Foundations Of Social Work Practice I
Practice In End Of Life Care
Program Development And Evaluation
A. My Research, Scholarship, and Innovations
My research, scholarship, and innovations increase our understanding of older, middle-aged, and underserved adults with chronic medical conditions:
— I detect and interpret symptom clusters (multiple symptoms of an illness in the same person) and symptom feedback (mutually causal symptoms of an illness) for insights into palliative care and related mental health care
— I detect and explain comorbidities (multiple illnesses in the same person) and other co-occurrences (for example, the objective stress and perceived strain of financial burden) that reveal patient subgroups at risk of inadequate healthcare
— I improve analytic methods to study synergy (statistical interactions) and feedback loops (simultaneous, bi-directional relationships) in these situations
— In other work, I develop original ideas that create or expand social work roles to improve illness-informed practice, transdisciplinary care, and disease management in community and healthcare settings
My research reveals components of symptom clusters, comorbidities, or other co-occurrences that interact with each other. These interactions reveal synergistic effects that magnify or buffer relationships to health or mental health outcomes, relative to the broader context where these predictors are scattered across the sample without necessarily co-occurring in the same person. Lately, I began considering this broader context for symptom feedback loops. It is practical to target synergistic effects and feedback loops since multidisciplinary healthcare teams will have more incentive to screen for them — and not merely co-occurring symptoms or illnesses — as their deleterious or protective effects become realized and as evidence distinguishes circumstances that call for medical versus mental health treatment or both.
My research and grant proposals emphasize synergistic or feedback effects in cancer, diabetes, excess weight, heart failure, lung disease, multiple organ system failure, or progressive cerebrovascular disease. These recent or current projects apply innovations I developed to statistical methods or models for deriving more valid findings. They aim to:
— improve the detection of interactions in multiple regression among physical symptoms that constitute symptom clusters, as well as the interpretation of their synergistic effects on comorbid mental health outcomes
— estimate exhaustively specified latent trait models in which progressive cerebrovascular conditions interact with comorbidities or co-occurrences to predict symptom clusters, or profiles, of late-life depression
— assess symptom feedback loops in cross-sectional data, using pairs of multiple regressions to test pain as a cause and effect of comorbid depression
or anxiety in separate medical conditions, especially as age advances
These new developments have potential for broad application in health, aging, social work, and other fields.
My research and scholarship fall within three interrelated areas (for each area, I list key achievements, and in the third area, also current projects):
1. Older and middle-aged adults coping with medical conditions or related physical symptoms who present with depression
— I focus on co-occurring illness conditions, symptoms, or psychosocial factors that interact to magnify their relationships to depression, or to reveal distinct profiles of depressive symptoms. My studies reveal that depression may be recognized or hidden (i.e., masked); screened using a single flexible item; experienced as sickness malaise when symptoms of cancer occur in pairs or clusters; and characterized by distinct profiles of depressive symptoms in subgroups of older adults with progressive cerebrovascular disease, diabetes, and/or excess weight (see "Research Interests," sections 1a, 2a, and 2b).
Andrea M. Barsevick, a prominent investigator of cancer symptom clusters, claims my initial study of symptom clusters (Francoeur, 2005; see "Refereed Articles") "...provides the first evidence that symptom pairs can have a synergistic or interaction effect in predicting patient outcomes" [based on the Symptom Management Model and the Theory of Unpleasant Symptoms]. Further, she maintains that the study presents "...the first test of the sickness behavior hypothesis" [in which an immune response, signaled by fever, triggers and sustains physical symptoms and depression known as sickness malaise. These quotations appear on page 975 in: Barsevick, A. M. (2007). The elusive concept of the symptom cluster. Oncology Nursing Forum, 34(5), 971-980]. Recently, I reported several symptom clusters that consistently support the role of fever in the sickness behavior hypothesis, which are distinguished from symptom clusters of the same symptoms in the absence of fever (i.e., the depression hypothesis; Francoeur, 2015 "Part II").
2. Hidden or emerging clinical issues in older and underserved populations with chronic illness, especially during palliative care
— A major focus in this area has been the use of indirect indicators to reveal whether subgroups receiving palliative care may be at risk of forgoing essential health care and necessities. For instance, I published several articles regarding the moderating influence of age on objective financial stress-subjective financial strain relationships. I revealed that the indicator of financial strain from difficulty paying bills, when used alone, would be misleading to identify older outpatients receiving palliative radiation who may be at risk. Compared to younger outpatients incurring similar levels of financial stress, older outpatients were found to report less difficulty paying bills, even as they were more concerned about a second indicator of financial strain, the adequacy of their financial resources and insurance to meet future health needs. This response pattern suggests older outpatients may be more likely to forgo care and necessities that would pose financial hardship. I qualified these relationships further based on the experience of a recent work transition or the number of days impaired by disability (see "Research Interests," sections 3c and 3d).
Through this work, I pioneered conceptual and methodological developments, and deepened empirical understanding, in testing age-related relationships between an overall index of objective family financial stress and indicators of subjective patient financial strain, based on a series of articles regarding financial burden in outpatients initiating palliative radiation (Francoeur, 2007, 2005, 2002, 2001). This foundational work has been an important influence in the conceptualization, design, and analysis of financial stress and strain in later studies of cancer survivors and other populations. A recent study by Sharp and Timmons (2015), for instance, cited my 2005 study eight times to guide their development of financial variables and inform their methods and interpretations.
