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This manuscript examines the measurement adequacy of the CES-D when applied in older African–Americans ( n =227). The response distribution was skewed towards less symptomatology on all items, and the internal consistency of the CES-D was acceptable (α=0.86). An exploratory factor analysis revealed four underlying factors of depressive symptomatology: (1) depressive/somatic; (2) positive; (3) interpersonal; and (4) social well-being. The primary factor was a combination of depression and somatic symptoms, a commonly reported uni-dimensional factor among ethnic groups. Additionally, a fourth factor emerged that has not previously been identified, labeled ‘social well-being’. This factor consisted of three items that may tap into the social interactions of the elderly: appetite, hopeful, and talk. These findings contribute to the growing body of evidence on the unique measurement properties of the CES-D across diverse populations.

OBJECTIVE: We investigated whether comorbidities differentially impacted health-related quality of life (HRQOL) for rheumatoid arthritis (RA) and osteoarthritis (OA) patients. METHODS: Adult patients with self-reported doctor-diagnosed RA (n=159) or OA (n=149) were recruited from multiple sources and completed an online cross-sectional survey. Patients self-reported sociodemographic variables, arthritis severity and comorbid conditions. HRQOL was assessed using the SF-12v2 and comorbidity counts were assigned using an expanded Functional Comorbidities Index. HRQOL (8 domain and 2 composite (physical and mental health) scores) was compared with norm-based general US population scores and between RA and OA patients to determine if they significantly differed from one another. Linear regression was used to test whether comorbidity count was associated with the physical and mental health of RA and OA patients. RESULTS: OA and RA patients experienced significantly worse HRQOL across all dimensions compared with that of the general US population. There were no significant differences between RA and OA patients on any HRQOL dimension. A higher comorbidity count was associated with worse physical (p=0.0007) and mental (p=0.0295) health scores when controlling for patient gender, age, education, and arthritis severity. CONCLUSION: Arthritis negatively impacted patients’ HRQOL. OA patients in our sample perceived their condition as similarly disabling in terms of physical and mental health as RA patients. Arthritis patients with more chronic comorbid conditions may be at particular risk for poor physical and mental health. Providers should discuss management of comorbid conditions with arthritis patients.

We used a multidimensional framework to describe the types of information about medication risks that rheumatologists provide to rheumatoid arthritis (RA) patients during routine office visits.We analyzed 1,094 audiotaped rheumatology office visits involving 450 RA patients. Each patient had up to 3 visits audiotaped. In conjunction with each office visit, patients also completed a self-administered questionnaire and interview and the rheumatologists provided ratings of patient health status.The number of medication risks discussed per visit ranged from 0-18, with a mean ± SD of 3.23 ± 2.93. The rheumatologist initiated ∼80% of the medication risk discussions. Approximately one-fourth of the discussions (25.6%) were limited to an assessment of whether or not the patient was experiencing a medication side effect. More risks were discussed during visits when changes to the patient's regimen were discussed than when no changes were discussed (X= 3.93, SD = 3.10 and X = 2.20, SD = 2.34, respectively; P0.0001). When medications were being proposed for addition to the patient's regimen, the most frequently discussed risk dimensions were the importance of monitoring (30%), probability (29.8%), things the patient should do to minimize risk (25.5%), and risk severity (21.8%).Most discussions of medication risks that we observed were quite limited and often restricted to an assessment of whether the patient was experiencing side effects from their current medications. The amount of information that is optimal and how to tailor information to the preferences and abilities of individual patients remain important areas for future research.

An Institute of Medicine (IOM) report recommends development of a standardized, core set of indicators focused on priority health outcomes (Institute of Medicine. Committee on Public Health Strategies to Improve Health, 2011). The IOM also recommends changes in the processes, tools and approaches for gathering information on health outcomes. Several groups have been working to identify and test concepts of health and function that are meaningful across countries and cultures (Taskforce on Health Status, 2005). The Patient-Reported Outcomes Measurement Information System (PROMIS; www.nihpromis.org) adopted the World Health Organization framework to define three components of health: physical, mental and social (World Health Organization, 1946) (see http://www.nihpromis.org/measures/domainframework). This is congruent with the biopsychosocial approach adopted by many health psychologists (Engel, 1977, 1980). Measures of social health will play a key role in applications that use ecologic (or determinants of health) models that emphasize how patients’ environments influence their health (Institute of Medicine, 2003; Institute of Medicine. Committee on Public Health Strategies to Improve Health, 2011; Whitehead, 1995). This is of particular significance given that social health has historically been a relatively neglected domain due to the lack of measures for clinical populations, as well as disagreement about how best to define and measure it (Hahn, Cella, Bode, & Hanrahan, 2010). Social health measures that can be used across chronic illness populations are essential given findings that individuals who receive appropriate social support and are integrated within their communities experience better health outcomes than those who experience social isolation (Broadhead et al., 1983; Bruhn & Philips, 1984; McDowell, 2006; Mitchell, Billings, & Moos, 1982). At the broadest level, social health includes health outcomes as well as social processes that play an important role in influencing other health outcomes, e.g., mediating or moderating the effects of stress on physical health and illness. In some contexts (e.g., family or group therapy), processes such as social support can be outcomes of interventions. The PROMIS domain framework for Social Health (v2.0) includes two primary sub-components: Social Function and Social Relationships (McDowell, 2006) (see supplemental Figure 1). As described in detail elsewhere, PROMIS initially developed two sets of Social Function items (Ability to Participate and Satisfaction with Participation, v1.0) and tested them in a general population English-speaking sample (Hahn et al., 2010). Results showed that some item refinement was necessary, and that clinical samples should be included in future testing to evaluate our conceptual models and produce measures for use across chronic illnesses. Additionally, development of Social Relationships items was needed as well as Spanish language versions in order to address the rising need for assessment tools appropriate for Latinos/Hispanics, who constitute the fastest growing group among minority populations that are often underserved in health care settings and excluded from research studies (Garber & Arnold, 2006; Yancey, Ortega, & Kumanyika, 2006). Establishing cultural equivalence across populations is particularly important for social health, which inherently includes cultural norms against which social roles and support are assessed (McDowell, 2006). The aim of the work we present here was to develop psychometrically sound, culturally relevant and linguistically equivalent English and Spanish language self-report measures of adult social health guided by a comprehensive conceptual model and applicable across chronic illnesses. This manuscript describes the work of the PROMIS Social Health Workgroup to refine and expand the PROMIS Social Health measures (v2.0), test the items with large samples of English- and Spanish-speaking adults, and derive item response theory (IRT)-based item banks (sets of calibrated items). These calibrated item banks are comprised of numerous items that allow for computerized adaptive testing (CAT) and development of multiple short forms of varying length that provide accurate measurement with low response burden (Cella, Gershon, Lai, & Choi, 2007).

