The experience of caregiving for adults with benign brain tumors: An integrative review.

Background: Caregiving for the adult benign brain tumor (aBBT) population is unique, as patients' extended period of survivorship poses significant challenges related to the long-term sequelae of the disease and the foreboding possibility of recurrence. In this integrative review, we examined the caregiving experience across the spectrum of the aBBT population. Methods: We searched OVID, CINAHL, and PubMed databases from 2000 to 2022. We included studies primarily focused on caregivers of aBBT and written in English. Results: Among 594 papers identified in the initial review, we included a final list of 7 papers. Among these 7 papers, 5 central themes emerged. First, we identified a theme surrounding psychosocial and emotional needs, which included the social isolation of caregiving. The second theme related to informational care needs, including what is considered to be the normal course of recovery after surgery. The third theme focused on access to services, including specialist neurosurgical care, and the fourth theme related to financial strain and the economic burdens associated with long-term follow-up. Lastly, we found a theme surrounding family role changes, which included the shift from spouse to caregiver. Conclusions: In this review, we identified themes highlighting similarities to the high-grade glioma population. However, we uncovered distinct differences in terms of caregiver characteristics, length of survivorship, and the burden of caregiving over time. Collectively, our findings underscore the incomplete understanding of the caregiving experience across the spectrum of the aBBT population.

The Impact of Chemotherapy-Related Cognitive Impairment on Social Roles and Well-Being in Breast Cancer Survivors.

PURPOSE: To explore the impact of disruptions in information processing (DIPs) on social roles, well-being, and quality of life (QOL) in breast cancer survivors after chemotherapy. PARTICIPANTS & SETTING: Experiences of DIPs were explored in eight breast cancer survivors aged 53-70 years, 12-60 months post-treatment, referred from a National Cancer Institute-designated cancer center and a nonprofit breast cancer support organization from January 6 to August 31, 2020. METHODOLOGIC APPROACH: This study used a mixed-methods approach. Participants journaled and answered questionnaires sent via mail that asked them about changes in their cognition, QOL, and social roles. Qualitative data were thematically analyzed using constant comparative analysis, and questionnaire scores were compared with qualitative data. FINDINGS: Journals revealed problems with functioning in occupational roles and increased stress, anxiety, and frustration. Women with more DIPs tended to have lower role satisfaction and QOL. Greater role satisfaction was associated with higher QOL and social role participation. IMPLICATIONS FOR NURSING: Mitigating the effects of DIPs on social function may allow women to continue in important roles, which has the potential to affect QOL.

Electrophysiological resting state brain network and episodic memory in healthy aging adults.

Recent studies have emphasized the changes in large-scale brain networks related to healthy aging, with the ultimate purpose to aid in differentiating normal neurocognitive aging from neurodegenerative disorders that also arise with age. Emerging evidence from functional Magnetic Resonance Imaging (fMRI) indicates that connectivity patterns within specific brain networks, especially the Default Mode Network (DMN), distinguish those with Alzheimer's disease from healthy individuals. In addition, disruptive alterations in the large-scale brain systems that support high-level cognition are shown to accompany cognitive decline at the behavioral level, which is commonly observed in the aging populations, even in the absence of disease. Although fMRI is useful for assessing functional changes in brain networks, its high costs and limited accessibility discourage studies that need large populations. In this study, we investigated the aging-effect on large-scale networks of the human brain using high-density electroencephalography and electrophysiological source imaging, which is a less costly and more accessible alternative to fMRI. In particular, our study examined a group of healthy subjects in the age range from middle- to older-aged adults, which is an under-studied range in the literature. Employing a high-resolution computation model, our results revealed age associations in the connectivity pattern of DMN in a consistent manner with previous fMRI findings. Particularly, in combination with a standard battery of cognitive tests, our data showed that in the posterior cingulate / precuneus area of DMN higher brain connectivity was associated with lower performance on an episodic memory task. The findings demonstrate the feasibility of using electrophysiological imaging to characterize large-scale brain networks and suggest that changes in network connectivity are associated with normal aging.

Amplitude of fNIRS Resting-State Global Signal Is Related to EEG Vigilance Measures: A Simultaneous fNIRS and EEG Study.

