Health Humanities: A Baseline Survey of Baccalaureate and Graduate Programs in North America.

The authors conducted a baseline survey of baccalaureate and graduate degree health humanities programs in the United States and Canada. The object of the survey was to formally assess the current state of the field, to gauge what kind of resources individual programs are receiving, and to assess their self-identified needs to become or remain programmatically sustainable, including their views on the potential benefits of program accreditation. A 56-question baseline survey was sent to 111 institutions with baccalaureate programs and 20 institutions with graduate programs. Respondents were asked about three areas: (1) program administration (managing unit, paid director, faculty lines, paid staff, funding sources); (2) educational program (curricular structure, CIP code usage, completion rates); and (3) views on accreditation for the field. A clear majority of respondents agreed that some form of accreditation or consultation service could address resource and sustainability issues. Overall, the survey responses to staffing, curricular structure, and support suggest the need for developing a sustainable infrastructure for health humanities.

Expert Consensus Guidelines for Assessing Students on the Social Determinants of Health.

PHENOMENON: Assessment and evaluation guidelines inform programmatic changes necessary for educational effectiveness. Presently, no widely accepted guidelines exist for educators to assess learners and evaluate programs regarding social determinants of health (SDOH) during physician and physician assistant (PA) education. We sought to garner expert consensus about effective SDOH learner assessment and program evaluation, so as to make recommendations for best practices related to SDOH education. APPROACH: We used a Delphi approach to conduct our study (September 2019 to December 2020). To administer our Delphi survey, we followed a three-step process: 1) literature review, 2) focus groups and semi-structured interviews, 3) question development and refinement. The final survey contained 72 items that addressed SDOH content areas, assessment methods, assessors, assessment integration, and program evaluation. Survey participants included 14 SDOH experts at US medical schools and PA programs. The survey was circulated for three rounds seeking consensus, and when respondents reached consensus on a particular question, that question was removed from subsequent rounds. FINDINGS: The geographically diverse sample of experts reached consensus on many aspects of SDOH assessment and evaluation. The experts selected three important areas to assess learners' knowledge, skills, and attitudes about SDOH. They identified assessment methods that were "essential", "useful, but not essential", and "not necessary." The essential assessment methods are performance rating scales for knowledge and attitudes and skill-based assessments. They favored faculty and patients as assessors, as well as learner self-assessment, over assessments conducted by other health professionals. Questions about separation versus incorporation of SDOH assessment with other educational assessment did not yield consensus opinion. The experts reached consensus on priority outcome measures to evaluate a school's SDOH program which included student attitudes toward SDOH, Competence-Based Assessment Scales, and the percentage of graduates involved in health equity initiatives. INSIGHTS: Based on the Delphi survey results, we make five recommendations that medical and PA educators can apply now when designing learner assessments and evaluating SDOH programming. These recommendations include what should be assessed, using what methods, who should do the assessments, and how they should be incorporated into the curriculum. This expert consensus should guide future development of an assessment and evaluation toolkit to optimize SDOH education and clinical practice.Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2022.2045490 .

Evolution in Health and Medical Humanities education: a proposal for accreditation.

The growth of Health and Medical Humanities baccalaureate and master's degrees in recent decades makes the present moment ideal for initiating field-defining conversations among health humanities constituents about the boundaries of this transdisciplinary field. Focusing on accreditation at the programme level rather than the individual level, we explore four models with different advantages for Health and Medical Humanities: a certification for practice; a network (umbrella organisation); a programme of merit (POM) model; and consultancy. We conclude that for a young field like health humanities that is transdisciplinary, does not have an established canon and does not lead to entry to a specific professional path (ie, gatekeeping), the POM model is the best fit. In contrast to a full accreditation model, POM credentialling leaves room for creativity, expansiveness, and diversity of approaches and will not restrict programmes from calling themselves health humanities programmes; POM enhances visibility rather than decides who can teach in the field and what they must teach. To implement this model, we suggest the creation of a semi-independent Health and Medical Humanities Program Accreditation Commission (HMHPAC) that would be administered by the Health Humanities Consortium. The HMHPAC should have three goals: ensure that health humanities educational programmes are of the highest quality, assist programmes in acquiring the resources they need from their institutions and help programmes attract potential students.

