Development of a behaviour change intervention for improving physical activity amongst stroke survivors with physical disabilities: a co-design approach.

BACKGROUND: Stroke survivors face many barriers to physical activity (PA). Solving physical inactivity after stroke requires a "systems-based" approach. We aimed to develop a complex intervention targeted at improving PA after stroke in Singapore using behaviour change theory and a co-design approach involving multiple stakeholders. METHODS: We carried out the intervention development in three phases: i. preparation phase, ii. co-design phase, and iii. intervention refinement phase. During the preparation phase, we conducted surveys (n = 38 stroke survivors, 71 physiotherapists and 35 exercise professionals) and interviews (n = 19 stroke survivors) to understand the factors influencing PA after stroke. The co-design phase consisted of two-co-design workshops held in August 2022 and were attended by 13 stroke survivors and 4 caregivers. Relevant domains of the Theoretical Domains Framework (TDF) and items in the Template for Intervention Description and Replication (TIDieR) checklist guided the discussion topics in the first co-design workshop. Solution prototypes such as exercise videos, arm and leg straps and information resources were shown in the second co-design workshop to gather feedback. In the intervention refinement phase, eight healthcare professionals from various sectors participated in two virtual Zoom meetings in August 2023, and used the Acceptability, Practicability, Effectiveness, Affordability, Spillover effects and Equity (APEASE) grid to rate the active ingredients in the complex intervention by considering the current healthcare landscape in terms of resources and manpower. RESULTS: Stroke survivors and caregivers want a personalised PA program, stroke-specific PA opportunities and information resources, medical clearance, advice and help from healthcare professionals skilled in stroke care, face-to-face sessions at preferred exercise spaces, and access to adaptive equipment. A complex intervention consisting of 21 behaviour change techniques, 6 intervention functions and 8 options was developed. CONCLUSIONS: Using behaviour change theory and a co-design approach involving multiple stakeholders, a complex intervention was developed to target physical inactivity after stroke. The intervention titled MOTIVATE is currently being tested in a type 1 hybrid effectiveness-implementation trial.

Adherence to secondary stroke prevention medications in Singapore: a single center study.

OBJECTIVES: Recurrent strokes are associated with greater disability and mortality than first-time strokes. However, adherence to secondary stroke prevention medications has been reported to be suboptimal. We assessed medication adherence to antihypertensives, antiplatelets, and statins after acute ischemic stroke and identified factors associated with non-adherence behavior to each drug class. METHODS: This single center study is an extension of a larger prospective cohort study of ischemic stroke patients assessed at an outpatient post stroke clinic. Medication adherence behavior and medication knowledge was determined by direct questioning, and perceptions towards medications via the Beliefs about Medicines Questionnaire. Factors associated with non-adherence in each drug class were determined using logistic regression. RESULTS: Rates of adherence differed between antihypertensives (77.9%), antiplatelets (80.3%), and statins (64.7%) (p < 0.001) amongst the 193 patients surveyed. Non-adherence to antihypertensives was associated with living alone, taking < 5 medications, and stronger beliefs that medications are harmful. For antiplatelets, non-diabetic patients and patients with stronger beliefs that medications are harmful were more likely to be non-adherent. Patients non-adherent to statins were more likely to have a longer time since ischemic event and have a transient ischemic attack as the index event. CONCLUSIONS: Overall, medication adherence behavior to secondary stroke prevention medications was poor, with statins the least adhered to. Factors associated with non-adherence to each drug class could guide the development of tailored interventions to improve adherence to secondary stroke prevention medications.

Effectiveness of mindfulness-based interventions delivered via technology versus therapist among patients on peritoneal dialysis at an outpatient clinic in Singapore.

