The purpose of the research is to examine the family experience of dementia caregiving and design an educational intervention to assist family members in the caregiving role. Stress results when a caregiver confronts environmental demands (dementia behaviors) that threaten personal well-being. The perception of threat is the process of primary stress appraisal. Caregivers evaluate coping options, a process of secondary stress appraisal. Positive secondary appraisal (view the situation as amenable to change) has the potential to trigger re-appraisal of the primary threat, and to reduce overall stress. Education is one way to affect secondary appraisal. Adult learners benefit from progressive (problem solving) approaches using self-directed learning principles. With self-directed learning, the educator facilitates the learner’s access to the information. Distance education is a form of self-directed learning. Distance techniques include postal mail, facsimile, telephone, video, teleconferencing, satellite conferencing, and the Internet. The research question is: to what extent can distance education (by postal mail, passive Internet, and multimedia, interactive Internet) alter the primary and secondary stress appraisals of dementia caregivers? A total of 189 caregivers participated in the study. The study design, Switching Replications, includes three waves of measurement over a two month period. With the design, some participants receive the intervention upon entry into the study, while others wait until after the second wave of measurement. Three study hypotheses relate to the construct of primary appraisal and the dependent variable of threat perception. Analysis of Variance (ANOVA) results do not support hypotheses that posit the form of education affects threat perception. Four hypotheses address the construct of secondary appraisal and the dependent variable of home modifications. ANOVA results support hypotheses that posit the form of education affects home modifications. Active web education is statistically better than receiving no education or receiving information by postal mail. Assuming no cure or effective treatment, the number of people diagnosed with dementia will increase to 8.6 million by 2040 (General Accounting Office,1998). Despite the stress, families are and will likely remain the primary caregivers. Distance education merits further study as a way to reach and help family caregivers.

Breast cancer is the second leading cause of cancer mortality in women in the United States. Because the majority of risk factors for breast cancer are not modifiable, early detection methods such as mammography are essential. However, concern exists for the equitable provision and use of mammography services in the U.S. Mammography is ofien underutilized by various subpopulations resulting, potentially, in these groups not experiencing the benefits of early detection. A subpopulation that has received little attention in the study of mammography utilization encompasses persons classified as disabled. The 1998 National Health Interview Survey provided the data for this analysis. A health services utilization model served as the conceptual framework and was adopted to analyze the multiple factors that influence mammography use, including factors such as the environment, population characteristics, health behaviors, and health outcomes. In this study, disability is defined as those women with any self reported limitations in activities of daily living, instrumental activities of daily living, cognition, or work, Results indicate that the mammography utilization rate for disabled women (n = 1,320) was 42.99%, and significantly lower than the rate of 57.37% for non disabled women (n = 4,733) (z = 646.83; p = .00). This finding was consistent across most study variables. Binary logistic regression results indicate that women with cognitive limitations were nearly half as likely than nondisabled women to utilize mammography (AOR = 0.66; 95% CI: 0.45, 0.97) afier controlling for other factors. In the logistic regression analysis, particular, population characteristics (i.e., age, race/ethnicity, education, and health insurance) and health behaviors (i.e., smoking status, clinical breast examination, and usual source of care) were shown to significantly influence mammography utilization. Results indicate that inequity in mammography utilization exists because disabled women’s utilization rates are lower than the rates for nondisabled women. Because disabled women, especially those cognitively impaired, used mammography at lower rates than non disabled women, disabled women may not realize the benefits of early detection of breast cancer. Furthermore, they may potentially experience both higher rates of undetected breast cancer and breast cancer mortality.

The metabolic syndrome, a clinical condition linked to diabetes and cardiovascular disease is a powerful predictor for overall mortality, and is present in more than 20% of the US. population (Ford, Giles, & Dietz, 2002). This study examines gender differences as well as other factors associated with metabolic syndrome as defined by the Adult Treatment Panel III of the National Cholesterol Education Program. A sample of 10,134 adults between 20-64 years of age was selected from the Third National Health and Nutrition Survey. Metabolic syndrome was present in 19.6 % of this sample. An ecological model of health services was used to analyze metabolic syndrome. The four model domains include population characteristics, environmental factors, health behaviors, and utilization of health care services. The descriptive results showed statistically significant differences in individuals with metabolic syndrome and without metabolic syndrome. Those with metabolic syndrome were proportionately more older, reported a past medical history of cardiovascular disease and family history of diabetes, had lower levels of education and a lower annual household income. There were no differences between men and women in age, geographic residence, education or health insurance coverage. However, there were higher proportions of women with metabolic syndrome in all race categories when compared to men with metabolic syndrome with the exception of Caucasians. A family history of diabetes, a family history of cardiovascular disease, a past personal history of cardiovascular disease, level of income, habitual activity and having a usual source of health care were found to be statistically significant between men and women with metabolic syndrome. Results of the logistic regression analysis revealed that overall, women were 30% less likely to have metabolic syndrome, yet African American women and Hispanic American women were nearly twice as likely to have metabolic syndrome than Caucasian women. Further research on gender differences for shared medical conditions is needed.

