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Objective: Examine psychometric properties of frailty instruments used in adults with rheumatoid arthritis (RA) to inform selection of frailty instruments for clinical and research use., Methods: A systematic review was registered in PROSPERO. Studies measuring frailty in adults with RA published before May 25, 2022, were searched in six electronic databases. Level of evidence of psychometric properties were synthesized and graded for each frailty instrument using Consensus-Based Standards for the Selection of Health Measurement Instruments methodology., Results: There were 22 articles included in the review, and psychometric properties of 16 frailty instruments were examined. RA cohorts were predominantly female with moderate RA disease activity, mean age was 60.1 years, and frailty prevalence ranged widely from 10% to 85%. Construct validity was the only psychometric property routinely examined for frailty instruments in RA, and nearly all (14/16) performed favorably in this domain. Frailty correlated most frequently with older age, higher RA disease activity, and worse physical function. Internal consistency, measurement error, and content validity were examined infrequently. Reliability and responsiveness data were not reported. Six frailty instruments were rated highest in adults with RA: three adaptations of Fried's Criteria, 32-Item and 45-Item Frailty Indexes, and the Comprehensive Rheumatologic Assessment of Frailty., Conclusion: Six frailty instruments possessed the highest-rated psychometric properties in RA. These instruments demonstrated construct validity of frailty with important outcomes in RA. Frailty assessment shows promise to inform risk stratification in RA, but studies are needed to evaluate reliability, responsiveness, and validity to support accuracy of frailty measurement in adults with RA who may have disease-related features that differentially impact outcomes., (© 2023 The Authors. ACR Open Rheumatology published by Wiley Periodicals LLC on behalf of American College of Rheumatology.)

Mobile health (mHealth) is used to encourage and support self-management skills in patients with heart failure. The purpose of the study was to describe the feasibility, fidelity, usability, and acceptability of mHealth interventions. This pilot study used a randomized 3-group (enhanced usual care, mHealth, and mHealth plus, which included a nurse practitioner and community health worker) repeated-measure design to determine the feasibility of using a self-management behavior app and a Bluetooth-enabled scale for daily self-monitoring of weights and medications. In the 2 mHealth groups, of the 48 patients, 38 (79%) engaged partially in recording daily weights and medications, and of the 74 patients in the sample, we obtained partial to complete data on 63 (85%) of the patients during follow-up outcome phone calls. Most patients found the intervention to be feasible, usable, and acceptable, and (93%) patients in the mHealth group and 100% of patients in the mHealth plus group agreed or strongly agreed that they learned how to self-manage their heart failure using the app. The intervention was reasonable to implement and provided insight for future intervention improvements., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Cardiovascular disease (CVD) risk reduction programs led by a nurse/community health worker team are effective in urban settings. This strategy has not been adequately tested in rural settings., Objective: A pilot study was conducted to examine the feasibility of implementing an evidence-based CVD risk reduction intervention adapted to a rural setting and evaluate the potential impact on CVD risk factors and health behaviors., Methods: A 2-group, experimental, repeated-measures design was used; participants were randomized to a standard primary care group (n = 30) or an intervention group (n = 30) where a registered nurse/community health worker team delivered self-management strategies in person, by phone, or by videoconferencing. Outcomes were measured at baseline and at 3 and 6 months. A sample of 60 participants was recruited and retained in the study., Results: In-person (46.3%) and telephone (42.3%) meetings were used more than the videoconferencing application (9%). Mean change at 3 months differed significantly between the intervention and control groups for CVD risk (-1.0 [95% confidence interval (CI), -3.1 to 1.1] vs +1.4 [95% CI, -0.4 to 3.3], respectively), total cholesterol (-13.2 [95% CI, -32.1 to 5.7.] vs +21.0 [95% CI, 4.1-38.1], respectively), and low-density lipoprotein (-11.5 [95% CI, -30.8 to 7.7] vs +19.6 [95% CI, 1.9-37.2], respectively). No between-group differences were seen in high-density lipoprotein, blood pressure, or triglycerides., Conclusions: Participants receiving the nurse/community health worker-delivered intervention improved their risk CVD profiles, total cholesterol, and low-density lipoprotein levels at 3 months. A larger study to explore the intervention impact on CVD risk factor disparities experienced by rural populations is warranted., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Heart failure (HF) is a multifaceted syndrome that requires self-management for adherence to treatment to control symptoms. Symptoms need to be monitored to prevent impending HF exacerbations. Few HF study authors have assessed efficacy of mobile health (mHealth) interventions particularly with virtual visits to evaluate outcomes such as symptoms and healthcare utilization., Objective: The aim of this pilot study was to evaluate the potential effect of mHealth self-management interventions on symptom status and health-related quality of life and describe health care utilization in patients with HF., Methods: This 3-month pilot study included 74 patients with HF and used a randomized 3-group repeated-measures design (enhanced usual care, mHealth, and mHealth plus [+] virtual visits). Surveys included the Heart Failure Symptom Survey, EuroQol, and a specialized phone application for patients to report weights and medications., Results: The mHealth groups had an overall decrease in most symptom severity and frequency, particularly shortness of breath. Compared to enhanced usual care, both the mHealth+ and mHealth groups showed promise with medium effect sizes (range .55-.60) in relation to shortness of breath and a medium effect (.51) for lower extremity edema for the mHealth+ group. There was a trend toward improvement in health-related quality of life in both intervention groups at month 3. The mHealth+ group had fewer rehospitalizations., Conclusions: In general, both mHealth groups fared better on symptoms and health care utilization. Small to medium effect sizes on selected symptom outcomes warrant this study to be conducted in a fully powered study. Virtual visits may assist in symptom recognition and self-management., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The goal of this study was to assess the utility of participatory needs assessment processes for continuous improvement of developing clinical and translational research (CTR) networks. Our approach expanded on evaluation strategies for CTR networks, centers, and institutes, which often survey stakeholders to identify infrastructure or resource needs, using the case example of the Great Plains IDeA-CTR Network. Our 4-stage approach (i.e., pre-assessment, data collection, implementation of needs assessment derived actions, monitoring of action plan) included a member survey ( n = 357) and five subsequent small group sessions ( n = 75 participants) to better characterize needs identified in the survey and to provide actionable recommendations. This participatory, mixed-methods needs assessment and strategic action planning process yielded 11 inter-related recommendations. These recommendations were presented to the CTR steering committee as inputs to develop detailed, prioritized action plans. Preliminary evaluation shows progress towards improved program capacity and effectiveness of the network to respond to member needs. The participatory, mixed-methods needs assessment and strategic planning process allowed a wide range of stakeholders to contribute to the development of actionable recommendations for network improvement, in line with the principles of team science., Competing Interests: The authors have no conflict of interest to declare., (© The Association for Clinical and Translational Science 2020.)

