Mixed-Methods Randomized Evaluation of FAMS: A Mobile Phone-Delivered Intervention to Improve Family/Friend Involvement in Adults' Type 2 Diabetes Self-Care.

BACKGROUND: Family and friends have both helpful and harmful effects on adults' diabetes self-management. Family-focused Add-on to Motivate Self-care (FAMS) is a mobile phone-delivered intervention designed to improve family/friend involvement, self-efficacy, and self-care via monthly phone coaching, texts tailored to goals, and the option to invite a support person to receive texts. PURPOSE: We sought to evaluate how FAMS was received by a diverse group of adults with Type 2 diabetes and if FAMS improved diabetes-specific family/friend involvement (increased helpful and reduced harmful), diabetes self-efficacy, and self-care (diet and physical activity). We also assessed if improvements in family/friend involvement mediated improvements in self-efficacy and self-care. METHODS: Participants were prospectively assigned to enhanced treatment as usual (control), an individualized text messaging intervention alone, or the individualized text messaging intervention plus FAMS for 6 months. Participants completed surveys at baseline, 3 and 6 months, and postintervention interviews. Between-group and multiple mediator analyses followed intention-to-treat principles. RESULTS: Retention, engagement, and fidelity were high. FAMS was well received and helped participants realize the value of involving family/friends in their care. Relative to control, FAMS participants had improved family/friend involvement, self-efficacy, and diet (but not physical activity) at 3 and 6 months (all ps < .05). Improvements in family/friend involvement mediated effects on self-efficacy and diet for FAMS participants but not for the individualized intervention group. CONCLUSIONS: The promise of effectively engaging patients' family and friends lies in sustained long-term behavior change. This work represents a first step toward this goal by demonstrating how content targeting helpful and harmful family/friend involvement can drive short-term effects. TRIAL REGISTRATION NUMBER: NCT02481596.

The Partnership to Improve Diabetes Education Trial: a Cluster Randomized Trial Addressing Health Communication in Diabetes Care.

BACKGROUND: Effective type 2 diabetes care remains a challenge for patients including those receiving primary care in safety net settings. OBJECTIVE: The Partnership to Improve Diabetes Education (PRIDE) trial team and leaders from a regional department of health evaluated approaches to improve care for vulnerable patients. DESIGN: Cluster randomized controlled trial. PATIENTS: Adults with uncontrolled type 2 diabetes seeking care across 10 unblinded, randomly assigned safety net clinics in Middle TN. INTERVENTIONS: A literacy-sensitive, provider-focused, health communication intervention (PRIDE; 5 clinics) vs. standard diabetes education (5 clinics). MAIN MEASURES: Participant-level primary outcome was glycemic control [A1c] at 12 months. Secondary outcomes included select health behaviors and psychosocial aspects of care at 12 and 24 months. Adjusted mixed effects regression models were used to examine the comparative effectiveness of each approach to care. KEY RESULTS: Of 410 patients enrolled, 364 (89%) were included in analyses. Median age was 51 years; Black and Hispanic patients represented 18% and 25%; 96% were uninsured, and 82% had low annual income level (< $20,000); adequate health literacy was seen in 83%, but numeracy deficits were common. At 12 months, significant within-group treatment effects occurred from baseline for both PRIDE and control sites: adjusted A1c (- 0.76 [95% CI, - 1.08 to - 0.44]; P < .001 vs - 0.54 [95% CI, - 0.86 to - 0.21]; P = .001), odds of poor eating (0.53 [95% CI, 0.33-0.83]; P = .01 vs 0.42 [95% CI, 0.26-0.68]; P < .001), treatment satisfaction (3.93 [95% CI, 2.48-6.21]; P < .001 vs 3.04 [95% CI, 1.93-4.77]; P < .001), and self-efficacy (2.97 [95% CI, 1.89-4.67]; P < .001 vs 1.81 [95% CI, 1.1-2.84]; P = .01). No significant difference was observed between study arms in adjusted analyses. CONCLUSIONS: Both interventions improved the participant's A1c and behavioral outcomes. PRIDE was not more effective than standard education. Further research may elucidate the added value of a focused health communication program in this setting.

