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The identification of precursors to safety incidents in aviation data is a crucial task, yet extremely challenging. The main approach in practice leverages domain expertise to define expected toler...

The purpose of this study was to determine the prevalence of respiratory and/or physical fitness health problems in adolescent (ages 18-21) water pipe (WP) smokers (with or without cigarette smoking), cigarette-only smokers, and nonsmokers.A comparative four-group study design was used to recruit a non-probability sample of 153 WP smokers only, 103 cigarette smokers only, and 102 cigarette+WP smokers along with 296 nonsmokers. Our hypothesis was that youth who smoked WPs and/or cigarettes would report more respiratory problems and/or poorer physical fitness than those who did not smoke.The results showed that coughs were significantly associated with smoking in all three of the smoking groups (p.05). Cigarette-only smokers reported the most adverse outcomes with more wheezing, difficulty breathing, and less ability to exercise without shortness of breath. A dose-response analysis showed similar patterns of adverse health effects for both WP and cigarette smokers. The combined use of both products was not appreciably worse than smoking one product alone. This could be due to cigarette+WP smokers' reporting using less of the respective products when only one product was smoked.Even during the adolescent years, WP and/or cigarette smoking youth experienced reportable negative health effects.

While individual and family risk factors that contribute to health disparities in children with type 1 diabetes have been identified, studies on the effects of neighborhood risk factors on glycemic control are limited, particularly in minority samples. This cross-sectional study tested associations between family conflict, neighborhood adversity and glycemic outcomes (HbA1c) in a sample of urban, young Black adolescents with type 1 diabetes(mean age = 13.4 ± 1.7), as well as whether neighborhood adversity moderated the relationship between family conflict and HbA1c. Participants (N = 128) were recruited from five pediatric diabetes clinics in two major metropolitan US cities. Diabetes-related family conflict was measured via self-report questionnaire (Diabetes Family Conflict Scale; DFCS). Neighborhood adversity was calculated at the census block group level based on US census data. Indictors of adversity were used to calculate a neighborhood adversity index (NAI) for each participant. Median family income was $25,000, suggesting a low SES sample. In multiple regression analyses, DFCS and NAI both had significant, independent effects on glycemic control (β = 0.174, P = 0.034 and β = 0.226 P = 0.013, respectively) after controlling for child age, family socioeconomic status and insulin management regimen. Tests of effects of the NAI and DFCS interaction on HbA1c found no significant moderating effects of neighborhood adversity. Even within contexts of significant socioeconomic disadvantage, variability in degree of neighborhood adversity predicts diabetes-related health outcomes in young Black adolescents with type 1 diabetes. Providers should assess social determinants of health such as neighborhood resources that may impact adolescents' ability to maintain optimal glycemic control. This article is protected by copyright. All rights reserved.

Purpose Chronic exposure to racial discrimination by pregnant African American women may lead to allostatic overload; thereby, predisposing women to systemic inflammation. Thus, the goal of this study was to examine if experiences of racial discrimination are related to systemic inflammation in pregnant African Americans. Methods A sample of 96 African American women from Chicago completed questionnaires and had blood drawn during the second trimester of pregnancy (19.7±2.5 weeks). Results Experiences of racial discrimination were associated with higher cytokine levels of interleukin (IL)-4 ( B =2.161, 95% CI=1.02–3.30, p p =.004) when controlling for covariates. Conclusion These findings suggest that experiences of racial discrimination may cause physiological wear and tear on the body leading to alteration of immune functions. Nurses should inquire about women's experiences of racial discrimination and make referrals for community or church support groups for women who report racial discrimination.

PURPOSE The purposes of this study were to (a) compare sleep quality of persons with and without injection-related venous ulcers (VU) and (b) examine associations between global sleep quality with age, sex, comorbidities, pain, nutrition, physical health rating, fatigue, emotional problems, health-related quality of life, attitude toward physical activity, and number of ulcers. DESIGN This study used a cross-sectional design. SUBJECTS AND SETTING The participants included 31 patients with VU and 30 without VU (men [n = 35] and women; mean age = 54 years) who were attending an indigent clinic for wound care or general health. METHODS Participants were recruited from an urban clinic when they came for primary care or wound care. Questionnaires were administered at that time and included the Pittsburgh Sleep Quality Index (PSQI), Mini Nutrition Assessment, Patient Reported Outcomes Measurement Information System (PROMIS) questions about general physical health, fatigue, emotional problems, and quality of life, Brief Pain Inventory worst pain rating, Positive Attitude and Motivation for Physical Activity Scale, wound assessment, and demographic factors. RESULTS The 2 groups did not differ on the PSQI in terms of time going to bed, minutes to fall asleep, time awakening, hours slept, and time in bed. Those with VU compared to without VU took more medications to help sleep (P≤ .03). There were no significant differences in PSQI correlations across groups. All study variables except age, gender, and quality of life were significantly related to Global sleep disturbance score. A higher number of comorbid conditions, worse pain, poorer nutrition, poor physical health rating, greater fatigue, more emotional problems, and poor attitude toward physical activity were related to greater sleep disturbances for all participants. Both groups had mean Global PSQI scores greater than 5 (with VU = 7.83 and without VU = 8.2), indicating sleep problems. CONCLUSIONS Study findings suggest that sleep disturbances may be a concern in persons with VU and are related to many variables. Assessing sleep along with other aspects of wound care may provide a more comprehensive assessment of factors affecting a person with a VU.

Purpose This study examined the relationships among father of the baby involvement during pregnancy, depressive symptoms, and psychological well-being in African American women. Study design and methods Using a prospective study design, a sample of 95 pregnant African American women receiving prenatal care at a medical center in Chicago completed the self-report instruments about father of the baby involvement, depressive symptoms, and psychological well-being twice during pregnancy, once at between 15 and 25 weeks and once between 25 and 37 weeks. Results Eighty percent of women reported that the father of the baby was involved during their pregnancy. Twenty-eight percent of women had clinically relevant depressive symptoms (CES-D scores ≥16) at the first data collection and 25% of women had clinically relevant depressive symptoms at the second data collection. Compared with women who reported no father involvement during pregnancy, women who reported father involvement during pregnancy had lower levels of depressive symptoms and higher levels of psychological well-being. Clinical implications Fathers' involvement is important during pregnancy; nurses should encourage fathers to participate at prenatal visits and ask questions, and educate fathers on pregnancy process and procedures during prenatal care.