Assessment and Evaluation in Social Determinants of Health Education: a National Survey of US Medical Schools and Physician Assistant Programs.

BACKGROUND: Social determinants of health (SDOH) curricular content in medical schools and physician assistant programs are increasing. However, there is little understanding of current practice in SDOH learner assessment and program evaluation, or what the best practices are. OBJECTIVE: Our study aim was to describe the current landscape of assessment and evaluation at US medical schools and physician assistant programs as a first step in developing best practices in SDOH education. DESIGN: We conducted a national survey of SDOH educators from July to December 2020. The 55-item online survey covered learner assessment methods, program evaluation, faculty training, and barriers to effective assessment and evaluation. Results were analyzed using descriptive statistics. PARTICIPANTS: One hundred six SDOH educators representing 26% of medical schools and 23% of PA programs in the USA completed the survey. KEY RESULTS: Most programs reported using a variety of SDOH learner assessment methods. Faculty and self were the most common assessors of learners' SDOH knowledge, attitudes, and skills. Common barriers to effective learner assessment were lack of agreement on "SDOH competency" and lack of faculty training in assessment. Programs reported using evaluation results to refine curricular content, identify the need for new content, and improve assessment strategies. CONCLUSIONS: We identified a heterogeneity of SDOH assessment and evaluation practices among programs, as well as gaps and barriers in their educational practices. Specific guidance from accrediting bodies and professional organizations and agreement on SDOH competency as well as providing faculty with time, resources, and training will improve assessment and evaluation practice and ensure SDOH education is effective for students, patients, and communities.

Assessing Perceived Barriers to Meditation: the Determinants of Meditation Practice Inventory-Revised (DMPI-R).

OBJECTIVES: Engaging in meditation on a regular basis has been shown to enhance well-being. However, barriers to adopting it as a health behavior are poorly understood. The Determinants of Meditation Practice Inventory (DMPI) is an existing scale designed to measure perceived barriers to meditation. However, it was developed without factor analyses; thus, the dimensionality and construct validity of overall scale and/or subscale scores are unknown. Using factor analyses and tests of convergent validity, the present study explored the psychometric properties of the DMPI and presents a revised, psychometrically valid scale (The Determinants of Meditation Practice Inventory-Revised; DMPI-R). METHODS: Adult participants living in the USA (n = 621) provided data through an online survey platform. Extensive exploratory factor analyses were conducted (n = 311) and followed by confirmatory factor analysis (n = 310) on the best-fitting model. Convergent validity was estimated using the full sample data. RESULTS: Five items were removed because they demonstrated high residual variances and cross loaded onto multiple factors. Relationships among the remaining items were best explained by a four-factor structure with the following subscales: low perceived benefit, perceived inadequate knowledge, perceived pragmatic barriers, and perceived sociocultural conflict. Convergent validity was evidenced by associations between subscale scores and experiential avoidance, distress tolerance, and curiosity. CONCLUSIONS: The multifactor structure of the DMPI-R indicates that there are multiple classes of perceived barriers on which people can vary. Validity analyses suggest that the DMPI-R is a promising measure of perceived barriers to meditation among North American adults.

Family Caregivers to Adults with Cancer: The Consequences of Caring.

A person living with cancer will potentially have some degree of physical, cognitive, and/or psychological impairment, periods of unemployment, financial concerns, social isolation, and existential questions, any or all of which can impact the family and friends who surround them. In our current era of health care, patients with cancer receive invasive diagnostic studies and aggressive treatment as outpatients, and then convalesce at home. As such, cancer family caregivers are de facto partners with the healthcare team. The cancer family caregiver role is demanding and may lead to increased morbidity and mortality-in effect, the cancer family caregiver can become a second patient in need of care. This chapter discusses the consequences cancer family caregivers may accrue. The topics covered include caregiver mood disturbance and psychological impairment and some of the mutable factors that contribute to these states (i.e., sleep disturbance, decline in physical health, restriction of activities, and financial concerns), uncertainty, spiritual concerns, and caregiver witnessing. There is a discussion of the factors that influence the caregiving experience (caregiver characteristics, patient characteristics, and social supports). The chapter concludes with comments on intervention studies that have been conducted to ameliorate the burden of caregiving, and the state of caregiver research.

