A Longitudinal Observational Study of Multimorbidity and Partner Support for Physical Activity Among People with Osteoarthritis.

BACKGROUND: Physical activity can improve osteoarthritis-related symptoms; however, many people with osteoarthritis (PWOA) are insufficiently active. Social support for physical activity from an intimate partner can help PWOA increase activity, but managing multiple, chronic physical or mental health conditions (i.e., multimorbidity) may influence provision and receipt of that support. METHOD: Data from a 1-year longitudinal observational study was used to examine associations between multimorbidity and three dimensions of partner support for physical activity-companionship partner support (doing activity together), enacted partner support, and social support effectiveness-in 169 insufficiently active PWOA and their partners. RESULTS: Multivariable-adjusted multi-level models indicated baseline differences in support by multimorbidity status: when partners had multimorbidity, PWOA reported receiving less companionship support and less effective support from partners; when PWOA had multimorbidity, partners reported providing less enacted support and both partners and PWOA reported less effective partner support. Broad trends (p < .05) indicate initial increases and subsequent decreases in companionship and enacted partner support when PWOA had multimorbidity, and among partners with and without multimorbidity. When PWOA had multimorbidity, an initial increase in support effectiveness was followed by no significant change; a similar trend was seen among partners with and without multimorbidity. CONCLUSION: Multimorbidity may generally contribute to less partner support for physical activity or less effective support, although influences on support over time are less clear. Physical activity interventions for couples experiencing multimorbidity would likely benefit from attention to the impact of multiple chronic health conditions on physical activity and physical activity-related partner support.

Chronic Disease Among African American Families: A Systematic Scoping Review.

INTRODUCTION: Chronic diseases are common among African Americans, but the extent to which research has focused on addressing chronic diseases across multiple members of African American families is unclear. This systematic scoping review summarizes the characteristics of research addressing coexisting chronic conditions among African American families, including guiding theories, conditions studied, types of relationships, study outcomes, and intervention research. METHODS: The literature search was conducted in PsycInfo, PubMed, Social Work Abstracts, Sociological Abstracts, CINAHL, and Family and Society Studies Worldwide to identify relevant articles published from January 2000 through September 2016. We screened the title and abstracts of 9,170 articles, followed by full-text screening of 530 articles, resulting in a final sample of 114 articles. Fifty-seven percent (n = 65) of the articles cited a guiding theory/framework, with psychological theories (eg, social cognitive theory, transtheoretical model) being most prominent. The most common conditions studied in families were depression (70.2%), anxiety (23.7%), and diabetes (22.8%), with most articles focusing on a combination of physical and mental health conditions (47.4%). RESULTS: In the 114 studies in this review, adult family members were primarily the index person (71.1%, n = 81). The index condition, when identified (79.8%, n = 91), was more likely to be a physical health condition (46.5%, n = 53) than a mental health condition (29.8%, n = 34). Among 343 family relationships examined, immediate family relationships were overwhelmingly represented (85.4%, n = 293); however, extended family (12.0%, n = 41) and fictive kin (0.6%, n = 2) were included. Most (57.0%, n = 65) studies focused on a single category of outcomes, such as physical health (eg, obesity, glycemic control), mental health (eg, depression, anxiety, distress), psychosocial outcomes (eg, social support, caregiver burden), or health behaviors (eg, medication adherence, disease management, health care utilization); however, 43.0% (n = 49) of studies focused on outcomes across multiple categories. Sixteen intervention articles (14.0%) were identified, with depression the most common condition of interest. CONCLUSION: Recognizing the multiple, simultaneous health issues facing families through a lens of family comorbidity and family multimorbidity may more accurately mirror the lived experiences of many African American families and better elucidate intervention opportunities than previous approaches.

The Role of Cohabitating Partner and Relationship Characteristics on Physical Activity among Individuals with Osteoarthritis.

