Full text for dissertations and theses included in this collection dates back to 2011. For older dissertations, check the library’s catalog CatalogUSMAI or Dissertations and Theses database.

Recent Submissions

  • Development and Usability Testing of a Mobile Health Game Application for Older Adults on Warfarin

    Opoku-Agyemang, Ernest; Johantgen, Mary E.; Nahm, Eun-Shim (2020)
    Background: Chronic disease management constitutes a special challenge in the United States due to deficiencies in the healthcare system. Chronic disease self-management (CDSM) using technology and gaming principles is a promising way to overcome these challenges. Yet, there are few disease-specific apps to benefit the populations likely to benefit from such innovations. Purpose: This proof of concept study evaluated the feasibility of a Warfarin game app for older adults. The aims were to: 1) Design and develop a mobile game app to educate patients on Warfarin; and 2) Conduct usability testing of the game app among patients on Warfarin receiving care at an anticoagulation clinic. Methods: Following the design and development of a Warfarin app called Coumadin Hero, the usability testing of the app was conducted with 25 participants. Heuristics and user testing were conducted. The Technology Acceptance Model (TAM) was the theory that informed the study design and implementation. An adaptation of the Perceived Health Web Site Usability Questionnaire (PHWSUQ) was used to assess the participant usability. Descriptive and correlational statistics were used to analyze game play data and responses to survey questionnaires. Results: The median percent correct of Vitamin K food identification was 79%. Generally, participants had higher knowledge of Vitamin K levels in green vegetables (92% - 96%). User technology experience and demographic characteristics were not associated with Vitamin K food knowledge or level of satisfaction. The overwhelming majority of users found the app easy to learn and use. The ease of reading and finding information were 68 – 72%, respectively. Conclusion: Because self-management is vital for people taking Warfarin, using a game app as a supplement to traditional teaching could have significant positive impact on their health. As apps are increasingly easy to develop and smartphone use increases, apps should be developed to help people manage chronic diseases. Findings from this study support people’s interest and ability to use apps.
  • Expanding Post-Stroke Telerehabilitation: A Qualitative Study of User Experience Piloting VA Secure Messaging Use in a Telerehabilitation Format

    Keldsen, Linda; Storr, Carla L.; 0000-0002-5395-1358 (2020)
    BACKGROUND: Stroke is the fourth leading cause of death and primary cause of long-term disability in the U.S. As many as 40% of stroke survivors are discharged home without any inpatient or outpatient comprehensive stroke rehabilitation leading to the need for continued care for basic activities of daily living (grooming, toileting and feeding). Barriers to post-discharge comprehensive stroke rehabilitation are distance to travel, lack of transportation and inadequate social support. Telerehabilitation has been suggested as a possible solution for the delivery of low cost, convenient, home-based rehabilitative care. OBJECTIVE: To understand the experience of researchers and stroke survivors piloting the use of the My HealtheVet personal health record and secure messaging for stroke telerehabilitation. METHODS: A retrospective qualitative study using semi-structured interviews with a convenience sample of five study participants from the intervention arm of VA funded stroke rehabilitation single-blinded randomized controlled trail was conducted in addition to a focus group of three of the research team members. A descriptive phenomenological approach was used to describe the study participants and selected research team members experience using the VA’s My HealtheVet personal health record and secure messaging in telerehabilitation research. RESULTS: Researchers and study participants reported benefits from using the My HealtheVet personal health record with secure messaging that included the ability to send and or respond to secure messages at a time and place of their choosing, flexibility in scheduling the time of their therapy, ability to use any internet-enable device to access their My HealtheVet account, and the ability to retrieve and reread or watch education provided by the therapist when needed. Barriers to use were outweighed by the increased flexibility in scheduling, feeling empowered and having caregiver support. CONCLUSIONS: This small feasibility pilot suggests My HealtheVet with secure messaging may be an appropriate telecommunication tool for telerehabilitation. The study researchers caution that this was a small pilot and consideration should be given to ensuring adequate resources to support a larger study panel if expanded.
  • Evaluating Antidepressant Use in Nursing Home Residents with Moderate to Severe Cognitive Impairment