Development of the Initial Surveys for the All of Us Research Program.

BACKGROUND: The All of Us Research Program is building a national longitudinal cohort and collecting data from multiple information sources (e.g., biospecimens, electronic health records, and mobile/wearable technologies) to advance precision medicine. Participant-provided information, collected via surveys, will complement and augment these information sources. We report the process used to develop and refine the initial three surveys for this program. METHODS: The All of Us survey development process included: (1) prioritization of domains for scientific needs, (2) examination of existing validated instruments, (3) content creation, (4) evaluation and refinement via cognitive interviews and online testing, (5) content review by key stakeholders, and (6) launch in the All of Us electronic participant portal. All content was translated into Spanish. RESULTS: We conducted cognitive interviews in English and Spanish with 169 participants, and 573 individuals completed online testing. Feedback led to over 40 item content changes. Lessons learned included: (1) validated survey instruments performed well in diverse populations reflective of All of Us; (2) parallel evaluation of multiple languages can ensure optimal survey deployment; (3) recruitment challenges in diverse populations required multiple strategies; and (4) key stakeholders improved integration of surveys into larger Program context. CONCLUSIONS: This efficient, iterative process led to successful testing, refinement, and launch of three All of Us surveys. Reuse of All of Us surveys, available at http://researchallofus.org, may facilitate large consortia targeting diverse populations in English and Spanish to capture participant-provided information to supplement other data, such as genetic, physical measurements, or data from electronic health records.

Depressed Mood, Perceived Health Competence and Health Behaviors: aCross-Sectional Mediation Study in Outpatients with Coronary Heart Disease.

BACKGROUND: Identifying potential mechanisms that link depressed mood with worse health behaviors is important given the prevalence of depressed mood in patients with coronary heart disease (CHD) and its relationship with subsequent mortality. Perceived health competence is an individual's confidence in his/her ability to successfully engineer solutions to achieve health goals and may explain how depressed mood affects multiple health behaviors. OBJECTIVE: Examine whether or not perceived health competence mediates the relationship between depressed mood and worse health behaviors. DESIGN: A cross-sectional study conducted by the Patient-Centered Outcomes Research Institute-funded Mid-South Clinical Data Research Network between August 2014 and September 2015. Bootstrapped mediation was used. PARTICIPANTS: Patients with coronary heart disease (n = 2334). MAIN MEASURES: Two items assessing perceived health competence, a single item assessing depressed mood, and a Health Behaviors Index including: the International Physical Activity Questionnaire (IPAQ); select items from the National Adult Tobacco Survey and the Alcohol Use Disorder Inventory Test; and single items assessing diet and medication adherence. KEY RESULTS: Depressed mood was associated with lower perceived health competence (a = - 0.21, p < .001) and lower perceived health competence was associated with worse performance on a Health Behaviors Index(b = 0.18, p < .001). Perceived health competence mediated the influence of depressed mood on health behaviors (ab = - 0.04, 95% CI = - 0.05 to - 0.03). The ratio of the indirect effect to the total effect was used as a measure of effect size (PM = 0.26, 95% CI: 0.18 to 0.39). CONCLUSIONS: Depressed mood is associated with worse health behaviors directly and indirectly via lower perceived health competence. Interventions to increase perceived health competence may lessen the deleterious impact of depressed mood on health behaviors and cardiovascular outcomes.

Association of Health Literacy and Numeracy with Interest in Research Participation.

