A path model examination: maternal anxiety and parenting mediate the association between maternal adverse childhood experiences and children's internalizing behaviors.

BACKGROUND: Children of mothers with adverse childhood experiences (ACEs) are at increased risk for developmental problems. However, the mechanisms through which a mother's experience of ACEs are transmitted to her offspring are understudied. The current study investigates potential modifiable mediators (maternal psychopathology and parenting) of the association between maternal ACEs and children's behavioral problems. METHODS: We utilized data from a pregnancy cohort study (N = 1030; CANDLE study) to investigate longitudinal associations between maternal ACEs, postpartum anxiety, observed parenting behavior, and child internalizing behaviors (meanage = 4.31 years, s.d. age = 0.38) in a racially diverse (67% Black; 33% White/Other) sample. We used structural equation modeling to test for direct associations between maternal ACEs and children's internalizing behaviors, as well as indirect associations via two simple mediations (maternal anxiety and parenting), and one serial mediation (sequence of maternal anxiety to parenting). RESULTS: Simple mediation results indicated that maternal anxiety and cognitive growth fostering behaviors independently mediated the association between maternal ACEs and child internalizing. We observed no evidence of a serial mediation from ACEs to internalizing via the effects of maternal anxiety on parenting. CONCLUSIONS: This study supports and refines extant literature by confirming the intergenerational association between maternal ACEs and child internalizing behaviors in a large, diverse sample, and identifies potential modifiable mediators: maternal anxiety and parenting behaviors related to fostering cognitive development. Findings may inform interventions targeting mothers who have experienced ACEs and suggest that providing support around specific parenting behaviors and addressing maternal anxiety may reduce internalizing behaviors in children.

Health-Related Quality of Life of Children with Congenital Adrenal Hyperplasia: A Mixed Methods Study.

PURPOSE: The purpose of this study was to examine the health-related quality of life (HRQOL) of female children with CAH as reported by children and their caregivers. DESIGN AND METHODS: A convergent mixed methods design was selected whereby quantitative and qualitative results were merged to provide a comprehensive understanding of HRQOL of children. Semi-structured interviews were conducted with 20 child-caregiver dyads. The full sample of child-caregiver dyads (N = 25) completed KINDL-R questionnaires, which provided a quantitative measure of children's HRQOL. RESULTS: Children and their caregivers reported good overall HRQOL. Children scored significantly lower on the KINDL-R School subscale compared to their caregivers. Associations were observed between the HRQOL score from one graphic rating scale item and the child's other health issues and child's diagnosis. Themes emerging from the child and caregiver interviews were health-related quality of life, impact of stigma on psychological well-being, information-sharing and disclosure of CAH, and improving the quality of life of children with CAH. CONCLUSION: This mixed methods study provided evidence to understand the health and complex needs of children with CAH. IMPLICATIONS: Clinicians may better support children and caregivers by expanding the focus beyond medication management to include: 1) psychological support and resources (i.e., developmentally appropriate coping and adaptation strategies); 2) continuous education for clinical staff, school nurses, emergency medical transport staff, and providers; and 3) public awareness beyond the clinic and hospital settings.

Living with an invisible illness: a qualitative study exploring the lived experiences of female children with congenital adrenal hyperplasia.

PURPOSE: Many chronic illnesses are self-evident. However, disorders like congenital adrenal hyperplasia (CAH) are invisible to the naked eye and unnoticeable to others. Therefore, invisible illness is often a shared, misconstrued experience for children with CAH, their caregivers, and the medical community. This experience, along with its lack of awareness and added stigma, may impact overall quality of life (QOL) of such individuals. To facilitate our understanding of QOL of children with CAH, we must first explore their subjective experiences. This study aimed to capture their lived experiences and provide recommendations to support children with CAH. METHODS: We conducted semi-structured interviews with 20 female children with CAH between 7 and 18 years and their caregivers. Interviews were transcribed verbatim, checked for accuracy, and independently coded by the first and second author. Content analysis was used to organize data so that codes could be condensed into categories and themes. Differences around code, category, and theme description were reconciled. RESULTS: Participants' experiences were described in five themes: (1) Making sense of the situation; (2) Emotional and psychological impact of an invisible illness; (3) Normalcy; (4) Disclosure of diagnosis; and (5) Improving the care of children with CAH CONCLUSION: Exploring children's views about living with an invisible illness illuminated individual aspects contributing to our in-depth understanding of experiences of children with CAH. Ongoing education and awareness of CAH is necessary to help mitigate the stigma associated with living with CAH.

THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer.

BACKGROUND: Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence. METHODS: In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an "App" group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an "App+Feedback" group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a "Usual Care" group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence. DISCUSSION: A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the "Triple Aim" - reduce costs while improving health outcomes and the patient care experience. TRIAL REGISTRATION: NCT03592771. Prospectively registered on July 19, 2018.

Exploring the factors that influence medication rating Web sites value to older adults: A cross-sectional study.