    Nalls, Victoria; Galik, Elizabeth; Resnick, Barbara (2020)
    Background: Antidepressants are commonly prescribed medications among nursing home residents and used to treat symptoms of dementia. Concerns have been raised, however, about disparities and potential inappropriate use of these medications within this population. Purpose: The purpose of this dissertation was to: (1) Describe factors associated with antidepressant use in nursing home residents with moderate to severe cognitive impairment; (2) Describe differences in antidepressant use between white and black nursing home residents with moderate to severe cognitive impairment; (3) Evaluate trends in antidepressants and antipsychotics prescribing among nursing home residents with moderate to severe cognitive impairment. Methods: This secondary data analysis used data from the Function and Behavior Focused Care (FBFC) for Nursing Home Residents with Dementia randomized control trial. A total of 336 residents were included in the study, who were mostly white, female, severely cognitively impaired (MMSE=7.8, SD=5.1) and the average age was 82. Data collection was done at baseline and 12 months and based on chart reviews, input from staff, and observation of residents. Descriptive statistics and logistic regression were used to address aims 1 and 2. Generalized linear mixed modeling with a binary distribution and logit link function was used for aim 3. Results: At baseline, 59% of the sample was taking an antidepressant. Race was significantly associated with antidepressant use (β=0.51; p=0.01). Black residents were half as likely to be on antidepressants compared to white residents (OR=0.499 CI=0.305-0.817) and received lower dosages of sertraline (t=2.68; p=0.01). There was no significant change in antidepressant or antipsychotic use at 12 months. Conclusions: Black nursing home residents with moderate to severe cognitive impairment were significantly less likely to be on antidepressants and when treated, were likely to be on lower dosages of some antidepressants. It is unknown if this is due to misdiagnoses and disparities in treatment or lack of need for antidepressants or differences in responses to specific drug classes. Further research is needed to explore these differences and evaluate the influence of resident, prescriber, and facility factors on the use of antidepressants among nursing home residents with moderate to severe dementia.
  • Burden and Mental Health of Family Caregivers of Cancer Patients: The Impact of Spirituality

    La, In Seo; Johantgen, Mary E. (2020)
    Background: As the primary source of care for individuals with cancer, family caregivers are relied on for treatment support and emotional care during the cancer trajectory. Studies on caregiver burden and psychological sequelae among cancer caregivers have been conducted cross-sectionally. Spirituality has been suggested as a potential buffer between burden and sequelae. Yet, there have been very few longitudinal studies addressing burden, depression, and spirituality, and there is limited information on psychometric properties of the spirituality measures in cancer caregivers. Purpose: The aims of this study were to: 1) evaluate validity of the Spiritual Perspective Scale (SPS) and explore differences in spirituality across caregiver and patient characteristics, 2) describe caregiver burden during active cancer treatment and explore caregiver and patient factors influencing caregiver burden, and 3) examine changes in caregiver burden, spirituality, and depression and explore the moderating effect of spirituality on burden-depression relationship over time. Methods: A secondary analysis of data from a longitudinal study of cancer caregivers from the NIH Clinical Center was conducted. Caregivers completed measures, including the Spiritual Perspective Scale (SPS), Caregiver Reaction Assessment (CRA), and NIH Toolbox and PROMIS® measures. Structural equation modeling and linear mixed modeling were used for testing study aims. Results: The SPS was found to have satisfactory psychometric properties in cancer caregivers. Adjusting for a direct effect of race did not alter the pattern of results, and caregivers who were older, female, racial/ethnic minorities, less educated, affiliated with a religion, and who provided care to anyone other than the patient reported higher levels of spirituality. Baseline mutuality between the caregiver and patient was negatively associated with initial burden. Changes in caregiver burden were related to being spouse caregivers, sole caregivers, and income. Scores on total burden, spirituality, and depression remained stable over time. Caregivers’ spirituality moderated the link between burden and depression (-1.26, p = .025). Conclusions: Higher levels of spirituality may act as a protective factor in the relationship between burden and depression during active cancer treatment. Identified factors related to burden and strategies to strengthen spirituality should be considered to improve caregiver mental health.
  • Adult Patients’ Experience Using Patient Portal: The Impact of Perceived Usability on Portal Use Behavior

    Son, Hyojin; Nahm, Eun-Shim (2020)
    Background: Patient portals (PPs) are a robust tool that can engage patients into their care. PPs can be especially helpful for older adults who have complex healthcare conditions. Usability of PPs is a major influencing factor for PP use. PP usability is more important for older adults who tend to be less familiar with technologies and may need additional support for using PPs. Currently, there has been a lack of studies that examined PP usability perceived by patients after PP implementation in healthcare settings. Objectives: The primary aim of the study was to test a modified PP Acceptance Model that explains factors affecting patients’ PP use. The secondary aim was to compare the difference in PP usability, PP self-efficacy, and PP use between older adults recruited from community settings and older adults recruited from hospital settings. Methods: To test the primary aim, an anonymous cross-sectional online survey was conducted with adult patients in an integrated healthcare system. Data from 743 patients who used PPs in the past 12 months were subject to structural equation modeling (SEM). For the secondary aim, a secondary data analysis was performed using descriptive statistics and content analysis (272 community-residing older adults). From this sample, those who used PPs (n=126) were compared with hospital/clinic-based older adults (n=174) by conducting regression analyses. Results: Among 743, about two-thirds were White and female (mean age, 53.1; range, 18-92). Mean PP usability was 36.6 (range, 6-42). The SEM revealed that the final model fit the data: CFI=.983, RMSEA=.059. PP self-efficacy and privacy/security concerns had a direct impact on PP use. PP use was indirectly influenced by PP usefulness, PP ease of use, eHealth literacy, education, and age. The secondary data analysis indicated that older adults recognized PP benefits and were willing to use PPs. However, their PP use was limited due to several challenges. The relationship between PP usability and PP use was stronger in the community sample. Conclusion: Findings suggest a strong potential for using PPs to engage patients in healthcare and strategies to improve patients’ PP use. Further studies need to include more diverse populations in various settings.
  • The Experiences and Expressions of Compassion Among Experienced Critical Care Nurses