BACKGROUND: There is much attention to recruitment of diverse populations in research, but little is known about the influence of health literacy and numeracy skills. OBJECTIVE: To determine if health literacy and numeracy affect individuals' interest to participate in research studies. DESIGN: Cross-sectional survey data were pooled from 3 large studies conducted in the Mid-South Clinical Data Research Network. PARTICIPANTS: Adult patients enrolled in 1 of 3 Mid-South Clinical Data Research Network studies. MAIN MEASURES: The survey domains included demographic items, the 3-item Brief Health Literacy Screen (range 3-15), and the 3-item Subjective Numeracy Scale (range 3-18). The outcome was a sum index measure of a 7-item instrument (range 7-21) assessing individuals' interest in participating in different types of research, including research that involves taking surveys, giving a blood sample, participating via phone or internet, taking an investigational medication, meeting at a local community center or school, including family, or staying overnight at a hospital. KEY RESULTS: Respondents (N = 15,973) were predominately women (65.5%), White (81.4%), and middle aged (M = 52.8 years, SD = 16.5); 32.4% previously participated in research. Self-reported health literacy was relatively high (M = 13.5 out of 15, SD = 2.1), and subjective numeracy skills were somewhat lower (M = 14.3 out of 18, SD = 3.6). After adjustment for age, gender, race, income, education, and other characteristics, lower health literacy and numeracy skills were each independently associated with less interest in research participation (p < 0.001 for each). Prior research participation was associated with greater interest in future research participation (p < 0.001). CONCLUSIONS: After adjustment for factors known to be predictive of interest, individuals with lower health literacy or numeracy scores were less interested in participating in research. Additional work is needed to elucidate reasons for this finding and to determine strategies to engage these populations.

Historical perspective on behavioral medicine's success in bringing different disciplines to the table.

This article presents the author's perspective on the success of the field of behavioral medicine in recruiting, involving, and retaining upwards of 17 different professional disciplines over the 40 years of its existence. Acknowledging that health psychologists have historically dominated this interdisciplinary field, the author presents some possible solutions to increasing the viability and visibility of the other disciplines in carrying out the mission of behavioral medicine.

Correction to: Health care providers' support of patients' autonomy, phosphate medication adherence, race and gender in end-stage renal disease.

In the original publication of the article, the majority of changes stem from misclassification of "medium adherence" when using the Morisky Medication Adherence Scale (MMAS-8) and not using the correct scoring algorithm for one of the responses when calculating MMAS-8 total scores.

Factors associated with women's desire for control of healthcare during childbirth: Psychometric analysis and construct validation.

The desire for control of healthcare is a significant moderator of outcomes related to childbirth. Researchers have shown that a sense of control of healthcare during childbirth is strongly correlated with postpartum maternal well-being. The aims of this study were to examine (a) the psychometric characteristics of an instrument to assess women's desire for control of healthcare during childbirth, and (b) examine desire for control in relation to parity, medical complications of pregnancy, and women's choices of childbirth providers and setting. The study design was cross-sectional using two different samples totaling 385 pregnant women. In Sample 1, (n = 193) we conducted an exploratory factor analysis to reduce the initial item pool. In Sample 2, (n = 192) we conducted a confirmatory factor analysis (CFA) of the final 12-item instrument and examined factors related to the desire for control. Results of the analysis in Sample 1 were supportive of a single-factor structure reflecting women's desire to influence the childbirth healthcare environment and decision-making. The final 12-item instrument had high internal consistency reliability (Cronbach's alpha = 0.93). CFA in Sample 2 was supportive of the single-factor structure with good model fit. The desire for control was directly correlated with an internal locus of control. Nulliparous women reported a lower desire for control compared with multiparous women. The desire for control among women with self-reported medical complications of pregnancy was comparable to that among women without pregnancy complications. The desire for control was a predictor of choosing midwives (vs. obstetricians), home or birth center (vs. hospitals), and professional labor support (e.g., doulas). Implications for future research on the impact of desire for control on maternal health outcomes are discussed.

Negative behaviours in health care: Prevalence and strategies.

