Support Care Cancer (2008) 16:37–45
DOI 10.1007/s00520-007-0273-4
ORIGINAL ARTICLE
Preparing patients for threatening medical treatments:
effects of a chemotherapy educational DVD on anxiety,
unmet needs, and self-efficacy
Penelope Schofield & Michael Jefford & Mariko Carey &
Kathryn Thomson & Melanie Evans & Carl Baravelli &
Sanchia Aranda
Received: 16 November 2006 / Accepted: 8 May 2007 / Published online: 30 May 2007
# Springer-Verlag 2007
Abstract
Goals of work Based on meta-analyses regarding the prepa-
ration of patients for potentially threatening medical proce-
dures, a DVD, incorporating behavioral role modelling, was
developed to prepare patients for chemotherapy and assist
them to self-manage side effects. It was hypothesized that
patients who watched the DVD (vs those who did not) would
report (1) lower anxiety; (2) higher self-efficacy related to
coping with treatment side effects; (3) fewer supportive care
needs; and (4) higher satisfaction with information received. It
was further hypothesized that these effects would be stronger
in those perceiving their treatment intent to be curative rather
than palliative.
Materials and methods Quasi-experimental design using a
historical control group was employed. Participants were
scheduled to receive their first ever chemotherapy treatment.
Group 1 (usual care; n=50) was prospectively recruited
before the release of the DVD and group 2 (DVD plus
P. Schofield (*) : M. Jefford : M. Carey : K. Thomson :
M. Evans : C. Baravelli : S. Aranda
Supportive Care Research Group,
Peter MacCallum Cancer Centre,
Locked Bag 1, A’Beckett Street,
Melbourne, Victoria 8006, Australia
e-mail: Penelope.schofield@petermac.org
P. Schofield : M. Jefford
Faculty of Medicine, Dentistry and Health Sciences,
The University of Melbourne,
Melbourne, Victoria, Australia
S. Aranda
Peter MacCallum Cancer Centre and Head, School of Nursing,
The University of Melbourne,
Melbourne, Victoria, Australia
usual care; n=50) after the release. Before commencing
chemotherapy, all patients completed reliable and valid
measures of self-efficacy, anxiety, and supportive care
needs. Data was stratified according to perceived treatment
intent. Independent sample t tests were performed for each
group (curative vs palliative).
Main results Significant differences were found between the
usual care and intervention groups: for self-perceived curative
patients in relation to self-efficacy for seeking social support
(p=0.044), with increased confidence in those watching the
DVD, and for self-perceived palliative patients in relation to
their satisfaction with information about side effects (p=
0.026), with increased satisfaction in those watching the
DVD. Overall, significant differences were found between
self-perceived curative vs palliative patients on measures of
self-efficacy and supportive care needs, with self-perceived
curative patients reporting more confidence and fewer needs.
Conclusions The educational DVD was considered highly
acceptable by patients and was found to increase self-
efficacy and reduce supportive care needs. Hence, it is
appropriate to give to patients before face-to-face chemo-
therapy education. Additional pretreatment education is
recommended, particularly for self-perceived palliative
patients, to reduce their pretreatment anxiety and enhance
their confidence in coping with treatment.
Keywords Patient education . Cancer . Information .
Anxiety . Treatment . Chemotherapy . Side effects . DVD .
Audiovisual resource
Introduction
Almost all people with cancer will undergo some form of
treatment; often receiving chemotherapy as a component of
38
their treatment. Common physical side effects of chemotherapy
include nausea, fatigue, hair loss, and neutropenia, while
psychological sequelae include treatment-related anxiety, nee-
dle phobias and concerns about treatment length [3, 7, 13].
High levels of anxiety and treatment-related concerns suggest
the need to better prepare patients who are about to receive
treatment. Meta-analyses suggest that optimal preparation of
patients for potentially threatening medical procedures
involves the provision of both sensory and procedural
information [30] and attention to a person’s emotional
concerns [16]. On the basis of these principles and the best
available evidence for self-care strategies to manage treatment
side effects, we developed and produced an educational DVD.
This DVD incorporated behavioral role modelling to assist
patients in preparing for chemotherapy [5]. This paper reports
on the effect of this DVD on patient pretreatment anxiety,
informational needs, and self-efficacy.
Importance of patient education
People with cancer express a strong desire for information
to prepare themselves for treatment, particularly in relation
to self-care. “To be informed about the things you can do to
help yourself get well” was ranked as the fourth highest
unmet need in a sample of people with various forms of
cancer [29]. Two factors combine to underscore the
importance of providing patients with improved informa-
tion about chemotherapy and providing skills to self-
manage potential side effects. Firstly, it is known that many
patients do not recall much of the information given within
a medical consultation [17] in which initial information
about chemotherapy is frequently provided. Secondly,
chemotherapy treatment is most commonly given on an
outpatient basis, leaving patients to manage side effects at
home. Twenty years ago, Dodd and colleagues established
the importance of patient self-management capacity in
mediating the distressing side effects of these treatments
[8, 9]. However, there is still considerable debate about how
to effectively educate patients in self-management skills.
Behavioral role modelling
On the basis of a comprehensive literature review, Krouse
[19] concluded that the clinical impact of pretreatment
patient educational audiovisual resources that incorporated
behavioral role modelling appeared to be beneficial.
Various studies have indicated that audiovisual information
improves anxiety before chemotherapy, colonoscopy, and
oral surgery [21, 22, 28] and leads to an increased use of
self-management strategies post-surgery, and pre-birth [10,
25]. One randomized controlled multisite trial involving 220
patients scheduled to receive chemotherapy and/or radio-
Support Care Cancer (2008) 16:37–45
therapy assessed the effect of a pretreatment educational
video [31]. Patients receiving the video reported compara-
tively lower anxiety and depression scores during treatment
and higher satisfaction with information received.
In contrast, other experimental trials of pretreatment
educational videos have failed to demonstrate an effect on
self-efficacy, knowledge, distress, or pretreatment worry [6,
