A Qualitative Investigation of the Impact of Home-Based Primary Care on Family Caregivers

BACKGROUND

Home-based primary care (HBPC) provides team-based clinical care for homebound patients who have difficulty accessing typical outpatient care. Interdisciplinary team members also provide social and emotional support and serve as a resource for family caregivers, who often experience significant emotional stress.

OBJECTIVES

This qualitative study explores the impact of HBPC on family caregivers to identify aspects of the program that caregivers find most helpful and meaningful as well as areas for improvement.

DESIGN

Semi structured recorded interviews were conducted with family caregivers of frail, elderly homebound patients. Interviews included the following topics: overall program satisfaction and suggestions for improvement.

SETTING

A HBPC program serving patients in Queens, Nassau and Suffolk counties in New York.

PARTICIPANTS

Nineteen family caregivers: 13 women, 6 men; 10 were adult children; 6 were spouses, and 3 were other family members of patients in a HBPC program.

MEASUREMENTS

Thematic coding of all recorded transcribed interviews was prepared by 3 qualitative coders. Interrater reliability was conducted to ensure reliability across coders before themes were disseminated and discussed until consensus was achieved with the larger group of investigators.

RESULTS

Three main themes were identified: the importance of staff emotional support; the burden of caring for homebound patients; and the need for a broader range of home-based services. Multiple family members noted that the program not only had saved their loved one's life, but had also metaphorically saved their own.

CONCLUSIONS

Family caregivers value the communication and accessibility of HBPC and report that the program has a positive impact on their stress and mental health. Results can inform key aspects that need to be retained or enhanced with the expansion in HBPC programs.

Relationships between depression, gender, and unhealthy weight loss practices among overweight or obese college students

INTRODUCTION

Unhealthy weight loss practices are common among female college students. It is unknown if these practices are also most common among women in the subset of overweight or obese college students or if these practices are related to depression. We examined the relationship between gender, depression, and unhealthy weight loss practices among overweight or obese college students.

METHODS

Students (body mass index between 25.0 and 34.9 kg/m(2)) from three Southern California universities (M(age) = 22 years, SD = 4; 70% women) were recruited from May 2011 to May 2012 for participation in a weight loss clinical trial (N = 404). Logistic regressions were performed with baseline data to assess the cross-sectional relationship between self-reported unhealthy weight loss practices and gender and depression as measured by the Center for Epidemiologic Studies Depression short form.

RESULTS

Twenty-nine percent of participants reported engaging in at least one unhealthy weight loss behavior (e.g., fasting, purging) over the last 30 days, with no differences by gender. Self-report of at least one unhealthy weight loss behavior was associated with report of symptoms of depression (e(B) = 1.14 [confidence interval, CI: 1.08-1.20]), adjusting for potential confounders. Interactions between gender and depression were not significant (e(B) = 1.04 [CI: 0.93-1.16]).

CONCLUSION

Among an overweight or obese sample of college students, unhealthy weight loss practices were equally common in both genders, and students with depressive symptomatology were at greatest risk. Obesity interventions targeting overweight or obese college students should educate both men and women about the dangers of unhealthy weight loss practices. In addition, screening for depression can help identify students who would benefit from additional supportive and coping strategies and resources.

Design and implementation of a randomized controlled social and mobile weight loss trial for young adults (project SMART)

PURPOSE

To describe the theoretical rationale, intervention design, and clinical trial of a two-year weight control intervention for young adults deployed via social and mobile media.

METHODS

A total of 404 overweight or obese college students from three Southern California universities (M(age) = 22( ± 4) years; M(BMI) = 29( ± 2.8); 70% female) were randomized to participate in the intervention or to receive an informational web-based weight loss program. The intervention is based on behavioral theory and integrates intervention elements across multiple touch points, including Facebook, text messaging, smartphone applications, blogs, and e-mail. Participants are encouraged to seek social support among their friends, self-monitor their weight weekly, post their health behaviors on Facebook, and e-mail their weight loss questions/concerns to a health coach. The intervention is adaptive because new theory-driven and iteratively tailored intervention elements are developed and released over the course of the two-year intervention in response to patterns of use and user feedback. Measures of body mass index, waist circumference, diet, physical activity, sedentary behavior, weight management practices, smoking, alcohol, sleep, body image, self-esteem, and depression occur at 6, 12, 18, and 24 months. Currently, all participants have been recruited, and all are in the final year of the trial.

