Differences in Transitional Care Provided to Mexican American and Non-Hispanic White Older Adults.

BACKGROUND: Transitional care, assisting patients to move safely through multiple health care settings, may be insufficient for older Hispanic patients. PURPOSE: Describe home health care services referral rates for Hispanic and non-Hispanic White (NHW) patients and factors that influence case managers' (CMs') discharge planning processes. DESIGN: Organized by the Ethno-Cultural Gerontological Nursing Model, health records were reviewed ( n = 33,597 cases) and supplemented with qualitative description ( n = 8 CMs). FINDINGS: Controlling for gender, insurance type, age, and hospital length of stay, NHW older adults received more home health care services referrals (odds ratio = 1.23). Insurance coverage was the most frequent determinant of CMs' post-hospital care choices, rather than patients' being Hispanic. NHW older adults were more likely to have insurance than Hispanic older adults. IMPLICATIONS: Insurance coverage being CMs' primary consideration in determining patients' dispositions is a form of systems-level discrimination for Hispanic vulnerable groups, which combined with other hospital-level constraints, should be addressed with policy-level interventions.

Multifaceted Prospective Memory Intervention to Improve Medication Adherence.

OBJECTIVES: To test whether a multifaceted prospective memory intervention improved adherence to antihypertensive medications and to assess whether executive function and working memory processes moderated the intervention effects. DESIGN: Two-group longitudinal randomized control trial. SETTING: Community. PARTICIPANTS: Individuals aged 65 and older without signs of dementia or symptoms of severe depression who were self-managing prescribed medication. MEASUREMENTS: After 4 weeks of initial adherence monitoring using a medication event monitoring system, individuals with 90% or less adherence were randomly assigned to groups. INTERVENTION: The prospective memory intervention was designed to provide strategies that switch older adults from relying on executive function and working memory processes (that show effects of cognitive aging) to mostly automatic associative processes (that are relatively spared with normal aging) for remembering to take medications. Strategies included establishing a routine, establishing cues strongly associated with medication taking actions, performing the action immediately upon thinking about it, using a medication organizer, and imagining medication taking to enhance encoding and improve cuing. RESULTS: There was significant improvement in adherence in the intervention group (57% at baseline to 78% after the intervention), but most of these gains were lost after 5 months. The control condition started at 68% and was stable during the intervention, but dropped to 62%. Executive function and working memory moderated the intervention effect, with the intervention producing greater benefit for those with lower executive function and working memory. CONCLUSION: The intervention improved adherence, but the benefits were not sustained. Further research is needed to determine how to sustain the substantial initial benefits.

Cardiovascular Disease Risk and Breast Cancer Outcomes: A Pilot Study.

PURPOSE/OBJECTIVES: To assess feasibility of using electronic health records for profiling multiple cardiovascular disease (CVD) risk factors in women with breast cancer at diagnosis and five years post-treatment, and to explore relationships among CVD risk factors and breast cancer outcomes
. DESIGN: Retrospective, descriptive
. SETTING: A comprehensive cancer center in the southwestern United States
. SAMPLE: 200 women with stage 0-III breast cancer.
. METHODS: A record review using an instrument to profile multiple CVD risk factors and breast cancer outcomes
. MAIN RESEARCH VARIABLES: CVD risk factors, such as blood pressure (BP) and hemoglobin A1C (HbA1C), and breast cancer outcomes, such as metastasis
. FINDINGS: Most data on CVD risk factors were undocumented. Even BP values to assess hypertension were missing in 35% of women at breast cancer diagnosis. Women with poor outcomes had trends toward higher blood glucose and HbA1C than women with good outcomes
. CONCLUSIONS: The study failed to comprehensively capture CVD risk factors in women with breast cancer because of missing data. Glucose control may be associated with breast cancer outcomes
. IMPLICATIONS FOR NURSING: Better documentation of shared risk factors for CVD and breast cancer is needed. Prospective studies are needed to evaluate shared CVD risk factors and breast cancer outcomes because of missing health record information
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The impact of a telenovela intervention on use of home health care services and Mexican American older adult and caregiver outcomes.

