Ginger Hanson

Collaborative care for chronic pain in primary care: a cluster randomized trial.

CONTEXT Chronic pain is common in primary care patients and is associated with distress, disability, and increased health care use. OBJECTIVE To assess whether a collaborative intervention can improve chronic pain-related outcomes, including comorbid depression severity, in a Department of Veterans Affairs primary care setting. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized controlled trial of a collaborative care assistance with pain treatment intervention vs treatment as usual at 5 primary care clinics of 1 Department of Veterans Affairs Medical Center. Forty-two primary care clinicians were randomized to the assistance with pain treatment intervention group or the treatment as usual group. The 401 patients had musculoskeletal pain diagnoses, moderate or greater pain intensity, and disability lasting 12 weeks or longer and were assigned to the same treatment groups as their clinicians. Recruitment occurred from January 2006 to January 2007 and follow-up concluded in January 2008. INTERVENTION Assistance with pain treatment included a 2-session clinician education program, patient assessment, education and activation, symptom monitoring, feedback and recommendations to clinicians, and facilitation of specialty care. MAIN OUTCOME MEASURES Changes over 12 months in pain-related disability (Roland-Morris Disability Questionnaire, range of 0-24), pain intensity (Chronic Pain Grade [CPG] Pain Intensity subscale, range of 0-100), and depression (Patient Health Questionnaire 9 [PHQ-9], range of 0-27), measured as beta coefficients (difference in slopes in points per month). RESULTS Intervention patients had a mean (SD) of 10.6 (4.5) contacts with the assistance with pain treatment team. Compared with the patients receiving treatment as usual, intervention patients showed greater improvements in pain-related disability (Roland-Morris Disability Questionnaire beta, -0.101 [95% confidence interval {CI}, -0.163 to -0.040]; P = .004 and CPG Pain Intensity subscale beta, -0.270 [95% CI, -0.480 to -0.061]; P = .01). Among patients with baseline depression (PHQ-9 score > or = 10), there was greater improvement in depression severity in patients receiving the intervention compared with patients receiving treatment as usual (PHQ-9 beta, -0.177 [95% CI, -0.295 to -0.060]; P = .003). The differences in scores between baseline and 12 months for the assistance with pain treatment intervention group and the treatment as usual group, respectively, were -1.4 vs -0.2 for the Roland-Morris Disability Questionnaire, -4.7 vs -0.6 for the CPG Pain Intensity subscale, and -3.7 vs -1.2 for PHQ-9. CONCLUSION The assistance with pain treatment collaborative intervention resulted in modest but statistically significant improvement in a variety of outcome measures. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00129480.

A Six-Month Randomized Controlled Trial of Exercise and Pyridostigmine in the Treatment of Fibromyalgia

OBJECTIVE A subset of fibromyalgia (FM) patients have a dysfunctional hypothalamic-pituitary-insulin-like growth factor 1 (IGF-1) axis, as evidenced by low serum levels of IGF-1 and a reduced growth hormone (GH) response to physiologic stimuli. There is evidence that pyridostigmine (PYD) improves the acute response of GH to exercise in FM patients. The purpose of this study was to evaluate the clinical effectiveness of 6 months of PYD and group exercise on FM symptoms. METHODS FM patients were randomized to 1 of the following 4 groups: PYD plus exercise, PYD plus diet recall but no exercise, placebo plus exercise, and placebo plus diet recall but no exercise. The primary outcome measures were the visual analog scale (VAS) score for pain, tender point count, and total myalgic score. Secondary outcome measures were the total score on the Fibromyalgia Impact Questionnaire (FIQ) and FIQ VAS scores for individual symptoms (fatigue, poor sleep, stiffness, and anxiety), as well as quality of life (QOL) and physical fitness (lower body strength/endurance, upper and lower body flexibility, balance, and time on the treadmill). RESULTS A total of 165 FM patients completed baseline measurements; 154 (93.3%) completed the study. The combination of PYD and exercise did not improve pain scores. PYD groups showed a significant improvement in sleep and anxiety in those who completed the study and in QOL in those who complied with the therapeutic regimen as compared with the placebo groups. Compared with the nonexercise groups, the 2 exercise groups demonstrated improvement in fatigue and fitness. PYD was generally well tolerated. CONCLUSION Neither the combination of PYD plus supervised exercise nor either treatment alone yielded improvement in most FM symptoms. However, PYD did improve anxiety and sleep, and exercise improved fatigue and fitness. We speculate that PYD may have improved vagal tone, thus benefiting sleep and anxiety; this notion warrants further study.