Caregivers of patients with multimorbidity are important for improving patient outcomes. This descriptive study examines health status and burden of 22 caregivers of patients with multimorbidity discharged from the hospital who were enrolled in a self-management intervention study. Caregivers did not receive an intervention. Factors that increased caregiver burden were financial issues, caring for others (e.g., family members), and home obligations. Caregivers averaged between 2 and 3 chronic conditions themselves. Perceived caregiver burden remained unchanged over time for the caregiver whether the patient was in the intervention or the usual care group. We recommend rigorous research with larger samples to better understand the caregiver role, needed resources and potential interventions to mitigate caregiver burden in the multimorbid population during and after care transitions. Longitudinal studies that include assessment and interventions for the caregivers of patients with multimorbidity are needed., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

The purpose of this study was to compare results using individual change in level of patient activation measure (PAM) scores, individual point change scores, and group means in an outcome analysis. We evaluated changes in PAM scores (increase in level or increase of ≥5 points) to mean group PAM scores on patients who completed a self-management intervention compared with usual care on health care utilization and health-related quality of life. The sample was a subset of 91 multimorbid patients with complete data at completion of a self-management intervention. Results indicated that using a change in points allowed for more refined analysis of change compared with level changes; however, both individual measures were more reflective of actual change than group means. When tailoring interventions, we should consider using individual change scores. Further research is needed to evaluate how best to use PAM scores to measure the impact on clinical and health care outcomes.

Researchers have employed various methods to identify symptom clusters in cardiovascular conditions, without identifying rationale. Here, we test clustering techniques and outcomes using a data set from patients with acute coronary syndrome. A total of 474 patients who presented to emergency departments in five United States regions were enrolled. Symptoms were assessed within 15 min of presentation using the validated 13-item ACS Symptom Checklist. Three variable-centered approaches resulted in four-factor solutions. Two of three person-centered approaches resulted in three-cluster solutions. K -means cluster analysis revealed a six-cluster solution but was reduced to three clusters following cluster plot analysis. The number of symptoms and patient characteristics varied within clusters. Based on our findings, we recommend using (a) a variable-centered approach if the research is exploratory, (b) a confirmatory factor analysis if there is a hypothesis about symptom clusters, and (c) a person-centered approach if the aim is to cluster symptoms by individual groups.

Aims and Objectives: To determine whether a weight management intervention (WMI) plus cardiac rehabilitation (CR) compared to CR alone improves outcomes for overweight and obese cardiac revascularisation patients., Background: Despite participating in cardiac rehabilitation (CR), few cardiac patients lose enough weight to achieve clinically significant cardiovascular disease risk reduction., Design: A randomised controlled design was used with measurements at baseline, 4 and 6 months, guided by the CONSORT checklist, see Supporting Information File S1. Adults who had undergone either coronary artery bypass surgery (CABS) or percutaneous coronary intervention (PCI) and participated in a rural CR programmes were recruited. Subjects were randomised to a 12-week telehealth WMI or control group. The primary outcome was weight loss. Secondary outcomes included physical activity, patient activation, perceived self-efficacy and use of weight management behaviours., Results: A total of 43 subjects participated, with a mean age of 63 (±9.3) years. The WMI group had significantly more weight loss averaged across the 4 and 6 months of 13.8 (±2.8) pounds compared to the control group [mean = 7.8 (±2.2) pounds]. There were no significant differences in physical activity (activity counts or daily minutes in moderate or more intense activity). The WMI group had significantly higher levels of patient activation. They also had significantly higher total scores on the Diet and Exercise Self-Management survey, and subscales that included self-efficacy for specific eating habits and managing diet behaviour., Conclusions: Findings demonstrated the usefulness and feasibility of using telehealth delivery of the WMI for cardiac rehabilitation participants in rural communities to improve weight management outcomes., Relevance to Practice: Study findings underscore the opportunity to further improve weight loss of overweight and obese cardiac participants using a weight management intervention to augment CR participation., (© 2019 John Wiley & Sons Ltd.)

Purpose: Using the RE-AIM framework, the primary purpose of this qualitative study was to conduct focus groups to identify areas for future adaptation of an evidence-based cardiovascular disease (CVD) risk intervention (COACH) developed for an urban primary care setting to urban American Indian (AI)-serving settings., Methods: This qualitative study involved conducting three focus groups with 31 urban AI patients with two or more CVD risk factors to maximize reach and efficacy of COACH. The patients had not yet participated in an adapted COACH program., Results: Findings from the focus groups indicate that a culturally adapted CVD risk reduction program modeled after COACH would be acceptable among urban AI populations. Recommendations for cultural adaptation include a need for images of AI people, traditional AI exercise activities and AI foods, information on the portion sizes of traditional foods, and expanded information on tobacco use and resources., Conclusion: With cultural adaptations, the COACH program can be pilot-tested in urban AI-serving primary care settings to address health concerns and behaviors that affect cardiovascular health outcomes.

Purpose: Using the RE-AIM framework, the primary purpose of this qualitative study was to assess focus group data to generate information on the applicability of an evidence-based cardiovascular disease (CVD) risk intervention developed for an urban setting for rural areas in Nebraska. We also sought to determine potential adaptations that may be necessary to implement the study in a rural setting. The CVD risk reduction intervention is based on the Community Outreach and Cardiovascular Health (COACH) program, which included nurse practitioner/community health worker teams., Methods: This qualitative study involved conducting 3 focus groups with patients with CVD risk factors to assess community readiness for participating in the intervention, the mode of the delivery of the intervention, the setting of the intervention, program content, and raising awareness of the intervention., Findings: Findings from the focus groups indicate acceptability toward a CVD risk reduction program modeled after the COACH. Participants favored initial in-person face-to-face interactions with a nurse practitioner that could transition to phone-based meetings and Skype. In addition, participants underscored that confidentiality can be a concern in small communities and therefore community health workers need to be trusted individuals. Calls for additions to COACH materials were very specific and participants underscored the need for social support., Conclusions: With minor adaptations, the COACH program can be pilot tested in rural settings to address key health concerns and behaviors that affect risk for cardiovascular health., (© 2018 National Rural Health Association.)