Recently, functional near-infrared spectroscopy (fNIRS) has been utilized to image the hemodynamic activities and connectivity in the human brain. With the advantage of economic efficiency, portability, and fewer physical constraints, fNIRS enables studying of the human brain at versatile environment and various body positions, including at bed side and during exercise, which complements the use of functional magnetic resonance imaging (fMRI). However, like fMRI, fNIRS imaging can be influenced by the presence of a strong global component. Yet, the nature of the global signal in fNIRS has not been established. In this study, we investigated the relationship between fNIRS global signal and electroencephalogram (EEG) vigilance using simultaneous recordings in resting healthy subjects in high-density and whole-head montage. In Experiment 1, data were acquired at supine, sitting, and standing positions. Results found that the factor of body positions significantly affected the amplitude of the resting-state fNIRS global signal, prominently in the frequency range of 0.05-0.1 Hz but not in the very low frequency range of less than 0.05 Hz. As a control, the task-induced fNIRS or EEG responses to auditory stimuli did not differ across body positions. However, EEG vigilance plays a modulatory role in the fNIRS signals in the frequency range of less than 0.05 Hz: resting-state sessions of low EEG vigilance measures are associated with high amplitudes of fNIRS global signals. Moreover, in Experiment 2, we further examined the epoch-to-epoch fluctuations in concurrent fNIRS and EEG data acquired from a separate group of subjects and found a negative temporal correlation between EEG vigilance measures and fNIRS global signal amplitudes. Our study for the first time revealed that vigilance as a neurophysiological factor modulates the resting-state dynamics of fNIRS, which have important implications for understanding and processing the noises in fNIRS signals.

Assessing Discrepancies in Neurocognitive and Patient-Reported Measures of Brain Tumor Survivors.

OBJECTIVES: To examine the association between performance-based neurocognitive and patient-reported cognitive function tests and identify characteristics that may explain observed discrepancies as a means to advance intervention development. SAMPLE & SETTING: 40 adults diagnosed with a primary brain tumor (PBT) (high-grade, n = 35) were recruited from two academic neuro-oncology clinics in North Carolina. METHODS & VARIABLES: Eligibility included a Mini-Mental State Examination score of 24 or greater, having completed cancer treatment, and having tumor stability. Participants completed performance-based neurocognitive and patient-reported cognitive function, demographic, and symptom assessment tests at one time point. RESULTS: Neurocognitive impairments included executive control, memory, and attention. Age, time since diagnosis, and tumor- or treatment-specific variables were not associated with neurocognitive or patient-reported cognitive function. Those reporting worse cognitive impairment tended also to report greater severity of PBT-specific and depressive symptoms. IMPLICATIONS FOR NURSING: Patient-reported cognitive concerns warrant additional assessment for potential interventions to maintain function.

Sleep-Disordered Breathing and Cerebral Oxygenation During Sleep in Adults With Mild Cognitive Impairment.

The current study examined relationships between laterality in cerebral oxygenation (L-COX), sleep-disordered breathing (SDB), and daytime function in 16 adults with mild cognitive impairment (MCI). All participants underwent two nights of diagnostic polysomnography. Using dual-cerebral oximetry, L-COX was defined by differences ≥4% in right- versus left-sided percent cerebral oxyhemoglobin saturation. Eight patients had SDB. L-COX was found in five patients, but only on nights with SDB. Greater L-COX was associated more severe SDB: higher frequency of apneas + hypopneas per hour (r = 0.66, p < 0.01), desaturations per hour (r = 0.73, p < 0.01), and percent time with oxygen saturation <88% (r = 0.65, p < 0.01). Greater laterality, but not severity of SDB, was associated with poorer functional ability (Lawton Instrumental Activities of Daily Living Scale: r = -0.83, p = 0.02), lower cognitive function (Mini-Mental State Examination: r = -0.76, p = 0.03), and greater daytime sleepiness (Epworth Sleepiness Scale: r = 0.85, p < 0.001). L-COX associated with SDB suggests disruptions in cerebral autoregulation and need for aggressive treatment of SDB in individuals with MCI. [Res Gerontol Nurs. 2018; 11(6):282-292.].

Accelerated vascular aging and persistent cognitive impairment in older female breast cancer survivors.

