Stimulating Research to Enhance Aging in Place

Older adults may benefit from interventions to successfully age in place. Research has an opportunity to test interventions and implementation strategies to fulfill the needs of older adults through collective evidence building. The purpose of this article is to describe the proceedings of the American Occupational Therapy Foundation (AOTF) 2019 Planning Grant Collective and describe the areas of research that were identified as critical. The AOTF convened scientists with expertise in the area of aging in place to catalyze research on aging in place for older adults. Four priority areas in the aging in place literature were highlighted: (a) identification of factors that support aging in place, (b) classification of processes by which family members and care partners are included in aging in place efforts, (c) categorization of technology supporting older adults to age in place, and (d) development of science that clarifies implementation of evidence-based practice.

Diabetes Is Devastating, and Insulin Is a Death Sentence: Provider Perspectives of Diabetes Self-Management in Arab-American Patients

IN BRIEF The purpose of this qualitative study was to examine providers' perspectives on cultural barriers and facilitators to diabetes self-management (DSM) in Arab Americans to identify factors to enhance DSM education in the Arab-American community. The main barriers to DSM from the providers' perspective were the disease itself and patients' denial or refusal to recognize it, reflecting the stigma of the disease. Cultural aspects also included overlapping themes that both facilitated and presented barriers to DSM. These results suggest that DSM education for Arab Americans will be most effective if developed and delivered in a manner consistent with the cultural facilitators and barriers noted by providers.

Impact of Grandchild Caregiving on African American Grandparents

The aim of this study was to describe the context and impact of caregiving for grandchildren with health concerns on grandparents. The study sample comprised 391 African American grandparents aged 55 or older. Logistic regression analysis indicated that grandparent caregivers of grandchildren with psychiatric or behavioral problems were more likely to experience a negative impact on their health (AOR = 7.86, p =.008) and leisure (AOR = 14.31, p =.024) than grandparent caregivers of grandchildren with no or other types of health problems. The findings underscore the need to support African American grandparent caregivers, particularly those raising grandchildren with mental health problems.

Diabetes self-management among Arab Americans: patient and provider perspectives

Background

Arab Americans have a high burden of diabetes and poor outcomes compared to the general U.S. population. Diabetes self-management (DSM) requires a partnership between patients and providers that fosters mutual understanding and shared decision-making. Cultural factors influence this process; however, little is known regarding the cultural impact on DSM or if perceptions differ between patients and providers.

Methods

Qualitative content analysis was used to analyze five focus groups–two groups with Arab American providers (n = 8) and three groups with adult Arab Americans with diabetes (n = 23). Focus groups examined patient and provider perspectives on the meaning of DSM and cultural barriers and facilitators among Arab American patients.

Results

Four distinct themes included limited resources for DSM education and support, stigma as a barrier to ongoing support, family support as an opportunity and challenge, and Arab American patient-provider relationships.

Conclusions

Findings indicate several domains should be considered for clinical practice including a need to develop linguistically and culturally reliant educational materials and relevant supports for use in the Arab American population. Findings highlight differing views among providers and patients on the familial role in supporting DSM efforts and why some patients feel dissatisfied with clinical encounters.

Qualitative Methods in Field Research: An Indonesian Experience in Community Based Practice

Occupational therapy is increasing its focus on community based practice, a focus that necessitates innovative approaches to evaluating rehabilitation programs. The appropriate match of methodology to research question is important, but conducting rigorous research in a community setting has numerous practical and academic difficulties, particularly in the cross-cultural context. A lack of cultural and religious sensitivity may compromise the quality of data collected, while thorough reliability procedures are required to enhance the credibility of study findings. The purpose of this article is to illustrate how a qualitative, multimethod approach to research (questionnaires, key informant interviews, and focus group interviews) was used in a cross-cultural evaluation study of volunteer community based rehabilitation cadres in Indonesia. The strengths and limitations of each method are examined in the context of their application to this experience in the field.

