"Don't Think Paralysis Takes Away Your Womanhood": Sexual Intimacy After Spinal Cord Injury.

Sexuality and intimacy are important components of health and well-being. Issues surrounding sexuality and intimacy are equally important for men and women living with physical disabilities, including spinal cord injury (SCI). Yet, women's sexuality after SCI remains largely unexamined. This article presents the findings from an in-depth qualitative investigation of the sexual and reproductive health experiences of 20 women with SCI in or around Detroit, MI. Findings echo existing literature documenting the sexual consequences of life after SCI and suggest new areas of inquiry important for better addressing sexual concerns across the lifespan. Specifically, findings suggest a need to consider the variable effects of SCI on sexual intimacy in relation to a person's developmental trajectory, the appropriate timing of sexual education, the need to expand conceptualizations of sexual intimacy, and the ways SCI may affect sexuality in later life.

Perceived Cognitive Impairment among African American elders: health and functional impairments in daily life.

OBJECTIVES: The Center for Disease Control began to assess Perceived Cognitive Impairment in 2009, yet there has been no in-depth study of how perceived decline in thinking or memory skills may be associated to the health and lifestyle of an independent community-dwelling older person. Among urban-dwelling older African Americans who are at elevated risk for cognitive impairment and dementia, we know even less regarding the interaction of these risk factors. METHOD: Five hundred and one African American elders (n=501) between the ages of 55 and 95 with an average age of 70.73 years (SD=8.6 years) participated in telephone interviews. RESULTS: Approximately one-third of the elders reported that their memory, thinking skills, or ability to reason was worse than a year ago (n=150; 29.9%) and 25% of this group (n=38) reported that this Perceived Cognitive Impairment impacted their daily activities and/or warranted a consultation with their doctor. Bivariate analyses indicated that Perceived Cognitive Impairment was associated with increased health problems, mobility limitations, depressed mood, and lower social functioning. CONCLUSION: Elders who reported that cognitive problems impacted their daily functioning reported the greatest health and mental health problems. Perceived Cognitive Impairment is an important health variable with implications for an older adult's overall health, mobility, and mental health.

Do risk perceptions explain sex differences in community integration and participation after Spinal Cord Injury?

OBJECTIVE: To describe how men and women with spinal cord injury (SCI) rate the risks posed by a set of everyday activities measured using the Risk Inventory for persons with Spinal Cord Injury (RISCI), and to examine whether sex differences are related to community integration and participation. DESIGN: Cohort study. SETTING: Metropolitan Detroit. PARTICIPANTS: One hundred and forty community-dwelling white and African-American men and women with SCI. OUTCOME MEASURES: RISCI scores, community integration, and level of and satisfaction with community participation. RESULTS: Study participants were just over age 40 years, and had been living with SCI for 10.8 years. One-third were women and 40% were African-American. Results showed women with SCI had higher RISCI scores (perceived more dangers) on every item on the RISCI Scale (P < 0.001). The items perceived to hold greatest risk were revealing personal information to others, going on a blind date, and going for a roll ("walk") alone after dark. Women with higher RISCI scores reported lower community integration (P < 0.05) and lower levels of and lower satisfaction with community participation (P < 0.01). For men, however, RISCI scores were mainly unrelated (except for community integration) to participation measures. CONCLUSION: More research is needed to determine whether the levels of risk perceived by women are warranted and whether a sense of vulnerability for women with SCI is unnecessarily limiting their chances at "a good life" after injury.

Self-rated health among persons with spinal cord injury: what is the role of physical ability?