AIM: To evaluate the effectiveness of a professionalism taskforce and the prevalence of negative behaviours across interdisciplinary groups at a south-eastern US academic medical centre. BACKGROUND: Negative behaviours within health care organisations may undermine patient safety. These behaviours are associated with decreased productivity, increased turnover, and poor patient and staff outcomes. METHODS: A pre-post study design using an adapted instrument, the Negative Behaviors in HealthCare (NBHC) survey, assessed perceptions of negative behaviours by physicians, clinical, and managerial staff both before and after a professionalism taskforce was convened in 2012 to identify and promulgate key strategies to improve behaviours. RESULTS: The 1,980 respondents completed the pre-survey in January 2012 and 1,423 completed the post-survey in 2014. Significant reductions in use of lateral aggression (LA) and vertical aggression (VA) (χ2  = 5.65, p < 0.017), observation of LA and VA (χ2  = 4.90, p < 0.027), and experience with contributing factors associated with negative behaviours (χ2  = 9.03, p < 0.003) were identified. CONCLUSIONS: Findings suggest that a professionalism taskforce guiding key strategies to elevate professionalism significantly affected beliefs about lateral and vertical aggression. IMPLICATIONS FOR NURSING MANAGEMENT: Decreasing negative behaviours in health care will require additional strategies and consistent implementation. Additional research addressing fear, retaliation, and job stress, and linking these behaviours to patient safety outcomes, is required.

Effect of Evidence-Based Practice (EBP) Courses on MSN and DNP Students' Use of EBP.

PURPOSE: The purpose of this study was to evaluate the effect of evidence-based practice (EBP) courses on nursing students' attitudes, perceived support from their professional network, self-efficacy, knowledge, and implementation of EBP. DESIGN: This study utilized a two-group, pre- and posttest design with 190 Masters of Science in Nursing (MSN) and 37 Doctorate of Nursing Practice (DNP) students. METHODS: An EBP instrument based on the theory of planned behavior was administered both before and after the EBP course (the intervention). FINDINGS: Both the pre- and posttest were completed by 126 students for a 56% response rate. No significant differences between the MSN (n = 102) and DNP (n = 24) students were found in precourse scores on any of the subscales except behavior, with the DNP students reporting they performed more EBP behaviors in the clinical setting. Overall, student scores on three of the four subscales of the EBP instrument (attitudes, self-efficacy, and behavior) significantly increased pre- to postcourse. The self-efficacy subscale demonstrated the greatest pre- to postcourse change scores. When the DNP and MSN students were compared, change scores on attitudes and self-efficacy remained significant in both groups. There was a significant positive change in EBP behavior only for the MSN students. Knowledge scores increased significantly only for the DNP students. LINKING EVIDENCE TO ACTION: EBP courses can increase self-reported EBP behaviors in the clinical setting, especially in MSN students. A precourse student evaluation will help faculty determine their learning needs in order to develop appropriate learning activities to support their acquisition of the essential knowledge, skills, and abilities to use EBP in the clinical setting. Administering the same evaluation postcourse can help faculty evaluate the effectiveness of their teaching. As a result, advanced practice nurses will be better equipped to facilitate and promote the implementation of EBP to support high-quality care and improved health outcomes.

Vitamin D deficiency and depressive symptoms in the perinatal period.

Depression affects 1 in 7 women during the perinatal period. Women with vitamin D deficiency may be at an increased risk for depression. This study investigated the relationship between maternal and cord blood 25-hydroxyvitamin D (25OHD) and maternal depressive symptoms over the perinatal period. Study objectives were to examine variations and relationships between maternal and cord blood vitamin D levels and maternal depressive symptoms over the perinatal period. At a large medical center in southern California, pregnant women (N = 126) were recruited for this longitudinal cohort study. Depressive symptoms (Edinburgh Postnatal Depression Screen, EPDS) and vitamin D status (25OHD) were measured at three time points in the perinatal period: time 1 (T1; N = 125) EPDS and 25OHD were collected in early pregnancy; time 2 (T2; N = 96) EPDS was conducted in the third trimester with blood collected at time of delivery; and time 3 (T3; N = 88) was collected postpartum. A significant inverse relationship between vitamin D status and depressive symptoms was observed between 25OHD and EPDS scores at all time points in this sample (T1 = - 0.18, P = 0.024; T2 = - 0.27, P = 0.009; T3 = - 0.22, P = 0.019). This association remained after controlling for confounders. Low cord blood 25OHD levels were inversely associated with higher EPDS scores in the third trimester (r = - 0.22, P = 0.02). Clinicians may want to consider screening women diagnosed with vitamin D deficiency for depression and vice versa. Vitamin D may represent an important biomarker for pregnant and postpartum women diagnosed with depression. Further studies examining underlying mechanisms and supplementation are needed.