Computer technology has become an integral part of health care, yet there have been few studies exploring the use of multimedia technology in the prevention of cancer, especially targeting children.The aims of this study were to develop and evaluate a new multimedia computer program for the primary prevention of skin cancer among a childhood population.An interactive CD-ROM program was developed, then pilot tested in a public elementary school in rural North Carolina. This intervention trial involved 8 third- and fourth-grade classes (N = 209 students), randomized into 3 groups: computer intervention, standard teacher-led intervention, and controls.Students were tested using pre- and postintervention surveys that measured knowledge, attitudes, and self-reported behaviors. A 7-month follow-up survey was performed.There was a significant increase in postintervention knowledge for the computer group when compared to either the teacher-led or control groups (mean scores out of 100: 75.2, 59.5, 55.0, respectively; p0.001). Attitudes about suntanning demonstrated a significant difference between the 3 groups (mean scores out of 100: 64.0, 53.0, 48.6, respectively; p = 0.002). There were slight improvements in the behavioral scores, especially among the computer group, but the overall differences were not significant. Similar overall results were found for the long-term follow-up survey, except that attitudes about suntanning no longer demonstrated a significant difference.These results indicate that this new educational tool is an effective way to introduce health education programs for young children in typical classroom settings. This prototype may serve as a model for the development of future preventive school-based programs, including applications to other conditions associated with high-risk behaviors among children.

To examine adolescent girls' perception of control over general health and sexually transmitted disease (STD) acquisition.Adolescents participating in a longitudinal study were asked questions regarding their perception of their locus of control. These questions, adopted from a previous measure, focused on six loci: internal control, control by parents, partners, peers, and health care providers, and chance.There were 128 girls (mean age, 17 years; range, 14.5 to 18.8); 82% were black and 18% white. Statistically significant associations were found between control of general health and STD acquisition for each locus of control subscale, with the exception of partner control. However, the girls reported significantly less control over STD acquisition than over general health for health care providers, parents, and by chance, and significantly more partner and internal control over STD acquisition than general health. The correlations between parental control over general health and over STD acquisition were inversely correlated with age. Partner control was positively related to current condom use, but internal control was not.The degree of the locus of control was specific for STD acquisition. Girls who believe they should be able to control STD acquisition may not be using condoms. The view of partners as having control over STD acquisition may represent joint communication or coercion. However, in general these findings support the development of female-controlled methods for STD prevention, such as topical microbicides.

Objective To evaluate the effectiveness of computer-tailored newsletter interventions in improving the number and variety of fruits and vegetables eaten by adults. Design The 4-group randomized trial with pre- and post-intervention measures consisted of a control group and 3 intervention groups receiving nontailored newsletters, computer-tailored newsletters, or tailored newsletters with tailored goal-setting information. Intervention groups received 1 newsletter each month for 4 months. Subjects Baseline surveys were completed by 710 health maintenance organization clients. Postintervention surveys administered 6 months after baseline were completed by 573 participants (80.8%). Intervention All newsletters contained strategies for improving fruit and vegetable consumption. Tailored newsletters used computer algorithms to match a person's baseline survey information with the most relevant newsletter messages for promoting dietary change. Main outcome measures Daily intake and weekly variety of fruits and vegetables were measured using a food frequency questionnaire. Statistical analyses performed Analysis of covariance and Tukey's honestly significant difference test were used to assess differences in the number and variety of fruits and vegetables consumed among intervention groups. Results For persons completing postintervention surveys (n=573), all 3 newsletter groups had significantly higher daily intake and variety scores compared with the control group. Although there was a trend of improved intake and variety with each added newsletter element, there were no significant differences at follow-up among the newsletter groups. Conclusions Newsletters can be effective in improving the fruit and vegetable consumption of adults. In this study, a computer-tailoring system did not significantly enhance the effect of the nutrition newsletters on fruit and vegetable intake. J Am Diet Assoc. 1999;99:705–709 .

Objective. To determine the relationship of mood management skills, and affective and cognitive states to changes in moods following mood induction among people with osteoarthritis. Methods. After completing questionnaires, participants underwent a negative mood induction. Momentary moods were assessed prior to, immediately following, and several minutes after the mood induction. Results. A specific mood management skill, mood clarity, consistently predicted changes in positive mood following the mood induction: people who scored high on mood clarity experienced less diminution in positive affect. In contrast, changes in negative affect were unrelated to mood management skills. However, people who scored higher on measures of depressive symptoms and pessimism rebounded from the negative induced mood less strongly than others. Conclusion. Positive and negative emotional states operate largely independently and are differentially influenced by mood clarity, depressive symptoms, and pessimism. High levels of mood clarity may be adaptive in illnesses such as osteoarthritis because negative affective experiences that may be unavoidable need not preclude positive affective states.