— I published agency, hospital, and community programming strategies that
1) engage agency social workers to monitor hypertension (Francoeur, 2010);
2) expand the palliative social work role in spirituality to facilitate coping with chronic illness and self-determination in advance care planning (Francoeur, Burke, and Wilson, in press), and 3) integrate police, pharmacists, medical providers, and social workers to ensure safe access to medication for palliative care while preventing prescription drug abuse (Francoeur, 2011). In the latter area, my commentary has been downloaded over 1,200 times. Among the sources that cite it are the American Society of Clinical Oncology website ("Cancer pain management: Safe and effective use of opioids," 2015 Educational Book, http://meetinglibrary.asco.org/content/11500593-156) and the Oxford Textbook of Palliative Nursing ("Chapter 7: Pain at the end of life," https://books.google.com/books?isbn=0199332347).
3. Creating innovations to statistical methods and models I use in my work that may influence research in health, aging, social work, and other areas
I created three innovations to statistical methods or models. I published two of the innovations to improve detection and interpretation of statistical interaction effects in multiple regression, a common statistical approach in health and aging research and many other disciplines. Both innovations stem from my work on cancer symptom clusters. They can be used together to discover and interpret influential pairs and clusters with synergistic — and not merely co-occurring — components based on symptoms, disease markers, or psychosocial factors. Currently, these two interrelated innovations are being programmed into an app to facilitate wider access by researchers (see "Research Interests," section 1b).
I am writing articles that will demonstrate a third innovation from my research on at-risk subgroups of older adults with progressive cerebrovascular conditions. These cerebrovascular conditions interact either with other comorbid conditions, such as diabetes and/or excess weight, or co-occurring psychosocial or developmental factors, such as education level, and these interactions predict unique profiles, or symptom clusters, of depressive symptoms from the CES-D Depression Inventory. This third innovation constitutes a unique modeling specification I discovered to estimate exhaustively specified latent trait models that combine confirmatory factor analysis with multiple regression. In addition, I am writing a grant proposal to demonstrate a fourth statistical innovation.
I now describe each of these statistical innovations:
— Sequential Residual Centering (SRC) is one of two statistical innovations I derived from my methodological work on cancer symptom clusters. SRC is a breakthrough because it overcomes low sensitivity in multiple regression to detect terms that involve interactions among predictor variables. This dilemma has challenged researchers ever since computer software for multiple regression became available in the 1960s. I also derived extended versions of SRC for further improvements in the sensitivity of moderated regressions with control, secondary, or curvilinear (quadratic) predictors (Francoeur, 2013, 2015 Part I, 2015 Part II; my open-access statistical article and both parts of my symptom cluster application were downloaded over 1,100 times each).
In addition, I devised a strategy based on the SRC to calculate the Total Net Moderator Effect, which reveals whether the buffering or magnifier effect is stronger in the sample, by aggregating each type of effect and comparing them. This strategy may be the only way to interpret complex interactions with more than three linear components or multiple curvilinear components. It also offers insight into the changing strength or direction of the Total Net Moderator Effect when different components of the interaction are considered to be the primary (non-moderating) variable. Finally, when the EZSC post-hoc procedure (in the next bullet) reveals both buffering and magnifier effects from an interaction, the strategy may be used to deduce which effect is stronger, since the stronger effect has the same nature as the Total Net Moderator Effect (Francoeur, 2013).
— The Extended Zero Slopes Comparison (EZSC) is the other statistical innovation I derived from my methodological work on cancer symptom clusters. EZSC extends an original algorithm, the Zero Slopes Comparison (ZSC), which is a post-hoc procedure to interpret interactions between two linear variables detected in multiple regression. EZSC offers new options to reveal the nature of moderator effects if one of the two interacting variables is not linear but quadratic (squared) in its influence, resulting in a curvilinear interaction, or if three linear variables interact. Both ZSC and EZSC overcome the need to re-estimate multiple regressions and construct related graphs to reveal the nature of moderator effects (magnifier and/or buffering). These graphs are not exhaustive; they are limited in displaying "snapshots" of moderator effects at pre-selected values of the predictor variables comprising the interaction. In contrast, both algorithms yield fewer interpretations of aggregate moderator effects across predictor ranges, and not at pre-selected values (Francoeur, 2011a).
At present, I am working with a computer scientist to develop a web app to calculate the reduced standard errors and resulting larger t-values of SRC regression coefficients, along with easy application of the ZSC and EZSC algorithms to interpret the nature and relative strength of statistical interactions detected in raw or SRC multiple regression. This web app will have potential for broad use across areas of research in gerontology and other fields whenever there is a need to interpret synergistic interactions among variables.
— I recently developed a third innovation that constitutes a modeling specification strategy to overcome a critical limitation in deriving valid findings from exhaustively specified models (i.e., all possible relationships are estimated) combining confirmatory factor analysis with multiple regression. These structural equations models are appealing to identify unique psychometric presentations or profiles within subgroups of participants because they simultaneously estimate the factor analysis of a latent construct (e.g., total depression) on its observed "multiple indicators" (i.e., the set of measured psychometric items) while regressing the latent construct and its multiple indicators on a set of "multiple causes" (i.e., predictor variables). However, when exhaustively specified, these multiple indicators-multiple causes (MIMIC) models lack sufficient exogenous information to yield valid estimates and are therefore under-identified. Prior to my new strategy, this limitation created a difficult dilemma for my work since only just-identified ("saturated") or over-identified models can ensure valid detection of unique psychometric profiles within subgroups of participants. I am writing articles about at-risk subgroups of older adults with unique profiles, or symptom clusters, of depressive symptoms when progressive cerebrovascular conditions interact with other comorbid conditions, such as diabetes and/or excess weight, or with co-occurring psychosocial or developmental factors, such as education level. Some profiles suggest distinct symptom phenomenologies of depression in the context of cerebrovascular conditions (see "Research Interests," section 2a).