OBJECTIVES: To determine the efficacy of the Power Over Pain–Coaching (POP-C) intervention to improve functional status among African American outpatients with cancer pain. SAMPLE & SETTING: 310 African American patients were recruited from an urban comprehensive cancer center. The study took place in the patients’ homes. METHODS & VARIABLES: A two-group randomized design with repeated measures was used. Data were analyzed with linear mixed effects regression analysis and structural equation change score models. Variables were pain, pain-related distress, functional status, perceived control over pain, and the following antecedents to control: medication management, pain advocacy, and living with pain. RESULTS: Functional status was improved in POP-C participants relative to control group participants (p < 0.05). Distress also was differentially decreased (p < 0.05). Pain intensity ratings decreased significantly in all patients (p < 0.05). The largest intervention effects were observed in the living with pain component. IMPLICATIONS FOR NURSING: Perceived control over pain was strongly related to functional status and is amenable to interventions using the POP-C intervention components described in this article.

Living in a lower-quality neighborhood is associated with higher levels of depressive symptoms in the general population as well as among pregnant and postpartum women. However, little is known of the important pathways by which this association occurs. We proposed a model in which perceived stress and social support mediated the effects of neighborhood quality on depressive symptoms during pregnancy (measured by the 20-item Center for Epidemiologic Studies-Depression, CES-D, scale) in a sample of 1383 African American women from the Detroit metropolitan area interviewed during their delivery hospitalization. Using structural equation modeling (SEM), we built a latent variable of neighborhood quality using 4 measures (neighborhood disorder, neighborhood safety/danger, walking environment, overall rating). We then tested two SEM mediation models. We found that lower neighborhood quality was associated with higher prevalence of depressive symptoms during pregnancy (standardized total effect = .16, p = .011). We found that perceived stress partially mediated the neighborhood quality association with depressive symptoms. Although the association of social support with depressive symptoms was negligible, social support mediated associations of neighborhood quality with perceived stress [standardized path coefficient = .38 (.02), p = .009]. Our results point to the need for public health, health care, as well as non-health related interventions (e.g. crime prevention programs) to decrease overall exposure to stressors, as well as stress levels of women living in poor quality neighborhoods. Interventions that increase the levels of social support of women during pregnancy are also needed for their potential to decrease stress and ultimately improve mental health at this important time in the life course.

Symptoms of depression have been related to lower gestational age and preterm birth (37 completed weeks gestation). Leisure time physical activity may have protective effects on preterm birth; however, less has been published with regard to other domains of physical activity such as walking for a purpose (e.g., for transportation) or the pathways by which symptoms of depression impact gestational age at birth.This was a secondary analysis of available data of African American women. Women were interviewed within 3 days after birth. We proposed a model in which walking for a purpose during pregnancy mediated the effects of symptoms of depression (measured by the 20-item Center for Epidemiologic Studies-Depression [CES-D] scale) on gestational age at birth in a sample of 1,382 African American women.Using structural equation modeling, we found that the direct effect of CES-D scores of 23 or greater, which have been correlated with major depression diagnosis, on gestational age at birth was -4.23 (p .001). These results indicate that symptoms of depression were associated with a decrease in gestational age at birth of 4.23 days. Walking for a purpose mediated the effect of CES-D scores of 23 or greater on gestational age at birth.Compared with African American women without symptoms of depression, African American women who had symptoms of depression walked less for a purpose during their pregnancy and delivered infants with lower gestational age at birth. If not medically contraindicated, clinicians should incorporate walking as part of prenatal care recommendations and reassure women about safety of walking during pregnancy.

Background: Oral anticoagulation therapy using Coumadin (warfarin) requires significant patient involvement. Limited validated instruments exist to test patient knowledge of Coumadin, and low health literacy may impede patient self-management. Objective: This article reports the psychometric testing of the Knowledge Information Profile–Coumadin (KIP-C20) to determine ( a) minimum number of items and dimensions, ( b) reliability, and ( c) construct validity. Methods: Participants (N = 192) were recruited from outpatient pharmacist-directed anticoagulation clinics associated with an urban teaching hospital in the Midwest United States. Instruments were the Animal Naming test (AN), Rapid Estimate of Adult Literacy in Medicine (REALM), and KIP-C20. Multidimensional item response theory modeling and exploratory factor analyses were used to determine the best fitting model. Results: The final instrument, renamed KIP-C14, with 3 factors and 14 items, had a good fit to data (M2 = 96.49, P < .0001; root mean square error of approximation = .04), and all factor loadings were .3 or larger. Internal consistency reliability was .65; test–retest correlation was .67. The KIP-C14 correlated positively, as expected, with years of Coumadin treatment. Subscales were differentially correlated with sociodemographic variables. Conclusions: The KIP-C14 had nearly identical, slightly higher reliability than the KIP-C20. Still, reliability was lower than expected, indicating a promising clinical assessment scale in need of further refinement.

Understanding the dynamics of mental health stigma through existing frameworks, especially in minorities with higher stigma, is problematic. There is a need to reconceptualize stigma, particularly in highly traumatized groups. The current study examines the validity of a new development-based trauma framework that conceptualizes stigma as a type III chronic trauma that contributes to negative mental health effects. This framework proposes that public stigma is a unique chronic traumatic stress that mediates the effects of similar trauma types in mental health patients. To test this proposition, this study explores the relationships between internalized stigma of mental illness (ISMI), different trauma types, and posttrauma spectrum disorders. ISMI, posttraumatic stress disorder, other posttrauma spectrum disorders, and cumulative trauma measures were administered to a sample of 399 mental health patients that included Arab (82%), Muslim (84%), and refugee (31%), as well as American patients (18%). Age in the sample ranged from 18 to 76 years ( M = 39.66, SD = 11.45), with 53.5% males. Hierarchical multiple regression, t tests, and path analyses were conducted. Results indicated that ISMI predicted posttraumatic stress disorder and other posttrauma spectrum disorders after controlling for cumulative trauma. ISMI was associated with other chronic collective identity traumas. While Arab Americans, Muslims, and refugees had higher ISMI scores than other Americans, the elevated chronic trauma levels of these groups were significant predictors of these differences. The results provide evidence to support ISMI traumatology model. Implications of the results for treating victims of ISMI, especially Arab Americans, Muslims and refugees are discussed.