Objective: The primary objective of this research is to examine how changing levels of nursing home staffing adequacy and variations in rehabilitation orientation have affected facility deficiencies and the quality of patient care as facilities responded to the Balanced Budget Act of 1997.Data Sources: Analyses were performed using data from the On-Line Survey Certification and Reporting System (OSCAR) data from years 1997, 1998, 1999, 2000 and 2001 and were merged with Area Resource File (ARF) data released in February 2001.Study Design: Contingency strategic adaptation provides the theoretical framework for developing the effects of environmental characteristics, organizational characteristics and strategic change on nursing facilities’ performance. The study employed a non-experimental, longitudinal panel design focusing on the individual nursing home as the unit of analysis. Measurement models were proposed and validated for each of the research constructs. Structural equation modeling was used to specify the relationships between staffing adequacy, rehabilitation orientation and nursing home quality.Principal Findings: Decreases in staffing adequacy and rehabilitation orientation, and also in nursing home quality occurred during the period of 1997 to 2001. Environmental and organizational characteristics have various direct effects on staffing, rehabilitation orientation and nursing facility performance. Staffing directly affects rehabilitation orientation; rehabilitation orientation directly affects quality. The variances accounted for in the final structural model are small.Conclusion: Staffing and rehabilitation orientation are, respectively, structures and processes of care subject to strategic change within organizations in response to changing environmental conditions. Changes in staffing and rehabilitation that occurred during the period of implementation of the BBA of 1997 reduced nursing facility performance. The relatively small contribution of each to the measurement of nursing facility performance suggests that other structures and processes should be identified, and their impact on the quality of care evaluated.Keywords: Staffing, rehabilitation, nursing home deficiencies, strategic adaptation, Balanced Budget Act of 1997.

Finding and maintaining employment is an ongoing problem for persons with disabilities, especially those with brain injuries. State vocational rehabilitation agencies are the primary authority responsible for providing employment-related services for individuals with disabilities throughout the United States. Little effort has been committed to identifying disparities in health and rehabilitation services provided to Americans with disabilities, particularly those with brain injuries. The purpose of this investigation was to utilize Aday and Andersen's Framework for the Study of Access to examine racial disparity within the Rehabilitation Services Administration 911 Database, and thus the vocational rehabilitation system, among clients with brain injury. Upon review of the descriptive findings, Whites and Asian or Pacific Islanders were more likely to be accepted for rehabilitation than Blacks and American Indians or Alaskan Natives. Acceptance rates for males and females were similar. Clients, who received their primary source of support from “other” sources at the time of application, were least likely to be accepted for vocational rehabilitation. Hispanics appeared to have lower acceptance rates than non-Hispanics. Persons with greater than a high school education were more likely to be accepted for rehabilitation than persons with less education who had completed schooling through the regular education system. Exhaustive CHAID findings suggest that racial disparity in rehabilitation acceptance rates is not a clear cut issue. Each of the racial groups was more likely to be accepted for rehabilitation under different circumstances. Consequently, a definitive broadcast statement about racial disparity within the Federal Rehabilitation System cannot be made. With regard to reason for closure, although the Chi-square analyses for the current investigation were significant, the degree of association was extremely modest. There did not appear to be a practical difference between White and non-White clients with regard to reason for closure. Future research, and practice and policy implications are discussed.

In spite of a decrease globally, the maternal mortality rate (MMR) in Nigeria and its Jigawa State has remained persistently high. Few efforts to address the MMR in Nigeria have been undertaken. The purpose of this study was to investigate the impact of Jigawa State's Free Maternal and Child Health Program (JSFMCHP), education, employment, and parity of pregnant women on health care utilization (the outcome variable), as measured by antenatal care (ANC) visits. Anderson's behavioral model served as the study's theoretical framework. The sample size included 400 antenatal records of pregnant women who were randomly selected from the state's Health Management and Information data collected between 2011 and 2015. Chi-square tests showed a significant association between those who did not participate in the JSFMCHP, education, employment, with ANC. There was no association between parity and the number of ANC visits. The odds ratio suggested that pregnant women who did not participate in the program were 5.53 times as likely to have 4 or more visits compared to those who participated. Furthermore, the recommended number (4 or more) of ANC visits was predicted by tertiary education and employment. This study's findings indicate the need for a reevaluation of JSFMCHP policy, with a focus on ensuring a minimum recommended number of ANC visits for all program participants. These results can influence positive social change if used by policy makers to strengthen policies that have a beneficial impact on maternal morbidity and mortality in Jigawa State, in particular, and Nigeria, in general.