In this cross-sectional study, we evaluated factors that affected the perceived value of medication rating Web sites to 284 people aged ≥ 60 years who were taking prescription medications. The Patient Reviews of Medication Experience (PROMEX) questionnaire score, which assessed participant opinions about the value of online reviews of medications, was positively associated with preference to share health care decision making with the health care provider and negatively associated with the Physical Component Summary (PCS-12) and Mental Component Summary scores of the Short Form 12 health survey. The Primary Care Assessment Survey Communication score, which measured participant satisfaction with the communication from the health care provider, was positively associated with PCS-12 and health literacy. In summary, older adults who had poor physical and mental health-related quality of life were more likely to believe that medication rating Web sites were useful and helpful in facilitating communication with health care providers.

Health literacy and asthma management among African-American adults: an interpretative phenomenological analysis.

OBJECTIVE: African-Americans share a disproportionate burden of asthma and low health literacy and have higher asthma morbidity and mortality. Factors that link the relationship between health literacy and health outcomes are unclear. This study aimed to use patients' experiences of managing asthma to better understand the relationship between health literacy and health outcomes. METHODS: This study was the qualitative component of a mixed methods study. Following quantitative data collection, four participants, two with low print-related health literacy and two with adequate print-related health literacy, completed semi-structured interviews. Interview data were analyzed using interpretative phenomenological analysis. RESULTS: Three themes emerged from the analysis: information desired versus information received, trial and error, and expectations of the patient-provider relationship. Individuals with adequate print-related health literacy had different strategies for overcoming barriers related to communicating with their providers, learning about their disease and experiences of discrimination within the healthcare system. CONCLUSIONS: Individuals with adequate print-related health literacy may be more equipped to participate in shared decision making and feel more confident to successfully manage their disease. It is also important that health literacy is discussed in the context of the cultural and racial background of the population of interest. This interdependent relationship between health literacy and culture is particularly important for African-Americans.

Self-efficacy, physical activity, and aerobic fitness in middle school children: examination of a pedometer intervention program.

Physical activity in children has been associated with a number of health benefits. Unfortunately, physical inactivity continues to increase. The purpose of this study was to examine the relationships among self-efficacy levels, physical activity, aerobic fitness, and body composition (relative body mass index [RBMI]) and to determine whether a school-based pedometer intervention program would improve those variables. The sample consisted of 116 rural 11- to 13-year-old students. Weakly positive correlations between self-efficacy, physical activity, and aerobic fitness and weakly correlated inverse relationships between self-efficacy, physical activity, aerobic fitness and RBMI were found. There was no statistical significance between the intervention and control group when analyzing outcome variables. These findings suggest that those with optimal RBMI levels have higher self-efficacy, physical activity and aerobic fitness levels. Although not statistically significant, the intervention group had greater improvements in mean self-efficacy scores, aerobic fitness levels, and RBMI.

Examining the relationship between antihypertensive medication satisfaction and adherence in older patients.

BACKGROUND: The relationship between medication adherence and treatment satisfaction has been consistently positive, however, this relationship has not been examined among older adults with hypertension. OBJECTIVES: The aim of this study was to examine the relationship between medication adherence and treatment satisfaction among a sample of older adults with hypertension. METHODS: This was a survey-based cross-sectional study in which seven community senior centers in the city of Memphis, Tennessee and its surrounding areas were visited. Individuals aged 60 years and older with self-reported hypertension who visited the community senior centers between August and December 2013 were asked to participate. The participants' satisfaction with their antihypertensive medications was assessed using a newly developed scale. The Short Form Health Survey (SF-12v2) was used to assess the health-related quality of life (HRQoL). The Primary Care Assessment Survey (PCAS) Communication scale was used to assess the satisfaction with health care provider communication. The Beliefs About Medicines Questionnaire (BMQ-General) was used to assess the participant beliefs about medications. The eight-item Morisky Medication Adherence Scale (MMAS-8) was used to assess adherence to antihypertensive medications. And the Single Item Literacy Screener (SILS) was used to assess health literacy. Multiple linear regression was conducted to examine the relationship between medication adherence and satisfaction with antihypertensive therapy controlling for multiple variables. RESULTS: One hundred and ninety participants with hypertension were included in the study. Most participants were white, women, aged ≥70 years, taking ≥2 prescription medications and having ≥2 medical conditions. After adjusting for age, education, number of prescription medications, race, health literacy, sex, marital status, SF-12v2 Physical Component Summary (PCS-12) and Mental Component Summary (MCS-12), and PCAS-Communication scores, the overall satisfaction score of the antihypertensive medication regimen was positively and significantly associated with MMAS-8 sore (ß = 0.262; 95% confidence interval, 0.007-0.517; P = 0.043). CONCLUSIONS: Treatment satisfaction was associated with higher medication adherence among older adults with hypertension.

The practice doctorate: perspectives of early adopters.

The emergence of the Doctor of Nursing Practice (DNP) degree is being described as a disruptive innovation that is altering the landscape of nursing and health care and creating a great deal of controversy within and beyond the profession of nursing. This article proposes that the DNP is actually the natural evolution of a larger disruptive innovation begun in the late 1960s with the advent of nurse practitioner programs. As expected with disruptive innovations, many challenges face those who are early adopters and who forge ahead during the early phase of innovation and later during the upmarketing phase. As faculty and administrators of one of the early, second-generation DNP programs, the authors are fully aware of ongoing discussion and issues related to the practice doctorate. This article shares the experiences of this group of early adopters and their insights into controversies surrounding the DNP movement.