A two-group randomized controlled trial tested a telenovela intervention (i.e., a culturally congruent videotaped dramatization with guided dialogue) to increase Mexican American older adults' and family caregivers' awareness of and confidence in home health care services (HHCS), thereby increasing use of HHCS and improving older adult and caregiver outcomes. Both groups had significant increases in awareness of and confidence in HHCS. The intervention group used HHCS more than the control group (91.1% versus 71.2% of total visits authorized); however, this was not a statistically significant difference (p = 0.18). Use of HHCS was associated with increased older adult and caregiver mutuality (i.e., the quality of the older adult-caregiver relationship) and decreased caregiving burden and depression. The predictive role and measurement of awareness and ways to improve the intervention are discussed. Findings are especially important with today's focus on transitional care to keep older adults at home and prevent unnecessary readmissions.

The effects of a community-based, culturally tailored diabetes prevention intervention for high-risk adults of Mexican descent.

PURPOSE: This article reports the results of a community-based, culturally tailored diabetes prevention program for overweight Mexican American adults on weight loss, waist circumference, diet and physical activity self-efficacy, and diet behaviors. METHODS: The intervention used content from the Diabetes Prevention Program but culturally tailored the delivery methods into a community-based program for Spanish-speaking adults of Mexican descent. The design was a randomized controlled trial (N = 58) comparing the effects of a 5-month educational intervention with an attention control group. The primary study outcome was weight loss. Secondary outcomes included change in waist circumference, body mass index, diet self-efficacy, and physical activity self-efficacy. RESULTS: There were significant intervention effects for weight, waist circumference, body mass index, and diet self-efficacy, with the intervention group doing better than the control group. These effects did not change over time. CONCLUSIONS: Findings support the conclusion that a community-based, culturally tailored intervention is effective in reducing diabetes risk factors in a 5-month program.

Effect of Tai Chi on physical function, fall rates and quality of life among older stroke survivors.

OBJECTIVE: To examine the effect of a 12-week Tai Chi (TC) intervention on physical function and quality of life. DESIGN: Single-blind, randomized controlled trial. SETTING: General community. PARTICIPANTS: Community-dwelling survivors of stroke (N=145; 47% women; mean age, 70y; time poststroke: 3y; ischemic stroke: 66%; hemiparesis: 73%) who were aged ≥50 years and were ≥3 months poststroke. INTERVENTIONS: Yang style 24-posture short-form TC (n=53), strength and range of movement exercises (SS) (n=44), or usual care (UC) (n=48) for 12 weeks. The TC and SS groups attended a 1-hour class 3 times per week, whereas the UC group had weekly phone calls. MAIN OUTCOME MEASURES: Physical function: Short Physical Performance Battery, fall rates, and 2-minute step test; quality of life: Medical Outcomes Study 36-Item Short-Form Health Survey, Center for Epidemiologic Studies Depression Scale, and Pittsburgh Sleep Quality Index. RESULTS: During the intervention, TC participants had two thirds fewer falls (5 falls) than the SS (14 falls) and UC (15 falls) groups (χ(2)=5.6, P=.06). There was a significant group by time interaction for the 2-minute step test (F2,142=4.69, P<.01). Post hoc tests indicated that the TC (t53=2.45, P=.02) and SS (t44=4.63, P<.01) groups had significantly better aerobic endurance over time, though not in the UC group (t48=1.58, P=.12). Intervention adherence rates were 85%. CONCLUSIONS: TC and SS led to improved aerobic endurance, and both are suitable community-based programs that may aid in stroke recovery and community reintegration. Our data suggest that a 12-week TC intervention was more effective in reducing fall rates than SS or UC interventions. Future studies examining the effectiveness of TC as a fall prevention strategy for community-dwelling survivors of stroke are recommended.

Personalized exercise for adolescents with diabetes or obesity.

