Examining the Relationship Between Social Support, Self-Efficacy, Diabetes Self-Management, and Quality of Life Among Rural Individuals With Type 2 Diabetes in Eastern China: Path Analytical Approach.

BACKGROUND: Patients with type 2 diabetes (T2D) in rural China frequently exhibit inadequate diabetes self-management (DSM) and a reduced quality of life (QoL). Social support and self-efficacy are known to influence DSM and QoL. However, the pathways through which social support and self-efficacy impact DSM and QoL among patients with T2D in rural China has yet to be fully elucidated. OBJECTIVE: This study offers a foundation for developing policies in rural chronic disease management, thereby, contributing to the improvement of T2D prevention and control in China and other transitional countries. METHODS: This study used a cross-sectional design, collecting data from a survey conducted between May and July 2021 on DSM and QoL among rural patients diagnosed with T2D in 2 townships in East China. All patients with T2D were enrolled through cluster sampling from the township health center database, and a questionnaire survey was administered by investigators. Structural equation modeling and multiple regression analyses were used to explore the pathways through which social support influences DSM and QoL, as well as the mediating role of self-efficacy. RESULTS: It was found that the DSM score (mean 37.42, SD 7.70) was less than half of the maximum theoretical score. The QoL score (mean 48.92, SD 8.88) accounted for 36% of the maximum theoretical score. Social support directly and positively affected the DSM and QoL of Chinese rural patients with T2D (P<.01); an increase of 1 unit in social support was associated with a direct increment of 0.339 units in DSM and 0.397 units in QoL. Self-efficacy played a positive mediating role (P<.01), further increasing DSM and QoL by 0.147 and 0.159 units, respectively. The mediating effect of self-efficacy accounted for 30.2% and 28.6% of the total effect of social support on DSM and QoL. Furthermore, the family and friend dimension of social support, along with the symptom and disease management dimensions of self-efficacy, were significantly associated with DSM or QoL (P<.01). CONCLUSIONS: The study confirmed the direct and indirect influences of social support on DSM and QoL and elucidated the mediating effect of self-efficacy among rural patients with T2D in eastern China. Interventions should be developed to enhance both social support and self-efficacy, creating a positive cycle of mutual reinforcement to improve DSM and QoL among this group.

Rural-Urban Differences in Self-Reported Participation in Diabetes Self-Management Education.

CONTEXT: Rural America faces a dual challenge with a higher prevalence of diabetes mellitus (hereafter, diabetes) and diabetes-related mortality. Diabetes self-management education (DSME) can improve glucose control and reduce adverse effects of diabetes, but certified DSME programs remain disproportionately limited in rural counties than in urban counties. OBJECTIVE: The goal of this study is to examine the proportion of urban and rural adults who report having received DSME using a nationwide, 29-state survey while considering the potential consequences of lower service availability. DESIGN: This cross-sectional study used data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS). Residence was defined as urban (metropolitan county) vs rural (non-metropolitan county). Logistic regression, incorporated survey weights, was used to determine the odds of having received DSME by residence. SETTING: BRFSS is a nationally representative survey, and this study included participants from 29 states that were distributed throughout all regions of the United States. PARTICIPANTS: The study sample consisted of 28,179 adults who reported having diabetes, lived in one of the states that administered the diabetes module in 2019, and answered all relevant questions. MAIN OUTCOME MEASURES: The main outcome measure was whether a participant had ever received DSME. Participants were considered to have received DSME if they self-reported having ever taken a class on how to manage diabetes themselves. RESULTS: Overall, 54.5% of participants reported having received DSME; proportionately fewer rural residents (50.4%, ±1.1%) than urban residents (55.5%, ±1.0%) reported DSME. Rural disparities persisted after adjusting for demographic, enabling, and need factors (Adjusted Odds Ratio  = 0.79; CI, 0.71-0.89). By sociodemographic factors, Hispanic persons vs non-Hispanic White persons and single vs married/coupled individuals were less likely to report DSME receipt (both 0.76 [0.62-0.94]). CONCLUSIONS: Ongoing national efforts addressing rural disparities in diabetes-related complications should target individuals most at risk for missing current diabetes educational programming and design appropriate interventions.

