Background: Diabetes prevalence in Scotland is increasing at ~4.6% annually; 247,278 (4.7%) in 2011. My Diabetes My Way (MDMW) is the NHS Scotland information portal, containing validated educational materials for people with diabetes and their carers. Internet-based interventions have potential to enhance self-management and shift power towards the patient, with electronic personal health records (PHRs) identified as an ideal method of delivery. In December 2010, a new service was launched in MDMW, allowing patients across Scotland access to their shared electronic record. The following thesis aims to identify and quantify the benefits of a diabetes-focused electronic personal health record within NHS Scotland. Methods: A diabetes-focused, population-based PHR was developed based on data sourced from primary, secondary and tertiary care via the national diabetes system, Scottish Care Information - Diabetes Collaboration (SCI-DC). The system includes key diagnostic information; demography; laboratory tests; lifestyle factors, foot and eye screening results; prescribed medication and clinical correspondence. Changes are tracked by patients over time using history graphs and tables, data items link to detailed descriptions explaining why they are collected, what they are used for and what normal values are, while tailored information links refer individuals to facts related to their condition. A series of quasi-experimental studies have been designed to assess the intervention using subjectivist, mixed-methods approaches incorporating multivariate analysis and grounded theory. These studies assess patient expectations and experiences of records access, system usage and uptake and provide preliminary analysis on the impact on clinical process outcomes. Survey questionnaires were used to capture qualitative data, while quantitative data were obtained from system audit trails and from the analysis of clinical process outcomes before and after the intervention. Results: By the end of the second year, 2601 individuals registered to access their data (61% male; 30.4% with type 1 diabetes); 1297 completed the enrolment process and 625 accessed the system (most logins=346; total logins=5158; average=8.3/patient; median=3). Audit trails show 59599 page views (95/patient), laboratory test results proving the most popular (11818 accesses;19/patient). The most utilised history graph was HbA1c (2866 accesses;4.6/patient). Users are younger, more recently diagnosed and have a heavy bias towards type 1 diabetes when compared to the background population. They are also likely to be a more highly motivated ‘early adopting’ cohort. Further analysis was performed to compare pre- and post-intervention clinical outcomes after the system had been active for nearly two and a half years. Results of statistical significance were not forthcoming due to limited data availability, however there are grounds for encouragement. Creatinine tests in particular improved following 1 year of use, with type 1 females in particular faring better than those in patient other groups. For other clinical tests such as HbA1c, triglycerides, weight and body mass index improvements were shown in mean and/or median values.96% of users believe the system is usable. Users also stated that it useful to monitor diabetes control (93%), improve knowledge (89%) and enhance motivation (89%). Findings show that newly diagnosed patients may be more likely to learn more about their new condition, leading to more productive consultations with the clinical team (98%). In the pre-project analysis, 26% of registrants expressed concerns about the security of personal information online, although those who actually went on to use it reported 100% satisfaction that their data were safe. Engagement remains high. In the final month of year two, 44.6% of users logged in to the system. 55.3% of users had logged in within the previous 3 months, 78.9% within the previous 6 months and 91.4% within the previous year. Some legacy PHRs have failed due to lack of uptake and deficiencies in usability, so as new systems progress, it is essential not to repeat the mistakes of the past. Feedback: "It is great to be able to view all of my results so that I can be more in charge of my diabetes".Conclusion: The MDMW PHR is now a useful additional component for the self-management of diabetes in Scotland. Although there are other patient access systems available internationally, this system is unique in offering access to an entire national population, providing access to information collected from all diabetes-related sources. Despite its development for the NHS Scotland environment, it has the potential to connect to any electronic medical record. This local and domain-specific knowledge has much wider applicability as outlined in the recommendations detailed, particularly around health service and voluntary sector ownership, patient involvement, administrative processes, research activities and communication. The current project will reach 5000 patients by the end of 2013.

