The relationship of health activation with risk of future cardiovascular disease among rural family caregivers of patients with chronic illnesses.

BACKGROUND: Family caregivers are at higher risk for developing cardiovascular disease (CVD) than non-caregivers. This risk is worse for those who live in rural compared to urban areas. Health activation, an indicator of engagement in self-care, is predictive of health outcomes and CVD risk in several populations. However, it is not known whether health activation is associated with CVD risk in rural caregivers of patients with chronic illnesses nor is it clear whether sex moderates any association. OBJECTIVES: Our aims were to determine (1) whether health activation independently predicts 10-year CVD risk; and (2) whether sex interacts with health activation in the prediction of 10-year CVD risk among rural family caregivers (N = 247) of patients with chronic illnesses. METHODS: Health activation was measured using the Patient Activation Measure. The predicted 10-year risk of CVD was assessed using the Framingham Risk Score. Data were analyzed using nonlinear regression analysis. RESULTS: Higher levels of health activation were significantly associated with decreased risk of developing CVD (p < 0.028). There was no interaction of sex with health activation on future CVD risk. However, male caregivers had greater risk of developing CVD in the next 10 years than female caregivers (p < 0.001). CONCLUSIONS: We demonstrated the importance of health activation to future CVD risk in rural family caregivers of patients with chronic illnesses. We also demonstrated that despite the higher risk of future CVD among male, the degree of association between health activation and CVD risk did not differ by sex.

Psychometric Properties of the Patient Activation Measure in Family Caregivers of Patients With Chronic Illnesses.

BACKGROUND: The Patient Activation Measure (PAM) is used clinically and in research to measure an individual's knowledge, skills, and confidence related to their health management engagement. Despite the use of "patient" in the title, the instrument can be used in nonpatient populations. A group at high risk for low activation concerning their own health is family caregivers of patients with chronic illnesses. The psychometric properties of the PAM have not been established in family caregivers. OBJECTIVES: This study aimed to examine the psychometric properties of the PAM 10-item version (PAM-10) in a sample of family caregivers of patients with chronic illnesses. Our focus was on family caregivers' health activation of their own healthcare needs. METHODS: We evaluated the internal consistency reliability of the PAM-10 in a sample of 277 family caregivers. Item-total correlations and interitem correlations were used to assess item homogeneity. Construct validity of the PAM-10 was examined using exploratory factor analysis and testing hypotheses on known relationships. RESULTS: The PAM-10 demonstrated adequate internal consistency. Item-total correlation coefficients and interitem correlation coefficients were acceptable. Construct validity of the instrument was supported. Factor analysis yielded two factors that explained 62.3% of the variance in the model. Lower levels of depressive symptoms were significantly associated with better activation, providing evidence of construct validity. Caregivers with high activation levels were significantly more likely to engage in and adhere to self-care behaviors such as regular exercise, eating a healthy diet, and engaging in stress reduction strategies. DISCUSSION: This study demonstrated that the PAM-10 is a reliable and valid measure for family caregivers of patients with chronic illnesses to measure caregivers' health activation of their own healthcare needs.

Developing a Public Health Improvement Consortium in Appalachian Kentucky: Harnessing the Power of the Local Collective.

Many Appalachian counties in Kentucky are known for poor health and limited resources, however, by harnessing the power of relationships in the eight counties of the Kentucky River Area Development District, a team developed a public health improvement consortium to maximize power of the local collective.

The Community Leadership Institute of Kentucky (CLIK): A Collaborative Workforce and Leadership Development Program.

BACKGROUND: The Community Leadership Institute of Kentucky (CLIK), a workforce development and leadership program within the Community Engagement and Research Core of the University of Kentucky's Center for Clinical and Translational Science (UK CCTS), was developed to enhance community members' capacity to address pernicious rural health inequities. OBJECTIVES/METHODS: In this article, we describe the development, implementation, and results of the program, examining program and project completion rates, quantitative and qualitative evaluations from participants, and professional achievements. RESULTS: Based on existing models from other Clinical and Translational Science Awards Programs (CTSAs), CLIK provides diverse programming in a local, supportive setting and supports mentors/academic partners through education and networking. Now in its sixth year, CLIK participants have included 41 leaders from varied local settings, including public school systems, health departments, county and local governments, and other non-profit organizations. Shaped by extensive CLIK participant input, the program offers eleven didactic and hands-on training sessions in evidence-based programming and health promotion; a mentored research project addressing relevant local health inequities; and extensive networking opportunities. CONCLUSIONS: CLIK has become an enrichment opportunity for local communities as well as a platform for academic engagement and bi-directional learning. Such community-academic partnerships are particularly needed in traditionally under-resourced rural communities.