Advances in breast cancer treatment have markedly increased survivorship over the past three decades, with over 3.1 million survivors expected to live into their 70s and 80s. Without symptom relief interventions, nearly 35% of these survivors will have life-altering and distressing cognitive symptoms. This pilot study explored associations between serum markers of vascular aging, laterality in cerebral oxygenation, and severity of cognitive impairment in women, 12-18 months after chemotherapy for stage 2/3 invasive ductal breast cancer. Fifteen women (52-84 years) underwent a brief cognitive assessment (Montreal Cognitive Assessment [MOCA]) and blood draws to assess markers of vascular aging (interleukin-6 [IL-6], tumor necrosis factor alpha [TNF-α], C-reactive protein [CRP], and insulin growth factor-1 [IGF-1]). All underwent a computer-based test protocol that is known to increase blood flow within the frontal lobes. Percent cerebral oxyhemoglobin saturation (rcSO2) was recorded during and after testing. Laterality in rcSO2 was defined by ≥ 3% difference between left and right rcSO2 (|rcSO2 meanRIGHT - meanLEFT|). Eight participants had MOCA scores between 21 and 25 points, suggestive of mild cognitive impairment. Neither CRP (r = -.24) nor IL-6 (r = .34) nor TNF-α (r = .002) were associated with MOCA scores. Higher IL-6 was associated with greater laterality (r = .41). MOCA scores were significantly lower in subjects with laterality in rcSO2 than in those without laterality (F(1,14) = 13.5, p = 003). Lower IGF-1 was significantly associated with greater laterality (r = - .66, p = .007) and lower cognitive function (r = .58). These findings suggest that persistent cognitive impairment is associated with phenotypical changes consistent with accelerated vascular aging.

EEG fluctuations of wake and sleep in mild cognitive impairment.

Amnestic Mild Cognitive Impairment (aMCI), a condition in which the memory functions of cognition are significantly impaired, is an established risk factor for Alzheimer's disease. Electroencephalography (EEG) is a tool capable of measuring the dynamics of the brain's neural networks, and is thus an important means in analysis and understanding of aMCI. In this proof-of-concept study, we compared the brain activation patterns of ten aMCI subjects with those of four healthy subjects during sleep by employing a 64-channel EEG data collection system. The power spectrum was analyzed to identify sleep stages, while spectral topography and source imaging techniques were employed to study the fluctuating patterns of the brain. Results of this study show an increase in activation power across all sleep stages in the delta and theta frequency bands alongside a decrease in alpha band activity for aMCI subjects. Source imaging analysis of the resting EEG identified default mode network, which becomes decoupled as sleep stages deepen. In the proof-of-concept study, our exploratory analysis demonstrated the feasibility of imaging dynamic network organization using EEG in aMCI.

Reducing Multi-sensor Monthly Mean Aerosol Optical Depth Uncertainty Part II: Optimal Locations for Potential Ground Observation Deployments.

Surface remote sensing of aerosol properties provides "ground truth" for satellite and model validation, and is an important component of aerosol observation system. Due to the different characteristics of background aerosol variability, information obtained at different locations usually have different spatial representativeness, implying that the location should be carefully chosen so that its measurement could be extended to a greater area. In this study, we present an objective observation array design technique that automatically determines the optimal locations with the highest spatial representativeness based on the Ensemble Kalman Filter (EnKF) theory. The ensemble is constructed using aerosol optical depth (AOD) products from five satellite sensors. The optimal locations are solved sequentially by minimizing the total analysis error variance, which means that observations at these locations will reduce the background error variance to the largest extent. The location determined by the algorithm is further verified to have larger spatial representativeness than some other arbitrary location. In addition to the existing active AERONET sites, the 40 selected optimal locations are mostly concentrated on regions with both high AOD inhomogeneity and its spatial representativeness, namely the Sahel, South Africa, East Asia and North Pacific Islands. These places should be the focuses of establishing future AERONET sites in order to further reduce the uncertainty in the monthly mean AOD. Observations at these locations contribute to approximately 50% of the total background uncertainty reduction.

Reducing multisensor satellite monthly mean aerosol optical depth uncertainty: 1. Objective assessment of current AERONET locations.

