Search

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.

Despite media reports and educators' concerns, little substantive data have been published to document or refute the emerging reports that children prenatally exposed to cocaine have serious behavioral problems in school. Recent pilot data from this institution have indeed demonstrated teacher-reported problem behaviors following prenatal cocaine exposure after controlling for the effects of prenatal alcohol use and cigarette exposure. Imperative in the study of prenatal exposure and child outcome is an acknowledgement of the influence of other control factors such as postnatal environment, secondary exposures, and parenting issues. We report preliminary evaluation from a large ongoing historical prospective study of prenatal cocaine exposure on school-age outcomes. The primary aim of this NIDA-funded study is to determine if a relationship exists between prenatal cocaine/alcohol exposures and school behavior and, if so, to determine if the relationship is characterized by a dose-response relationship. A secondary aim evaluates the relationship between prenatal cocaine/alcohol exposures and school achievement. Both relationships will be assessed in a black, urban sample of first grade students using multivariate statistical techniques for confounding as well as mediating and moderating prenatal and postnatal variables. A third aim is to evaluate the relationship between a general standardized classroom behavioral measure and a tool designed to tap the effects thought to be specific to prenatal cocaine exposure. This interdisciplinary research team can address these aims because of the existence of a unique, prospectively collected perinatal Database, funded in part by NIAAA and NICHD. The database includes repeated measures of cocaine, alcohol, and other substances for over 3,500 births since 1986. Information from this database is combined with information from the database of one of the largest public school systems in the nation. The final sample will be composed of over 600 first grade students for whom the independent variables, prenatal cocaine/alcohol exposures, were prospectively assessed and quantified at the university maternity center. After informed consent, the primary dependent variable, school behavior, is assessed, using the PROBS-14 (a teacher consensus developed instrument), the Child Behavior Check List, and the Conners' Teacher Rating Scale. The secondary dependent measure, school achievement, is measured by the Metropolitan Achievement Text and the Test of Early Reading Ability. Control variables, such as the environment and parenting, are measured by several instruments aimed at capturing the child and family ecology since birth. All analyses will be adjusted as appropriate for prospectively gathered control variables such as perinatal risk, neonatal risk, and other prenatal drug and cigarette exposures. Further adjustment will be made for postnatal social risk factors which may influence outcome. Of particular concern are characteristics of the home (adaptation of HOME), parent (depression, stress), and neighborhood (violence exposure). Finally, postnatal exposure to lead and other drugs is being considered.

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.

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.

A sensitive, secure, and consistent relationship with their mother is critical for young children. There is a dearth of knowledge about the quality of mothering of young children by women with bipolar disorder. These mothers are frequently challenged, unable to provide consistency, and are at risk for loss of child custody. The model described in this article reflects a critical analysis of conceptual and empirical literature regarding mothering quality, resourcefulness, disorder severity, medication adherence, social supports, and child-rearing beliefs. The model can provide a conceptual framework for research, direct the selection of research instruments, and hypothesize the relationships among constructs.

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.

Measures that screen for mental health in multiple traumatized populations (e.g., refugees, minorities, mental health patients, prison inmates) lack theoretical clarity that makes it difficult to develop a measure that has robust psychometrics. The paper proposes cumulative trauma disorders (CTD) model and develops a scale that measures the concept and can be used as a general mental health screening tool in such populations. The measure has been tested on two studies: on representative community sample of Iraqi refugees in Michigan and on a clinic sample of refugees. Further, the measure was used on samples of Iraqi refugee and African American adolescents, West Bank and Gaza in Palestinian territories, as well as a mental health screening tool in some centers that screen refugees and torture survivors in US. The measure has been found to have high alpha and test-retest reliability, good construct, concurrent, discriminative and predictive validity in the two main samples and on all the studies and centers that utilized it. The measure can be used as a general mental health screening tool for adult and adolescent in public health settings in different cultures, as well as for refugees, torture survivors, and highly traumatized populations.

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.

Research on forgiveness on the interpersonal level has found evidence of its positive health and mental health effects. However, there is no research on the health and mental health benefits of forgiveness in political conflicts. The removal of the dictator and the war in Iraq has provided researchers with opportunities to answer some questions about the effects of forgiveness in political conflicts. This study used a modified measure of forgiveness and measures of posttraumatic stress disorder (PTSD), cumulative trauma disorder (complex PTSD), health, and religiosity with a sample of 501 Iraqi refugees in Wayne County, Michigan. Results indicated that forgiveness of the collaborators has some positive mental health benefits and is associated with religiosity, whereas not forgiving them has serious health and mental health consequences. However, counter to predictions, un-forgiveness of the dictator was found to be associated with positive health and mental health. Health mediated the effects of un-forgiv...

