Joseph T. Hepworth

Burden experienced by caregivers of relatives with dementia in Taiwan

BACKGROUND The burden produced by caring for relatives with dementia is an increasing problem in the United States and Taiwan, necessitating a better understanding of the interrelationships of the factors that influence burden. OBJECTIVES To test a theoretical model specifying how the demands of care, filial obligation, caregiving self-efficacy, coping strategies, and caregiving involvement affect caregiver burden. METHOD A descriptive cross-sectional design with a convenience sample (n = 150) from outpatient clinics of three hospitals in Taiwan was used. The Caregiver Burden Inventory and the Cost of Care Index assessed caregiver burden. The antecedents of burden were assessed by the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living, the Mini-Mental State Examination, the Revised Memory and Behavior Problem Checklist, the Montgomery obligation subscale, Cicirellis obligation scale, the Caregiving Self-efficacy Scale, the Caregiving Involvement Scale, and the Ways of Coping Questionnaire. RESULTS The original model did not fit the data well but minor respecifications produced a good model as evidenced by a chi2/df ratio of 2.1, a goodness-of-fit index of .89, and a comparative fit index of .93. Demands of care on the caregiver and filial obligation had direct positive effects on caregiving involvement. Caregiving involvement and emotion-focused coping had direct positive effects on caregiving burden. Filial obligation, caregiving self-efficacy, and problem-focused coping had direct negative effects on caregiving burden. Six of the seven original hypothesized structural relationships were confirmed in the final model. CONCLUSIONS The Burden Model tested in this study corroborates findings from other burden studies and extends our knowledge of caregiver burden. Filial obligation, self-efficacy, demands of care, involvement in care, and coping were shown to predict burden in this sample of Taiwanese caregivers. Future study is needed to evaluate interventions designed for family caregivers of persons with dementia. Especially needed is research in the area of counseling and mental health services to assist caregivers in dealing with manifestations of burden.

Improving Diabetic Retinopathy Screening Ratios Using Telemedicine-Based Digital Retinal Imaging Technology The Vine Hill Study

OBJECTIVE—To evaluate the impact of a telemedicine, digital retinal imaging strategy on diabetic retinopathy screening rates in an inner-city primary care clinic. RESEARCH DESIGN AND METHODS—This retrospective cohort study included all diabetic patients aged ≥18 years (n = 495) seen at Vine Hill Community Clinic between 1 September 2003 and 31 August 2004. Patients were offered ophthalmology referral or digital screening. Patients choosing referral received the next available (within 3 months) appointment at the Vanderbilt Eye Clinic; patients choosing digital screening were screened during the visit. RESULTS—Retinal screening was documented for 293 (59.2%) patients, a significant improvement compared with the 23% baseline rate. Of 293 patients screened, 92 (31.4%) were screened in ophthalmology, and 201 (68.6%) were digitally screened. Among the 201 digitally screened patients, 104 (51.7%) screened negative and were advised to rescreen in 1 year, 75 (37.3%) screened positive and were nonurgently referred to ophthalmology, and 22 (11.0%) screened positive for sight-threatening eye disease and were urgently referred for ophthalmological follow-up. Digital imaging technical failure rate was 0.5%. Referral status was associated with race/ethnicity (χ2 = 7.9, P < 0.02) with whites more likely to screen negative than non-whites (62.4 vs. 47.8%, respectively). Sight-threatening disease among non-whites (14.7%) was more than double that observed for whites (5.9%). CONCLUSIONS—Digital imaging technology in the primary care visit can significantly improve screening rates over conventional methods, increase access to recommended diabetic eye care, and focus specialty care on medically indigent patients with greatest need.

Improving cancer pain management through patient and family education.

The purpose of this study was to determine if continued access to information following a baseline pain education program would increase knowledge and positive beliefs about cancer pain management, thus resulting in improved pain control during a 6-month follow-up period. Patients with cancer-related pain and their primary caregivers received a brief pain education program, and were then randomized into one of three information groups: a) usual care, b) pain hot line, and c) weekly provider-initiated follow-up calls for 1 month post-education. Sixty-four patients and their primary caregivers were recruited. Both patients and caregivers showed an improvement in knowledge and beliefs after the baseline pain education program. Continued access to pain information with either the pain hot line or provider-initiated weekly follow-up calls did not affect long-term outcomes of pain intensity, interference because of pain, adequacy of analgesics used, or pain relief. In addition, long-term outcomes did not differ between patients who had improvement and those who showed decline in knowledge and beliefs pre-post education. These findings suggest that a brief pain education program can improve knowledge and beliefs of both patient and primary caregiver. Continued access to pain related information using either a patient- or provider-initiated format did not affect long-term pain outcomes.