Various space-based sensors have been designed and corresponding algorithms developed to retrieve aerosol optical depth (AOD), the very basic aerosol optical property, yet considerable disagreement still exists across these different satellite data sets. Surface-based observations aim to provide ground truth for validating satellite data; hence, their deployment locations should preferably contain as much spatial information as possible, i.e., high spatial representativeness. Using a novel Ensemble Kalman Filter (EnKF)-based approach, we objectively evaluate the spatial representativeness of current Aerosol Robotic Network (AERONET) sites. Multisensor monthly mean AOD data sets from Moderate Resolution Imaging Spectroradiometer, Multiangle Imaging Spectroradiometer, Sea-viewing Wide Field-of-view Sensor, Ozone Monitoring Instrument, and Polarization and Anisotropy of Reflectances for Atmospheric Sciences coupled with Observations from a Lidar are combined into a 605-member ensemble, and AERONET data are considered as the observations to be assimilated into this ensemble using the EnKF. The assessment is made by comparing the analysis error variance (that has been constrained by ground-based measurements), with the background error variance (based on satellite data alone). Results show that the total uncertainty is reduced by ~27% on average and could reach above 50% over certain places. The uncertainty reduction pattern also has distinct seasonal patterns, corresponding to the spatial distribution of seasonally varying aerosol types, such as dust in the spring for Northern Hemisphere and biomass burning in the fall for Southern Hemisphere. Dust and biomass burning sites have the highest spatial representativeness, rural and oceanic sites can also represent moderate spatial information, whereas the representativeness of urban sites is relatively localized. A spatial score ranging from 1 to 3 is assigned to each AERONET site based on the uncertainty reduction, indicating its representativeness level.

Hydrate for health: listening to older adults' need for information.

An interdisciplinary team of faculty and students developed the Hydrate for Health project to provide relevant and evidence-based information to community-dwelling older adults. Evidence-based factsheets on bladder health, nighttime urination, medication safety, and physical activity/exercise, as well as a fluid intake self-monitoring tool, were developed. Four focus groups were conducted and included older adults (N = 21) who participated in activities at two local senior centers to obtain their feedback about the relevance of the factsheets. Extensive revisions were required based on the feedback received. Older adults expressed a desire for pragmatic information (i.e., how to determine fluid sources from food, how to measure water, how to determine their own fluid needs). They also wanted information that could be easily incorporated into daily life. Nurses play a central role in listening to and incorporating older adults' voices into consumer education materials.

Nocturia in older adults: implications for nursing practice and aging in place.

Nocturia is a bothersome symptom that increases with age, resulting in sleep disruption, an increased risk of falls, and a greater likelihood of rating one's health as poor. It is often a symptom of conditions that cause low volume voiding, overproduction of urine across the day or only at night and a symptom of a sleep disorder. Nocturia affects quality of life and has an impact on aging in place, thus assessment and treatment are essential. Behavioral treatments should be explored first, keeping in mind what the affected older adult defines as the desired outcomes of treatment.

Psychological stress and arterial stiffness in Korean Americans.

OBJECTIVE: Arterial stiffness is identified as a causative factor for hypertension. The purpose of this study was to explore the relationship between psychological stress and arterial stiffness in Korean Americans. METHODS: A convenience sample of 102 Korean Americans (aged 21-60 years, 60% women) was recruited from North Carolina. Psychological stress was measured by the Perceived Stress Scale, the Social, Attitudinal, Familiar, and Environmental (SAFE) Acculturative Stress Scale, and the Spielberger's State-Trait Anxiety Inventory. Arterial stiffness was measured by carotid-femoral pulse wave velocity (cfPWV) using the SphygmoCor system (AtCor Medical, Australia). RESULTS: This study shows that the emotional stress response, measured by anxiety, significantly predicted arterial stiffness (ß=.25, p=.008), independently of such confounding factors as age, mean arterial pressure (MAP), gender, body mass index, smoking, education, and income. Anxiety was neither related to age (r=.12, p=.212) nor MAP (r=.14, p=.151). Additionally, this sample of Korean Americans had higher levels of psychological stress when compared to previous findings from studies of other racial/ethnic groups in the U.S. CONCLUSION: Findings demonstrate that anxiety is a significant and independent determinant of arterial stiffness. Given that anxiety was not related to MAP, these findings suggest that arterial stiffness may be a pathway to explain the connection between anxiety and hypertension risk. Studies that scrutinize the relationship between anxiety and arterial stiffness are an important next step for future research. Further studies are also recommended to explore cultural factors and individual characteristics that may affect anxiety in Korean Americans.

Cerebral oxygenation in wake and during sleep and its relationship to cognitive function in community-dwelling older adults without sleep disordered breathing.