AIMS: This study aimed to (i) evaluate the effectiveness of mindfulness-based interventions in improving self-efficacy, reducing stress and anxiety among peritoneal dialysis patients, and (ii) compare the most effective method of mindfulness based interventions. METHODS: This randomized three-arm controlled trial recruited first-time peritoneal dialysis patients from the peritoneal dialysis outpatient clinic in Singapore. Patients were randomly allocated to either video-assisted mindfulness training, therapist-assisted mindfulness training or treatment-as-usual. All groups received 4.5 days of structured peritoneal dialysis training at the peritoneal dialysis centre, while video-assisted mindfulness training and therapist-assisted mindfulness training groups were taught additional mindfulness-based techniques. The perceived stress scale, self-efficacy, and anxiety (State and Trait Anxiety Inventory) were measured at baseline, 4- and 12 weeks post-randomization, using reliable and valid instruments. RESULTS: Thirty-nine patients were recruited (13 in each group). All the therapies showed a significant time trend in anxiety. Only therapist- and video-assisted mindfulness training showed a significant trend in perceived stress scale scores but not treatment-as-usual. All Intervention X Time interactions were not significant. Patients in therapist- and video-assisted mindfulness training groups had reduced perceived stress scale scores compared to treatment-as-usual at week 12. CONCLUSION: This study demonstrated the potential of mindfulness-based interventions in reducing stress among first-time PD patients.

Mindfulness-based therapy for insomnia for older adults with sleep difficulties: a randomized clinical trial.

OBJECTIVE: Poor sleep is a modifiable risk factor for multiple disorders. Frontline treatments (e.g. cognitive-behavioral therapy for insomnia) have limitations, prompting a search for alternative approaches. Here, we compare manualized Mindfulness-Based Therapy for Insomnia (MBTI) with a Sleep Hygiene, Education, and Exercise Program (SHEEP) in improving subjective and objective sleep outcomes in older adults. METHODS: We conducted a single-site, parallel-arm trial, with blinded assessments collected at baseline, post-intervention and 6-months follow-up. We randomized 127 participants aged 50-80, with a Pittsburgh Sleep Quality Index (PSQI) score ⩾5, to either MBTI (n = 65) or SHEEP (n = 62), both 2 hr weekly group sessions lasting 8 weeks. Primary outcomes included PSQI and Insomnia Severity Index, and actigraphy- and polysomnography-measured sleep onset latency (SOL) and wake after sleep onset (WASO). RESULTS: Intention-to-treat analysis showed reductions in insomnia severity in both groups [MBTI: Cohen's effect size d = -1.27, 95% confidence interval (CI) -1.61 to -0.89; SHEEP: d = -0.69, 95% CI -0.96 to -0.43], with significantly greater improvement in MBTI. Sleep quality improved equivalently in both groups (MBTI: d = -1.19; SHEEP: d = -1.02). No significant interaction effects were observed in objective sleep measures. However, only MBTI had reduced WASOactigraphy (MBTI: d = -0.30; SHEEP: d = 0.02), SOLactigraphy (MBTI: d = -0.25; SHEEP: d = -0.09), and WASOPSG (MBTI: d = -0.26; SHEEP (d = -0.18). There was no change in SOLPSG. No participants withdrew because of adverse effects. CONCLUSIONS: MBTI is effective at improving subjective and objective sleep quality in older adults, and could be a valid alternative for persons who have failed or do not have access to standard frontline therapies.

Stroke survivors' preferences for post-stroke self-management programs: A discrete choice experiment.

BACKGROUND AND PURPOSE: Self-management programs enhance survival in stroke patients. However, they require patient-centered designs to be effective. The aim of this study was therefore to investigate the type of post-stroke self-management programs that appeal to stroke survivors, and to estimate their willingness to participate in such programs. METHODS: A Discrete Choice Experiment was administered to patients who had either a transient ischemic attack (TIA) or stroke within the past 3 years and were cognitively intact (i.e., stroke survivors). Stroke survivors were presented with eight choice tasks and asked to choose between 'No Program' and two hypothetical post-stroke management programs that varied by six attributes: Topics covered by the program; schedule of the program; frequency and duration of the sessions; number of participants; out-of-pocket registration fee for the whole program; and rewards for completing the program. RESULTS: The analysis involved 146 stroke survivors. Based on the mixed logit model, the predicted willingness to participate ranged from 53% to 76%. The most popular characteristics in a program were topics on health education and risk management, being scheduled during weekends as four sessions that are each 2 hours long and involve four participants, a registration fee of SGD50 (∼USD36), and SGD500 (∼USD359) reward for program completion. CONCLUSIONS: Interest in post-stroke self-management programs was high, with at least half of the sample showing interest in participating in these programs. Program features such as focusing on health education and risk management, charging a low registration fee, and offering incentives helped to increase the demand.