— I am writing a grant proposal to develop an approach I conceived for distinguishing causality from reverse-causality in multiple regression to target specific contexts that call for medical versus mental health treatment, or both, to relieve symptom feedback loops that link pain to comorbid depression or anxiety in heart failure, lung disease, or multiple organ system failure.
Finally, numerous other scholars have cited my articles and book chapters (Google and Google Scholar reveal 234 works, of which 75 cite one of my symptom clusters studies 105 times), and in two discussion forums for specific statistical software (Stata, SPSS). Although not an exhaustive record, Google Books shows actual citations to my work that appear in 8 books in social work or social welfare, 17 books in health, medicine, or nursing, and 3 books in social science. I am delighted that my findings and innovations are influencing investigators in health, aging, social work, and other disciplines.
I maintain an active presence on ResearchGate, a professional networking site for researchers and scientists (https://www.researchgate.net/profile/Richard_Francoeur). For a more extensive discussion of my research, scholarship, and innovations, see "Research Interests" below.
B. My Clinical and Teaching Experiences
My experiences in social work practice and evaluation continue to influence the development of my substantive and methodological interests in health and aging, as well as enrich my teaching and field advising. Foremost among my clinical positions, I served a diverse group of veterans and families as a medical social worker at the VA Pittsburgh Healthcare System. For more than seven years, I gained invaluable clinical experience across a wide range of healthcare settings — ambulatory, outpatient, inpatient, intensive care, physical rehabilitation, dementia care, and community nursing homes.
During this odyssey, I met with patients and family caregivers who were grappling with serious medical conditions, physical symptoms, and care demands. At times, hidden mental health conditions weakened coping and the effectiveness of care. For instance, some older adults with good cognitive functioning seemed withdrawn and disinterested, but denied sickness malaise or feeling blue. This response pattern deterred relatives and health providers from detecting "masked" depression, which may be a sign of illness exacerbation and risk for inpatient readmission, as well as an indicator of compromised safety, care adherence, and spousal caregiving at home. I also became intrigued that in response to screening items, patients and spouses reported lower financial strain when they were older, despite experiencing similar levels of economic stress as patients and spouses at younger ages. These limitations in detecting depression or financial difficulties in older adults sparked my interest in the phenomenon of biopsychosocial issues that remain hidden despite assessment.
I remain committed to the process of revealing hidden or emerging needs, issues, and strategies. Master's and doctoral students in my classes, and Master's students and agency supervisors I advise in field placements, inform me about needs and issues in client populations and the evolution of service delivery at community agencies. I share insights with them from my own clinical, programming, and research experiences, and from my published scholarship, when there may be implications for social work roles, program development, or evaluation. In the classroom, I encourage students to engage each other and me in mutual learning. This shared process is similar to how social workers interact with clients and co-workers in clinical situations, and with colleagues at meetings, trainings, and conferences. I acknowledge when fresh perspectives emerge from mutual learning and try to incorporate some of them into my activities.
In the Master of Social Work (MSW) program, I am currently teaching the first-year course, Foundations of Social Work Practice I, and the second-year advanced elective, Practice in End-of-Life Care. Recently, I revised the latter course to incorporate a greater focus on palliative care and advance care planning as part of the illness trajectory that may lead eventually to the end-of-life, as well as distinct interventions such as existential psychotherapy and forgiveness therapy. In previous years, I taught the first-year course, Human Behavior Theory for Social Work Practice I, and the second-year seminar, Contemporary Social Work. In the latter course, advanced Master's students select and research a specific social problem, purposely integrating knowledge across the four major areas of the curriculum (social work practice; human behavior theory, assessment, and diagnosis; social policy and organizations; and social work research).
In the social work doctoral (Ph.D.) program, I teach a course in Program Development and Evaluation. Over time, I have supplemented the traditional focus on crafting and critiquing program logic models with new course content and assignments to prepare doctoral students to engage in evidence-based practice, including evidence-based program development and evaluation. Doctoral students learn methods for critiquing and conducting systematic reviews and meta-analyses of the empirical literature, and they are introduced to mixed-methods evaluation (i.e., integration of qualitative and quantitative methods within the same study). In previous years, I occasionally taught a course in Advanced Research Topics.
Gerontology; social work in health care/public health
Program development and evaluation
Systems thinking and analysis in agencies and community practice
Systematic reviews and meta-analysis; mixed methods research
Social work practice, including use of human behavior theories
My background in clinical practice and program development, and experience in adapting and applying specific quantitative methods and statistical models, have led to important insights and directions for my work in the following areas:
1. Co-occurring symptoms that interact as "symptom clusters"
Co-occurring symptoms may behave independently and consistently in their effects on important outcomes, or as symptom pairs and clusters (hereafter "symptom clusters") with synergistic (interactive) effects that become magnified or minimized at specific symptom levels or ranges. Symptom clusters can vary across specific conditions, with illness progression, and as side effects from drugs and medical procedures. Different symptom clusters may occur across service settings and populations, such as outpatient care (e.g., disease-modifying treatments with palliative care), nursing/rehabilitative care, home-based hospice, and the community (e.g., post-treatment survivors).
Social workers, health care providers, and medical researchers all seek to identify and monitor individuals with unrelieved symptoms, treatment side effects, or at risk of diverting or abusing prescription drugs. These demands create a critical need for research on symptom clusters that affect outcomes such as adherence to care, quality of life, depression, and mortality. Thus, knowledge of symptom clusters can be used to target screening efforts within particular patient subgroups so that individuals at greater risk for developing negative outcomes can be identified more easily and followed more closely.
