Finding the New Normal: Accepting Changes After Combat-Related Mild Traumatic Brain Injury.

INTRODUCTION: More than 300,000 soldiers have returned from Southwest Asia (i.e., Iraq and Afghanistan) with combat-related mild traumatic brain injuries (mTBIs). Despite less visible physical injuries, these soldiers demonstrate various physical and cognitive symptoms that impact their ability to reintegrate post-mTBI. This study explores family reintegration experiences, as described by married dyads, following a combat-related mTBI. METHODS: Nine soldiers with mTBI and their spouses participated, and a total of 27 interviews, both joint and individual, were conducted. Strauss and Corbin's grounded theory methodology and semistructured interviews were used to collect participants' perceptions and analyze the data. FINDINGS: The overarching theme of the reintegration experience is described as finding the "new normal." A new normal was defined by participants as the couple's new, post-mTBI expectation of the family unit or family routine. Some participants indicated that they had accepted the post-mTBI changes and were working toward this new normal, whereas others indicated these changes were unacceptable and continued their efforts to return to pre-injury functioning. CONCLUSIONS: Individuals with mTBI and their families may benefit from interventions that directly address mismatched expectations and promote the acceptance of a new normal.

Compassion fatigue in adult daughter caregivers of a parent with dementia.

Adult daughters face distinct challenges caring for parents with dementia and may experience compassion fatigue: the combination of helplessness, hopelessness, an inability to be empathic, and a sense of isolation resulting from prolonged exposure to perceived suffering. Prior research on compassion fatigue has focused on professional healthcare providers and has overlooked filial caregivers. This study attempts to identify and explore risk factors for compassion fatigue in adult daughter caregivers and to substantiate further study of compassion fatigue in family caregivers. We used content analysis of baseline interviews with 12 adult daughter caregivers of a parent with dementia who participated in a randomized trial of homecare training. Four themes were identified in adult daughter caregiver interviews: (a) uncertainty; (b) doubt; (c) attachment; and (d) strain. Findings indicated adult daughter caregivers are at risk for compassion fatigue, supporting the need for a larger study exploring compassion fatigue in this population.

Finding meaning in caring for a spouse with dementia.

Dementia caregiving can be burdensome with many challenges, especially for spousal caregivers who are elderly and may have limited resources and chronic conditions of their own. However, it can also be an opportunity for growth and transcendence. Thematic qualitative analysis was conducted with 11 caregiver interviews to investigate how spousal caregivers of individuals with dementia found personal meaning in their caregiving experience. Caregivers commonly had altruistic values, and the discipline to live those values. They found meaning by believing in a choice of attitude and perceiving satisfaction in living according to their values in life. They had faith in a higher power, a strong sense of love for their spouses and they derived strength from past challenges. Positive attitudes among caregivers of individuals with dementia may be enhanced by sharing these stories and strategies. Study results also provide an expansion beyond commonly held views of caregiving for nurses.

Correlates of care relationship mutuality among carers of people with Alzheimer's and Parkinson's disease.

AIM: This paper presents findings from secondary analysis of longitudinal data on correlates of care relationship mutuality collected from 91 carers of people with Alzheimer's disease and Parkinson's disease in the control group of a randomized trial of home-care skill training. BACKGROUND: Many family members and other informal carers are reported to suffer multiple adverse social, financial, psychological and physical caregiving outcomes. High levels of mutuality, the perception that the quality of the care relationship is positive, reportedly ameliorate these negative outcomes. METHOD: Multilevel models for change were used to explore whether care recipient functional ability, carer gender, depressive symptoms, kin relation to care recipient (spouse, non-spouse) and years of caregiving experience were related to carers' perceptions of care relationship mutuality over a 12-month period. Data collection took place between 2003 and 2008. RESULTS: Carers who reported lower mutuality: (1) were caring for care recipients with lower functional ability, (2) had less caregiving experience and (3) had more depressive symptoms. CONCLUSION: Informal carers who perceive little mutuality in their relationship with the care recipient may be more likely to terminate care early. Clinicians and researchers should explore the quality of the caregiving relationship as a critical factor in carer and care recipient outcomes. Home-care skill training may need to include relationship-building skills to offset adverse carer outcomes.

Implementing the research budget.

Reworking a reduced budget after the award and monitoring and managing the budget once funds are received are critical to the success of a research project. Few resources are available to help principal investigators and research teams deal with these components of grant implementation. This article will address strategies and concerns related to the revision of the postaward budget and the implementation of the budget. Among the strategies discussed for the revision of the postaward budget are cost sharing, renegotiation with administration, and reallocation of funds. Also addressed are topics related to monitoring and managing the budget, including understanding budget guidelines, account management and documentation, tracking expenditures, and challenges in grant budget management.