This paper describes development of a new measure to assess one dimension of health motivation, the salience of health concerns. The new, five-item, measure was administered to 578 women as part of a larger investigation examining the determinants of exercise and calcium consumption. The study used a cross-sectional survey research design. Data were analyzed separately for premenopausal and menopausal women, allowing us to cross-validate our findings in two independent samples. Our findings suggest that the new measure has many desirable psychometric properties. It is internally consistent (Cronbach's alpha = 0.85 and 0.86 for premenopausal and menopausal women, respectively). For both samples, factor analysis revealed that over 60% of the total item variance was explained by a single underlying factor. All factor loadings exceeded 0.74. The measure also correlated in predictable ways with measures of other health beliefs, differentiated among women in different stages of change with respect to exercise and calcium consumption, and discriminated between women on the basis of their information-seeking behavior. We discuss the potential applications of this new measure in future research. Hopefully, the measure will facilitate research on the role that health salience plays in the behavior change process.

OBJECTIVES: The Medicare Trust Fund is expected to be bankrupt in the next decade, thus threatening the viability of the Medicare Program. We have ascertained what Medicare enrollees' priorities for insured services would be, and why, if it were fiscally necessary to limit Medicare benefits to maintain the viability of the Program. DESIGN: A cross-sectional survey using anonymous, in-person interviews and an innovative instrument to elicit choices. SETTING: General Internal Medicine outpatient clinic at a university teaching hospital. PARTICIPANTS: One hundred five adults, 65 years of age and older, who had primary care physician visits between July and September 1995. MEASUREMENTS: Desire to personally select insurance benefits, insurance benefit choices, and the reasons for selection or rejection of benefits. RESULTS: Subjects of various educational and economic backgrounds were able to carry out the selection process with relative ease, and four-fifths of respondents preferred to make their own choices about insured services. The most frequently selected services were hospitalization, outpatient care, prescription drugs, eye care, and home care, in descending order. Subjects selected 52 different combinations of services. Only 2% of respondents picked the current Medicare service package. The reasons given for selection varied by service; cost and current or anticipated need for a service were the most frequently cited forces driving the choices made. CONCLUSION: These data suggest that Medicare enrollees prefer some element of choice about their health insurance coverage. Their choices vary widely and differ from the current Medicare package.

The primary objective of the current study was to examine the relationship between social support and physical activity within the theory of planned behavior (TPB) theoretical framework. This study used data from the Internet Support for Healthy Associations Promoting Exercise randomized controlled trial. A total of 134 female undergraduate students participated in the study, which included baseline and post measures of perceived social support for physical activity (esteem, informational, and companionship), TPB variables related to physical activity (perceived behavioral control, intention, and attitude), and physical activity behavior. Path analysis revealed a significant indirect relationship between change in companionship support and physical activity mediated by change in intention (.13, p

With the aim of developing a novel strategy for identifying vulnerability for early sexual activity and adjustment problems, African American girls (n = 39) completed partially structured scenarios in which female characters of similar age faced circumstances characterized by varying levels of risk. Most girls indicated that they believed the characters would have sex, regardless of their own sexual history or the level of risk in the scenario. However, the combination of girls’ sexual history and girls’ predictions of characters’ behavior in the scenario provided more information regarding the girls at greatest risk for adjustment problems. Implicit techniques offer an additional strategy for identifying girls most vulnerable to adjustment difficulties in the context of early sexual activity.

Fuzzy trace theory was used to develop a coding scheme that captures the gist that patients extract from information about medication risks and benefits and to explore the extent to which different patients extract different gist representations from the same information.Data were collected from 2003-2007 in a study that included audiotape recording office visits that rheumatoid arthritis (RA) patients had with their rheumatologists. Each patient (n = 365) had up to 3 visits audiotape recorded. The audiotapes were transcribed to facilitate content analysis. Four patients with RA who did not participate in the original study guided development of the coding scheme and used it to code the transcripts.The coding scheme contains 14 gist themes centering on medication effectiveness, need, and safety. There was considerable variation among the gist coders in the specific themes they extracted from individual transcripts. We observed the greatest intercoder agreement for the 4 gist theme variables related to whether the rheumatologist wanted to make changes to the medication regimen. Furthermore, the coders rarely used the "not clear" category to code these 4 variables. In contrast, intercoder agreement for the remaining gist themes, which were designed to capture issues central to the communication of information about medication risks and benefits, was low and the "not clear" category was used more frequently.Our study findings suggest that different people exposed to the same information may form different gist representations. Patient-provider communication concerning medication risks and benefits might be enhanced by better understanding the factors that influence the gist extraction process.