Background and Purpose:  To examine the co-occurrence of cardiovascular risk factors and cluster subgroups of college students for cardiovascular risks., Methods: A cross sectional descriptive study was conducted using co-occurrence patterns and hierarchical clustering analysis in 158 college students., Results: The top co-occurring cardiovascular risk factors were overweight/obese and hypertension (10.8%, n = 17). Of the total 34 risk factors that co-occurred, 30 of them involved being overweight/obese. A six-cluster-solution was obtained, two clusters displayed elevated levels of lifetime and 30-year cardiovascular disease risks., Conclusions: The hierarchical cluster analysis identified that single White males with a family history of heart disease, overweight/obese, hypertensive or diabetes, and occasionally (weekly) consumed red meat, take antihypertensive medication, and hyperlipidemia were considered the higher risk group compared to other subgroups., (© 2018 Springer Publishing Company, LLC.)

Study Objectives: Obstructive Sleep Apnea (OSA) contributes to all-cause mortality. An American Academy of Sleep Medicine task force is focusing on improving detection and categorization of OSA symptoms and severity to promote screening, assessment, and diagnosis. The purpose of this study was to psychometrically compare measures used in OSA screening (Berlin, Epworth Sleepiness Scale (ESS), STOP Bang) and a portable sleep monitor (PSM) to apnea-hypopnea index (AHI) and levels from polysomnogram (PSG)., Methods: An observational, cross-sectional design was used. Patients referred to a sleep specialist were enrolled at initial sleep evaluation. Participants completed measures used in OSA screening, then sent home for one night using PSM. PSGs were ordered by the physician and AHI results were obtained from the medical record., Results: Participants (N = 170) were enrolled in the study. Almost all participants completed the OSA measures, approximately half-completed PSM measurement, and the majority completed laboratory PSG. The STOP Bang had the highest levels of sensitivity; the ESS had the lowest. The ESS had the highest specificity and reliability levels; the STOP Bang had the lowest. The PSM measure had the highest positive predictive value (PPV) and the strongest psychometric properties of the screening measures., Conclusions: The STOP Bang was the preferred self-report OSA screening measure because of high levels of sensitivity. The ESS was the least desirable measure. PSM measurement consistently predicted the presence of OSA but at the expense of low sensitivity at AHI levels ≥30. This expands the knowledge of validity testing of screening measures used for OSA., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Cardiovascular disease is the leading cause of death and hospitalization in the rural United States. Midwestern farmers are integral to rural communities, but little is known about the effect of occupational variability of seasonal work and technology use on their cardiovascular disease risk., Aims: This study describes the relationships of health behaviors and cardiovascular disease risk in 40 Midwestern farmers during peak and off-peak farming seasons., Methods: Objectively measured physical activity and self-report of demographics, diet, and health-related quality of life were collected during each farming season., Results and Conclusions: Farmers in this study were physically active, ate consistent diets, and reported high health status ratings throughout the year. Cardiovascular disease risk was positively correlated with age and body mass index (P < .01), and half of young and middle-age farmers reported anxiety and depression problems. Cardiovascular disease risk reduction interventions for farmers should address both physical and emotional aspects of farming.

The purpose of this pilot study was to assess the cost-effectiveness of four different doses (based on patients' level of cognition and activation) of a home-based care transitions intervention compared with usual care at 2 and 6 months after hospital discharge to home for 126 adult patients with three or more chronic diseases. Health care utilization was measured, and a cost-effectiveness analysis was used to estimate incremental costs and quality-adjusted life-years associated with each intervention arm. At 6 months, results from this pilot study are very promising and support cost-effectiveness for Group 2-low cognition/high activation, Group 3-normal cognition/low activation, and Group 4-normal cognition/high activation patients. However, Group 1-low cognition/low activation needs a more intensive treatment than what was provided in the intervention, because of their low cognition and activation levels. Our intervention strategies provided to the groups would be scalable to a larger patient population and across different facilities.

Objective: To assess college students' knowledge and perception of cardiovascular risk factors and to screen for their cardiovascular risks., Participants: The final sample that responded to recruitment consisted of 158 college students from a midwestern university., Methods: A cross-sectional, descriptive study was performed using convenience sampling., Results: College students were knowledgeable about cardiovascular risk factors but did not perceive themselves at risk for cardiovascular disease (CVD). Knowledge of cardiovascular risk factors was correlated with the lifetime risk estimates (ρ = .17, p = .048), and perception of cardiovascular risk was positively associated with 30-year CVD risk estimates (ρ = .16, p = .048). More than 50% of the participants had 1 or more cardiovascular risk factors., Conclusions: High knowledge level of cardiovascular risk factors was not sufficient to lower cardiovascular risks within this study population, but changing perception of cardiovascular risk factors may play a bigger role in reducing long-term cardiovascular risks.