Elderly Inner City Women Who Return Home to Live Alone

This study examined the status of 107 elderly inner city women who returned to their home after being in a geriatric rehabilitation unit at a large urban medical center. Prior to admission, all women had been living at home alone. After rehabilitation, 50 of the women were discharged directly to their homes, 26 followed within 3 months, 11 were back home alone by 6 months, and 20 additional women were still not home by 6 months. Results showed that, as measured by standardized assessments of physical functioning and cognition, the women who were most functionally independent returned home alone more quickly. Furthermore, those who achieved live-alone status some time after discharge (but not at discharge) did not report the same level of self-care and home maintenance task independence as women who were discharged home alone immediately at discharge. The findings raise questions about the minimum level of functional performance required to return home alone and the interaction of functional ability, assistance from others, and a variety of social and environmental factors on live-alone status.

The Impact of Arab American Culture on Diabetes Self-management Education

Purpose

The purpose of this study was to better understand barriers and facilitators of diabetes self-management education (DSME) among Arab American patients with diabetes. Little is known about the impact of Arab culture on DSME.

Methods

Arab American adults (N = 23) with medically managed diabetes participated in 1 of 3 focus groups. An Arabic-speaking, trained moderator conducted video-recorded sessions. Verbatim Arabic transcripts were translated into English. Transcripts underwent a qualitative content analysis approach.

Results

Arab American cultural traditions such as food sharing, religious beliefs, and gender roles both facilitated and at times impeded DSME. Patients also held conflicting views about their interactions with their providers; some participants praised the authoritative patient-physician relationship style while others perceived the gaps in communication to be a product of Arab culture. Participants expressed that lack of available educational and supportive resources are key barriers to DSME.

Conclusion

Arab American culture affects DSM activities, and culturally sensitive educational resources are lacking. Development of DSME programs tailored to address relevant aspects of Arab culture might improve DSME outcomes in Arab American population.

“Most of Them Are Amateurs”: Women with Spinal Cord Injury Experience the Lack of Education and Training among Medical Providers While Seeking Gynecological Care

<span>Although the American Disabilities Act (ADA, 1990) became federal law more than two decades ago, individuals with disabilities continue to experience substandard healthcare. We use this article to hone in on disabled women's experiences of seeking gynecological care and the access disparities they still face. The data for this qualitative study were gathered using in-depth interviews with 20 women living with spinal cord injuries in or around Detroit, Michigan. Each interviewee was questioned about overall health and physical functioning, accessibility of doctor offices, interactions with health care providers, and gynecological health-seeking behaviors. In this paper we report on women's gynecological healthcare experiences and related attitudes and practices, and what women see as the primary structural and social barriers to comprehensive care. Findings echo past literature about the inaccessibility of doctor's offices, including the lack of suitable exam tables. However, our findings also suggest that the lack of education and training among medical providers could be a key social barrier and determinant of whether individual women actually secure gynecological care.</span>

Refashioning One's Place in Time: Stories of Household Downsizing in Later Life

Older adults face a daunting task: while continuing engagements in multiple relationships, investment in their own and others' futures, and developing life interests and capacities, they also reexamine and sometimes reconfigure the place where their social lives and objects are housed. Some relocate, downsize, to a new smaller place and reducing possessions to ensure an environment supportive of their capacities and desired daily activities. This article examines how key contours of the experiences of place during residential downsizing are infused with unexpectedly heightened awareness and cultivation of one's sense of place in multiple timeframes. In a discovery mode, the downsizing stories of 40 older adults in southeast Michigan are examined. Findings indicate conflicting temporalities and the natures of cognitions related to decision-making and thinking about being leave-taking and being in place. Findings also highlight in particular how making sense of one's place is predicated on notions of its time, of being on time and downsizing on time. Further, these characterizations of the lived worlds of older adults' modes of conceptualizing the nature of downsizing show how an understanding of the meaningfulness of place in later life relocations requires a layered sense of home as places-in multiple timelines.