BACKGROUND: This descriptive cross-sectional study investigated the relationships between cerebral oxygen reserve and cognitive function in community-dwelling older adults. METHODS: Participants (72 women and 40 men) underwent standard polysomnography, including regional measures of percent oxyhemoglobin saturation (rcSO(2)) determined by cerebral oximetry. Two variables were used to calculate cerebral oxygen reserve: (a) awake rcSO(2) (mean presleep rcSO(2)) and (b) the change in rcSO(2) from before sleep to the end of the first non-rapid-eye movement cycle. General linear models, adjusted for the effects of education and occupation, tested differences in performance on standard tests of memory, attention, and speed of mental processing. RESULTS: Awake rcSO(2) values were normal (60%-79.9%) in 64 participants, marginal (50%-59.9%) in 41, and low (43%-49.9%) in 7. Participants with normal awake levels had higher cognitive function than those with low levels (p < .05). Changes in rcSO(2) were greatest in participants with marginal awake rcSO(2) values; among whom, those who increased rcSO(2) during sleep (n = 17) had better memory function than the 24 who did not (p < .05). CONCLUSIONS: Low awake rcSO(2) values mark individuals with low cerebral oxygen reserves and generally lower cognitive function; marginal awake rcSO(2) values that fall during sleep may indicate loss of cerebral oxygen reserve and an increased risk for cognitive decline. Further studies may clarify the significance of and mechanisms underlying individual differences in awake rcSO(2) and the changes that occur in rcSO(2) while asleep.

Intimate partner violence, health status, and health care access among women with disabilities.

BACKGROUND: Evidence suggests that intimate partner violence (IPV) against women with disabilities is more pervasive than against women without disabilities. However, little is known about the relationship between IPV, health status, and access to care among women with disabilities. OBJECTIVES: This study 1) describes the prevalence of IPV among women with disabilities and compares IPV prevalence among women with and without disabilities, 2) examines if health status and health care access differ between women with disabilities experiencing IPV and those not experiencing IPV, and 3) examines the association between IPV, health status, and health care access among women with disabilities. METHODS: We conducted secondary analyses of data from 23,154 female respondents to the 2006 Behavioral Risk Factor Surveillance System in 7 states administering the IPV module in 2006. Of these respondents, 6,309 had a disability. We performed chi(2) and logistic regression analyses to address the study objectives. RESULTS: Women with disabilities are significantly more likely to have experienced IPV as compared with those without disabilities (33.2% and 21.2%, respectively). Women with disabilities who have experienced IPV are 35% less likely to report their health as good to excellent and are 58% more likely to report an unmet health care need owing to cost than their disabled counterparts not experiencing IPV, when holding selected sociodemographic factors constant. IMPLICATIONS: Practitioners should be aware of the increased risk of IPV among women with disabilities and its association with health status and access to health care. Practitioners, policy makers, and disability advocates should work together to remove barriers to accessing the health care system for women with disabilities, particularly those experiencing IPV.

Cerebrovascular disease and patterns of cerebral oxygenation during sleep in elders.

PURPOSE: The aim of this descriptive exploratory study was to describe patterns of cerebral oxygen reserves during sleep and their association with cerebrovascular risk factors in elders. METHOD: Participants--115 elders, age 70+ years--were monitored overnight using standard polysomnography. Measures included arterial oxyhemoglobin (SaO2) and regional measures of percentage of cerebral oxyhemoglobin saturation (rcSO2) via cerebral oximetry. Participants were classified based on the magnitude of change in rcSO2 from resting baseline to the end of the first nonrapid-eye-movement (NREM) period. One-way ANOVA and Chi-square were used to test group differences in SaO2 and the prevalence of cerebrovascular risk factors. FINDINGS: 20 participants (Group 1) experienced an increase in rcSO2 during sleep along with sleeping rcSO2 levels >or= 55%; 95 participants experienced a decline in rcSO2; 72 participants (Group 2) had sleeping rcSO2 levels >or= 55%; and 23 participants had sleeping rcSO2 levels <55% (Group 3). Although all three groups had equivalent declines in SaO2 levels during sleep, Group 3 had more cardiovascular comorbidity than Groups 1 and 2. CONCLUSIONS: Although SaO2 levels decline in most people during sleep, compensatory vascular responses to these drops in SaO2 are important for preventing rcSO2 from falling during sleep. Those entering sleep with lower baseline rcSO2 levels and those with greater declines in cerebral oxygenation during sleep may have greater cardiovascular burden and be at greater risk for stroke and other forms of disabling cerebrovascular disease.