O estudo parte do reconhecimento da crescente disputa por materiais recicláveis no atual estágio de alargamento das formas desregulamentadas, degradadas e precarizadas de trabalho, condicionadas pelo imperativo da sobrevivência. Situa o trabalho intensivo da pré-reciclagem no circuito inferior da economia urbana e discute o incalculável custo humano deste trabalho que alimenta as indústrias recicladoras e traz enaltecidos benefícios ambientais à coletividade. Partindo do entrecruzamento da Economia Solidária e do campo de Saúde do Trabalhador, procurou-se identificar as potencialidades e limites da organização do trabalho cotidiano pelos trabalhadores da Cooperativa de Reciclagem de Matéria-Prima de Embu (Coopermape) e suas repercussões à saúde dos trabalhadores. O trabalho de campo permitiu reconhecer a complexidade do contínuo replanejamento do trabalho cotidiano e as dificuldades de construção da autogestão para compatibilizar a logística e o faturamento capazes de assegurar as expectativas de retirada mensal dos cooperados e, ao mesmo tempo, construir um processo horizontal de tomada de decisão que considere também a atenção às condições de trabalho e saúde. Na Coopermape, esse desafio é potencializado ainda por limitações impostas pelas constantes oscilações e condicionalidades do mercado da reciclagem e pelas pressões sofridas pela prefeitura de Embu. Num ambiente em que estão em jogo pesadas forças e interesses divergentes aos da cooperativa, o aprendizado do grupo se faz \"a duras penas\". Apesar da configuração exógena do processo de trabalho, a experiência de campo mostrou que existe uma margem residual, mas importante, de decisão dos cooperados sobre o processo cotidiano de trabalho. As experiências de reconfiguração de algumas etapas de trabalho e atitudes preventivas identificadas indicam que em algumas situações os cooperados conseguem compatibilizar a agilidade do processo e a minimização da sobrecarga e desgaste os trabalhadores. Ainda que a maioria destas pequenas mudanças não tenha sido promovida com a intencionalidade deliberada e explícita de poupar a saúde dos trabalhadores, elas permitem alimentar esperanças de reorganização do trabalho a favor dos trabalhadores. / The study begins by recognizing the increasing struggle for recycling material at the actual period of extension of unregulated, decreased and precarious work occupations, determinated by mandatory survival. Associates the intensive work made before the recycling process to low urban economy circuit and discusses the incommensurable human price of the this work that feeds recycling industry and brings exalt environment profities to society. Leaving from the crossing of Solidarity Economy and Workers\' Health field, the objective was to identify the possibilities and limits of work organization conducted by Cooperativa de Reciclagem de Matéria-Prima de Embu (Coopermape)\' workers and its effects to workers\' health. The empiric work allowed recognizing the complexity of day-by-day continuous replanning of work and the difficulties to build workers\' self-management. These difficulties are connected to the need to consider both the logistics and invoicing able to assure the workers expected rewarding and the construction of an even decision making process that also considers the regard to work and health condition. At Coopermape, this challenge is even bigger because of the limits imposed by the constant variation and conditionality of recycling trade and by Embu\'s city hall pressure. On a surrounding involving heavy power and disagreeing interests in relation to the ones of the cooperative, the learning takes a high cost. Although the exogenous conformation of work process, the empiric experience showed that there is a remaining, but important, border of decision of the day-by-day work process by the workers. The experiences of changing conformation at some work stages and provident attitudes demonstrates that in some situations the cooperative\' workers can consider the process agility and the reducing of workload and workers consuming. Though the majority of these little changes were not encouraged with the premeditated and explicit intention of guarding workers\' health, they allow feeding hopes of work rearrangement in favor of workers.

This manuscript includes two studies. The research design for study 1 was a single-subject reversal design, while study 2 was a case study with 5 experimental conditions. These studies investigated the effects of a Tier 3 peer-matching self-management intervention on two elementary school students who had previously been less responsive to Tier 1 and Tier 2 interventions. The Tier 3 self-management intervention, which was implemented in the classroom, included daily electronic communication between teachers and the two students' parents. Results indicated that this intervention effectively reduced disruptive behaviors and increased total engagement when implemented with integrity; without integrity, results were variable.

