Identificación de peligros, evaluación de riesgos y determinación de controles

As discussed in Chapter 1, the philosophical approach to the research predominantly lies within critical realism. It is, therefore, assumed that the

measures used within the questionnaire study will give an indication of realities for participants, rather than represent the whole truths. The nature of psychological difficulties is assumed to have elements that can be objectively rated, however these are through the subjective realities of patients. Therefore, a high score on a depression scale will be interpreted as an indication of depression, rather than assumed that the participant is experiencing depression. This is in keeping with the purpose of measures of psychological issues in particular, which were designed as screening test to indicate issues such as depression, rather than to be diagnostic (e.g. Zigmond & Snaith, 1983).

4.4.1 Demographic and disease factors

Relationship status (single, married, civil partnership, separated, divorced, widowed, partnered/in a relationship), living arrangements (live alone, live with partner or spouse, live with parents or relatives, live with friends, live with children, other (please state)), and age were all measured using forced answer choices in response to single-item questions. Type of cancer(s) diagnosed, date of diagnosis, stage of cancer or prognosis, and treatments received were assessed using open answer questions in order to avoid forced answers, particularly given the

differences among cancer types and their treatments. Participants’ postcodes were taken in order to gain both a measure of deprivation through the SIMD (Scottish Index of Multiple Deprivation, The Scottish Government, 2009) and a measure of

rurality (Scottish Government Urban Rural Classification, The Scottish

Government, 2012). The SIMD ranks postcode areas from high to low deprivation. The Urban Rural Classification provides each postcode with one of six categories ranging from large urban areas (settlements of over 125,000 people) to remote rural areas (areas with a population of less than 3,000 people, and with a drive time of over 30 minutes to a Settlement of 10,000 or more).

4.4.2 Social support

Social support was measured using the Social Provisions Scale (Cutrona, & Russell, 1987). This standardised, validated, 24-item measure examines perceived support and has been used previously in the field of oncology (Evans et al., 1995; Karnell et al., 2006; Roberts et al., 2006). It was felt that perceived support rather than actual support would better assess additional needs around social support. It was also felt that this measure was preferable over a range of other cancer-specific and general social support questionnaires; sometimes these made assumptions about who someone should be receiving support from, and that people should be receiving support regardless of need (e.g., Lehto-Järnstedt, 2004; Sherbourne & Stewart, 1991; Stansfield & Marmot, 1992). The Social Provisions Scale was worded in a way that asked if people would receive support if they needed it.

4.4.3 Psychological factors

Two measures of psychological factors were utilised. These explore the common mental health problems seen in cancer patients, as discussed in Chapter

& Snaith, 1983). A measure of distress was also taken using the Distress Thermometer (DT; Akizuki et al., 2003; Roth at al., 1998). The DT has been developed for use with cancer patients and measures level (0-10) and sources of distress for the patient in the last week. It is a validated scale and is being

increasingly used in cancer services. However, there are questions about its validity as a screening tool so it was felt important to examine both the DT and the HADS (Mitchell, 2007). More recently, the validity of the HADS has been

questioned. This is particularly in relation to its ability to examine anxiety and

depression as independent constructs (Cosco et al., 2012; Coyne & van Sonderen, 2012). A pragmatic decision was made to analyse anxiety and depression in the HADS as separate (but related) constructs, given the clinical levels (20% for depression and 29% for anxiety, and there was only some overlap of cases).

4.4.4 Health behaviours

Health behaviours (as defined in Chapter 1) were measured using questions assessing self-reported smoking, alcohol, fruit and vegetable intake, and exercise. Although there are other health behaviours, such as drug use, that could have been investigated, it was felt that the four areas explored here captured the key lifestyle issues, without over burdening participants with too many questions. Health behaviour questions were developed based on UK government targets around the behaviours, in order to generate data around numbers meeting

guidelines, where possible. Questions also assessed their desire to improve their health, through a fixed answer question (yes/no/haven’t thought about it), and self-

efficacy which was measured following each health behaviour question using a 5- point Likert scale.

4.4.5 Support needs

Support needs were defined here as the perceived support needed around a given issue (Helgeson & Cohen, 2006). It was measured throughout the

questionnaire following each section, therefore, gathering information on desire for further support around all the issues measured (anxiety and depression, distress, social support, and each health behaviour). Participants were also asked whether or not they were aware of the support available to them (yes/no), if they have accessed support services (yes/no) and details of barriers to attending services or whether or not they felt that any accessed services had helped them (both open answer questions). The last section of the questionnaire sought information about accessing services, including factors that may encourage them to access support services, their confidence in accessing services and whether they feel they need more help to access services.