Characterizing the disability experience among adults living with HIV: a structural equation model using the HIV disability questionnaire (HDQ) within the HIV, health and rehabilitation survey.

BACKGROUND: People aging with HIV can experience a variety of health challenges associated with HIV and multimorbidity, referred to as 'disability'. Our aim was to characterize the disability experience and examine relationships between dimensions of disability among adults living with HIV. METHODS: We performed a structural equation modeling analysis with data from the Canadian web-based HIV, Health and Rehabilitation Survey. We measured disability using the HIV Disability Questionnaire (HDQ), a patient-reported outcome (69 items) that measures presence, severity and episodic features of disability across six domains: 1) physical symptoms, 2) cognitive symptoms, 3) mental-emotional health symptoms, 4) difficulties carrying out day-to-day activities, 5) uncertainty and worrying about the future, and 6) challenges to social inclusion. We used HDQ severity domain scores to represent disability dimensions and developed a structural model to assess relationships between disability dimensions using path analysis. We determined overall model fit with a Root Mean Square Error of Approximation (RMSEA) of < 0.05. We classified path coefficients of ≥ 0.2-0.5 as a medium (moderate) effect and > 0.5 a large (strong) effect. We used Mplus software for the analysis. RESULTS: Of the 941 respondents, most (79%) were men, taking combination antiretroviral medications (90%) and living with two or more simultaneous health conditions (72%). Highest HDQ presence and severity scores were in the uncertainty domain. The measurement model had good overall fit (RMSEA= 0.04). Results from the structural model identified physical symptoms as a strong direct predictor of having difficulties carrying out day-to-day activities (standardized path coefficient: 0.54; p < 0.001) and moderate predictor of having mental-emotional health symptoms (0.24; p < 0.001) and uncertainty (0.36; p < 0.001). Uncertainty was a strong direct predictor of having mental-emotional health symptoms (0.53; p < 0.001) and moderate direct predictor of having challenges to social inclusion (0.38; p < 0.001). The relationship from physical and cognitive symptoms to challenges to social inclusion was mediated by uncertainty, mental-emotional health symptoms, and difficulties carrying out day-to-day activities (total indirect effect from physical: 0.22; from cognitive: 0.18; p < 0.001). CONCLUSIONS: Uncertainty is a principal dimension of disability experienced by adults with HIV. Findings provide a foundation for clinicians and researchers to conceptualize disability and identifying areas to target interventions.

Advancing research and practice in HIV and rehabilitation: a framework of research priorities in HIV, disability and rehabilitation.

BACKGROUND: HIV increasingly is experienced as a complex chronic illness where individuals are living longer with a range of physical, cognitive, mental and social health-related challenges associated with HIV, comorbidities and aging, a concept that may be termed 'disability'. Rehabilitation such as physical therapy and occupational therapy can help address disability and has the potential to improve quality of life in people living with HIV. Hence, the role for rehabilitation in the context of HIV, aging and comorbidities is emerging. Our aim was to establish a framework of research priorities in HIV, disability and rehabilitation. METHODS: We convened people living with HIV, clinicians, researchers, service providers, representatives from community-based organizations and policy and funding stakeholders to participate in the first International Forum on HIV and Rehabilitation Research. We conducted a multi-stakeholder consultation to identify current and emerging issues in HIV, disability and rehabilitation. Data were collated and analyzed using content analytical techniques. RESULTS: Ninety-two participants attended the Forum from Canada, United Kingdom (UK), Ireland and the United States. Situated within three overarching themes (episodic health and disability across the life course; rehabilitation; and methodological advances), the Framework of Research Priorities in HIV, Disability and Rehabilitation includes six research priorities: 1) episodic health and disability; 2) aging with HIV across the life course; 3) concurrent health conditions; 4) access to rehabilitation and models of rehabilitation service provision; 5) effectiveness of rehabilitation interventions; and 6) enhancing outcome measurement in HIV and rehabilitation research. The Framework includes methodological considerations and environmental and personal contextual factors (or lenses) through which to approach research in the field. Knowledge translation should be implemented throughout the development and application of research knowledge to inform HIV clinical practice, programming and policy. CONCLUSIONS: These priorities highlight the emerging priorities of living long-term with HIV and outline a plan for HIV and rehabilitation research in resource-rich countries such as the UK and Canada.

Making space: integrating meaningful interprofessional experiences into an existing curriculum.