Introduction: Chronic joint (CJ) pain is the foremost osteoarthritis (OA) symptom that affects older African Americans’ (AAs) functional ability. Every effort should be made to reduce the development of high-impact chronic pain. One way to effectively do this is for older AAs to consistently engage in self-management utilizing the recommended OA treatments. Recommended behaviors include land-based exercise, water-based exercise, strength (muscle and endurance) training and stretching, self-management education, analgesic medications, thermal (warm/cool) modalities, and use of assistive and/or orthotic devices. However, evidence suggests these core behaviors of chronic pain self-management are not optimally utilized in older AAs. Methods: A convergent, parallel mixed-methods study explored patterns, preferences, and predictors of stage of engagement (pre-contemplation, preparation, or action) in recommended OA and CJ self-management behaviors. One hundred ten AAs aged 50 and older from communities in north Louisiana completed quantitative surveys, and a subset of 18 participated in audio-recorded qualitative interviews. Using SPSS, multinomial and binomial regression were used to build predictive models to determine which contextual and cognitive factors predict stage of engagement in each recommended and complementary OA self-management behaviors. A qualitative descriptive approach underscored a conventional content analysis of qualitative data. Results: Older AAs were “dealin’ with it [pain]” in a variety of ways, and their experience of having OA and CJ pain was based on their ability and willingness to bear the pain, understand the nature of OA pain, and experience life with daily pain. These dimensions of dealin’ with pain acted as a catalyst for engagement in complementary and recommended behaviors. In addition, participants’ and providers’ cultural receptivity may limit or enable engagement in certain recommended evidence-based OA behaviors. Specifically, each recommended OA self-management behavior was associated with different predictors of engagement. Confidence to manage pain was a predictor for land-based exercise, while there were no factors associated with water-based exercise. The most reasonable explanation for this finding of lack of participation in water-based exercise is likely due to inability to swim and lack of access to a personal or community pool. Engagement in strength training was significantly associated with confidence, knowledge of strength training recommendation, motivation, pain interference, and spirituality. For self-management education, only knowledge of self-management education recommendation was a predictor. Most AA older adults were unaware that this was recommended or didn’t have access to a self-management program; subsequently the majority had never participated in such but were in the preparation stage. Predictors for medication use included confidence, knowledge, and pain interference. Almost all AAs were using either over-the-counter or prescribed medications. Use of thermal modalities was predicted by pain interference. Lastly, using assistive and/or orthotic devices was significantly associated with employment status, OA pain severity, pain interference, and perceived social support. Assistive and/or orthotic device use was evenly split between users and non-users. Pain interference emerged as the most salient factor predicting stage of engagement in any of the recommended behaviors. Depending on the specific behaviors, pain interference prevented or motivated engagement. Conclusion: OA and CJ pain is a significant symptom in older AAs. This study’s mixed method approach uncovered what older AAs do to manage pain. More specifically, these results illuminate the daily patterns and preferences for self-management. We identified specific barriers and motivators that influence engagement in OA self-management behaviors, and determined the most relevant predictors for each stage of engagement. In addition, we were able to develop a model of OA and CJ pain self-management based on the predictors.

Cardiovascular diseases (CVD) and diabetes are the most significant chronic diseases globally due to their high prevalence and mortality. People with CVD or diabetes need to know how to self-manage their health conditions to promote, maintain, and restore their health status. The Nursing Outcomes Classification (NOC) has assisted nurses and other health care providers to evaluate and quantify the status of the patient and has reflected the current health care issues that are to prevent progression of chronic diseases. Based on the current health focus, additional knowledge and self-management NOC outcomes were developed and added to the latest edition of NOC published in 2013. Generally, validation of measurement tools is required to provide trustworthy evidence for use in practice. As measurement tools, NOC outcomes with their definitions, indicators, and measurement scales need to be validated for accuracy, meaningfulness, and usefulness before they are widely used in various health settings. To provide clinical evidence for effective nursing practice such as accurate assessments and evaluations, validation of NOC outcomes is required. The purpose of this study was to validate 12 NOC outcomes focused on knowledge and self-management for people with CVD and diabetes. A descriptive exploratory design was used to validate the selected NOC outcomes, and a two round survey using the Delphi technique was used to collect data from the invited experts via email. Two subject populations were invited. The first expert group was related to standardized nursing languages (SNL) and invited experts were members of NANDA International or a fellow of the Center for Nursing Classification and Clinical Effectiveness (CNC). The second expert group was related to self-management and invited experts were members of two research interest groups which are Health Promoting Behaviors Across the Lifespan and Self Care in the Midwest Nursing Research Society (MNRS). Descriptive statistics were used to determine the definition adequacy, clinical usefulness of measurement scales, and similarity between content of knowledge and self-management outcomes. The Outcome Content Validity (OCV) method was used for the content validity of outcomes and their indicators. A total of 46 and 27 nurse experts participated in the first and second round surveys, respectively. The mean age of participants was 51.87 years (SD=13.03) and the mean of experience in nursing was 27.67 (SD=14.75) years. Most participants had experience using SNL (82.6%). Each outcome reported acceptable psychometric properties. The range of definition adequacy of the 12 NOC outcomes was from 3.71 to 4.29 (perfect score is 5.0). The range of clinical usefulness for using measurement scales was from 3.77 to 4.29. The range of content similarity of the six pairs was from 3.88 to 4.35. Every evaluated NOC outcome identified as critical with over .80 OCV scores (perfect score 1.0). More than 80% of indicators were categorized in the critical level in the first round. Thus, psychometric properties of the 12 NOC outcomes were acceptable to use in the clinical settings. By using validated NOC outcomes, nurses caring of patients with CVD or diabetes can evaluate patient outcomes effectively, and determine the effect of nursing interventions accurately. Development of new NOC outcomes and validation of them will provide nurses with measurement tools to use with patients, clinical evidence for quality improvement and knowledge development in nursing.