Objective The primary purpose of the study was to determine whether Multisystemic Therapy adapted for health care settings (MST-HC) improved asthma management and health outcomes in high-risk African American adolescents with asthma. Method Eligibility included self-reported African American ethnicity, ages 12 to 16, moderate to severe asthma, and an inpatient hospitalization or at least 2 emergency department visits for asthma in the last 12 months. Adolescents and their families (N = 170) were randomized to MST-HC or in-home family support. Data were collected at baseline and posttreatment (7 months) based on an asthma management interview, medication adherence phone diary, and lung function biomarker (forced expiratory volume in 1 s [FEV1]). Analyses were conducted using linear mixed modeling for continuous outcomes and generalized linear mixed modeling for binary outcomes. Results In intent-to-treat analyses, adolescents randomized to MST-HC were more likely to improve on 2 of the measures of medication adherence and FEV1. Per-protocol analysis demonstrated that MST-HC had a medium effect on adherence measures and had a small to medium effect on lung function and the adolescent's response to asthma exacerbations. Conclusion There are few interventions that have been shown to successfully improve asthma management in minority youth at highest risk for poor morbidity and mortality. MST, a home-based psychotherapy originally developed to target behavior problems in youth, improved asthma management and lung function compared to a strong comparison condition. Further follow-up is necessary to determine whether MST-HC reduces health care utilization accounting for seasonal variability. A limitation to the study is that a greater number of participants in the control group came from single-parent families than in the MST group.

Significant racial disparities exist in pregnancy outcomes, but few researchers have examined the relationship between trust in providers and pregnancy outcomes. The Trust in Physician Scale (TPS), the most widely used tool, has not been tested in pregnancy. We assessed the psychometric properties of the TPS and identified correlates of trust in 189 pregnant African American women. Evidence supports internal consistency reliability (>.85) and internal structure of the TPS (CFI = .97; RMSEA = .05; χ(2) (42) = 65.93, p = .001), but TPS scores did not predict pregnancy outcomes. African American women reported a high level of trust in obstetric providers. Trust did not differ by provider type (physician or midwife) but was related to the women's history of perceived racism and strength of ethnic identity.

Objective Prior research suggests that adverse neighborhood conditions are related to preterm birth. One potential pathway by which neighborhood conditions increase the risk for preterm birth is by increasing women's psychological distress. Our objective was to examine whether psychological distress mediated the relationship between neighborhood conditions and preterm birth. Design and Sample One hundred and one pregnant African-American women receiving prenatal care at a medical center in Chicago participated in this cross-sectional design study. Measures Women completed the self-report instruments about their perceived neighborhood conditions and psychological distress between 15–26 weeks gestation. Objective measures of the neighborhood were derived using geographic information systems (GIS). Birth data were collected from medical records. Results Perceived adverse neighborhood conditions were related to psychological distress: perceived physical disorder (r = .26, p = .01), perceived social disorder (r = .21, p = .03), and perceived crime (r = .30, p = .01). Objective neighborhood conditions were not related to psychological distress. Psychological distress mediated the effects of perceived neighborhood conditions on preterm birth. Conclusions Psychological distress in the second trimester mediated the effects of perceived, but not objective, neighborhood conditions on preterm birth. If these results are replicable in studies with larger sample sizes, intervention strategies could be implemented at the individual level to reduce psychological distress and improve women's ability to cope with adverse neighborhood conditions.

Pre-Conference Workshop in conjunction with the Annual Meeting of the Geriatrics Society of America San Diego Convention Center, San Diego, CA, USA, 14 November 2012 In 2004, the NIH awarded contracts to initiate the development of high-quality psychological and neuropsychological outcome measures for the improved assessment of health-related outcomes. The workshop introduced these measurement development initiatives, the measures created and the NIH-supported resource (Assessment Center) for internet or tablet-based test administration and scoring. Presentations covered item response theory and assessment of test bias, construction of item banks and computerized adaptive testing, and the different ways in which qualitative analyses contribute to the definition of construct domains and the refinement of outcome constructs. The panel discussion included questions about representativeness of samples and the assessment of cultural bias. © 2013 Expert Reviews Ltd.

Background The Respiratory Distress Observation Scale © (RDOS) is a means for assessing respiratory distress when a patient is unable to give a dyspnea self-report. Cut-point determination was needed to guide clinical application. Method A Receiver Operating Characteristic (ROC) curve analysis was conducted in a prospective, observation study with inpatients ranked by nurse practitioners (NP) into levels of respiratory distress. A research assistant simultaneously measured RDOS blinded to NP ranking. Results Participants were 84 adults: mean age of 72.6 (SD = 15.2) years, 53.6% male, 77.4% African-American. NP ranking was distributed: none (30%), mild (26%), moderate (31%), and severe (13%) distress. RDOS scores ranged 0–13 ( M = 4.8, SD = 3). NP ranking was significantly correlated with RDOS ( rho = .91, p p Conclusions Intensity cut-point enhances the clinical utility of the RDOS.

To provide information about a quality improvement project examining falls in persons seeking outpatient wound care.This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.After participating in this educational activity, the participant should be better able to:1. Describe the scope of the problem and the related quality improvement project. 2. Delineate the results of the project and their implications for treatment of patients with venous ulcers.The authors aim to examine fall occurrence and fall injuries in persons seeking outpatient wound care and to compare falls, balance confidence, and lower-body strength in persons with injection-related venous ulcers (IRVUs) versus persons with venous ulcers (VUs) related to other risk factors besides injection drugs (VUs-other).This quality improvement project used a cross-sectional, comparative design. Participants responded to demographic questions, the Activities-specific Balance Confidence (ABC) Scale, fear of falling, fall numbers, and injuries and performed the 30-second chair-rise test.Outpatient wound service.Patients (N = 106; mean age, 59.94 years) included men (66%) and women.Sixty patients reported falling; 47 were recurrent fallers. Twenty patients stated they were injured, but did not go to an emergency department. A higher number of total falls was significantly related to more comorbidities. Total falls were significantly related to fear of falling and ABC Scale scores. Those with VUs-other had significantly more comorbidities and higher body mass index values than those with IRVUs. Those with IRVUs were comparable to those VUs-other on number of falls and fear of falling, respectively. Those with IRVUs (7.30) performed significantly more chair rises than those with VUs-other (4.72). Persons with IRVUs had significantly higher ABC Scale scores (63.24%) than those with VUs-other (49.38%).Falls are a common occurrence in persons seeking outpatient wound care. Despite greater strength sufficient to perform more chair rises among those with IRVUs, fall rates were comparable to those of weaker individuals with other types of VUs. With the high occurrence of falls during the project, long-term risk for fall injury would be high. Further research is needed to clarify interactions between VU risk and patient factors such as strength, age, agility, and impaired cognition.