An overview of proceedings, findings, and recommendations from the workshop on "Advancing Symptom Science Through Symptom Cluster Research" sponsored by the National Institute of Nursing Research (NINR) and the Office of Rare Diseases Research, National Center for Advancing Translational Sciences, is presented. This workshop engaged an expert panel in an evidenced-based discussion regarding the state of the science of symptom clusters in chronic conditions including cancer and other rare diseases. An interdisciplinary working group from the extramural research community representing nursing, medicine, oncology, psychology, and bioinformatics was convened at the National Institutes of Health. Based on expertise, members were divided into teams to address key areas: defining characteristics of symptom clusters, priority symptom clusters and underlying mechanisms, measurement issues, targeted interventions, and new analytic strategies. For each area, the evidence was synthesized, limitations and gaps identified, and recommendations for future research delineated. The majority of findings in each area were from studies of oncology patients. However, increasing evidence suggests that symptom clusters occur in patients with other chronic conditions (eg, pulmonary, cardiac, and end-stage renal disease). Nonetheless, symptom cluster research is extremely limited and scientists are just beginning to understand how to investigate symptom clusters by developing frameworks and new methods and approaches. With a focus on personalized care, an understanding of individual susceptibility to symptoms and whether a "driving" symptom exists that triggers other symptoms in the cluster is needed. Also, research aimed at identifying the mechanisms that underlie symptom clusters is essential to developing targeted interventions., (© The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Background: Although individual symptoms and symptom trajectories for various cardiovascular conditions have been reported, there is limited research identifying the symptom clusters that may provide a better understanding of patients' experiences with heart disease., Aims: To summarize the state of the science in symptom cluster research for patients with acute coronary syndrome, myocardial infarction, coronary artery bypass surgery, and heart failure through systematic review and to provide direction for the translation of symptom cluster research into the clinical setting., Methods: Databases were searched for articles from January 2000 through to May 2015 using MESH terms "symptoms, symptom clusters, acute coronary syndrome (ACS), myocardial infarction (MI), coronary heart disease (CHD), ischemic heart disease (IHD), heart failure (HF), coronary artery bypass surgery (CABS), cluster analyses, and latent classes." The search was limited to human studies, English language articles, and original articles investigating symptom clusters in individuals with heart disease. Fifteen studies meeting the criteria were included., Results: For patients with ACS and MI, younger persons were more likely to experience clusters with the most symptoms. Older adults were more likely to experience clusters with the lowest number of symptoms and more diffuse and milder symptom clusters that are less reflective of classic ACS presentations. For HF patients, symptom clusters frequently included physical and emotional/cognitive components; edema clustered in only three studies. Symptom expression was congruent across geographical regions and cultures., Conclusions: The findings demonstrated similarities in symptom clusters during ACS, MI, and HF, despite multiple methods and analyses. These results may help clinicians to prepare at-risk patients for proper treatment-seeking and symptom self-management behaviors.

Knowledge is a prerequisite for changing behavior, and is useful for improving outcomes and reducing mortality rates in patients diagnosed with chronic kidney disease (CKD). The purpose of this article is to describe baseline CKD knowledge and awareness obtained as part of a larger study testing the feasibility of a self-management intervention. Thirty patients were recruited who had CKD Stage 3 with coexisting diabetes and hypertension. Fifty-four percent of the sample were unaware of their CKD diagnosis. Participants had a moderate amount of CKD knowledge. This study suggests the need to increase knowledge in patients with CKD Stage 3 to aid in slowing disease progression., Competing Interests: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity., (Copyright© by the American Nephrology Nurses Association.)

The purpose of this review is to provide a guide for researchers and clinicians in selecting an instrument to measure four commonly occurring symptoms (dyspnea, chest pain, palpitations, and fatigue) in cardiac populations (acute coronary syndrome, heart failure, arrhythmia/atrial fibrillation, and angina, or patients undergoing cardiac interventions). An integrative review of the literature was conducted. A total of 102 studies summarizing information on 36 different instruments are reported in this integrative review. The majority of the instruments measured multiple symptoms and were used for one population. A majority of the symptom measures were disease-specific and were multi-dimensional. This review summarizes the psychometrics and defining characteristics of instruments to measure the four commonly occurring symptoms in cardiac populations. Simple, psychometrically strong instruments do exist and should be considered for use; however, there is less evidence of responsiveness to change over time for the majority of instruments., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Patient activation and self-management have been associated with improved patient outcomes, including decreased re-hospitalization; however, little research has identified factors that predict patient activation in the multimorbid hospitalized patient. This descriptive correlational study included 200 patients with three or more chronic diseases discharged to home post-hospitalization. Standard multiple regression was used to identify correlates of patient activation. Multimorbid patients with lower activation scores had more acute care utilization (re-hospitalization and emergency department visits) 30 days post-discharge than patients with higher activation scores. Predictors of patient activation were health literacy (p = .013), satisfaction with social role (p = .014), and involvement in chronic illness care (p = .001). Care transition programs focusing on health literacy, role satisfaction, and promoting patient-centered care may improve patient outcomes for multimorbid patients., (© The Author(s) 2016.)

Objectives: To compare the percentage of patients who had an oral cancer examination (OCE) by their primary care provider (PCP) in medical clinics participating in a web-based education with poster reminder intervention to that of patients in control clinics. To also determine the effects for PCPs in medical clinics participating in the web-based education with poster reminder intervention as compared with those in control clinics regarding: a) index of knowledge of oral cancer risk factors (RiskOC) and b) index of knowledge of oral cancer diagnostic procedures (DiagOC)., Methods: Six medical clinics were recruited to participate in this study and randomly assigned to an intervention group or a control group. PCPs (physicians, physician assistants, and advanced practice registered nurses) took a pretest; 2 weeks later, they participated in the web-based educational program, including a posttest (intervention group) or took a posttest only (control group). In each clinic, 1 week following completion of the PCPs' posttests, 94 patients were recruited to complete a one-page survey., Results: The intervention clinics were found to be a significant factor for the PCPs to perform patient OCEs, after controlling for significant covariates, that is, age, main reason for clinic visit, OCE for patient in the past year, clinic's mean DiagOC score, and clinic's mean RiskOC score. The intervention also resulted in the PCPs increasing their pretest to posttest RiskOC scores., Conclusions: The use of intervention has the potential to increase PCPs' short-term knowledge and to increase the frequency of PCPs' routine, nonsymptomatic opportunistic OCE on patients., (© 2016 American Association of Public Health Dentistry.)

The purpose of this study was to describe physical activity (PA) behaviors and physical functioning of prehypertensive and Stage I hypertensive African American Women (AAW) and to examine the relationships between PA behavior, physical functioning, personal factors, and behavior-specific influences. Pender's Health Promotion Model was the conceptual framework for the study. A cross-sectional design and convenience sample were used. The PA domain where the greatest amount of time was spent was in work-related activity, followed by household, leisure time, and transportation activity. Personal factors most strongly correlated to lower PA were greater body mass index and waist circumference. AAW perceived moderate barriers to PA and minimal family and friend social support for PA. Future interventions need to focus on removing barriers to and improving social support for PA among AAW., (© The Author(s) 2016.)