The Perceived Medical Condition Self-Management Scale can be applied to patients with chronic kidney disease.

Chronic Kidney Disease (CKD) is a major burden on patients and the health care system. Treatment of CKD requires dedicated involvement from both caretakers and patients. Self-efficacy, also known as perceived competence, contributes to successful maintenance of patient's CKD self-management behaviors such as medication adherence and dietary regulations. Despite a clear association between self-efficacy and improved CKD outcomes, there remains a lack of validated self-report measures of CKD self-efficacy. To address this gap, the Perceived Kidney/Dialysis Self-Management Scale (PKDSMS) was adapted from the previously validated Perceived Medical Condition Self-Management Scale. We then sought to validate this using data from two separate cohorts: a cross-sectional investigation of 146 patients with end-stage renal disease receiving maintenance hemodialysis and a longitudinal study of 237 patients with CKD not receiving dialysis. The PKDSMS was found to be positively and significantly correlated with self-management behaviors and medication adherence in both patient cohorts. The PKDSMS had acceptable reliability, was internally consistent, and exhibited predictive validity between baseline PKDSMS scores and self-management behaviors across multiple time points. Thus, the PKDSMS is a valid and reliable measure of CKD patient self-efficacy and supports the development of interventions enhancing perceived competence to improve CKD self-management.

Development and Initial Testing of the FLOW Instrument: Novel Assessment of Lower Urinary Tract Symptoms in Men.

PURPOSE: We sought to develop a method to assess lower urinary tract symptoms regardless of literacy and numeracy. MATERIALS AND METHODS: We convened focus groups and developed a questionnaire based on 4 identified domains of urinary function, including frequency, incontinence (leakage), nocturia (overnight voiding) and weak stream. We pilot tested the novel FLOW (frequency, leakage, overnight voiding and weak stream) questionnaire in 64 men and performed quantitative analysis to determine internal consistency. Criterion validity was established via direct comparison to the AUA (American Urological Association) symptom score in a larger cohort of 161 men. RESULTS: Median time to complete the FLOW questionnaire was 18.0 seconds (IQR 15.8-21.0). The mean number of positive responses to the FLOW instrument was 1.7. Test-retest reliability was 0.91 and the Cronbach α was 0.67. In the validation cohort there was a significant correlation between FLOW scores and AUA symptom score (r = 0.63, p <0.001). All men regardless of health literacy completed FLOW. However, fewer men with low health literacy completed the AUA symptom score compared to men with adequate health literacy (81% vs 100%, p <0.001). For FLOW health literacy was unrelated to the median completion time (21.5 seconds), the median number of prompts needed (0) or the median score (2). CONCLUSIONS: A critical analysis of the AUA symptom score using valid health literacy scales revealed that it is frequently not completed, requires prompting and takes longer to complete for men with low health literacy. The FLOW instrument represents a novel method to assess lower urinary tract symptoms in all men. It represents a valid alternative to the AUA symptom score.

Parenting Self-Efficacy, Parent Depression, and Healthy Childhood Behaviors in a Low-Income Minority Population: A Cross-Sectional Analysis.

Objectives Childhood obesity prevention and treatment depends, in part, on parents acting as agents of change for their children. Our objective was to measure the associations between parenting self-efficacy, parent depressive symptoms, and preschool child behaviors that support healthy growth. Methods We performed a cross-sectional analysis of baseline data from a randomized controlled trial. Parenting self-efficacy was measured using a 5-item version of the Parenting Sense of Competence (PSOC-5) scale (α= 0.8). Parent depressive symptoms were measured using the Center for Epidemiological Studies-Depression (CESD) scale. Child outcomes included diet (24 h diet recall), physical activity (accelerometry), sleep (parent-report), and media use during meals (parent-report). We performed separate multiple linear regressions for each outcome controlling for other covariates. Results The sample consisted of 601 parent-child pairs. Median child age was 4.3 (IQR 3.6-5.1) years; median child body mass index (BMI) percentile was 79.1% (IQR 66.8-88.5%); 90% of children were Hispanic/Latino, and 6% of children were non-Hispanic Black. Median parent age was 31.5 (IQR 27.6-36.0) years; 22% of parents met criteria for depression. Parenting self-efficacy (median PSOC-5 25; IQR 24-28) was negatively correlated with depressive symptoms (ρ = -0.16; p < 0.001). In adjusted models, higher parenting self-efficacy was associated with duration of child's sleep and fewer meals eaten in front of a TV (p < 0.001). There was a significant interaction of parenting self-efficacy and parental depressive symptoms on child sleep duration (p < 0.001). Parenting self-efficacy and depressive symptoms were not significantly associated with child physical activity or child diet. Conclusions In this minority population, higher parenting self-efficacy was associated with longer child sleep and fewer meals in front the TV, but parent depressive symptoms mitigated that protective effect for child sleep duration.