    Walker, Mark; Scrandis, Debra (2020)
    BACKGROUND: Compassion is a core attribute of nursing practice and is associated with improved patient satisfaction and outcomes. For the last several decades, nurse researchers have been focused on the concept of compassion fatigue. Only recently has compassion appeared in nursing literature. Therefore, the purpose of this study was to explore the experiences and expressions of compassion among critical care nurses. METHODS: This dissertation includes a literature review of compassion within nursing education and practice, how it is currently defined, and a review of the empirical data. Next, two interpretative phenomenological qualitative studies were conducted. One study explored the experiences of compassion among experienced critical care nurses recognized as being highly compassionate. In the second study, leaders who had identified the compassionate nurses addressed how compassion is expressed. RESULTS: The review of the literature determined that the concept of compassion is not consistently operationalized in nursing practice. The qualitative study of the experiences of compassion revealed that these critical care nurses are motivated to connect emotionally with their patients. These meaningful connections facilitate an understanding of the patient’s circumstances which enables the nurse to identify how to best provide compassion. Three themes emerged from their experiences: presence, actions and being genuine. Additionally, the nurses obtain a deep sense of satisfaction and joy from this care that is self-sustaining. In the second study it was found that the compassionate nurses are recognized for prioritizing patient care over tasks and were able to balance the emotional and physical care of their patients. Expressions of compassion were actions that humanized the patient experience and being present with patients ANALYSIS: By exploring both the personal experiences, observations of what compassion means and how it is expressed we have a deeper insight into how compassion is operationalized in critical care settings. CONCLUSION: This study validated similar findings from previous studies that sought to define and operationalize compassion in nursing. The two studies revealed that compassionate nurses are sustained by their resilience, and deep meaningful relationships with patients and families.
  • The Use of Naltrexone Among Young Adults with Opioid Use Disorder

    Rozenberg, Ilya; Storr, Carla L. (2020)
    Background: The rapid growth of opioid addiction carries catastrophic consequences for the young generation affecting families and society at large. To address problems of compliance and retention in treatment, new, innovative approaches synthesizing available interdisciplinary models with both medical and psychosocial approaches adapted to the user’s environment are necessary. Purpose: This dissertation explored the evidence in literature on the use of naltrexone (XR-NTX) in adolescents and young adults. It also examined relationships between retention in treatment and 1) family engagement, 2) assertive community outreach and 3) use of other substances in a sample of youth being treated for opioid use disorders (OUD). Methods: A scoping literature review provided a synthesis of the current state of evidence on safety and efficacy of XR-NTX use in treating youth with OUD and alcohol use disorders. Relationships between retention in treatment and family engagement, assertive outreach, and comorbid substance use were explored using data from a retrospective chart review of 41 young adults (16-26 years of age) who participated in a randomized open-label pilot study of OUD treatment at a community-based substance use disorder treatment program. Results: Family sessions contributed to increased retention in treatment, evidenced by the increase in number of injections. More frequent communication resulted in a higher number of received injections. There is a positive correlation between number of family sessions and number of doses. The total number of significant other contacts does not have a significant effect on the number of injections while the total number of patient contacts was significant. The study showed that most young adults seeking treatment for opioid use disorder are also using other substances and that the longer they stay in treatment, the greater the chance of decreasing use of other drugs. The review of 13 studies with 462 young adults found that Naltrexone is effective in improving treatment retention, extending abstinence, and preventing relapses in adolescents and young adults with OUD. Conclusion: Family support and ongoing communications could result in increasing retention in treatment. The study allowed for a better understanding of the relationship between treatment of opioid use and use of other substances.
  • Psychosocial Care Needs of Children with Cancer and Their Families: Perceptions and Experiences of Omani Oncologists and Nurses

    Al Balushi, Amal Juma; Johantgen, Mary E.; Mooney-Doyle, Kim (2019)
    Background: Much evidence demonstrates the psychosocial impact of childhood cancer on children and their families. While many health care systems are evolving to integrate psychosocial services into clinical care, barriers exist that must be understood before changes can be implemented in systems new to this care. Oncologists and nurses are on the front lines of care and have unique perspectives about the needs of their patients and families. Objectives: The purposes of this study were: 1) describe the experiences and perceptions of pediatric oncology physicians and nurses in Oman regarding the psychosocial care needs of children with cancer and their families; and 2) describe the barriers and facilitators to providing psychosocial care. Methods: A qualitative, phenomenological study was conducted. Purposive sampling strategy was used to recruit 26 oncologists and nurses with experience caring for children with cancer and their families. Individual, semi-structured interviews were conducted and recorded. Colaizzi's method of data analysis was utilized to inductively determine themes, clusters, and categories. Data saturation was achieved, and methodical rigor was established. Result: Four themes emerged from the data. The first was “perceived need for care beyond medicine.” The oncologists and nurses recognized that more psychosocial assessment, care, and services were needed. The second theme was “recognition of pediatric oncology as a challenging clinical practice area,” which had two subthemes: emotional burden and challenging situations. Participants described the challenges they faced trying to meet the needs of children and extended families. The third theme was “barriers to providing effective psychosocial care,” which had three subthemes: barriers related to the health care system, barriers related to health care providers, and barriers related to infrastructure and environment. The fourth theme was “providing optimal supportive care within the available facilities,” which had two subthemes: supportive care and facilitating factors. Cultural and community factors were highlighted. Conclusion: As the pediatric oncology services in Oman mature, clinicians are eager to develop the psychosocial assessments and needed services. Future research is needed to elicit the perspectives of Omani children with cancer and their families. Resources will be needed from higher authorities to design, implement, and evaluate the recommended changes.
  • Caregiver Distress and Burden and Patient Distress Across the Outpatient Peri-Allogenic Bone Marrow Transplantation Period