Living Arrangement Decisions at Discharge and Later: Differences in Criteria and Outcomes

This study examined the pattern of post rehabilitation living arrangements over 18 months of 172 adults discharged from a geriatric rehabilitation unit at a large urban medical center, all of whom were living alone prior to admission. Results showed the diminishing importance of physical function and cognition as factors in decisions to return home as the length of time after hospital discharge increased. Patients who returned home to live alone after a period of time living in more supported environments had significantly lower assessment scores on physical function (p < 0.001) and cognition (p < 0.001) compared to patients who went home to live alone immediately upon discharge. As well, patients who returned home to live alone later than three months post discharge were significantly more likely to move to more supported environments by 18 months after discharge (p = 0.043) and to experience re-hospitalizations (p = 0.008), which raises questions about the appropriateness of these later decisions.

Occupational therapist home evaluations: inequalities, but doing the best we can?

OBJECTIVE

The purpose of this study was (a) to describe the occupational therapy recommendations provided to patients discharged to inner city homes, and (b) to examine the relationship between patient health insurance and the number and type of occupational therapist recommendations for equipment and home modifications.

METHOD

An archival review was conducted of all referrals to the home evaluation program (n = 755) at a large urban rehabilitation hospital between January 1, 1994, and December 31, 1998. Additional patient demographic data and Functional Independence Measure (FIM) data were obtained in electronic form from the hospital information database.

RESULTS

Analysis of results showed that while the pattern of equipment and modification recommendations varied little, publicly insured patients received fewer home modification recommendations compared to privately insured patients (t = 3.7; p < .0005), and were discharged from rehabilitation with significantly lower functional independence (MANOVA F = 3.9; p = .05).

CONCLUSION

Results alert occupational therapists to the relationship between health insurance and treatment recommendations and point to patient advocacy and health policy as potential pathways to desired a achieve social change.

After rehabilitation: an 18-month follow-up of elderly inner-city women

OBJECTIVE

Elderly inner-city women (n = 125) greater than the age of 60 and living alone and who were consecutively admitted to a large, urban, university-based rehabilitation hospital were followed to (a) examine the power of standardized clinical measures to predict who was living alone 18 months after discharge, (b) determine whether live-alone women at 18 months' follow-up were more independent in instrumental activities of daily living (IADL) than women who were not living alone, and (c) investigate whether women who return home to live alone and have low or declining physical function are at risk for subsequent relocation or death.

METHOD

Data from four standardized assessments (physical function, cognition, comorbidity, and depression) and demographic information were gathered during in-patient rehabilitation. Self-report IADL data were collected via telephone interviews at 3, 6, and 18 months' follow-up.

RESULTS

Statistical analysis of results showed that physical function, cognition, and comorbidity were significant and independent predictors of living alone at 18 months' follow-up. Women living alone at 18 months reported significantly greater IADL independence than women who were not living alone. Path analysis confirmed that the relationship between the clinical measures and living situation at 18 months was mediated by self-reported IADL functioning.

CONCLUSION

Standard clinical data obtained at discharge are useful to identify who can return home to live alone after rehabilitation, but in-home assessment of IADL remains key to understanding the complex skills required to live alone.

Self-care independence after spinal cord injury: patient and therapist expectations and real life performance

PURPOSE

To evaluate changes in self-care performance between rehabilitation discharge and 1 year follow-up and to compare patients' and therapists' expectations of self-care independence with actual self-care performance after discharge.

METHODS

Prospective study of 55 patients with tetraplegia (21 complete and 34 incomplete) after spinal cord injury (SCI) consecutively admitted to a large urban rehabilitation hospital [injury levels: C4 (5), C5 (33), C6 (9), C7 (4), and C8 (4)]. Data were collected using structured patient interviews, occupational therapists' predictions of patients' self care, and Functional Independence Measure ratings by rehabilitation staff.