Parent and Provider Preferences for Parenting Intervention Delivery in Rural Appalachia: A Qualitative Analysis Guiding Adaptation.

The public health impact of behavioral parent training (BPT) is limited, especially in underserved communities such as rural central Appalachia. To improve access to BPT in this region, we completed the first two steps of the ADAPT-ITT framework for systematic adaptation of evidence-based interventions: (1) assessing community perspectives about BPT delivery, and (2) deciding upon a specific intervention and adaptations needed to increase its acceptability and accessibility in rural central Appalachian counties. Guided by a community advisory board, we conducted key informant interviews with parents (N = 21) and three focus groups with child service providers to elicit stakeholders' perspectives about child behavior problems in their communities; existing resources; and preferences regarding four characteristics of BPT delivery: interventionist, modality, dose, and location. Results of directed content analysis led to the selection of local, trusted community health workers to deliver a brief, tailored BPT with flexibility in modality and location.

The relationship between psychological states and health perception in individuals at risk for cardiovascular disease.

Backgrounds: Perceptions of health are important to motivate people to change behaviors. Non-adherence to healthy behaviors that prevent cardiovascular disease may result from inadequate health perceptions. However, there are few studies investigating relationships between health perceptions and psychological states. Objective: To determine whether psychological states (ie, depressive symptoms and anxiety) are associated with the congruency between health perception and estimated risk for cardiovascular disease in adults with 2 or more cardiovascular disease risk factors. Methods: Community dwellers at risk for cardiovascular disease were asked to complete the Patient Health Questionnaire-9 and the anxiety subscale of the Brief Symptom Inventory to measure depressive symptoms and anxiety, respectively. Participants rated their perceived health from excellent to poor. The estimated cardiovascular disease risks were measured with the 10-year cardiovascular disease Framingham risk scores. Participants were grouped into three health perception groups based on congruency between levels of health perception and cardiovascular disease risk. Multivariate multinomial logistic regression was done to examine the association between psychological states and health perception groups. Results: Of 828 participants 54.7%, 12.0%, and 33.3% had congruent, pessimistically biased, and optimistically biased health perception, respectively. Depressive symptoms were significantly associated with pessimistic bias (adjusted odds ratio: 1.070, 95% confidence interval 1.010-1.133), but not anxiety. Optimistic bias was not associated with either depressive symptoms or anxiety. Conclusions: A mismatch between individual health perceptions and cardiovascular disease risks was associated with depressive symptoms. As health perception is affected by depressive symptoms, clinicians should assess depressive symptoms when exploring health perceptions and engaging individuals in decision-making about a healthy lifestyle.

Building interventions when distress is under debate: a case study from Appalachia.

Scholarship on idioms of distress has emphasized cross-cultural variation, but devoted less attention to intra-cultural variation-specifically, how the legitimacy of distress may vary according to the context in which it is expressed, social position, and interaction with medical categories of distress. This variation can pose challenges for interventionists seeking to establish culturally acceptable ways of identifying distress and creating relevant resources for recovery. We describe efforts over three years (2014-2016) to identify and adapt a culturally appropriate evidence-based intervention for depressed rural Appalachian women. Though the prevalence of depression among rural women is high, limited services and social barriers restrict treatment access. Formative research revealed varied understandings of distress. Depression was (a) medicalized as a treatable condition, (b) stigmatized as mental illness, (c) accepted as a non-pathological reaction to regional poverty and gendered caregiving responsibilities, (d) rejected as a worthy justification for seeking individual care, and (e) less represented in comparison to other competing forms of distress (i.e., multiple morbidities, family members' distress). In a small pilot trial, we applied an implementation science perspective to identify and implement appropriate evidence-based programming for the context. We outline how we reached Appalachian women despite these diverse understandings of depression and established a flexible medicalization of depression that enabled us to legitimize care-seeking, work with varied rural healthcare professionals, and engender culturally relevant support. Our adaptation and implementation of the concept of "mental health recovery" enabled the development of programming that furthered non-pathological communicative distress while resisting the normalization that silences women in the context of deep health disparities.

What Role Can Community Health Workers Play in Connecting Rural Women with Depression to the "De Facto" Mental Health Care System?

