This study focuses on the association between patient characteristics, which include both demographic and contextual factors, and patients' experiences with health care. The pre-existing literature provides rich information about patients' various demographics related to patient experience. Despite the abundance of empirical evidence showing that patients' demographics do affect how they perceive their health care. However, there is little to no empirical knowledge explaining the significance of such factors. As the existing literature points out the need for taking into contextual factors such as patient's beliefs, attitudes, skills that are pertinent to dealing with health care, my study proposes patient activation as such a contextual factor that explains the association between patient demographics and patient experience. Findings suggest that patient activation is a strong predictor of two patient experience measures: patients' rating of doctor-patient communication and their self-reported difficulties in getting needed care. However, it is also observed that the mediating effects of patient activation vary by the two dimensions of patient experiences. Though this study demonstrates that promoting patient activation may be able to normalize how patients report the quality of doctor-patient interaction, further research is needed to address access to care issues.

Health care reform has caused consumers to learn more about what it means to have health insurance and its costs. Patient engagement, a critical component of health care reform, reflects provider and consumer attention to shared decision making between patient and physician. The problem addressed in this study is that although researchers have studied patient engagement, there has been insufficient exploration of the relationship between financial literacy and patient engagement, which could negatively impact health outcomes not only for patients or consumers but for society as a whole. The purpose of this quantitative research was to determine if a relationship exists between patient financial literacy and patient engagement, as measured by the patient activation measure. The potential effects of increased patient financial responsibility due to high deductible health plans, measured via an item inquiring about participants' deductible, as well as shared decision making between physician and patient were also evaluated as potential moderators between financial literacy and patient engagement. Theories used to provide conceptual context include Shim's cultural health capital theory and Bourbeau's (2008) self-management model. Two hierarchical linear multiple regression models were used to test the research hypotheses. While the research did not find a significant relationship between patient financial literacy and patient engagement, it did confirm the importance of mental health status and patient-physician shared decision making as important predictors of patient engagement. These findings provide a better understanding of financial literacy and specific financial behaviors in the context of healthcare environment today.

Patient reported outcome (PRO) measurement of disability is integral to a patient-centered approach to health care and gauging the biopsychosocial impact of health conditions from the patient's perspective. This thesis investigates disability after proximal humerus, elbow and distal radius fractures; conditions that constitute a major burden in musculoskeletal health care and a substantial impact on health-related quality of life (HrQoL). Disability is defined by the World Health Organisation (WHO) International Classification of Disability, Functioning and Health (ICF) as ‘a multi-dimensional construct involving a dynamic interaction between impairment, activity limitations and participation restrictions, that are influenced by contextual factors'. This international, consensus-based framework acts as a guide for the application of outcome measures in performing scientific research. The WHO ICF also considers other patient perspectives on health and health care systems, including patient experience and patient activation within the contextual factors component. Patient experience encompasses aspects such as satisfaction, expectation management and confidence with care, and is measured using a variety of scales and questionnaires. Patient activation relates to 'the knowledge, skills and confidence a person has in managing their own health and health care'. This concept is quantified using patient activation measures (PAMs). The overarching goal of this thesis is to identify the most influential factors predicting disability after proximal humerus, elbow and distal radius fractures. This work also aimed to define the relationship between disability, experience and activation to inform the development of a patient-centred approach to managing these challenging injuries. The first systematic review highlights the dominance of psychosocial factors in influencing disability associated with a range of upper extremity conditions. Few studies have assessed this relationship in specific trauma populations. The second review underlines the paucity of upper extremity PRO measures incorporating fracture populations in their original development. It also reports the highly variable quality of initial studies introducing these measures. The final review demonstrates the superior measurement properties of computer adaptive tests (CATs), a contemporary form of PRO measurement, over fixed-scale instruments. Few studies apply CATs in trauma and few have been performed outside the U.S. These reviews collectively informed the selection of PRO measures for the experimental studies in this thesis. Firstly, a pilot study establishes a methodology for addressing the key objectives and the feasibility of using a web-based platform for measuring patient outcomes. Strong correlation between PROMIS Physical function CAT, a computer adaptive measure of physical function, and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), a region-specific, fixed scale is observed. The core experiment (n=734) expands upon this work and demonstrates correlations between a range of generic and region-specific measures in an upper extremity trauma population. Disability is shown to correlate with satisfaction, and the strength of this correlation increases over time. Applying PRO measures of disability in populations with shoulder, elbow and wrist fractures show that self-efficacy (i.e. coping ability) within 6 weeks of injury was the strongest predictor of medium-term disability at 6-9 months. In proximal humerus and elbow fractures, kinesiophobia (i.e. fear of movement) within a week of injury was also a strong predictor of disability. The final study concludes that greater patient activation is associated with greater health-related and experiential outcomes. However, psychosocial factors including self-efficacy, superseded activation in predicting disability and satisfaction. This thesis contributes evidence for musculoskeletal health care professionals (HCPs) to consider specific psychosocial factors, such as coping abilities, and patient activation early in the recovery process to improve disability following these injuries.