Exploring the individual patterns of spiritual well-being in people newly diagnosed with advanced cancer: a cluster analysis.

PURPOSE: Research shows that spiritual well-being correlates positively with quality of life (QOL) for people with cancer, whereas contradictory findings are frequently reported with respect to the differentiated associations between dimensions of spiritual well-being, namely peace, meaning and faith, and QOL. This study aimed to examine individual patterns of spiritual well-being among patients newly diagnosed with advanced cancer. METHODS: Cluster analysis was based on the twelve items of the 12-item Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale at Time 1. A combination of hierarchical and k-means (non-hierarchical) clustering methods was employed to jointly determine the number of clusters. Self-rated health, depressive symptoms, peace, meaning and faith, and overall QOL were compared at Time 1 and Time 2. RESULTS: Hierarchical and k-means clustering methods both suggested four clusters. Comparison of the four clusters supported statistically significant and clinically meaningful differences in QOL outcomes among clusters while revealing contrasting relations of faith with QOL. Cluster 1, Cluster 3, and Cluster 4 represented high, medium, and low levels of overall QOL, respectively, with correspondingly high, medium, and low levels of peace, meaning, and faith. Cluster 2 was distinguished from other clusters by its medium levels of overall QOL, peace, and meaning and low level of faith. CONCLUSIONS: This study provides empirical support for individual difference in response to a newly diagnosed cancer and brings into focus conceptual and methodological challenges associated with the measure of spiritual well-being, which may partly contribute to the attenuated relation between faith and QOL.

Cancer family caregiver depression: are religion-related variables important?

OBJECTIVE: Prevalence estimates for clinical depression among cancer family caregivers (CFC) range upwards to 39%. Research inconsistently reports risk for CFC depressive symptoms when evaluating age, gender, ethnicity, or length of time as caregiver. The discrepant findings, coupled with emerging literature indicating religiosity may mitigate depression in some populations, led us to investigate religion-related variables to help predict CFC depressive symptoms. METHODS: We conducted a cross-sectional study of 150 CFC. Explanatory variables included age, gender, spousal status, length of time as caregiver, attendance at religious services, and prayer. The outcome variable was the Center for Epidemiological Studies Depression Scale score. RESULTS: Compared with large national and state datasets, our sample has lower representation of individuals with no religious affiliation (10.7% vs. 16.1% national, p = 0.07 and 23.0% state, p = 0.001), higher rate of attendance at religious services (81.3% vs. 67.2% national, p < 0.001 and 30.0% state, p < 0.001), and higher rate of prayer (65.3% vs. 42.9% national, p < 0.001; no state data available). In unadjusted and adjusted models, prayer is not significantly associated with caregiver depressive symptoms or clinically significant depressive symptomology. Attendance at religious services is associated with depressive symptoms (p = 0.004) with an inversely linear trend (p = 0.002). CONCLUSION: The significant inverse association between attendance at religious services and depressive symptoms, despite no association between prayer and depressive symptoms, indicates that social or other factors may accompany attendance at religious services and contribute to the association. Clinicians can consider supporting a CFC's attendance at religious services as a potential preventive measure for depressive symptoms.

Psychosocial burden of family caregivers to adults with cancer.

A person living with cancer will potentially have some degree of physical, cognitive, and/or psychological impairment, periods of unemployment, financial concerns, social isolation, and existential questions, any or all of which can impact the family and friends who surround them. In our current era of healthcare, patients with cancer receive invasive diagnostic studies and aggressive treatment as outpatients, and then convalesce at home. As such, cancer family caregivers are essential partners with the healthcare team. The intricacies of the cancer family caregiver role and responsibilities are demanding and may lead to increased morbidity and mortality-in effect, the cancer family caregiver can become a second patient in need of care. This chapter discusses the psychosocial burden of family caregivers to adults with cancer, and includes information on caregiver mood disturbance and psychological impairment and some of the mutable factors that contribute to these states (i.e., sleep disturbance, decline in physical health, and restriction of activities), uncertainty, spiritual concerns, and caregiver witnessing. There is a discussion of the factors that influence the caregiving experience (caregiver characteristics, patient characteristics, and social supports). The chapter concludes with comments on the state of caregiver research.