To determine whether obstructive sleep apnea mediates the relationship between posttraumatic stress disorder (PTSD) and psychosomatic and somatic disorders and its implications for self-rated health (SRH) among Iraqi immigrants in the United States.A random sample of immigrants who had left Iraq before the 1991 Gulf War (n = 145) or after (n = 205) and are residing in metropolitan Detroit responded to a structured interview covering questions on sociodemographics, premigration trauma, SRH, physician-diagnosed and -treated obstructive sleep apnea, somatic disorders, and psychosomatic disorders. Structural equation modeling was used to evaluate the relationship between premigration trauma scores and health, as well as to explore mediating pathways between PTSD, obstructive sleep apnea, and health.The prevalence of obstructive sleep apnea among post-Gulf Warimmigrants (30.2%) was significantly higher than among pre-Gulf War immigrants (0.7%; p.001). Premigration trauma scores were positively associated with depression and PTSD. Structural equation modeling supported a model in which obstructive sleep apnea mediated the relationship between PTSD and psychosomatic and somatic disorders. Premigration trauma also related directly to SRH.Part of the PTSD-associated adverse health effects observed in Iraqi immigrants is mediated by obstructive sleep apnea. Because sleep apnea in the current study is based on medical history and current treatment, there is a need for future confirmatory polysomnographic studies.

Depression and inflammation are associated with poorer birth outcomes. African-American women have higher levels of inflammatory biomarkers, more depressive symptoms, and a disparate burden of poorer birth outcomes, but the association between depressive symptoms and inflammation within this higher-risk group is unknown. We examined this association among African-American women in the second trimester of pregnancy and additionally tested whether body mass index (BMI) mediates or moderates this relationship. We recruited 187 women from the obstetrics clinics of a large urban health system. Depression symptoms were measured with the Center for Epidemiological Studies Depression (CES-D) scale and inflammatory biomarkers (high-sensitivity C-reactive protein [hs-CRP], interleukin [IL]-6, IL-10, IL-1β, and tumor necrosis factor-α [TNF-α]) with enzyme immunoassays. Multivariate regression models were fitted to determine the association between CES-D score and each inflammatory biomarker. CES-D was not associated with hs-CRP or TNF-α. CES-D was directly associated with IL-1β (P=0.03). BMI moderated the relationship between CES-D and IL-6 (P

We evaluated the psychometric properties of a revised version of the Parental Monitoring of Diabetes Care questionnaire (PMDC-R) designed to evaluate parental supervision and monitoring of adolescent diabetes care behaviors. The revised measure was intended to capture a broad range of ways used by parents to gather information about youth adherence to diabetes care.Two hundred sixty-seven caregivers of 12-18-year-old adolescents with type 1 diabetes completed the PMDC-R. Measures of parental knowledge of youth illness management, illness management behavior, and metabolic control were also obtained.The PMDC-R demonstrated good internal consistency (alpha coefficient = .91) and test-retest reliability (r = .79, p.001). Supporting the instrument's construct validity, a bifactor model with one primary factor and three secondary factors had an acceptable fit to the data (comparative fit index = .92, root mean square error of approximation = .06). Concurrent validity was also supported. In structural equation models, parental monitoring, as assessed by the PMDC-R, had a significant direct effect on parental knowledge of adolescent diabetes management and, through knowledge, an indirect effect on adolescent diabetes management and metabolic control.The PMDC-R displayed strong psychometric properties and represents an important next step in refining the measurement of parental monitoring for youth with chronic illnesses.

The Internet has the potential for engaging urban seniors in managing their health. This study examined computer and Internet use among urban seniors and their interest in using the Internet as a health-management tool. Findings indicated that many participants were interested in storing and accessing health-related information using an elder-friendly health web portal. Further research, using a community of urban older adults as active members of a health portal design team, could provide a unique viewpoint on how the Internet might be used as a health-information and management tool for older adults.

Diversifying the health professional workforce and enhancing cultural competence are recommended for decreasing health disparities. We tested a structural equation model of the predictors of culturally competent behaviors in a mailed survey of three groups of underrepresented nurse practitioners (n = 474). Our model had good fit and accounted for 29% of the variance in culturally competent behaviors. Life experiences with diversity had direct effects on awareness/sensitivity and behaviors, and diversity training had a direct effect on behaviors. Cultural awareness/sensitivity mediated the relationship between life experiences with diversity and culturally competent behaviors; all paths remained after controlling for covariates. For unique experiences that contribute to workplace diversity, life experiences with diversity, and diversity training are important for culturally competent behaviors. © 2011 Wiley Periodicals, Inc. Res Nurs Health 34:327–341, 2011

Biomarkers of ionising radiation exposure are useful in a variety of scenarios, such as medical diagnostic imaging, occupational exposures, and spaceflight. This study investigates to what extent microRNA (miRNA) expression signatures in mouse peripheral blood can be used as biomarkers for exposures to radiation with low and high linear energy transfers.Mice were irradiated with doses of 0.5, 1.5, or 5.0 Gy γ-rays (dose rate of 0.0136 Gy/s) or with doses of 0.1 or 0.5 Gy (56)Fe ions (dose rate of 0.00208 Gy/s). Total RNA was isolated from whole blood at 6 h or 24 h after irradiation. Three animals per irradiation condition were used. Differentially expressed miRNA were determined by means of quantitative real-time polymerase chain reaction.miRNA expression signatures were radiation type-specific and dose- and time-dependent. The differentially expressed miRNA were expressed in either one condition (71%) or multiple conditions (29%). Classifiers based on the differentially expressed miRNA predicted radiation type or dose with accuracies between 75% and 100%. Gene-ontology analyses show that miRNA induced by irradiation are involved in the control of several biological processes, such as mRNA transcription regulation, nucleic-acid metabolism, and development.miRNA signatures induced by ionising radiation in mouse blood are radiation type- and radiation dose-specific. These findings underline the complexity of the radiation response and the importance of miRNA in it.