In addition, some symptom clusters with interacting symptoms could be used as leads and preliminary evidence to reveal when interventions for sentinel symptoms may be generating impacts that also reduce co-occurring symptoms, an optimal situation that could lead to developing strategies for symptom management that are simpler, better, and more cost-effective than treating each symptom separately. These "cross-over" impacts could relieve co-occurring symptoms that stem from the underlying disease process and/or from side effects of a drug or treatment.
a. I am making empirical contributions to the evolving, multidisciplinary area of symptom clusters. I published a highly influential article (Francoeur, 2005c), cited 101 times by 72 publications, which assessed how co-occurring physical symptoms interact to influence the relationship between a primary physical symptom (e.g., pain) and a mental health outcome (i.e., depressive malaise from illness). This study of cancer outpatients initiating palliative radiation to relieve bone pain — one of the first published articles to investigate symptom clusters as statistical interactions — reported a number of findings, with symptoms contributing to different clusters based on severity and treatment.
These empirical findings were derived using a moderated regression approach to detect symptom interactions, and then follow-up graphical plots to interpret the nature of the influence of co-occurring symptoms on the relationship between a primary physical symptom and an outcome of depressive malaise. The follow-up graphical plots reported in the article showed that relationships between a primary physical symptom (e.g., pain) and the mental health outcome of depressive malaise differed depending upon the severity of other co-occurring symptom(s) (e.g., fatigue-weakness). This oncology research was demanding, in part, because it was taxing and time-consuming to apply this traditional approach of constructing follow-up graphical plots in order to evaluate statistical interactions among ordinal-scaled physical symptoms and identify derivative symptom clusters. Therefore, after completing the study, I decided to develop an easier approach.
b. In recent years, I developed important revisions and extensions to two rarely used mathematical procedures in order to adapt them to provide more sensitive or easier approaches for detecting and interpreting statistical interactions in moderated multiple regression, including those that reveal symptom clusters:
— Extended Zero Slopes Comparison (EZSC), a follow-up strategy to interpret the nature (i.e., buffering and/or magnifying) and strength of moderator effects, which are captured jointly by a set of ordinal or continuous predictors (e.g., x, w, z) and their derivative interaction terms (e.g., xw, xz, wz, xwz);
— Sequential Residual Centering (SRC), an analytical strategy that alleviates multicollinearity (shared variation among predictors) after data collection and reduces standard errors of regression slopes, resulting in improved, yet unbiased, detection of statistical interactions
I developed the first strategy (EZSC) as an extension to the Zero Slope Comparison (ZSC), a published procedure from the mid-1990s to interpret linear interactions between two variables. EZSC not only incorporates ZSC to interpret two-way linear interactions, but also interprets more complex types of statistical interactions among: 1) two variables where one is curvilinear; and 2) three linear variables. In contrast to traditional piecemeal approaches requiring multiple targeted analyses and graphs based on arbitrarily selected, discrete values of moderator variables, EZSC can be simpler and quicker, yet comprehensive, yielding interpretations for a range of moderator values that are similar in the nature of their effects (Francoeur, 2011a).
I developed the second strategy (SRC) to reduce high levels of multicollinearity that undermine statistical power for detecting statistical interactions. SRC is a valid replacement to the recently discredited, yet still widespread, practice of using "mean centering" to reduce multicollinearity in order to improve detection of statistical interactions. As an innovation, SRC is derived from "residual centering," an obscure procedure published in the late 1980s that provides an alternative to mean centering for reducing multicollinearity and improving detection of statistical interactions.
SRC overcomes prohibitive biases in the original residual centering procedure by adopting a sequential algorithm, and incorporates new extensions and adaptations for a wider scope of application. SRC may be used in models of linear interactions among two variables and in more complex models (e.g., curvilinear interactions, interactions among three variables). In addition, SRC may be adapted to condition away additional sources of multicollinearity related to control, secondary, and quadratic (curvilinear) predictors, which are not derivative components of the interaction term and its related terms. Finally, SRC allows a direct interpretation (i.e., without a follow-up procedure) of the net total moderator effect across the full range of predictor values that contribute to the interaction term and its related terms, thus determining whether magnifier or buffering effects are predominant across the sample range. These unique features position SRC as a promising innovation for advancing synergistic frontiers of research (Francoeur, 2013).
In the search for interactive symptom clusters, SRC and EZSC can be used together in moderated multiple regression, as well as in structural equation models, for more sensitive and valid detection of symptom interactions, along with insights into their nature and strength. Recently, I used both approaches: 1) to replicate a common symptom pair (pain—fatigue/weakness) and cluster (pain—fatigue/weakness—sleep problems) in the oncology literature; and 2) to demonstrate that the co-occurring symptoms interact, magnifying the relationship between pain and the outcome of depressive affect (Francoeur, 2015, Part I). Further analysis revealed the influential symptom pair and cluster to be restricted to fever-related contexts of "sickness behavior" and pyretic side effects. However, an expanded (four-way) symptom cluster (i.e., pain—fatigue/weakness—sleep problems—depressive affect) in non-fever contexts predicts a broader outcome (mobility problems), with depressive affect switching as the outcome to join the cluster as its fourth interacting symptom (Francoeur, 2015, Part II).
These findings (Francoeur, 2015, Part II) call attention to the need for future research on a specific cytokine and neurological mechanism that could perpetuate these symptom clusters in cancer survivors who are trying to quit smoking or to resist starting again. Cancer survivors may find it especially difficult to quit smoking, or to resist a relapse, because nicotine relieves neuropathic pain, fatigue, and related symptoms through the robust cholinergic anti-inflammatory pathway, which has numerous nicotinic acetylcholine receptors. Indeed, future research could indicate whether cancer survivors who smoke, recently quit smoking, or are former smokers may benefit from periodic follow-up by social workers and other clinicians to reassess symptoms, and through patient education and motivational interviewing, to encourage efforts and alternatives for smoking cessation (e.g., use of a nicotine inhaler, patch, spray or gum). Finally, these findings also provide clinical insights into the effectiveness of cognitive behavioral treatment in a published randomized control trial for a similar three-way cluster (pain—fatigue—sleep disturbance; Francoeur, 2015, Part I, Part II), and support the use of methylphenidate, a psychostimulant, in these symptom clusters (Francoeur, 2015, Part II).