    Caves, Meredid Soto; Storr, Carla L. (2019)
    Background: Outpatient allogenic bone marrow transplants (alloBMT) are feasible due to improved vigilance and decreased transplant-related toxicities. The outpatient setting compels caregivers to fulfill non-physician roles. Few studies have examined the relationship between caregiver distress and burden and how they are manifested in the context of outpatient alloBMT; there is also scarce information on how distress manifests itself within the patient/caregiver dyad when faced with a life-threatening treatment. Purpose: Aim 1 examined the trajectory and association of caregiver distress and burden, and the movement of caregivers between caregiving states longitudinally. Aim 2 examined the distress trajectory of patients and caregivers, and assessed how they moved between low/high distressed states both individually and as a dyad. Aim 3 explored the possible association between absolute neutrophil count (ANC) and patient distress. Methods: This observational longitudinal repeated-measures study recruited patients and caregivers undergoing outpatient alloBMT. Surveys were administered at 3 time-points: infusion of donated bone marrow (T0), ANC recovery (T1), and discharge (T2). Caregivers were asked to respond to distress and burden questions using the Distress Thermometer (DT) and Caregiver Burden Scale, which measured objective and subjective demand, and subjective stress burden. Patients completed the DT surveys. ANC values for patients were extracted through medical chart review at the same time surveys were completed. Results: Caregiver distress and subjective stress burden were associated at all time points. Increase in burden leads to increase in distress. For patients and caregivers, distress was the highest at baseline and improved over time. As a dyad, the transition between high/low distressed states was ever-changing, demonstrating the dynamic nature of the alloBMT process. No significant differences were found in the distress scores of patients and caregivers, but there was a difference in distress scores along the alloBMT period, suggesting a temporal effect. ANC and patient symptomology were not consistently associated with patient distress. Conclusion: Caregiver distress and burden are related throughout the duration of the alloBMT period. As the dyad moves through the alloBMT period, they display the mutuality of distress, influencing each other as they face this difficult but life-saving journey together.
  • Humor & Opioid Recovery

    Canha, Benjamin; Scrandis, Debra (2019)
    Abstract Background: The prevalence and mortality rates of opioid use disorders (OUD) have drastically increased in recent years in the United States. Narcotics Anonymous (N.A.) is a successful behavioral program supporting recovery for individuals with OUD. Humor may play an important role in maintaining group involvement and continuing support within the culture of the N.A. program. Purpose: The purpose of this study was to understand the ideas, beliefs, attitudes and behaviors of humor in individuals recovering from OUD who are participating in the N.A. program. Design: Qualitative ethnography design was used with three types of complementary data collection methods: observations at meetings and social gatherings, personal interviews, and a focus group session. Results: Instances of humor between N.A. members were noted in observations. Recorded one-on-one interviews with ten members recovering from OUD provided details of various experiences of humor and led to development of five essential themes: Feels Good, Social, Lighten Up, Healing and Alienate. These findings highlight the mostly positive personal and social benefits participants experienced, as well as possible negative effects. A focus group of seven N.A. members provided interactive discussion of humor and discussed the need to become more conscientious of the detrimental effects of humor. Conclusion: The implications of this study suggest the need to explore various humor interventions to assess their relative effectiveness in enhancing recovering, and reducing relapses. Due to the small number of participants, results may not be generalizable to all those with OUD in N.A. or represent the possibly wide range of N.A. meetings. This study added to the depth of knowledge about the effects of humor on this population and their recovery process. The importance of humor and having fun in the recovery of OUD should be more widely recognized by nurses as they help those with OUD, as humor definitely has a role to play in supporting N.A. members’ recovery from OUD.
  • Prescription Medication Adherence among Socioeconomically Diverse Black Men