Use of response cards with a group of students with learning disabilities including those for whom English is a second language.

The current study compared the effects of hand raising and response cards during a writing instruction class in a middle-school resource classroom with students who were learning English as their second language. Response cards increased the rate and accuracy of academic responding, increased weekly quiz scores, and had mixed effects on off-task behavior, but most students reported that they preferred hand raising.

Chasing the care: soldiers experience following combat-related mild traumatic brain injury.

OBJECTIVE: One of the most common, yet most difficult to detect injuries sustained by U.S. soldiers in Iraq and Afghanistan is mild traumatic brain injury (mTBI). Left untreated, mTBI can negatively impact soldiers' postdeployment adjustment. This research describes the rehabilitation experiences of soldiers with a history of mTBI and their spouses. METHOD: Nine soldiers with mTBI and their spouses participated in the study. A total of 27 interviews were conducted exploring couples' post-mTBI rehabilitation experiences. Participants consisted of active duty soldiers with mTBI who had returned from deployment within 2 years, and their civilian spouses. Strauss and Corbin's grounded theory methodology was used to collect and analyze the data. FINDINGS: The majority of the soldiers and spouses who participated (16/18) indicated that uncertain prognosis and symptom management were the greatest challenges of post-mTBI. Other challenges, such as delayed diagnosis, limited access to mental health care, and difficulty navigating an unfamiliar military health care system was also reported. CONCLUSIONS: Because of mTBI's lack of visible manifestation, soldiers may confuse their mTBI symptoms with those of other deployment-related injuries and this leads to a delay in treatment. Future research should explore the standardization of post-mTBI rehabilitation programs and the effectiveness of soldier education to promote early detection and treatment.

mHealth interventions for weight loss: a guide for achieving treatment fidelity.

UNLABELLED: mHealth interventions have shown promise for helping people sustain healthy behaviors such as weight loss. However, few have assessed treatment fidelity, that is, the accurate delivery, receipt, and enactment of the intervention. Treatment fidelity is critical because the valid interpretation and translation of intervention studies depend on treatment fidelity assessments. We describe strategies used to assess treatment fidelity in mobile health (mHealth) interventions aimed at sustaining healthy behaviors in weight loss. We reviewed treatment fidelity recommendations for mHealth-based behavioral interventions and described how these recommendations were applied in three recent weight loss studies. We illustrate how treatment fidelity can be supported during study design, training of providers, treatment delivery, receipt of treatment, and enactment of treatment skills. Pre-planned strategies to ensure the treatment fidelity of mHealth interventions will help counter doubts concerning valid conclusions about their effectiveness and allow investigators and clinicians to implement robustly efficacious mobile health programs. TRIAL REGISTRATION NUMBER: 1F31 NR012599.

Development of a Theoretically Driven mHealth Text Messaging Application for Sustaining Recent Weight Loss.

BACKGROUND: Mobile phone short message service (SMS) text messaging, has the potential to serve as an intervention medium to promote sustainability of weight loss that can be easily and affordably used by clinicians and consumers. OBJECTIVE: To develop theoretically driven weight loss sustaining text messages and pilot an mHealth SMS text messaging intervention to promote sustaining recent weight loss in order to understand optimal frequency and timing of message delivery, and for feasibility and usability testing. Results from the pilot study were used to design and construct a patient privacy compliant automated SMS application to deliver weight loss sustaining messages. METHODS: We first conducted a pilot study in which participants (N=16) received a daily SMS text message for one month following a structured weight loss program. Messages were developed from diet and exercise guidelines. Following the intervention, interviews were conducted and self-reported weight was collected via SMS text messaging. RESULTS: All participants (N=16) were capable of sending and receiving SMS text messages. During the phone interview at 1 month post-baseline and at 3 months post-baseline, 13/14 (93%) of participants who completed the study reported their weight via SMS. At 3 months post-baseline, 79% (11/14) participants sustained or continued to lose weight. Participants (13/14, 93%) were favorable toward the messages and the majority (10/14, 71%) felt they were useful in helping them sustain weight loss. All 14 participants who completed the interview thought SMS was a favorable communication medium and was useful to receive short relevant messages promptly and directly. All participants read the messages when they knew they arrived and most (11/14, 79%) read the messages at the time of delivery. All participants felt that at least one daily message is needed to sustain weight loss behaviors and that they should be delivered in the morning. Results were then used to develop the SMS text messaging application. CONCLUSIONS: Study results demonstrated the feasibility of developing weight loss SMS text messages, and the development of an mHealth SMS text messaging application. SMS text messaging was perceived as an appropriate and accepted tool to deliver health promotion content.