Cross-Cutting mHealth Behavior Change Techniques to Support Treatment Adherence and Self-Management of Complex Medical Conditions: Systematic Review.

Background: Mobile health (mHealth) interventions have immense potential to support disease self-management for people with complex medical conditions following treatment regimens that involve taking medicine and other self-management activities. However, there is no consensus on what discrete behavior change techniques (BCTs) should be used in an effective adherence and self-management-promoting mHealth solution for any chronic illness. Reviewing the extant literature to identify effective, cross-cutting BCTs in mHealth interventions for adherence and self-management promotion could help accelerate the development, evaluation, and dissemination of behavior change interventions with potential generalizability across complex medical conditions. Objective: This study aimed to identify cross-cutting, mHealth-based BCTs to incorporate into effective mHealth adherence and self-management interventions for people with complex medical conditions, by systematically reviewing the literature across chronic medical conditions with similar adherence and self-management demands. Methods: A registered systematic review was conducted to identify published evaluations of mHealth adherence and self-management interventions for chronic medical conditions with complex adherence and self-management demands. The methodological characteristics and BCTs in each study were extracted using a standard data collection form. Results: A total of 122 studies were reviewed; the majority involved people with type 2 diabetes (28/122, 23%), asthma (27/122, 22%), and type 1 diabetes (19/122, 16%). mHealth interventions rated as having a positive outcome on adherence and self-management used more BCTs (mean 4.95, SD 2.56) than interventions with no impact on outcomes (mean 3.57, SD 1.95) or those that used >1 outcome measure or analytic approach (mean 3.90, SD 1.93; P=.02). The following BCTs were associated with positive outcomes: self-monitoring outcomes of behavior (39/59, 66%), feedback on outcomes of behavior (34/59, 58%), self-monitoring of behavior (34/59, 58%), feedback on behavior (29/59, 49%), credible source (24/59, 41%), and goal setting (behavior; 14/59, 24%). In adult-only samples, prompts and cues were associated with positive outcomes (34/45, 76%). In adolescent and young adult samples, information about health consequences (1/4, 25%), problem-solving (1/4, 25%), and material reward (behavior; 2/4, 50%) were associated with positive outcomes. In interventions explicitly targeting medicine taking, prompts and cues (25/33, 76%) and credible source (13/33, 39%) were associated with positive outcomes. In interventions focused on self-management and other adherence targets, instruction on how to perform the behavior (8/26, 31%), goal setting (behavior; 8/26, 31%), and action planning (5/26, 19%) were associated with positive outcomes. Conclusions: To support adherence and self-management in people with complex medical conditions, mHealth tools should purposefully incorporate effective and developmentally appropriate BCTs. A cross-cutting approach to BCT selection could accelerate the development of much-needed mHealth interventions for target populations, although mHealth intervention developers should continue to consider the unique needs of the target population when designing these tools.

Patient-Reported Dry Eye Treatment and Burden of Care.

OBJECTIVES: Dry eye is a common condition that can decrease the quality of life. This survey-based study of persons with dry eye investigated self-reported treatments (initial, current), out-of-pocket expenses, time spent on self-management, sources of care, and sources of information about their condition. METHODS: Online dry eye newsletters and support groups were emailed a link to an electronic survey asking members to participate. Survey respondents were not required to answer every question. RESULTS: In total, 639 persons with self-reported dry eye responded (86% women, 14% men [n=623]; mean ± SD age, 55 ± 14 years [n=595]). Artificial tears were the most reported intervention (76% initially, 71% currently). The median (interquartile range) out-of-pocket treatment cost annually was $500 ($200-$1,320 [n=506]). In addition, 55% (n=544) estimated 5 to 20 min daily on self-management; 22% spent an hour or more. Ophthalmologists provided most dry eye care (67%, n=520). Only 48% (n=524) reported that their primary source of dry eye information came from their eye care clinician. CONCLUSIONS: Artificial tears are the primary treatment for dry eye. Ophthalmologists provide most dry eye care, but half of patients report that their eye care provider is not their primary source of information. Almost one fourth of patients spend an hour or more daily on treatments.

