Background: Arm morbidity continues to impact the lives of many breast cancer survivors long after acute treatments are completed. The most debilitating symptoms of arm morbidity are pain, lymphedema and limitation with range of motion (ROM). As a chronic condition, management of arm morbidity symptoms requires survivors to engage in self-management practices that alleviate symptoms. Objective: To explore self-management practices performed by breast cancer survivors, and the treatments women receive from healthcare practitioners in managing symptoms of arm morbidity. Methods: A secondary analysis of quantitative and qualitative data was undertaken. A descriptive correlational design was used to analyze data from breast cancer survivors (N = 740). Logistic regression identified variables related to self-management that were associated with pain, lymphedema and ROM limitations. A descriptive qualitative design was used to analyze data from a subset of participants (n = 40). Inductive content analysis approach was applied to develop codes, categories and themes related to how women self-manage arm morbidity symptoms and the treatments they received from healthcare providers to manage their arm morbidity. Results: Participants reported ongoing symptoms of pain (24%), lymphedema (21%), and range of motion limitation (34%) 30 to 36 months post-surgery. Pain was associated with experiencing swelling, taking pain medications, and discussing treatments for pain. Lymphedema was associated with swelling and receiving treatment for pain. ROM limitations were associated with swelling, receiving treatment for pain and taking pain medication. Two overarching qualitative themes emerged: 1) physical symptoms self-management, and 2) psychosocial self-management of uncertainty. Themes for treatments options included: rehabilitation and taking medications. Conclusion: Findings highlight that women living with symptoms of arm morbidity require ongoing monitoring and support for self-management, and there is a need for multidisciplinary approaches. Self-management practices reported are in line with the current lymphedema guidelines, however, the complexities associated with self-management practices can be burdensome to women. Chronic pain and ROM limitation necessitates further investigation to understand their cause and develop management strategies. Oncology nurses are well positioned to implement survivorship care plans that address survivorship needs with multidisciplinary teams and primary healthcare practitioners when women with breast cancer transition from acute cancer care to home. Future research is needed to provide an in depth understanding of self-management of arm morbidity in breast cancer survivors.

Class of 2017 Abstract / Objectives: The purpose of the study was to identify the types of motivation that promote sustained physical activity among adolescents between the ages of 11-17 who are diagnosed with type 1 diabetes (T1D) to prevent diabetes related complications. Methods: Questionnaires were distributed and collected among the Juvenile Diabetes Research Foundation’s (JDRF) listserv, Facebook page, and events in Phoenix and Tucson, Arizona on motivations for managing diabetes and exercise and confidence in diabetes management and performing physical activity. Demographic data was collected on age, gender, and race/ethnicity. Physical activity, levels of activity intensity, weight, height, health- related risk behaviors, chronic health conditions, and use of preventative services were also included in this study. Results: 11 adolescents completed questionnaires, categorized by participants who exercise less than 60 minutes daily (Group below recommended exercise level, GBRE) and participants who exercise more or equal to 60 minutes daily (Group meeting recommended exercise level, GMRE). GBRE’s average mean age was 15.75 and GMRE’s average mean age was 13.92. GMRE was associated with higher intensity physical activity (42.85% versus 0%). GBRE had a relative autonomy index (RAI) of 1.67 on the Treatment Self-regulation Questionnaire (TSRQ) compared to GMRE with a RAI of 3.81 (Mann-Whitney U 19, p-value 0.412). GBRE scored 73.75 on the Diabetes Self-efficacy Scale (DSES) and GMRE scored 78.71 (Mann-Whitney U 7, p-value 0.23). Conclusions: Adolescents who exercised ≥ 60 minutes daily were observed to be self-motivated in managing their diabetes, especially maintaining exercise recommendations to decrease diabetes related complications.

The purpose of the current study is to investigate the extent to which mindfulness (observing and describing), dispositional optimism and personal meaning are associated with self-efficacy for managing a chronic disease (SEMCD) among 57 people living with HIV in the DFW Metroplex. Several statistical analyses, including a hierarchical linear regression analysis, were conducted. Results indicate, after controlling for age and gender, the overall model accounted for a significant proportion of the variance (adjusted R2 = .39) in self-efficacy for managing chronic disease, F (6, 50) = 5.80, p < .01. Both subscales of mindfulness were significantly related to self-efficacy. However, observing was negatively, associated with SEMCD (β = -0.44, p < .05), and describing was positively associated with self-efficacy (β = 0.60, p < .01). As a result, incorporating these mindfulness skills into self-efficacy based self-management programs may greatly improve self-management, thus positively influencing psychological and physiological health outcomes that are essential to the health and wellbeing of people living with HIV/AIDS. Future research should investigate methods of manipulating observing and describing, and determine what proficiency in these skills is most beneficial to improve self-efficacy.

