Self-Care Instruments to Measure Nutrition Practices in Children and Parents: Psychometric Analysis.

The purposes of this study were to evaluate the psychometric properties of English and Spanish instruments that measure the nutrition behavior and practices of children and their parents. Orem's self-care deficit nursing theory was used in this methodological study. A convenience sample of 333 children and 262 mothers participated from two schools in Washington, D.C. and two schools in Santiago, Chile. Principal component analysis indicated three component per instrument corresponding to Orem's Theory of operations demonstrating construct validity of the instrument. The study findings showed evidence for validity and reliability of the English and Spanish versions and indicated that the instruments appropriately represented Orem's operations. The results have implications for the development of health behavior measurement instruments that are valid, reliable, designed for children, culturally appropriate, and efficient. Measuring the nutrition behavior of children and parents is critical for determining the effectiveness of nutrition intervention programs. Furthermore, instruments are needed so that researchers can compare corresponding child and parent behaviors or compare behaviors across cultures.

The Association Between Hunter-Killed Deer and Lyme Disease in New Jersey, 2000-2014.

Years when the deer population is robust during the autumn hunting season may point toward an elevated risk of Lyme disease (LD) in the human population two summers later. We applied overdispersed Poisson regression models to county-specific data from New Jersey for each year from 2000 to 2014. The average relative risk of LD for each additional hunter-killed deer per square mile was 1.12 (1.10, 1.14) for 2000-2007 and 1.11 (1.09, 1.13) for 2008-2014. The hunting data already collected for conservation and wildlife management purposes may be a relevant component of LD surveillance activities.

Demonstration of two types of fatigue in subjects with chronic liver disease using factor analysis.

PURPOSE: The purpose of this investigation was to determine if it was possible to separate fatigue self-reports into two distinct types of fatigue symptom clusters in research subjects with chronic liver disease (CLD). It was hypothesized that when items from the Medical Outcomes Study Short-Form (SF-36v2) are combined with items from the Fatigue Severity Scale (FSS), these distinct factors will emerge. METHODS: Confirmatory and exploratory factor analyses from data collected in a prospective, natural history study of CLD patients were conducted. Items were selected from the SF-36v2 and the FSS for entry into the factor analyses. In order to establish convergent and discriminant validity, derived factor scores were correlated with subscale scores of the Human Activity Profile (HAP), Mental Component Score (MCS) from the SF-36v2, and the Emotional Functioning Subscale of the Chronic Liver Disease Questionnaire (CLDQ-EF). RESULTS: 106 participants with CLD were included (50% female; age: 51 ± 10). Two factors were identified. The factors included one that clustered around questions addressing fatigue related to physical activity (peripheral fatigue) and the other to the questions addressing generalized fatigue that did not require physical tasks to produce the fatigue (central fatigue). The standardized factor loadings of all items were greater than 0.6 on their underlying constructs. Moreover, all factor loadings are significant at p < 0.01. Peripheral fatigue was related to HAP (r = 0.26, r = 0.24, p < 0.01), as was central fatigue (r = -0.34, r = -0.33, p < 0.01). Central fatigue was related to MCS and CLDQ-EF (r = -0.60; r = -0.63, p < 0.01), whereas peripheral fatigue was not (r = 0.07, p > 0.40). We then tested the original scales to determine if the newly created factors correlated better with the validity measures. The full FSS did not correlate as well as the newly created central fatigue scale, while the original peripheral fatigue scale (the SF-36v2 physical functioning) was more related to HAP than the newly created scale. CONCLUSIONS: In individuals with CLD, two separate factors pertaining to fatigue were identified. This recognition of the multifaceted nature of fatigue may help increase the specificity of self-reports of fatigue and lead to treatments that can specifically address the underlying factors contributing to fatigue.

Inpatient healthcare provider bypassing by women and their children in urban Bo, Sierra Leone.