Background: Religious involvement is widespread and may influence patient engagement with their healthcare (patient activation) and health outcomes. This dissertation examined the association between religiosity and patient activation, changes in health-related quality of life (HRQOL), readmissions, and survival after hospitalization for acute coronary syndrome (ACS). Methods: We recruited 2,174 patients hospitalized for ACS in Georgia and Central Massachusetts (2011-2013) in a prospective cohort study. Participants self-reported three items assessing religiosity – strength/comfort from religion, petition prayers for health, and awareness of intercessory prayers by others. Patient activation was measured using the 6-item Patient Activation Measure. Generic HRQOL was assessed with the SF-36®v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated with the Seattle Angina Questionnaire Quality of Life subscale. Unscheduled readmissions were validated from medical records. Mortality status was obtained from national and state vital statistics. Results: After adjustment for several sociodemographic, psychosocial, and clinical variables, reports of strength/comfort from religion and receipt of intercessions were associated with high activation. Praying for one’s health was associated with low activation. Prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL. Neither strength/comfort from religion, petition, nor intercessory prayers were significantly associated with unscheduled 30-day readmissions and two-year all-cause mortality. Conclusions: Most ACS survivors acknowledge religious practices for their health. Religiosity was associated with patient activation and changes in HRQOL. These findings suggest that religiosity may influence patient engagement in their healthcare and recovery after a life-threatening illness, buttressing the need for holistic approach in patient management.

Background. AHA guidelines have been established to reduce Acute Coronary Syndrome (ACS)-related morbidity, mortality and recurrent events post-discharge. These recommendations emphasize the patient as an engaged member of the health care team in secondary prevention efforts. Patients with high levels of activation are more likely to perform activities that will promote their own health and are more likely to have their health care needs met. Despite evidence and strong expert consensus supporting patients as active collaborators in their own ACS care, the complexity and unexpected realities of self-managing one’s care at home are often underestimated. This study seeks to examine the correlates of patient activation at hospital discharge and then identifies activation trajectories in this same cohort in subsequent months. Lastly, this study examines the association between patient activation and health care utilization in the year subsequent to an ACS event. Methods. This study incorporates three aims: Aim 1, identification of the correlates of low patient activation post-discharge; Aim 2, identification of patient activation trajectories among this same cohort in the months following hospitalization; and Aim 3, examination of the association between patient activation and health utilization, post-discharge. Results. Fifty-nine percent of ACS patients identified as being at the lowest two activation stages at the time of hospital discharge. Perceived stress (pidentified post-discharge: low, stable (T1), high, sharp decline (T2), and sharp improvement (T3). The majority of patients (67%) identified as being in T1. Those patients of older age (OR: 2.22; CI 1.4- 3.5), identifying as Black in race (OR: 2.14: CI 1.1- 4.3), and reporting moderate/high perceived stress (OR: 2.54: CI 1.4- 4.5) had increased odds of being in the low, stable trajectory. The bivariate analysis indicated a significant association (P=0.008) between low patient activation and self-reported hospital readmissions in the months following discharge. In the final model, moderate to severe depression (OR: 1.60; CI 1.1- 2.3) was the strongest predictor of readmissions in the 12 months subsequent to discharge. Conclusions: Patients reported low activation at hospital discharge after an ACS event indicated that these patients were not prepared to take an active role in their own care. Correlates of low activation at discharge include moderate to high perceived stress, depression, and low social support. Furthermore, in the months following hospital discharge, the majority of these patients followed either a low/stable or a sharp decline activation trajectory. Hence, these results suggest that over time patients feel less and less confident to take an active role in self-management. Lastly, we found that patient activation may impact healthcare utilization in the year subsequent to hospital discharge, although patient self-reported depression appears to be the strongest predictor of utilization in the subsequent year. Future research is needed to better understand the relationship(s) among patient activation, depression, and health care utilization.