Beyond symptom clusters, EZSC and SRC can be used together to improve detection and facilitate interpretation of statistical interactions among related disease markers and biopsychosocial factors, as well as much more broadly — whenever synergistic relationships are investigated in social work, medicine, or other disciplines.
2. Co-occurring illness conditions and factors that interact to influence the symptom presentation or phenomenology of depression
a. In research with epidemiologic data, I am preparing articles on distinct profiles of depressive symptoms that suggest differences in the overall experience, or phenomenology, of depressive symptoms in community-residing older adults with progressive vascular conditions (i.e., hypertension, atherosclerosis, vascular cognitive impairment, stroke, post-stroke cognitive impairment, low diastolic blood pressure, excess weight, and diabetes; see "Grants/Sponsored Research" for details). These findings will have implications for mental health assessment of older adults.
b. In research with 146 inner-city African-American and Latino outpatients from the Harlem Palliative Care Network, I provided evidence that a single item with forced-choice response options (either 'yes' or 'no') to screen for depression in inner-city minorities may fail to detect older minority men at risk; however, the inclusion of a middle category for ambivalent or missing responses improves sensitivity of the item (Francoeur, 2006).
3. Hidden clinical issues in older and underserved populations
a. Recently, I reviewed and proposed clinical, programmatic, and community innovations for inner cities and rural areas to ensure safe access to medications for palliative care while preventing prescription drug abuse (Francoeur, Murty, & Sandowski, 2011; Francoeur, 2011b).
At a 2011 conference on the "Science of Abuse Liability Assessment" — which was jointly sponsored by the National Institute of Drug Abuse, the Food and Drug Administration, and the College on Problems of Drug Dependence — I presented a novel analytic strategy regarding the application of Multiple Indicators-Multiple Causes (MIMIC) structural equation models in a prescription drug safety trial in order to identify symptoms (known as adverse events) and their interacting clusters that predict psychometric scale items and overall scores from a drug safety trial questionnaire.
This application would detect when two different types of measures converge to reveal a more reliable signal of prescription drug abuse potential (i.e., when a spontaneous adverse event or cluster is supported by scores on a frequently administered psychometric scale or on specific scale items). A series of MIMIC runs may help inform the creation of a shorter, streamlined, and validated safety trial questionnaire for a particular drug by identifying psychometric scales for the same construct or dimension—and individual items from these scales— that are best predicted by specific adverse events and their interacting clusters.
b. Uncontrolled hypertension is highly prevalent, presents without symptoms, and constitutes a major risk factor for atherosclerosis, heart disease, stroke, and diabetes. Social service agencies are uniquely positioned to assume an effective public health role for gaining better control of hypertension within the community because they serve populations that do not receive periodic primary care. I advance the case for developing hypertension screening and prevention programs in social service agencies for clients who are already meeting with a social worker (Francoeur, 2010). Social workers could be trained to direct and monitor receptive clients in accurate blood pressure self-screening with a digital device, refer clients with elevated readings to health professionals for follow-up care, and suggest related lifestyle changes that could be addressed with the social worker as intermediate steps in achieving other goals that are especially valued by the client.
c. In my study of 146 inner-city African American and Latino outpatients from the Harlem Palliative Care Network, my co-investigators and I revealed that among outpatients either identifying with a religion or affiliated with a religious institution, those who were uninsured reported more hopeful attitudes than other patients towards their pain and symptoms, while those covered only by Medicaid reported less hopeful attitudes. These findings may be related to other evidence from the literature that referrals to palliative care are often delayed until disease conditions become full-blown, which makes it difficult to gain control over long-neglected pain and symptoms. Uninsured residents, in particular, may be prone to delayed referrals.
If this is correct, the more hopeful pain and symptom attitudes of uninsured patients referred through religious networks, and who anticipate becoming eligible for Medicaid, could diminish over time once Medicaid coverage begins, which implies some degree of eventual disillusionment. These differences in health expectations between the uninsured and Medicaid groups suggest that social workers, clergy, church members, and neighborhood leaders should give attention to how uninsured residents may be reached and referred earlier in the disease course, when there may be more options for achieving and maintaining control over pain and symptoms (Francoeur, Payne, Raveis, & Shim, 2007).
d. Using a sample of 287 outpatients initiating palliative radiation for cancer recurrence, I provided empirical support for a social psychological coping process in chronically ill elders who desire to avoid debt. In contrast to younger outpatients incurring similar levels of recent bills and expenses, older outpatients reported less difficulty paying bills. Thus, older outpatients may cope by accommodating more than younger outpatients to the level of bills and expenses that they incur. This coping process may be a positive adaptation, however some elders may forgo medical care and other necessities, which may influence their perceptions of financial strain from recent bills and expenses to be, misleadingly, more favorable than circumstances warrant.
This process of accommodating to current financial circumstances may be sustained to the extent that older outpatients project their concerns or fears of financial inadequacy onto plausible future situations of cancer progression that demand greater consumption of health care. These reactions may lead older outpatients to dissociate somewhat from their current financial circumstances, which may make them less aware how much they have already curbed consumption over the illness course. It should be recognized that common financial screening items: 1) typically focus only on recent stressors that can be readily recalled, such as meeting bills and expenses; and 2) do not reflect the extent to which necessities were forgone nor the perceived inadequacy of financial resources for meeting future health needs, such as health insurance coverage. As a result, vulnerable older outpatients may remain hidden from clinicians (Francoeur, 2007, 2005, 2002, 2001).