OBJECTIVE: This study examined adherence to a personalized, community-based exercise intervention by sedentary adolescents with type 1 or type 2 diabetes or those with obesity. RESEARCH DESIGN AND METHODS: We conducted a pretest-posttest investigation to explore the application of an individualized exercise prescription based upon current fitness level for 39 adolescents (20 with type 1 diabetes, 9 with type 2 diabetes, and 10 obese) over 16 weeks in community settings. Subjects were recruited from a university-based pediatric endocrinology clinic in the southwestern United States. Adherence to the exercise prescription was monitored using accelerometers over the entire intervention period. RESULTS: Moderate-to-vigorous physical activity (MVPA) levels significantly increased over sedentary baseline values (p < .001), but the average of 42.5 ± 22.1 min/day of MVPA determined at the end of the study was still less than the recommended 60 min/day. Perceptions of health were significantly increased for the total group following the intervention (p = .008). For those with type 1 diabetes, there was a significant association between MVPA duration and percentage change in HbA1c (r = -.526, p = .02). CONCLUSIONS: Recruitment and retention of adolescent participation in daily exercise is challenging. Personalized approaches that include adolescent choices with family support and ongoing motivation can improve individual exercise adherence and a sense of personal health.

Challenges and success of recruiting and retention for a culturally tailored diabetes prevention program for adults of Mexican descent.

PURPOSE: The purpose of this article is to describe methods used to recruit and retain high-risk, Spanish-speaking adults of Mexican origin in a randomized clinical trial that adapts Diabetes Prevention Program (DPP) content into a community-based, culturally tailored intervention. METHODS: Multiple passive and active recruitment strategies were analyzed for effectiveness in reaching the recruitment goal. Of 91 potential participants assessed for eligibility, 58 participated in the study, with 38 in the intervention and 20 in the attention control group. The American diabetes association risk assessment questionnaire, body mass index, and casual capillary blood glucose measures were used to determine eligibility. RESULTS: The recruitment goal of 50 individuals was met. Healthy living diabetes prevention presentations conducted at churches were the most successful recruiting strategy. The retention goal of 20 individuals was met for the intervention group. Weekly reminder calls were made by the promotora to each intervention participant, and homework assignments were successful in facilitating participant engagement. CONCLUSIONS: A community advisory board made significant and crucial contributions to the recruitment strategies and refinement of the intervention. RESULTS: support the feasibility of adapting the DPP into a community-based intervention for reaching adults of Mexican origin at high risk for developing diabetes.

Predictors of depressive symptoms among community-dwelling stroke survivors.

BACKGROUND: Depression is a common yet often unrecognized consequence of stroke, affecting between 25% and 70% of all survivors. Untreated depression post-stroke leads to a poorer prognosis and increased mortality. However, the pattern and profile of post-stroke depression in chronic stroke are poorly understood. OBJECTIVE: The aim of this study was to examine the independent predictors of depressive symptoms in chronic stroke. METHODS: Community-dwelling stroke survivors (n = 100) completed the Center for Epidemiological Studies-Depression (CES-D) scale, Multidimensional Scale of Perceived Social Support, Medical Outcomes Study Short Form-36, and the Pittsburgh Sleep Quality Index. Functional disability and cognitive impairment were assessed using standardized procedures. Multiple linear regression was conducted to explore potential independent predictors of depressive symptoms. RESULTS: Subjects were, on average, 70 ± 10 years old and 39 ± 49 months post-stroke. The majority were white/European-American (78%), college educated (79%), and retirees (77%). Annual income was $50 000 or greater for 32%. Hemiparesis was common (right side, 39%; left side, 42%); 35% had a Center for Epidemiological Studies-Depression scale score of 16 or higher, and 21% had a history of major depression. Approximately 64% of the variance in depressive symptoms could be explained by the independent variables in the model: quality of life, sleep quality, social support, cognitive impairment, functional disability, months post-stroke, age, gender, history of major depression, and lesion location (R = 0.64, F12,87 = 12.97, P < .01). Only poor quality of life (t1,87 = -6.99, P < .01) and low social support (t1,87 = -2.14, P = .04) contributed uniquely and significantly to the severity of depressive symptoms among these stroke survivors. CONCLUSION: Depressive symptoms are prevalent in chronic stroke survivors, even among an educated and economically advantaged population. Our findings are similar to reports by others that poor quality of life and low social support are major contributors to depressive symptoms in chronic stroke and should be routinely assessed and monitored to improve long-term rehabilitation efforts and promote wellness and community reintegration.