OBJECTIVES: Self-rated health (SRH) is a powerful concept that has greatly advanced our understanding of health and health outcomes. The SRH measure has become increasingly common in health research. Yet, puzzles remain about what shapes SRH ratings. The absence of knowledge is particularly acute in the context of disability. The aim of this study was to examine the relationship between SRH and self-rated physical ability in a sample of individuals with spinal cord injury (SCI). METHODS: Data from 140 eligible participants drawn from a study of life in the community after SCI were analyzed. The study, cross-sectional in design, was conducted in a large urban city in the mid-western United States. Basic statistics such as ANOVA and chi-square tests were performed as appropriate, and a multiple linear regression analysis modeled the relationship between SRH and physical ability adjusting for potential confounding variables. RESULTS: Self-rated physical ability was significantly associated with SRH after controlling for relevant covariates (P < 0.001). An analysis of the interaction between physical ability and level of injury revealed that the relationship was significant for persons with paraplegia but not for persons with tetraplegia. CONCLUSIONS: This study provides evidence that self-rated physical ability is an important factor associated with SRH for persons with SCI, but that the strength of the relationship depends on level of injury (paraplegia vs. tetraplegia). The challenge for future research is to replicate the study using a more comprehensive measure of physical ability and to ask how beliefs in one's ability to do those activities that are most meaningful and desired shape SRH. Only in this way will our understanding of the physical ability-SRH relationship be clarified.

Effect of a DVD intervention on therapists' mental health practices with older adults.

PURPOSE: We tested the effectiveness of an educational intervention in DVD format aimed at strengthening the mental health practices of occupational therapists working with older adults. METHOD: The DVD intervention was tested in a pretest-posttest design. Occupational therapists (n = 30) completed a brief knowledge and attitude questionnaire; a chart review (n = 383) of therapists' (n = 20) patients at 3 mo before and 3 mo after DVD training was also conducted. RESULTS: Questionnaire data showed that the percentage of therapists with correct answers increased 20%-30% for 5 of the 11 knowledge items. Chart review data showed therapists spoke more often with their older patients about mood, depression, and cognitive impairment; screened more often for depression and cognitive impairment; and reported findings more often to the treatment team after training. CONCLUSION: Educational interventions can significantly improve therapists' mental health practice with older adults.

The 'risk inventory for persons with spinal cord injury': development and preliminary validation of a risk assessment tool for spinal cord injury.

PURPOSE: To present a new short instrument to measure perceived risks of common everyday activities engaged in by persons with spinal cord injury (SCI), and to provide preliminary data on its psychometric properties. METHOD: Community-dwelling men and women with SCI (N = 139) in metropolitan Detroit completed the risk inventory for persons with spinal cord injury (RISCI). They also answered a risk-taking identity question ('Are you a risk-taker'?) and completed the risk orientation questionnaire (ROQ) (Rohrmann, http://www.rohrmannresearch.net/ , 2008), a risk propensity measure. RESULTS: All items of the RISCI correlated positively with each other and the total score; internal reliability as measured by Cronbach's alpha was 0.86. Principal components factor analysis confirmed a one-factor structure which explained 41% of the variance. A three-factor solution with readily interpretable factors explained 64% of the variance. Content validity was established through extensive consultations with persons with SCI in the development of the measure. Discriminant validity was supported by the ability of the RISCI to distinguish between subsamples (for example, between men and women, those with paraplegia and tetraplegia) for whom differences in risk assessment might be expected. Criterion validity was supported by significant relationships in the expected directions between the RISCI and risk-taking identity and between the RISCI and the ROQ. CONCLUSIONS: Findings suggest that the RISCI is a brief, easy to administer and psychometrically sound measure of perceived risk of activities common in daily life for use with persons with SCI.

Environmental factors and their role in community integration after spinal cord injury.

BACKGROUND: The International Classification of Functioning, Disability and Health (ICF) model presents an opportunity to better understand previously neglected longterm social outcomes after traumatic spinal cord injury (SCI), especially the experience of participation. PURPOSE: The study explored the relationship between perceived environmental barriers and perceived community integration (a participation proxy) in a sample of adults with traumatic SCI. METHODS: The study interviewed African American and White women and men (n = 136) who had lived with SCI for an average of 11.5 years. RESULTS: Participants reported environmental barriers at twice the level indicated by previous studies; the natural environment and the policies of government were the most problematic. Levels of community integration were also high. Data suggest a significant relationship (p < .01) between perceived environmental barriers and community integration for adults with SCI, providing support for the ICF model. IMPLICATIONS: Improved measures and more sophisticated concepts and theories are needed to explicate the relationship between environmental factors and participation concepts in the ICE With respect to practice, occupational therapists need to be aware that removal of environmental barriers is only a first step in the more complex effort to facilitate optimal community integration after SCI.

Investigating differences among older adults' access to specialized rehabilitation services.