Foot and ankle problems are common in adults, and large observational studies are needed to advance our understanding of the etiology and impact of these conditions. Valid and reliable measures of foot and ankle symptoms and physical function are necessary for this research. This study examined psychometric properties of the Foot and Ankle Outcome Score (FAOS) subscales (pain, other symptoms, activities of daily living [ADL], sport and recreational function [sport/recreation], and foot- and ankle-related quality of life [QOL]) in a large, community-based sample of African American and white men and women ages ≥50 years.Johnston County Osteoarthritis Project participants (n = 1,670) completed the 42-item FAOS (mean age 69 years, 68% women, 31% African American, mean body mass index [BMI] 31.5 kg/m(2) ). Internal consistency, test-retest reliability, convergent validity, and structural validity of each subscale were examined for the sample and for subgroups according to race, sex, age, BMI, presence of knee or hip osteoarthritis, and presence of knee, hip, or low back symptoms.For the sample and each subgroup, Cronbach's alpha coefficients ranged from 0.95-0.97 (pain), 0.97-0.98 (ADL), 0.94-0.96 (sport/recreation), 0.89-0.92 (QOL), and 0.72-0.82 (symptoms). Correlation coefficients ranged from 0.24-0.52 for pain and symptoms subscales with foot and ankle symptoms and from 0.30-0.55 for ADL and sport/recreation subscales with the Western Ontario and McMaster Universities Osteoarthritis Index function subscale. Intraclass correlation coefficients for test-retest reliability ranged from 0.63-0.81. Items loaded on a single factor for each subscale except symptoms (2 factors).The FAOS exhibited sufficient reliability and validity in this large cohort study.

To measure physicians' attitudes regarding telephone medicine and identify determinants of these attitudes.Cross-sectional survey.Ten internal medicine residency programs in the United States.Graduates from 1988 through 1992. The response rate was 62% (n = 356).Survey items were assigned to one of four types of variables: demographic, attitude, training, or system variables. We used factor analysis to consolidate information from the individual questions about attitudes. Six scales describing attitudes toward telephone medicine were identified. Cronbach's alpha was greater than 0.70 for all scales. One scale measured physicians' satisfaction and confidence with the management of patient calls. Other attitude scales measured the helpfulness of personal experience or informal education and the importance of formal training in telephone medicine. Three of the scales measured how comfortable the physician felt prescribing over the telephone. We used regression analysis to predict physician attitudes towards telephone medicine using the demographic, training, and system variables. Availability of the patient's chart, feeling prepared for telephone medicine by one's residency training, and being comfortable prescribing narcotics by telephone predicted satisfaction and confidence with the management of patient calls (R2 = .25).Several physician attitudes regarding telephone medicine can be measured reliably. Our findings suggest that improving systems for managing patient calls and improving telephone training for physicians will improve physician satisfaction and confidence with the practice of telephone medicine.

Social support has been found to predict success with health behavior change but, as yet, few studies examine the relationship between social support and dietary change in a low-income population. We developed a social support for dietary change measure for a low-income, hypercholesterolemic population and tested its predictive utility in a clinical trial with a dietary intervention. Questions were administered by telephone to 443 patients enrolled in the trial. Dietary change was measured by the Dietary Risk Assessment Factor analysis revealed three social support factors: friend, family and negative support, and a fourth factor, motivation to change. Multiple regression analysis revealed that motivation to change was predictive of change to a less atherogenic diet Results of a gender-stratified analysis revealed that friend support was a significant predictor of dietary change for women but not for men. Interaction

The Physicians' Reactions to Uncertainty (PRU) scales were developed to measure physicians' affective reactions to uncertainty. However, the structural (factor) model for the two PRU scales has not been cross validated on an independent sample of physicians. We surveyed 337 physicians in internal medicine at Indiana University to test the structural model for the PRU scales using confirmatory factor analysis and, if necessary, to refine the constructs and scales. The structural model of the original PRU scales did not fit the data (X2=559.26,p

The utility of measuring both positive and negative affective states for assessing rheumatoid arthritis (RA) patients was examined in 3 independent samples of male and female RA patients (Sample A: 179 women, 48 men; Sample B: 177 women, 24 men; Sample C: 134 women, 38 men). Confirmatory factor analyses of each sample indicated that positive and negative affect constituted separate, negatively correlated factors. The relations among disease variables, coping, and affects were consistent with a model in which coping mediates the relationship between disease variables and positive and negative affect. Patients with higher pain and limitation from RA had higher levels of maladaptive coping, and maladaptive coping was associated with lower positive affect and higher negative affect. Those RAs with higher activity limitation also reported less adaptive coping, which was associated with less positive affect.

The primary purpose of this article is to document whether demographic, clinical, regimen-related, intrapersonal, and interpersonal factors predict medication non-adherence for vasculitis patients. A secondary purpose is to explore whether adherence varies by medication type and whether patients experienced drug-related side effects. Vasculitis patients (n = 228) completed online baseline and 3-month follow-up surveys. Demographic (age, gender, education, race, marital status, and insurance status), clinical (perceived vasculitis severity, disease duration, vasculitis type, and relapse/remission status), regimen-related (experience of side effects), intrapersonal (depressive symptoms), and interpersonal (adherence-related support from family and friends) factors were measured at baseline. Medication non-adherence was assessed at follow-up using the Vasculitis Self-Management Survey medication adherence subscale (α = 0.89). Variables that significantly correlated (p < 0.05) with non-adherence were included in a linear regression model to predict non-adherence. Younger age (r = −0.23, p < 0.001), female sex (r = 0.16, p < 0.05), experience of side effects (r = 0.15, p < 0.05), and more depressive symptoms (r = 0.22, p < 0.001) were associated with more medication non-adherence. In the regression model, younger age (β = −0.01, p = 0.01) and more depressive symptoms (β = 0.01 p = 0.02) predicted worse adherence. For six out of eight vasculitis medication types, patients who experienced side effects were less adherent than patients who did not experience side effects. Multiple factors are associated with medication non-adherence for vasculitis patients. Providers should discuss medication adherence and drug-related side effects with vasculitis patients. Providers may want to particularly target younger patients and patients with clinical signs of depression.

