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When people are healthy, they are able to accomplish with relative ease what they set out to do, such as going to work, traveling, meeting with friends, and taking care of their personal necessities. However, once chronic illness becomes a factor in a person’s life, he or she is faced with limitations in the ability to perform daily activities, take care of health needs and participate in life activities. More effort is required for everyday activities, leading to abandonment of previously enjoyed routines and further declines in health and quality of life (Erlandsson, 2013a). In response to the complex, dynamic, and often unpredictable care requirements of individuals with one or more chronic conditions, newer primary care delivery models were developed to improve health management and reduce costs (Sevick et al., 2007). The expectation is that these interprofessional team–based models are the best way to address the needs of persons with multiple chronic conditions (Piette et al., 2011). However those charged with providing primary care based on these models have been unable to expand beyond disease-based episodic approaches and healthcare delivery is thus perceived as inadequate in fully serving this growing population (Fortin et al., 2013). The author developed and implemented occupation-based occupational therapy (OT) services and the VA Everyday Matters workshop to demonstrate that OT should be included as a vital component of a primary care effort aimed at meeting the complex needs of Veterans with chronic conditions. Health behavior theory and occupational therapy models informed the role of OT in primary care and the development of the workshop. The use of an occupation-based approach represents an innovative change in how health promotion is conceptualized and delivered in the traditional primary care setting. The immediate and long-term outcomes of this project will have important implications for occupational therapy practice and will contribute to a growing body of knowledge about the health promoting effects of occupation. Findings from the program evaluation will be disseminated throughout the VA and will inform the continued development of innovative ways occupational therapy and primary care can partner to optimize function and quality of life for at-risk Veteran populations.

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The purpose of this thesis was to determine the relationships between gender or sex with mobility in middle aged and older community-dwelling adults with chronic conditions. Study one was a systematic review of published literature on whether gender or sex predict mobility in middle aged and older adults with chronic conditions in community-dwelling setting. Study two was a secondary analysis study (data from a randomized controlled trial where there were no statistically significant differences between rehabilitation intervention group and control group) to determine whether age and sex predict self-reported and performance-based mobility-related outcomes in community-dwelling middle and older aged adults with chronic conditions. This relationship was also examined in the context of sociodemographic and comorbidity variables. The information gained from these studies could be used to inform and guide future research and prevention intervention programs for people with risk of mobility limitation. / Thesis / Master of Science (MSc)

Adults aged 50 years and older are a growing segment of the population and are more likely than their younger counterparts to experience significant stressors such as the death of a relative or friend, onset of chronic conditions, and increased health burden. The current studies use Pearlin's stress process model to evaluate the impact of these stressors on outcomes of depression. Study 1 used Wave 1 data from the ORANJ BOWL research panel of 5,688 New Jersey residents aged 50 and older to explore the relationship between relational life events, private religious practices, and depressed mood. Cross-sectional structural equation modeling was used to evaluate these relationships. Results showed that relational life events had a significant positive influence on depressive symptoms and this relationship was partially mediated by private religious practices. Findings indicate that non-personal life events are important sources of stress that may otherwise be overlooked when assessing risk factors among older adults. Study 2 used data from 640 men from the Research on Older Adults with HIV (ROAH) study to evaluate the impact of HIV-related health burden on depressed mood and to assess the mitigating effects of social support adequacy. Structural equation modeling showed that greater health burden was associated with more depressive symptoms; this relationship was significantly partially mediated by emotional support adequacy, which was a measure of unmet social need. Findings indicate that health burden has a cumulative impact on psychological health and programs and supports that target social wellness can improve this relationship. These studies point to the importance of understanding sources of risk and resilience among older people and in an attempt to improve overall health outcomes. / Ph. D. / Older adults constitute a growing portion of the population in the United States and around the world. Better understanding of challenges older adults face, including stressful life events and changes in health, could contribute to better outcomes in their later years. Two studies were designed to: (1) understand the relationship between events that affect one’s friends and family (i.e., relational life events) and feelings of depression, and explore whether religious expression is useful in reducing stress; and (2) evaluate the influence of health burden on feelings of depression in older adults with HIV and understand how social support can reduce stress from living with HIV. Data for this work come from the ORANJ BOWL research panel of interviews with 5,688 New Jersey adults and the Research on Older Adults with HIV (ROAH) study of 914 New York City residents aged 50 and older with HIV in 2005. Findings from the first study show that relational life events are associated with more depressive symptoms and more private religious expression. Thus, relational life events are an important risk factor to which family members and health service providers should pay attention. Findings from the second study demonstrate that more health difficulties in people with HIV is associated with more depressive symptoms. This is especially true when self-rated health is poorer and the number of overall chronic conditions are greater. Social support is an important resilience factor that lessens the influence of health burden on psychological health, so relatives and service providers should promote social wellness in addition to HIV treatment-specific interventions. Together, the results of these studies reveal numerous risk and resilience factors to consider when working to improve the lives of older people.