A telephone-only motivational intervention to increase physical activity in rural adults: a randomized controlled trial.

Background: Both urban and rural adults are likely to be inactive, but rural adults have less access to exercise classes or facilities to increase physical activity. Objectives: To evaluate whether a telephone-only motivational interviewing (MI) intervention would increase daily physical activity of rural adults. Methods: This randomized controlled trial enrolled 86 physically inactive adults living in rural communities (mean age = 58 years, range = 30-81 years) who stated that they were ready to increase physical activity during the next 6 months. Participants were assigned randomly to MI intervention (n = 43) or control (n = 43) groups. The MI group participants received a pedometer and monthly MI telephone calls over 6 months from a counselor. Control group participants received an equal number of telephone calls without MI content. Physical activity was measured by self-report using the Community Healthy Activities Model Program For Seniors Physical Activity Questionnaire for Older Adults. Data were collected by mailed surveys and analyzed using analysis of variance. Results: Seventy-two participants completed the study (35 in the intervention group and 37 in the control group). The telephone-only MI intervention increased self-efficacy for exercise (p = .019) but did not increase levels of physical activity (p = .572) compared with controls. Discussion: The intervention increased self-efficacy for exercise but did not increase physical activity, possibly due to seasonal effects, the control condition, or the length of the MI intervention. Even so, future studies are warranted because telephone-only MI has potential as a practical, relatively inexpensive method to provide health counseling to rural adults in a broad geographic area. This study produced an effect size on physical activity that will be useful to guide future studies.

Risk for reassault in abusive female same-sex relationships.

OBJECTIVES We revised the Danger Assessment to predict reassault in abusive female same-sex relationships. METHODS We used focus groups and interviews to evaluate the assessment tool and identify new risk factors and telephone interviews at baseline and at 1-month follow-up to evaluate the revised assessment. RESULTS The new assessment tool comprised 8 original and 10 new items. Predictors included increase in physical violence (relative risk ratio [RRR]=1.95; 95% confidence interval [CI]=0.84, 4.54), constant jealousy or possessiveness of abuser (RRR = 4.07; 95% CI = 0.61, 27.00), cohabitation (RRR = 1.96; 95% CI = 0.54, 7.12), threats or use of gun by abuser (RRR=1.93; 95% CI=0.79, 4.75), alcoholism or problem drinking of abuser (RRR=1.47; 95% CI=0.79, 2.71), illegal drug use or abuse of prescription medications by abuser (RRR = 1.33; 95% CI = 0.72, 2.46), stalking by abuser (RRR=1.39; 95% CI=0.70, 2.76), failure of individuals to take victim seriously when she sought help (RRR=1.66; 95% CI=0.90, 3.05), victims fear of reinforcing negative stereotypes (RRR=1.42; 95% CI=0.73, 2.77), and secrecy of abuse (RRR=1.72; 95% CI=0.74, 3.99). Both unweighted (P < .005) and weighted (P < .004) versions of the revised assessment were significant predictors of reassault. CONCLUSIONS The revised Danger Assessment accurately assesses risk of re-assault in abusive female relationships.

Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study

BackgroundConsumer-driven homecare models support aging and disabled individuals to live independently through the services of homecare workers. Although these models have benefits, including autonomy and control over services, little evidence exists about challenges homecare workers may face when providing services, including workplace violence and the negative outcomes associated with workplace violence. This study investigates the prevalence of workplace violence among homecare workers and examines the relationship between these experiences and homecare worker stress, burnout, depression, and sleep.MethodsWe recruited female homecare workers in Oregon, the first US state to implement a consumer driven homecare model, to complete an on-line or telephone survey with peer interviewers. The survey asked about demographics and included measures to assess workplace violence, fear, stress, burnout, depression and sleep problems.ResultsHomecare workers (n = 1,214) reported past-year incidents of verbal aggression (50.3% of respondents), workplace aggression (26.9%), workplace violence (23.6%), sexual harassment (25.7%), and sexual aggression (12.8%). Exposure was associated with greater stress (p < .001), depression (p < .001), sleep problems (p < .001), and burnout (p < .001). Confidence in addressing workplace aggression buffered homecare workers against negative work and health outcomes.ConclusionsTo ensure homecare worker safety and positive health outcomes in the provision of services, it is critical to develop and implement preventive safety training programs with policies and procedures that support homecare workers who experience harassment and violence.