Requests for Self-managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women's Health Organization Decision.

This study assesses changes in online telemedicine requests to self-manage abortions with medications before vs after the Dobbs v Jackson Women's Health Organization Supreme Court decision overturning Roe v Wade.

Questionnaire Survey-Based Quantitative Assessment of the Impact of Transitional Care on Self-Management of Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

METHODS: Clinical information of 78 COPD patients treated with TC (intervention group) or routine care (control group) in Shanghai Pulmonary Hospital during March 2019 and August 2020 was gathered. Patients were followed up for 3 months after discharge. The intervention group (n = 39) was subjected to a TC plan for 3 months to help patients and their family caregivers for self-management of COPD. TC was provided by specially trained nurses, and patients were supported by standardized tools. Nursing measures in the control group (n = 79) included transitional support for 30 d after hospital discharge. In this way, patients were guaranteed to follow discharge plans and transit to outpatient nursing. Patient's anxiety and depression symptoms, sleep quality, survival quality, mobility, and life quality at admission and after 3 months of discharge were assessed by Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, Quality of Life Scale Abbreviated Version, Activity of Daily Life Scale, St. George's Respiratory Questionnaire, and COPD Assessment Test. RESULTS: Except for anxiety and depression, patient's sleep quality, survival quality, mobility, and life quality in two groups were significantly improved. Moreover, average change of total CAT score during 3 months of intervention was -5.44, while that in the control group was -1.74 (p = 0.011). Improvement of survival quality of patients in the intervention group (p = 0.001) was markedly greater than that in the control group (p = 0.016). CONCLUSION: Altogether, TC based on quantification by questionnaire survey is beneficial to COPD patient's life quality and self-management.

Association between Self-Reported Gluten Avoidance and Irritable Bowel Syndrome: Findings of the NutriNet-Santé Study.

Self-management of irritable bowel syndrome (IBS) is increasingly focusing on exclusion diets. In particular; patients are showing a significant interest in the gluten-free diet for the treatment of IBS. However; the lack of scientific evidence prevents the establishment of clear dietary guidelines and attention is needed as dietary restriction can lead to potentially adverse effects. This cross-sectional study aims to explore the practice of gluten avoidance in participants identified with IBS in a large cohort of non-celiac French adults. The population included 15,103 participants of the NutriNet-Santé study who completed a functional gastrointestinal disorder questionnaire based on the Rome III criteria to identify IBS in 2013 and a food avoidance questionnaire in 2016. Data on diet and anthropometric and sociodemographic characteristics were collected. Multivariate logistic regression models were used to compare the avoidance of gluten between IBS and non-IBS participants. Participants were mainly women (73.4%) and the mean age in this population was 55.8 ± 13.2 years. Among these individuals, 804 (5.4%) participants were identified as IBS cases. Among them, the prevalence of gluten avoidance was estimated at 14.8%, of which 3.0% reported total avoidance; versus 8.8% and 1.6% in non-IBS participants. After adjustments; gluten avoidance was higher in IBS participants compared to their non-IBS counterparts: (OR = 1.86; 95%CI = 1.21, 2.85) for total and (OR = 1.71; 95%CI = 1.36, 2.14) for partial avoidance. Participants identified with IBS were more associated with gluten avoidance than non-IBS participants. Further studies are needed to explore the long-term consequences of dietary interventions and to provide consistent dietary guidance connected to patient perception.

Clinical Preventive Services and Self-Management Practices Among Adult Cancer Survivors in the United States Over Time.