The prevalence of depression among rural women is nearly twice the national average, yet limited mental health services and extensive social barriers restrict access to needed treatment. We conducted key informant interviews with community health workers (CHWs) and diverse health care professionals who provide care to Appalachian women with depression to better understand the potential roles that CHWs may play to improve women's treatment engagement. In the gap created by service disparities and social barriers, CHWs can offer a substantial contribution through improving recognition of depression; deepening rural women's engagement within existing services; and offering sustained, culturally appropriate support.

Mental health treatment seeking patterns and preferences of Appalachian women with depression.

This qualitative study explored social-cultural factors that shape treatment seeking behaviors among depressed rural, low-income women in Appalachia-a region with high rates of depression and a shortage of mental health services. Recent research shows that increasingly rural women are receiving some form of treatment and identifying their symptoms as depression. Using purposive sampling, investigators recruited 28 depressed low-income women living in Appalachian Kentucky and conducted semistructured interviews on participants' perceptions of depression and treatment seeking. Even in this sample of women with diverse treatment behaviors (half reported current treatment), participants expressed ambivalence about treatment and its potential to promote recovery. Participants stressed that poor treatment quality-not merely access-limited their engagement in treatment and at times reinforced their depression. While women acknowledged the stigma of depression, they indicated that their resistance to seek help for their depression was influenced by the expectation of women's self-reliance in the rural setting and the gendered taboo against negative thinking. Ambivalence and stigma led women to try to cope independently, resulting in further isolation. This study's findings reiterate the need for improved quality and increased availability of depression treatment in rural areas. In addition, culturally appropriate depression interventions must acknowledge rural cultural values of self-reliance and barriers to obtaining social support that lead many women to endure depression in isolation. (PsycINFO Database Record

Care Coordination for Community Transitions for Individuals Post-stroke Returning to Low-Resource Rural Communities.

High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors' transitions to the community. The Kentucky Care Coordination for Community Transitions (KC3T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were enrolled in this program between July 2015 and May 2016. Data collection included: incidence of comorbidities; access to healthcare, insurance, medical equipment (DME), and medications; type of follow-up education provided; and number of 30-day rehospitalizations and Emergency Department (ED) visits. Participants required navigation in their home and community transition with support in: patient-provider communication; insurance support; accessing follow-up care; education on managing chronic health conditions, the stroke process, transfers and mobility; and accessing DME and essential medications. There were no 30-day ED visits for the KC3T participants and only one 30-day hospital readmission, which was not stroke-related. Individuals returning to rural communities following a stroke require, but often don't receive, follow-up education on chronic disease management, support in navigating the healthcare system and accessing essential resources. KC3T's navigator program appears to be effective in supporting the community transitions of individuals poststroke.

Identifying Community Perspectives for a Lung Cancer Screening Awareness Campaign in Appalachia Kentucky: The Terminate Lung Cancer (TLC) Study.

Lung cancer screening with low-dose computed tomography (LDCT) scan is now covered by Centers for Medicare & Medicaid Services following an evidence-based recommendation, but a shared decision making process should inform patients of risks and limitations. An awareness campaign promoting LDCT screenings is an opportunity to elicit patient engagement with health providers about the risks and benefits. Focus groups representing three regions of Appalachian Kentucky known for high lung cancer rates discussed development of a lung cancer screening campaign. Recommendations included messaging content, appeals or design, campaign implementation, and trusted information or communication sources. Community health workers (CHWs) from three Eastern Kentucky regions recruited individuals from their local communities using established client files. CHWs hosted six total focus groups (7-11 participants each) using questions guided by the Communication-Persuasion Matrix framework. All sessions were recorded and transcribed for independent content analysis. A total of 54 individuals (61.1 % female; >55 pack year history) were participated. Prior to discussion, most participants had not heard of lung cancer screening. Cited needs for content of a campaign included benefits of early detection and payment information. Messages considered most persuasive were those that include personal testimony, messages of hope, prolonged life, and an emphasis on family and the ambition to survive. Having information come from one's family doctor or specialty provider was considered important to message communication. Messages about survivorship, family, and prolonged life should be considered in lung cancer screening awareness campaigns. Our results provide community input about messages regarding screening options.

Community health workers improving diabetes outcomes in a rural Appalachian population.

Community health workers (CHWs) play a key role in the emerging health infrastructure. They are successful in identifying individual or family needs and matching resources to help overcome the social determinants of health, and the lack of trust in the health care system. This study captures the CHW experience as research assistants and evaluates the effectiveness of CHWs' health coaching and support in improving diabetes health outcomes. By being immersed in the culture and values of the population, CHWs offer research support to assure more representative client samples, increased adherence to study protocols, and in reducing attrition rates.