11, 12, 15, 20]. The variation in findings may be due to
methodological issues, such as small sample size, or to
differences in the content of the audiovisual resources.
Hypotheses
The aim of this study was to evaluate the effect of an
educational DVD about chemotherapy when given to chemo-
therapy naive patients. It was hypothesized that, compared to
patients who did not watch the DVD, those who watched it
would:
1. Report lower levels of pretreatment anxiety
2. Report higher levels of self-efficacy related to coping
with the side effects of chemotherapy
3. Report fewer unmet information needs related to
treatment, and
4. Report higher levels of satisfaction with information
received
In the production of generic patient education materials,
there is a tension between producing material that has broad
applicability and resources that are more specific and
relevant to individual circumstances. A DVD featuring
people ‘cured’ of cancer may be less successful at
ameliorating anxiety or promoting confidence in managing
symptoms for a patient who is receiving palliative treat-
ment, than for a patient receiving curative treatment. Hence,
it was also hypothesized that the above effects would be
more pronounced in those who perceive the intent of their
treatment to be curative rather than palliative.
Materials and method
Design and setting
A two-group prospective quasi-experimental design with a
historical control was used. Group 1 (usual care) was
prospectively recruited during the development of the DVD
and received usual care alone. Group 2 (intervention)
received the DVD in addition to usual care. The study
was conducted at a single site (Peter MacCallum Cancer
Centre, a specialist cancer hospital in Melbourne, Australia)
after approval by the Human Research Ethics Committee.
Support Care Cancer (2008) 16:37–45
Participants
Inclusion criteria were patients with a histologically or
cytologically confirmed diagnosis of cancer, age 18 years
or older, ability to read and write English, and scheduled to
receive first ever chemotherapy treatment. Exclusion
criteria were serious psychiatric or cognitive impairment
that would prevent the patient from completing the study
requirements. For group 2, not watching the DVD also
precluded them from being recruited. Fifty patients were
recruited to each of the two groups. For group 2, the sample
was approximately matched to group 1 in terms of gender,
cancer type, and self-perceived treatment intent.
Measures
Demographic variables Age, sex, marital status, education
level, employment status, and whether English was the
participant’s first language were recorded.
Disease variables One item assessed patient’s perception of
treatment intent. The stem was “what do you understand to
be the main aim of chemotherapy treatment for your
cancer” with response options “to cure it”, “to prevent the
cancer recurring”, (curative intent) and “to control it”
(palliative intent). Information on diagnosis, disease stage,
and purpose of treatment (e.g., curative, palliative) were
retrieved from the participant’s medical record or from the
treating physician. All references to treatment intent in this
paper refer to the patients’ perception of their treatment
intent, regardless of the actual purpose of treatment.
Satisfaction with information Four questions on five-point
Likert scales were used to assess satisfaction with informa-
tion received. For example, “How satisfied are you with the
information you’ve received at Peter Mac about your
chemotherapy treatment?”
Anxiety and depression This was assessed using the Hospital
Anxiety and Depression Scale (HADS) [33]. Subscale scores
are reliable and valid measures of anxiety and depression,
which have been validated with cancer patients [24]. In a
randomized controlled trial of a video to prepare patients for
chemotherapy, both the anxiety and depression subscales of
HADS were found to be responsive to the intervention [31].
Perceived confidence in coping with cancer (self-efficacy)
The Cancer Behaviour Inventory (CBI; version 2) [23]
was used. This has 33 items and 7 subscales, each with 5
items except the last subscale. The seven subscales are
maintaining activity and independence; seeking and under-
standing medical information; stress management during
39
treatment; coping with treatment-related side effects;
accepting cancer/maintaining a positive attitude; affect
regulation; and seeking social support. The CBI has high
internal consistency (0.80–0.88), test–retest reliability for
the whole scale (0.74), and convergent and discriminant
validity [23].
Perceived needs of patients The Supportive Care Needs
Survey (SCNS)-short form [2] was used to assess patients’
unmet needs, in particular their health information needs.
The SCNS has 31 items and 5 subscales: psychological,
health information, physical and daily living needs, patient
care and support needs, and sexuality. This measure displays
high internal consistency and construct validity [2].
Procedure
For group 1, a research assistant screened chemotherapy
day unit treatment lists to identify potentially eligible
participants. Potential participants were approached in the
waiting room of the chemotherapy day unit on their first
day of chemotherapy treatment. Patients were provided
with information about the study, and written consent was
obtained. Consenting patients completed the questionnaire
before beginning their treatment. For group 2, a research
assistant screened outpatient clinic lists to identify poten-
tially eligible patients. These people were approached in the
outpatients’ clinic several days before the first day of their
planned treatment and were given a copy of the DVD to
take home to watch. The research assistant met with the
patient in the chemotherapy day unit on his or her first day
of chemotherapy treatment to provide him or her with
information about the study, obtain informed consent, and
administer the questionnaire.
Intervention
The educational DVD focused on preparation for receiving
chemotherapy and self-management of eight common side
effects: nausea and vomiting, constipation, diarrhea, muco-
sitis, fever and infection, hair loss, infertility, and effects on
intimacy and sexuality. Four key principles were identified
as important in the development of the DVD: (1) stakeholder
consultation involving ongoing feedback from consumers
and health professionals; (2) evidence-based content derived
from a systematic literature review to support the recom-
mended self-care strategies for eight common chemotherapy
side effects; (3) provision of appropriate information to
prepare patients for the medical procedure, based on relevant
meta-analyses; and (4) promotion of patient confidence by
role modelling adaptive coping behaviors [5].
40 Support Care Cancer (2008) 16:37–45