The objective of this research was to determine if the engagement/participation in health promotion activities of cancer survivors in the United States (US) changed between 2006 and 2015. We pooled two independent cross-sectional data of cancer survivors using Medical Expenditure Panel Surveys from 2006 (N = 791; weighted N = 9,532,674) and 2015 (N = 1067; weighted N = 15,744,959). Health promoting activities consisted of past year influenza immunization, routine physical examination, and dental visit. Self-care included maintaining normal weight, not smoking, and engagement in recommended vigorous physical activity. We conducted unadjusted and adjusted logistic regression analyses to examine the change in engagement in health promoting activities over time. We found rates of annual influenza immunization (66.8% vs 70.3%), dental visit (71.8% vs 70.3%), and normal weight (33.9% vs 33.5%) did not change from 2006 to 2015. The percent with physical examination (90.8% vs 93.8%; P = .03) and non-smokers increased (87.9% vs 91.2; P = .04). Between 2006 and 2015, despite guidelines and recommendations for personalized cancer survivorship health plans, health promoting activities among cancer survivors did not change significantly.

Self-Rehabilitation for Post-Stroke Motor Function and Activity-A Systematic Review and Meta-Analysis.

Background. Due to an increasing stroke incidence, a lack of resources to implement effective rehabilitation and a significant proportion of patients with remaining impairments after treatment, there is a rise in demand for effective and prolonged rehabilitation. Development of self-rehabilitation programs provides an opportunity to meet these increasing demands.Objective. The primary aim of this meta-analysis was to determine the effect of self-rehabilitation on motor outcomes, in comparison to conventional rehabilitation, among patients with stroke. The secondary aim was to assess the influence of trial location (continent), technology, time since stroke (acute/subacute vs chronic), dose (total training duration > vs ≤ 15 hours), and intervention design (self-rehabilitation in addition/substitution to conventional therapy) on effect of self-rehabilitation.Methods. Studies were selected if participants were adults with stroke; the intervention consisted of a self-rehabilitation program defined as a tailored program where for most of the time, the patient performed rehabilitation exercises independently; the control group received conventional therapy; outcomes included motor function and activity; and the study was a randomized controlled trial with a PEDro score ≥5.Results. Thirty-five trials were selected (2225 participants) and included in quantitative synthesis regarding motor outcomes. Trials had a median PEDro Score of 7 [6-8]. Self-rehabilitation programs were shown to be as effective as conventional therapy. Trial location, use of technology, stroke stage, and intervention design did not appear to have a significant influence on outcomes.Conclusion. This meta-analysis showed low to moderate evidence that self-rehabilitation and conventional therapy efficacy was equally valuable for post-stroke motor function and activity.

Exploring community-dwelling stroke survivors' experiences of receiving a nurse-led theory-based stroke self-management programme: A qualitative study.

ABSTRACT: International evidence-based guidelines recommend self-management support for stroke survivors to improve their health outcomes. We developed a 4-week nurse-led stroke self-management programme (SSMP) and conducted a randomised controlled trial to assess its effects. This paper reports the findings of a qualitative study nested within the randomised controlled trial to explore stroke survivors' experiences of SSMP participation. Semi-structured interviews were conducted with all adult participants who were clinically diagnosed with a first or recurrent ischaemic or haemorrhagic stroke, residing at home, communicable in Cantonese, had a Montreal Cognitive Assessment score below the second percentile, and participated in at least 1 SSMP session. All interviews were conducted in Cantonese, lasted approximately 45 minutes, and were audio-recorded. Interview data were transcribed verbatim and analysed thematically. Sixty-four stroke survivors (mean age 66.33 years, SD 12.34) were recruited, and 59 were interviewed via phone immediately after completion of SSMP. Three themes were derived. Overall, participants were satisfied with the SSMP. Their understanding of self-management was improved, and they recognised its importance in recovery. Their confidence in self-management was also enhanced through the use of multifaceted strategies. Suggestions were made to enhance their participation experiences, including increased home visits and group sessions, making group session attendance optional and arranging them more accessibly, meeting the survivors who shared their survival experiences in the videos, and access to the videos online. This study concurred that the SSMP enhanced stroke survivors' self-efficacy in self-management. Rearrangement of the programme format and enhancements in accessibility could be further examined to enable more effective stroke self-management.