Objective Despite being used in multiple studies, the Menopause-Specific Quality of Life Questionnaire (MENQOL) has not been assessed with factor analysis, a common method of item reduction in quality of life tools. Methods The Menopause Epidemiology Study is a cross-sectional population-based study of women 40 to 65 years old in the United States chosen from a source population selected by random digit dialing and probability sampling. We focused on 2,703 postmenopausal women for our analyses. Before analysis and to prevent model overfitting, we split our sample into two equal groups using a uniform random sample. Using parallel analysis for factor extraction, we performed confirmatory factor analysis on the MENQOL to examine the current factor structure and to evaluate the efficiency of the items in the existing tool. Reliability coefficients (Cronbach α) were calculated for each of the domains. Results With few exceptions, the items from the original MENQOL factored into the domains under which they were originally placed. Using this method, five items did not add significant statistical value to the scoring of the domains: difficulty sleeping; poor memory; accomplishing less than I used to; changes in appearance, texture, or tone of my skin; and feeling tired. Reliability coefficients for the four original domains were acceptable: vasomotor, 0.87; psychosocial, 0.85; physical, 0.88; and sexual, 0.77. Conclusions Results from factor analysis indicate that although the MENQOL was developed more than 15 years ago, the strength of the items is still highly valuable today in the assessment of women's menopause-related quality of life.

Translating questionnaires for cross-cultural research is fraught with methodological pitfalls that threaten research validity. Some flaws are difficult to detect, leading to the erroneous conclusion that cultural differences are substantive when, in fact, they stem from semantic inconsistencies. We describe the process of translation and validation of the Hebrew version of an American questionnaire for cross-cultural comparisons of medical students' attitudes toward preventive medical services. The results provide evidence to support the validity of the Hebrew instrument for cross-cultural comparisons. Although it is always possible to contend that differences in cross-cultural comparisons result from metiodological flaws rather than actual differences, we believe that the arduous step-by-step process of validation described here reduces that possibility to an acceptable minimum.

OBJECTIVES. To achieve the Healthy People 2000 objectives, public health professionals must develop effective dietary interventions that address psychosocial and behavioral components of change. This study tested the effect of individually computer-tailored messages designed to decrease fat intake and increase fruit and vegetable intake. METHODS. Adult patients from four North Carolina family practices were surveyed at baseline and then randomly assigned to one of two interventions or to a control group. The first intervention consisted of individually computer-tailored nutrition messages; the second consisted of nontailored nutrition information based on the 1990 Dietary Guidelines for Americans. Patients were resurveyed 4 months postintervention. RESULTS. The tailored intervention produced significant decreases in total fat and saturated fat scores compared with those of the control group (P < .05). Total fat was decreased in the tailored group by 23%, in the nontailored group by 9%, and in the control group by 3%. Fruit and vegetable consumption did not increase in any study group. Seventy-three percent of the tailored intervention group recalled receiving a message, compared with 33% of the nontailored intervention group. CONCLUSIONS. Tailored nutrition messages are effective in promoting dietary fat reduction for disease prevention.

This study examined the reliability of a revised version of the Burn Specific Health Scale (BSHS). Two hundred fifty-four former patients recruited from eight burn centers in the southeastern United States participated in the study. Data were collected via chart review and mailed questionnaire. Factor analyses were used to identify seven subscales containing a total of 31 items. Subsequent analyses provided strong support for the reliability and validity of the revised measure. Each subscale exhibited a high level of reliability (Cronbach's alpha ranged from 0.82 to 0.94). Each subscale also correlated in a predictable manner with measures used for validation. The revised measure should improve the ability of both researchers and clinicians to assess the impact of non-fatal burn injury accurately and comprehensively. Language: en

Purpose. We examined whether or not there are systematic differences in how people appraise different types of illness-related problems and in how they cope with these problems. Methods. Two hundred thirty-five adults with recently diagnosed rheumatoid arthritis completed a mailed questionnaire followed by a telephone interview. A series of stress appraisal and coping variables were assessed in relation to three areas: household activities, leisure activities, and pain management. Results. Pain Differed significantly from household and leisure activities with regard to several appraisal and coping variables. Participants reported the least control over problems with pain, while attaching the most importance to pain control. Leisure activities also stood out as unique on several variables. Participants perceived greater ability and were more satisfied with their ability in relation to leisure activities. Conclusion. These findings show that, at least early in the disease, appraisal and coping strategies differ across the areas of household activities, leisure activities, and pain management.

Over the past 40 years, the advent of more effective treatment regimens has transformed vasculitis from a frequently fatal, acute disease to a chronic condition with relapsing and remitting episodes with which patients can live for many years. Because vasculitis is now viewed as a chronic disease, the role of treatment has expanded from an almost exclusive focus on reducing mortality and inducing remission to include improving patient quality of life. In fact, most research studies with vasculitis patients, including clinical trials and observational studies, now measure patient quality of life to determine what factors hinder and facilitate optimal patient functioning and well-being. The World Health Organization has defined quality of life as “individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns” (WHO, 1997, p. 1). Implicit in this definition is the fact that many layers of influence, ranging from intrapersonal beliefs to environmental factors, affect quality of life. In chronic disease populations, researchers often focus on patient health-related quality of life (HRQOL). Although HRQOL is more narrowly focused than quality of life, it is a still a complex concept that refers to the overall perceived well-being of an individual as well as his/her ability to function in daily life (Hays et al., 1993). There are many definitions of HRQOL, but most scholars agree that HRQOL includes both multidimensional and subjective components (Cella, 1994). The multidimensional component refers to the many dimensions (e.g. physical, functional, emotional, financial, and social) on which chronic disease can affect the patient’s health and functioning. The subjective component suggests that patients, rather than health care providers, for example, are in the best position to report their HRQOL. Although the HRQOL literature has primarily described how vasculitis negatively impacts patients’ physical and mental health, there is also some evidence that patients experience positive impacts. Moreover, in addition to directly affecting the patient, vasculitis also has the potential to influence patients’ relationships with spouses, family members, and friends. Garnering a holistic understanding of how vasculitis affects patients and their social networks is of interest because individuals having a chronic disease often seek support from others to help cope with disease-related stressors, which can lead to improved physical and mental health (Pennix et al., 1996). This chapter not only describes how vasculitis positively and negatively impacts patients’ HRQOL, but also, the impacts of vasculitis on members of patients’ social networks. We first focus on patient HRQOL issues, including an examination of how vasculitis affects patients