BACKGROUND: Most individuals with knee or hip osteoarthritis do not meet recommendations for physical activity. The Social Cognitive Theory suggests that the social environment (e.g., spouses/partners) may influence the physical activity of individuals with osteoarthritis. The purpose of this study was to examine whether the physical activity of insufficiently active, coupled adults with osteoarthritis was associated with received partner support for physical activity, partner's engagement in physical activity, and relationship satisfaction. METHODS: Cross-sectional data from 169 couples were collected. Accelerometers estimated moderate-to-vigorous physical activity and daily steps for participants with osteoarthritis and their partners. Participants with osteoarthritis reported total received partner support for physical activity and relationship satisfaction. RESULTS: Participants with osteoarthritis were on average 65 years old, 65% female, 86% non-Hispanic white, and 47% retired. Receiving total partner support more frequently was associated with more minutes of moderate-to-vigorous physical activity but not with steps. Relationship satisfaction moderated the association of partner's physical activity on the daily steps of individuals with osteoarthritis such that having a partner who accomplished more daily steps was associated with participants with osteoarthritis accomplishing more daily steps themselves when they reported greater relationship satisfaction. CONCLUSIONS: Partners and relationship satisfaction may play an important role in the physical activity of individuals with osteoarthritis. Interventions seeking to increase physical activity in this population may be enhanced by promoting partner support. Additional research is needed to further explain these associations within the context of relationship satisfaction.

Perceptions of Rural African American Adults About the Role of Family in Understanding and Addressing Risk Factors for Cardiovascular Disease.

PURPOSE: African Americans (AAs) in rural south and southeast regions of the United States have among the highest prevalence of cardiovascular disease (CVD) in the country. The purpose of this qualitative, exploratory study is to understand family influences on CVD-related knowledge and health-related behaviors among rural AA adults. DESIGN: Qualitative descriptive study design using a community-based participatory research approach. SETTING: Two rural North Carolina counties. PARTICIPANTS: Eligible participants were AA adults (at least 21 years of age), who self-reported either CVD diagnosis or selected CVD risk factor(s) for themselves or for an adult family member (N = 37). METHOD: Directed content analysis of semistructured interviews by community and academic partners. RESULTS: Family health history and familial norms and preferences influenced participants' CVD-related knowledge, beliefs, and health-related behaviors. Participants reported their families were helpful for increasing motivation for and overcoming barriers to healthy behaviors, including hard-to-access community resources and physical challenges. Conversely, and to a lesser extent, participants also reported that family members hindered or had little influence (positive or negative) on their engagement in healthy behaviors. CONCLUSION: Family played an important role in helping individuals overcome personal and community-related challenges. Efforts to reduce CVD burden among rural AAs should seek to understand the family-related facilitators, barriers, and processes associated with CVD knowledge and risk-reduction behaviors.

Four Methods of Recruiting Couples Into a Longitudinal Study of Physical Activity in People With Osteoarthritis: Recruitment, Retention, and Lessons Learned.

Increases in physical activity can reduce joint pain among people with osteoarthritis (PWOA) who are insufficiently physically active. Because evidence suggests that social support from intimate partners may help PWOA become more active, researchers have been interested in recruiting couples to studies of physical activity interventions; however, little guidance exists describing efficient and effective strategies for engaging couples in research. We describe methods used to recruit couples and contrast methods in terms of the proportion of individuals enrolled, sample demographic composition, retention, and resources. We used four recruitment methods to enroll couples in a longitudinal study of PWOA: (1) visiting community sites, (2) sending university-wide emails, (3) contacting patients identified through electronic medical records (EMR), and (4) partnering with a county-based osteoarthritis (OA) research cohort. We found that these methods differed in their challenges and contribution to enrollment goals but demonstrated similar levels of retention. We contacted 747 PWOA; 56% were screened for eligibility and 23% enrolled in the study. The largest proportion of participants recruited were from the email method (35.1%), followed by the community (26%), EMR (22.0%), and OA cohort (19.6%). Couples enrolled through the different methods differed by age, employment, education, and household income. Across the methods for both PWOA and partners, over 80% of participants were non-Hispanic white, about 11% were non-Hispanic black, and 6-8% identified as another race. Over 12 months of follow-up, 31 (17.9%) PWOA and 36 (20.8%) partners were lost to follow-up. Using four distinct recruitment methods allowed us to meet recruitment goals and provided a broader, more diverse population compared to using one method. We recommend that researchers consider several recruitment methods to meet enrollment goals, to ensure a diverse sample, and to match available resources. The lessons learned from this research fill a critical gap in the understanding of how to overcome barriers to recruiting and retaining couples in behavioral research.