Use of role models was a central feature of the DVD,
with the bulk of the content being delivered by cancer
survivors. Each survivor discussed their experiences when
having chemotherapy, side effects they experienced, and
self-care strategies they used to manage these side effects.
Relevant excerpts of interviews were matched to the script.
A medical oncologist and oncology nurse presented
relevant medical and nursing information. The resource
was produced in both DVD and video format and is 25 min
long. The development and pilot testing of this resource are
reported in detail elsewhere [4].
Usual care
Usual care chemotherapy education consisted of a generally
brief description of the treatment procedure and side effects
provided by the patient’s medical oncologist or hematolo-
gist. Data were collected before treatment. The treatment
session included a half-hour education session with a
chemotherapy nurse.
Statistical consideration
All statistical analyses were conducted using SPSS Version
15. A missing data analysis was conducted to evaluate the
amount and distribution of missing data. On average, there
were 2% missing data, which were found to be random.
Records with missing data were excluded analysis by
analysis on a pair-wise basis. Baseline differences between
treatment groups were tested using chi-square for categor-
ical demographic data and an independent sample t test for
age. Subscale scores were calculated for the CBI, SCNS,
and HADS. The four satisfaction with information items
were analyzed as individual items.

Table 1 Demographic and disease characteristics by treatment group for curative and palliative patients