Many health professional education programs have instituted, or are in the process of developing, structures for implementing interprofessional education (IPE). Professional organizations are also adopting IP competencies for their respective memberships and accreditations. Our IPE design and educational framework was informed by evidence gathered from professional organizations; the students' lived experience with traditional approaches and evolving IPE designs and data from our school's longitudinal curriculum evaluation study. This paper briefly describes the evolution and design of an embedded IPE program within an existing master's level curriculum - which meets not only curriculum competencies but also nationally recognizes IPE competencies. In addition, the embedded program articulates with a mandatory faculty-wide IPE initiative. The creation of embedded IPE within existing courses allowed for enriched learning opportunities for both discipline-specific and IPE knowledge without changing the overall curriculum structure.

Deliberative curriculum inquiry for integration in an MD curriculum: Dalhousie University's curriculum renewal process.

BACKGROUND: Dalhousie University's MD Programme faced a one-year timeline for renewal of its undergraduate curriculum. AIM: Key goals were renewed faculty engagement for ongoing quality improvement and increased collaboration across disciplines for an integrated curriculum, with the goal of preparing physicians for practice in the twenty-first century. METHODS: We engaged approximately 600 faculty members, students, staff and stakeholders external to the faculty of medicine in a process described by Harris (1993) as 'deliberative curriculum inquiry'. Temporally overlapping and networked intraprofessional and interprofessional teams developed programme outcomes, completed environment scans of emerging content and best practices, and designed curricular units. RESULTS: The resulting curriculum is the product of new collaborations among faculty and exemplifies distinct forms of integration. Innovations include content and cases shared by concurrent units, foundations courses at the beginning of each year and integrative experiences at the end, and an interprofessional community health mentors programme. CONCLUSION: The use of deliberative inquiry for pre-med curriculum renewal on a one-year time frame is feasible, in part through the use of technology. Ongoing structures for integration remain challenging. Although faculty collaboration fosters integration, a learner-centred lens must guide its design.

Curriculum evaluation: linking curriculum objectives to essential competencies.

BACKGROUND: The essential competencies of occupational therapy practice are agreed upon and documented (ACOTRO, 2003), yet they have not been used to evaluate educational programs. PURPOSE: To evaluate the match between the planned curriculum and the nationally recognized competencies that define safe, effective, and ethical practice. METHODS: Utilizing a comparative and systematic approach, course learning objectives in the approved curriculum map were matched to the ACOTRO (2003) competencies. FINDINGS: A total of 218 links were made between the 179 learning objectives and the 30 essential competencies. There were no links to three competencies. Learning objectives were not equally represented across the ACOTRO units; initial analyses indicate the distribution is likely appropriate. IMPLICATIONS: This novel evaluative process allowed critical appraisal and subsequent minor revision of Dalhousie curriculum. The appropriate, relative weighting of curriculum content is unknown and is a professional issue for discussion by regulators, educators, and the profession at large.

Validity of using the Assessment of Motor and Process Skills to determine the need for assistance.

OBJECTIVE: This study evaluated the validity of using Assessment of Motor and Process Skills (AMPS) measures as evidence of the need for assistance in the community. METHOD: In a retrospective analysis of existing data (N = 64,466), receiver operating characteristic (ROC) curves were generated, and a split-sample method was used to validate the predictions. RESULTS: When identifying people who need assistance versus those who do not need assistance in the community, activity of daily living (ADL) motor and ADL process measures have fair and good discriminating value, respectively (areas under the ROC curves were .78 and .84). Evidence supports placing ADL motor and ADL process independence cutoff measures at 1.50 logits (sensitivity = .67, specificity = .72) and 1.00 logit (sensitivity = .81, specificity = .70), respectively. Accuracy was highest when matched motor and process decisions occurred (sensitivity = .85, specificity = .83). CONCLUSION: Evidence supports using ADL ability measures from the AMPS to provide evidence of a client's need for assistance in the community.

Assessment of Awareness of Disability measures among persons with acquired brain injury.