Family presence and participation during medical visits of heart failure patients: An analysis of survey and audiotaped communication data.

OBJECTIVE: To describe the frequency, roles, and utility of family companion involvement in the care of patients with Heart Failure (HF) care and to examine the association between audiotaped patient, companion, and provider communication behaviors. METHODS: We collected survey data and audiotaped a single medical visit for 93 HF patients (36 brought a companion into the examination room) and their cardiology provider. Communication data was analyzed using the Roter Interaction Analysis System. RESULTS: There were 32% more positive rapport-building statements (p<0.01) and almost three times as many social rapport-building statements (p<0.01) from patients and companions in accompanied visits versus unaccompanied patient visits. There were less psychosocial information giving statements in accompanied visits compared to unaccompanied patient visits (p<0.01.) Providers made 25% more biomedical information giving statements (p=0.04) and almost three times more social rapport-building statements (p<0.01) in accompanied visits. Providers asked fewer biomedical and psychosocial questions in accompanied versus unaccompanied visits. Providers made 16% fewer partnership-building statements in accompanied versus unaccompanied visits (p=0.01). CONCLUSIONS: Our findings are mixed regarding the benefits of accompaniment for facilitating patient-provider communication based on survey and audiotaped data. PRACTICE IMPLICATIONS: Strategies to enhance engagement during visits, such as pre-visit question prompt lists, may be beneficial.

The Diabetic Health of African American Grandmothers Raising their Grandchildren.

PURPOSE: The purpose of this study is to compare the health of primary caregiving African American grandmothers with diabetes with African American women with diabetes who were not primary caregivers. DESIGN: Using a comparative, descriptive, cross-sectional design, 34 African American primary caregiving grandmothers were compared with 34 non-caregiving women with diabetes mellitus; women aged 55-75 years were recruited for this study throughout the central Arkansas. METHODS: To measure the overall health, data on blood pressure, body mass index measurements, HbA1c levels, total cholesterol, and urine protein and creatinine levels were collected from all the participants. RESULTS: Statistically significant differences between the caregivers and non-caregivers groups in systolic pressure (t = -3.42, P = 0.001) and diastolic pressure (t = -3.790, P = 0.000) and urine protein (W = 294.00, P = 0.000) were noted. Additionally, a clinically significant difference in HbA1c was noted between groups. CONCLUSION: Differences in systolic and diastolic pressures, urine protein, and clinically significant differences in HbA1c suggest that African American primary caregiving grandmothers with diabetes mellitus may have more difficulty in maintaining their diabetic health than non-caregiving African American women.

Adolescents and parental caregivers as lay health advisers in a community-based risk reduction intervention for youth: baseline data from Teach One, Reach One.

The purpose of the current study is to describe the demographic, behavioral, and psychosocial characteristics of adolescent and caregiver lay health advisers (LHAs) participating in an intervention designed to reduce risk behaviors among rural African-American adolescents. Teach One, Reach One integrates constructs from the Theory of Planned Behavior and Social Cognitive Theory. It acknowledges that changing the sexual behaviors of African-American adolescents requires changing one's knowledge, attitudes, normative beliefs about the behavior of peers, and self-efficacy regarding adolescent sexual behavior, parent-teen communication about sex, and healthy dating relations among adolescents. Study participants completed baseline questionnaires assessing demographics and psychosocial determinants (knowledge, attitudes, perceived social norms, and self-efficacy) of sexual behaviors. Sixty-two adolescent and caregiver dyads participated. Caregivers included biological parents, legal guardians, or other parental figures. Strengths and areas in need of improvement were determined using median splits. Few adolescents had initiated sex. Their strengths included high levels of open parent-teen communication; positive attitudes and normative beliefs regarding both sex communication and healthy dating relationships; and high knowledge and self-efficacy for healthy dating behaviors. Areas needing improvement included low knowledge, unfavorable attitudes, poor normative beliefs, and low self-efficacy regarding condom use. Caregiver strengths included positive attitudes, normative beliefs, and self-efficacy for sex communication; positive attitudes and self-efficacy for condom use; and low acceptance of couple violence. Areas needing improvement included low levels of actual communication about sex and low knowledge about effective communication strategies and condom use. The current study highlights the value of assessing baseline characteristics of LHAs prior to intervention implementation, as it enables a better understanding of the key characteristics necessary for planning and implementing interventions, as well as engaging in targeted training activities.