    DeVance-Wilson, Crystal Lynn; Storr, Carla L. (2019)
    Abstract Background: Non-adherence to prescription medications may at least partially explain high rates of morbidity and mortality from chronic illness among Black men. Black men from lower socioeconomic backgrounds have previously been identified as low adherers but little is known about Black men with adequate incomes and access to healthcare resources. The Ecological Model is used as a framework to examine barriers and facilitators of medication adherence among Black men. Purpose: The purpose of this study is to estimate the prevalence and identify barriers and facilitators to medication adherence among a socioeconomically diverse group of Black men with a range of chronic illnesses. Methods: A cross-sectional study using a 105 item anonymous survey questionnaire was conducted. A convenience sample of 276 Black men (age 35-75 years) was recruited from 15 churches in Baltimore City, and Baltimore, Montgomery and Prince George’s counties. Mann-Whitney U, Kruskall-Wallis and Chi-square analysis were used to examine group differences and multinomial logistic regression provided odds ratio estimates of the association between various factors and low (reference), medium and high medication adherence. Results: Half the sample (49%) were low adherers. Socioeconomic differences in medication adherence were identified by homeownership (X2 = 6.327, p = .042). No statistically significant differences were found for education, employment, income and health insurance coverage. Personal and interpersonal factors found to be associated with medium adherence were coping (AOR=.91, 95% CI=.84-.99), self-efficacy (AOR=6.74, 95% CI=2.79-16.27), income – (low - AOR=10.94, 95% CI=2.42-49.51, middle –AOR=3.34, 95% CI=1.38-8.10), marriage or having a significant other (AOR=5.40, 95% CI=1.83-15.92) and homeownership (AOR=3.37, 95% CI=1.04-10.92). Personal and interpersonal factors found to be associated with high adherence were self-efficacy (AOR=6.63, 95% CI=1.89-23.27), homeownership (AOR=9.32, 95% CI=1.41-61.60), income (low - AOR=8.55, 95% CI=1.31-55.68) and not sharing information with others (AOR=2.89, 95% CI=1.17-7.13). No associations were identified for community, organizational or government/policy level factors. Conclusions: Higher self-efficacy, homeownership and marital status were facilitators and higher coping, higher income and some forms of social support were barriers to medication adherence. This study illuminates opportunities for improving prescription medication education and implementing practice innovations to increase rates of adherence among Black men across the socioeconomic spectrum.
  • Participation and Effectiveness of Worksite Health Promotion Program

    Han, Myeunghee; Doran, Kelly; Storr, Carla L. (2019)
    Background: Worksite Health Promotion Programs (WHPPs) are limited by low participation and engagement. However, little is known about what factors influence participation and the relationship between participation and changes in body weight and composition. Mobile health technology (mHealth) may facilitate participation and engagement in WHPPs as mhealth is not limited by time or location, which are known barriers to participation and engagement. Yet, few studies have examined the use and effectiveness of WHPPs using mHealth interventions that aimed to change body weight and composition. Purpose: To explore the features and effectiveness of WHPPs in previous studies that used mHealth interventions. To identify factors influencing participation and engagement in a WHPP and the relationship between participation and changes in body weight and composition. Methods: A systematic literature review was conducted to explore features of WHPPs using mHealth that aimed to change body weight and composition. A secondary data analysis was conducted using data obtained from participants in the intervention group of a WHPP to identify: 1) factors that influence participation and engagement and 2) the relationship between participation and body weight and composition changes. Results: From the systematic review, 10 out of 12 WHPP studies using mHealth significantly improved body weight and composition. The most commonly used mHealth interventions were providing information, goal setting, and data entry. Based on the secondary data analysis, low levels of stress, anxiety, or high job satisfaction were significantly related to high participation in a WHPP. Significant relationships between participation and body weight and composition changes were not found due to a small sample size. However, this study found that those who reduced five pounds of body weight at six months among overweight or obese participants showed high participation in physical activity and/or diet components of a WHPP. Conclusions: WHPPs using mHealth can significantly improve body weight and composition. Employees’ psychological factors should be considered to increase participation in WHPPs. Further studies with larger sample size are needed to identify the relationship between participation and changes in body weight or body composition.
  • Neonatal Nurses' Work in a Single Family Room NICU

    Doede, Megan; Trinkoff, Alison M. (2019)
    Background: In the past twenty years, neonatal intensive care units (NICUs) have undergone changes in layout from open-bay (OPBY) to single family room (SFR). SFR layout may be advantageous to nurses’ work in that it improves the quality of the physical environment, patient care, and parent-nurse interactions. SFR layout may disadvantage nurses’ work in terms of decreased interaction among the NICU patient care team, increased nurse workload, and decreased visibility on the unit. It is unclear exactly how SFR layout is producing these changes. Purpose: This study asked: what is it like for neonatal nurses to work in a SFR NICU? Methods: Interpretive description, a qualitative methodology, guided this study. Interviews and observations were conducted in one SFR NICU over a six-month period. Data were coded broadly, then collapsed into themes as patterns within the data emerged. The Systems Engineering Initiative for Patient Safety model aided interpretation of nurses’ job demands. Emotional work was conceptualized as being preceded by emotional demands and anteceded by stress and burnout. Results: A total of 15 nurses participated. Overall, privacy, visibility, and proximity were integral in shaping nurses’ work. Regarding job demands, four themes emerged: challenges in infant surveillance and informal communication, alarm fatigue, and increased walking distances. Regarding emotional work, four themes emerged: families “living on the unit,” isolation of infants, ability to form trust and bonds, and sheltering. Emotional demands increased when families were living on the unit or when infants were left in isolation but were absent when nurses were able to form trusting relationships with parents and shelter them. Privacy gains on SFR NICUs may serve to balance losses in visibility and proximity for nurses. Conclusions: NICU layout impacts nurses’ job demands and emotional work. Future research should investigate unit layouts that maximize visibility and proximity for nurses while maintaining privacy. Neonatal clinicians transitioning to SFR layout should consider overall visibility and proximity of patients, equipment, and staff members from any point on the unit as a primary avenue for decreasing nurses’ work demands. Neonatal nurses will benefit from tactics that improve their communication skills with families.
  • Examining Dietary Patterns and Relationship to Caloric Intake in a Sample of Youth with Antipsychotic Induced Weight Gain