INTRODUCTION: Bypassing refers to a person's decision to seek care at a healthcare facility that is not the nearest one of its type to the person's home. METHODS: This study examined inpatient care facility bypassing in urban Bo, Sierra Leone using data from 1,980 women with children 15 years of age and younger who were interviewed in 2010-2011. The locations of residential structures and hospitals were identified using a geographic information system (GIS), and the road distances from participating households to the nearest and preferred inpatient care facilities were measured. RESULTS: Nine inpatient care facilities serve Bo residents, but more than 70% of the participating women reported that the city's main public hospital (Bo Government Hospital), located in the city center, was their preferred inpatient care provider. Participants resided within a median distance of 0.9 km (Interquartile range (IQR): 0.6, 1.8) from their closest inpatient facility, but they would travel a median distance of 2.4 km (IQR: 1.0, 3.3) to reach their preferred providers. About 87% of the women would bypass their nearest inpatient care facility to access care at a preferred provider. Bypassing rates were similar for various demographic and socioeconomic groups, but higher for women living farther from the city center. CONCLUSION: Although Bo has a diverse healthcare marketplace, access to affordable advanced care options is limited. Most women in Bo would choose to bypass facilities nearer to their homes to seek the low-cost and comprehensive care offered by Bo Government Hospital.

Current and future health care professionals attitudes toward and knowledge of statistics: How confidence influences learning.

BACKGROUND: Health care professionals require some understanding of statistics to successfully implement evidence based practice. Developing competency in statistical reasoning is necessary for students training in health care administration, research, and clinical care. Recently, the interest in healthcare professional's attitudes toward statistics has increased substantially due to evidence that these attitudes can hinder professionalism developing an understanding of statistical concepts. METHODS: In this study, we analyzed pre- and post-instruction attitudes towards and knowledge of statistics obtained from health science graduate students, including nurses and nurse practitioners, enrolled in an introductory graduate course in statistics (n = 165). RESULTS AND CONCLUSIONS: Results show that the students already held generally positive attitudes toward statistics at the beginning of course. However, these attitudes-along with the students' statistical proficiency-improved after 10 weeks of instruction. The results have implications for curriculum design and delivery methods as well as for health professionals' effective use of statistics in critically evaluating and utilizing research in their practices.

Psychometric evaluation of the nurses' attitudes toward eICU scale.

The eICU technology system has been implemented nationwide to facilitate efficient and safe care for patients. The purpose of this study was to provide psychometric evidence of the reliability and validity of an instrument, the Nurses' Attitudes Toward eICU Scale (NATES). The study involved 117 registered nurses working in critical care units that had not yet implemented eICU technology. The reliability for the total scale was .91. Factor analysis results supported construct validity and indicated that five factors accounted for 67.3% of variance in the data: Cost and Benefit; Patient Care and Quality; Anxiety and Confidence: Effort; and Anger and Fear. The NATES showed promise as a psychometrically sound instrument for assessing nurses' attitudes toward eICU technology.

Measurement of substance abuse treatment outcomes over time.

There are many different ways of calculating the impact of treatment on drug use; percentage of positive drug tests, probability of drug use, percentage of patients abstaining from any use, total number of days of use, daily probability of use and average days till next use, are some examples reported in the literature. We prefer average days till next use because (1) it allows intermittent drug use and relapse; (2) it fits the client's count of drug-free days, and (3) it simultaneously accounts for both tests results and time between tests. We show by way of an example, how conclusions arrived at using average days till next use are likely to be different from other measures in analysis of recent data from impact of online treatment on drug use.

Impact of online counseling on drug use: a pilot study.

PURPOSE: To examine the effect of online counseling abuse counseling on drug use among underserved patients. METHODS: Subjects were recruited from an Indian Reservation in Eagle Butte, South Dakota; a family court in Newark, New Jersey; a probation office in Alexandria, Virginia; and a co-occurring disorders treatment clinic in Washington, District of Columbia. Subjects were predominantly poor, undereducated, unemployed, court involved, or diagnosed with co-occurring psychiatric disorders. A total of 79 subjects volunteered to participate in the project. Subjects were randomly assigned to either a control group or an experimental group. The control and experimental groups were both issued an Internet-ready computer and 1 year of Internet service. Only the experimental group had access to online counseling intervention. Drug use was measured using a combination of self-usage reporting and supervised urine tests. RESULTS: Urine tests were available for 37% of subjects. Exit surveys containing self-reported usage were obtained from 54% of the subjects. Self-usage reports or urine test results were available from 70% of subjects. The difference of the rates of drug use in the control and experimental groups (as calculated from urine tests or through self-report) was not significantly different from zero, suggesting that online counseling had not led to a reduction in substance use. It is possible that the study lacked sufficient power to detect small differences in the rate of drug use in the experimental and control groups. CONCLUSIONS: Additional research is needed to establish the efficacy of online counseling in hard-to-reach populations.