Cancer family caregivers: a new direction for interventions.

BACKGROUND: Descriptive studies of cancer family caregivers demonstrate role-related psychosocial and physical burden; however, little is known about which factors contribute to or obviate burden. Systematic reviews of caregiver intervention studies demonstrate mixed results, perhaps because some caregiver needs are still unknown and not adequately addressed. The purpose of our study was to explore the lived experience of being a caregiver for an adult with lung or colon cancer, so as to guide the development of future intervention studies. METHOD: Using phenomenologic methods, open-ended interviews were conducted at a chemotherapy clinic, New Haven, CT with 135 caregivers to adults with lung or colon cancer. Interviews were audio-recorded and transcribed. Thematic analysis was conducted with transcripts coded, reviewed, and recoded multiple times. The final 69 codes were reduced to 13 code clusters (thematic categories) distributed among 4 themes. RESULTS: Four inter-related themes emerged: 1) becoming a caregiver; 2) new and altered relationships; 3) personal responses to caregiving and 4) antecedents and social context. Caregivers describe hearing the cancer diagnosis as "life-changing". The cancer creates the context for the caregiver's relationships (with the patient, self, others, and the healthcare system), and cognitive, behavioral, affective, and spiritual responses. The caregiver's antecedent experiences and social support network form the foundation for their perceptions of the diagnosis, relationships, and personal responses. CONCLUSION: This study implicates several intervention components to be developed and tested as favorably supporting caregivers, namely, reinforcing positive aspects of caregiving, cultivating open communication, and acknowledging the prior experiences and social foundation of the caregiver's life that can be supportive or burdensome.

Psychosocial care for family caregivers of patients with cancer.

PURPOSE: To understand family caregivers' needs for better preparation and care, this state-of-the-science review examines the effect of caregiving on the health and well-being of caregivers, the efficacy of research-tested interventions on patient and caregiver outcomes, implications of the research on policy and practice, and recommendations for practice and future research. METHODS: We reviewed research that described the multiple effects of cancer on caregivers' well-being. Five meta-analyses were analyzed to determine the effect of interventions with caregivers on patient and caregiver outcomes. In addition, we reviewed legislation such as the Affordable Care Act and the Family Leave Act along with current primary care practice to determine whether family caregivers' needs have been addressed. RESULTS: Research findings indicate that caregiver stress can lead to psychological and sleep disturbances and changes in caregivers' physical health, immune function, and financial well-being. Research-tested interventions delivered to caregivers of patients with cancer or other chronic illnesses can reduce many of these negative effects and improve caregivers' coping skills, knowledge, and quality of life. Although these interventions also decrease patients' symptoms, reduce mortality (non-dementia patients), and improve patients' physical and mental health, they are seldom implemented in practice. CONCLUSION: Recommendations for practice include development of standardized guidelines that address caregiver assessment, education, and resources; identification of "caregiver champions" in practice settings; provision of referrals to established support organizations for caregivers (eg, Cancer Support Community, Cancer Care); and collaboration among caregiving, professional, and cancer-related organizations to advocate policy and practice changes for family caregivers.

Barriers to meditation by gender and age among cancer family caregivers.