Effects of mindfulness-based therapy for insomnia and a sleep hygiene/exercise programme on subjective-objective sleep discrepancy in older adults with sleep disturbances: Exploratory secondary analysis of a randomised clinical trial.

Older adults with poor sleep tend to show a discrepancy between objective and self-reported sleep parameters, which can trigger a vicious cycle that worsens their sleep complaints. Cognitive-behavioural therapy can reduce this discrepancy, but alternative behavioural therapies remain untested. The present exploratory study aimed to investigate the effects of mindfulness-based therapy for insomnia (MBTI) on reducing sleep discrepancies in comparison with a sleep hygiene, education, and exercise programme (SHEEP). Older adults were randomly allocated into the mindfulness-based therapy for insomnia group (n = 55) or the sleep hygiene, education, and exercise programme group (n = 58). Subjective and objective sleep parameters were measured using sleep diaries, polysomnography (PSG), and actigraphy. Sleep discrepancies were calculated using the Bland-Altman method for sleep onset latency (SOL) and wake after sleep onset (WASO). Additionally, correlations between the change in sleep discrepancies and the change in subjective sleep quality and trait mindfulness were measured within each group. Sleep onset latency discrepancy measured by polysomnography and actigraphy decreased significantly after the MBTI and SHEEP interventions. In contrast, there was no significant change in wake after sleep onset discrepancy in either group. The change in sleep onset latency discrepancy was correlated with the change in insomnia symptoms and objectively measured trait mindfulness. Mindfulness-based therapy for insomnia was effective in reducing sleep onset latency discrepancies and improving sleep perception in older adults with sleep disturbances, which in turn drove an improvement in sleep quality and insomnia symptoms. Increases in trait mindfulness may have been an important mechanism in improving sleep perception in the mindfulness-based therapy for insomnia group.

Mindfulness-based cognitive therapy in functional dyspepsia: A pilot randomized trial.

BACKGROUND AND AIM: Patients with functional dyspepsia (FD) often have concomitant anxiety and depression. Mindfulness-based cognitive therapy (MBCT) combines the principles of cognitive behavioral therapy and mindfulness. It is a group-based therapy and has been shown to be efficacious in functional gastrointestinal disorders. There are no randomized controlled trials (RCTs) evaluating MBCT in FD. We aimed to evaluate feasibility and efficacy of MBCT in FD management. METHODS: We performed a mixed-method single-center pilot randomized trial of 28 patients fulfilling ROME-III criteria for FD. Fifteen patients were randomized to an 8-week MBCT program while 13 underwent treatment-as-usual (TAU). Patients completed questionnaires at baseline and at week 8. Two focus-groups were conducted. Feasibility of recruitment, acceptability of randomization, procedures and intervention, handout compliance and feasibility of quantitative measures were assessed. The primary outcome was subjective-clinical-assessment of FD symptoms (SCA-FD). Secondary outcome measures included Short-form Nepean Dyspepsia Index (SF-NDI), subjective-clinical-assessment of general health (SCA-GH), EuroQoL-Visual Analog Scale (EuroQoL-VAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21). RESULTS: Twelve of 15 patients in the MBCT group completed the program. There was a trend towards symptom improvement, with 90% in the MBCT group reporting improvement in SCA-FD compared with 45% in TAU(P = 0.063). Patients who underwent MBCT reported greater improvement in SF-NDI (mean change: -8.8 (SD: 7.5) vs -0.7 (7.2), P = 0.018) and DASS-21 (-19.8 (29.5) vs -5.5 (6.6) P = 0.13) compared with TAU. There was no difference in SCA-GH and EuroQoL-VAS. Based on SCA-FD improvement, the eventual RCT will require 50 patients (25 in each group). CONCLUSIONS: Mindfulness-based cognitive therapy is likely efficacious for FD, and it would be feasible to conduct a RCT.