Patients at risk of developing oral and/or oropharyngeal cancer (OPC) are more likely to see primary care providers (PCPs) than a dentist. Many PCPs do not regularly perform oral cancer examination (OCE). The purpose of this study was to design a web-based educational program based on a behavioral framework to encourage PCPs to conduct OCE. PCPs were solicited to provide feedback on the program and to evaluate their short-term knowledge. The integrated behavioral model was used to design the program. Fifteen PCPs (five in each group: physicians, physician assistants, and nurse practitioners) reviewed the program and took a posttest: (1) index of knowledge of risk factors for oral cancer (RiskOC) and (2) index of knowledge of diagnostic procedures for oral cancer (DiagOC). Findings from the process evaluation were mainly positive, with comments on the length of the program comprising the ten negative comments. No significant difference among groups of PCPs (physicians, physician assistants, and nurse practitioners) was detected for DiagOC (p = 0.43) or RiskOC (p = 0.201). A program on OPC for PCPs should be less than 40 min. Postviewing knowledge outcomes were similar for all PCPs. The web-based program on OPC based on a behavioral framework could have similar short-term knowledge outcomes for all PCPs and may increase the number of PCPs performing OCEs.

Background: Chronic kidney disease is a growing health problem on a global scale. The increasing prevalence of chronic kidney disease presents an urgent need to better understand the knowledge, confidence and engagement in self-managing the disease., Objectives: This study examined group differences in patient activation and health-related quality of life, knowledge, self-management and confidence with managing chronic disease across all five stages of chronic kidney disease., Design: The study employed a descriptive correlational design., Settings: Participants were recruited from five primary care, three nephrology clinics and one dialysis centre in two Midwestern cities in the United States., Participants: The convenience sample included 85 adults with hypertension, diabetes mellitus and chronic kidney disease, including kidney failure, who spoke English., Measurements: Seven measurements were used to collect data via telephone interviews with participants not receiving haemodialysis, and face-to-face interviews with those receiving haemodialysis at the beginning of their treatment session., Results: Analyses indicated that half the participants were female (50.58%), the mean age was 63.21 years (SD = 13.11), and participants with chronic kidney disease stage 3 were the most activated. Post hoc differences were significant in patient activation and blood pressure self-management and anxiety across chronic kidney disease stages, excluding stage 5., Conclusion: Engaging patients in the self-management of their health care and enhancing patients' ability to self-manage their blood pressure may work to preserve kidney health. Healthcare providers should collaborate with patients to develop strategies that will maintain patients' health-related quality of life, like reducing anxiety as kidney disease progress., (© 2015 European Dialysis and Transplant Nurses Association/European Renal Care Association.)

Background and Purpose: To test the psychometric properties of two measures of knowledge and perception of cardiovascular risk factors (CRFs)., Methods: A methodological study using a modified version of the Heart Disease Fact Questionnaire (HDFQ) and the Health Beliefs Related to Cardiovascular Disease (HBCVD) questionnaires was administered to 100 college-aged students., Results: The HDFQ Kuder-Richardson-20 reliability estimate was .73. The HBCVD Cronbach's alpha was .70. Principal component analysis demonstrated the HBCVD questions load onto components representing the perceived susceptibility and severity of CRFs. There was an inverse relationship between knowledge and perception of CRFs (ρ = -.26, p = .009), as knowledge increased, perception of risk decreased., Conclusions: The HDFQ and HBCVD questionnaires had adequate internal consistency reliability and documented construct validity for use in college students.

This extensive literature review focuses on cardiovascular risk factors in young adults, with an emphasis on hyperlipidemia and hypertension. Multiple studies have confirmed that hyperlipidemia and hypertension during young adulthood are associated with coronary heart disease (CHD) in later decades, and CHD is one type of cardiovascular disease. The primary risk factors identified in the literature that are predictive of CHD are age; gender; race/ethnicity; smoking status; high blood pressure; and elevated lipid levels, especially low-density lipoprotein cholesterol. The current guidelines are insufficient to address screening and treatment in young adults with cardiovascular risk factors. Future studies are warranted to confirm the extent of cardiovascular risks in young adults, which can then be targeted to this population for prevention and intervention strategies.

The prevalence, effect on health outcomes, and economic impact of chronic kidney disease (CKD) have created interest in self-management interventions to help slow disease progression to kidney failure. Seven studies were reviewed to identify knowledge gaps and future directions for research. All studies were published between 2010 and 2013; no investigations were conducted in the United States. Knowledge gaps included the focus on medical self-management tasks with no attention to role or emotional tasks, lack of family involvement during intervention delivery, and an inability to form conclusions about the efficacy of interventions because methodological rigor was insufficient. Educational content varied across studies. Strategies to improve self-management skills and enhance self-efficacy varied and were limited in scope. Further development and testing of theory-based interventions are warranted. There is a critical need for future research using well-designed trials with appropriately powered sample sizes, well-tested instruments, and clear and consistent reporting of results., (© The Author(s) 2014.)

Challenges arise in building the knowledge needed for evidence-based practice partially because obtaining clinical research data is expensive and complicated, and many studies have small sample sizes. Combining data from several studies may have the advantage of increasing the impact of the findings or expanding the population to which findings may be generalized. The use of common data elements will allow this combining and, in turn, create big data, which is an important approach that may accelerate knowledge development. This article discusses the philosophy of using common data elements across research studies and illustrates their use by the processes in a developmental center grant funded by the National Institutes of Health. The researchers identified a set of data elements and used them across several pilot studies. Issues that need to be considered in the adoption and implementation of common data elements across pilot studies include theoretical framework, purpose of the common measures, respondent burden, teamwork, managing large data sets, grant writing, and unintended consequences. We describe these challenges and solutions that can be implemented to manage them., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Oral and/or oral pharyngeal cancer (OPC) has an approximately 53% five-year survival rate in the United States. It is postulated that the rationale for this low survival rate is due to delayed diagnosis and treatment of OPC at its later stages. Recently the United States Preventive Services Task Force found insufficient evidence to recommend for or against oral cancer examination (OCE) by primary care providers (PCP), i.e., medical providers who are not dental providers or otolaryngologists. The purpose of the paper is to provide a logical discussion of the varied research on OCE, while presenting the evidence for annual opportunistic OCE in the primary care setting. Trained PCPs in OCE have the likelihood of detecting OPC at an early non symptomatic stage, which could result in lower treatment morbidity and mortality due to the disease. This review of the OCE research summarizes evidence that points to a logical benefit of OCE. Opportunistic annual non symptomatic OCE by PCPs who have been trained in OCE techniques may result in consistent early detection of OPC, particularly for patients at high risk for developing the disease.