BACKGROUND: Despite solid basic science research supporting meditation's physiologic benefits, meditation remains a marginalized practice for many Westerners; observational and descriptive studies indicate a spectrum of barriers to meditation practice. OBJECTIVE: The aim of this study was to determine differences in barriers to meditation by gender and age. METHODS: A cross-sectional survey study of 150 family caregivers to adults with cancer visiting an outpatient chemotherapy center in Connecticut was conducted. The primary outcome was the Determinants of Meditation Practice Inventory. Explanatory variables included demographic characteristics, Center for Epidemiologic Studies-Depression Scale, Big Five Inventory, and Caregiver Reaction Assessment. RESULTS: Participants included 98 women and 52 men. Age range was 18-84 years (M = 52.3 years). The highest frequency of barriers for both genders related to misconceptions about meditation. The total number of barriers to meditation did not significantly vary by gender (p = .10) nor age (p = .27). After adjusting for personality trait, reactions to caregiving, and emotional distress, gender (adjusted ß = 0.81, SE = 1.70, p = .63) and age (adjusted ß = 0.02, SE = 0.05, p = .67) still did not predict the number of barriers to meditation. Backward elimination in model building showed that personality trait and reactions to caregiving account for 32% of the variability in barriers. DISCUSSION: The total number of barriers to meditation was examined, and a difference was not found by age or gender. It is possible that differences by age and gender exist at the item level of evaluation but were not evident when evaluating total scores. Further study is needed with samples large enough to have statistical power for item-level analysis.

Cancer family caregivers during the palliative, hospice, and bereavement phases: a review of the descriptive psychosocial literature.

OBJECTIVE: Because caregiving to an adult with cancer is a dynamic process, a caregiver's perceived burden and psychosocial concerns may be different at different phases of the patient's disease. There is evidence of escalation in caregiver anxiety, depression, and psychological distress as the patient's functional status declines and as the patient nears death. The purpose of this review was to organize the literature in a meaningful way that can potentially capture the unique needs of caregivers to patients receiving palliative and/or hospice care, and caregivers who are in the post-death bereavement phase. METHOD: A systematic review was conducted. Major databases were searched for non-intervention descriptive studies that included psychosocial variables of family caregivers to adults with cancer during the palliative, hospice, or bereavement phases. RESULTS: The 19 studies reviewed were conducted in six countries and varied considerably by samples, outcome measures, methodologies, and analytic approaches. Despite limiting to the palliative, hospice, and bereavement phases, inconsistent results were found for key variables, such as age, gender, and relationship to the patient. When patient-caregiver dyad analysis was conducted, with rare exception, there was mutuality between the patient's condition and the caregiver's response. Across the 19 studies, 89 unique instruments were used, almost half of which were study specific with no psychometric testing reported. CONCLUSIONS/SIGNIFICANCE OF RESEARCH: As a direct consequence of assuming the caregiver role, cancer family caregivers in the palliative, hospice, and bereavement phases are at increased risk for physical and mental morbidity. Often, the psychological burden of the caregiver exceeds that of the critically ill patient. It is possible that distressed caregivers have a deleterious influence on patient well-being. This review demonstrates the need to develop research standards, especially regarding measurement instruments, so that caregiver research can mature and interventions can be developed to support family caregivers.

Determinants of meditation practice inventory: development, content validation, and initial psychometric testing.

Background Meditation health benefits have been difficult to document, as many efficacy studies are marred by lack of statistical power secondary to small sample size and/or threats to validity from high attrition. To date, no published studies have examined barriers to meditation that are likely responsible for low enrollment and high attrition. Objective To develop an instrument to capture barriers to meditation use, namely, the Determinants of Meditation Practice Inventory (DMPI). Design A five-step, mixed-methods approach was used, including literature review, qualitative interviews, content validation, reliability testing, and construct validation. Participants/Setting Four distinct participant groups contributed. Four meditation teachers participated in qualitative interviews. Five expert panelists conducted the content validation. Ten nonmeditators participated in the pilot test. For reliability testing and construct validation, 150 cancer family caregivers participated. Outcome Measures Big Five Inventory (BFI) and Caregiver Reactions Assessment (CRA) were used to test convergent construct validity. Results The three content domains are perceptions and misconceptions, pragmatic concerns, and sociocultural beliefs. Initially, 53 items were generated. Three reviews by the expert panel concluded with a 22-item survey. After pilot testing, a 17-item survey was created. Data from 150 caregivers showed Cronbach's coefficient alpha of 0.87. The intraclass correlation for baseline and retest was 0.86 (confidence interval 0.82-0.90). BFI and CRA were significantly and positively correlated with DMPI. Conclusion Preliminary results indicate the DMPI is psychometrically sound. By identifying barriers to meditation, the DMPI will enable researchers to address the needs and concerns of the target population when designing recruitment and intervention procedures, potentially maximizing recruitment, minimizing attrition, and optimizing interpretation of results.