CONCLUSION

Theory-driven, evidence-based strategies for physical activity, sedentary behavior, and dietary intake can be embedded in an intervention using social and mobile technologies to promote healthy weight-related behaviors in young adults.

Randomized trial of a family-based, automated, conversational obesity treatment program for underserved populations

OBJECTIVE

To evaluate the acceptability and feasibility of a scalable obesity treatment program integrated with pediatric primary care (PC) and delivered using interactive voice technology (IVR) to families from underserved populations.

DESIGN AND METHODS

Fifty parent-child dyads (child 9-12 yrs, BMI > 95th percentile) were recruited from a pediatric PC clinic and randomized to either an IVR or a wait-list control (WLC) group. The majority were lower-income, African-American (72%) families. Dyads received IVR calls for 12 weeks. Call content was informed by two evidence-based interventions. Anthropometric and behavioral variables were assessed at baseline and 3-month follow-up.

RESULTS

Forty-three dyads completed the study. IVR parents ate one cup more fruit than WLC (P < 0.05). No other group differences were found. Children classified as high users of the IVR decreased weight, BMI, and BMI z-score compared to low users ( P < 0.05). Mean number of calls for parents and children were 9.1 (5.2 SD) and 9.0 (5.7 SD), respectively. Of those who made calls, >75% agreed that the calls were useful, made for people like them, credible, and helped them eat healthy foods.

CONCLUSION

An obesity treatment program delivered via IVR may be an acceptable and feasible resource for families from underserved populations.

Person perception and autonomic nervous system response: the costs and benefits of possessing a high social status

This research was designed to investigate the relationship between sympathetic and parasympathetic autonomic nervous system (ANS) responses to the perception of social targets varying in social status. Participants varying in subjective financial status were presented with faces assigned with either a low, average, or high financial status. Electrocardiographic and impedance cardiography signals were recorded and measures of sympathetic (pre-ejection period; PEP) and parasympathetic (high frequency heart rate variability; HF HRV) cardiac control were derived. These measures associated with the presentation of each face condition were examined in relation to the subjective status of the perceivers. Participants with high subjective financial status showed reduced sympathetic activity when viewing low- and medium-status targets as compared to high-status targets, and lower parasympathetic response when viewing high- and medium-status targets relative to low-status targets.

Self-efficacy, psychosocial factors, and exercise behavior in traditional versus modified cardiac rehabilitation

BACKGROUND

Self-efficacy and social support are established determinants of exercise adherence and have potential usefulness for tailoring independent exercise regimens for cardiac patients. Highly supervised traditional cardiac rehabilitation programs may be a barrier for independent exercise self-efficacy in low - and moderate-risk patients.

PURPOSE

The authors evaluated changes in psychosocial measures including self-efficacy and social support in 80 cardiac patients with low to moderate risk randomized to a traditional cardiac rehabilitation protocol (TP) or modified protocol (MP). These measures also were assessed for their potential to predict subsequent exercise behavior.

METHODS

The TP (n = 38) emphasized a supervised exercise regimen and included continuous electrocardiogram (ECG) monitoring for 3 months. The lower cost MP (n = 42) emphasized independent exercise and included group education/support meetings, and gradually weaned patients from continuous ECG monitoring and direct medical supervision.

RESULTS

Repeated measures analyses of variance indicated that MP patients had higher levels of self-efficacy for independent exercise without continuous ECG monitoring (P < .05). No other protocol differences were found. Multiple regression analyses using the pooled sample (excluding dropouts) indicated that self-efficacy for independent exercise was the only significant predictor of exercise over 6 months (R2=.28 [adjusted R2= .221 P < .01). In contrast to previous reports, social support for exercise was not a significant predictor of exercise behavior.

CONCLUSIONS

These findings suggest cardiac rehabilitation programs for low- and moderate-risk patients should emphasize educational and patient monitoring methods that promote patient self-efficacy for independent exercise. Programs that emphasize highly supervised exercise including longer term use of continuous ECG monitoring may impair self-efficacy for independent exercise. Longer-term studies are needed to fully determine the value of using psychosocial measures for designing individualized exercise programs and predicting long-term exercise behavior in cardiac patients.