Curative Palliative

n Usual care Intervention Test statistic n Usual care Intervention Test statistic

Gender
Male 37 18 19 χ2(1)=0.868, 15 9 6 χ2(1)=0.259,
Female 32 12 20 p=0.246 16 11 5 p=0.447
Age [mean (SD)] 54 57.50 57.40 (13.09) t(52)=0.026, 56.88 56.50 (18.10) t(25)=0.056,
(14.89) p=0.979 (16.79) p=0.956
Marital status
Never married 8 4 4 χ2(3)=1.129, 3 2 1
Married/de facto 48 19 29 p=0.770a 23 14 9 χ2(2)=0.663,
Separated/divorced 5 3 2 5 4 1 p=0.718a
Widowed 8 4 4
Employment status
Full-time 18 8 10 χ2(3)=1.313, 4 3 1 χ2(4)=1.476,
Part-time 11 6 5 p=0.726a 2 2 0 p=0.831a
Unemployed 8 3 5 7 5 2
Retired 23 8 15 11 7 4
Studying 2 1 1
Education level
University 16 8 8 χ2(4)=4.098, 8 4 4 χ2(3)=4.526,
TAFE/trade cert 15 5 10 p=0.393 6 4 2 p=0.210
Completed 16 8 8 6 6 0
secondary
Did not complete 19 7 12 11 6 5
secondary
Other 2 2 0
Language
English 60 26 34 χ2(1)=0.004, 28 18 10 χ2(1)=0.007,
Other 9 4 5 p=0.612a 3 2 1 p=0.719a
Tumor type
Breast 8 3 5 χ2(6)=2.226, 1 0 1
Gastrointestinal 7 2 5 p=0.898a 1 1 0
Gynecological 12 4 8 6 5 1 χ2(6)=7.504,
Head and neck 23 12 11 3 2 1 p=0.277a
Lung 6 3 3 11 7 4
Prostate/testicular 5 2 3 3 3 0
Other 8 4 4 6 2 4

a
At least one cell has an expected cell count less than 5.
Support Care Cancer (2008) 16:37–45 41

To test the hypotheses, curative and palliative patients CBI self-efficacy

were assessed separately due to the potentially confounding
effect of perceived treatment intent. A series of independent
sample t tests were conducted for each of the outcome
measures by treatment group (usual care or intervention).
Alpha levels were set at 0.05.
Results
Demographic and disease characteristics
The response rate for participation was 59.5% (50/84) for the
‘usual care’ group. For the intervention group, 88 were
approached, 25 refused to participate, 13 took the DVD but
did not watch it, resulting in a response rate of 56.8% (50/88).
No significant differences were found in the demographic and
disease characteristics of the usual care and intervention
groups (see Table 1 for frequencies, means and standard
deviations, and significance tests).
A significant difference was found for self-perceived curative
patients between the usual care vs intervention groups for self-
efficacy in seeking social support [t(67)= −2.048, p=0.044],
with patients who watched the DVD rating themselves as
more confident about seeking social support than those who
had not watched the DVD (see Fig. 2).
No significant differences were found for self-perceived
palliative patients between the usual care vs intervention
groups across any of the self-efficacy areas.
SCNS supportive care needs
No significant differences were found for either self-
perceived curative or palliative patients between the usual
care vs intervention groups across any of the domains of
supportive care need. Figure 3 indicates that both curative
and palliative patients reported having more psychological
needs than any other type of supportive care, and sexuality
as the least needed type of supportive care.

HADS anxiety and depression scores Satisfaction with health information received

No significant differences were found in either the anxiety
or depression subscale scores between the usual care vs
intervention groups, for either the self-perceived curative or
palliative patients (see Fig. 1).
Self-perceived palliative patients in the intervention group
were significantly more satisfied with the information they
had received about side effects than the usual care group
[t(29)=2.348, p=0.026]. There were no significant differ-
ences for the self-perceived curative patients (see Fig. 4).