Telephone-delivered health education and interpersonal counseling improve quality of life for Latinas with breast cancer and their supportive partners.

OBJECTIVE: This study aims to test two telephone-delivered interventions for their efficacy in improving quality of life (QOL) (psychological, physical, social, and spiritual) among Latinas with breast cancer and their family members or friends (labeled supportive partners in this study). METHODS: Latinas with breast cancer and their supportive partners (SPs) were randomly assigned to one of two telephone delivered 8-week interventions: (i) telephone interpersonal counseling (TIP-C) or (ii) telephone health education (THE). QOL assessments were made at baseline, immediately after the 8-week interventions ended, and at an 8-week follow-up. Seventy Latinas and their 70 SPs completed all assessments (36 in health education and 34 in counseling) and were included in the final analysis. RESULTS: Both Latinas with breast cancer and their SPs had significant improvements in virtually all dimensions of QOL over the 16 weeks of the investigation. However, there was no evidence documenting the superiority of either intervention for improving QOL. Preliminary cost analysis found that the counseling intervention cost about $164.68 for one dyad compared with $107.03 for health education. The majority of participants reported benefit from the intervention and liked that the intervention was in Spanish, included SPs, and was delivered by telephone. CONCLUSION: The results of this study show that relatively brief, culturally appropriate, and highly accessible telephone-delivered interventions that provide emotional and information support can bring about substantial improvements in QOL for both Latinas with breast cancer and their SPs.

A multifaceted prospective memory intervention to improve medication adherence: design of a randomized control trial.

Adherence to prescribed antihypertensive agents is critical because control of elevated blood pressure is the single most important way to prevent stroke and other end organ damage. Unfortunately, nonadherence remains a significant problem. Previous interventions designed to improve adherence have demonstrated only small benefits of strategies that target single facets such as understanding medication directions. The intervention described here is informed by prospective memory theory and performance of older adults in laboratory-based paradigms and uses a comprehensive, multifaceted approach to improve adherence. It incorporates multiple strategies designed to support key components of prospective remembering involved in taking medication. The intervention is delivered by nurses in the home with an education control group for comparison. Differences between groups in overall adherence following the intervention and 6 months later will be tested. Systolic and diastolic blood pressure levels also will be examined between groups and as they relate to adherence. Intra-individual regression is planned to examine change in adherence over time and its predictors. Finally, we will examine the association between executive function/working memory and adherence, predicting that adherence will be related to executive/working memory in the control group but not in the intervention group.

Recruiting hospitalized Mexican American elder adults and caregivers: challenges and strategies.

Minority group members' participation in clinical research is essential for eliminating health disparities. Early recruitment procedures for a randomized control trial involving minority elder adults at local hospitals were unsuccessful, with challenges at the hospital and individual levels. These challenges included referrals for home health care being written late during hospitalization, hospital staff being reluctant to assist recruiters, ill minority elder adults, and protective or unavailable caregivers. We met these challenges with evidence-based strategies, including changing inclusion criteria, increasing study staff, branding our study, using a consistently respectful manner, and pacing our process. After revising our approaches in various ways, we recruited close to our goal, with relatively good retention. Participants reported that benefiting the community, rather than monetary reward, was a strong motivator to join the study. Unexpected recruitment expenditures exceeded the recruitment budget. Our experiences include strategies that can be more cost effective in future studies at both hospital and individual levels.

Predictors of gait velocity among community-dwelling stroke survivors.