    Bussell, Kristin Lynn; Scrandis, Debra; Friedmann, Erika; 0000-0002-3128-0178 (2019)
    ABSTRACT BACKGROUND: Antipsychotic medication (APM) treatment has risen dramatically over the past 15 years in children/adolescents with serious mental illness, increasing risk for serious cardiometabolic sides effects such as rapid weight gain, increased lipids/triglycerides, reduced insulin sensitivity and hyperglycemia. Given the long-term nature of childhood onset mental illness these youths are at considerable high risk for early onset diabetes, cardiovascular disease, chronic morbidity and shortened lifespan. Although clinical practice guidelines for assessment/monitoring have been established none have been developed for dietary assessment/interventions in weight management. Studies examining APM effects eating behaviors and nutritional composition/adequacy are lacking. METHODS: This dissertation includes a literature review related to weight loss strategies in youth treated with APM. Next a secondary analysis of dietary data collected from 117 overweight/obese youth treated with APM was conducted to examine baseline dietary status and change over 6 months after 8 session of healthy lifestyle education. Lastly, qualitative data collected from the parent/child regarding facilitators/barriers to healthy eating was analyzed. RESULTS: Literature review found primarily intervention studies with metformin, which was moderately effective, but without examining diet/exercise. Several dietary/exercise studies reported decreased weight/BMI but did not report dietary intake. Analysis in this study found excess consumption of carbohydrates, protein, fat and total/added sugar while deficient in fruits, vegetables, whole grains, fiber and water when compared to the USDA recommended daily allowance. Change in dietary intake over 6 months found significant decreases in calories, carbohydrates, protein, total/saturated/solid fat, total/added sugar, refined grains, total dairy and cheese with small increases in whole fruit, total vegetables and dark green/orange vegetables, although not statistically significant. Qualitative responses from youths/parents on barriers/facilitators to healthy eating identified barriers as excessive appetite/cravings for sweets, junk food in the home, fast food, disliking fruits/vegetables, and lack of meal planning and food shopping/preparation. Facilitators included encouragement from family, removing junk foods, eating home more, making healthy foods tasteful and including the child in meal planning. CONCLUSIONS: This study provides new information which contributes to understanding dietary intake/eating behaviors in youth treated with APM. Findings suggest a possible influence of a simple dietary intervention on changes in food intake.
  • Smoking Cessation Among People With Severe Mental Illness

    Alghzawi, Hamzah Mohammad; Storr, Carla L. (2019)
    Introduction: People living with mental illnesses have a high rate of smoking and make up over half of those dependent on nicotine. A considerable body of research has shown that social support, stressful life events (SLE), receiving help for tobacco/nicotine use, intention to quit, and smoking use-related factors are associated with smoking cessation in the general population. Yet, little is known about these factors among people with severe mental illness (SMI). Purpose: This study aims to: 1) examine gender differences in the interrelations among social support, SLEs, and smoking cessation, 2) estimate the probability of remission from NUD by type of help/services received for tobacco/nicotine use (pharmacological, non-pharmacological, and both), and 3) estimate gender and racial/ethnic differences in the probability of smoking cessation among those with a history of intention to quit. Methods: A sample of 4610 people with SMI and a history of tobacco/nicotine use were identified in a public limited dataset of the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC-III). Four mediation and moderated mediation models were used in the first manuscript, whereas survival analyses were used in the second and third manuscripts. All analyses took into account the complex sampling design and controlled for possible confounders (i.e. sociodemographic characteristics) and covariates (i.e. comorbidity with another mental illness). Results: Total, appraisal, and tangible support in females exerted indirect effects on improving smoking cessation via decreased SLEs (total=.0094, appraisal=.0229, tangible=.0298; p<.05). The probability of remission from NUD was higher among those who received non-pharmacological services (28.5%, HR=1.95, p<.05) or those who received both services (19.6%, HR=1.52, p<.05) compared to those who only had pharmacological services (17.6%). Among those with a history of intention to quit, 31.7% had stopped. The probability of smoking cessation was highest for Hispanic females (HR=2.07, p<.05), non-Hispanic other females (HR=1.59, p<.05), non-Hispanic other males (HR=1.45, p<.05), Hispanic males (HR=1.40, p<.05), and non-Hispanic Black females (HR=1.35, p<.05) compared to non-Hispanic Black males. Conclusion: A greater understanding of subgroup differences and the correlates of smoking cessation among tobacco/nicotine users with SMI can enhance efforts to design and implement smoking cessation programs for people with SMI.
  • Substance Use Disorders during Pregnancy: Comprehensive Care and Predictors of Delivery Outcomes