Curative vs palliative patients

12
Curative Overall, significant differences were found between self-
Palliative
11 perceived curative and palliative patients in their levels of
self-efficacy and their supportive care needs. Self-perceived
10 curative patients rated themselves as significantly more
Mean HADS Scores

confident than self-perceived palliative patients in main-

9
taining activity and independence, stress management,

8 9.0
Curative
Mean Self Efficacy Scores

8.5
Palliative
8.0
7 7.5

7.0

6.5
6
6.0

5.5

5 5.0
Intervention

Intervention

Intervention

Intervention

Intervention

Intervention

Intervention
Usual Care

Usual Care

Usual Care

Usual Care

Usual Care

Usual Care

Usual Care
Intervention

Intervention
Usual Care

Usual Care

Maintaining Seeking & Stress Coping with Accepting Affective Seeking

Activity & Understanding Management Treatment Cancer / Regulation Social
Independence Medical During Related Side Maintaining a Support
Information Treatment Effects Positive
Attitude
Anxiety Depression
Fig. 1 HADS anxiety and depression scores by treatment group for Fig. 2 CBI self-efficacy scores by treatment group for curative and
curative and palliative patients palliative patients
42 Support Care Cancer (2008) 16:37–45

5.0 5.0
Curative
Mean Supportive Care Needs Scores

Palliative
4.5 4.5

Mean Satisfaction Scores

4.0 4.0

3.5 3.5

3.0 3.0

2.5 2.5

2.0 2.0
Curative
1.5 1.5 Palliative

1.0 1.0
Intervention

Intervention

Intervention

Intervention

Intervention
Usual Care

Usual Care

Usual Care

Usual Care

Usual Care

Intervention

Intervention

Intervention

Intervention
Usual Care

Usual Care

Usual Care

Psychological
Fig. 3 SCNS supportive care needs scores by treatment group for
curative and palliative patients
coping with side effects, accepting cancer and maintaining
a positive attitude, affective regulation, and seeking social
support (see Table 2).
No significant differences were found between self-
perceived curative and palliative patients in their anxiety or
depression scores, nor in their ratings of satisfaction with
information received.
Discussion
The results of this study did not support the first hypothesis
that, compared to patients who did not watch the DVD,
those who watched it would report lower levels of
pretreatment anxiety. Indeed, there were nonsignificant
trends in the opposite direction. The results provide partial
support for the second hypothesis that patients who
watched the DVD would report higher levels of self-
efficacy related to coping with cancer. For self-perceived
curative patients, those who watched the DVD reported
higher levels of self-efficacy in relation to seeking social
support. Nonsignificant trends in other areas of perceived
confidence indicates the potential for significant differences
to be found in a larger sample.
No significant differences were found to support the
third hypothesis that watching the DVD reduced patients’
supportive care needs. With respect to the fourth hypoth-
esis, watching the DVD was associated with higher
satisfaction about side effects information provision in
self-perceived palliative patients, but not self-perceived
curative patients. This may be because information about
managing treatment side effects could be perceived as a
mechanism for introducing some control and hope for good
quality of life for people with an incurable disease.
Thus, the DVD appears to provide some benefits in terms
of confidence in coping with cancer for self-perceived
Usual Care
Health System Physical & Patient Care & Sexuality
& Information Daily Living Support
Type of Cancer Your How to Look How Your
You've Been Chemotherapy After Side Concerns About
Diagnosed With Treatment Effects from Chemotherapy
Treatment Have Been
Dealt With
Fig. 4 Satisfaction with information received scores by treatment
group for curative and palliative patients
curative patients and in terms of satisfaction with information
provision specific to side effects for self-perceived palliative
patients. The DVD did not significantly increase anxiety or
depression for either group. Hence, we conclude that it is safe
to provide this DVD to patients. However, as with any
informational/educational resource, it should be paired with a
face-to-face tailored education session. The DVD can then
provide general information about chemotherapy to help
patients and their family members generate questions specific
to their individual circumstances and particular chemotherapy
regimen.
Overall, participants reported that they were very
satisfied with the information received, whether through
the DVD or usual care. While ‘satisfaction’ is a construct
which is known to be influenced by the social desirability
response [1], it is nevertheless important that participants
were satisfied with the provision of a pretreatment
educational resource. The vast majority of cancer patients
indicate that they wish to receive as much information as
possible, both good and bad, and frequently report a gap
between the amount of information they want and the
amount they receive [17]. It is vital to explore cost-effective
avenues to close this gap, as education is known to have
beneficial effects for oncology patients. A systematic
review demonstrated that educational interventions im-
proved knowledge, lowered decisional conflict about
treatment options, and assisted patients to take a more
active part in their medical care [26].
Curative vs palliative treatment intent
As anticipated, the DVD resulted in a differential effect,
depending on the patient’s perception of treatment intent.
Support Care Cancer (2008) 16:37–45 43