Our objective is to explore how vasculitis affects patients' friendships and social participation.Vasculitis patients (n=221) completed an online questionnaire that asked if, and how, relationships with friends have changed since receiving a vasculitis diagnosis. Participants' written responses were imported into Atlas.ti, and two independent researchers used both structured and unstructured coding to identify themes. After reaching 100% consensus on the themes present in each participant's responses, the coders determined how themes were interrelated across participants.Over half of patients (52%) expressed that vasculitis negatively impacted their friendships and 25% noted a negative impact on their social participation. At times, this negative impact was related to structural changes in patients' social networks due to loss of friendships. Reduced social participation was also associated with friends' inability to understand vasculitis and its effects, vasculitis-related fatigue, and lifestyle changes such as not being able to drink alcohol and avoiding infection-prone events. Additionally, patients withdrew from social engagements due to fatigue or because of physical symptoms and side effects.The unique circumstances associated with a rare chronic illness like vasculitis can create significant barriers to friendships, including loss of these relationships. Interventions designed to help patients cope with the social impact of vasculitis are implicated, especially if they increase patients' ability to engage in dialogue about their illness with their friends.

Objective.Few studies have investigated whether the utility of social support for patients with a relapsing, remitting illness varies by activity level of the disease. Our goal was to determine whether disease status (relapse vs remission) moderates the effect of medication-related support from physicians and partners on the health-related quality of life (HRQOL) of patients with vasculitis.Methods.Patients with vasculitis (n = 228) completed baseline measures of disease status and medication-related support and a 3-month followup measure of HRQOL (RAND 36-item health survey 1.0). We calculated 8 HRQOL dimensions: physical functioning, physical role limitations, bodily pain, general health, vitality, social functioning, emotional role limitations, and mental health. Bonferroni-corrected t tests compared the HRQOL of patients in relapse to patients in remission, and multivariate analysis of covariance determined whether disease status moderated the effect of medication-related support from physicians and partners on patient HRQOL. Wilks’ lambda assessed whether the support-by-disease status interaction terms were significant.Results.Relapsing patients reported significantly worse quality of life compared with nonrelapsing patients for every HRQOL dimension except physical role limitations. Disease status did not moderate the effect of physician (lambda = 0.48; p = 0.86) or partner (lambda = 1.51; p = 0.16) medication-related support on HRQOL, although greater physician and partner support predicted better HRQOL for all dimensions except bodily pain and vitality.Conclusion.Vasculitis patients experience compromised HRQOL but the magnitude of the compromise is greater for patients experiencing a relapse. Medication-related support from physicians and partners is beneficial for patients’ HRQOL regardless of disease status.

Background. The psychometric properties of the Modified Work APGAR (MWA) scale are not established, yet researchers use this scale as an overall measure of job satisfaction. Objective. Perform psychometric analyses on the MWA scale using data from two populations. Methods. A landmark occupational cohort and a clinical cohort are populations with low back pain studied. The first five items of the MWA scale measure social support from coworkers, one item measures dissatisfaction with job tasks, and the sixth item measures lack of social support from a supervisor. Exploratory principal components analyses were conducted in both cohorts. Results. In both cohorts, the first five items of the MWA scale loaded consistently onto one factor, social support from coworkers subscale. Conclusions. Unless researchers are interested in measuring social support from coworkers only, future studies should use other reliable and valid instruments to measure a broad range of psychosocial work characteristics.

We describe the development and validation of the Parent Health Locus of Control (PHLOC) scales. Using factor analytic and item analytic methods, 30 items comprising six scales were extracted from a pool of 84 items. The individual scales correspond to beliefs in Child, Divine, Fate, Media, Parental, and Professional Influence over child health. Results were compared for six samples totalling 822 parents. Internal consistency reliabilities were above .70 for all scales with all samples. Test-retest correlations based on a separate sample were all above .60. Validity was assessed by means of a known groups strategy that made use of presumed differences among the six samples studied. The results generally agreed with predicted differences, offering good initial evidence of the validity for the PHLOC scales.

Background. Physicians face increasing pressure to counsel their hypercholesterolemic patients about diet. To design effective physician-based treatment programs, a better understanding of current dietary counseling practice and its determinants is needed. Methods. Using a survey previously tested for reliability and validity, we examined the relationship of dietary knowledge, attitudes, beliefs, organizational barriers, and treatment practices for cholesterol management among 60 resident and attending physicians practicing in the general medicine clinic of a university medical center that serves primarily rural and disadvantaged patients. The survey was administered in October of 1988 prior to the release of the National Cholesterol Education Program Guidelines. Results: The response rate was 100%. Ninety-two percent of physicians surveyed believe that dietary treatment effectively lowers cholesterol and 68% feel responsible for providing such therapy. However, most (72%) feel ill-prepared to give diet counseling, lack confidence in their ability to help patients make meaningful dietary changes (95%), and cite organizational barriers, such as limited time (72%) or inadequate educational materials (47%). Physicians were more likely to report behaviorally focused diet counseling practices if they felt prepared to counsel (r = 0.42, P < 0.001), were confident in their counseling skills (r = 0.39, P < 0.01), or reported personally following a prudent diet (r = 0.36, P < 0.01). We discuss the implications of these findings and how they should guide the design of physician-based dietary interventions for cholesterol reduction.