1. National Institute of Mental Health. Research Project Small Grant Award, R03 ($100,000).
This grant supported my investigation of the etiology and phenomenology of masked depression (with low endorsed dysphoric mood) in community-residing older adults with progressive vascular conditions (i.e., hypertension, atherosclerosis, vascular cognitive impairment, stroke, post-stroke cognitive impairment, low diastolic blood pressure) that manifest in specific sociodemographic and comorbidity contexts. This grant also supported a study that suggested older minority men (African-Americans and Latinos) from the inner city who were receiving palliative care may be at risk for hidden depression based on their overall attitude about their physical symptoms.
2. John A. Hartford Foundation. Geriatric Social Work Faculty Scholar Award ($100,000).
Obesity and diabetes are known to accelerate atherosclerosis and vascular conditions. This grant provided the funding for me to investigate the etiology and phenomenology of depression in community-residing older adults when excess weight or diabetes occurs in the context of a progressive vascular condition (i.e., hypertension, atherosclerosis, vascular cognitive impairment, stroke, post-stroke cognitive impairment). The identification of at-risk subgroups is important because earlier health and mental health interventions may prevent, identify, or reduce not only depression, but also poor glycemic and symptom control, diabetic complications, strokes, and dementia.
3. Project on Death in America, Open Society Institute. Social Work Leadership Development Award ($65,000).
This grant provided the funding for me to investigate predictors and outcomes involving hidden depression, pain and symptom attitudes, religious affiliation, and underinsurance in inner-city African-Americans and Latinos receiving palliative care.
Francoeur, R. B. & Wilson, A. M. (2016). Social work practice with older adults to prevent and control diabetes and complications. In Daniel Kaplan and Barbara Berkman (Eds.). Handbook of Social Work in Health and Aging (Second Edition). (pp. 353-362). New York, NY: Oxford University.
Francoeur, R. B., Murty, S., & Sandowski, B. (2011). Chapter 13: Special considerations in rural and inner city areas. In Terry Altilio and Shirley Otis-Green (Eds.). Oxford Textbook of Palliative Social Work. (pp. 125-140). New York, NY: Oxford University.
Francoeur, R. B., & Elkins, J. (2006). Social work practice with older adults with diabetes and complications. In B. Berkman (Eds.). Handbook of Social Work in Health and Aging. (pp. 29-40). New York: Oxford University.
Christ, G., Sormanti, M., & Francoeur, R. (2001). Chronic physical illness and disability. In A. Gitterman (Eds.). Handbook of Social Work Practice with Vulnerable and Resilient Populations. (pp. 124-162). New York: Columbia University.
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Francoeur, R. B., Burke, N., & Wilson, A. M. (2016), The social work role in spiritual care to facilitate coping with illness and self-determination in advance care planning. Social Work in Public Health, In Press
Francoeur, R. B. (2015), Using an innovative multiple regression procedure in a cancer population (Part II): Fever, depressive affect, and mobility problems clarify an influential symptom pair (pain–fatigue/weakness) and cluster (pain–fatigue/weakness–sleep problems)
. OncoTargets and Therapy, 8,
Francoeur, R. B. (2015), Using an innovative multiple regression procedure in a cancer population (Part I): Detecting and probing relationships of common interacting symptoms (pain, fatigue/weakness, sleep problems) as a strategy to discover influential symptom pairs and clusters
. OncoTargets and Therapy, 8,
Francoeur, R. B. (2013), Could sequential residual centering resolve low sensitivity in moderated regression? Simulations and cancer symptom clusters
. Special Issue on "Statistical Methods and Analysis," Open Journal of Statistics, 3(6A),
Francoeur, R. B. (2011), Ensuring safe access to medications for palliative care while preventing prescription drug abuse: Innovations for American inner cities, rural areas, and communities overwhelmed by addiction
. Risk Management and Healthcare Policy, 4,
Francoeur, R. B. (2011), Interpreting interactions of ordinal or continuous variables in moderated regression using the zero slope comparison: tutorial, new extensions, and cancer symptom applications
. Special issue on "Assessment Methods in Social Systems Science," International Journal of Society Systems Science, 3 (1/2),
Francoeur, R. B. (2010), Agency social workers could monitor hypertension in the community
. Social Work in Health Care, 49 (5),
Francoeur, R. B. (2007), The influence of age on perceptions of anticipated financial inadequacy by palliative radiation outpatients
. Patient Education and Counseling, 69 (1-3),
Francoeur, R. B., Payne, R., Raveis, V. H., & Shim, H. (2007), Palliative care in the inner-city: Patient religious affiliation, underinsurance, and symptom attitude
. Cancer, 109 (2 Suppl),
Francoeur, R. B. (2006), A flexible item to screen for depression in inner-city minorities during palliative care symptom assessment
. American Journal of Geriatric Psychiatry, 14 (3),
Francoeur, R. B. (2005), Cumulative financial stress and strain in palliative radiation outpatients: The role of age and disability
. Acta Oncologica, 44 (4),
Kramer, B., Christ, G., Bern-Klug, M., & Francoeur, R. (2005), A proposed social work research agenda for palliative and end-of-life care. Journal of Palliative Medicine, 8 (2),
Francoeur, R. B. (2005), The relationship of cancer symptom clusters to depressive affect in the initial phase of palliative radiation
. Journal of Pain and Symptom Management, 29 (2),
Francoeur, R. B. (2002), Use of an income equivalence scale to understand age-related changes in financial strain
. Research on Aging, 24 (4),
Francoeur, R. B. (2001), Reformulating financial problems and interventions to improve psychological and functional outcomes in cancer patients and their families. Journal of Psychosocial Oncology, 19 (1),
Francoeur, R. B. (1999), In pursuit of a living wage: The ethical and economic thought of Father John A. Ryan from the late 1890s until the New Deal. Social Thought: Journal of Religion in the Social Services, 19 (1),
Francoeur, R. B., Copley, C., & Miller, P. (1997), The challenge to meet the mental health and biopsychosocial needs of the poor: Expanded roles for hospital social workers in a changing healthcare environment. Social Work in Health Care, 26 (2),
Francoeur, R. B. (1997), Improving access, efficacy, and cost-effectiveness of alcohol rehabilitation for poor medical patients: Social work interventions. Journal of Health and Human Services Administration, 19 (4),
Francoeur, R., & Stevens, R. (1988), Increasing the utilization of health services in rural areas of the United States and Britain: Implications for Michigan. Michigan State University Department of Agricultural Economics Report, No. 510
Showing first 5 of 10.