Table 2 Mean differences in HADS, CBI, SCNS, and satisfaction scores by treatment intent

Curative [mean (SD)] Palliative [mean (SD)] Test statistic

HADS
Anxiety 10.43 (2.90) 10.93 (2.88) t(95)=−0.786, p=0.434
Depression 5.59 (2.74) 6.80 (3.44) t(97)=−1.859, p=0.066
CBI self-efficacy
Maintaining activity and independence 7.39(1.04) 6.64 (1.65) t(39.5)=2.277, p=0.028a
Seeking and understanding medical information 7.95 (1.20) 7.48 (1.30) t(97)=1.739, p=0.085
Stress management 7.32 (1.25) 6.62 (1.64) t(44.3)=2.069, p=0.044a
Coping with treatment-related side effects 6.96 (1.41) 5.93 (1.57) t(97)=3.213, p=0.002
Accepting cancer/maintaining a positive attitude 8.04 (1.01) 7.29 (1.35) t(43.8)=2.756, p=0.008a
Affective regulation 7.13 (1.26) 6.26 (1.58) t(97)=2.890, p=0.005
Seeking social support 7.47 (1.42) 6.63 (1.67) t(97)=2.546, p=0.012
SCNS supportive care needs
Psychological 2.52 (1.01) 3.07 (0.92) t(97)=−2.545, p=0.013
Health system and information 2.32 (0.93) 2.70 (0.84) t(97)=−1.919, p=0.058
Physical and daily living 2.07 (1.07) 2.54 (1.05) t(96)=−2.033, p=0.045
Patient care and support 1.99 (0.79) 2.33 (0.78) t(97)=−1.956, p=0.053
Sexuality 1.80 (0.96) 1.92 (1.00) t(96)=−0.553, p=0.581
Satisfaction with information received
Cancer type 4.35 (1.03) 4.35 (0.95) t(95)=−0.029, p=0.977
Chemotherapy treatment 4.29 (1.02) 4.03 (0.88) t(97)=1.233, p=0.220
Side effects 4.12 (1.08) 3.81 (1.22) t(96)=1.279, p=0.204
Concerns about chemotherapy 4.01 (0.93) 3.87 (0.89) t(96)=0.724, p=0.471
a
Equal variances not assumed