    Seger, Celeste Marie; Storr, Carla L. (2019)
    Introduction: Illicit substance use is increasing among pregnant women seeking treatment for substance use disorders. Resources are scarce for this vulnerable population in terms of addressing their complex needs. Comprehensive care programs offering perinatal care services and substance abuse treatment in a single location have been found to favorably treat pregnant clients and positively affect neonatal and maternal delivery outcomes. Purpose: To review comprehensive care program studies, evaluate research quality, and examine outcome criteria. Also, to examine the impact of pregnant women’s comprehensive care attendance and pre-treatment psychiatric severity on neonatal and maternal delivery outcomes. Methods: A systematic literature review was conducted on treatment programs offering a so called “one-stop” comprehensive care approach. A secondary analysis study was employed to examine the effects of treatment attendance on neonatal and maternal delivery outcomes for pregnant women with substance use disorders receiving comprehensive care. A subsequent secondary analysis study was completed to determine the relationship between pre-treatment psychiatric severity and delivery outcomes for pregnant clients with substance use disorders in a comprehensive program. Results: The literature review identified thirteen comprehensive care studies, most of which used an observational design. Overall study quality was assessed as moderate for reporting and strength of evidence. Outcome criteria measures often included neonatal parameters such as weight, estimated gestation age, neonatal abstinence syndrome, and hospital length of stay, and maternal delivery outcomes frequently included urine toxicology screens on delivery and hospital length of stay. The first data analysis indicated comprehensive care attendance was favorably related to most neonatal and maternal delivery outcomes. The second data analysis showed similar neonatal and maternal outcomes regardless of psychiatric severity grouping, suggesting comprehensive care as an effective treatment for those with high levels of psychiatric symptomology. Conclusion: Results across all three manuscripts illustrate comprehensive care models as a favorable treatment approach for pregnant women with substance use disorders.
  • A Comparative Study of Preventive Healthcare Behaviors Among African Immigrant Women (AIW) and African American Women (AAW): Barriers and Facilitators of Cervical Cancer Prevention

    Kuffour-Manu, Vera Akosua; Ogbolu, Yolanda; Johantgen, Mary E. (2018)
    Abstract Background: Early screening, detection, and treatment of cervical pre-cancerous cells could prevent up to 80% of cervical cancers and reduce cervical cancer mortality by 52% globally. In the United States cervical cancer incidence has decreased by as much as 50% over the past 40 years due to widespread utilization of preventive health services. Yet, health disparities in cervical cancer persist among African immigrant women (AIW) and African American women (AAW) in the US. There is limited research exploring the barriers and facilitators of preventive health services for AIW and AAW. Purpose: To explore perceived barriers and facilitators, and lived experiences of AIW and AAW related to cervical cancer prevention services. Methods: A qualitative study included 14 AIW and 14 AAW, residing in the Washington, DC-Baltimore Metropolitan area. Purposive sampling technique was used to recruit participants from churches,community center, grocery stores and a radio station. A semi-structured interview guide and a demographic questionnare were used for data collection. Data were analyzed using the Intepretative Phenomenological Analysis Method. Nvivo software was used to organize and code the data. Results: The mean age of participants was 41.1(11.9), with most of the women being college educated (93%), with health insurance (96%) that paid for cervical cancer prevention (89%). Many (79%) had not received HPV vaccine and 82% had a pap smear within 1-4years. AIW and AAW data were triangulated and revealed few differences between the groups. Six broad themes emerged grounded in the Health Belief Model. Barriers identified included limited knowledge and awareness of HPV infection, risk, and vaccines; myths related to abstinence, fear, and cleanliness of healthcare facilities; lack of trust and reliance on God for healing. Facilitators included the need to feel safe and healthy; prevent and treat disease; utilize informal and formal support systems; and receive recommendation from providers and public health education related to preventive services. Conclusion: Study findings can be used to mitigate barriers and enhance facilitators to develop culturally tailored interventions for AAW and AIW. The active engagement of health providers, the community and faith based partners can be leveraged to strengthen the development of prevention research.
  • Firearm Injuries in Maryland, 2005-2014: Trends, Recidivism, and Costs

    THURMAN, PAUL; Johantgen, Mary E.; 0000-00022134-8415 (2018)
    Background: Violent injuries related to firearms are common in the U.S., whether accidental or intentional. Restrictions on use of Federal dollars for research on injury prevention involving firearms has limited our knowledge of how firearm injury impacts the health care system. The objectives of this study are to characterize firearm injuries (FI) in Maryland, quantify recidivism, and to describe hospital treatment and their associated costs for Maryland. Methods: ED and inpatient hospital records utilizing E codes consistent with FI were linked across visits to create unique cases from 2005-2014. Recidivism was defined as any subsequent ED visit or hospitalization for FI. The relationship of social determinants of health derived from US Census data to the rate of FI hospitalization by zip code were examined with generalized linear models, as were FI associated hospital costs. Results: Those with a FI are primarily single young black males, with overall hospitalizations decreasing over the time period. While 9% died in their initial FI, recidivism occurred in 3% of the individuals. Personal Disadvantaged (IRR = 1.13) and Working Disadvantaged (IRR = 1.04) factors were associated with increased rates of FI within zip codes. Hospital costs were significantly predicted by being self-pay/charitable and injury severity, with estimated mean costs for one FI of $47,364. In 2013, FI hospitalizations totaled $14m, of which 25% (n=129) accounted for over $10m. Discussion and Implications: FI hospitalizations are decreasing and are increasingly linked to social determinants of health, which require multifaceted interventions with short term goals of interrupting ongoing violence and long-term goals of preventing future violence. The states are absorbing much of the health cost burden. Further research is needed, which should include developing a registry linking hospitalizations, deaths, and crime data that can be used to evaluate trends and effectiveness of interventions.
  • Neuroimaging in Headache Patients: The Sensitivity of Computerized Tomography (CT) in Missed Stroke Diagnoses