Abstract available in the Journal of Adolescent Health.

Self-management support (SMS) is considered an effective approach to chronic pain (CP) management. However, the provision of SMS for chronic pain patients faces challenges within primary care facilities in Ontario. An innovative SMS program led by a Registered Nurse (RN) at the Bruyère Family Health Team in Ottawa has been created for chronic pain patients. The goal of this program is to improve the current chronic pain management using SMS in an outpatient facility by harnessing the skills of primary health care team members. The hope would be that this program could be spread and scaled across other programs in the region. This thesis exists in two parts: 1. Evaluate the RN-led chronic pain self-management program to determine its effectiveness in terms of self-reported pain scales and Morphine Equivalence Quotient (MEQ) 2. Understand the perspectives of health care practitioners, administrators and patients within the RN-led chronic pain self-management program Patients meet with the RN for initial face-to-face visit for an hour, for SMS and then for at least one follow up visit. The primary outcome variables of interest were their self-reported pain evaluated using validated pain scales. Opioid use was also assessed before and after the porgram based on the MEQ. Results were analyzed using SPSSversion20. An online questionnair was distributed to team members. All responses were conceptually arranged into a SWOT analysis, which will be directed toward the ongoing management needs of the clinic. Between January 2016 and August 2018, 125 patients were seen of these 58 patients (12 males and 46 females) had at least one follow up appointment with the RN. In 46.2% of the population there was a decrease in their total opioid dose from their first to their last appointment and of these 4 patients (15.4%) had a daily MEQ of 0 by their last appointment. There was a significant average difference between patient’s daily MEQs at their first and last appointment (t20= 2.245, p<0.05). On average patients came into their first appointment with a daily MEQ of 23.88 higher than at their last visit (95% CI [1.69, 46.07]). Staff and patients who participated in the online survey identified the following strengths: multidisciplinary approach, increased accessibility for patients, cost effectiveness, better patient engagement, and no refills of opioids Canada needs a better strategy to manage the CP epidemic. This chronic pain self-management program led by an RN focuses on a multidisciplinary approach that is readily accessible to patients and integrated within primary care to best meet and prioritize the needs of chronic pain patients.

Diabetes is a devastating disease in American. The disease can cause chronic health comorbidities, and untreated diabetes has negative consequences for individuals and on our nation's economy. Newly diagnosed diabetics often have a lack of knowledge about the disease process. The purpose of this project was to design and implement a diabetes educational program to enhance participants' knowledge about diabetes management and self-care using the Health Belief Model. Diabetes Self-Management Education (DSME) is critical in improving patient outcomes and the prevention of diabetes related complications. Participation in a standardized diabetic educational intervention will improve patient knowledge, as measured by a reliable and valid pretest and posttest questionnaire. The objective was to develop a DSME curriculum that will be recognized and approved by the American Diabetes Association. A one group pretest /posttest method was employed with ten participants. A sample of ten participants between the age of 22 years old through 65 years old included eight women and two men all identified as African American. Upon completion of the 5-week DSME program, participants were noted to have started participating in weekly exercise or increased the number of days of exercise from 2 days to 3 days per week. Participants also noted a decrease in their systolic and diastolic blood pressure reading. Participants noted on average a 2-3 pound weight loss. Significant improvements were shown on both the knowledge scale and confidence scale of the modified Diabetes Project Participation Questionnaire. Results from this project indicated that participants applied knowledge from the DSME program to improve their own health status.

The Hispanic population has an elevated prevalence of diabetes, resulting in large part from a lack of self-management skills required to obtain glycemic control. The purpose of this project was to determine whether diabetes self-management knowledge was improved through the use of a culturally-based diabetes self-management program for Hispanic adults with diabetes using elements of the Hispanic culture. The research question asked whether a researcher-developed diabetes self-management education program that incorporated elements of the Hispanic culture improved diabetes knowledge in the Hispanic population when compared to a non-culturally based diabetes self-management program. The project was conducted using a quasi-experimental control group pre-test/post-test design using the stages of change transtheroretical model as its theoretical framework. Twenty-three Hispanic adults who had a diagnosis of diabetes and a Hemoglobin A1c level of greater than 7%, were recruited for the project. All project participants were recruited through a referral process from a local community clinic located in Montgomery County Texas. Pre/post-test data for the project were obtained through use of the University of Michigan's Diabetes Knowledge Test. A paired-sample t test was conducted to compare the pre-test and post-test results of the experimental group and the control group The project data results showed a significant difference (p < 0.05) between the pre/post-test scores of the experimental group but showed no difference between the 2 scores for the control group, leading to the recommendation that diabetes self-management education should be culturally based. Positive social change was gained from this project through the empowerment of Hispanics in the self-management of diabetes.

Abstract available in the Journal of Adolescent Health.