BACKGROUND: Limited self-awareness of disabilities can compromise individuals' occupational performance. PURPOSE: The Assessment of Awareness of Disability (AAD) provides occupational therapists with a standardized methodology for measuring clients'self-awareness when performing activities of daily living (ADL). This is the first study that formally examines the stability of the AAD measures. METHODS: The AAD was administered twice to 15 participants with acquired brain injury (ABI) within one or two days. One participant's data were excluded because significant changes in his ADL process abilities were detected. Two criteria were used to examine the stability of the remaining 14 participants' AAD measures: standardized difference Z-scores and a difference of 0.65 logits. FINDINGS: All 14 participants' AAD measures were stable on the basis of theirZ-scores; 13 participants' measures were stable based on the 0.65 logit difference. IMPLICATIONS: Occupational therapists can have confidence that the AAD generates stable measures when administered to adults with ABI.

Allen Cognitive Level Screen for the classification of subjects treated for addiction.

Introduction The Cognitive Disabilities Model (CDM) is an occupational approach that can allow the classification of the functional-cognitive abilities of persons with addictions. The objective of the study was to explore the applicability of the ACLS-5 to assess a sample of persons undergoing addiction-rehabilitation treatment. Methods A sample of 232 participants was recruited from an outpatient treatment centre in Madrid (Spain). The ACLS-5, the Montreal Cognitive Assessment (MoCA), and the Prefrontal Symptom Inventory (PSI) were administered. Sociodemographic and addiction-related data were also obtained. Results Half of the sample showed serious deficits in functional cognition, which ultimately could be related to problems in their daily performance. Scores of ACLS-5 showed significant correlations with the severity of addiction, with those obtained with the MoCA, and with attentional symptoms on the PSI scale. Conclusions The data suggest the applicability of the ACLS-5 in assessing the degree of functional cognition in subjects treated for addiction, providing evidence to support ecological validity and facilitating the development of well-targeted cognitive rehabilitation programmes from an occupational perspective. The use of occupational-based instruments to assess the functioning of those with addictions is a requirement of occupational therapy professionals working in this general area.

ADL differences in individuals with unilateral hemispheric stroke.

BACKGROUND: Literature regarding the ability of individuals who have a cerebrovascular accident (CVA) to perform activities of daily living (ADL) is inconclusive regarding the impact of gender, age or side of the lesion. PURPOSE: To determine if people with a CVA differ in their abilities to perform ADL tasks and actions as affected by their gender, age, and side of the lesion. METHOD: A descriptive comparison of 3878 people with a right or left CVA included in the Assessment of Motor and Process Skills (AMPS) database. RESULTS: People with stroke demonstrated statistically significant gender, age, and side of CVA differences in overall ADL ability. However, the gender and side of CVA differences were not clinically detectable. Increased age was associated with a gradual decline in ADL ability. CONCLUSION: Individuals with a right or left CVA have similar abilities when performing ADL tasks and actions. PRACTICE IMPLICATIONS: These findings indicate that occupation-based intervention, which focuses on the utilization of intact ADL skills to compensate for ADL skill deficits (vs. the utilization of tests of body function), may be a more efficient and effective means of planning and implementing occupational therapy intervention for individuals with a stroke.

HIV and disability: a pilot study exploring the use of the Assessment of Motor and Process Skills to measure daily life performance.

INTRODUCTION: Limitations in performing activities of daily living (ADL) are important indicators of health and overall wellness, yet relatively few studies specifically identify the ADL abilities of people living with HIV/AIDS (PHAs). Given the wide range of abilities and ages of PHAs, there is an urgent need to utilize an assessment of ADL ability that can validly evaluate those who are very able, as well as those who are very disabled, without the presence of ceiling or floor effects, to provide sensitive measures to detect change. PURPOSE: The purpose of this study was to gather preliminary evidence of the validity of using the Assessment of Motor and Process Skills (AMPS) with PHAs. METHODS: By utilizing existing data records of PHAs from the international AMPS database, we explored (a) demographic factors; (b) person response validity by examining person and individual item goodness-of-fit to the AMPS measurement model; and (c) trends in ADL abilities of PHAs. FINDINGS: There were 137 data records in the international AMPS database (0.08% of the database). Goodness-of-fit analyses revealed that >90% of the individuals in the sample fit AMPS measurement model and >99% of the individual item ratings fit the model. More than 80% of the data record had ADL motor abilities that were significantly lower than age expectations, and 67% had ADL process ability measures that were significantly lower than age expectations. CONCLUSIONS: The findings indicate that the AMPS is a valid measure of ADL ability for PHAs. Coupled with the lower than expected number of AMPS data records for PHAs and the significant ADL ability challenges that were encountered by this sample, this pilot study may indicate that PHAs encounter barriers to accessing rehabilitation services and/or may not receive referrals until significant ADL challenges are encountered.