THE DOMESTIC VIOLENCE SURVIVOR ASSESSMENT (DVSA): A TOOL FOR INDIVIDUAL COUNSELING WITH WOMEN EXPERIENCING INTIMATE PARTNER VIOLENCE

The Domestic Violence Survivor Assessment (DVSA) was developed to measure survivor movement toward a violence free life over time. This paper reports our testing of the validity and reliability of the DVSA. Exploratory factor analysis (n = 162) found a single factor explaining 66% of the variance. Hierarchical multiple regression indicated that physical abuse severity, survivor and perpetrator substance abuse, economic and citizenship dependency, and children under 18 at home explained 10% of the variance p > .05. A second model examined the strength of interventions for survivors, controlling for influencing factors; R2 was.24 (p < .001). The strongest interventions were individual counseling (p < .001) and resource referrals and other services (p < .05). The DVSA was found to have construct validity, sensitivity to change over time, and reliability. A county agency that adopted the DVSA evaluated its programs using the DVSA change scores and used this evaluation for program improvement.

Patterns of Work-Related Intimate Partner Violence and Job Performance Among Abusive Men

This study assesses different types of work-related intimate partner violence (IPV) perpetration and their relationship to perpetrators’ work performance and employment. We determine if groups of abusive men with similar patterns of work-related IPV exist and then examine whether the patterns are related to their characteristics, job performance, and employment outcomes. Participants were 198 adult men (60% Latino, 40% non-Latino) from batterer intervention programs (BIPs) who self-reported their lifetime work-related IPV and job outcomes. Five distinct clusters were identified and named based on the pattern (predominance or absence) of different work-related abusive behaviors reported: (a) low-level tactics, (b) job interference, (c) job interference with threatened or actual violence, (d) extreme abuse without jealousy and (e) extreme abuse. Analyses revealed significant differences between the clusters on ethnicity, parental status, partner’s employment status, income, education, and (among Latinos only) acculturation. The probability of men’s work-related IPV substantially impacting their own job performance was nearly 4 times greater among those in the extreme abuse cluster than those in the low-level tactics cluster. These data inform the development of employee training programs and workplace policies for reducing IPV that affects the workplace.

Knowledge, Awareness, Perceptions, and Use of Emergency Contraceptives among Survivors of Intimate Partner Violence.

The study examines emergency contraception (EC) knowledge, awareness, perceptions, and prior use and identifies predictors of EC use among a sample of survivors of intimate partner violence (IPV). The majority (66.2%) of 154 survivors at risk of pregnancy reported EC awareness, only 15.3% reported prior EC use. Logistic regression identified perceived abusive intimate partner approval (OR = 2.25; 95% CI = 1.15–4.41) and lack of moral/religious objections (OR = 12.83; 95% CI = 5.48–30.03) as the strongest predictors of EC use. Health care provider interventions acknowledging barriers to EC use, such as partner approval, and education that improves awareness of and knowledge about EC, may have the impact of empowering survivors in their reproductive choices, reducing unwanted pregnancies.

Addressing Younger Workers' Needs: The Promoting U through Safety and Health (PUSH) Trial Outcomes.

Most younger workers, less than 25 years old, receive no training in worker safety. We report the feasibility and outcomes of a randomized controlled trial of an electronically delivered safety and health curriculum for younger workers entitled, PUSH (Promoting U through Safety and Health). All younger workers (14–24 years old) hired for summer work at a large parks and recreation organization were invited to participate in an evaluation of an online training and randomized into an intervention or control condition. Baseline and end-of-summer online instruments assessed acceptability, knowledge, and self-reported attitudes and behaviors. One-hundred and forty participants (mean age 17.9 years) completed the study. The innovative training was feasible and acceptable to participants and the organization. Durable increases in safety and health knowledge were achieved by intervention workers (p < 0.001, effect size (Cohen’s d) 0.4). However, self-reported safety and health attitudes did not improve with this one-time training. These results indicate the potential utility of online training for younger workers and underscore the limitations of a single training interaction to change behaviors. Interventions may need to be delivered over a longer period of time and/or include environmental components to effectively alter behavior.