In order to facilitate cancer patients' adjustment to their illness, efforts need to be made to understand and address their support needs throughout the cancer experience.

Objective: To examine how the pre-existing doctor-patient relationship predicts conceptually distinct service use within an Interactive Cancer Communication System (ICCS) for underserved women with breast cancer and in turn how service utilization influences the doctor-patient relationship., Methods: Study sample included 231 recently diagnosed, lower income breast cancer patients. Participants were provided a free computer, Internet access and training in how to use an ICCS called the Comprehensive Health Enhancement Support System (CHESS) "Living with Breast Cancer" program. Survey data was collected at pre-test and 4-months after using the system, and use data about how women used the system was also collected., Results: The only statistically significant predictor of service use was that patients with a more negative appraisal about the doctor-patient relationship used the Ask an Expert service more frequently, and there were trends toward a more negative appraisal of the doctor-patient relationship being associated with higher use of Information and Interactive services. Conversely, there was a trend toward a more positive appraisal predicting higher use of the Discussion Group service. In terms of statistically significant effects, more frequent utilization of Information services was associated with a more positive appraisal of the doctor relationship., Conclusion: While a more negative perception of the doctor-patient relationships at pre-test was associated with higher use of most of the conceptually distinct services within this ICCS, use of the Information services was associated with having a more positive appraisal of the doctor-patient relationship at post-test suggesting that high-quality information on the Internet can serve to improve patients' satisfaction with their doctor.

To provide insights about how women with breast cancer learn from interactive cancer communication systems (ICCSs), this study examined how use of different types of services that employ conceptually distinct pedagogical methods relates to learning outcomes. The study sample included 231 recently diagnosed, lower income breast cancer patients. Participants were provided a free computer, Internet access and training in how to use an ICCS called the Comprehensive Health Enhancement Support System 'Living with Breast Cancer' program. Data comprised survey information collected at pre-test and 4 months after using the system and computer records of how women used the system (use data). The findings suggest that use of the information and interactive services independently contributed to perceived information competence, though the communication services, including both discussion group and ask an expert, did not. Consistent with expectations, use of discussion group and interactive services amplified the learning effects of using the information services. However, use of the ask an expert service did not amplify the learning effects of using the information services as predicted. Some constructivist pedagogical methods-specifically online support groups and intelligently designed, computer-driven interactive services-may supplement and extend the learning potential of information services delivered via a transmission-oriented pedagogical approach.

This study examined what characteristics predict participation in online support groups for women with breast cancer when users are provided free training, computer hardware, and Internet service removing lack of access as a barrier to use. The only significant difference between active and inactive participants was that active users were more likely at pretest to consider themselves active participants in their healthcare. Among active participants, being white and having a higher energy level predicted higher volumes of writing. There were also trends toward the following characteristics predictive of a higher volume of words written, including having a more positive relationship with their doctors, fewer breast cancer concerns, higher perceived health competence, and greater social/family well-being. Implications for improving psychosocial interventions for women with breast cancer are discussed, and future research objectives are suggested.

Written expression about emotionally traumatic events is associated with physical and mental health benefits, and this study examines how insightful disclosure within a computer-mediated support group for women with breast cancer affects breast cancer-related concerns, emotional well-being, and self-reported physical well-being. Using a word counting program that notes the percentage of words related to various linguistic dimensions, this research specifically examined the effects of insightful disclosure written within these groups. Surveys were administered just before group access and then 2 months and 5 months later. Insightful disclosure improved emotional well-being and reduced negative mood but did not influence breast cancer-related concerns or self-reported physical well-being. Despite the common and frequent use of computer-mediated social support (CMSS) groups for people coping with health concerns, very little research to date has quantitatively tested the effects of participating in CMSS groups, and this is among the first published studies to quantitatively link any specific activity within a CMSS group to any specific outcomes. Implications for improving psychosocial interventions for people with health concerns are discussed, and future research objectives are suggested.

A fundamental challenge to helping underserved women and their families cope with breast cancer is providing them with easily accessible, reliable health care information and support. This is especially true for low-income families living in rural areas where resources are few and frequently distant as well as low-income families in urban areas where access to information and support can be complex and overwhelming. The Internet is one mechanism that has tremendous potential to help these families cope with breast cancer. This article describes a feasibility test of the potential for the National Cancer Institute's (NCI's) Cancer Information Service (CIS) to provide access to an Internet-based system that has been shown to improve quality of life for underserved breast cancer patients. The test was conducted in rural Wisconsin (low socioeconomic status [SES] Caucasian women) and in Detroit, Michigan (low SES African American women), and compares the effectiveness of several different dissemination strategies. Using these results we propose a model for how CIS telephone and partnership program services could efficiently disseminate such information and support systems. In doing so we believe that important steps can be taken to close the digital divide that separates low-income families from the resources they need to effectively face cancer. This is the first of two articles coming from this study. A companion article reports on an evaluation of the use and impact of this system on the women who were given access to it.

This article is the second of a two-part series reporting on a population-based study intended to use an eHealth system to examine the feasibility of reaching underserved women with breast cancer (Gustafson, McTavish et al., Reducing the digital divide for low-income women with breast cancer, 2004; Madison Center for Health Systems Research and Analysis, University of Wisconsin; Comprehensive Health Enhancement Support System [CHESS]) and determine how they use the system and what impact it had on them. Participants included women recently diagnosed with breast cancer whose income was at or below 250% of poverty level and were living in rural Wisconsin (n = 144; all Caucasian) or Detroit (n = 85; all African American). Because this was a population-based study all 229 participants received CHESS. A comparison group of patients (n = 51) with similar demographics was drawn from a separate recently completed randomized clinical trial. Use rates (e.g., frequency and length of use as well as type of use) as well as impact on several dimensions of quality of life and participation in health care are reported. Low-income subjects in this study logged on and spent more time on CHESS than more affluent women in a previous study. Urban African Americans used information and analysis services more and communication services less than rural Caucasians. When all low-income women from this study are combined and compared with a low-income control group from another study, the CHESS group was superior to that control group in 4 of 8 outcome variables at both statistically and practically significant levels (social support, negative emotions, participation in health care, and information competence). When African Americans and Caucasians are separated the control group's sample size becomes 30 and 21 thus reducing power. Statistical significance is retained, however, in all four outcomes for Caucasians and in two of four for African Americans. Practical significance is retained for all four outcomes. We conclude that an eHealth system like CHESS will be used extensively and have a positive impact on low-income women with breast cancer.

This study examined the relationship between breast cancer patients' experience of barriers to accessing health information and their psychosocial health outcomes and explored the extent to which this relationship was mediated by patient perceptions of competence in dealing with health-related issues. Study sample consisted of 225 women surveyed within 6 months of diagnosis. Regression analyses suggested that patients who reported greater difficulty in accessing needed information experienced lower emotional (P=0.05), functional (P<0.05), and social/family (P<0.05) well-being as well as lower perceptions of health competence (P<0.001). Also, patient perceptions of health competence mediated the relationship between barriers to accessing information and patient outcomes (emotional well-being, P<0.05; functional well-being. P<0.01; social/family well-being, P=0.01). Breast cancer patients often report dissatisfaction with the extent to which their information needs are addressed by their health care providers. Our findings underscore the need for designing and implementing interventions that would aid providers in better meeting the information needs of their patients.