Assessment of Hypertension Control Among Adults Participating in a Mobile Technology Blood Pressure Self-management Program.

Importance: It is unclear whether mobile technology hypertension self-management programs are associated with blood pressure (BP) control. Objective: To examine whether engagement with a hypertension self-management program with a BP monitor and connected smartphone application with clinically based digital coaching was associated with BP control during a follow-up period of as long as 3 years. Design, Setting, and Participants: This cohort study enrolled US adults with elevated BP or hypertension between January 1, 2015, and July 1, 2020. The hypertension self-management program was provided through the participant's (or their spouse's) employer health plan. Exposures: Program engagement, defined by average number of application sessions. Main Outcomes and Measures: Systolic and diastolic BP measured by a US Food and Drug Administration-cleared BP monitor, with categories defined as normal (systolic BP, <120 mm Hg), elevated (systolic BP, 120-129 mm Hg), stage 1 hypertension (systolic BP, 130-139 mm Hg), and stage 2 hypertension (systolic BP ≥140 mm Hg). Other measures included age, gender, depression, anxiety, diabetes, high cholesterol, smoking, geographic region, area deprivation index, self-reported weight, and device-measured physical activity (steps per day). Results: Among 28 189 participants (median [IQR] age, 51 [43-58] years; 9424 women [40.4%]; 13 902 men [59.6%]), median (IQR) baseline systolic BP was 129.5 mm Hg (120.5-139.6 mm Hg) and diastolic BP was 81.7 mm Hg (75.7-88.4 mm Hg). Median systolic BP at 1 year improved at least 1 category for 495 of 934 participants (53.0%) with baseline elevated BP, 673 of 966 (69.7%) with baseline stage 1 hypertension, and 920 of 1075 (85.7%) with baseline stage 2 hypertension. Participants in the program for 3 years had a mean (SEM) systolic BP reduction of 7.2 (0.4), 12.2 (0.7), and 20.9 (1.7) mm Hg compared with baseline for those starting with elevated, stage 1 hypertension, and stage 2 hypertension, respectively. Greater engagement was associated with lower systolic BP over time (high-engagement group: 131.2 mm Hg; 95% CI, 115.5-155.8 mm Hg; medium-engagement group: 133.4 mm Hg; 95% CI 116.3-159.5 mm Hg; low-engagement group: 135.5 mm Hg; 95% CI, 117.3-164.8 mm Hg; P < .001); these results persisted after adjusting for age, gender, depression, anxiety, diabetes, high cholesterol, smoking, area deprivation index rank, and US region, which was partially mediated by greater physical activity. A very high BP (systolic BP >180 mm Hg) was observed 11 637 times from 3778 participants. Greater engagement was associated with lower risk of very high BP; the estimated probability of a very high BP was greater in the low-engagement group (1.42%; 95% CI, 1.26%-1.59%) compared with the medium-engagement group (0.79%; 95% CI, 0.71%-0.87%; P < .001) and the high-engagement group (0.53%; 95% CI, 0.45%-0.60%; P < .001 for comparison with both groups). Conclusions and Relevance: The findings of this study suggest that a mobile technology hypertension self-management program can support long-term BP control and very high BP detection. Such programs may improve real-world BP monitoring and control.

Expect the unexpected: Adolescent and pre-teens' experience of diabetes technology self-management.