Intravenous micronutrient therapy (Myers' Cocktail) for fibromyalgia: a placebo-controlled pilot study.

OBJECTIVES: Intravenous micronutrient therapy (IVMT), and specifically the Myers' Cocktail, is a popular approach for treating fibromyalgia syndrome (FMS) among complementary and alternative medicine practitioners, but its efficacy is uncertain. This trial assessed the feasibility, safety, and provided insights into the efficacy of this therapy. DESIGN: This was a randomized, double-blind, placebo-controlled pilot study. LOCATIONS: The study locations were an academic research center, teaching hospital, and affiliated Integrative Medicine Center in Derby, CT. SUBJECTS: The subjects were 34 adults with American College of Rheumatology (ACR)-defined FMS. INTERVENTION: Subjects were randomly assigned either to treatment (weekly infusions of IVMT) or to placebo (weekly infusions of lactated Ringer's solution) for 8 weeks. OUTCOME MEASURES: Primary outcome was change in the Tender Point Index, assessed 8 and 12 weeks after initiation. Secondary measures included a Visual Analog Scale to assess global pain, and validated measures of physical function (Fibromyalgia Impact Questionnaire), mood (Beck Depression Index), and quality of life (Health Status Questionnaire 2.0). RESULTS: Clinically significant improvements were noted (of a magnitude similar to other effective interventions). However, in part because of the high placebo response and the small sample size, no statistically significant differences were seen between groups, in any outcome measure, at 8 and 16 weeks. Statistically significant within-group differences were seen in both the intervention and placebo groups, demonstrating a treatment effect for both IVMT and placebo. At 8 weeks, the IVMT group experienced significantly improved tender points, pain, depression, and quality of life directly following treatment (all p < or = 0.02), while the placebo group experienced significantly improved tender points only (p < or = 0.05). The treatment effects of IVMT persisted at 4 weeks postintervention for tender points, pain, and quality of life, while placebo effects persisted only for tender points. A single minor adverse event was noted in one subject in the intervention group. CONCLUSIONS: This first controlled pilot study established the safety and feasibility of treating FMS with IVMT. Most subjects experienced relief as compared to baseline, but no statistically significant differences were seen between IVMT and placebo. The efficacy of IVMT for fibromyalgia, relative to placebo, is as yet uncertain.

Effects of a nursing intervention on quality of life outcomes in post-surgical women with gynecological cancers.

OBJECTIVE: Women with gynecological cancers have reported poor health-related quality of life (QOL), with complex physical and psychological needs post-surgery and during chemotherapy treatment. There are no studies reporting interventions addressing these needs post-hospital discharge in this population. METHODS: Patients were randomized into two groups. The intervention group received 6 months of specialized care by an Advanced Practice Nurse (APN); in addition, women with high distress were evaluated and monitored by a psychiatric consultation-liaison nurse (PCLN). The attention control group was assisted with symptom management by a research assistant. The effects of the 6-month intervention were evaluated using self-report questionnaires at baseline (24-48 h after surgery), 1, 3, and 6 months post- surgery. QOL assessments included the Center for Epidemiological Studies-Depression Scale , the ambiguity subscale of the Mishel Uncertainty in Illness Scale , the Symptom Distress Scale, and the Short-Form Health Survey (SF-12). The sample for the longitudinal analysis included 123 who completed QOL outcome measures across three occasions post-surgery. RESULTS: The APN intervention resulted in significantly less uncertainty than the attention control intervention 6 months after surgery. When the sub-group who received the APN plus PCLN intervention was compared with the total attention control group, the sub-group had significantly less uncertainty, less symptom distress, and better SF-12 mental and physical QOL over time. CONCLUSION: Nurse tailored interventions that target both physical and psychological aspects of QOL in women recovering from cancer surgery and undergoing chemotherapy produce stronger outcomes than interventions that target solely one QOL aspect.

The caregiving experience in a racially diverse sample of cancer family caregivers.