Assessment of small intestinal bacterial overgrowth in Alzheimer's disease.

There is great interest in crosstalk between the gastrointestinal and immune systems. Small intestinal bacterial overgrowth (SIBO) is a bowel disorder prevalent among patients with Parkinson's disease; SIBO treatment has been shown to modulate neurological inflammation, motor and cognitive outcomes there. However, to date, no link between Alzheimer's dementia and SIBO has been established. This pilot study sought to estimate the prevalence of SIBO in Alzheimer's dementia in the outpatient setting in Singapore General Hospital. It entailed performing a hydrogen breath test and objectively scoring gastrointestinal symptoms and their severity in 48 patients, comparing symptom scores and mean breath test values in those with mild to moderate Alzheimer's against age- and sex-matched controls that did not fulfill DSM-V criteria for probable Alzheimer's. Here, the prevalence of positive breath tests and symptoms of SIBO were no greater among Alzheimer's patients than in controls. This suggests that the gut microbiome changes and increased bowel inflammation seen in previous studies on Alzheimer's patients are likely effected through pathways other than SIBO, and are likely more complex than a mere increase in small bowel bacterial volume. Rather, future research could be directed along the lines of qualitative changes in small bowel microbiota, or pathologies in other parts of the gastrointestinal tract such as the colon or stomach, aspects which are not adequately captured by the hydrogen breath test. Keywords: Alzheimer's disease; dementia; gut-brain axis; small intestinal bacterial overgrowth; microbiome.

Modifiable Factors Associated with Non-Adherence to Secondary Ischaemic Stroke Prevention Strategies.

BACKGROUND: Secondary stroke-prevention strategies proven to reduce stroke recurrence include pharmaceutical agents and lifestyle modifications. AIMS: We aimed to study factors associated with adherence to medications and lifestyle modifications amongst ischaemic stroke and transient ischaemic attack (TIA) patients. METHODS: In a prospective cohort study, we surveyed 200 outpatients attending stroke clinic at a Singaporean tertiary hospital. We determined medication knowledge and lifestyle modification adherence through direct questioning. We also administered the Beliefs About Medicines Questionnaire, Trust in Physician Scale, Patient Health Questionnaire and Hospital Anxiety and Depression Scale. Multivariable logistic regression models were used to identify factors associated with adherence. RESULTS: The rates of adherence to medications, smoking cessation, dietary modification, and exercise were 52.3%, 71.0%, 80.0% and 78.5% respectively. Subjects who lacked medication knowledge (OR=3.47; 95% CI=1.55-7.74) or possessed negative medication beliefs (OR=1.20; 95% CI=0.72-0.96) were less likely to be adherent to medications. TIA as an index event (OR=5.04; 95% CI=1.39-18.32), younger age (OR=1.04; 95% CI=1.01-1.08) and higher income (OR=2.40; 95% CI=1.09-5.25) were also associated with medication non-adherence. There were no associations between adherence to medications and lifestyle modifications. Dietary adherence was independently associated with exercise adherence (OR=17.2; 95% CI=3.21-92.22). CONCLUSIONS: Our findings of suboptimal adherence to medications and lifestyle modifications show that many stroke patients are not benefitting from proven secondary stroke prevention strategies. We identified medication knowledge and medication beliefs as potential target areas for studies to improve medication adherence.

The types of caregiving reactions experienced by the older spouse caregivers.