Cross-sectional analysis of health-related quality of life and elements of yoga practice.

BACKGROUND: Mind-body practices such as yoga have been studied for their generally positive effects on health-related quality of life (HRQOL). The association between how a person practices yoga and the person's HRQOL is not known. MATERIALS AND METHODS: Yoga practitioners were sent invitations to participate in an online survey via email. Yoga characteristics, HRQOL, and other sociodemographics were collected. Analyses of data from 309 consenting responders evaluated associations between yoga practice characteristics (use of yoga tools, length of practice, location, method, etc.) and the 10-item PROMIS Global Health scale for both physical and mental health components. RESULTS: Multivariable regression models demonstrated higher mental health scores were associated with regular meditation practice, higher income, and the method of practicing in a community group class (versus one-on-one). Higher physical health scores were associated with length of lifetime practice, teacher status, Krishnamacharya yoga style, and practicing in a yoga school/studio (versus at home). CONCLUSIONS: Meditation practice in yoga is positively associated with mental health. Length of lifetime yoga practice was significantly associated with better physical health, suggesting yoga has a potential cumulative benefit over time. Different locations and methods of practice may be associated with varying effects on health outcomes. Comparative cross-sectional and longitudinal studies on the variations in yoga practice are needed to further characterize health benefits of yoga.

Measurement properties of the brief resilient coping scale in patients with systemic lupus erythematosus using rasch analysis.

BACGROUND: Resilience has been defined as the capacity or the ability to rebound from and positively adapt to significant stressors, despite experiences of significant adversity or trauma. To capture to what extent an individual copes with stress in a resilient fashion the Brief Resilient Coping Scale (BRCS) was developed. This tool was validated in people with chronic disease, such as rheumatoid arthritis using standard psychometric techniques of classical test theory, but not yet in patients with Systemic lupus erythematosus (SLE). The aim of this study was to explore the psychometric properties of the Brief Resilient Coping Scale in patients with SLE using Rasch analysis. METHOD: This study used cross-sectional data. The BRCS was administered to 232 patients with systemic lupus erythematosus. The aspects analyzed were unidimensionality, local independence and differential item functioning (DIF) to construct an interpretative scale of scores with the Rasch model. RESULTS: Rating scale mode (RSM) showed that the four categories used in the items of the BRCS are properly ordered. The four items provided a good fit to the polytomous Rasch model. Moreover, the parameters were sufficiently separated to measure resilience in patients with SLE. BRCS is a unidimensional scale (eigenvalue = 1.843) of resilience and the items were locally independent. There was no DIF between males and females in the sample. Only marginally significant differences depending on the level of education were found. The BRCS showed adequate discriminant validity between groups of scores. CONCLUSIONS: BRCS is a suitable scale for measuring resilience in patients with SLE. This scale might be useful for clinicians to obtain information concerning the degree of resilience that each patient has, allowing individuals with low resilience to be identified who need interventions aimed at developing coping skills.

Modified social learning theory re-examined: correlates of self-management behaviors of persons with Type 2 diabetes.