Chronic venous disorders (CVD) and peripheral arterial disease (PAD) may affect diverse physical activity domains. How CVD and PAD and other relevant variables affect physical activity was examined in 569 opioid-addicted adults. Both CVD and PAD were significantly inversely related to daily walking, sports, and active living. Effects remained significant in the latent variable regression after controlling covariates. Overall activity was very low; most participants walked less than a half mile daily and rarely engaged in sports. Motivation for physical activity was the strongest predictor (β = .55) of daily physical activity. Health-care professionals promoting physical activity for injection users should consider the vascular health of their legs and motivational variables in addition to general health. © 2010 Wiley Periodicals, Inc. Res Nurs Health 33:426–440, 2010

The effects of discrimination and the post-9/11 backlash on Iraqi refugees have not yet been fully examined. The present study aimed to adapt a scale of the perceived backlash (BTS; a modified version of the Race Related Stressors Scale), and measure its relationships with Cumulative Trauma Dose (CTD), Post-traumatic Stress Disorder (PTSD), and health. The BTS was found to have high reliability; and construct, convergent, divergent, and predictive validities. The BTS predicted PTSD and poor health after controlling for the cumulative effects of other reported life traumas. The BTS correlated significantly with neurological, respiratory, digestive and blood disorders, and non-life-threatening illnesses. The results provided evidence for the validity of the trauma model of backlash and discrimination and its importance in the treatment of Iraqi refugees.

Standard measures of dyspnea rely on self-report. Cognitive impairment and nearness to death may interfere with symptom distress reporting leading to underrecognition and overtreatment or undertreatment. Previous psychometric testing of the Respiratory Distress Observation Scale (RDOS) demonstrated internal consistency and convergent validity with dyspnea self-report and discriminant validity with pain and no dyspnea. Additional testing was needed with patients unable to self-report. The aim of this study was to establish further the reliability and construct validity of a revised RDOS.An observational design was used with 89 consecutive patients referred for inpatient palliative care consultation and at risk for dyspnea who had one or more of lung cancer, chronic obstructive pulmonary disease (COPD), heart failure, or pneumonia. Patients were observed and the RDOS scored once each day for up to three days after the initial consultation. Other measures included: dyspnea self-report, neurologic diagnoses, opioid or benzodiazepine use, peripheral oxygen saturation, end-tidal carbon dioxide level, consciousness, cognitive state, nearness to death, and patient demographics.Perfect interrater reliability across data collectors was achieved. No differences in RDOS scoring were found by patient demographics. RDOS was associated with use of oxygen (p0.01), oxygen saturation (p0.01) and nearness to death (p0.01). A significant decrease in RDOS was found over time corresponding with treatment (p0.01). The reliability of this 8-item scale using Cronbach alpha is 0.64.Declining consciousness and/or cognition are expected when patients are near death. The RDOS performed well when tested with terminally ill patients who were at risk for respiratory distress, most of whom could not self-report dyspnea. The tool is sensitive to detect changes over time and measure response to treatment. The RDOS is simple to use; scoring takes less than 5 minutes. The RDOS has clinical and research utility to measure and trend respiratory distress and response to treatment.

Functional breast cancer literacy was assessed among African-American women and measured at the domain level over time. We used the Kin Keeper(SM) Cancer Prevention Intervention to educate 161 African-American women on three domains of breast cancer literacy: (i) cancer awareness, (ii) knowledge of breast cancer screening modalities and (iii) cancer prevention and control. A breast cancer literacy assessment was administered pre- and post-educational intervention at two time points followed by another assessment 12 months after the second intervention. Generalized estimating equations were specified to predict the probability of correctly answering questions in each domain over time. Domain-level literacy differentials exist; at baseline, women had higher test scores in the breast cancer prevention and control domain than the cancer awareness domain (odds ratio = 1.67, 95% confidence interval 1.19-2.34). After Kin Keeper(SM) Cancer Prevention Intervention, African-American women consistently improved their breast cancer literacy in all domains over the five time stages (P < 0.001) though at different rates for each domain. Differences in domain-level breast cancer literacy highlight the importance of assessing literacy at the domain level. Interventions to improve African-American women's breast cancer literacy should focus on knowledge of breast cancer screening modalities and cancer awareness domains.

Standard measures of dyspnea rely on the patient's self-report. Declining consciousness and/or cognitive function and nearness to death may interfere with dyspnea reporting making the patient vulnerable to undertreatment or overtreatment.An observational design was used with 89 consecutive patients referred for inpatient palliative care consultation. Patients were included if they were at risk for dyspnea because of one or more of the following: lung cancer, chronic obstructive pulmonary disease (COPD), heart failure, or pneumonia. Patients were asked "Are you short of breath?" and asked to quantify any distress by pointing to a visual analogue scale (VAS). Other measures included: consciousness, cognitive state, terminal illness severity, and patient demographics.More than half of the patients (54%) were unable to provide a yes or no response. Only 20 of 41 (49%) able to respond with yes or no were able to quantify any distress with the VAS. Ability to self-report was positively associated with consciousness (p0.01), cognitive state (p0.01), and terminal illness severity (p0.01). A significant inverse relationship was found between consciousness and terminal illness severity (p0.01). Declines in consciousness and cognitive state were strongly correlated with nearness to death (p0.01).Declining consciousness and/or cognitive state are expected when patients are near death. The ability to give even the simplest self-report (yes or no) about dyspnea is lost in the near-death phase of terminal illness, yet the ability to experience distress may persist and may be overlooked and undertreated or overtreated. Other methods for symptom assessment are needed in this context.

Objective Examine the occurrence of and risk factors for peripheral arterial disease (PAD) in a sample in drug treatment. Design Cross-sectional/stratified design. Setting Ten methadone treatment centers in a large Midwestern metropolitan area in the United States. Participants Six hundred forty participants (290 men [45.3%]; mean [SD] age, 46.54 years [8.85 years]) were included in the study. Sixty-one percent were African American, and 93.5% had a history of smoking cigarettes. Main outcome measures PAD was defined as an ankle brachial index of less than 0.90 in at least 1 leg. Measures included demographic, health, and illicit drug use history questionnaires; the Walking Impairment Questionnaire; and body mass index. The Positive Attitude Toward Physical Activities/Exertion Questionnaire was added 9 months into the study; this decreased the sample size of the logistic regression for the predictors of PAD to 498. Main results PAD was identified in 16.7% of the sample; the mean ankle brachial index value for persons with PAD was 0.84 (SD, 0.05). Multiple logistic regression analysis found that sex (women) (odds ratio [OR], 2.10), history of ever smoking cigarettes (OR, 5.16), years of smoking cigarettes (OR, 1.60 per 10 years' smoking), and having a positive attitude toward physical activities/exertion (OR, 0.63) made significant contributions to the predictors for PAD after controlling other background and risk variables. Conclusion PAD is prevalent in persons undergoing drug treatment and is best accounted for by cigarette smoking, sex differences, and physical inactivity. PAD in drug abusers should be evaluated, and the current findings merit further investigation.