Childhood obesity study: a pilot study of the effect of the nutrition education program Color My Pyramid.

The need for successful nutrition interventions is critical as the prevalence of childhood obesity increases. Thus, this pilot project examines the effect of a nutrition education program, Color My Pyramid, on children's nutrition knowledge, self-care practices, activity levels, and nutrition status. Using a pretest-posttest, quasiexperimental design, 126 fourth- and fifth-grade students from experimental and control schools are compared. The intervention program incorporates an online component www.MyPyramid.gov, Orem's Self-Care Deficit Nursing Theory, and consists of six classes taught over a 3-month period. Results indicated that the program increased nutrition knowledge in the control group. Furthermore, it increased activity time from pretest to posttest and decreased systolic blood pressure for children in both groups; however, there were no significant differences in BMI percentiles. The findings indicate that Color My Pyramid can be successfully employed in school settings and thus support school nursing practice.

Two decades of nurse-led research on smoking during pregnancy and postpartum: concept development to intervention trials.

Tobacco use during pregnancy and postpartum is a leading cause of preventable morbidities for women and their infants. Over the past two decades, nursing research has addressed this recalcitrant clinical problem from a variety of conceptual and methodological perspectives. The 64 published studies (1988-2009) that met inclusion criteria for this systematic review represent the full research trajectory from concept development to intervention testing. Meta-analysis demonstrated an overall significant trend in nursing intervention efficacy (OR = 1.14, 95% CI = 1.08-1.2) for studies that examined comparable prenatal and postpartum smoking cessation outcomes. Implications for future nursing research and evidence-based policy are presented.

Health care research: alternative approaches to study design and data analysis.

In determining intervention effects, quality improvement researchers typically use statistical testing--Fisher's "significance testing" and/or Neyman and Pearson's "hypothesis testing." Such tests are employed in an effort to demonstrate whether or not a statistically and practically significant difference exists when comparing experimental and comparison group(s). Although power analysis is often not considered when these tests are applied, this article postulates potential benefits of including power analysis in the early stages of a study's design. Two procedures developed by Fisher and Neyman and Pearson are reviewed. Important background statistical concepts including alpha values, beta values, P values, effect sizes, and statistical power analysis are defined and discussed. A proposed statistical approach combining both Fisher and Neyman-Pearson procedures along with power analysis for sample size determination and the effect sizes is described and illustrated in a hypothetical research context. The benefits of this combination are discussed within a framework of adding value to a study design and data analysis.

Self-experiments and analytical relapse prevention.

Patients give many reasons for why they have not kept up with their resolutions; research shows that many of these causal attributions are wrong. This article provides a tool to help patients sort out causes of and constraints on their behavior, in general, and exercise, in particular. Patient's diary data can be analyzed to flag erroneous causal attributions, and thus assist patients to understand their behavior. To start the diary, the clinician works with the patient to assemble a list of possible causes. Using the list, a diary is organized that tracks the occurrences of various causes and the target behavior. At the end of 2 to 3 weeks, the diary data is analyzed using conditional probability models, causal Bayesian networks or logistic regression. A key issue in the analysis of diary data is to separate out the effect of various causes. Typically, causes co-occur, making it difficult to understand their independent effects. Another problem with analysis of diary data is the small size of the data. This article shows how small longitudinal data from patient diaries can be analyzed. The analysis may refute or support causes hypothesized by the client. The patient uses the insights gained from the diary analysis to prevent relapse to unhealthy behaviors. The process is continued for several cycles of organizing, keeping, and analyzing the diary data. In each cycle, the patient gains new insights and makes additional attempts to create a positive environment that allows him or her to succeed even if his or her motivation waivers. This article provides details of how diary data can be analyzed to help patients make correct causal attributions.