Background and Purpose: The purpose of this study was to document the psychometric properties of the Patient Activation Measure (PAM) in hospitalized multimorbid patients., Methods: Data from 313 patients were used for psychometric testing., Results: Estimated reliability of the PAM was .88; the content validity index was .91. Convergent and divergent validity with measures of physical functioning, depression, quality of care, severity of illness, and number of multimorbid conditions were confirmed. Confirmatory factor analysis did not support a good fit of the 1-factor model., Conclusion: The PAM is a reliable and valid instrument to assess patient activation in hospitalized multimorbid patients. Further study is needed to determine what factors predict activation and how activation can assist in tailoring discharge planning.

Purpose: If clinicians and researchers are aware of specific cardiovascular risks associated with women's rural status, whether it be large or small/isolated rural areas, it may help in developing more relevant rural resources. The purpose of this study was to examine whether there were differences in modifiable cardiovascular risk factors of overweight and obese rural women living in large or small/isolated rural areas., Sample: This secondary analysis examined baseline cross-sectional data from the "Web-based Weight Loss and Weight Maintenance Intervention for Older Rural Women" clinical trial. Analysis included data from 299 rural Midwestern women, ages 40-69 years with a baseline body mass index of 28-45 kg/m 2 , who provided rural classification data and were randomized into groups., Methods: Demographic and biomarker baseline data were used. Chi-square and independent t-tests were used for data analyses., Findings: There are no significant differences found in overweight and obese women with cardiovascular risk factors when compared to rural classification, with one exception. Total cholesterol was associated with rural classification (p=0.047), where women living in large rural areas were more likely to have elevated total cholesterol levels (≥240 mg/dL) compared to women living in small/isolated areas (18.5% vs. 10.0%, respectively). Demographic characteristics such as age and education demonstrated no significant differences by rural classification; however, the majority of women in this study were of high socioeconomic status., Conclusions: Although this secondary analysis found that rural women have similar cardiovascular risk factors and demographic characteristics, this study highlights the need for clinicians to carefully consider the rural community characteristics for primary prevention.

Two broad issues that beginning graduate nursing students face are identifying a research focus and learning how to organize complex information. Developing a mind map is 1 strategy to help students clarify their thinking and lay the foundation for in-depth expertise related to their research focus, review of the literature, and conceptual framework. The authors discuss their use of mind mapping combined with feedback using a fishbowl technique.

Background: Overall perceived health (OPH) is a powerful and independent predictor of negative health outcomes and low health-related quality of life. Overall perceived health is conspicuously low in patients with heart failure (HF)., Objective: The purpose of this study was to determine the key predictors of OPH in persons with HF and explore possible mediating relationships., Methods: This cross-sectional predictive correlational study was a secondary analysis of an existing data set. Individual characteristics, biophysiological variables, physical symptoms, psychological symptoms, and physical and social functioning were identified from the Wilson and Cleary Model and tested as predictors of OPH in a 5-step hierarchical regression analysis., Results: The sample (n = 265) was primarily male (64.2%) and white (61.9%), with a mean age of 62 years, and had at least a high school education and a household income enough or more than enough to meet needs. Most (69.1%) had systolic dysfunction, and 78.5% were New York Heart Association class III or IV. The final model containing 15 predictors explained 39.2% of the variance in OPH. Six variables were significant independent predictors of OPH: perceived sufficiency of income, social functioning, comorbid burden, symptom stability, race, and the interaction of gender and social functioning, the last indicating social functioning as a stronger predictor for men than for women. In a multiple mediation analysis, the effects of shortness of breath and fatigue on OPH were mediated by physical and social functioning. Gender moderated the effect of fatigue through social functioning., Conclusions: These variables explained a significant portion of the variance in OPH and can be used to target individuals at risk for low OPH and to tailor interventions. If OPH is low, a focus on patient symptoms and ability to participate in life activities is appropriate, with particular attention to social functioning in men.

Background: Cognitive impairment is a recognized consequence of heart failure; however, there are no neuropsychological batteries with documented psychometric data in the chronic heart failure population., Aims: To document the psychometric properties of a brief neuropsychological battery in a chronic heart failure sample., Methods: The Repeatable Battery for the Assessment of Neuropsychological Status, Trail Making Test Part A and Part B, and letter fluency was administered to a sample of individuals with chronic heart failure., Results: Eighty individuals with stable heart failure participated in this study. Individuals with chronic heart failure scored significantly lower than expected age and education adjusted norms in the domains of attention (p < 0.001), memory (p < 0.001), language (p < 0.001), executive function (p < 0.001), and psychomotor speed (p = 0.02). Scores on the tests of memory and executive function correlated to functional status (r = 0.28, p = 0.02 and r = 0.29, p = 0.03, respectively). Acceptable convergent validity and test-retest reliability were documented for this battery., Conclusion: The neuropsychological battery had adequate reliability and validity in individuals with chronic heart failure.