Modified social learning theory (MSLT) applied to health predicts that health behavior is a multiplicative function of health value and perceptions of control over health. The self-management behaviors of persons with Type 2 diabetes mellitus, internal diabetes locus of control (IDLC), diabetes self-efficacy (DSE), and health value (HV) were assessed with an index of diabetes self-care activities in 107 patients receiving insulin. Multiple regression analysis showed DSE as the only MSLT construct that correlated with the index of diabetes self-care behaviors (ß = .21, p < .05). While the predicted three-way interaction of IDLC × DSE × HV was significant (∆R2 = 4.5 %, p < .05) in the final step of the hierarchical model, the pattern of the findings only partially supported MSLT. Instead of finding that patients who were simultaneously high on all three predictors scored highest on the behavioral index, we found that patients who were low on all three constructs reported the least amount of diabetes self-care behavior. Implications for further modification of MSLT and its applications to clinical practice are discussed.

Effects of stress, health competence, and social support on depressive symptoms after cardiac hospitalization.

Little is known about the role of stress on the psychological well-being of patients after cardiac hospitalization or about factors that protect against or exacerbate the effects of stress. We use prospective data from 1542 patients to investigate the relationship between post-discharge stress and changes in depressive symptoms, and whether the level of prior depressive symptoms, health competence, and perceived social support moderate this relationship. Net of depressive symptoms in the 2 weeks prior to hospitalization, higher levels of post-discharge stress significantly increase depressive symptoms 30 days after discharge. The level of prior depressive symptoms moderates the effect of stress. On the other hand, perceived health competence and social support buffer the negative effects of post-discharge stress. Knowing which patients are particularly vulnerable to experiencing stress and a subsequent increase in depressive symptoms can help trigger interventions prior to discharge and possibly ameliorate the prevalence of depression.

Health care providers' support of patients' autonomy, phosphate medication adherence, race and gender in end stage renal disease.

This study was designed to assess dialysis subjects' perceived autonomy support association with phosphate binder medication adherence, race and gender. A multi-site cross-sectional study was conducted among 377 dialysis subjects. The Health Care Climate (HCC) Questionnaire assessed subjects' perception of their providers' autonomy support for phosphate binder use, and adherence was assessed by the self-reported Morisky Medication Adherence Scale. Serum phosphorus was obtained from the medical record. Regression models were used to examine independent factors of medication adherence, serum phosphorus, and differences by race and gender. Non-white HCC scores were consistently lower compared with white subjects' scores. No differences were observed by gender. Reported phosphate binder adherence was associated with HCC score, and also with phosphorus control. No significant association was found between HCC score and serum phosphorus. Autonomy support, especially in non-white end stage renal disease subjects, may be an appropriate target for culturally informed strategies to optimize mineral bone health.

What Patient Characteristics Influence Nurses' Assessment of Health Literacy?

Overestimation of patients' health literacy skills is common among nurses and physicians. At Vanderbilt University Hospital, nurses routinely ask patients the 3 Brief Health Literacy Screen (BHLS) questions. Data from 2 studies that recruited patients at Vanderbilt University Hospital-the Health Literacy Screening (HEALS) study and the Vanderbilt Inpatient Cohort Study (VICS)-were analyzed to compare the BHLS score recorded by nurses during clinical care with the score recorded by trained research assistants during the same hospitalization. Logistic regression models determined which patient characteristics were associated with nurses documenting higher health literacy scores than research assistants. Overall, the majority (60%) of health literacy scores were accurate, though nurses recorded meaningfully higher health literacy scores in 28.4% of HEALS patients and 35.6% of VICS patients. In the HEALS cohort, patients who were male and had less education were more likely to have higher health literacy scores recorded by nurses (odds ratio [OR] = 1.93, 95% confidence interval [CI] [1.24, 3.00]; and OR = 0.80, 95% CI [0.74, 0.88], respectively). In the VICS cohort, patients who were older, were male, and had less education were more likely to have higher health literacy scores recorded by nurses (OR = 1.01, 95% CI [1.003, 1.02]; OR = 1.49, 95% CI [1.20, 1.84]; and OR = 0.87, 95% CI [0.83, 0.90], respectively). These findings suggest that health literacy scores recorded by nurses for male patients and patients with less education could be overestimated. Thus, health care professionals should be aware of this tendency and should verify the results of routine health literacy screening tests, especially in certain patient groups.