AIMS: To examine factors associated with the four types of caregiver reactions according to the modified Caregiver Reaction Assessment (mCRA) and assess the differences in the narrative assessment from spouse caregivers between the high-positive and high-negative caregiver reactions. BACKGROUND: There is a limited understanding of the factors contributing to positive and negative reactions among older spouse caregivers with chronic illnesses. Narrative assessment from spouse caregivers has not been studied before. DESIGN: The study design was a paired-sample, mixed-method survey design. Data were collected from spouse caregivers (≥55 years old) and care-recipients in one medical institute from February 2017-December 2017. This manuscript used STROBE checklist to ensure complete reporting. METHODS: Demographic, socioeconomic, Frailty Index, perceived stress, and quality of life data were gathered from caregiver dyads. mCRA, relationship, and life satisfaction data were collected from caregivers. mCRA identified the four types of caregiver reactions: (a) high-positive, low-negative; (b) high-positive, high-negative; (c) low-positive, high-negative; and (d) low-positive, low-negative. A qualitative interview was conducted to understand the differences in the narrative and choice of words used to describe caregiving experience. RESULTS: Seventy-five caregiver dyads were recruited. Total perceived stress was found to be negatively associated with high-positive, low-negative caregiver reaction (baseline category: low-positive, high-negative) by multinomial logistic regression. Content analyses showed that low-positive and high-negative caregivers used words that implied a lack of volition. Caregivers with positive experience viewed caregiving as a responsibility; the opposite viewed it as having 'no choice'. CONCLUSIONS: Perceived stress is an important indicator of caregiver reactions. Words used when describing caregiving experiences can potentially depict the spouse caregivers' current state of being as a caregiver. RELEVANCE TO CLINICAL PRACTICE: Spouse caregiver's narrative of their caregiving experience may provide easy and quick insights if interventions are needed. Early identification of negative reactions will allow for prompt interventions in mitigating caregivers' stress.

Mindfulness-based therapy improves brain functional network reconfiguration efficiency.

Mindfulness-based interventions are showing increasing promise as a treatment for psychological disorders, with improvements in cognition and emotion regulation after intervention. Understanding the changes in functional brain activity and neural plasticity that underlie these benefits from mindfulness interventions is thus of interest in current neuroimaging research. Previous studies have found functional brain changes during resting and task states to be associated with mindfulness both cross-sectionally and longitudinally, particularly in the executive control, default mode and salience networks. However, limited research has combined information from rest and task to study mindfulness-related functional changes in the brain, particularly in the context of intervention studies with active controls. Recent work has found that the reconfiguration efficiency of brain activity patterns between rest and task states is behaviorally relevant in healthy young adults. Thus, we applied this measure to investigate how mindfulness intervention changed functional reconfiguration between rest and a breath-counting task in elderly participants with self-reported sleep difficulties. Improving on previous longitudinal designs, we compared the intervention effects of a mindfulness-based therapy to an active control (sleep hygiene) intervention. We found that mindfulness intervention improved self-reported mindfulness measures and brain functional reconfiguration efficiency in the executive control, default mode and salience networks, though the brain and behavioral changes were not associated with each other. Our findings suggest that neuroplasticity may be induced through regular mindfulness practice, thus bringing the intrinsic functional configuration in participants' brains closer to a state required for mindful awareness.

Content development of the VISION-Cog: a novel tool to assess cognitive impairment in visually impaired older adults in Singapore.

OBJECTIVES: Current cognitive screening and diagnostic instruments rely on visually dependent tasks and are, therefore, not suitable to assess cognitive impairment (CI) in visually impaired older adults. We describe the content development of the VISually Independent test battery Of NeuroCOGnition (VISION-Cog)-a new diagnostic tool to evaluate CI in visually impaired older Singaporean adults. DESIGN: The content development phase consisted of two iterative stages: a neuropsychological consultation and literature review (stage 1) and an expert-panel discussion (stage 2). In stage 1, we investigated currently available neuropsychological test batteries for CI to inform constructions of our preliminary test battery. We then deliberated this battery during a consensus meeting using the Modified Nominal Group technique (stage 2) to decide, via agreement of five experts, the content of a pilot neuropsychological battery for the visually impaired. SETTING: Singapore Eye Research Institute. PARTICIPANTS: Stakeholders included researchers, psychologists, neurologists, neuro-ophthalmologists, geriatricians and psychiatrists. OUTCOME MEASURE: pilot VISION-Cog. RESULTS: The two-stage process resulted in a pilot VISION-Cog consisting of nine vision-independent neuropsychological tests, including the modified spatial memory test, list learning, list recall and list recognition, adapted token test, semantic fluency, modified spatial analysis, verbal subtests of the frontal battery assessment, digit symbol, digit span forwards, and digit span backwards. These tests encompassed five cognitive domains-memory and learning, language, executive function, complex attention, and perceptual-motor abilities. The expert panel suggested improvements to the clarity of test instructions and culturally relevant test content. These suggestions were incorporated and iteratively pilot-tested by the study team until no further issues emerged. CONCLUSIONS: We have developed a five-domain and nine-test VISION-Cog pilot instrument capable of replacing vision-dependent diagnostic batteries in aiding the clinician-based diagnosis of CI in visually impaired older adults. Subsequent phases will examine the VISION-Cog's feasibility, comprehensibility and acceptability; and evaluate its diagnostic performance.