What factors are associated with local enforcement of laws banning illegal tobacco sales to minors? A study of 182 law enforcement agencies in California

OBJECTIVES

The aims of this study were to understand the attitudes of local law enforcement staff regarding policies to reduce youth access to tobacco, to determine what proportion of these agencies have conducted unannounced compliance checks in the past year, and to examine factors associated with conducting compliance checks.

METHODS

A written questionnaire was completed by 182 law enforcement officials representing 200 cities and counties in California (some officials represented multiple jurisdictions). Logistic regression analyses were conducted to identify factors associated with conducting compliance checks.

RESULTS

Only 36% of local enforcement agencies reported conducting one or more compliance checks in the previous year. Agencies were more likely to conduct compliance checks if they perceived fewer barriers to enforcement, reported more frequent collaboration with other community agencies to enforce youth access laws, and believed that youth access to tobacco is a problem in their community.

CONCLUSIONS

Because active enforcement of youth access laws using unannounced compliance checks has been shown to reduce the rate of illegal tobacco sales to minors and may reduce youth smoking, efforts to increase the level of enforcement should be promoted. These study results may be used to inform efforts to encourage local agencies to enforce existing youth access laws.

Does smoking abstinence self-efficacy vary across situations? Identifying context-specificity within the Relapse Situation Efficacy Questionnaire

According to self-efficacy and relapse theories. abstinence self-efficacy (ASE) ratings should be context-specific: they should vary across situations. This variability may be important, as it could signal high-risk for relapse situations. In this study, confirmatory factor analysis was used to identify situational variability in a novel ASE assessment (Relapse Situation Efficacy Questionnaire. or RSEQ). Results supported a hierarchical structure, where both context-specific and unidimensional measures of ASE exist within the assessment. Context-specific factors included Negative Affect, Positive Affect, Restrictive Situations (to smoking). Idle Time, Social-Food Situations, Low Arousal, and Craving. Multiple context-specific factors and the aggregate factor predicted cessation outcome, even after controlling for concurrent smoking rate. However, the context rated with the least confidence proved to be the best outcome predictor, suggesting the existence of "Achilles' heel" situations. These data indicate the internal and predictive validity of the RSEQ.

The relationship between home smoking bans and exposure to state tobacco control efforts and smoking behaviors

PURPOSE

To examine the relationship between home smoking bans and adult smokers' exposure to the statewide California Tobacco Control Program (TCP) and their cigarette smoking behavior.

DESIGN

Cross-sectional survey that was part of the statewide Independent Evaluation of the California Tobacco Control, Prevention and Education Program.

SETTING

Random telephone interviews within 18 California counties.

SUBJECTS

A representative sample of 1315 adult smokers, aged 25 years and older.

MEASURES

The telephone survey included questions about smoking behavior, quitting smoking, exposure to tobacco control program components, home smoking rules, and attitudes related to tobacco use and environmental tobacco smoke (ETS).

RESULTS

Smokers with a home smoking ban were twice as likely (OR = 2.29; 95% CI 1.22, 4.29) to have heard of TCP community programs and three times more likely (OR = 3.18; 95% CI 1.34, 7.57) to have seen and talked about the ETS media spot than smokers with no home smoking policy. Multivariate regression models indicated that having a home smoking ban was related to smoking fewer cigarettes per day and greater interest in quitting smoking compared with smokers with no smoking rules in the home (p < .05).

CONCLUSIONS

These findings suggest that smokers reporting exposure to the California TCP were more likely to have restrictive home smoking policies and that more restrictive home smoking policies were associated with reduced smoking behavior.

Opinion leaders' support for tobacco control policies and participation in tobacco control activities

OBJECTIVES

Because opinion leaders hold positions from which they may influence tobacco control efforts, this study examined their support for tobacco control policies and their involvement in tobacco control activities.

METHODS

A telephone survey was administered to 712 California opinion leaders who were randomly selected from constructed lists representing 8 types of organizations: health, education, law enforcement, media, government, business, ethnic, and youth. Hierarchical regression analysis was used to identify predictors of support for and participation in tobacco control activities.

RESULTS

Approximately one half to two thirds of opinion leaders supported the tobacco control policies queried; 60% reported involvement in tobacco control-related activities during the previous year. Organizational affiliation was a strong predictor of support and involvement, with leaders from health and educational organizations reporting the highest levels and business and media leaders reporting the lowest. Tobacco issue involvement variables (e.g., having a friend or family member with a smoking-related illness) were significantly associated with the outcomes, while sociodemographics, for the most part, were not.