OBJECTIVE: Only 17% of adolescents with type 1 diabetes (T1D) are currently meeting their glycemic targets despite advances in diabetes technologies. Self-management behaviors and challenges specific to use of diabetes technologies are insufficiently studied in adolescents. We aimed to describe the experience of diabetes technology self-management, including facilitators and barriers, among preteens/adolescents with low and high A1C. RESEARCH DESIGN AND METHODS: Youth (10-18 years of age) with T1D who use insulin pump therapy were recruited from the larger quantitative cohort of a mixed methods study for participation in semi-structured qualitative interviews. Maximum variability sampling was used to recruit youth with A1C <7.5% (n = 5) and A1C >9% (n = 5). Participants' personal insulin pump and continuous glucose monitoring data were downloaded and served as a visual reference. Interviews were analyzed using a qualitative descriptive approach. RESULTS: Participants were 50% female with a median age of 14.9 years and 80% used CGM. The sample was predominantly white (90.0%). Analysis produced four major themes, Bad Day, Expect the Unexpected, Nighttime Dependence, and Unpredictability, It's Really a Team and interconnecting subthemes. Youth characterized ''Bad Days'' as those requiring increased diabetes focus and self-management effort. The unpredictability (''Expect the Unexpected'') of glucose outcomes despite attention to self-management behaviors was considerable frustration. CONCLUSIONS: Diabetes devices such as insulin pumps are complex machines that rely heavily on individual proficiency, surveillance, and self-management behaviors to achieve clinical benefit. Our findings highlight the dynamic nature of self-management and the multitude of factors that feed youths' self-management behaviors.

Development and initial validation of the nonalcoholic fatty liver disease self-management questionnaire.

The prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing, and self-management is essential to improve health outcomes in this population. Despite the importance of self-management, there is no instrument to assess it in patients with NAFLD. The purpose of this study was to develop and validate an initial version of a self-management questionnaire for patients with NAFLD. This was a methodological and psychometric study conducted between April and November 2019. The NAFLD self-management questionnaire was developed after a theoretical and literature review and focus group interviews in three phases: (1) item generation, (2) item evaluation, and (3) psychometric evaluation. Participants (N = 155) were recruited from a hospital in Seoul, South Korea. Items were generated based on clinical NAFLD guidelines and the individual and family self-management theory. Construct validity was assessed using exploratory factor analysis. Six-factors were extracted from 22 items: lifestyle management, medical treatment compliance, management of medication and dietary supplements, alcohol consumption management, sleep management, and family support. These factors accounted for 67.4% of the total variance; each factor had an eigenvalue greater than 1, and Cronbach's alpha for the scale was 0.87. The NAFLD self-management questionnaire showed acceptable initial validity and reliability. The instrument can prove useful in the formulation of tailored interventions based on individual patients' care needs. Furthermore, it may be used as an indicator of health outcomes in this population.

The Impact of the COVID-19 Pandemic on Self-Reported Outcomes in Patients With Adrenal Insufficiency.

CONTEXT: The COVID-19 pandemic has impacted healthcare environment. OBJECTIVE: To determine the impact of the pandemic on self-reported outcomes in patients with adrenal insufficiency (AI). DESIGN AND SETTING: Prospective longitudinal survey study at 2 tertiary centers. PARTICIPANTS: Patients with AI. INTERVENTION: Patient-centered questionnaire. MAIN OUTCOME MEASURES: Depression Anxiety Stress Scales-21, Short Form-36, and AI self-management. RESULTS: Of 342 patients, 157 (46%) had primary AI, 109 (32%) had secondary AI, and 76 (22%) had glucocorticoid-induced AI. When compared to prepandemic, daily glucocorticoid dose and number of adrenal crises did not change. However, patients reported a higher financial impact from AI (34% vs 23%, P = 0.006) and difficulty accessing medical care (31% vs 7%, P < 0.0001) during the pandemic. A third of patients reported difficulty managing AI during the pandemic. After adjusting for duration and subtypes of AI, younger patients [odds ratio (OR) 2.3, CI 95% 1.3-4.1], women (OR 3.7, CI 95% 1.9-7.1), poor healthcare access(OR 4.2, CI 95% 2.3-7.7), lack of good insurance support (OR 2.8, CI 95% 1.3-5.9), and those with a higher financial impact (OR 2.3, CI 95% 1.3-4.3) reported greater difficulties managing AI. Patients were more likely to report a higher anxiety score (≥8) if they found managing AI challenging during the pandemic (OR 3.0, CI 95% 1.3-6.9), and had lower Physical Component Summary (OR 4.9, CI 95% 2.2-11.0) and Mental Component Summary (OR 4.1, CI 95% 1.8-9.5) scores prior to the pandemic. CONCLUSIONS: A third of patients with AI reported difficulties with management of AI during the pandemic, particularly in younger patients, women, and those with poor healthcare access.