Background Water-pipe smoking is a rapidly growing form of tobacco use worldwide. Building on an earlier report of experimentation with cigarette and water-pipe smoking in a U.S. community sample of Arab-American youth aged 14–18 years, this article examines water-pipe smoking in more detail (e.g., smoking history, belief in harmfulness compared to cigarettes, family members in home who smoke water pipes) and compares the water-pipe–smoking behaviors of Arab-American youth with non–Arab-American youth in the same community. Methods A convenience sample of 1872 Arab-American and non–Arab-American high school students from the Midwest completed a 24-item tobacco survey. Data were collected in 2004–2005 and analyzed in 2007–2008. Results Arab-American youth reported lower percentages of ever cigarette smoking (20% vs 39%); current cigarette smoking (7% vs 22%); and regular cigarette smoking (3% vs 15%) than non–Arab-American youth. In contrast, Arab-American youth reported significantly higher percentages of ever water-pipe smoking (38% vs 21%) and current water-pipe smoking (17% vs 11%) than non–Arab-American youth. Seventy-seven percent perceived water-pipe smoking to be as harmful as or more harmful than cigarette smoking. Logistic regression showed that youth were 11.0 times more likely to be currently smoking cigarettes if they currently smoked water pipes. Youth were also 11.0 times more likely to be current water-pipe smokers if they currently smoked cigarettes. If one or more family members smoked water pipes in the home, youth were 6.3 times more likely to be current water-pipe smokers. The effects of ethnicity were reduced as a result of the explanatory value of family smoking. Conclusions Further research is needed to determine the percentages, patterns, and health risks of water-pipe smoking and its relationship to cigarette smoking among all youth. Additionally, youth tobacco prevention/cessation programs need to focus attention on water-pipe smoking in order to further dispel the myth that water-pipe smoking is a safe alternative to cigarette smoking.

This study presents a new short scale for measuring cumulative trauma dose, types, and profiles that is based on the APA (American Psychological Association) trauma Group (currently division 56) definition of trauma and a new, two-way development-based taxonomy of trauma. The new measure was tested using a sample of 501 Iraqi refugees who are one of the most traumatized groups. The following six salient factors were found: collective identity, family, personal identity, interdependence or secondary, man-made or nature-made survival, and abandonment types of traumas. The study provided evidence of adequate reliability; construct, convergent, divergent and predictive validity of the new scale and provided partial confirmation of the validity of the development-based taxonomy of traumas. A new method was introduced to measure trauma types and profiles and their differential association with different symptom configurations and health disorders. The newly developed measure can be used in clinical trauma-infor...

The purpose of this study was to develop and conduct preliminary psychometric assessment of instruments measuring knowledge and self-care practices regarding behaviors needed for blood pressure (BP) control among African Americans. Items were empirically derived and scored on a 7-point, bipolar scale. The instruments were evaluated in a sample of 306 community-dwelling African Americans. Results revealed acceptable reliability and validity of the BP Knowledge Scale. Results for the BP Self-Care Scale were mixed. A structural equation model of these scales, recorded BP, and covariates fit well. There was an unexpected positive correlation between self-care and BP suggesting a potential bi-directional relationship. The scales demonstrated acceptable psychometric properties and, with minor revisions, may have clinical utility as measures of BP knowledge and self-care.

PURPOSE Injection drug users are at high risk for chronic venous disorders (CVD), a condition resulting in a progressive deterioration of venous function of the legs. However, the effects of CVD on walking mobility in this population have not been studied. We examined a causal model of the relationship between injection drug use, CVD, and Walking Mobility. The validity of the Tinetti Balance and Gait scales and walk speed as a composite measure of Walking Mobility was also explored. SETTING AND SUBJECTS The participants were 104 men and women from a methadone maintenance treatment center. Drug use included 18 persons who injected drugs only in the hands, arms, and above the waist; 70 who injected all over the body including the lower extremities; and 16 who never injected drugs but used illegal substances by other routes. Forty-nine percent of participants had moderate to severe CVD. DESIGN Participants were classified into 2 groups according to their history of injection drug use: (a) those who injected in the lower extremities (n = 70) and (b) those who injected in the arms plus those who did not inject (n = 34). All measurements were obtained at baseline and again approximately 6.5 weeks later. Structural equation modeling was used to examine the causal effect of CVD on Walking Mobility. The validity of the Balance and Gait scales and the walk time variable as measures of a Walking Mobility factor was examined using a second-order confirmatory factor analysis. INSTRUMENTS Questionnaires included the Demographic and Health History and Drug History. The lower extremities were evaluated with the clinical portion of the Clinical-Etiology-Anatomy-Pathophysiology classification. Participants completed the Tinetti Balance and Gait test. A timed 6-m walk at the person's normal pace was used to calculate walk speed. RESULTS Test-retest reliability of the Tinetti Balance and Gait test and walk speed ranged from 0.79 to 0.86. Balance and gait scores were skewed toward the high end of the scale. Walking speed was slow. The leg-injecting group had lower Balance (P < .05) and Gait (P < .01) scores. A structural equation modeling showed that CVD was related to Walking Mobility after controlling for age, gender, body mass index, and comorbidities. Injection drug use and age were linked to Walking Mobility through CVD severity. Although fall information was not collected as part of our study, 15% of participants had a Tinetti score of less than 19, indicating a high risk for falls. CONCLUSIONS Tinetti Balance and Gait scales and walking speed are reliable and valid measures for the evaluation of walking mobility among persons with a history of drug use. Further research is needed to alleviate the impact of venous disease on walking mobility.

Diabetes mellitus is an important public health problem that disproportionately affects minorities. Using a cross sectional, convenience sample, we estimated the prevalence of self-reported diabetes for Whites (n = 212), Arabs (n = 1,303), Chaldeans (n = 828), and Blacks (n = 789) in southeast Michigan. In addition, using a logistic regression model, we estimated odds ratios and 95% confidence intervals for the association between ethnicity and diabetes before and after adjusting for demographic, socioeconomic status, health care, chronic conditions, and health behavior variables. The overall age- and sex-adjusted prevalence of diabetes was 7.0%. Estimates were highest for Blacks (8.0%) followed by Arabs and Whites (7.0% for each group) and Chaldeans (6.0%). In the fully adjusted model, the association between ethnicity and diabetes was not statistically significant. Future studies should collect more detailed socioeconomic status, acculturation and health behavior information, which are factors that may affect the relationship between race/ethnicity and diabetes.