Adaptive Challenges Rising from the Life Context of African-American Caregiving Grandmothers with Diabetes: A Pilot Study.

To understand the challenges arising from the context within which diabetic African-American caregiving grandmothers self-manage their diabetes we used the Adaptive Leadership Framework. Additionally, challenges to retaining this population in a longitudinal study were examined. In this exploratory, longitudinal, qualitative pilot study, data were collected at five time-points over 18 months. We coded the data using content analysis and conducted the within-case and cross-case analyses using data matrices. Lack of awareness of available resources, represented a technical challenge within the life context of these grandmothers and the remaining three themes: family upheaval; priority setting (with subthemes of difficulty meeting basic needs and competing demands); and self-silencing and self-sacrifice represented adaptive challenges. The context of African-American grandmothers' lives created primarily adaptive challenges that were complex and without immediate solutions. Research is needed to develop culturally and contextually appropriate interventions to help this vulnerable group develop capacity for adaptive work.

The effect of Teach One Reach One (TORO) on youth acceptance of couple violence.

This study evaluated the impact of the Teach One Reach One intervention, a community-based participatory research project designed to address the co-occurrence of adolescent risk behaviors on acceptance of teen dating violence. Data were derived from 331 rural African American youth between 10-14 years of age who participated in caregiver-youth dyads as either: 1) peer lay health advisor dyads, or Ambassadors, 2) caregiver-youth dyads recruited by Ambassadors, or Allies, or 3) comparison dyads. The following study focuses on participating youth only and our results indicated that: 1) Ambassadors and Allies reported less acceptance of couple violence than youth within the comparison group, and 2) less family cohesion, greater family conflict, and greater knowledge of healthy dating behaviors predicted greater acceptance of couple violence. Our findings highlight the efficaciousness of the TORO intervention, which directly engaged participants in prevention efforts through community-based participatory research methods and the use of lay heath advisors.

An experiential Cardiovascular Health Education Program for African American College Students.

OBJECTIVE: To pilot test a culturally specific and developmentally appropriate curriculum for African-American college students that included self and family assessment to increase awareness of their risk of cardiovascular disease (CVD). METHODS: Students were recruited from a historically Black university to participate in small group workshops focusing to increase their knowledge of their family history of CVD as well as reducing CVD risks. Focus groups were conducted to determine the effectiveness and ways to improve to the intervention. RESULTS: Positive findings were found regarding program efficacy, increased understanding of their family history and strategies to reduce their own risk of CVD. CONCLUSION: Small group experiential workshop approach can be effective in helping African- American college students understand risk and establish healthy heart habits aimed at decreasing risk of coronary heart disease.

The "invisible caregiver": multicaregiving among diabetic African-American grandmothers.

PURPOSE: To explore the multicaregiving roles African-American grandmothers assume while self-managing their diabetes. DESIGN & METHODS: This longitudinal, qualitative pilot study explored the challenges of self-managing diabetes among six African-American caregiving grandmothers. Data were collected at 5 times points across 18 months. Content analysis, guided by the Adaptive Leadership framework, was conducted using data matrices to facilitate within-case and cross-case analyses. RESULTS: Although participants initially stated they cared only for grandchildren, all had additional caregiving responsibilities. Four themes emerged which illustrated how African-American caregiving grandmothers put the care of dependent children, extended family and community before themselves. Using the Adaptive Leadership framework, technical and adaptive challenges arising from multicaregiving were described as barriers to diabetes self-management. IMPLICATIONS: When assisting these women to self-manage their diabetes, clinicians must assess challenges arising from multicaregiving. This might require developing collaborative work relationships with the client to develop meaningful and attainable goals.

Examining the effectiveness of a case management program for custodial grandparent families.

Researchers have identified complex needs of custodial grandparent families and lack of access to needed resources such as housing, financial and legal assistance, and health care. Case management links these families with needed services while helping them develop skills to promote their health and well-being. This paper describes a case management program for custodial grandparent families using a nurse-social worker case management team. data were collected from 50 grandparents and 33 children using surveys and semi-structured instruments. Physical and mental health outcomes were measured using Short Form-12 Health Survey (SF 12) to measure the perceived quality of health for grandparents and the Child Behavior Checklist to measure the emotional and behavioral functioning of grandchildren. Grandparents more positively perceived their mental health after participating in the program. Perceptions about physical health were generally the same before and after the program. Grandparents' reported that many grandchildren had emotional and behavioral problems in the clinical range. These findings highlight the need for further research on the mental health needs of children being parented by grandparents as well as determining effective models and interventions to minimize adverse effects of parenting on grandparents.