CONCLUSIONS

Study results can be used to mobilize opinion leaders' support for tobacco control more effectively.

Cluster subtypes within stage of change in a representative sample of smokers

In this paper a three-level conceptualization of approaches to matching self-help behavior change strategies to individuals is presented based on the Transtheoretical Model of Change. Two of the model's intervention approaches, tailoring to Stage-of-Change and creating completely individualized interventions, have already been developed and implemented in previous research. A third intervention approach, in between stage-tailored and individualized, is targeting subtype groups within each Stage of Change. The subtype targeted intervention approach is in the initial development stage of empirically determining and validating the stage subtypes. Three studies are presented which investigate stage subtypes within a representative sample of 4,144 smokers in the Precontemplation, Contemplation, and Preparation Stages of Change. Within each Stage-of-Change study, two cluster analyses were performed using the Pros, Cons, and Situational Temptations from the Transtheoretical Model to establish cluster replicability. Cluster solutions were externally validated using the 10 Processes of Change and 2 smoking behavior variables. Four distinct subtypes were found in Precontemplation and Contemplation, and five subtypes were found in Preparation. These subtypes closely replicate subtypes previously found in a convenience sample of smokers and provide strong evidence for the existence of subtypes within the first three Stages of Change.

Smoking bans in the home and car: Do those who really need them have them?

BACKGROUND

This paper addresses the question of whether individuals who are most in need of household and car smoking bans, such as individuals with children living at home or who have many friends who smoke, are the ones who have them.

METHOD

A representative sample of 6985 California adults ages 18 and older participated in telephone interviews.

RESULTS

Overall, 76% of adults report having home smoking bans and 66% have car smoking bans. Being a smoker or African American, not having children in the home, having more friends who smoke, and lower household income were associated with lower prevalence of both home and car smoking bans (P < 0.01). In multivariate analyses, nonsmokers were 7.9 (95% CI = 3.56, 17.31) times more likely to have a home smoking ban when none of their friends were smokers compared to when most of their friends were smokers. Among smokers, there was an interaction between having children at home and the proportion of friends who smoke. Only 27 to 55% of smokers had home smoking bans unless most of their friends were smokers, then the odds of having a ban were 6.1 (95% CI = 2.76, 13.68) times higher for smokers with children (67% with home bans) than for smokers without children at home (25% with home bans).

CONCLUSIONS

Efforts to increase home and car smoking bans for nonsmokers who have friends who smoke and smokers with children living at home are needed.

Mortality of sheep exported by sea: evidence of similarity by farm group and of regional differences

OBJECTIVE

To determine whether mortality of sheep exported by sea is similar for sheep from the same farm exported in different years or is associated with the region of origin.

DESIGN

Mortalities were monitored in farm groups of sheep exported from the southwest of Western Australia under normal commercial conditions.

PROCEDURE

Mortalities were monitored on commercial shipments from 1985 to 1996. For each consignment, the mortality rate was assigned its percentile ranking within the month and year of loading of the ship. A mortality rate was high if its percentile ranking was above a selected cut-off value. Five cut-off values were used in separate analyses. The spatial distribution of farms with high mortality was compared between and within zones of rainfall and length of pasture-growing season.

RESULTS

A total of 479 groups of sheep from 405 farms was monitored. Mortality rates ranged from nil to 28.2%. Half of all deaths were from 14.2% of the consignments. There was a significant association (P < 0.05) between the category of mortality (high or low) in the first and second years of monitoring for four of the five cut-off values. The spatial analyses indicated that there were more high-mortality groups, and the average mortality was higher, in the zones of higher rainfall and longer pasture-growing season (P < 0.001).

CONCLUSION

Mortality data can be used to identify regions and groups of sheep that are at risk of suffering high death rates when exported by sea.

Which adults do underaged youth ask for cigarettes?

OBJECTIVES

This study identified adults' demographic and smoking behavior characteristics that are related to being asked to provide tobacco to a minor.

METHODS

Telephone interviews were conducted with 6352 California adults. Predictors included age, sex, household income, and smoking status.

RESULTS

Only 10.1% of California adults had been asked to provide tobacco to a minor in the previous year. Fewer than 3% of individuals 55 years and older had been asked to provide tobacco, but among younger smokers 59.0% of 18- and 19-year-olds and 39.3% of 20- to 24-year-olds had been approached.