Factors Associated With Use of an Online Telemedicine Service to Access Self-managed Medical Abortion in the US.

Importance: People in the US have been seeking self-managed abortions outside the formal health care system using medications obtained through online telemedicine. However, little is known about this practice, including potential motivating factors. Objective: To examine individual reasons for accessing medication abortion through an online telemedicine service as well as associations between state- and county-level factors and the rate of requests. Design, Setting, and Participants: This population-based cross-sectional study examined all requests for self-managed medication abortion through an online consultation form available from Aid Access, a telemedicine service in the US, between March 20, 2018, and March 20, 2020. Main Outcomes and Measures: Individual-level reasons for accessing the telemedicine service were examined as well as the rate of requests per 100 000 women of reproductive age by state. Zip code data provided by individuals making requests were used to examine county-level factors hypothesized to be associated with increased demand for self-managed abortion: distance to a clinic (calculated using location data for US abortion clinics) and the population proportion identifying as a member of a racial/ethnic minority group, living below the federal poverty level, and having broadband internet access (calculated using census data). Results: During the 2-year study period, 57 506 individuals in 2458 counties in 50 states requested self-managed medication abortion; 52.1% were aged 20 to 29 years (mean [SD] age, 25.9 [6.7] years), 50.0% had children, and 99.9% were 10 weeks' pregnant or less. The most common reasons cited by individuals making requests were the inability to afford in-clinic care (73.5%), privacy (49.3%), and clinic distance (40.4%). States with the highest rate of requests were Louisiana (202.7 per 100 000 women) and Mississippi (199.9 per 100 000 women). At the county level, an increase of 1 SD (47 miles) in distance to the nearest clinic was significantly associated with a 41% increase in requests (incidence rate ratio, 1.41; 95% CI, 1.31-1.51; P < .001), and a 10% increase in the population living below the federal poverty level was significantly associated with a 20% increase in requests (incidence rate ratio, 1.20; 95% CI, 1.13-1.28; P < .001). Conclusions and Relevance: In this cross-sectional study, clinic access barriers were the most commonly cited reason for requesting self-managed medication abortion using an online telemedicine service. At the county level, distance to an abortion clinic and living below the federal poverty level were associated with a higher rate of requests. State and federal legislation could address these access barriers.

Association of health literacy and medication adherence with health-related quality of life (HRQoL) in patients with ischemic heart disease.

BACKGROUND: Medication Adherence (MA) and Health Related Quality of Life (HRQoL) are two inter-connected concepts, co-influenced by Health Literacy (HL), with significant impact on patient management and care. Thus, we aimed to estimate the association of HL and MA with HRQoL in IHD patients. METHODS: Cross-sectional study of 251 IHD patients recruited from Lahore over 6 months period. HL, MA and HRQoL was assessed using validated questionnaires; 16-items of HL, Morisky Green Levine Scale (MGLS) and SF-12, respectively. Chi-square for significance, logistic-regression for association and linear regression for predictions were used. RESULTS: IHD patients; males (p = 0.0001), having secondary-higher education (p = 0.0001), middle/upper class (p = 0.0001) and employed (p = 0.005) had adequate HL, and were more likely to be adherent (OR; 4.3, p = 0.014). Both physical (PCS-12) and mental (MCS-12) component scores of HRQoL for age, gender, education, area of residence, employment and MA were significantly higher in patients with adequate HL. In multinomial regression, improved PCS-12 scores tend to be higher in subjects having secondary-higher education (OR; 3.5, p = 0.067), employed (OR; 6.1, p = 0.002) and adherent (OR; 2.95, p = 0.218), while MCS-12 scores tend to be higher in patients < 65 years (OR; 2.2, p = 0.032), employed (OR; 3, p = 0.002) and adherent (OR; 4, p = 0.004). In adjusted model, HL (ß;0.383, p = 0.0001) and MA (ß; - 0.133, p = 0.018) were significantly associated with PCS-12, and MCS-12 with MA (ß; - 0.161, p = 0.009) only. CONCLUSION: Data suggested that adequate HL was significantly associated with adherence and both physical and mental dimensions of HRQoL were higher in IHD patients with adequate HL. Besides, HL and MA are independent predictors of HRQoL in IHD patients.