Bakgrund: Smärta är en multidimensionell och subjektiv upplevelse som kan drabba alla människor. Smärta är den vanligaste orsaken till uppsökande av sjukvård samt orsakande av funktionsnedsättningar och oförmåga att arbeta. Personer med långvarig smärta måste självständigt utföra en stor del av sin behandling och omvårdnad i form av egenvård. Det ingår i sjuksköterskans uppdrag att uppmuntra och stödja patienter till att utföra egenvård, dock finns ingen entydig definition av begreppet egenvård. Syfte: Att redogöra för hur personer med långvarig smärtproblematik beskriver egenvård. Metod: En litteraturöversikt baserad på tio vetenskapliga artiklar med kvalitativa och kvantitativa ansatser. Artiklarna togs fram via sökningar i databaserna CINAHL Complete och MEDLINE, och var publicerade mellan åren 2005-2015. Artiklarna har analyserats enligt Fribergs analysmetod. Resultat: Resultatet i litteraturöversikten presenterade att personer med långvarig smärta beskrev egenvård som multidimensionell. Egenvård ansågs bestå av personliga förmågor samt mentala och praktiska strategier. Personer med långvarig smärta ansåg även att utbildning och stöd ifrån hälso- och sjukvården var viktigt för utförandet av egenvård. Diskussion: Resultatet har diskuterats utifrån Dorothea Orems omvårdnadsteori om egenvårdsbalans samt vetenskapliga publiceringar. Egenvårdens innebörd för personer med långvarig smärta har jämförts med de olika definitioner av egenvård som tillämpas inom hälso- och sjukvården. Vidare har egenvårdsdefinitionernas betydelse för hälso- och sjukvårdens egenvårdsstödjande insatser diskuterats. / Background: Pain is a multidimensional and subjective experience that can affect anyone. Pain is the most common reason to seek medical care and is the main cause to disability and inability to work. People with chronic pain need to independently manage a large part of their treatment and care in the form of self-management. One part of the nursing role is to encourage and support patients to perform self-management, however there is no clear definition of the term self-management. Aim: To illustrate how people with chronic pain describes self-management. Method: The literature review was based on ten scientific articles, with qualitative and quantitative approaches. The articles were found through searches in the databases CINAHL Complete and MEDLINE, with publication between the years 2005-2015. The articles were analyzed using Fribergs method of analysis. Results: The literature review showed that people with chronic pain described that self-management was multidimensional. Self-management was considered to involve both personal abilities, mental and practical strategies. People with chronic pain also believed that education and support from healthcare was essential for self-management. Discussion: The result has been discussed against Dorothea Orems nursing theory about self-care and relevant scientific publications. The ​​meaning of self-management for people with chronic pain has been compared with various definitions of self-management that are applied in healthcare. Furthermore the definitions of self-management were put in relation to how the healthcare provide supporting self-management interventions.

The purpose of this study was to identify factors that predict quality of life (QOL) for aging adults and to examine and compare Baby Boomers', Older Adults' and Younger Adults' responses to the 2010 National Health Interview Survey/QOL Functioning and Disability. Significant findings included several significant values based on the multivariate regression to estimate a model to predict QOL. In particular, being male, four ethnicities other than white, being older than Boomer, age in 10 years, the Functional Difficulty Index, the Functional Limitation Index scores, chronic heart disease, asthma, and arthritis all had significant p values. Adults with chronic heart disease, asthma, or arthritis scored lower on the QOL index, but cancer, stroke, or diabetes were not associated with the QOL index. Two hypotheses had strong support. Lower scores on both the Functional Difficulty Index and the Functional Limitation Index yielded lower QOL scores. Further research recommendations include establishing reliability and validity of the QOL index; running additional regressions for demographics (ethnicity, marital status, etc.) to predict possible combinations of variables predicting QOL or barriers to QOL; and investigating the viability of incorporating the QOL index into an electronic medical record (EMR) dashboard parameter to serve as a screening mechanism for those aging adults most at risk for chronicities or co-morbidities that place them at risk for losing their ability to age in place in the home of their choosing.