Description of practice as an ambulatory care nurse: psychometric properties of a practice-analysis survey.

Changes within nursing demand that a specialty conduct periodic, appropriate practice analyses to continually validate itself against preset standards. This study explicates practice analysis methods using ambulatory care nursing as an exemplar. Data derived from a focus group technique were used to develop a survey that was completed by 499 ambulatory care nurses. The validity of the instrument was assessed using principal components analysis; reliability was estimated using Cronbach's alpha coefficient. The focus group with ambulatory care experts produced 34 knowledge and activity statements delineating ambulatory care nursing practice. The survey data produced five factors accounting for 71% of variance in the data. The factors were identified as initial patient assessment, professional nursing issues and standards, client care management skills, technical/clinical skills, and system administrative operations. It was concluded that practice analyses delineate a specialty and provide input for certification examinations aimed at measuring excellence in a field of nursing.

Statistical and nonstatistical significance: implications for health care researchers.

Quality improvement professionals have to decide whether a change has led to improvement. This is typically done through testing the statistical significance of the findings. In this article, we explore controversies surrounding statistical significance testing with attention to contemporary criticism of bad practice resulting from the misuse of statistical significance testing. Most statistical significance tests use tests (eg, F, chi) with known distributions with the P values used as the main evidence to evaluate whether tests are statistically significant. The primary conclusion of this article is that the P value alone as a measure of statistical significance does not give sufficient information about testing of hypotheses. When it is coupled with other measures, however, such as the point estimation of the effect size and the use of a confidence interval around it, the combination of these statistics can provide a more thorough explanation of statistical testing. This article offers recommendations for process improvement investigators as to when to appropriately apply and not to apply statistical significance testing.

Costs and benefits of combining probation and substance abuse treatment.

AIMS OF THE STUDY: We compared seamless combination of probation and treatment (where the probation officer is co-located with treatment provider or is actively engaged in treatment) to traditional probation where treatment is left to the client's choice. METHODS: Clients were randomly assigned to either seamless or traditional probation. We used a decision analytic approach which had two advantages: First it separated estimation of probability of adverse events (e.g. hospitalization) from the daily cost of the adverse event, thereby allowing use of estimates of daily costs available within the literature. Second, the reliance on daily probability of various adverse events also had the benefit of reflecting both length of the event and its intermittent re-occurrence. Subjects were 272 clients on probation in Northern Virginia and Maryland in the United States. Clients were randomly assigned to seamless and traditional probation and were followed for an average of 2.75 years (arrest information was only available for 1 year); 77% of clients participated in the follow-up interviews. At baseline, there was no statistically significant difference among the clients. RESULTS: During the follow-up period, clients in the seamless probation had less recidivism but the cost savings from this component (dollar 2.31 per client per follow-up day) was not sufficient to overcome increased costs due to mental hospitalization of seamless clients (dollar 13.50 per client per follow-up day), cost of delivery of seamless probation (dollar 2.58 per client per follow-up day), more frequent use of jail/prison for clients in the seamless group (dollar 2.08 per client per follow-up day) and additional treatment costs (dollar 1.24 per client per follow-up day). The expected cost of seamless probation and its consequences was dollar 38.84 per follow-up day. The expected cost of traditional probation and its consequences was dollar 21.60 per follow-up day. Seamless probation was dollar 6,293 more expensive than traditional probation per client per year. DISCUSSION: Sensitivity analysis suggested that the analysis was not sensitive to small change in any single cost or probability estimate. Sensitivity analysis suggested that increased supervision intensity and use of sanctions had contributed to lower cost-effectiveness. IMPLICATIONS: One possible way of improving seamless probation is to improve the intensity of the substance abuse treatment while reducing the intensity of supervision to its traditional levels. This analysis was limited to 2.75 years follow-up period and does not address cost savings that might occur after this period.