Francoeur, R. B. (2008, March). Issues in palliative care, illness comorbidity, and depression [Adelphi Interdisciplinary Social & Behavioral Sciences Symposium (Part B); initially presented as a Brown Bag Lunch Seminar at the Adelphi University School of Social Work, March 2007]. Garden City, NY.
Francoeur, R. B. (2005, May). A flexible item to screen for depression in inner-city African-Americans and Latinos during comprehensive palliative care assessments [Columbia University-New York University Geriatric Education Center (Social Work Module)]. New York, NY.
Francoeur, R. B. (2003, October). Comorbid conditions in late-life depression: Diabetes, cerebrovascular disease, and chronic life stress [The October Institute of the Hartford Geriatric Social Work Faculty Scholars Program and the Gerontological Society of America]. Washington, DC.
Francoeur, R. B. (2003, July). Religious identity disclosed by underserved minorities in palliative care: A robust predictor of psychological well-being and physical symptom attitudes [Social Work Leaders Retreat, Project on Death in America, Open Society Institute]. Brewster, MA.
Francoeur, R. B. (2003, May). Sickness behavior: Depressed affect and comorbid physical symptoms during the initial phase of palliative radiation [Columbia University-New York University Geriatric Education Center (Social Work Module)]. New York, NY.
Francoeur, R. B. (2002, November). Using MIMIC to examine the etiology of masked depression in blacks and whites. [Measurement Meeting, Culture Fair Assessment in Research, Columbia University Stroud Center]. New York, NY.
Francoeur, R. B. (2002, July). Improving pain/symptom distress and the psychological well-being of inner-city minorities with financial and material burden: Palliative care as an adjunct to primary care. [Social Work Leaders Retreat, Project on Death in America, Open Society Institute]. Lake Tahoe, NV.
Francoeur, R. B. (2001, May). Initiating palliative radiation for recurrent cancer: Aging and diverging perceptions about current and anticipated financial strain. [Grand Rounds, Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center]. New York, NY.
Francoeur, R. B. (2001, March). Comorbidity in chronic illness: Depression with low sadness. [Palliative Care Multi-Site Call, Special Projects of National Significance Program of the Ryan White CARE Act]. New York, NY.
Francoeur, R. B. (1999, May). Family financial burden and chronic illness: The case of cancer [Columbia University-New York University Geriatric Education Center (Social Work Module)]. New York, NY.
Showing first 5 of 13.
Francoeur, R. B. (2013). Advanced cancer symptom clusters predict mobility problems in the absence of fever. In Gerontological Society of America, Health Sciences Section. New Orleans, LA.
Francoeur, R. B. (2012). The role of fever in clarifying the cancer symptom cluster of pain, fatigue, and sleep problems. In Gerontological Society of America, Health Sciences Section. San Diego, CA.
Francoeur, R. B. (2012). The role of fever in clarifying the pain-fatigue-sleep problems symptom cluster: A new method dramatically lowers multicollinearity in biomarker/symptom interactions. In International Symposium on Supportive Care in Cancer, Multinational Association of Supportive Care in Cancer. New York, NY.
Francoeur, R. B. (2011). Validating psychometric measures as abuse potential signals to inform a shorter drug safety questionnaire: A proposed study of adverse events and clusters that simultaneously predict a psychometric scale and unique variation in scale items. In National Institute of Drug Abuse/Food and Drug Administration/College on Problems of Drug Dependence (NIDA/FDA/CPDD) Conference on Science of Abuse Liability Assessment. Rockville, MD.
Francoeur, R. B. (2007). Palliative care in the inner city: Patient religious affiliation, underinsurance, and symptom attitude. In Annual Assembly of the American Association of Hospice and Palliative Medicine. Salt Lake City, UT.
Francoeur, R. B. (2007). A flexible item to screen for depression in inner-city minorities during palliative care symptom assessment. In Annual Assembly of the American Association of Hospice and Palliative Medicine. Salt Lake City, UT.
Francoeur, R. B. (2006). Palliative care for inner-city African Americans and Latinos: Patient religious affiliation, underinsurance, and pain and symptom attitude. In Behavioral Research Center, American Cancer Society Conference (Exploring Models to Eliminate Cancer Disparities among African American and Latino Populations: Research and Community Solutions). Atlanta, GA.
Francoeur, R. B. (2005). A flexible item to screen for depression during comprehensive palliative care assessments of inner-city minorities. In Gerontological Society of America, Clinical Medicine Section. Orlando, FL.
Francoeur, R. B. (2004). Cancer symptom clusters from middle through late adulthood: Pain, comorbid physical symptoms, and depressed affect. In Gerontological Society of American, Clinical Medicine Section. Washington, DC.
Francoeur, R. B. (2001). Adjusting out-of-pocket costs using an income-equivalency scale to model age-related changes in financial stress-strain relationships. In Gerontological Society of America, Social Research Section. Chicago, IL.