A mensuração da Qualidade de Vida Relacionada à Saúde (QVRS) tem se tornado um componente integrado na avaliação clínica e também na avaliação de resultados de novos tratamentos, inclusive em crianças e adolescentes. Estudos sobre o processo de adaptação transcultural de instrumentos são importantes para a obtenção de medidas válidas e confiáveis. Este estudo metodológico, transversal, teve como objetivo descrever o processo de tradução, adaptação cultural e validação do instrumento DISABKIDS-37 para o Brasil, incluindo a análise de suas propriedades psicométricas iniciais. A pesquisa foi conduzida em ambulatórios pediátricos e a amostra incluiu 118 crianças e adolescentes com asma ou diabetes e seus pais ou cuidadores. Além do DISABKIDS-37 foram utilizados dois outros instrumentos, relativos à validação semântica. Os softwares Multitrait Analysis Program e Statistical Package for Social Sciences, 10.0 auxiliaram as análises, que revelaram valores para a estatística alfa de Cronbach de = 0,92 e = 0,93, para a versão crianças/adolescentes e pais/cuidadores, respectivamente. A análise das correlações entre itens e dimensões, mostrou validade convergente e discriminante satisfatórias. A versão adaptada do DISABKIDS 37 para a cultura brasileira pode constituir-se em instrumento válido e confiável para mensuração da Qualidade de Vida Relacionada à Saúde de crianças e adolescentes com condições crônicas. / The Quality of Life Related to Saúde (QVRS) has became a component in the clinical evaluation and also in the evaluation of results of new treatments, included children and adolescents. Studies about the process of cross-cultural adaptation of instruments are important for the obtain valid and confiable measures. This methodological study, cross-sectional, aims to analyse the translation, cultural adaptation and validation process of the DISABKIDS 37 and its beginnings psychometric analysis. The study was conducted in pediatric ambulatories in a sample of 118 children and adolescents with asthma or diabetes and their parents or carengivers. Another two instruments was utilized to analyze the semantic validation. The internal consistency of the DISABKIDS 37 was calculed using Cronbach´s alpha with the softwares Multitrait Analysis Program and Statistical Package for Social Sciences 10.0. For the overall score the values were = 0.92 for child version and = 0.93 for proxy version. The DISABKIDS 37 discriminates well chronic conditions. It distinguishes between differences in the impairment of health-related quality of life (HRQoL) in children with different chronic conditions. We believe that the finally versions of the DISABKIDS 37 for Brazil could be a useful tool for analyse HRQoL in children/adolescents with chronic conditions.

Care Coordination Home Telehealth (CCHT) maintains a positive impact on the delivery of patient care in the primary care clinic at the Department of Veterans Administration Medical Center (VAMC). This quality improvement initiative targets patients with chronic conditions such as diabetes, hypertension, heart failure, and chronic obstructive pulmonary disease. These patient are frequently seen in the emergency room, and are often admitted to the hospital, where they saturate the outpatient clinics' waiting room with multiple walk-ins. CCHT has, to some extent, reduced walk-ins, emergency room visits, and hospitalization while minimizing the strain on access to care at the VAMC. Sustaining self-management skills of veterans with chronic conditions at the VAMC continues to impose challenges. In this project, retrospective data from 95 randomly selected charts reviewed during a 2-year period were used to compare hospitalizations, emergency room visits, and primary care visits. The findings of the study indicate veterans enrolled in Home Telehealth show positive social change. The social change is evidenced by change in behavior patterns, such as maintaining a healthy diet, performing daily physical activity, and compliance with medication administration. Enrolled veterans had better outcomes regarding hospitalization, emergency room visits, and primary care visits. The data highlighted the need for incorporating disease-specific protocols guiding care coordinators at first point of contact with the veteran patient. Following these protocols may enhance communication style that matches the patient's stage of behavioral change with interventions.