Feasibility, comprehensibility and acceptability of the VISION-Cog, a novel tool to assess cognitive impairment in visually impaired older adults: a cross-sectional pilot study in Singapore.

OBJECTIVES: We pilot-tested the VISually Independent test battery Of NeuroCOGnition (VISION-Cog) to determine its feasibility, comprehensibility and acceptability in evaluating cognitive impairment (CI) in visually impaired older Asian adults. DESIGN: The VISION-Cog was iteratively fine-tuned through pilot studies and expert-panel discussion. In the first pilot study (Stage 1), we recruited 15 visually impaired and cognitively normal participants aged ≥60 years to examine the pilot VISION-Cog's feasibility (length of time to administer), comprehensibility (clarity of instructions) and acceptability (participant burden). We then presented the pilot results to the expert panel (Stage 2) who decided via agreement on a revised version of the VISION-Cog. Subsequently, we conducted a second pilot study (Stage 3) on another four participants to ascertain improvement in feasibility, comprehensibility and acceptability of the revised version. SETTING: Singapore Eye Research Institute. PARTICIPANTS: Nineteen Asian adults aged ≥60 years with visual impairment (defined as near visual acuity worse than N8) were recruited. OUTCOME MEASURE: Revised VISION-Cog. RESULT: The VISION-Cog was deemed feasible, taking approximately 60 min to complete on average. All participants agreed that the test instructions were clear, and the battery did not cause undue discomfort or frustration. The data collector rated all tests as very user-friendly (score of 5/5). Minor modifications to the pilot VISION-Cog were suggested by the panel to improve its safety, clarity of instructions and content validity, which were incorporated and iteratively tested in the second pilot study until no further issues emerged. CONCLUSIONS: Using an iterative mixed-methods process, we have developed a feasible, comprehensible and acceptable 5-domain and 9-item visually independent VISION-Cog test battery suitable to assist CI diagnosis in older adults with visual impairment. We will assess its diagnostic potential against clinician-based assessment of CI in subsequent phases.

Dissociable changes in sleep architecture with mindfulness and sleep hygiene intervention in older adults: Secondary and exploratory analysis of polysomnography data from the Mindfulness Sleep Therapy (MIST) trial.

OBJECTIVES: We conducted a secondary analysis of the Mindfulness Sleep Therapy study, a randomized controlled trial testing Mindfulness-Based Therapy for Insomnia (MBTI) against a sleep hygiene education and exercise program (SHEEP). We investigated whether the interventions led to changes in sleep macroarchitecture (N2, N3 and REM), and microarchitecture (sleep fragmentation, slow wave activity, spectral band power) measured by ambulatory polysomnography (PSG). METHODS: 48 MBTI and 46 SHEEP participants provided usable PSG and subjective sleep quality data both pre- and post intervention. The interventions consisted of 8 weekly 2-hour group sessions, and daily practice. PSG data were staged according to the American Academy of Sleep Medicine criteria by 2 technicians blind to time point and condition. Repeated-measures ANOVA and permutation analysis were used to test for differences over time and between the interventions. RESULTS: Self-reported sleep quality improved in both study groups. We observed significant increases in N2 in MBTI but not SHEEP (p = .045), and significant increases in N3 in SHEEP but not MBTI (p = .012). No significant differences over time or between group were observed in N1, REM, or sleep fragmentation. Higher frequency non-REM EEG power decreased in SHEEP but not MBTI. Slow wave activity and slow wave activity dissipation did not differ over time or between groups. Among all variables, significant time by group interactions were observed in only N3 and non-REM alpha power. CONCLUSIONS: MBTI and sleep hygiene education had different effects on sleep macro and microarchitecture, suggesting that the underlying mechanisms of mindfulness training in improving sleep quality may differ from traditional interventions.