Polypharmacy, a concurrent chronic use of multiple prescribed and over-the-counter medications by the same individual, is one of the clinical problems facing primary care providers. Polypharmacy creates the potential for adverse drug-related events, especially in the elderly. The advent of electronic medical records (EMR) may help identify and respond to these potential adverse events. The purpose of this project was to investigate the relationship between the total number of medication taken by elderly, 65 years and older, and the severity of drug-drug and drug-disease interactions triggered by the EMR system. The study used a retrospective chart review of the EMRs. Three independent variables (age, gender, and number of medications) and 4 dependent variables (major drug-drug, moderate drug-drug, major drug-drug, and moderate drug-drug interactions) were analyzed among a sample of 247 individuals, ranging in age from 65 to 98 years. The total number of medications used among this sample ranged from 2 to 27 medications, with 177 (71.7%) patients using 2 to 9 medications, and 70 (28.3%) using 10 or more medications. Correlational analysis showed a positive relationship between number of medication and major drug-drug, moderate drug-drug, major drug-disease, and moderate drug-disease interactions (r = 0.240, p = 0.0001; r = .596, p = 0.0001; r = 464, p =0.0001; r = 669, p = 0.0001, respectively). However, there was no significant relationship between age and major and moderate drug-drug and drug disease interactions. The results of this study contribute to positive social change by increasing primary care providers' understanding of the EMR as a tool to improve the identification and management of patients with polypharmacy.

Researchers have identified adult children of alcoholics (ACOAs) as being susceptible to substance abuse, intimate partner violence, mental health instability, and a myriad of psychosocial inadequacies. Growing up within an adverse childhood environment has also imprinted an unwanted stigma among ACOAs. Although there are many studies on the ACOA population, there is a significant gap in the literature between ACOAs exhibiting resilience and those who succumb to the negative characteristics of growing up within an adverse environment. The purpose of this hermeneutic, phenomenological study was to examine the lived experiences of adult children of alcoholics who have succeeded despite their upbringing. A purposive sample of 11 participants from the northwestern United States were interviewed regarding their childhood experiences. The overarching research question was focused on how resilience has affected their life, and the secondary research question addressed perspectives regarding positive adaptation and the stigma of familial alcoholism. The theoretical frameworks that provided support included the health belief model as well as the social cognitive theory, and hermeneutic phenomenological study helped identify and construct the essence of the phenomenon from in-depth interviews from participants. Common themes (perseverance, positivity, and determination) were identified and categorized for ease of analysis. The results contribute to positive social change by helping health care providers in delivering valuable, pertinent assistance to those ACOAs who continue to struggle for a better quality of life.

Depression negatively impacts the American economy, and there is a shortage of physicians to provide treatment. Nurse practitioners are viable alternatives to provide high-quality treatment of depression. The project's purpose was to describe nurse practitioners' attitudes toward nonpharmacological interventions to treat clinical depression. Attitude theory provided the theoretical framework. The American Psychiatric Association's guidelines for treating major depression provided the conceptual framework. The project used a quantitative nonexperimental descriptive survey research design. A purposeful sample of 63 nurse practitioners was obtained from members of the American Association of Nurse Practitioners. Data were collected through an online survey that included questions about participant demographics, attitudes about depression treatment modalities, and experience with individual and group psychotherapy in the treatment of depression. Frequencies and percentages were calculated for demographic information and information related to the use of individual and group therapy. Means and standard deviations were calculated for each of the Likert scale items. The findings showed that participants had more knowledge about medications used to treat depression and individual therapy than they did about group therapy. Findings showed that the participants believed that medication combined with individual therapy was the most effective treatment for individuals diagnosed with depression. Barriers to using group therapy were identified. These findings provided information to nurse practitioners about preferred treatment modalities for depression and the barriers to using group therapy to treat depression.

Brand-name drug costs continue to create a burden for many US seniors who receive care from healthcare institutions. Generic medication is as therapeutic as is brand-name drugs and, in most cases, costs far less. Despite this cost difference, physicians continue to prescribe brand-name drugs. The purpose of this cross-sectional study was to explore physicians' patterns of prescribing brand-name drugs over generic drugs. This study was guided by the medical home model, which was developed in 1967 by the American Academy of Pediatrics. The study incorporated a purposeful sampling approach with a sample size of 151 physicians. Multiple linear regression was used to examine the associations between cost of treatment using generic medications and determinants of physicians' pattern of prescribing brand-name medications over generic medications. There were no statistically significant associations between physician belief of cost using generic medications and determinants of physicians' pattern of prescribing brand-name medications over generic medications, suggesting that physicians' prescription patterns are not solely determined by cost of the drug to the patients. The positive social change implication of this study is in the awareness that it generates among physicians, with evidence to suggest the need for more education on the utility of generic drugs instead of brand-name medications.