Objectives Patient-reported outcomes (PROs) are essential when evaluating many new treatments in health care; yet, current measures have been limited by a lack of precision, standardization, and comparability of scores across studies and diseases. The Patient-Reported Outcomes Measurement Information System (PROMIS) provides item banks that offer the potential for efficient (minimizes item number without compromising reliability), flexible (enables optional use of interchangeable items), and precise (has minimal error in estimate) measurement of commonly studied PROs. We report results from the first large-scale testing of PROMIS items. Study Design and Setting Fourteen item pools were tested in the U.S. general population and clinical groups using an online panel and clinic recruitment. A scale-setting subsample was created reflecting demographics proportional to the 2000 U.S. census. Results Using item-response theory (graded response model), 11 item banks were calibrated on a sample of 21,133, measuring components of self-reported physical, mental, and social health, along with a 10-item Global Health Scale. Short forms from each bank were developed and compared with the overall bank and with other well-validated and widely accepted (“legacy”) measures. All item banks demonstrated good reliability across most of the score distributions. Construct validity was supported by moderate to strong correlations with legacy measures. Conclusion PROMIS item banks and their short forms provide evidence that they are reliable and precise measures of generic symptoms and functional reports comparable to legacy instruments. Further testing will continue to validate and test PROMIS items and banks in diverse clinical populations.

Objective This article explores the effect of conflicting information, defined as contradictory information about medication topics from different sources, on medication adherence in a sample of chronically ill patients. We specifically investigate whether conflicting information and physician support directly affect medication adherence or whether the effect is mediated by adherence self-efficacy and outcome expectations for medications. Methods Vasculitis patients ( n =228) completed two on-line questionnaires which contained measures of conflicting information, adherence self-efficacy, outcome expectations, physician support, and medication adherence. We conducted a mediation analysis using a bootstrapping approach to generate point estimates and 95% confidence intervals to test the significance of each mediated effect. Results A majority of patients (51.3%) received conflicting medication information. Conflicting information had a direct negative effect on medication adherence, which was not mediated by self-efficacy or outcome expectations. Alternatively, self-efficacy mediated the positive effect of physician support on medication adherence. Conclusion Patients who encounter conflicting medication information are less adherent to their medications. The presence of a supportive physician may counteract the negative effect of conflicting medication information. Practice implications Physicians should initiate conversations about conflicting medication information with their patients. Consensus-based guidelines that address medication discrepancies may also reduce the availability of conflicting information.

Objective. Satisfaction with abilities and perceived importance of abilities are 2 factors involved in the process of self-evaluation. We examined the role that these factors play in adjustment to rheumatoid arthritis (RA). Methods. Data were collected, via telephone interview and mailed questionnaire, from 234 individuals with recently diagnosed RA. Disease severity information was obtained from participants'physicians. Results. Consistent with study hypotheses, satisfaction was associated with psychological well-being only among those who viewed as very important the abilities being evaluated

Low income Americans are at greatest risk for coronary heart disease but have least access to health promotion programs for life style modification. Primary care physicians may represent one of the few sources of preventive care available to the poor. However, the majority of physicians feel unprepared to help patients achieve dietary change, and few existing nutrition intervention programs address the special needs of low literacy populations. The Food for Heart Program was developed to facilitate dietary counseling experienced by primary care physicians who care for low literacy patients and to overcome barriers to behavior change faced by patients. The program consists of three components: (1) a validated dietary risk assessment that rapidly identifies atherogenic eating habits and requires no nutritional expertise to administer or interpret, (2) a structured diet treatment program that is culturally specific for a southern patient population and links practical behavior change recommendations with results of the diet assessment, and (3) a system for monitoring and reinforcement that prompts physicians to review progress, reinforce prior messages, and reward positive change. Behavior change theory is used to guide the intervention and readability of the material has been assessed at the 5–6th grade level. An evaluation study of the Food for Heart Program suggests that it has a positive impact on physician counseling and that patients are responding favorably to these efforts.

Despite growing awareness of uncertainty in technical and scientific fields, uncertainty among physicians, except among physicians in training, is not well researched. Existing studies have primarily used small samples and qualitative methods. This article reports the first rigorously developed measures of uncertainty administered to a large sample of practicing physicians. In contrast to denial and the tendency to minimize uncertainty reported in field studies of trainees, physicians in this study readily acknowledged uncertainty in a number of areas.

The main objective of this study is to investigate the long-term effects, 3 years after the end of a 2-year pulmonary rehabilitation program with three weekly 1-h exercise sessions and 32 h of education in patients with chronic obstructive pulmonary disease. The method consists of open prospective observational study with 30 patients. Outcome measures were quality of life (QoL) (St George’s Respiratory Questionnaire, SGRQ), physical exercise performance (6-min walking test, 6MWT), self-management abilities, lung function, hospitalization, and self-reported exercise. FEV1 at baseline was 40.1% of predicted. The participants had statistical and clinical significant decrease in SGRQ (improved QoL) and increase in 6MWT during the program. They maintained the level of health they achieved during the program in the next 3 years, with a stable SGRQ score (−0.5 points, 95% CI −3.8 to 2.6 P = 1.000) and 6MWT (+10 m 95% CI 28 to −4, P = 0.273). Eighty percent of the participants had exercised at least 30 min three times a week from the end of the program to year 5. In conclusion, the participants had maintained their achieved level of health, improved their lung function slightly, and continued to exercise regularly 3 years after the end of the program.