Chronic pain is one of the most frequent reasons for a primary health care visit and people with pain identify improved function as an important goal. Self-management support provides an opportunity to improve function for people with chronic pain, but existing evidence suggests negligible changes in function. This thesis includes five manuscripts with overarching objectives of improving the understanding of reductions in function related to pain and evaluating a new self-management program aimed at improving function for people with chronic pain. The first manuscript is a cross-sectional evaluation of factors associated with reduced function in people with chronic pain referred for self-management support in primary health care. The findings suggest number of medications, depressive symptoms, cognitive factors associated with pain, mechanical hyperalgesia, and duration of symptoms explain 63% of the variance in function in people with chronic pain, multiple comorbidities, and barriers to accessing healthcare. The second manuscript is a case-series describing the participation and outcomes of six participants in Chronic pain self-management support with pain science education and exercise (COMMENCE). This study contributes to the literature by detailing the COMMENCE intervention and describing the varied responses of six participants. The third and fourth manuscripts are a protocol for a randomized controlled trial (RCT) and a completed RCT evaluating the effectiveness of COMMENCE in comparison to a wait-list control. The results suggest COMMENCE improves function for people with chronic pain (mean difference = -8.0 points on the Short Musculoskeletal Function Assessment; 95% confidence interval: -14.7 to -1.3). The fifth manuscript is a planned secondary analysis of the RCT described above. This study suggested people with a greater number of comorbidities are likely to have poorer function at the end of COMMENCE after controlling for age, gender, and baseline function. Together, these factors explained 63% of the variance in function. / Thesis / Doctor of Philosophy (PhD) / Chronic pain is associated with suffering, disability, and health care costs. This thesis includes five papers aimed at better understanding reduced function and evaluating a new self-management program for people living with chronic pain. The results of this research suggests people with more medications, longer lasting pain, negative thoughts and emotions related to their pain, and sensitivity to pressure are more likely to have poor functional abilities. A new self-management approach, Chronic pain self-management support with pain science education and exercise (COMMENCE), is described and evaluated. The results suggest people with chronic pain participating in COMMENCE experience greater improvements in function than people on a wait-list for the program. It appears people living with more chronic health conditions are likely to have poorer function at the end of the program. The findings of this thesis may help to inform management of chronic pain in primary healthcare.

Background. A reliable and valid instrument printed in English that measures self-management for adults with vascular diseases receiving hemodialysis therapy was not found in the literature. The Vascular Disease Self-Management Instrument (VSMI) was developed to support the measurement and assessment of self-management. Objectives. The primary objective was to assess the feasibility of the study methods to develop and explore the psychometric properties of the Vascular Disease Self-Management Instrument (VSMI) for adults receiving hemodialysis therapy. Feasibility outcomes included recruitment, consent and completion rates. The secondary objective was to begin to explore the reliability (internal consistency and test-retest), and construct validity using exploratory factor analysis and criterion-related validity. Method. This feasibility study used seminal work (Thabane et al., 2010) and clinical expertise to determine feasibility outcomes. Examination of psychometric properties was based on Streiner & Norman (2008). Results. Of the 267 eligible patients, a total of 136 patients were recruited into the study. The consent rate was 51% and completion rate was 32% for the test-retest analysis. Study participants were primarily male (61%), diagnosed with chronic kidney disease for 12 years and receiving hemodialysis therapy for 6 years. Half (50%) the participants were at moderate risk for psychological distress and used avoidant-oriented coping. Preliminary psychometric analysis suggested good reliability (Cronbach’s alpha = 0.945) and stability (Intraclass correlation coefficient = 0.927, p <0.0001). The results of the exploratory factor analysis indicated four main factors comprised the self-management instrument including collaborative partnerships, self-advocacy, self-monitoring and normalcy. Preliminary evidence of criterion-related validity demonstrated a significant positive relationship between task-orientated coping and self-management. Conclusion. Feasibility outcomes were successfully met. Preliminary evidence suggests that the VSMI has the potential to become a reliable and valid instrument. A full-scale psychometric evaluation with a sample that includes adults receiving peritoneal dialysis is needed to support utilization of the VSMI in research and clinical practice. / Dissertation / Doctor of Philosophy (PhD) / Background: Adults receiving dialysis therapy must engage in self-management of their illnesses. A questionnaire on self-management activities based on the individuals’ experiences would help health care providers to identify areas where people struggle. This information could be used to develop programs that support self-management. What Did We Learn: A total of 136 people took part in the study. The development and testing of a self-management questionnaire for adults undergoing hemodialysis is a worthwhile and reasonable goal. The questionnaire provided people with the opportunity to describe their self-management activities. Half the people that participated in the study were at risk for experiencing anxiety and depression and tried to avoid stress. Conclusions: The questionnaire would assist health care providers to engage in future research projects and develop programs and resources that help people more independently manages their illnesses.