INTRODUCTION: Gait velocity is an objective, fundamental indicator of post-stroke walking ability. Most stroke survivors have diminished aerobic endurance or paretic leg strength affecting their walking ability. Other reported underlying factors affecting gait velocity include functional disability, balance, cognitive impairment, or the distance they are required to walk. OBJECTIVE: To examine the relationship between gait velocity and measures of physical and cognitive functioning in chronic stroke. METHODS: Cross-sectional design using baseline data from community-dwelling stroke survivors enrolled in an exercise intervention study. Functional disability (modified Rankin Scale), aerobic endurance (2-min step-test), leg strength (timed 5-chair stand test), balance (single-leg stance) and cognitive impairment (Mini-Mental Status Exam) were assessed. Gait velocity was assessed using a timed 4-m walk test. Multiple linear regression was used to explore potential independent predictors of gait velocity. RESULTS: Subjects had an average gait velocity of 0.75±0.23m/s, categorized as limited community walkers. Approximately 37% of the variance in gait velocity, could be explained by the 5 independent variables, functional disability, aerobic endurance, leg strength, balance, and cognitive impairment (R(2)=0.37, F(5,74)=8.64, p<0.01). Aerobic endurance (t(1,74)=3.41, p<0.01) and leg strength (t(1,74)=-2.23, p=0.03) contributed significantly to gait velocity. CONCLUSION: Diminished aerobic endurance and leg strength are major contributors to slow gait velocity in chronic stroke. Long term rehabilitation efforts are needed to improve gait velocity in chronic stroke, and may need to incorporate multifaceted strategies concurrently, focusing on aerobic endurance and leg strength, to maximize community ambulation and reintegration.

A personalized approach to exercise promotion in adolescents with type 1 diabetes.

PURPOSE: This exploratory study tested the feasibility of conducting a novel, personalized exercise intervention based upon the current fitness levels of adolescents with type 1 diabetes (T1DM). The relationships of perceptions of benefits and barriers to exercise, exercise self-efficacy and family support to exercise adherence and changes in cardiovascular (CV) fitness, quality of life (QOL), and glycemic control were studied. METHODS: Adolescents who were sedentary received a graded exercise test to determine their current fitness level (VO(2peak)). A 16-wk personalized exercise program was developed for each adolescent based upon individual fitness level and exercise preferences. Pretest and posttest measures of exercise self-efficacy, benefits and barriers to exercise, family support, and diabetes QOL were completed. A1c levels were obtained using the DCA2000. Adherence to exercise was measured using the Actigraph Accelerometer. RESULTS: Twelve adolescents completed the study. Accelerometry data revealed adherence to 60 min of moderate-to-vigorous physical activity (MVPA) per day for a mean of 45.5 (SD = 23.9)% of the days the accelerometer was worn. Adolescents' perceptions of family support for exercise improved following the intervention (p = 0.03). Adolescents who had more daily bouts of exercise lasting 60 min increased their CV fitness (r = 0.59, p = 0.04). A1c remained unchanged. CONCLUSIONS: Encouraging 60 min of accumulated exercise bouts/d can improve fitness levels in adolescents with T1DM, minimizing future CV risks. Although physical activity increased in adolescents, family based strategies are required to promote current physical activity recommendations.

Cognitive adaptability as a moderator of expressive writing effects in an HIV sample.

This study explored the effects of expressive writing on positive and negative outcomes related to perceived psychosocial and health status among persons with HIV. This was the first study to examine the moderating effects of cognitive adaptability--consisting of dispositional optimism coupled with perceived competence--on outcomes of expressive writing. Thirty-seven participants wrote about either traumatic experiences or trivial topics in four 20-min sessions. Dependent measures obtained at baseline were repeated 1 month later. Although no main effects for group were found, baseline levels of cognitive adaptability were differentially associated with changes in a positive outcomes index, and a pain and physical functioning index in those assigned to the two groups. No moderating effects of cognitive adaptability were found for changes in a negative outcomes index. Findings underscore the importance of identification of moderating variables in understanding the impact of expressive writing interventions among individuals with HIV or other conditions.

Caregiving burden, acculturation, familism, and Mexican American elders' use of home care services.