<p>With the increasing prevalence of chronic disease throughout the world, electronic Personal Health Records (ePHRs) have been suggested as a way to improve chronic disease self-management. However, ePHRs are not yet widely used by consumers. Protection Motivation Theory (PMT) has been successfully used to explain health related behaviours among chronic disease patients. In addition, Information Systems (IS) theories such as Task Technology Fit (TTF) have been successfully used to explain information technology adoption. This study combines PMT with Perceived Task Technology Fit (PTTF) and the health self-management readiness concept of the Patient Activation Measure (PAM) to propose a research model which will aid in the understanding of ePHR adoption by chronic disease patients. The role of educational interventions on various elements of the proposed model is also examined. A survey-based study of 230 participants is used to empirically validate the proposed model via structural equation modeling techniques. Results reveal that the PMT constructs, as well as PTTF and PAM all have significant direct or indirect effects on the intention to adopt an ePHR. In addition, the educational intervention analysis indicates that the provision of advanced ePHR education positively influences various constructs in the model, while the use of fear appeals through Diabetes complication education does not have an effect.</p> / Doctor of Philosophy (PhD)

Questa ricerca ha un approccio diadico che coinvolge sia i pazienti con malattie cardiovascolari che il loro partner durante l'ospedalizzazione. Il primo studio indaga l'effetto del coping diadico (DC) sulla soddisfazione coniugale dei partner considerando l'effetto moderatore del distress psicologico dei partner. I risultati mostrano che l'effetto benefico del DC positivo e comune sulla soddisfazione coniugale si verifica quando il distress psicologico dei partner è basso, al contrario il DC negativo diminuisce la soddisfazione coniugale tra coloro che hanno alti livelli di distress psicologico. Il secondo studio si propone di indagare la relazione tra DC, aderenza farmacologica e patient activation. La relazione è mediata dall'autoefficacia per la salute del paziente: il DC positivo e comune aumentano l'autoefficacia che a sua volta aumenta l'aderenza farmacologica e la patient activation; al contrario il DC negativo è dannoso durante il ricovero e anche dopo la dimissione. Il terzo studio indaga la relazione tra il distress psicologico e la qualità del supporto del partner (iperprotezione, ostilità e supporto al patient engagement) attraverso il ruolo moderatore del DC. I risultati mostrano che un alto distress psicologico è associato ad un peggior supporto del partner tra coloro che hanno basso DC positivo e alto DC negativo. / This research has a dyadic approach involving both patients with cardiovascular disease and their partner during the hospitalization. The first study investigates the effect of dyadic coping (DC) on partners’ marital satisfaction considering the moderating effect of the partners’ psychological distress. The results show that the beneficial effect of positive and common DC on marital satisfaction occurs when the partners’ psychological distress is low, on the contrary negative DC decreases marital satisfaction among those who have high levels of psychological distress. The second study aims to investigate the relationship between DC, adherence to medications and patient activation. The relationship is mediated by the patient health self-efficacy: positive and common DC increase patient health self-efficacy which in turn increases adherence to medication and patient activation; on the contrary, the negative DC is detrimental during hospitalization and also over time after discharge. The third study investigates the relationship between psychological distress and the quality of partner support (overprotection, hostility and support for patient engagement) through the moderating role of DC. The results show that high psychological distress increases worse partner support among those with low levels of positive DC and high negative DC.

The American Indians population in Minneapolis, Minnesota has experienced limited health care access and threefold diabetes health disparity. The purpose of this study was to measure the extent to which collaborating marketplace clinics and community-based support groups expanded diabetes care and provided self-management education for this largely urban Indian neighborhood. The marketplace clinics located in nearby CVS, Walmart, Target, and Supervalu stores committed financial support, certified educators, and pharmacy staff for the community-based support group. The study was conducted within the patient activation measure (PAM) analytical framework to assess the participants' acquired knowledge, skills, and confidence for diabetes self-management. A case-control study and 3 years retrospective analysis of secondary data were used to test whether the Minneapolis marketplace clinics and the Phillips community diabetes support group participants (n = 48) had improved diabetes health outcomes relative to the control group (n = 87). The intervention group employed motivational interviewing and PAM in coaching diabetes self-care and behavioral modification. The control group received only basic self-management education. T test and Cohen's d effect size measurements were used to quantify the size of the health outcome variables' difference between the study intervention and comparison groups. The positive effects of marketplace clinics and community-based complementation were shown through improved blood sugar control (A1C), weight loss (BMI), and healthful lifestyle changes. Social change progress could be realized by incorporating PAM with diabetes prevention programs for 33 Urban Indian Health Organizations that are located in large cities throughout the United States.