Despite increased attention to providing seamless transitions after hospitalization, patients often feel unprepared, lack knowledge, and may be confused by what to expect during recovery at home after a cardiac event. Care transition after hospital discharge could be improved by informing and counseling patients more specifically about expected recovery after a cardiac event. Therefore, an integrative review of research was conducted to evaluate cardiac patients' trajectory of recovery after hospitalization. A total of 61 studies were included in this review. Studies included were those of cardiac patients who had been hospitalized for significant cardiac events and those focused on acute coronary syndrome (n = 18), percutaneous coronary intervention (PCI) (n = 12), cardiac surgery (coronary artery bypass surgery and valve surgery; n = 25), and heart failure (n = 6). Studies included quantitative, mixed-methods, and qualitative designs, with sample sizes ranging from 4 to 2121 participants. Notwithstanding the limitations of this review, findings demonstrated that patients' perceptions of their cardiac event evolved over time from uncertainty, fears, anxiety, and depression, which were often associated with a lack of knowledge of their cardiac condition, to a phase of self-management of their cardiac condition. Furthermore, patterns of commonly occurring symptoms and changes in functioning abilities during recovery after hospitalization were apparent among the different cardiac groups. These findings may be useful to both patients and clinicians to inform them about the recovery trajectory after a cardiac event to improve preparation for the transition from hospital to home.

Older women have lower levels of physical functioning and higher associated health care costs than men after coronary artery bypass surgery (CABS). Clinical trials have demonstrated that interventions to increase physical activity levels can reduce the risk of recurrent cardiac events, reduce health care expenditures, prolong life, improve functional capacity, and increase quality of life in the elderly cardiac population. It is important for the patients, providers, health care payers, and policymakers to identify a cost-effective recovery intervention that has the potential to increase women's physical activity and functioning during their early recovery from CABS, especially in this time of limited health care resources. This home-based symptom management intervention has the potential to reduce the risk of recurrent cardiac events and health care cost by improving women's physical activity level after surgery. This information is vital to nursing leaders in making resource decisions regarding followup care of women who have had heart surgery.

Purpose: The purpose of this sub-analysis was to compare the early recovery of elderly patients following coronary artery bypass surgery (CABS) by geographic location (urban/rural) on physical functioning and physical activity., Methods: The sample was 124 subjects who had been in the usual care group (or control group) of a randomized controlled trial. Subjects were categorized into geographic locales using Rural Urban Commuting Area (RUCA) codes: urban n=35, large rural n=17, small rural n=23 and isolated rural n=33. Measures included the Medical Outcomes Study Short-Form 36 and the RT3® accelerometer. Mixed linear models were used to analyze the data., Results: No significant differences were found for physical functioning by RUCA group. However, there was a statistically significant difference for physical activity, for average kcals/kg/ per day (F = 3.01, p < .05) and average daily activity counts (F = 3.95, p <.01), with the subjects in large rural communities having significantly (p < 0.05) more average kcals/kg per day than urban subjects (M = 29.04 and M = 27.25 respectively). Subjects in the large rural also had significantly (p < .005) more average daily activity counts than urban (M = 216635 and M = 161221 respectively)., Conclusions: This is the first study to compare early recovery functioning and activity outcomes of CABS subjects by rural/urban locations. Additional study is warranted to evaluate why these differences exist and the potential need to tailor interventions for CABS based on geographic location.

Aim and Objective: To examine the interventions used to improve self-care of heart failure patients. The specific objectives were to examine the efficacy of interventions to improve heart failure self-care (self-maintenance and self-management behaviours) and patient-related factors such as knowledge about heart failure, self-efficacy for heart failure self-care (confidence) and beliefs regarding heart failure self-care., Background: Despite the significant advances in the treatment and management of heart failure, there continues to be poor patient outcomes associated with this clinical syndrome., Design: An integrative review., Method: A search of MEDLINE, PsychINFO, Cochrane data base of clinical trials and the cumulative index of nursing and allied health literature (CINAHL) databases was conducted using 14 search terms for a period from 2000-2010. Hand searching of reference lists and author lists was also conducted. Nineteen eligible self-care intervention studies were included in this review., Results: Cognitive-behavioural intervention mechanisms were most frequently used to improve patient's heart failure self-care. In the majority of the studies, the interventions demonstrated efficacy by improving heart failure patients' self-care maintenance and management behaviours. Intervention group subjects, in the majority of studies, had significantly higher levels of knowledge pertaining to heart failure and heart failure related self-care., Relevance to Clinical Practice: Based on these findings, there are improved patient outcomes when standard patient education for heart failure is augmented using cognitive-behavioural strategies that include additional evidence-based education and counselling., (© 2011 Blackwell Publishing Ltd.)

Background: Despite known gender differences in recovery, few studies have examined symptom management (SM) interventions or responses by gender after coronary artery bypass surgery (CABS)., Objective: The purpose of this subanalysis was to describe and evaluate differences in response by gender to an SM intervention on the presence and burden of symptoms, physical activity, and physical functioning in elderly CABS patients during the early discharge period (3 and 6 weeks after CABS, and 3 and 6 months after CABS)., Methods: The parent study whose data were analyzed to examine gender differences involved a two-group, randomized clinical trial design. The 6-week early recovery SM telehealth intervention was delivered by the Health Buddy. Measures included the Cardiac Symptom Survey, a Modified 7-Day Activity Interview, an RT3 accelerometer, an Activity Diary, and the Medical Outcomes Study Short Form 36. This study was not powered for a gender × group analysis, and we used descriptive statistics, χ(2) tests, t tests, and analysis of variance for statistical analyses., Results: Subjects (n = 232) included 192 men and 40 women, with a mean age of 71.2 SD, 7 years. The intervention group consisted of 86 men and 23 women, and the usual care (UC) group consisted of 106 men and 17 women. Data trends suggest that the SM intervention exerted greater impact on women than on men for symptoms such as fatigue, depression, sleep problems, and pain. Again, men exhibited higher levels of physical activity than did women. However, women in the SM group generally had higher scores than did women in the UC group., Conclusion: Although the parent study found no effect of an early recovery SM intervention, this exploratory secondary analysis indicated that women in the intervention group demonstrated more improvement in measures of physical activity than did those in the UC group. Further study, using a larger sample, is necessary to test these preliminary results., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Numerous studies have reported that exercise is safe and beneficial for breast cancer survivors; however, long-term adherence to exercise programs is not easy to accomplish. This secondary analysis examined the demographic and clinical characteristics, adherence to exercise, and cognitive-behavioral intervention components data collected on 120 postmenopausal women with a history of breast cancer and bone loss who had been randomized to the exercise group in a 24-month study. Hierarchical regression was used to identify variables that predicted adherence to exercise. Mean adherence to exercises was 61.89%. Feedback and support were the most frequently used cognitive-behavioral intervention components. In hierarchical regression, predictors for adherence to exercise were feedback (β = .40, p < .001) and adherence to exercise in the previous time period (β = .31, p < .001). Participants receiving more frequent feedback had higher adherence to exercise.