IntroductionThe STARx Questionnaire was designed with patient and provider input, to measure self-management and transition skills in adolescents and young adults (AYA) with chronic health conditions. With proven reliability and an empirically-based factor structure, the self-report STARx Questionnaire requires further validation to demonstrate its clinical and research utility. In this study we examine the concurrent, predictive, and discriminant validity of the STARx Questionnaire.MethodsTo examine concurrent validity, the STARx Questionnaire was compared to two other published transition readiness tools. Predictive validity was examined using linear regressions between the STARx Total Score and literacy, medication adherence, quality of life, and health services use. Discriminant validity was examined by comparing the performance of three chronic illness conditions on the STARx Total Score and associated subscales.ResultsThe STARx Questionnaire and its subscales positively correlated with the scores for both transition readiness tools reflecting strong concurrent validity. The STARx Questionnaire also correlated positively with the literacy, self-efficacy, and adherence measures indicating strong predictive validity; however, it did not correlate with either quality of life or health care utilization. The performance of AYA across three different clinical conditions was not significant, indicating the clinical utility of this HCT tool for a variety of chronic health conditions.ConclusionThe strong validity of the STARx Questionnaire, in tandem with its strong reliability, indicated adequate psychometric properties for this generic self-report measure. These strong psychometric properties should contribute to the STARx being a viable measure of health care transition for both research and clinical purposes.

Self-regulation (SR) and executive functioning (EF) are important factors for successful student outcomes. Research suggests that executive skills facilitate the process of behavioral self-regulation. Well-developed SR and EF skills make learning more likely. Proper SR has the ability to improve attention levels and EF includes the use of working memory, both of which are essential components of the information processing system that students use continuously. One type of SR, referred to as self-management, involves a cycle of observing and recording one’s own behavior, then evaluating one’s self-assessments against those of an external observer. Self-management interventions have previously been found to reduce students’ inappropriate and off-task behaviors as well as increase classroom preparedness, on-task behavior, and academic performance. This study investigated the impact of a self-management intervention on a middle school student’s classroom preparation behaviors and his EF skills. Results suggest the participant’s overall classroom preparation behaviors were enhanced through his participation in the intervention. A few significant changes were also found in the participant’s pre- and post-intervention EF scores.

The purpose of this dissertation was to evaluate the biological, behavioral, and psychosocial attributes of individuals diagnosed with chronic obstructive pulmonary disease (COPD). Specific aims were to: 1) explore the predictive power of spirometry measures for event-free survival in patients with heart failure and suspected COPD, focusing on the differences in survival between those with and without airflow limitation; 2) examine the psychometric properties of the Multidimensional Scale of Perceived Social Support (MSPSS) in patients with concomitant COPD and heart failure; and 3) test the efficacy of a theory-based, multidimensional, self-care educational intervention using an eHealth platform on measures of symptom severity and variability, anxiety and depressive symptoms, perceived self-care ability, perceived self-care adherence, and selfcare information needs (knowledge) in a sample of adult patients with stable COPD. Specific aim one was addressed by evaluation of the predictive power of spirometry measures (forced expiratory volume/second [FEV1], forced vital capacity [FVC], and the ratio of FEV1/FVC) for event-free time to combined hospitalization/mortality after controlling for clinical and sociodemographic variables. This analysis revealed that those patients with airflow limitation were 2.2 times more likely to experience hospitalization/mortality compared to those without airflow limitation. The second specific aim was addressed with a psychometric evaluation of the Multidimensional Scale of Perceived Social support (MSPSS) which included determination of internal consistency reliability, the factor structure and construct validity by hypothesis testing in participants with comorbid COPD and heart failure. The MSPSS was a valid and reliable instrument to measure perceived social support in patients with comorbid COPD and heart failure. The third specific aim was addressed by a trial of an eHealth educational intervention in participants with COPD (N = 20). This intervention resulted in significant change in symptom severity evaluation in patients categorized as having medium symptom severity for the following symptoms: distress due to cough, chest tightness, dyspnea with activity and fatigue; these symptoms were perceived as more severe in the intervention period. Anxiety, depressive symptoms and perceived self-care ability were unchanged; however, perceived self-care adherence scores improved, and knowledge needs were significantly reduced after the intervention.