The relationship between body mass index/body composition and survival in patients with heart failure.

PURPOSE: The purpose of this review was to summarize the literature on the relationship between obesity and survival in persons with heart failure (HF). In particular, the article examines the ways in which studies define body size/composition (body mass index [BMI], body composition, weight, cachexia, fluid retention, or albumin) and the relationship of BMI and survival after controlling for factors such as HF severity, etiology of the HF, gender, race, age, and/or time since HF diagnosis. DATA SOURCES: The keywords heart failure and body mass index, heart failure and obesity, and heart failure and body composition were indexed in PubMed. Articles published from 1999 to 2006 that used multivariate analyses to examine the relationship between obesity and survival in persons with HF were included in the review. CONCLUSIONS: BMI is the standard most often used for measuring body weight in patients with HF. Yet, BMI does not address other major components of body weight (fat, lean body mass, and fluid) that may factor into the mortality of patients with HF. Four of the six studies reviewed reported a positive relationship between obesity and improved survival. However, the studies are limited by design, with the majority being cross-sectional. Furthermore, most of the data were collected through secondary data analysis from patient records in the 1990s, before contemporary HF treatment was used. IMPLICATIONS FOR PRACTICE: Until further research solidifies a clear association between higher BMIs and improved survival in patients with HF, nurse practitioners and others should continue to counsel their patients with HF who are overweight to lose weight. Assessing BMI alone as a predictor of survival for patients with HF may be misleading and should be performed in the context of other factors. Moreover, care should be taken in managing patients with HF who are cachexic because these patients have a worrisome prognosis.

Exploratory analysis of cerebral oxygen reserves during sleep onset in older and younger adults.

OBJECTIVES: To explore differences in cerebral oxygen reserves during sleep in old and young adults. DESIGN: Descriptive cross-sectional study. SETTING: General clinical research center. PARTICIPANTS: Nine old (aged 65-84) and 10 young (aged 21-39) adults. MEASUREMENTS: Subjects were monitored during the first nightly sleep cycle using standard polysomnography, including measures of arterial oxyhemoglobin saturation (SaO(2)). Changes in regional cerebral oxyhemoglobin saturation (rcSO(2)) were used to estimate cerebral oxygen reserves. General linear models were used to test group differences in the change in SaO(2) and rcSO(2) during sleep. RESULTS: Older subjects had lower SaO(2) than young subjects before sleep (baseline) (F((1,18))=5.1, P=.04) and during sleep (F((1,18))=10.7, P=.01). During sleep, half of the older subjects and none of the younger ones had SaO(2) values below 95%. In addition, the older subjects had more periods of oxygen desaturation (drops in SaO(2) > or = 4%) (chi-square=24.3, P=.01) and lower SaO(2) levels during desaturation (F((1,18))=11.1, P<.01). Although baseline values were similar, rcSO(2) decreased during sleep 2.1% in older subjects (F((1,8))=3.8, P=.05) but increased 2.1% during sleep in younger subjects (F((1,9))=4.6, P=.04). When the older subjects awakened from sleep, rcSO(2), but not SaO(2), returned to baseline; both returned to baseline in younger subjects. CONCLUSION: This exploratory analysis generated the hypothesis that lower SaO(2), combined with declines in regional blood flow, contributes to decline in cerebral oxygen reserves during sleep in older subjects. Further study will assess the effects of factors (e.g., medical conditions, subclinical disorders, and sleep architecture) that might account for these differences.

Tailoring protocols to successfully recruit and retain older adults in a longitudinal study of sleep and cognition.

Many studies attest to the challenges of recruiting and retaining older adults in longitudinal studies. This article presents the methods used by the Physiological Research to Improve Sleep and Memory project to recruit and retain 115 adults (age 70 and older) in a 2-year study that involved annual administrations of two neurocognitive test batteries and two nights of polysomnography. Strategies built on knowledge obtained from participant informants and the use of tailored, individualized protocols are described. Together, these strategies enabled participants to become vested in the research process and to fully participate in all aspects of the study.