The patient enablement instrument for back pain: reliability, content validity, construct validity and responsiveness.

BACKGROUND: Currently, there are no outcome measures assessing the ability of people with non-specific low back pain to self-manage their illness. Inspired by the 'Patient Enablement Instrument', we developed the Patient Enablement Instrument for Back Pain (PEI-BP). The aim of this study was to describe the development of the Patient Enablement Instrument for Back Pain (PEI-BP) and investigate content validity, construct validity, internal consistency, test-retest reliability, measurement error, responsiveness and floor and ceiling effects. METHODS: The PEI-BP consists of 6 items that are rated on a 0-10 Numeric Rating Scale. Measurement properties were evaluated using the COSMIN taxonomy and were based on three cohorts from primary care with low back pain: The content validity cohort (N = 14) which participated in semi-structured interviews, the GLA:D® Back cohort (N = 272) and the test-retest cohort (N = 37) which both completed self-reported questionnaires. For construct validity and responsiveness, enablement was compared to disability (Oswestry Disability Index), back pain beliefs (Brief Illness Perception Questionnaire), fear avoidance (Fear-Avoidance Beliefs Questionnaire-physical activity), mental health (SF-36), educational level and number of previous episodes of low back pain. RESULTS: The PEI-BP was found to have acceptable content validity, construct validity, reliability (internal consistency, test-retest reliability and measurement error) and responsiveness. The Smallest Detectable Change was 10.1 points illustrating that a patient would have to change more than 1/6 of the scale range for it to be a true change. A skewed distribution towards the high scores were found at baseline indicating a potentially problematic ceiling effect in the current population. CONCLUSIONS: The PEI-BP can be considered a valid and reliable tool to measure enablement on people seeking care for non-specific LBP. Further testing of the PEI-BP in populations with more severe LBP is recommended. TRIAL REGISTRATION: Not applicable.

Self-monitored versus supervised walking programs for older adults.

ABSTRACT: Walking is an effective, well accepted, inexpensive, and functional intervention. This study compared the outcomes and changes in walking behavior of self-monitored (SM) and supervised (SU) walking interventions for older adults.Participants were assigned to SM (n = 21) and SU (n = 21) walking groups according to their place of residence. Both groups exercised and wore a pedometer for 3 months.The outcome measures were step count, body mass index (BMI), and physical function. Two-way repeated-measure ANOVA and independent t tests were used to compare the intervention effects. We also plotted the trends and analyzed the walking steps weekly.Only BMI exhibited a group × time interaction. The pre-posttest differences showed knee extension muscle strength (KEMS) and Timed Up and Go test were significantly improved in the SM group, whereas BMI, KEMS, 30-s sit-to-stand, functional reach were significantly improved, but 5-m gait speed significantly slower in the SU group. For participants attending ≥50% of the sessions, those in the SM and SU groups had similar results for all variables, except for 2-min step (2MS) and daily walking step counts.Both self-monitored and supervised walking benefit older adults in most physical functions, especially lower-extremity performance, such as muscle strength, balance, and mobility. The effects of both programs do not differ significantly, except for BMI and 2MS (ie cardiopulmonary endurance). We recommend pedometer-assisted self-monitored walking for older adults because of its ability to cultivate exercise habits over the long term, whereas supervised walking to establish effective exercise intensity.