Impact of beliefs about medication on the relationship between trust in physician with medication adherence after stroke.

OBJECTIVE: To investigate the relationship between medication adherence, trust in physician and beliefs about medication among stroke survivors. To determine whether beliefs about medication would mediate the relationship between trust in physician and medication adherence. METHODS: A sample of 200 patients with a diagnosis of ischemic stroke or transient ischemic attack (TIA) completed a one-time survey, including the shortened Medication Adherence Report Scale (MARS-5), Beliefs about Medicines Questionnaire (BMQ), and Trust in Physician Scale (TIPS). RESULTS: Our study found that medication adherence was associated with trust in physician (p = 0.019) and four factors of beliefs about medication (BMQ1-Necessity: p < 0.001; BMQ2-Concerns: p = 0.024; BMQ3-Overuse: p = 0.016; BMQ4-Harm: p < 0.001). Furthermore, we found monthly income of survivors moderated the relationship between trust in physician and medication adherence (p = 0.007, CI(95%): [-0.822, -0.132]). CONCLUSIONS: The beliefs about medication mediating the relationship between trust in physician and medication adherence were different based on the stroke survivors' income bracket. PRACTICE IMPLICATIONS: Interventions being developed to improve medication adherence may benefit from improving stroke survivors' trust in physician and addressing their beliefs about medication. In addition, healthcare providers are advised to take monthly income into consideration to effectively address stroke survivors' concerns regarding prescribed medications to mitigate stroke recurrence.

The validation of culturally appropriate scales to assess the family health climate in a multi-ethnic Asian population.

Background: The Family Health Climate (FHC) is a family environment attribute postulated to influence the health behaviors of family members. It can be measured by domain scales for physical activity (FHC-PA) and nutrition (FHC-NU), which have been validated and used to identify health climate patterns in families in Western populations. To extend the use of the scales to Asian settings, this study aimed to adapt and validate the instruments for use in the multi-ethnic population of Singapore, accounting for language and cultural differences. Methods: In Part A (n = 40) to adapt the scales for the Singapore population, we performed cognitive interviews, face validity testing and pre-testing of the instruments (n = 40). Besides English, the scales were translated into Chinese and Malay. In Part B (n = 400), we performed exploratory and confirmatory factor analyses respectively on two random samples. We also tested for item discriminant validity, internal consistency reliability, construct validity, and measurement invariance. Results: The findings from the cognitive interviews in Part A led to scale adaptations to accommodate cultural and linguistic factors. In Part B, EFA on Sample I resulted in a three-factor model for the PA scale (accounting for 71.2% variance) and a four-factor model for the NU scale (accounting for 72.8% variance). CFA on Sample II indicated acceptable model fits: FHC-PA: χ2 = 192.29, df = 101, p < 0.001, χ2/df = 1.90; SRMR = 0.049; RMSEA = 0.067; CFI = 0.969; TLI = 0.963; FHC-NU: χ2 = 170.46, df = 98, p < 0.001, χ2/df = 1.74; SRMR = 0.036; RMSEA = 0.061; CFI = 0.967; TLI = 0.960. The scores of family members demonstrated significant agreement on the FHC-PA (Sg) [ICC(2, 2) = 0.77] and FHC-NU (Sg) [ICC(2, 2) = 0.75] scales. Findings suggest good evidence for item discriminant validity, internal consistency reliability, construct validity, and measurement invariance. Short versions of the scales were also developed. Conclusion: We adapted, translated and validated the scales for assessing the health climate of families in Singapore, including the development of short versions. The results showed good psychometric properties and the constructs had significant relationships with health behaviors and routines. Improving our understanding of family influences on individual health behavior will be important in developing multi-level strategies for health promotion and chronic disease prevention.