Specifically, the DVD was associated with increased
confidence in seeking support for self-perceived curative
patients and greater satisfaction about information provision
for self-perceived palliative patients.
Patients who perceived the intent of treatment to be
palliative rather than curative reported higher levels of anxiety,
depression, and unmet supportive care needs across all
domains with significant differences for psychological needs
and physical and daily living needs. These patients further
reported lower confidence across all domains of self-efficacy,
with significant differences in all domains except seeking and
understanding medical information. Overall, palliative
patients also tended to be less satisfied with the information
they had received than curative patients.
Patients with an incurable disease face worsening quality
of life and may have to confront existential and spiritual
questions, which in addition to increasing physical symp-
toms, can cause significant psychological distress [18].
Patients’ social interactions also suffer, as symptoms restrict
functioning in social, family, and work-related roles [14].
Many people with advanced cancer are concerned that they
may impose a burden on their carers [27]. In this context, it
is understandable that people with incurable disease report
comparatively higher levels of pretreatment anxiety, lack of
confidence in coping with physical and emotional chal-
lenges, and greater need for supportive care. The message for
health professionals is that patients receiving palliative
chemotherapy treatment require special attention in terms
of pretreatment education, especially to decrease pretreat-
ment anxiety, increase confidence, and meet unmet needs in
coping with their illness, treatment regimen, and side effects.
Limitations
There are several limitations to this research. Firstly, it
would have been preferable to use a randomized controlled
trial design. However, once the DVD was completed, it was
expected that it would be made publicly available. Hence, a
randomized controlled trial was not possible. Secondly, a
sample of convenience was used. Therefore, the study
design and sample size may have been insufficient to detect
clinically significant differences between the two groups.
Post hoc power analyses revealed that for the small effect
sizes (Cohen’s d ranging between 0.03 and 0.35) observed
in the current sample for most of the specific hypotheses,
the sample sizes used produced between 6 and 42% power to
detect small differences. Even with the large effect size
(Cohen’s d=0.95) observed for self-perceived palliative
patients in relation to satisfaction with information received
about side effects, the current sample only just achieved 80%
power. Nevertheless, a larger sample size may be able to
detect more statistically significant differences. The possibil-
ity of detecting differences between groups may also have
been affected by the location of the study in a comprehensive
cancer center where attention to patient pre-chemotherapy
education, commencing with the first discussion with a
44
medical oncologist, is likely to be high. Third, it may be that
the intervention was not sufficiently intense and too general
to achieve change. As patient’s individual needs vary [17], it
is clear that systematically assessing the most prominent
needs and tailoring the intervention specifically to those
needs is an important aspect of an effective intervention [32].
This reinforces the importance of pairing educational
resources with tailored education sessions.
Our pilot test data showed that more than 90% of patients
and health professionals believed that the DVD would allow
people starting chemotherapy to “feel less anxious about
treatment”, “prepare themselves for chemotherapy”, “under-
stand how to manage side effects”, “understand possible side
effects of treatment”, and “understand what treatment will feel
like” [4]. The present study partially supported this for
curative patients and indicated that palliative patients have
specialized needs. It may be that timing of the delivery of the
DVD was not optimal. Pretreatment is a time of particularly
high anxiety, and therefore, it may be that the content of our
DVD did not address the patients’ most pressing concerns at
this time point. While sensory and procedural information
about chemotherapy was presented, much of the content of
the DVD relates to management of side effects, which may
be more relevant to people who have commenced chemo-
therapy treatment.
Conclusions and future work.
This study aimed to explore the impact of a pre-chemo-
therapy DVD on pretreatment anxiety, perceived self-
efficacy in managing treatment side effects, unmet needs
and satisfaction with information received in patients
receiving their first ever course of chemotherapy. The
DVD was found to significantly influence aspects of self-
efficacy and satisfaction with information received. The
differences related to perceived treatment intent confirm
that self-perceived palliative patients require additional
support before commencing treatment.
Pre-chemotherapy education is a central part of nursing
management of chemotherapy patients, yet there is a paucity
of evidence to guide the timing, content, and style of this
education. In practice, many health professionals also
express concern about giving patients information through
resources such as DVDs unmediated by a nurse who can
tailor the interpretation of the information to the specific
situation of each patient. This study has shown that use of
this DVD to prepare patients for chemotherapy may increase
confidence to cope with cancer and reduce their supportive
care needs. Importantly, it indicates that the provision of an
evidence-based DVD before a formal pre-chemotherapy
Support Care Cancer (2008) 16:37–45
education session is safe and does not significantly increase
patient anxiety.
This study also raises several important research questions:
– Would the effect of the DVD resource be enhanced if
paired with tailored nurse-led education?
– Would the use of a question prompt sheet increase the
effects of the DVD on anxiety and self-efficacy in
communicating with health professionals about treatment?
– What further strategies are required to improve the
readiness in managing treatment side effects in those
for whom treatment intent is palliative and who may
already be unwell at the time chemotherapy starts?
We are currently conducting a randomized controlled trial
of a chemotherapy educational intervention to address these
questions.
The use of a DVD and other generalized resources as
adjuncts to health professional education is important given
the increasing shift to ambulatory care in cancer and global
workforce shortages, both of which limit the time available to
support each person through their treatment journey. Despite
their importance, many such resources are developed without
a sound evidence base and are not rigorously tested for their
impact on key patient outcomes. This study contributes to our
understanding of the impact of such resources and provides
several directions for future testing of these materials.
Acknowledgements The DVD development was supported by a grant
from the Peter MacCallum Cancer Foundation. Dr. Penelope Schofield is
the Pratt Foundation Senior Research Fellow. We also wish to thank
volunteers from the Cancer Connect program and The Cancer Council
Victoria for assisting with this project. The research staff who undertook
this study were partially supported by grants from the Leukaemia
Foundation Australia and a project grant from the National Health and
Medical Research Council for conduct of the randomized controlled trial.
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