The purpose of this study was to (a) describe rehabilitation in-patients aged 65 and older who received specialized occupational therapy home evaluation services and (b) examine these data for evidence of inequalities based on patient gender, race, age, and health insurance status. An archival review was conducted of all in-patient admissions (2,767) to a large urban rehabilitation hospital who were 65 years and older and eligible to receive a home evaluation. Logistic regression was used to predict the likelihood of receiving an occupational therapy home evaluation. Analysis showed that 9.7% of subjects received an in-home evaluation and those who did had significantly longer rehabilitation hospital stays (p < 0.0001) and were significantly more dependent at discharge as measured by the Functional Independence Measure (p < 0.0001) than those who did not. We found no evidence of inequalities on the basis of gender, race, age, and health insurance type after controlling for the level of functional independence of patients. Although this study found little evidence of inequalities, it does raise several critical policy questions including "How many rehabilitation in-patients should receive a home evaluation?" and "How should rehabilitation services be allocated?"

Long-term community reintegration: concepts, outcomes and dilemmas in the case of a military service member with a spinal cord injury.

PURPOSE: Despite growing knowledge about medical and functional recovery in clinical settings, the long-term issue of community reintegration with a spinal cord injury (SCI) in the military context remains virtually unexamined. Thus, the U.S. Department of Defense created the SCI Qualitative Research Program to advance knowledge about service members' reintegration into civilian life. The purpose of this paper is to better characterize the long-term outcomes related to the community participation experienced and desired vis-à-vis a case study of a military veteran who suffered a service-related traumatic SCI. METHODS: An in-depth anthropological interview was used with Jake, a 28-year old marine with a service-related C5/C6 SCI. Data were analyzed using content analysis. FINDINGS: Three significant themes were identified: opportunities for better engaging socially meaningful others may not be adequately included in so-called "client-centered" interventions; how management of the social self in inter-personal interactions and public spaces is critical to gaining broader societal acceptance; and how meaningful age normative relationships and activities are essential to establish lasting inclusive social connections. CONCLUSIONS: Jake's case challenges existing models of rehabilitation predominantly focused on physical capacity building. Study findings point to the need for rehabilitation to invest more resources in efforts to address the existential and social elements of long-term social reintegration. Implications for Rehabilitation Both the veteran with SCI and their meaningful support network face challenges socially reintegrating after injury and rehabilitation. Empowering clients to envision future possibilities in terms of family, intimate relationships, and meaningful work are important to successful long-term social reintegration. Addressing the existential desires and social capacities of the individual may be as important as addressing physical functioning skills after SCI.

Allocation of rehabilitation services: who gets a home evaluation.

OBJECTIVE: The purpose of this study was to (a) identify and describe the subpopulation of rehabilitation inpatients who receive specialized occupational therapy home evaluation services, and (b) examine these data for evidence of inequalities in access to services based on patient gender, race, age, and health insurance status. METHOD: An archival review was conducted of all inpatient admissions (7,871) to a large urban rehabilitation hospital between January 1, 1994, and December 31, 1998. We had complete data on 7,791 of these patients of whom 6,038 were eligible to receive a home evaluation. Patient demographic data and Functional Independence Measure (FIM) data were obtained in electronic form from the hospital information system. RESULTS: Analysis showed that 12.4% (749/6038) of eligible inpatients received an in-home evaluation, and those who did were significantly more dependent (as measured by the FIM) than those who did not (p < 0.0001). We found no evidence of inequalities in access to this specialized rehabilitation service on the basis of gender, race, age, and type of medical insurance after controlling for level of functional independence. CONCLUSIONS: This study found no evidence of inequalities in the allocation of home evaluation services. However, it raises the larger question of how we determine whether inequalities exist. A proper assessment of inequalities in service provision requires that we know the principles by which these services should be allocated and have appropriate measures of the application of these principles. For programmatic and policy reasons, more research is needed to develop well-defined principles of resource allocation, and adequate measures of their impact so we can know whether resources and services are distributed in the way we intend.

Quality of life and supported employment: a case study of three women with developmental disabilities.