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.

The focus of this study was to explore the effects of watching or listening to news about the war in Iraq on the physical and mental health in a sample of 501 Iraqi refugees. We used measures of media exposure, families and friends killed in the war, cumulative trauma, torture, post-traumatic stress disorder (PTSD), cumulative trauma disorders, and health. Data indicates media exposure to war news was highly predictive of PTSD and poor health after controlling for the effects of previous cumulative traumas and demographics. The effect of media exposure was comparable in its physical and mental health effects to the war-related death or injury of family members and friends, and stronger than other previous traumas. We used mass communication, globalization, secondary trauma, identity trauma, taxonomy of trauma, and cognitive and value processing theories to interpret the results. Results suggest that war media exposure is a Type III collective identity secondary trauma for Iraqis, which is the most damagin...

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.

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.

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.

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

The goal of this study was to examine whether the retributive justice enacted by the elimination of the oppressive regime in Iraq has positive mental health effects on Iraqi refugees. The study was conducted on a sample of 501 Iraqi refugees. Data was collected with measures for retributive justice, post-traumatic stress disorder (PTSD), cumulative trauma disorder (CTD), cumulative trauma, futuristic orientation, sociocultural adjustment, post-traumatic growth, social support, and other measures. Multiple regression and path analyses found that the variable regaining self-control and executive functions was the most predictive of the positive mental health gains. However, improvements in PTSD symptoms were not observed, possibly because of previous traumas or the ongoing trauma of discrimination and the war in Iraq.

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.

Pain is a common problem that affects the functional status and quality of life of people in all communities. This study explored the occurrence of pain and the pain self-treatment modalities used by 723 community residents. Mean worst pain scores were moderate to severe and interfered with all activities at a low-to-moderate level. Participants reported taking nonopioid analgesics (75%), opioid analgesics (15%), adjuvant analgesics (11.6%), and herbal products and supplements (29%); 68% used nonpharmacological modalities. Current regimens were reported to relieve only 45% of pain. Twenty-eight percent of participants reported that they had not informed their primary care practitioner of their self-treatment choices. Knowledge of self-treatment choices is imperative in planning treatment regimens for pain or other health problems to prevent potential interactions or side effects.

The purpose of the current study was to conduct a pilot investigation to determine the effectiveness of Multisystemic Therapy (MST) for improving regimen adherence and metabolic control among adolescents with poorly controlled Type 1 diabetes. Thirty-one adolescents were randomly assigned to either MST or a control condition. MST treatment lasted approximately six months. Data were collected at study entry and at a six-month posttest. Twenty-five adolescents completed the study. Adolescents who received MST had significantly improved adherence to blood glucose testing and metabolic control from study entry to the six-month posttest, whereas controls did not. Adolescents receiving MST also had a decreased number of inpatient admissions at the six-month posttest. Improvements in metabolic control were related to improvements in parent report of adolescent adherence. Results suggest that MST holds promise as an intervention for improving adherence behavior and health outcomes among adolescents in poor metabolic control.

Purpose/objectives To demonstrate the effects of a program, directed at homecare nurses, of structured educational interventions on the management of pain and opioid-related side effects in homecare patients with cancer. Design A longitudinal multilevel, randomized, controlled clinical trial. Setting Midwestern region in the United States. Sample 202 nurses caring for patients with cancer recruited from homecare agencies. Methods The two-tiered educational program focused on basic and advanced pain management strategies, particularly in the area of pharmacologic options and assertive communication skills. Instruments used were the Nurses' Knowledge and Attitudes Survey Regarding Pain, the barriers questionnaire, perception of control over pain, and a demographic questionnaire. Main research variables Knowledge and attitudes about pain management, barriers to pain management, and perception of control over pain. Findings Nurses in the intervention group had a significant increase in their knowledge, a more positive attitude about pain management, fewer perceived barriers to pain management, and an increase in perceived control over pain compared to the nurses who did not receive the intervention. Conclusions The educational program Power Over Pain has beneficial effects for homecare nurses caring for patients with cancer pain. Implications for nursing A need exists for homecare nurses to gain more insight into pain management strategies and enhance their advocacy skills to improve pain management for patients with cancer treated in the home.

Introduction: This study examined how parents of children with bleeding disorders defined quality health care, their expectations for care at the clinic, and indicators of quality health care important to them. Methods: Parents (N = 54) answered two open-ended questions and completed the Quality Health Care Questionnaire, which examined the importance of 33 indicators of quality care. Results: The most important indicators of quality care to parents were being included in decisions about their child's care (M = 4.98), being cared for by nurses who are competent and up-to-date (M = 4.94), and being cared for by doctors who are competent and up-to-date (M = 4.94). Discussion: The results of this study are consistent with earlier research involving other groups of consumers. Parents view quality care as being included in decisions about their child's care and having competent and caring providers with whom they can communicate. In contrast to earlier research, however, waiting time was the least important indicator of quality care. J Pediatr Health Care. (2002). 16, 125-130.