The purpose of this secondary analysis was to describe symptom management strategies used by elderly patients (n = 236) 3 and 6 weeks after coronary artery bypass surgery (CABS). Three weeks after surgery, the most frequently used strategies were rest to manage shortness of breath (53%) and fatigue (53%), medications for incision pain (24%), and repositioning for swelling (35%) and sleep disturbance (18%). Overall, fewer patients experiencing sleep disturbances (39%), incision pain (39%), swelling (46%), and appetite problems (17%) reported using a strategy to manage their symptom. Nurses must assist patients in symptom identification and problem solving to accomplish effective symptom management., (Published by Elsevier Inc.)

Objective: The purpose of this secondary analysis was to describe medication use and examine the relationship between medications and postoperative symptoms/problems in the first 3 months after coronary artery bypass surgery (CABS)., Methods: The sample consisted of older (≥65 years) men and women (n = 232) who had undergone CABS. Medication data were collected through self-report 3 and 6 weeks and 3 months after surgery., Results: Most patients reported taking aspirin (88.2%-85.7%), statins or cholesterol-lowering drugs (88.6%-87%), and beta-blockers (68%-55.6%). No significant differences were found between the proportion of patients taking and not taking beta-blockers, antiarrhythmics, cholesterol-lowering drugs, or angiotensin-converting enzyme inhibitor medications for common medication-specific symptoms/problems., Conclusion: Patients experience symptoms after surgery, but these symptoms did not seem to be side effects from medications. Nursing assessments and interventions targeting postoperative symptoms, symptom management, and medication side effects can enhance recovery and reinforce medication adherence., (Copyright © 2011 Elsevier Inc. All rights reserved.)

This pilot study examined the impact of a hospital transition intervention for older adults (≥ 65 years of age) with heart failure (HF) to promote medication use self-management. Forty subjects, hospitalized with either primary or secondary HF, had a mean age of 76.9 ± 6.5 years; 65% were males. The majority of subjects (55%) had NYHA Class III HF. A prospective, repeated measures experimental design was used. Baseline and follow-up data (1- and 3-months after hospitalization) were obtained using the Medication Regimen Complexity Index, Brief Medication Questionnaire, Drug Regiment Unassisted Grading Scale, and Kansas City Cardiomyopathy Questionnaire. Using repeated measures analysis of covariance (ANCOVA), with baseline measures as covariates, the transition intervention group had higher levels of medication adherence (F(1,35) = 13.4, p < .001), self-efficacy for HF self-care (F(1,35) = 17.9, p < .001) and had significantly fewer HF related symptoms that impaired health related quality of life (F(1,35) = 9.1, p = .006).

The purpose of this study was to determine which symptoms are the most reported occur most frequently, have the greatest severity, and cause the most bother for patients on hemodialysis (HD), and to determine if the symptoms experienced differ between the first (HD1) and second (HD2) treatments of the week. An observational, comparative design was used to determine participants' HD symptoms experienced on HD1 and HD2, and the effect of the symptom experience on quality of life (QOL). One hundred subjects were recruited from five dialysis centers. The adapted Dialysis Frequency, Severity, and Symptom Burden Index (DFSSBI) and the Medical Outcomes Study Short Form 36 (MOS SF 36) were administered (N = 99) on HD1 and the DFSSBI again on HD2. Data were analyzed for significance among symptom experience test scores in relation to HD1 and HD2, QOL, and gender and age. Of 31 symptoms assessed respondents reported an average of 9.77 symptoms on HD1 and 7.51 symptoms on HD2. Overall, more symptoms were reported and were more frequent, severe, and bothersome on HD1 when the level of metabolic waste is highest. The most reported symptoms included tiredness, dry skin, difficulty falling asleep, itching, numbness/tingling, difficulty staying asleep, decreased interest in sex, and bone/joint pain. Females scored consistently higher than males in the four symptom dimensions. Respondents reported about the same as the population norm (50) on the physical component summary score of the MOS SF 36 and higher than the norm (65.23) on the mental component summary score. The study found patients on HD experience multiple symptoms that can be frequent, severe, and bothersome. Interventions should be developed and tested to reduce symptom bother and improve QOL.

Although there is extensive literature on symptoms experienced by patients after coronary artery bypass surgery (CABS), there is a paucity of data on symptom clusters and their impact on functional outcomes. The purpose of these descriptive, secondary analyses was to identify and describe cluster subgroups of 226 elderly CABS patients at discharge and to examine the cluster's impact on psychosocial functioning over time (baseline, 6 weeks, and 3 months) using the 36-item Medical Outcome Study Short Form subscales. Cluster analysis revealed a 3-cluster solution with low, low-moderate, and moderate symptom burden clusters. Significant differences were detected for Duke Activity Status Index (F(2,223) = 5.12, P = .007), Barnason Efficacy Expectation Scale (F(2,223) = 9.60, P < .0001), Hospital Anxiety and Depression Scale (F(2,219) = 15.14, P < .0001), and New York Heart Association classification (chi = 17.44, P = .008). Significant differences were noted on all variables between the low and moderate symptom burden clusters with differences between the low-moderate and moderate clusters for only the Barnason Efficacy Expectation Scale and the Hospital Anxiety and Depression Scale. Those in the moderate symptom burden cluster had more symptoms, anxiety, and depression along with lower self-efficacy and physiological functioning than those in the other 2 clusters. There was no interaction or simple main effects for the role-emotional or social subscales as measured by the 36-item Medical Outcome Study Short Form. There was no significant interaction for mental functioning by time and cluster (F(4,641) = .30, P = .88); however, there was a simple main effect for cluster (F(2,641) = 4.11, P = .02). Follow-up analysis indicated significant differences between the low and low-moderate clusters, indicating that those with low symptom burden had significantly better mental health functioning than those with moderate symptom burden. Findings provide a foundation of knowledge on symptom clusters in CABS populations and may be useful to clinicians to identify patients at risk for slowed or delayed recovery and for early intervention.