This paper presents the findings of a qualitative case study of the quality of life of three women with developmental disabilities. In-depth interview data were collected from the women who had previously worked in a sheltered workshop environment and were, at the time of study, working in supported employment in the community. Interviews were also conducted with each woman's job coach and a family member or close friend. On-site observations of the women in their supported employment environments were also undertaken. Results show that the women's own perceptions about their quality of life were not always as family members and job coaches expected, and that the purported benefits of supported employment for the three women with developmental disabilities were not always realized. Occupational therapists have an opportunity to facilitate the occupational performance of adults with developmental disabilities but they must be willing to engage in wider health and social policy change if they are to make significant gains.

"I see it now": Using photo elicitation to understand chronic illness self-management

BACKGROUND: How people integrate self-management into daily life remains underexamined, and such processes are difficult to elicit through traditional approaches used to understand human occupation. PURPOSE: This paper will provide a brief overview of one visual research method, photo elicitation, that holds promise for studying self-management of health behaviours and will present findings from an analysis of how the use of photo elicitation interviews contributed additional insights into self-management beyond those generated from the data collected through the other methods used in the study. METHOD: A qualitative, multiple-methods, multiple-case study was conducted with a purposive sample of 10 low-income women ages 40 to 64 with type 2 diabetes. FINDINGS: The photo elicitation interviews contributed insights beyond those generated from other study methods about how individuals viewed their self-management behaviours and how occupations changed across time. IMPLICATIONS: Photo elicitation is a valuable research method for better understanding clients' chronic illness self-management practices.

Falls efficacy and self-rated health in older African American adults.

Fear of falling and mobility restrictions have a significant negative impact on the quality of life of older adults. Because older African American adults are at increased risk for various modifiable health problems, understanding potential constraints on their overall health and mobility is critical in this population. The current study investigated this issue by analyzing a dataset of 449 older African American adults (mean age=72.3 years) living in Detroit. We characterized and investigated the relationships among the following falls- and health-related variables: previous falls, falls efficacy, mobility, self-rated health (SRH), and depression and well-being. As a whole, participants reported moderate health and well-being, little depression, few mobility problems (mean=8.4/40), and very high falls efficacy (mean=94.9/100) despite the fact that a quarter of the sample experienced a fall within the past year. Correlation results indicated that previous falls, falls efficacy, mobility, SRH and depression and well-being were all inter-related. Regression analyses revealed that higher falls efficacy was more closely associated with better SRH than was having previously fallen. Findings suggest that improving falls efficacy in older African American adults may be beneficial to their mobility and overall health and well-being. Further, by asking a single-item SRH question, clinicians may be able to quickly identify older African American adults who have low falls efficacy and are at high risk for falling.

Community engagement: an essential component of well-being in older African-American adults.

Active engagement in life is a critical factor for successful aging. Research indicates that community engagement is strongly associated with health and well-being in late life. However, less is understood regarding the influence of neighborhood conditions on health and well-being, particularly in older African-American adults. The current study describes a convenience sample of older African Americans (N = 501, mean age = 70.7 [range 55-95] years) living in Detroit. The specific goal is to examine the relationships between their perceptions of neighborhood conditions, level of community engagement, and their health and well-being. Survey findings reveal a sample of highly engaged older African Americans in reasonable health who perceive their neighborhoods favorably. Regression analysis results indicate that community engagement is closely associated with both neighborhood perceptions and well-being in this sample. We propose that community engagement or "participation" mediates the relationship between neighborhood conditions and well-being for older African Americans living in Detroit.

DVD training for depression identification and treatment in older adults: a two-group, randomized, wait-list control study.

OBJECTIVE. To test the effectiveness of an educational intervention aimed at improving mental health knowledge and skills in occupational therapists working with older rehabilitation patients. METHOD. The DVD-format educational intervention was evaluated using a two-group randomized wait-list control design. Occupational therapists (n = 75) completed a 32-item knowledge questionnaire at three time points. Patient charts were reviewed (n = 960) at 3 months before and 3 and 6 months after DVD training to evaluate clinical practice change. RESULTS. A two-way analysis of variance showed knowledge scores increased significantly for both groups after DVD training. A significant Group × Time interaction and significant main effects for time and group were found. Chart review data also showed significant increases in desired clinical behaviors in both groups after training. The greatest single item of clinical practice change was use of a standardized depression screen. CONCLUSION. DVD-based training can significantly improve mental health practice.