Effect of Tai Chi on Physical Function, Fall Rates and Quality of Life Among Older Stroke Survivors

OBJECTIVE To examine the effect of a 12-week Tai Chi (TC) intervention on physical function and quality of life. DESIGN Single-blind, randomized controlled trial. SETTING General community. PARTICIPANTS Community-dwelling survivors of stroke (N=145; 47% women; mean age, 70y; time poststroke: 3y; ischemic stroke: 66%; hemiparesis: 73%) who were aged ≥50 years and were ≥3 months poststroke. INTERVENTIONS Yang style 24-posture short-form TC (n=53), strength and range of movement exercises (SS) (n=44), or usual care (UC) (n=48) for 12 weeks. The TC and SS groups attended a 1-hour class 3 times per week, whereas the UC group had weekly phone calls. MAIN OUTCOME MEASURES Physical function: Short Physical Performance Battery, fall rates, and 2-minute step test; quality of life: Medical Outcomes Study 36-Item Short-Form Health Survey, Center for Epidemiologic Studies Depression Scale, and Pittsburgh Sleep Quality Index. RESULTS During the intervention, TC participants had two thirds fewer falls (5 falls) than the SS (14 falls) and UC (15 falls) groups (χ(2)=5.6, P=.06). There was a significant group by time interaction for the 2-minute step test (F2,142=4.69, P<.01). Post hoc tests indicated that the TC (t53=2.45, P=.02) and SS (t44=4.63, P<.01) groups had significantly better aerobic endurance over time, though not in the UC group (t48=1.58, P=.12). Intervention adherence rates were 85%. CONCLUSIONS TC and SS led to improved aerobic endurance, and both are suitable community-based programs that may aid in stroke recovery and community reintegration. Our data suggest that a 12-week TC intervention was more effective in reducing fall rates than SS or UC interventions. Future studies examining the effectiveness of TC as a fall prevention strategy for community-dwelling survivors of stroke are recommended.

Coping and depressive symptoms in adults living with heart failure.

Background and Research Objective: This study used process coping theory as the basis for investigating how coping strategies are associated with depressive symptoms in individuals living with heart failure (HF). Demographic factors also were examined as correlates of depressive symptoms. Subjects and Methods: The convenience sample of adults living with HF (n = 75) who participated in this study ranged in age from 27 to 82 years (M = 55). Sixty-nine percent of the participants were men, 59% were married or partnered, with the majority being Caucasian and from the middle class. Subjects were recruited from a comprehensive HF program located within an academic health science center in the southeastern United States. A single wave of data collection occurred. All study questionnaires were verbally administered in a clinic room selected for privacy during a routine HF clinic visit. Results and Conclusion: Individuals who used more planful problem-solving and social support seeking coping strategies had fewer depressive symptoms, whereas individuals who used more escape-avoidance coping (eg, wishful thinking) had more depressive symptoms. When demographic factors also were included in a regression analysis assessing depressive symptoms, marital status, functional impairment, and the coping strategies of planful problem-solving and escape-avoidance were all statistically significant predictors of depression. Single individuals, those who used more escape-avoidance, less planful problem-solving coping, and more functional impairment had more depressive symptoms. These results suggest that psychosocial factors, in addition to physical parameters, and the ways individuals cope with the stressors of living with heart failure may be important predictors of depressive symptoms.

Cognitive-behavioral intervention effects on adolescents' anxiety and pain following spinal fusion surgery.