Mobile health messages help sustain recent weight loss.

BACKGROUND: Using regulatory focus theory, an intervention of daily weight loss-sustaining messages was developed and tested for acceptability, feasibility, and efficacy on helping people sustain weight loss. METHODS: Participants (n = 120) were randomized to a promotion, prevention, or an attention-control text message group after completion of a weight loss program. Participants completed baseline assessments, and reported their weight at 1 and 3 months postbaseline. RESULTS: Participants found the message content and intervention acceptable and valuable. A minimum of one message per day delivered at approximately 8:00 am was deemed the optimal delivery time and frequency. The sustained weight loss rate at month 3 for the control, promotion, and prevention groups was 90%, 95%, and 100%, respectively. Medium-to-large effects were observed for the promotion and prevention groups at month 1 and for prevention at month 3 relative to controls. The mean weight loss for promotion and prevention was 15 pounds, compared with 10 in the controls at month 3. CONCLUSION: A clinically significant decrease in mean weight, higher rate of sustained weight loss, and medium-to-large effects on sustained weight loss occurred in the promotion and prevention interventions. Tools such as this text message-based intervention that are constructed and guided by evidence-based content and theoretical constructs show promise in helping people sustain healthy behaviors that can lead to improved health outcomes.

A comparative qualitative analysis of stories of spousal caregivers of people with dementia: negative, ambivalent, and positive experiences.

BACKGROUND: Caregivers of people with dementia describe a wide spectrum of caregiving experiences, from very negative to very positive. Previous research reveals that differences exist, but how or why the experiences differ has not been well addressed. OBJECTIVE: The purpose of this study was to explore how the experiences of spousal caregivers of people with dementia differ. METHODS: This study was a secondary analysis of interviews collected from a longitudinal caregiver skill training intervention for caregivers of those with degenerative diseases (parent study). For the purpose of this analysis, 57 interviews from 21 spousal caregivers of people with dementia in the control group of the parent study were analyzed. The interviews from the parent study were collected at baseline, 6 months, and 12 months post-enrollment. RESULTS: Three groups of caregivers were identified based on how they described their experience; a negative group, an ambivalent group and a positive group. The negative group described both past and present relationships with their spouse in negative terms. These caregivers expressed no positives in caregiving. Their focus was on their own unmet needs rather than their spouses' needs. These caregivers reported significant caregiving burden. The ambivalent group reported that the relationship they had with the spouse was lost, but they still described satisfaction in being able to care for the spouse. They described mixed emotions about caregiving and had difficulty accepting that their partners could no longer reciprocate in the relationship. The positive group described both their past and present relationship with the care recipient in loving terms. They focused on aspects of the relationship they still had, rather than what had been lost. They expressed satisfaction with caregiving, were other-focused, and not highly burdened by caregiving. They understood that their partner could not reciprocate, and expected nothing in return. Descriptions of the positive group suggest target areas for caregiver interventions. CONCLUSION: Spousal caregivers of people with dementia can be encouraged toward more positive caregiving experiences through empathy-building interventions and enhanced understanding and acceptance of changes in the care recipient.

Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians.

BACKGROUND: Low mobility is common during hospitalization and is associated with adverse outcomes. Understanding barriers to the maintenance or improvement of mobility is important to the development of successful interventions. OBJECTIVES: To identify barriers to mobility during hospitalization from the perspectives of older patients and their primary nurses and physicians, to compare and contrast the perceived barriers among these groups, and to make a conceptual model. DESIGN: Qualitative interviews analyzed and interpreted using a grounded theory approach. SETTING: Medical wards of a university hospital. PARTICIPANTS: Twenty-nine participants--10 patients >or= 75 years, 10 nurses, and 9 resident physicians. MEASUREMENTS: Participants were interviewed using a semistructured interview guide, with similar questions for patients and health care providers. Interviews were audiotaped, transcribed, and reviewed for common themes by independent reviewers. Perceived barriers to mobility were identified, and their nature and frequency were examined for each respondent group. RESULTS: Content analysis identified 31 perceived barriers to increased mobility during hospitalization. Barriers most frequently described by all 3 groups were: having symptoms (97%), especially weakness (59%), pain (55%), and fatigue (34%); having an intravenous line (69%) or urinary catheter (59%); and being concerned about falls (79%). Lack of staff to assist with out-of-bed activity was mentioned by patients (20%), nurses (70%), and physicians (67%). Unlike patients, health care providers attributed low mobility among hospitalized older adults to lack of patient motivation and lack of ambulatory devices. CONCLUSIONS: Recognizing and understanding perceived barriers to mobility during hospitalization of older patients is an important first step toward developing successful interventions to minimize low mobility.