Francoeur, R. B. (2001). Financial burden and psychosocial oncology: Clarifying the relationship. In Association of Oncology Social Work. Cleveland, OH.
Francoeur, R. B. (2000). The transition into palliative care for recurrent cancer: Do older outpatients accommodate more to objective family financial stress? In Association of Oncology Social Work, the Canadian Association of Psychological Oncology, and the American Society of Psychological and Behavioral Oncology/AIDS. Vancouver, BC, Canada.
Francoeur, R. B. (1999). Subjective perceptions of financial strain by home care patients initiating palliative radiation for recurrent cancer: Do older adults accommodate more to objective family financial stress? In 11th National Symposium on Doctoral Research in Social Work. Columbus, OH.
Victor Hainsworth (2014). A Quasi-Experiment to Examine Whether Social Enterprise Improves Sustainability of Nonprofit Agencies. Adelphi University.
Stacey Nelson (2011). Supervisory Working Alliance and Organizational Commitment in Social Work. Adelphi University.
Kimiko Tanaka (2007). The Impact of Schizophrenia on Well Siblings: Are Their Narcissistic Needs Met? Columbia University.
Honors and Accomplishments
Fellow, Gerontological Society of America (Social Research, Policy, & Practice section). Elected May 2015.
Who's Who in America
Who's Who in Social Sciences Higher Education
One course load release for grant proposal development (2008, 2011, 2015)
Ph.D., University of Pittsburgh
M.S.W., University of Pittsburgh
M.S., Michigan State University
B.S., Cornell University
Editorial board and reviewer, Journal of Social Work in End-of-Life & Palliative Care (2004-2012, 2014-Present).
Editorial board and reviewer, Journal of Psychosocial Oncology (since 1999).
Editorial advisory board and reviewer for the Social Work Series, Journal of Palliative Medicine (2004-2006).
Reviewer, Journal of Pain and Symptom Management (Invited, 2008, 2014).
Reviewer, Psychooncology (Invited, 2014).
Reviewer, Annals of Epidemiology (Invited, 2011).
Reviewer, Journal of Gerontological Social Work (Invited, 2011).
Reviewer, International Journal of Public Health (Invited, 2009).
Reviewer, International Journal of Society Systems Science (Invited, 2009).
Adelphi University Authors and Artists Exhibitions (Swirbul Library, September-October 2008-2015).
Guest speaker for colloquium on: 1) "Social Work in Psychiatric Settings: Identifying Evidence-Based Information Using 'Google Scholar' and 'Google Books'" at Adelphi University School of Social Work, Garden City, NY (November 2009) and 2) "Using 'Google Scholar' to search for practice evidence" at Vassar Brothers Hospital, Poughkeepsie, NY (April 2008). Addressed social work students, alumni, community leaders, and faculty/administration from the Garden City or Hudson Valley campuses. (Sponsored by the New York State Office of Mental Health).
Alumni and Friends Event 2008: Understanding and Implementing Evidence-Based Practice, with Ken Shriver, MPH, MD, Adelphi University, Garden City, NY (May 2008). Discussed applications of evidence-based practice to health and aging as part of a panel with two Adelphi social work colleagues (Professors Fenster and Joyce). Specifically, I spoke on "A vision of evidence based practice for health promotion with older adults: An expanded role for community social workers in hypertension screening and management."
Translation and Diffusion of Geriatric Social Work Research Retreat for Hartford Scholars and Fellows, Chantilly, VA (April 2008). Participant in discussion sessions regarding application of the RE-AIM model for research translation and diffusion into current clinical practice for preventing, ameliorating, or enhancing coping with chronic health conditions.
Research Affiliate, Center for the Psychosocial Study of Health & Illness, Columbia University Mailman School of Public Health (New York, NY). Consultant to Victoria Raveis on her grant-supported intervention for facilitating older caregiver spouses' adjustment to widowhood (2006-2008). I advised on community outreach and linkages to aging programs and services, and I provided clinical feedback and consultation for the interventionists.
Hartford Faculty Scholars & Doctoral Fellows Research Retreat, John A. Hartford Foundation, Rye, NY (2004).
Community and Corporate Leadership
Member, Search Committee for the Director of the Center for Health Innovation (January-December, 2013).
Core Faculty Member, Adelphi Caregiver Project, Center for Health Innovation (September 2011-June 2012)
Member, Unit Peer Review Committee, Adelphi University School of Social Work (September 2011-Present; Chair, 2014-2015)
Member, Adelphi University Public Health Programming Work Group (April 2010-June 2011)
Member, Doctoral Program Task Force, Adelphi University School of Social Work (September 2010-June 2011)
Adelphi University Faculty Senate Committee on Academic Affairs (September 2008-June 2011)
Invited speaker about my personal experience with hearing loss and hearing aids as part of the Diversity Dialogue Series (Adelphi University School of Social Work, March 24, 2010)
Moderator of the Health Care Action Student Group during Social Action Day
(Adelphi University School of Social Work, March 1, 2010)
Founding Member of the Social Work Hospice and Palliative Care Network (SWHPN, January 2008).
Community Advisory Committee to the Physical Health-Mental Health Integration Program, Flushing Hospital Medical Center (Queens borough, New York City, 2007-2008).
Social Work Practice Committee, Chair (Adelphi University School of Social Work, September 2007-June 2010).
Planned the 2004 and 2005 social work continuing education module "Culturally Appropriate Geriatric Care" of the Columbia-New York University Geriatric Education Center (2003-2006).
Hartford Geriatric Faculty Scholars Cohort IV Leadership (Washington, DC) and Teaching (Palo Alto, CA) Institutes, John A. Hartford Foundation (2004).
Assistant Professor, Columbia University School of Social Work (1998-2006).