The purpose of the study was to assess whether therapist treatment fidelity was a predictor of treatment outcome in a randomized clinical trial of multisystemic therapy with 10- to 16-year-old youths with chronically poorly controlled Type I diabetes (N = 40). Treatment fidelity was assessed by objective ratings of therapy sessions and questionnaires completed by caregivers and by therapists. Relationships between fidelity measures were assessed. Structural equation modeling (SEM) was used to test whether high fidelity would lead to improved regimen adherence and to improved metabolic control outcomes via regimen adherence. Objective ratings of treatment fidelity were significantly related to therapist-reported but not to caregiver-reported treatment fidelity. SEM results supported a completely mediated pathway between treatment fidelity and metabolic control, with regimen adherence mediating the relationship. Results suggest that conducting complex behavioral interventions with a high degree of fidelity can improve treatment outcomes among youths with chronic illnesses.

The primary purpose of this study was to determine if there were differences in trajectories of metabolic control between African American and White youth with type 1 diabetes in the first 5 yr after diagnosis. A secondary purpose was to investigate other sociodemographic variables that often covary with race/ethnicity such as number of parents in the home and family income to determine if they predicted trajectories of metabolic control in youth with diabetes over and above the effects of ethnicity. A convenience sample of 71 youth was recruited. Multilevel modeling was used to estimate the population trajectory and to investigate the contribution of other variables. Differences in metabolic control between African American and White youth began shortly after diagnosis and continued to accelerate well beyond the point of diagnosis. However, subsequent analysis showed that deterioration in metabolic control could equally well be explained by living in a single-parent household. At 24 months postdiagnosis, the metabolic control in youth from single-parent families worsened almost three times as fast as that in youth from two-parent families (0.11 vs. 0.04%/month). The difference in hemoglobin A1c level at 24 months was 1.34% (p = .007). Neither family income nor clinical variables such as child's age, Tanner stage, or body mass index was significant predictor of metabolic control. Diabetes care providers should consider developing targeted interventions such as parent social support resources or school-based youth monitoring programs for youth in single-parent families.

African Americans bear a disproportionate burden of hypertension. A causal-modeling design, using Donabedian's Quality Framework, tested hypothesized relationships among structure, process, and outcome variables to assess quality of care provided to this population. Structural assessment revealed that administrative and staff organization affected patients' trust in their provider and satisfaction with their care. Interpersonal process factors of racism, cultural mistrust, and trust in providers had a significant effect on satisfaction, and perceived racism had a negative effect on blood pressure (BP). Poorer quality in technical processes of care was associated with higher BP. Findings support the utility of Donabedian's framework for assessing quality of care in a disease-specific population.

Cancer treatment is increasingly being provided in outpatient settings, requiring many of the responsibilities for patient care to be undertaken by family caregivers. Pain is one of the most frequent and distressing symptoms experienced by cancer patients and is a primary concern for the family caregiver. Caregivers struggle with many issues that lead to inadequate management of cancer pain. The purpose of this study was to determine pain management knowledge and examine concerns about reporting pain and using analgesics in a sample of primary family caregivers of cancer patients receiving homecare. The Barriers Questionnaire and the Family Pain Questionnaire were administered to 46 primary caregivers. Between 46% and 94% of the caregivers reported having at least some agreement with the various concerns that are barriers to reporting pain and using analgesics, and up to 15% reported having strong agreement. The areas of greatest concern were about opioid-related side effects, fears of addiction, and the belief that pain meant disease progression. Results showed that caregivers with higher pain management knowledge had significantly fewer barriers to cancer pain management, supporting the importance of increasing caregiver's knowledge of management of cancer pain.

Background:Contingency management (CM) interventions, which use operant conditioning principles to encourage completion of target behavioral goals, may be useful for improving adherence to behavioral skills training (BST). Research-to-date has yet to explore CM for weight loss in minority adolescents.Objective:To examine the effects of CM in improving adolescent weight loss when added to BST.Design:The study utilized an innovative experimental design that builds upon multiple baseline approaches as recommended by the National Institutes of Health.Participants/setting:Six obese African-American youth and their primary caregivers living in Detroit, Michigan, USA.Intervention:Adolescents received between 4 and 12 weeks of BST during a baseline period and subsequently received CM targeting weight loss.Main outcome measures:Youth weight.Statistical analysis performed:Linear mixed effects modeling was used in the analysis.Results:CM did not directly affect adolescent weight loss above that of BST (p=0.053). However, when caregivers were involved in CM session treatment, contingency management had a positive effect on adolescent weight loss. The estimated weight loss due to CM when caregivers also attended was 0.66 kg/week (pConclusion:This study demonstrates application of a novel experimental approach to intervention development and demonstrated the importance of parent involvement when delivering contingency management for minority youth weight loss. Lessons learned from contingency management program implementation are also discussed in order to inform practice.

Introduction. Belief in one's ability to control pain is a significant predictor of health outcomes and is related to improved functional status. The purpose of this study was to introduce a novel formulation of the construct, Perceived Control Over Pain and to test its effects on functional status. Methods. Participants (N = 301) were primarily African American (92%); and were adults with low income attending a primary care clinic and reporting pain within the past 2 weeks. A cross-sectional design was used with confirmatory factor analysis and structural equation modeling. The Perceived Control Over Pain construct consisted of four measures—two specific measures of control over pain and two general measures of control over life events . Perceived Control Over Pain has not been defined in this way previously. Results. Mean worst pain scores for the past week were 8.4, where “0” ( no pain ) to “10” ( pain as bad as you can imagine ). The model demonstrated good construct validity for the components of pain, Perceived Control Over Pain and functional status. Mediation by Perceived Control Over Pain was partial but strong, accounting for a reduction of 29% in the effect of pain on functional status. Discussion. In minority populations with low income, factors such as perceived control over pain and its effect on the outcome of patient function need to be considered. Improving Perceived Control Over Pain has the potential for improving patients’ feelings of life control and purpose or meaning in life, and psychological and physical functioning for adults living with pain.