This study investigated which daily hassles (i.e., Parent, School, Peer, Neighborhood, and Resource) were perceived by Arab Muslim immigrant adolescents as most stressful over a three-year time period and according to child's gender and mother's immigration status (i.e., refugee or non refugee). Data were collected at three time points during adolescence and analyzed using doubly multivariate analysis of covariance (MANCOVA) with linear and quadratic trends. School and Parent hassles were greater than other hassles at every time point. Main effects of time, immigration status, and father's employment, but not child's gender, were statistically significant. School and Parent hassles increased while Peer and Resource hassles decreased over time. Adolescents with refugee mothers reported greater School and Neighborhood and fewer Parent hassles than those with non refugee mothers. Adolescents with unemployed fathers reported significantly more School and Neighborhood hassles. Study findings identify two at risk subgroups: those adolescents with refugee mothers and/or those adolescents with unemployed fathers; and pinpoint problematic daily hassles. Additional research is needed to explore vicarious trauma effects as a potential underlying reason for the pattern of daily hassles noted in adolescents with refugee mothers.

Background: African Americans have a higher prevalence and greater severity of hypertension than do other minorities and whites. This fact is particularly problematic when one realizes that the rate of control and treatment of hypertension in the US population is getting worse rather than better. Alternative strategies to promote blood pressure control need to be tested. Objectives: The purpose of this pilot study was to test the following hypothesis: Persons who participate in nurse-managed home telemonitoring (HT) plus usual care or who participate in nurse-managed community-based monitoring (CBM) plus usual care will have greater improvement in blood pressure from baseline to 3 months’ follow-up than will persons who receive usual care only. Methods: This study used a randomized controlled design; participants were randomly assigned to 1 of 3 groups that were stratified by use or nonuse of antihypertension medication. One-way analysis of variance (ANOVA) and analysis of covariance (ANCOVA) controlling for age and body weight were used to determine changes in blood pressure from baseline to 3 months. The sample contained 26 African Americans with a mean age of 59 years. Results: Both the HT group and the CBM group had clinically and statistically significant (P

The purpose of this research was to evaluate the effectiveness of an individualized scheduled toileting (IST) program on incontinent, memory-impaired elders being cared for at home. Using a 2 x 2 mixed design analysis of variance (group by time), 118 patients were randomly assigned to experimental or control groups. Caregivers in the experimental group were taught the IST procedure. Urinary incontinence (UI) was measured at baseline and at 6 months. Weeklong voiding records were kept by caregivers and were used to calculate the percentage of times the incontinence occurred. UI significantly decreased in the experimental group, whereas in the control group it did not. The baseline cognitive ability, mobility, and consistency of implementing IST were entered into a discriminant function equation and significantly predicted patients who would improve with IST. Cognitive ability was the best predictor, with mobility also emerging as a meaningful predictor. Candidates for IST should be selected based on elders' cognitive ability and their ability to cooperate with toileting. Moderately cognitively impaired elders and ones able to cooperate with toileting protocols are prime candidates for IST.

Persons with a history of injection drug use have many risk factors for the development of chronic venous insufficiency (CVI), yet this phenomenon has not been studied systematically in this population. Persons (N = 204) with a history of injection drug use who were in enrolled in a treatment center were examined for clinical manifestations of CVI. The CVI clinical classification was graded on a 7-point scale for each leg. Most participants (n = 179, 87.7%) exhibited clinical evidence of CVI. Significant predictors of CVI clinical manifestations were leg infections/cellulitis (rho =.53); years injection in the veins of the groin, legs, and feet (rho =.47); deep vein thrombosis (rho =.37); and total years injection heroin (rho =.27). There was a linear functional relationship between years of injection drug use and the CVI clinical classification, but only when the injections were in the veins of the groin, legs, or feet; otherwise, the specific mechanisms of this relationship were not evident. The findings indicate that CVI is a common occurrence in persons who have injected drugs.