Postpartum tobacco use: developing evidence for practice.

Most women who quit smoking during pregnancy return to tobacco use within 6 months after delivery. Findings demonstrate that minimal intervention effectiveness exists with strategies to prevent postpartum smoking relapse. This article provides a synthesis of current research on postpartum tobacco use. Whether in the labor and delivery suite, the postpartum floor, or the neonatal ICU, acute and critical care nurses have a valuable role to help reduce the incidence of tobacco-related maternal and child outcomes.

Simulated environment is not appropriate.

In the Spring 2005 issue of Quality Management in Health Care, Borckand et al examined the performance of Tukey's chart in a simulated environment. Unfortunately, the simulated environment does not reflect the type of settings where Tukey's chart has been proposed to be most effective. Tukey's charts are ideally used on relatively small data sets. In these data sets, we hypothesize that it is unlikely to have the high autocorrelations simulated in the Borckand et al study. Furthermore, Tukey's chart will perform well in data coming from non-Normal or non-Uniform distributions. The simulation study was based on random numbers generated with Uniform or Normal distributions. We encourage Borckand et al to examine the performance of Tukey's chart in the modified circumstances.

Activity based costing of probation with and without substance abuse treatment: a case study.

BACKGROUND: Since many offenders have drug problems, investigators have proposed that drug testing and treatment should be an integral part of probation. In 1994, the Office of National Drug Control Policy (ONDCP) funded a demonstration project designed to integrate drug treatment with traditional supervision services. As part of this demonstration a new procedure called 'seamless' probation was set up in which treatment providers were co-located with probation officers and probation officers coordinated offenders' participation in treatment. AIMS OF THE STUDY: This study examines the cost of providing substance abuse treatment coordination through probation agencies. METHODS: We used Activity Based Costing (ABC) to examine the cost of probation with and without treatment coordination in one probation agency. Agency budget was analyzed and allocated to various programs. A questionnaire was developed to assess probation officer's activities. The cost of coordinating treatment for one offender was calculated by dividing the total cost of the program by units of various activities done by the probation officers. RESULTS: Preliminary test of reliability of the instrument showed that it was accurately portraying the probation officers time allocation. Probation officers spent 6.9% of their time in seamless supervision and 83.3% time in traditional supervision (83.83%). The seamless probation officers had more group meetings and more phone contact with their offenders than traditional probation officers. The average cost per offender per day was 12 dollars for seamless probation and 7 dollars for traditional probation. DISCUSSION: This study is limited because it focuses on one agency at one point in time. Results may not be relevant to other agencies or to the same agency as it makes its operation more efficient. This study provides a method of allocating budget cost to per client costs using survey of probation officer's activities -- a tool developed in this study. Comparison of seamless and traditional supervision activities showed major differences in terms of the probation officers' activities and costs. IMPLICATIONS: There are significant costs associated with asking probation officers to coordinate treatment. Studies should be undertaken to examine the relative benefits that can be derived from this increased cost.

Construct validity and reliability of scores on scales to measure the impairment of health-related quality of life in persons with asthma.

The purpose of this study was to test the reliability, validity, and effectiveness of a health-related quality of life (HRQOL) instrument--the MiniAQLQ--among persons with asthma who were using a web-based intervention for guided self-management (www.MyAsthma.com). The MiniAQLQ was completed online in 1999 by 307 participants referred to www.MyAsthma.com by their primary care physicians. Construct validity of the MiniAQLQ was assessed by principal components analysis; reliability was estimated using Cronbach's alpha coefficient; and differences in means between pretest and posttest were analyzed using paired t test. The analysis produced four empirically meaningful factors with reliability of scores ranging from 0.65 to 0.94. Participants reported significant improvement in HRQOL after participating in this intervention. The four factors (activities, symptoms, emotions, and environment) generated by the principal components analysis empirically supported the four domains used in the development of the MiniAQLQ. Scores for the four factors were internally consistent and assessed the distinct domains. The MiniAQLQ appears to be a psychometrically sound instrument for measuring HRQOL online among asthma patients who are participating in online interventions.