The purpose of this study was to analyze and measure the short-term and long-term impacts of a chronic disease self-management program (CDSP) for individuals living with HIV/AIDS. This study was a follow-up study on an HIV/AIDS Organization in Southern California’s (HAOSC’s) CDSP programs in 2007 and 2008 called “Newly Empowered Women” (NEW), a six (6) week CDSP for women diagnosed with HIV/AIDS which sought to promote self-efficacy through education and self-management skills. A retrospective longitudinal study on the female clients who participated with this program in 2007 and 2008 determined whether clients retained the skills taught in the CDSP and if they attained self-efficacy through improved behavioral changes in better overall self-management that were influenced as a result of their participation. Behavioral changes were examined and measured in the areas of self-rated health, anxiety and stress, social activities, communication with physicians, and the client’s overall self-confidence in managing symptoms related to the disease. The measurement of change in these areas informed the study on the effectiveness and practicality of the skills being taught in the CDSP and their effectiveness in the promotion of self-efficacy. It also highlighted which skills seem to be most helpful and impactful to clients, and if the skills they learned were retained over time. The study measured the short-term impacts from completion of the CDSP to the 6-month follow-up period and also measured the long-term impacts the CDSP had on client health outcomes three (3) and four (4) years after the initial program was implemented to see if there was a correlation between increased self-efficacy and improved health outcomes. Participant CD4 and viral load counts were analyzed, as these are determinant biological markers in measuring the immunological impacts of the disease. Measuring these variables over time for individuals that were in a CDSP gave the study insight into the CDSP’s short-term and long-term effectiveness in the promotion and sustainment of self-efficacy for individuals living with HIV/AIDS and how the effective management of their chronic illness can lead to overall better health outcomes. Additionally, this study sought to better understand the experience of the women who participated in the CDSP through incorporating a mixed methods qualitative approach, by interviewing some of the women who had participated in the CDSP to identify common themes or lessons learned, best practices of the program, and areas for improvement. Although this study was not able to show that changes in behavior and increased self-efficacy impact health outcomes, more complex analysis should be done in this area, as this study highlighted the positive impacts a CDSP can have on increasing self-management skills and promoting self-efficacy over the short-term and long-term for individuals diagnosed with HIV/AIDS.

Background: Diabetic foot ulcers are the result of multiple complications from hyperglycemia and lead to poor quality of life and high healthcare costs. The annual diabetes foot screening exam (ADFSE) and prevention interventions can reduce DFUs up to 75%. In 2015, 71% of the US population received the ADFSE. Objectives: The main objectives of this dissertation were: 1) to determine the association between adherence to diabetes self-management behaviors and the ADFSE, 2) to determine the association between concordant and discordant comorbidities and the ADFSE and 3) to determine the association between the performance of diabetes preventive care processes, number of office visits for diabetes and the completion of the ADFSE. Methods: Three cross-sectional studies used data from the 2015 Behavioral Risk Factor Surveillance System. Logistic regression models were evaluated to assess the association between the self-management behaviors and the ADFSE. Structural equation modeling (SEM) was used to assess the simultaneous, direct effects of concordant and discordant comorbidity loads on the ADFSE and the performance of diabetes preventive care processes and the number of office visits for diabetes care on the ADFSE. Results: In 2015, between 78.2% and 80.4% of the US population with diabetes received the ADFSE. Performance of the ADFSE was 77% less likely (OR: 0.33, 95%CI: 0.25-0.44) in those who do not perform self-foot inspections and 40% (OR: 0.59, 95%CI: 0.45-0.76) less likely in those who have never received the pneumococcal vaccination. Receiving the ADFSE was 50-80% less likely in patients who do not self-monitor blood glucose at least one time per day, depending on insulin use and receipt of diabetes education. Neither concordant comorbidities (β=0.226, p=0.086) nor discordant comorbidities (β=0.080, p=0.415) had a direct association with the performance of the ADFSE. The collection of preventive care processes demonstrated a 7% (OR: 1.07, 95% CI: 1.05-1.10) increase in the likelihood the ADFSE was performed Conclusions: Performance of the ADFSE may be improved through multiple types of interventions. Patient-based interventions to increase adherence to self-management behaviors is one route. Programs to improve overall diabetes care in the clinical setting may also help to further improve completion of the ADFSE.