Terminate lung cancer (TLC) study-A mixed-methods population approach to increase lung cancer screening awareness and low-dose computed tomography in Eastern Kentucky.

For low dose CT lung cancer screening to be effective in curbing disease mortality, efforts are needed to overcome barriers to awareness and facilitate uptake of the current evidence-based screening guidelines. A sequential mixed-methods approach was employed to design a screening campaign utilizing messages developed from community focus groups, followed by implementation of the outreach campaign intervention in two high-risk Kentucky regions. This study reports on rates of awareness and screening in intervention regions, as compared to a control region.

Cervical cancer screening: exploring Appalachian patients' barriers to follow-up care.

This article describes a community-based Patient Navigation (PN) project conducted to identify potential barriers to seeking follow-up cervical cancer care in southeastern Kentucky. Patient navigators (PNs) were placed in cervical cancer programs within county public health departments where they interviewed patients about their perceived barriers to seeking follow-up care after receiving a positive Pap test result. Participants identified various potential barriers at three levels: the individual/personal level, the health care system level and the community/environmental level. One identified barrier that was unique to this study was a lack of consistency between follow-up recommendations and follow-up guidelines for patients under age 21. Implications are discussed.

Effectiveness of an Intervention for Adherence to Follow-up Recommendations for Abnormal Pap Tests in Appalachian Kentucky.

OBJECTIVE: In collaboration with rural county health departments (CHDs), we developed a patient navigation intervention to increase adherence to follow-up recommendations for women with abnormal Pap tests. METHODS: Local women were recruited, trained and placed in CHDs. Navigation was tailored to the follow-up care recommended. Effectiveness was evaluated in a quasi-experimental trial that included 13 intervention CHDs and 13 comparison group CHDs. Participants were enrolled from September 2008 through July 2010. RESULTS: A total of 478 participants were enrolled. The proportion that received recommended follow-up care was greater in the intervention CHDs (91.6%) than in the comparison group CHDs (80.8%) (p = .01). CONCLUSIONS: These results suggest that development of policy to promote navigation with rural health care delivery systems has great potential to improve patient outcomes.

Effectiveness of community health workers in providing outreach and education for colorectal cancer screening in Appalachian Kentucky.

The purpose of this study was to examine the effectiveness of a community health worker (CHW)-delivered cancer education program designed to increase knowledge and awareness of colorectal cancer screening options. The study population was an extremely vulnerable and medically underserved geographic region in Appalachian Kentucky. CHWs enrolled participants in face-to-face visits, obtained informed consent, and administered a baseline assessment of knowledge of colorectal cancer risks and the benefits of screening and screening history. An educational intervention was then provided and participants were re-contacted 6 months later when a posttest was administered. The mean score of the 637 participants increased from 4.27 at baseline to 4.57 at follow-up (p < .001). Participants who reported asking their health care provider about colorectal cancer screening increased from 27.6% at baseline to 34.1% at follow-up (p = .013). Results suggest that CHWs were very effective at maintaining the study population; no loss to follow-up occurred. The results also showed increased knowledge and awareness about colorectal cancer screening education. Implications for social work practice, policy and research are discussed.

Patient navigation for breast and colorectal cancer in 3 community hospital settings: an economic evaluation.

BACKGROUND: The Ralph Lauren Cancer Center implemented patient navigation programs in sites across the United States building on the model pioneered by Harold P. Freeman, MD. Patient navigation targets medically underserved with the objective of reducing the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation. In this study, the authors assessed the incremental cost effectiveness of adding patient navigation to standard cancer care in 3 community hospitals in the United States. METHODS: A decision-analytic model was used to assess the cost effectiveness of a colorectal and breast cancer patient navigation program over the period of 1 year compared with standard care. Data sources included published estimates in the literature and primary costs, aggregate patient demographics, and outcome data from 3 patient navigation programs. RESULTS: After 1 year, compared with standard care alone, it was estimated that offering patient navigation with standard care would allow an additional 78 of 959 individuals with an abnormal breast cancer screening and an additional 21 of 411 individuals with abnormal colonoscopies to reach timely diagnostic resolution. Without including medical treatment costs saved, the cost-effectiveness ratio ranged from $511 to $2080 per breast cancer diagnostic resolution achieved and from $1192 to $9708 per colorectal cancer diagnostic resolution achieved. CONCLUSIONS: The current results indicated that implementing breast or colorectal cancer patient navigation in community hospital settings in which low-income populations are served may be a cost-effective addition to standard cancer care in the United States.