Utilizing AMPS ability measures to predict level of community dependence.

The aim of the study was to examine the efficacy of utilizing Assessment of Motor and Process Skills (AMPS) ability measures as evidence for determining level of community dependence. The sample for the study was drawn from existing data from the AMPS International Project database, and consisted of adults from numerous world regions, with varying diagnoses and levels of ability (n=64,466). Findings support using ADL motor and process ability measures as evidence of a client's level of community dependence. When using ADL motor or process ability measures to identify the need for moderate to maximal assistance, the areas under the ROC curves were 0.74 (fair discrimination power) and 0.82 (good discrimination power), respectively. New ADL motor and process cutoff measures demarcating maximum assistance were set at 1.00 logit (sensitivity=0.70, specificity=0.66) and 0.70 logit (sensitivity=0.79, specificity=0.69), respectively. While ADL process ability continues to be the better predictor, the highest accuracy estimates occurred when motor and process decisions matched (n=30,835). For the first time, multiple AMPS cutoff measures, demarcating independent in the community and in need of maximal assistance, have been proposed.

ADL skill profiles across three psychiatric diagnoses.

BACKGROUND: Occupational therapists' ability to develop diagnostic-specific ADL intervention strategies is facilitated by an understanding of the ADL abilities of diagnostic groups. AIM: To determine whether there are significant differences in ADL ability and ADL skill profiles between samples of persons with bipolar disorder depression (n=158), bipolar disorder mania (n=200), and schizophrenia (n=200). Methods. All participants were assessed using the Assessment of Motor and Process Skills (AMPS). Mean ADL ability and skill item calibrations were compared between the three diagnostic samples. FINDINGS: No clinically significant differences were found in mean ADL ability. The ADL process skill item "Attends" was more difficult for those with bipolar disorder mania than for those with bipolar disorder depression. This difference did not disrupt the measurement model. IMPLICATIONS: The findings fail to support the idea that valid predictions of skill performance can be made on the basis of psychiatric diagnosis. Thus, occupational performance must be assessed individually. The findings also provide solid evidence that valid measures of ADL ability are generated when persons with bipolar disorder and schizophrenia complete the AMPS. Intervention strategies are recommended to address limitations in the skill Attends among persons with bipolar disorder manic episode.

Vocational assessment: a review of the literature from an occupation-based perspective.

The vast majority of the currently available vocational assessments are used to measure a worker's physical body functions and/or work capacity, while very few, if any, can be utilized to measure actual work performance. Within this research project, the authors conducted a brief review of the literature and synthesized the existing evidence related to some of the key vocational assessments that are utilized by occupational therapists. It was found that the current "gold standard" of vocational assessment is the Functional Capacity Evaluation, yet the evidence does not fully support its reliability and validity in determining an employee's ability to safely return to work. Alternative assessment options were explored, emphasizing the utilization of occupation-focused, performance-based assessment strategies. It is concluded that occupational therapists need to take action to develop and promote the use of performance-based measures of actual work ability. Occupational therapists must capitalize on their unique strengths of evaluating occupational performance and take the lead to develop standardized means of assessing, measuring, and predicting work performance and work status.

Gender differences in the performance of activities of daily living.

OBJECTIVES: To verify that the activities of daily living (ADL) motor and process skill items and tasks in the Assessment of Motor and Process Skills (AMPS) are free from gender bias, and to compare mean differences in ADL motor and process ability between men and women. DESIGN: Descriptive comparison; convenience sample. SETTING: Existing data from the AMPS database. PARTICIPANTS: Potential participants included nonwell persons (age range, 18-99y) matched within 3 age groups, first by functional level and then by diagnostic category. The resulting sample included 9250 men and 9250 women. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The AMPS, a standardized observational assessment of the quality of ADL task performance. RESULTS: None of the AMPS task calibrations and 1 motor skill item calibration (Lifts) demonstrated an observable difference between men and women. Men had higher ADL motor ability (F(1,18494)=11.58, P<.01) and women had higher ADL process ability (F(1,18494)=76.18, P<.01). CONCLUSION: The results suggest that the AMPS is free of gender bias. Although differences were found between men and women in mean ADL motor and process ability, they were not considered clinically detectable differences.