My odyssey as a medical social worker in the VA Pittsburgh Healthcare System stimulates and informs my research, scholarship, and teaching on physical and mental health symptoms in specific or coexisting health conditions; coping with illness by middle-age/older adults; chronic care; palliative care; social work direct practice (including evidence-based and organizational); and program development and evaluation.
My published research on co-occurrences focuses on coexisting medical conditions (or multimorbidities), clinically relevant depression/depressive symptoms, physical symptoms, self-care, and patient reactions. This quest calls for deriving new types of knowledge and spurs me to create innovations in statistical modeling—which, to date, sharpen the detection of interactions, facilitate interpretation of their synergies, unveil elusive or unbiased psychometric subgroups (item clusters), and improve data mining of homogeneous subsamples (clusters of observations). I am developing a protocol for a more thorough means to adjust unknown and unspecified confounding when assessing scales or panels of items (e.g., symptoms, biomarkers, activities of daily living) in overall groups or interactive subgroups (e.g., coexisting medical conditions, risk factors).
I pursue scholarship on social work roles in health care. Over the past few decades, I have generated, developed, and published ideas for novel or improved program components, and programs, in several areas. These include contributions to increase inner-city and rural access to health care and palliative care; ensure safe access to pain medications while preventing prescription drug abuse; integrate spirituality into advance care planning; monitor hypertension in the community; screen hidden depression in minority men receiving palliative care using a single item that incorporates uncertain and missing responses; reformulate financial problems and interventions to improve psychosocial and functional outcomes; and meet needs (mental health, biopsychosocial, alcohol rehabilitation) of medical patients experiencing poverty.
Research Projects and Grants
I completed several research projects mostly on my own, such as 1) symptom clusters of late-life "depression without sadness" (presenting with low dysphoric—yet also low positive—affect) in progressive vascular disease (hypertensive, arterial, cardiac, cerebral), including with excess weight and/or diabetes (metabolic syndromes); 2) cancer neuroimmune symptom interactions (related to cytokines—signaling cell proteins—that induce inflammation) and comorbid "sickness malaise" (a broad index from items that tap negative affect—distress, depression—or low positive affect); and 3) financial strain as age-based reactions by cancer patients to specific and cumulative family financial stress.
As part of a new protocol for studies of personalized medicine (see above), I am extending the first of these projects to explore symptom clusters of late-life depression in congestive heart failure, with multimorbidity from diabetes and vascular conditions.
I also plan to reassess meta-analyses of breast cancer support groups to improve symptoms and survival.
I attracted more than a quarter million dollars in funding (direct costs) as principal investigator of a National Institute of Mental Health grant (R03) on late-life vascular depression, a Hartford Geriatric Social Work Faculty Scholar Award, and an Open Society Social Work Leadership Award (Project on Death in America).
Innovations in Statistical Modeling
♦ Currently, I am leading a project with an Adelphi computer science alumnus to build an easy-to-use web application that will execute algorithms I developed (see below) to probe effects of interacting variables.
As stated previously, I am developing a new protocol for studies of personalized medicine to reveal promising clinical targets by using a more thorough means to adjust confounding when assessing a panel of symptoms, activities of daily living, biomarkers, or metabolites in main or interactive epidemiological contexts (diagnoses, genes, epigenetics, environmental or other risks). It will provide guidance for unveiling unbiased clusters of psychometric items (the individual symptoms, activities of daily living, biomarkers, or metabolites) of a latent trait (the overall level of the panel of items) within these main or interactive contexts.
I am also honing a way to adjust bias in meta-analysis in order to derive more credible meta-analyses of clinical practices and programs when the evidence is based on heterogeneous participants, study conditions, interventions, and/or research methods. These more valid findings are important in the process of justifying and adopting sound evidence-based practices, programs, and policies.
♦ Recently, I forged data-mining of heterogeneous samples in multiple regression to derive homogeneous subgroups with similar effects, by adjusting heteroscedasticity, multicollinearity, and missing variables.
I discovered a second way to specify latent trait models so that they more fully adjust otherwise uncontrolled confounding within groups or subgroups (see below for an earlier approach I devised).
♦ Previously, I created or extended ways to probe models based on multiple regression for co-occurrence, including comorbidity and multimorbidity, and for clustering of items or symptoms, namely to:
• Detect interactions in moderated regression (MR) more sensitively and precisely (with lower standard errors, tighter confidence intervals);
• Interpret quickly the nature (magnifying and/or buffering), strength, and statistical significance of MR synergies across discrete values of interacting variables (this advance avoids the need to respecify predictors at different levels, re-estimate MR repeatedly, and construct multiple graphs; app pending); and
• Unveil elusive clusters of psychometric items (or symptoms) of a latent trait, either broadly (across a group) or uniquely (within an MR-targeted subgroup)
The advance in the last bullet affords insight into distinct presentations, even phenomenologies, tapped by a latent trait that occur across a group (determined by a predictor), or synergistically, within a subgroup (determined by interacting predictors). It overcomes the potential for common, insidious confounding in regression-based multiple indicators-multiple causes (MIMIC) models, which can estimate direct (unique) effects of predictors to the latent trait and to all but one of its items or symptoms. Even if it seems justified not to specify the direct effect to a certain item (i.e. it is fixed usually at zero), hidden bias may infect the latent trait and proliferate across items, undermining the validity of specified (shared and direct) effects.