The literature supports a variety of predictor variables to account for the psychological and stress burden experienced by cancer family caregivers. Missing among the predictor variables are the differences by or influence of race/ethnicity. The purpose of this study was to describe the sample, explore differences in outcomes by patient and family caregiver characteristics, and determine if any of the patient and family characteristics, including race/ethnicity, predicted outcomes. Cross-sectional surveys were used to determine sociodemographics, psychological and physical health, and burdens of caregiving among 54 caregivers. The analysis consisted of descriptive methods, including frequencies and t tests, and regression modeling. The sample was 35% African American or Hispanic. African American and Hispanic caregivers were younger than white caregivers and more often women, were rarely the spouse of the patient, and frequently had other dependents, including children and older parents. African American and Hispanic caregivers reported lower incomes and more burden related to finances and employment than did white caregivers. When controlling for sociodemographic factors, there was no difference by race/ethnicity on the outcome measures. The experience of caregiving may supersede race/ethnicity and may be its own cultural entity. Areas of concern include the interrelationship between socioeconomic status and race/ethnicity, the absence of cultural frameworks to direct caregiver research, and the question of cultural relevance of measurement tools.

Massage therapy for osteoarthritis of the knee: a randomized controlled trial.

BACKGROUND: Massage therapy is an attractive treatment option for osteoarthritis (OA), but its efficacy is uncertain. We conducted a randomized, controlled trial of massage therapy for OA of the knee. METHODS: Sixty-eight adults with radiographically confirmed OA of the knee were assigned either to treatment (twice-weekly sessions of standard Swedish massage in weeks 1-4 and once-weekly sessions in weeks 5-8) or to control (delayed intervention). Primary outcomes were changes in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and functional scores and the visual analog scale of pain assessment. The sample provided 80% statistical power to detect a 20-point difference between groups in the change from baseline on the WOMAC and visual analog scale, with a 2-tailed alpha of .05. RESULTS: The group receiving massage therapy demonstrated significant improvements in the mean (SD) WOMAC global scores (-17.44 [23.61] mm; P < .001), pain (-18.36 [23.28]; P < .001), stiffness (-16.63 [28.82] mm; P < .001), and physical function domains (-17.27 [24.36] mm; P < .001) and in the visual analog scale of pain assessment (-19.38 [28.16] mm; P < .001), range of motion in degrees (3.57 [13.61]; P = .03), and time to walk 50 ft (15 m) in seconds (-1.77 [2.73]; P < .01). Findings were unchanged in multivariable models controlling for demographic factors. CONCLUSIONS: Massage therapy seems to be efficacious in the treatment of OA of the knee. Further study of cost effectiveness and duration of treatment effect is clearly warranted. .

Perspectives on spirituality at the end of life: a meta-summary.

OBJECTIVE: A meta-summary of the qualitative literature on spiritual perspectives of adults who are at the end of life was undertaken to summarily analyze the research to date and identify areas for future research on the relationship of spirituality with physical, functional, and psychosocial outcomes in the health care setting. METHODS: Included were all English language reports from 1966 to the present catalogued in PubMed, Medline, PsycInfo, and CINAHL, identifiable as qualitative investigations of the spiritual perspectives of adults at the end of life. The final sample includes 11 articles, collectively representing data from 217 adults. RESULTS: The preponderance of participants had a diagnosis of cancer; those with HIV/AIDS, cardiovascular disease, and ALS were also represented. Approximately half the studies were conducted in the United States; others were performed in Australia, Finland, Scotland, and Taiwan. Following a process of theme extraction and abstraction, thematic patterns emerged and effect sizes were calculated. A spectrum of spirituality at the end of life encompassing spiritual despair (alienation, loss of self, dissonance), spiritual work (forgiveness, self-exploration, search for balance), and spiritual well-being (connection, self-actualization, consonance) emerged. SIGNIFICANCE: The findings from this meta-summary confirm the fundamental importance of spirituality at the end of life and highlight the shifts in spiritual health that are possible when a terminally ill person is able to do the necessary spiritual work. Existing end-of-life frameworks neglect spiritual work and consequently may be deficient in guiding research. The area of spiritual work is fertile ground for further investigation, especially interventions aimed at improving spiritual health and general quality of life among the dying.