BackgroundCognitive-behavioral interventions, typically effective in reducing anxiety and pain, have not been applied to adolescents undergoing major orthopaedic surgery. ObjectivesTo determine the effectiveness of three cognitive-behavioral interventions for reducing adolescents’ postoperative anxiety and pain following spinal fusion surgery for scoliosis, and whether effectiveness depended on preoperative anxiety and age. MethodsA randomized controlled trial with four groups receiving a videotape intervention (information only, coping only, information plus coping, or control) used a convenience sample of 109 adolescents (88 female, 93 White), 11–18 years of age (M = 14). Speilberger’s (1983) State Anxiety scale assessed anxiety preoperatively and postoperatively on Day 2. A visual analogue scale assessed pain postoperatively on Days 2 and 4. ResultsInformation plus coping was most effective for reducing postoperative anxiety in adolescents with high preoperative anxiety. Coping instruction led to less postoperative anxiety and pain for adolescents ages 13 and younger. The control group reported the highest levels of pain on Day 4. ConclusionsCognitive-behavioral interventions designed to prepare adolescents for surgery should be tailored to individual factors and developmental needs, especially the adolescents’ preoperative anxiety level and age.

Children's Preoperative Coping and Its Effects on Postoperative Anxiety and Return to Normal Activity

A model was tested to assess childrens preoperative coping with major orthopedic surgery and how coping is related to two different postoperative outcomes, anxiety and return to normal activities. Ninety children, ages 8 to 17, participated. Data were collected the day before surgery, the second postoperative day, and at 3-, 6-, and 9-month recovery periods. A respecified model was not significantly different from the data (p = .90), indicating a good fit. Children who were older, more anxious, and more internal in locus of control exhibited more vigilant coping. Avoidant coping was associated with less anxiety 2 days postoperatively, and vigilant coping was associated with return to normal activities over the course of recovery.

Effect of crew resource management on diabetes care and patient outcomes in an inner-city primary care clinic

Background: Diabetes care in our inner-city primary care clinic was suboptimal, despite provider education and performance feedback targeting improved adherence to evidence-based clinical guidelines. A crew resource management (CRM) intervention (communication and teamwork, process and workflow organisation, and standardised information debriefings) was implemented to improve diabetes care and patient outcomes. Objective: To assess the effect of the CRM intervention on adherence to evidence-based diabetes care standards, work processes, standardised clinical communication and patient outcomes. Methods: Time-series analysis was used to assess the effect on the delivery of standard diabetes services and patient outcomes among medically indigent adults (n = 619). Results: The CRM principles were translated into useful process redesign and standardised care approaches. Significant improvements in microalbumin testing and associated patient outcome measures were attributed to the intervention. Conclusions: The CRM approach provided tools for management that, in the short term, enabled reorganisation and prevention of service omissions and, in the long term, can produce change in the organisational culture for continuous improvement.

Clustering of U.S. women receiving no prenatal care: Differences in pregnancy outcomes and implications for targeting interventions

Objectives: Prenatal care is an established mechanism for identifying and managing risk factors impacting pregnancy outcomes. Despite aggressive efforts in the United States (US) to assure that all women begin care in the first trimester, every year about 70,000 women in the US receive no care prior to delivery. We hypothesized that US women receiving no prenatal care comprise clusters (subgroups) with distinctive behavioral, socio-demographic, and medical risks and that birth outcomes differ among the clusters. Methods: White, Black, and Hispanic women (n = 126,220) receiving no prenatal care and delivering a live, singleton infant were identified from linked birth and death certificates for years 1995 through 1997. Cluster analysis was used to group women with similar characteristics, and cluster assignment was evaluated using discriminant analysis. Birth outcomes for any care and no-care women were then examined using logistic regression. Results: Six replicable clusters of women with no care were identified. Birth outcomes varied significantly among clusters and were two to four times worse for no-care clusters compared to outcomes for women receiving any care. Conclusions: Cluster analysis is an effective alternative for grouping individuals for use in public health education, intervention, and outreach programming. Women receiving no prenatal care were characteristically different from women receiving any care in this study, but they did not represent a homogenous group. Findings suggest that interventions should target reducing the proportion of women receiving no care and should be tailored to specific no-care clusters.

Telephone-delivered health education and interpersonal counseling improve quality of life for Latinas with breast cancer and their supportive partners.

This study aims to test two telephone‐delivered interventions for their efficacy in improving quality of life (QOL) (psychological, physical, social, and spiritual) among Latinas with breast cancer and their family members or friends (labeled supportive partners in this study).