The advance avoids this difficulty by offering a new way to specify a MIMIC model that enables the direct effect on every single item or symptom of a scale or subscale to be unveiled (while still adjusting shared effects across, and possibly between, the items or symptoms to account for the level of the latent trait). It reveals the subset of items or symptoms that have statistically significant direct effects, which comprise the item or symptom cluster within the group or subgroup.
• Social work practice; social work in chronic, palliative, and end-of-life care
• Evidence-based practice; client monitoring with single-case designs
• Organizational context of practice; social enterprises by social workers
• Program development and evaluation; systematic reviews; meta-analysis
Francoeur, R. B., & Sergiacomi, K. (2022). When inner cities are motivated by compassion: The role of palliative social work. In Terry Altilio and Shirley Otis-Green (Eds.). Oxford Textbook of Palliative Social Work (Second Edition). (pp. 443-452). New York, NY: Oxford University. https://books.google.com/books?id=xfhgEAAAQBAJ&lpg=PA443&ots=FE56eFQrqR&dq=%22francoeur%2C%20rb%22&lr=lang_en&pg=PA443#v=onepage&q&f=false
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.
Francoeur, R. B. (2022). Synergies vs. clustering only of depressive symptoms in diabetes and co-occurring conditions: Symmetric indicators with asymmetric, bidirectional influences in MIMIC models. Special issue on "Mathematical Models and Methods in Various Sciences," Symmetry, 14(11), 2275.
Francoeur, R. B. (2021). Multimorbidity from diabetes, heart failure, and related conditions: Assessing a panel of depressive symptoms as both formative and reflective indicators of a latent trait. Special issue on "Methods and Applications of Statistics in the Social and Health Sciences," Mathematics, 9(21), 2715.
Francoeur, R. B. (2020). Data-mining homogeneous subgroups in multiple regression when heteroscedasticity, multicollinearity, and missing variables confound predictor effects. Special issue on "New Frontiers in Data Sciences and Data Analytics Tools and Applications," Advances in Data Science and Adaptive Analysis, 12(02), 2041004(1-59).
Francoeur, R. B. (2016). Symptom profiles of subsyndromal depression in disease clusters of diabetes, excess weight, and progressive cerebrovascular conditions: A promising new type of finding from a reliable innovation to estimate exhaustively specified multiple indicators–multiple causes (MIMIC) models. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, 9, 391-416.
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, 31(5), 453-466.
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, 57—72.
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, 45-56.
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), 24-44.
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, 97-105.
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), 137-158.
Francoeur, R. B. (2010), Agency social workers could monitor hypertension in the community. Social Work in Health Care, 49 (5), 424-443.
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), 84-92.
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), 425-434.
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), 227-235.
Francoeur, R. B. (2005), Cumulative financial stress and strain in palliative radiation outpatients: The role of age and disability. Acta Oncologica, 44 (4), 369-381.
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), 418-431.
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), 130-155.
Francoeur, R. B. (2002), Use of an income equivalence scale to understand age-related changes in financial strain. Research on Aging, 24 (4), 445-472.
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), 1-20.
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), 1-14.
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), 1-13.
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), 425-441.
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.
Francoeur, R. B. (2017, July). Masked depression in older men: Hypertension, silent cerebrovascular disease, and metabolic syndrome. In International Association of Gerontology and Geriatrics (IAGG) World Congress of Gerontology and Geriatrics. San Francisco, CA.
Francoeur, R. B. (2017, July). Masked depression after stroke or with vascular cognitive impairment: Sex, obesity, diabetes status. In International Association of Gerontology and Geriatrics (IAGG) World Congress of Gerontology and Geriatrics. San Francisco, CA.
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.
Francoeur, R. B. (2015, March). Introducing systematic reviews and meta-analysis. Methods in a Minute: The Center for Health Innovation Faculty Scholar Lecture Series, Adelphi University. Garden City, NY.
Francoeur, R.B. (2012, May). 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. Phone Conference of the Pfizer Neuropsychiatry and Abuse Potential Advisory Council.
Francoeur, R.B. (2012, February). 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. Phone Conference of the Cross-Company Abuse Liability Consortium.
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.
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.
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