Introduction African American women have higher rates of preterm birth and low-birth-weight infants compared with non-Hispanic white women. Symptoms of depression have also been related to these negative birth outcomes. Lower levels of social support and higher levels of avoidance coping and cortisol have been related to more symptoms of depression in pregnant women. The purpose of this pilot study was to examine the relationships among symptoms of depression, social support, avoidance coping, cortisol, and negative birth outcomes (ie, preterm birth, low-birth-weight infants) in a sample of African American women. Methods This study used a prospective design. A convenience sample of 90 African American women completed questionnaires and had blood drawn in the second trimester of pregnancy. Birth data were collected from medical records. Results Based on the Center for Epidemiological Studies-Depression (CES-D) Scale scores, 28% of women were at increased risk for clinical depression (CES-D ≥ 16). Compared to women who gave birth at term, women who had preterm birth had higher CES-D scores (11.67 and 19.0, respectively) and used avoidance coping more often (7.98 and 13.14, respectively). Compared to women with normal-birth-weight infants, women with low-birth-weight infants had higher levels of cortisol (61.75 mcg/dL and 89.72 mcg/dL, respectively). Women at increased risk for clinical depression were 16 times more likely to have preterm birth and 4 times more likely to have low-birth-weight infants. Women with plasma cortisol levels in the top 25th percentile were 7 times more likely to have low-birth-weight infants. Preeclampsia during pregnancy also predicted preterm birth and low-birth-weight infants. Discussion Symptoms of depression in pregnancy may predict adverse birth outcomes. Interventions that have the potential to improve the mental health of pregnant women and ultimately birth outcomes need to be explored.

The purpose of this study was to develop an adaptive behavioral treatment for African American adolescents with obesity. In a sequential multiple assignment randomized trial, 181 youth ages 12-16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression. There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for nonresponders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

Background: The Respiratory Distress Observation Scale© is an innovative solution to assessment when a dyspnea report cannot be elicited. The Respiratory Distress Observation Scale has acceptable reliability and validity psychometrics. Aim: To identify distress-intensity cut-points of the Respiratory Distress Observation Scale. Design: Receiver operating characteristic curve analysis was conducted with inpatients stratified by four levels of respiratory distress—none, mild, moderate, or severe. Patients provided three self-report measures of dyspnea: dichotomous (yes/no); a ranking of none, mild, moderate, or severe; and a numerical rating scale. Respiratory distress was assessed using the Respiratory Distress Observation Scale instrument. Setting/participants: Participants were 136 adult inpatients, mean age 61.8 years (standard deviation = 13.18 years), 89.7% African American, and 56.6% female, who were recruited from an urban, tertiary care hospital in the Midwest of the United States. Results: In all, 47% ( n = 64) self-reported dyspnea (yes/no). Ranking was distributed as follows: none = 36, mild = 35, moderate = 40, and severe = 25. Numerical rating scale scores ranged from 0 to 10, mean = 4.99 (standard deviation = 2.9). Respiratory Distress Observation Scale scores ranged from 0 to 7, median (interquartile range) = 2 (1–3). Receiver operating characteristic curve analysis–determined Respiratory Distress Observation Scale score of 0–2 suggests little or no respiratory distress; score ≥3 signified moderate to severe distress. Conclusion: A Respiratory Distress Observation Scale score ≥3 signifies a patient’s need for palliation of respiratory distress. An end-point for identifying responsiveness to treatment, in other words, respiratory comfort, is Respiratory Distress Observation Scale

This study investigated the effect of mother's coping resources, cognitive resources, family stress, and demographic variables on diabetes management and the mediating role of diabetes management on metabolic control among children with diabetes. Mothers (N = 59) completed self-report measures. HbA1c was obtained from the medical records. Although cognitive resources, coping resources, and family stress accounted for 30% of the variance in diabetes management, the hypothesis of mediation was not supported. The only significant predictor of HbA1c was African American race/ethnicity. The findings identify modifiable targets for practice and highlight the increased risk for poor metabolic control for minority children.

Between 1993 and 2002, 39 clinical trial staff were investigated for scientific misconduct by the Office of Research Integrity (ORI). Analysis of ORI case records reveals practices regarding workload, training and supervision that enable misconduct. Considering the potential effects on human subjects protection, quality and reliability of data, and the trustworthiness of the clinical research enterprise, regulations or guidance on use of clinical trial staff ought to be available. Current ORI regulations do not hold investigators or institutions responsible for supervision and training of clinical trial staff. Given the important issues at stake, the definition of research misconduct should encompass the intentional or negligent mismanagement of scientific projects. Individual institutions and professional associations not only can but should adopt stricter standards of conduct than those reflected in federal regulations.

Objective To determine whether multisystemic therapy (MST) improved family relationships among youths with poorly controlled type 1 diabetes and whether these changes mediated MST effects on health outcomes. The moderating effect of family demographics on study outcomes was also assessed. Methods A randomized controlled trial was conducted with 127 youths. Changes in general family relationships and caregiver support for diabetes care from baseline to treatment completion were assessed. Structural equation modeling (SEM) was used to test whether changes in family relations mediated improvements in frequency of blood glucose testing (BGT) and metabolic control. Results MST increased support for diabetes care from both primary and secondary caregivers in two-parent but not in single-parent families. However, MST had the strongest effects on BGT and metabolic control in single-parent families. SEM did not support family relations as the mediator of improved BGT or metabolic control. Rather, MST had a direct effect on BGT for all participants. BGT mediated improvements in metabolic control among single-parent families. Conclusions MST improved family relationships for youths with diabetes in two-parent but not in single-parent families. Objective outcomes related to diabetes were strongest for single-parent families. Other processes such as increased parental monitoring may have been responsible for improved health outcomes among these families.

OBJECTIVE—The aim of this study was to determine whether multisystemic therapy (MST), an intensive, home-based psychotherapy, could improve adherence and metabolic control and decrease rates of hospital utilization among adolescents with chronically poorly controlled type 1 diabetes. RESEARCH DESIGN AND METHODS—A randomized controlled trial was conducted with 127 adolescents with type 1 diabetes and chronically poor metabolic control (HbA1c [A1C] ≥8% for the past year) who received their diabetes care in a children’s hospital located in a major Midwestern city. Participants randomly assigned to MST received treatment for ∼6 months. Data were collected at baseline and at 7 months posttest (i.e., treatment termination). Changes in A1C adherence, as measured by semistructured interviews and blood glucose meters and hospital admissions and emergency department visits, were assessed. RESULTS—In intent-to-treat analyses, participation in MST was associated with significant improvements in the frequency of blood glucose testing as assessed by blood glucose meter readings (F[1,125] = 16.75, P = 0.001) and 24-h recall interviews (F[1,125] = 6.70, P = 0.011). Participants in MST also had a decreasing number of inpatient admissions, whereas the number of inpatient admissions increased for control subjects (F[1,125] = 6.25, P = 0.014). Per protocol analyses replicated intent-to-treat analyses but also showed a significant improvement in metabolic control for adolescents receiving MST compared with control subjects (F[1,114] = 4.03, P = 0.047). CONCLUSIONS—Intensive, home-based psychotherapy improves the frequency of blood glucose testing and metabolic control and decreases inpatient admissions among adolescents with chronically poorly controlled type 1 diabetes.