RESULTS

Analysis showed that for all skills, expectations of patients (mainly African American men) were higher than therapists' predictions, and for 3 of these skills, the differences were statistically significant: eating (Z = -4.47, P < .001 ); bathing (Z = -3.67, P < .001 ); and dressing (Z = -3.16, P = .002). Occupational therapists were better predictors of patients' actual self-care performance at discharge than were patients, although both tended to overestimate patients' performance. There was no evidence that self-care capability declined between discharge and 12 months follow-up, but routine self-care performance varied widely across patient and personal circumstances.

CONCLUSIONS

Differential attrition reduced the study sample to 25 SCI patients who were primarily more severely injured African American men. Results showed that these patients maintained their self-care performance 1 year after discharge, but more innovative strategies must be developed to customize self-care retraining to address the unique needs of this patient population.

The functional performance of elderly urban African-American women who return home to live alone after medical rehabilitation

OBJECTIVE

Elderly women who live alone are at increased risk for loss of independence. Hospitalization, in particular, often marks the transition from independent living to institutional care. The purpose of this study was to examine the relationship of rehabilitation admission to the subsequent function of elderly women and their ability to return to live-alone status.

METHOD

The women in the study (N = 138) were admitted to a geriatric rehabilitation unit at a large urban medical center between September 1997 and September 1998. The findings reported here pertain to the subset of African-American women (n = 122), the majority of the sample. Data were collected using several standardized assessments, including the Functional Independence Measure (FIM).

RESULTS

The FIM motor scores improved significantly for the total sample between admission and discharge, and the mean FIM motor score for the group that subsequently attained live-alone status was significantly higher than the non-live-alone group at 3 months and 6 months postdischarge. The participants who returned to live alone also reported significantly greater independence than did their non-live-alone counterparts across a variety of activities of daily living and instrumental activities of daily living skills.

CONCLUSION

These data suggest that rehabilitation is associated with improved functional outcomes, and higher functional performance is related to live-alone status.

A severe adverse reaction to mefloquine and chloroquine prophylaxis

A 23 year old man with no history of neurological or psychiatric illness ingested three weekly 228 mg doses of mefloquine base (250 mg salt) as malaria prophylaxis while in India. He experienced an increasingly severe adverse reaction after each dose, including symptoms of paranoia, hallucinations, and suicidal ideation. The man discontinued mefloquine and continued malaria prophylaxis with chloroquine. Shortly after the first 300 mg dose of chloroquine base (500 mg chloroquine phosphate salt), symptoms acutely intensified and became debilitating. Severe symptoms persisted for 12 months following the discontinuation of both antimalarial drugs.

Revisiting community participation

Community participation in health is a complex entity that has been examined extensively in the literature and continues to be of great interest among community health workers. The genesis of the idea and its conceptual development are primarily attributed to large multinational health institutions, particularly the World Health Organization. However, the implementation of community participation is the ultimate responsibility of local health programme initiators. It is therefore at the local level where day to day realities of incorporating community participation into health service delivery are confronted. This paper reviews the value of community participation in health and provides a detailed examination of the challenges facing its implementation and sustainability. In 1978, the World Health Organization placed community participation squarely at the centre of their strategy to achieve Health For All By The Year 2000. As the year 2000 nears, it is time to critically re-examine the notion of community participation and the most pressing challenges to its viability.

Professional expertise of occupational therapists in community practice: results of an Ontario survey

This paper presents findings of a study, The Community Practice Project, that examined the situation of occupational therapists practising in community based settings in the province of Ontario, Canada in 1992. In addition to providing a profile of the typical community based therapist, the study considered issues relating to: the principal roles in places of employment; specific job skills and areas of professional expertise utilized in the community; and how well occupational therapists; formal training prepared them for their community oriented roles and tasks. Results indicate that great opportunities exist and job satisfaction is high in community settings. Nonetheless, therapists feel inadequately prepared for the new role of consultant and its concomitant skills in a field that has re-oriented itself toward the client and is increasingly focused on health promotion and disability prevention.