Development and validation of the health competence beliefs inventory in young adults with and without a history of childhood cancer.

BACKGROUND: Adolescent and young adult survivors of childhood cancer are a vulnerable population. Health beliefs may be related to necessary follow-up care. PURPOSE: This study seeks to develop a measure of health beliefs for adolescents and young adults with and without a history of cancer. METHODS: Inductive and deductive methods and focus groups were used to develop the Health Competence Beliefs Inventory. Cancer survivors (n = 138) and comparison participants (n = 130) completed the Health Competence Beliefs Inventory and other measures. Healthcare providers reported current medical problems. RESULTS: A series of iterative exploratory factor analyses generated a 21-item four-factor solution: (1) Health Perceptions; (2) Satisfaction with Healthcare; (3) Cognitive Competence; and (4) Autonomy. Survivors reported significantly different Health Competence Beliefs Inventory scale scores than comparisons (p < .05). The Health Competence Beliefs Inventory was associated with beliefs, affect, quality of life, posttraumatic stress symptoms, and medical problems. CONCLUSIONS: The Health Competence Beliefs Inventory is a promising measure of adolescent and young adult perceptions of health and well-being.

Measuring health-related beliefs of mothers of adolescent and young adult childhood cancer survivors.

Childhood cancer has long-term implications for survivors and their family members. While the impact of cancer on the family continues into adulthood, little research exists on family related issues during this important developmental period. In order to advance our understanding of families of adolescent and young adult (AYA) childhood cancer survivors, a measure of health-related beliefs for parents of AYA cancer survivors was developed. Exploratory factor analysis based on the mothers' data was used to identify four factors among 23 items: Social Competence, Satisfaction with Healthcare, Health Perceptions, and Health Apprehension. The scales are associated with psychological distress, quality of life, and posttraumatic stress symptoms but unrelated to age of the child at diagnosis and cancer treatment intensity. The beliefs identified in this study are consistent with clinical observations of families of young adult survivors and provide indications for the importance of ongoing attention to the families of childhood cancer survivors.

The mediating role of trust in physician and self-efficacy in understanding medication adherence in severe asthma.

OBJECTIVE: To investigate the relationships between beliefs about medication, trust in physician, self-efficacy, and medication adherence in severe asthma patients. METHODS: A sample of 117 patients with a diagnosis of Severe Asthma on Step 4 or 5 of GINA assessment of control treatment ladder completed a one-time survey, including the shortened Medication Adherence Report Scale (MARS-5), Beliefs about Medicines Questionnaire (BMQ), Trust in Physician Scale (TIPS), and Self-Efficacy in Taking Medication (SEAMS). RESULTS: Our study found that medication adherence was associated with trust in physician (p = 0.033); factor one of beliefs about medication - Necessity of taking medication (BMQ1-Necessity: p = 0.025); and two factors of self-efficacy in taking medication (SEAMS1-Difficulty: p = 0.001; SEAMS2-Uncertain: p = 0.005). Furthermore, two factors of self-efficacy and trust in physician together significantly mediated the relationship between beliefs about medication and medication adherence in a serial multiple mediator model. CONCLUSIONS: Beliefs about medication are fundamental in affecting asthma patients' trust in physician and self-efficacy, which in turn impact medication adherence. CLINICAL IMPLICATIONS: Interventions being developed to improve medication adherence may benefit from emphasizing on asthma patients' concerns about overuse and harm of medication. In addition, education program targeting to improve provider-patient relationship could help with patients' confidence in taking medication.

A pilot randomized controlled trial examining the benefits of an adjuvant psycho-behavioural intervention in comparison to a health education program, on psychological well-being and freezing-of-gait in patients with Parkinson's disease.

This study investigated the effectiveness of a psycho-behavioural intervention (PBI) for freezing of gait (FOG) management in people with Parkinson's disease, through a double-blind randomized controlled pilot trial conducted with nineteen participants. Though no significant between-group differences were found, PBI was feasible, well-tolerated by participants, and exhibited a trend towards improvement for FOG and depression, thereby warranting further longitudinal investigations.