Caregiving burden has been shown to predict use of home care services among Anglo Americans. In a previous study, only one of two dimensions of caregiving burden predicted such use among Mexican American caregivers. Because acculturation and familism may affect burden, we conducted analyses to test three hypotheses: increased acculturation decreases familism; decreased familism increases burden; and increased burden increases use of home care services. Among 140 Mexican American family caregivers, acculturation was positively correlated with familism; familism was not significantly correlated with burden; objective burden was positively correlated with use of home care services, and objective and subjective burden significantly interacted in their effect on the use of home care services. Targeted interventions may be needed to increase use of home care services and preserve the well-being of Mexican American elders and caregivers.

Environmental changes to increase physical activity: perceptions of older urban ethnic-minority women.

Despite the numerous benefits of physical activity, older adults continue to be more sedentary than their younger counterparts, and sedentary behavior is more prevalent among older racial and ethnic minorities than among Whites. This study used the nominal group technique (NGT) to examine participants' perceptions of what neighborhood environmental changes would encourage greater physical activity for older African American and Hispanic women. Participants age 50-75 years were recruited from 2 urban community health clinics. Nine NGT sessions (45 participants) were conducted. The women were asked what changes in their neighborhood environment would encourage them to become more physically active. Responses to the research question were tabulated, and qualitative analysis was used to identify themes and categories. Major categories were physical environment changes, safety, and activities/social support. Although the physical environment received the greatest number of points, concerns for personal safety cut across categories. Participants indicated the need for more facilities in which to be active.

Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic.

BACKGROUND: Diabetes care in our inner-city primary care clinic was suboptimal, despite provider education and performance feedback targeting improved adherence to evidence-based clinical guidelines. A crew resource management (CRM) intervention (communication and teamwork, process and workflow organisation, and standardised information debriefings) was implemented to improve diabetes care and patient outcomes. OBJECTIVE: To assess the effect of the CRM intervention on adherence to evidence-based diabetes care standards, work processes, standardised clinical communication and patient outcomes. METHODS: Time-series analysis was used to assess the effect on the delivery of standard diabetes services and patient outcomes among medically indigent adults (n = 619). RESULTS: The CRM principles were translated into useful process redesign and standardised care approaches. Significant improvements in microalbumin testing and associated patient outcome measures were attributed to the intervention. CONCLUSIONS: The CRM approach provided tools for management that, in the short term, enabled reorganisation and prevention of service omissions and, in the long term, can produce change in the organisational culture for continuous improvement.

Parents' self-identified stressors and coping strategies during adolescents' spinal surgery experiences.

Spinal fusion surgery for idiopathic scoliosis during adolescence is a tremendous stressor for parents. This study investigated parents' pre- and postoperative stressors and their coping strategies. Ninety-two parents identified their predominant stressor and completed the Ways of Coping Questionnaire during their adolescent's preoperative clinic visit and 77 completed this procedure 4 days postoperatively. Results showed that primary stressors were parental role loss (28.26%), possibility of poor surgical outcomes (28.26%), and uncertainty about successful recovery (27.17%) preoperatively, and concerns about pain (32.47%) and parental role loss (32.47%) postoperatively. The greatest increase from pre- to postoperative periods occurred in concerns about pain. Parents used both emotion-focused and problem-focused coping strategies with significant increases postoperatively in confrontive coping, planful problem solving, and positive reappraisal and significant decreases in self-control and seeking social support. Providers should target interventions to alleviate stress and bolster coping for parents.

Changing social and built environments to promote physical activity: recommendations from low income, urban women.

BACKGROUND: Middle age and older (mean = 58.7 y), racial/ethnic minority women report low levels of physical activity. Recommendations to change the social and built environments to promote physical activity in this group are underdeveloped. Two research questions guided this study: What environmental changes are recommended by racial/ethnic minority women? What policies are related to the environmental changes? METHODS: The findings from nine Nominal Group Technique sessions with 45 subjects were analyzed. RESULTS: More police protection, cleaner streets, removal of drugs from streets, more street lights, walking groups, and free gyms were prioritized by subjects as the most important recommendations. The relevant policies included municipal, police department, sanitation department, public works, and transportation department. CONCLUSIONS: Racial/ethnic minority women living in low income, urban areas recommend improvements that affect overall quality of life. Meeting basic needs may be a prerequisite for use of physical activity resources.