Low-income Americans are at greatest risk for coronary heart disease. Dietary assessment methods are needed that can efficiently and effectively guide diet counseling to reduce serum cholesterol in this population. The Dietary Risk Assessment is a brief food frequency questionnaire designed to guide an intervention program for cholesterol reduction. It can easily be administered and scored in 10 to 15 minutes by persons who are not trained in nutrition. The assessment is culturally specific for a low-income southern population, identifies positive as well as problematic dietary behaviors, is easily interpreted, and measures potential barriers to dietary change. The assessment was validated against 3 days of dietary recall data in a sample of 42 low-income individuals recruited from the waiting room of an ambulatory care clinic. A Keys score, which measures the serum-cholesterol-raising potential of the diet, was calculated for each patient from their recall data. The Keys and Dietary Risk Assessment scores were significantly correlated (r = .60, P less than .001). We conclude that the Dietary Risk Assessment can rank individuals by level of dietary atherogenic risk adequately to guide a dietary treatment program for low-income patients, an underserved population with a high prevalence of diet-induced elevations in serum cholesterol.

Seventy-two women with rheumatoid arthritis (RA) were randomly assigned to view a depiction of a woman having either very mild or very severe RA and coping either quite weal or quite poorly with the illness. Subjects rated the woman's arthritis severity, her coping with RA, their own arthritis severity, and their own coping with RA. These ratings provided an indirect assessment of how subjects evaluated themselves relative to the stimulus woman. In addition, subjects compared their RA severity and coping directly with the stimulus woman's. In the direct comparisons, subjects who saw the good coper did not acknowledge her coping superiority, despite having done so on the indirect assessment. No effects were obtained for the severity condition. These findings suggest that individuals extract self-enhancing information from social comparisons, even when the comparison target and dimension are constrained and the target's status is superior

Objective: To examine the psychometric properties of the Arthritis Body Experience Scale (ABES) in a US sample of people with osteoarthritis, rheumatoid arthritis, fibromyalgia and other rheumatic conditions. Methods: The ABES, with the scoring direction modified, was phone-administered to 937 individuals who self-identified as having one or more arthritis conditions based on a validated, US, national survey assessment tool. Descriptive statistics of demographic variables and factor analysis of scale items were conducted. Scale dimensionality was assessed using principal component analysis (PCA) with oblique rotation. Criteria for assessing factors were eigenvalues > 1, visual as- sessment of scree plot, and structure and pattern matrices. Results: The predominantly female (74.2%) and Caucasian (79.9%) sample had a mean age of 61.0 ± 13.1 years, and a mean BMI of 30.2 ± 7.1. Major arthritis conditions reported were rheumatoid arthritis, osteoarthritis and fibromyalgia. A three-factor structure with cronbach alpha values of .84, .85 and .53 was elicited, and accounted for 72% of the variance. Discussion: Compared to the two-factor structure evidenced by the original ABES scale in a sample of UK adults, the data from this sample evidenced a three-factor structure with higher variance. The third factor's cronbach alpha of .53 was low and could be improved by the addition of salient questions derived from further qualitative interviews with patients with arthritis and other rheumatic conditions and from current literature findings. Conclusion: The observed psychometrics indicate the scale usefully assesses body image in populations with arthritis and related conditions. However, further testing and refinement is needed to determine its utility in clinical and other settings.

This study examined the equivalency of disability estimates obtained from the health assessment questionnaire (HAQ) and the modified HAQ (MHAQ). We found that although the MHAQ and HAQ scores were highly correlated, MHAQ scores were significantly lower than HAQ scores, were not normally distributed, and exhibited a restricted range. Implications of these findings are discussed.

The relationships among symptom severity, symptom exacerbation, negative affect, and social comparison processes were examined among 71 rheumatoid arthritis (RA) patients. Social comparisons were operationalized by means of multiple measures derived from theory and developed for this investigation. We proposed that experiencing severe or worsening arthritis symptoms would be associated with more depression and lower self-esteem, which, in turn, would be associated with downward social comparison. The results substantially supported these hypothesized relationships. Three different types of social comparison measures all revealed a preponderance of downward comparisons. A composite of depression and low self-esteem was significantly related to symptom severity. Social comparisons operationalized as information choices revealed that, in general, negative affect was related to downward comparison. These findings are consistent with formulations suggesting that chronic health problems can threaten self-worth ...

The purpose of this systematic review is to assess the literature pertinent to healthy coping in diabetes management and to identify effective or promising interventions and areas needing further investigation.A PubMed search identified 186 articles in English published between January 1, 1990, and July 31, 2006, addressing diabetes and emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem solving, couples therapy, or marital therapy.Connections among psychological variables, behavioral factors, coping, metabolic control, and quality of life are appreciable and multidirectional. Interventions for which well-controlled studies indicate benefits for quality of life and/or metabolic control include general self-management, coping/problem-solving interventions, stress management, support groups, cognitive-behavioral therapy, behavioral family systems therapy, cognitive-analytic therapy, multisystemic therapy, medications for depression, and the Pathways intervention integrating case management, support of medication, and problem-solving counseling.Psychological, emotional, related behavioral factors, and quality of life are important in diabetes management, are worthy of attention in their own right, and influence metabolic control. A range of interventions that achieve benefits in these areas provide a base for developing versatile programs to promote healthy coping.