    Heetderks, Elizabeth; Johantgen, Mary E. (2018)
    Background: Stroke is the leading cause of disability in the US, costing $34 billion a year and affecting 800,000 patients. Early detection and treatment is the best way to improve outcomes. Yet, 12.5% of strokes are discharged from the ED within the prior 30 days, with headache the most common diagnosis. Neuroimaging, ideally, would catch an impending stroke, but head CT has variable sensitivity based on onset of symptoms and there are both Federal and provider-led (including Choosing Wisely and the American College of Radiology Appropriateness Criteria (ACR-AC) initiatives to reduce overuse of imaging. Purpose: This study examined variation in ED treatment for patients presenting with a headache, particularly focusing on use of neuroimaging. Potential missed strokes were identified to determine if CT or MRI could have captured stroke. Methods: Using HCUP 2013 Maryland State Emergency Department Dataset, and State Inpatient Data, patients who were seen in the ED within 30 days of a stroke with a complaint of headache were identified. Generalized linear mixed modeling determined if neuroimaging predicted stroke bounce back while controlling for patient and hospital variables. Results: Of the 63,942 headache visits in Maryland EDs, 337 patients presented with a stroke within 30 days of ED discharge. Half (54%) were seen in the ED the day of their stroke and 72% were seen within 7 days. A large majority of the stroke patients (82%) underwent CT for their ED headache visit. Patients who underwent CT for their headache were 2.5 times more likely to return with ischemic stroke, and 7.7 times more likely to return with hemorrhagic. Patients who underwent MRI were 1.7 times more likely to return with any stroke, and 2.8 times more likely to return with ischemic stroke. Conclusions: Providers were concerned about pathology, given the large percentage of patients imaged; however, imaging did not catch active ischemia or bleeding. The negative predictive value of imaging for headache may need to be reconsidered. Patients with high suspicion of pathology should be placed in observation and have appropriate follow up testing. The ACR-AC should be incorporated into diagnostic pathways to optimize use.
  • Steps Towards an Intervention: Exploring Correlates and Measurement of Fatigue in Osteoarthritis

    Hackney, Alisha Jean; Klinedinst, N. Jennifer; 0000-0002-0928-0366 (2018)
    Background: Fatigue affects up to 90% of adults with osteoarthritis and contributes to disability and reduced quality of life. Treatment options are non-specific and limited to self-management. These limitations are due to least two gaps in current research: the lack of a standardized, reliable, and valid fatigue measure, and the lack of mechanistic insight. Purpose: To begin to address these limitations, the purposes of this three-manuscript dissertation were: 1) to examine standardized, valid, and reliable measures of osteoarthritis fatigue and 2) to explore correlates of fatigue to provide mechanistic insight. Methods: The first manuscript is a narrative literature review of osteoarthritis fatigue correlates. The second and third manuscripts analyze data from cross-sectional, retrospective studies. Analyzing pilot study data in SPSS and WINSTEPS, the second manuscript examines psychometrics of the standardized PROMIS Fatigue Short Forms 8a and 7a in osteoarthritis. The third manuscript uses data from the 2007-2010 National Health and Nutrition Examination Survey (NHANES) to examine fatigue correlates. Using SPSS complex samples analysis, adjusted logistic regression models were generated to predict odds of osteoarthritis fatigue as a function of a biological correlate (i.e., systemic inflammation: c-reactive protein [CRP] and white blood cell count [WBCC]). Results: Correlates of osteoarthritis fatigue include age, gender, medications, comorbidities, anxiety, depression, joint pain, physical activity, physical exercise, physical function, sleep quality, and systemic inflammation. The 8a and 7a were reliable (α =.86-.93) in adults with osteoarthritis. Differences existed in 8a, but not 7a, total scores, between adults with (N=20) and without osteoarthritis (t29=-2.8, p<.001; N=11). From the NHANES data, with every 1 mg/dL increase in CRP, adults with osteoarthritis had 3.19 times higher odds of fatigue (95% CI 1.11-9.19, p=.03) when controlling for age, pain, depression, sleep quantity, sleep disturbances, and body mass index. Conclusion: These findings have begun to fill the gaps that hindered development and testing of targeted interventions. Future research is necessary to gain more understanding of the use of the 7a and 8a in osteoarthritis and to delineate the relationship between other correlates, including additional systemic inflammatory markers, and fatigue in osteoarthritis. This will propel development and testing of targeted interventions.

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