CONCLUSIONS

Interventions to reduce the social availability of tobacco are needed.

Testing 40 predictions from the transtheoretical model

Sensitive measurement of behavior change requires dependent measures that are sensitive to the whole spectrum of change, not just a single aspect of change. Traditional outcome variables such as point prevalence for smoking cessation focus on a single discrete event and ignore all other progress. Alternatively, the criterion measurement model (CMM) is an approach that posits a three-construct outcome model (habit strength, positive evaluation strength, and negative evaluation strength), where different constructs are sensitive to change for different aspects of the temporal domain. In this article, a series of 40 differential a priori predictions were tested using a large representative sample of smokers. The focus was on the prediction of specific effect sizes rather than statistical significance. A series of comparisons involving stage transitions was examined using five variables representing the three CMM constructs. The predictions involved movement from one of three initial stages (precontemplation, contemplation, and preparation) to stage membership 12 months later. Thirty-six of the 40 predictions were confirmed, indicating that the outcome model has strong construct validity and accurately reflects movement between the stages of change.

Dynamic typology clustering within the stages of change for smoking cessation

Dynamic typology clustering was employed to find homogeneous subgroups of smokers within each of three early stages of change (precontemplation, contemplation, preparation) in a representative sample of smokers. Individual change profiles were created by coding the stage of change for each subject at five consecutive assessment points over a 2-year period (baseline and 6, 12, 18, and 24 months). A total of 446 unique change profiles were found in the sample of 2,088 smokers who had complete data for all five time points. The sample was initially split into three groups determined by baseline stage of change. Within each initial stage, subgroups that shared similar patterns of change were interpreted by examining the shape and elevation of the change profiles. Four major types of profiles emerged: a stable profile, a progressing profile, a vacillating profile, and a regressing profile. External validation revealed significant differences among the dynamic typology subtypes on key transtheoretical model constructs (processes of change, decisional balance, situational temptations). These results both support and complement key construct relationships within the transtheoretical model and can provide important predictive information to direct and enhance treatment interventions for smoking cessation.

The duration of lot-feeding of sheep before sea transport

Adult wethers (n = 750) were lot-fed for 13 days, 8 days or 3 days before a simulated voyage lasting 18 days to examine whether the period of lot-feeding affected the proportion of sheep that ate pelleted feed and their body weight change during simulated shipping. There was no significant difference in the proportion of non-feeders between treatment groups on days 7 and 14 of the voyage. Body weights were not significantly different between the treatment groups on days 14 and 18 of the voyage. Overall body weight loss, from the farm to the end of simulated shipping, was 4.08 kg (+/- 0.28, s.e.m.), 4.58 kg (+/- 0.28) and 4.51 kg (+/- 0.28) in sheep lot-fed for 13 days, 8 days and 3 days, respectively, and was not significantly different between treatments. It was concluded that lot-feeding for 13 days conferred no advantage in body weight or numbers of non-feeders compared with shorter periods in this study.

Management of inappetant sheep during export by sea

In the first of 2 experiments, a simulated voyage was conducted to examine the effects of various treatments on bodyweight change and feeding frequency of inappetant sheep at the end of lot-feeding (non-feeders). The treatments, applied during simulated shipping, were: normal quantities of feed and length of troughs; extra trough length; extra feed. Adult Merino wethers (n = 108) were used in each treatment. A voyage to the Middle East was then conducted to establish whether shipboard mortality could be reduced by separating non-feeders (n = 305) from feeders (n = 5,620) late in the feedlot hase and housing the groups separately aboard ship. A control group of non-feeders (n = 215) mixed with feeders (n = 5,732) was used for comparison. Bars (marker bars), containing a coloured dye, were attached to feed troughs to mark sheep that fed. Most non-feeders (82%) began eating when placed in shipping pens in both studies. However, there was no significant difference in percentage of sheep that fed between non-feeders given extra trough length or extra feed compared with non-feeders given standard management at any stage of simulated shipping. There was no significant difference in mean bodyweights between treatment groups on days 1, 8 and 15 of simulated shipping. Differences in bodyweight on d 22 were probably associated with different levels of gut fill. Death rates were not significantly different in separated and control groups (1.1%, 0.9%, P = 0.6) in the voyage of 14 d to the Middle East.(ABSTRACT TRUNCATED AT 250 WORDS)