Background Although depressive symptoms during pregnancy have been related to negative maternal and child health outcomes such as preterm birth, low birth weight infants, postpartum depression, and maladaptive mother–infant interactions, studies on the impact of neighborhood environment on depressive symptoms in pregnant women are limited. Pregnant women residing in disadvantaged neighborhoods reported higher levels of depressive symptoms and lower levels of social support. No researchers have examined the relationship between neighborhood environment and avoidance coping in pregnant women. Guided by the Ecological model and Lazarus and Folkman's transactional model of stress and coping, we examined whether social support and avoidance coping mediated associations between the neighborhood environment and depressive symptoms in pregnant African-American women. Methods Pregnant African-American women (n = 95) from a medical center in Chicago completed the instruments twice during pregnancy between 15 and 25 weeks and between 25 and 37 weeks. The self-administered instruments measured perceived neighborhood environment, social support, avoidance coping, and depressive symptoms using items from existing scales. Objective measures of the neighborhood environment were derived using geographic information systems. Findings Perceived neighborhood environment, social support, avoidance coping, and depressive symptoms were correlated significantly in the expected directions. Objective physical disorder and crime were negatively related to social support. Social support at time 1 (20 ± 2.6 weeks) mediated associations between the perceived neighborhood environment at time 1 and depressive symptoms at time 2 (29 ± 2.7 weeks). An increase in avoidance coping between times 1 and 2 also mediated the effects of perceived neighborhood environment at time 1 on depressive symptoms at time 2. Conclusion Pregnant African-American women's negative perceptions of their neighborhoods in the second trimester were related to higher levels of depressive symptoms in the third trimester. If these results are replicable in prospective studies with larger sample sizes, intervention strategies could be implemented at the individual level to support pregnant women in their ability to cope with adverse neighborhood conditions and ultimately improve their mental health.

Despite extensive research on defining and measuring quality of care, less attention has been given to consumers' views. The purpose of the study reported here was to identify indicators of quality of healthcare and nursing care important to clinic patients. The most important indicators of healthcare quality were getting better, getting care and services when needed, and having diagnoses and treatment options explained. The most important indicators of nursing care quality were communicating with the nurse, being treated with respect, being cared for by nurses who were up-to-date, teaching by the nurse, and not being rushed through the visit.

Objective/purpose: Psychosocial adjustment, coping, and quality of life for persons with a venous ulcer and a history of intravenous drug use were examined. Design: A cross-sectional design was used. Setting and subjects: Data were collected in an urban outpatient clinic. All eligible persons were asked to participate. Thirty-two patients agreed to participate, providing an 89% response rate. The mean age of participants was 44.6 years (SD = 4.3); 91% were African American, and 72% were male. Instruments: Subjects responded to questions about their health and substance abuse history and completed the Quality of Life With a Leg Ulcer Questionnaire, Psychosocial Adjustment to Illness Scale (PAIS), Ways of Coping Instrument, and Pain Questionnaire. Leg ulcer tracings were measured with the SigmaScan computer program. Methods: Questionnaires were read to participants. Leg ulcers were traced at their borders onto plastic. Results: Wound area correlated significantly with the domestic environment ( r = .43) and the psychosocial distress ( r = .38) scores of the PAIS. Wound area was negatively correlated to Quality of Life With a Leg Ulcer Questionnaire score ( r = -.52). Pain interference was significantly related to the self-controlling coping score ( r = .40), domestic environment score of the PAIS ( r = .51), and Quality of Life With a Leg Ulcer Questionnaire score ( r = -.65). Cox and Wermuth's multiple regression modeling approach was used to summarize the study's variables. Conclusions: A larger wound area was associated with greater illness-induced difficulties in the home environment, greater psychological distress, and poor quality of life. Pain interference was associated with a greater effort to regulate one's feelings and actions, difficulties in the home, and poor quality of life. (J WOCN 2000;27:227–39)

Purpose: Despite extensive research on defining and measuring health care quality, little attention has been given to consumers' perspectives of high-quality health care. The purposes of this study were to (a) identify the importance to consumers of attributes of health care quality and nursing care quality, and (b) examine the relationship of consumer perspectives to health status and selected demographic variables. Design: Exploratory. Consumers (N = 239) were recruited from waiting rooms of clinics and in neighborhoods of a large metropolitan area in the Midwestern United States that included both urban and suburban populations. Methods: Participants completed the Quality Health Care Questionnaire (QHCQ) and the SF-36 Health Survey. On the QHCQ, they rated the importance of 27 attributes of health care and nursing care quality. The SF-36 is a 36-item instrument for measuring health status in eight general areas. Findings: The most important indicators of high-quality nursing care to consumers were: being cared for by nurses who are up-to-date and well informed; being able to communicate with the nurse; spending enough time with the nurse and not feeling rushed during the visit; having a nurse teach about the illness, medications, treatments, and staying healthy; and being able to call a nurse with questions. The lowest-rated item was having an opportunity to be cared for by nurse practitioners. Ratings differed by race, age, years of education, income, and health status. Conclusions: The importance that consumers place on teaching by the nurse was emphasized, particularly among people with less education, low income levels, and chronic illnesses.