Studying the clinical encounter with the Adaptive Leadership framework.

In this paper we discuss the concept of leadership as a personal capability, not contingent on one's position in a hierarchy. This type of leadership allows us to reframe both the care-giving and organizational roles of nurses and other front-line clinical staff. Little research has been done to explore what leadership means at the point of care, particularly in reference to the relationship between health care practitioners and patients and their family caregivers. The Adaptive Leadership framework, based on complexity science theory, provides a useful lens to explore practitioners' leadership behaviors at the point of care. This framework proposes that there are two broad categories of challenges that patients face: technical and adaptive. Whereas technical challenges are addressed with technical solutions that are delivered by practitioners, adaptive challenges require the patient (or family member) to adjust to a new situation and to do the work of adapting, learning, and behavior change. Adaptive leadership is the work that practitioners do to mobilize and support patients to do the adaptive work. The purpose of this paper is to describe this framework and demonstrate its application to nursing research. We demonstrate the framework's utility with five exemplars of nursing research problems that range from the individual to the system levels. The framework has the potential to guide researchers to ask new questions and to gain new insights into how practitioners interact with patients at the point of care to increase the patient's ability to tackle challenging problems and improve their own health care outcomes. It is a potentially powerful framework for developing and testing a new generation of interventions to address complex issues by harnessing and learning about the adaptive capabilities of patients within their life contexts.

"Give me some sugar!" the diabetes self-management activities of African-American primary caregiving grandmothers.

PURPOSE: To compare the diabetes self-management activities of African American primary caregiving grandmothers before and after the initiation of caregiving and to compare the diabetes self-management activities of African American primary caregiving grandmothers to diabetic women who were not caring for their grandchildren. DESIGN: Using a cross-sectional, descriptive design, 68 African American women 55 to 75 years of age were recruited as part of a larger study examining the impact of caregiving responsibilities on the diabetic health of African American primary caregiving grandmothers. Each participant was asked the frequency of their performance of six self-management activities. Caregiving grandmothers were asked about these activities before and after the initiation of caregiving. RESULTS: Dependent and independent t-tests with Bonferroni correction were used to analyze the data. Statistically significant differences were noted in diet (t=4.400, p=.000) and self-monitoring of blood glucose (SMBG; t=3.484, p=.001) before and after the initiation of caregiving. For the caregiver versus non-caregiver comparison, statistically significant differences were noted in SMBG (t=-3.855, p=.000) and eye examinations (t=-3.211, p=.001). CONCLUSIONS: The findings provide preliminary data to support further research examining the self-management activities of diabetic African American primary caregiving grandmothers. Diabetic African American primary caregiving grandmothers may have a decreased ability to integrate self-management activities into their daily patterns of living. Additional research is needed to determine what factors prevent this population from performing these tasks routinely. CLINICAL RELEVANCE: African American primary caregiving grandmothers were found to have more difficulty performing some of their self-management activities, which may severely impact their overall diabetic health.

An evaluation of standardized patients in improving clinical breast examinations for military women.

There is a need to improve the quality of clinical breast examination (CBE) and breast cancer screening for women. The purpose of this study was to determine whether instructions from a standardized patient to military healthcare providers would increase the quality of CBE and breast cancer screening for military women. The study used a 2-group pretest and posttest experimental design with random assignment by study site. Before and after the intervention, the providers completed a 13-item survey to assess their current breast cancer screening practices and the standardized patient used an investigator-developed checklist to assess the providers' breast cancer screening performance. The survey of breast cancer screening practice scores and the interview and CBE performance scores were analyzed using analysis of covariance with the pretest scores as covariates. Results showed the experimental group made significantly more improvement than did the control group in their total scores on the observational checklist of interview and CBE skills (F = 19.18, P < .001, observed power = 0.99). In conclusion, this method of continuing education was effective with military healthcare providers.