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1.  How Efficacious Are Patient Education Interventions to Improve Bowel Preparation for Colonoscopy? A Systematic Review 
PLoS ONE  2016;11(10):e0164442.
Bowel preparation is inadequate in a large proportion of colonoscopies, leading to multiple clinical and economic harms. While most patients receive some form of education before colonoscopy, there is no consensus on the best approach.
This systematic review aimed to evaluate the efficacy of patient education interventions to improve bowel preparation.
We searched the Cochrane Database, CINAHL, EMBASE, Ovid, and Web of Science. Inclusion criteria were: (1) a patient education intervention; (2) a primary aim of improving bowel preparation; (3) a validated bowel preparation scale; (4) a prospective design; (5) a concurrent control group; and, (6) adult participants. Study validity was assessed using a modified Downs and Black scale.
1,080 abstracts were screened. Seven full text studies met inclusion criteria, including 2,660 patients. These studies evaluated multiple delivery platforms, including paper-based interventions (three studies), videos (two studies), re-education telephone calls the day before colonoscopy (one study), and in-person education by physicians (one study). Bowel preparation significantly improved with the intervention in all but one study. All but one study were done in a single center. Validity scores ranged from 13 to 24 (maximum 27). Four of five abstracts and research letters that met inclusion criteria also showed improvements in bowel preparation. Statistical and clinical heterogeneity precluded meta-analysis.
Compared to usual care, patient education interventions appear efficacious in improving the quality of bowel preparation. However, because of the small scale of the studies and individualized nature of the interventions, results of these studies may not be generalizable to other settings. Healthcare practices should consider systematically evaluating their current bowel preparation education methods before undertaking new interventions.
PMCID: PMC5065159  PMID: 27741260
2.  Internet-Based Dementia Resources: Physician Attitudes and Practices 
Despite the potential of the internet for informing clinical practice, little is know about physicians’ use of and attitudes about internet use for dementia care. We surveyed 373 physicians to inform development of on-line dementia education resources. Two thirds reported using internet-based resources in their clinical practices at least three times per week; 61% participated in on-line continuing medical education. Three fourths agreed that internet-based resources are helpful in clinical care but most expressed mixed views about quality of available information. Respondents reported limited awareness and use of dementia-specific internet resources, but expressed an interest in such information regarding screening, treatment, community resources, and patient education. National Institute on Aging-funded Alzheimer’s Disease Centers are in a unique position to disseminate on-line resources for physicians on dementia diagnosis, treatment, and care. Our study suggests that such a resource would be well received and utilized by physicians.
PMCID: PMC3137376  PMID: 21769164
Alzheimer’s disease; Internet; Medical Education
3.  Effects of a Telephone-Based Exercise Intervention for Dementia Caregiving Wives: A Randomized Controlled Trial 
Despite the importance of self-care for dementia caregivers, few interventions have included a focus on health behaviors. The current study reports outcomes of a telephone-based exercise intervention designed for women caring for a spouse with dementia. Caregivers (N = 137) were randomized to intervention or control conditions. Participants with at or below-median exercise scores at baseline had a significantly greater increase in exercise at six-month follow-up compared to their control counterparts. At 6 months, participants had greater reductions in perceived stress relative to controls. Participants also reported significantly greater increases in exercise self-efficacy than caregivers in the control group at both follow-up points. . Results indicate that spouse caregivers are able to increase their physical activity and that a focus on exercise in multi-component interventions may be beneficial. Debate and discussion is needed to inform expectations for program impacts and their maintenance and to explore the interface between enhanced self-care and caregiving perceptions.
PMCID: PMC3121165  PMID: 21709757
Alzheimer’s disease; physical activity; self-care; self-efficacy; spouse
4.  Public beliefs and knowledge about risk and protective factors for Alzheimer's disease 
The purpose of this study was to assess public beliefs and knowledge about risk and protective factors for Alzheimer's disease (AD).
A brief survey module was added to the Health and Retirement Study, a longstanding national panel study of the U.S. population over the age of 50.
Respondents were 1641 adults (mean age = 64.4 years, 53.6% female, 81.7% White). Most (60.1%) indicated interest in learning their AD risk, with 29.4% expressing active worry. Many failed to recognize that medications to prevent AD are not available (39.1%) or that having an affected first-degree relative is associated with increased disease risk (32%). Many respondents believed that various actions (e.g., mental activity, eating a healthy diet) would be effective in reducing AD risk.
Older and middle-aged adults are interested in their AD risk status and believe that steps can be taken to reduce disease risk. Tailored education efforts are needed to address potential misconceptions about risk and protective factors.
PMCID: PMC4163539  PMID: 24630852
Illness perceptions; Public understanding; Health education; National survey; Attitudes and beliefs
5.  Antecedents of Physical Activity Among Family Caregivers 
We examined exercise behaviors among family caregivers and the degree to which aspects of the caregiving role influenced exercise behaviors. Understanding factors associated with caregiver physical activity provides practitioners the means to design and tailor interventions to be effective for caregivers.
Caregivers (N=208) participating in a self-care intervention to promote caregiving skills were surveyed at baseline, prior to training. Measures included caregiver characteristics, care recipient characteristics, attitudes and intentions toward exercise and levels of physical activity.
Mental health variables and self-efficacy for exercise were significantly related to exercise levels in bivariate analyses. Regression analyses revealed that caregiver and care recipient characteristics accounted for a small percentage of the variance in exercise behavior.
Caregiver vitality and self-efficacy for exercise were key variables most significantly related to exercise behaviors. Findings suggest that mental health factors and attitudes about exercise may be more important predictors of exercise than caregiving factors.
PMCID: PMC4226062  PMID: 25392600
caregivers; physical activity; exercise; self-efficacy; vitality
6.  Overestimation of physical activity in a nationally-representative sample of underactive adults with diabetes 
Medical care  2012;50(5):441-445.
Using data from the national Health and Retirement Study, we sought to: a) estimate the proportion of U.S. adults with diabetes over age 50 who do not meet physical activity guidelines but believe they are sufficiently active, and b) examine demographic and health-related correlates of such ‘overestimation.’
Research design
Respondents who were classified as underactive according to a detailed activity inventory, but reported exercising at least the ‘right amount’, were designated as overestimating their physical activity. Multiple logistic regression was used to examine the association of demographic and health-related correlates with the odds of overestimation.
Fifty-four percent of the survey sample did not meet physical activity guidelines, and one-quarter of this underactive group overestimated their physical activity. The adjusted odds of overestimation were higher among respondents who held the perception that they were the right weight or underweight (OR=2.42; 95% C.I. = 1.49–3.94), who had good or better self-assessed diabetes control (1.84; 95% C.I. = 1.12–3.04), and who were Black or Hispanic (OR=1.89; 95% C.I. 1.13–3.16). Experiencing shortness of breath reduced the odds of overestimation (OR=0.34; 95% C.I. = 0.19–0.61).
Overestimation of physical activity is common among adults with diabetes, and is associated with the perceptions that one is the right weight and that one has good control of diabetes, and with being Black or Hispanic. Clinicians should be aware that these factors may affect their patients' beliefs about how much physical activity is adequate.
PMCID: PMC4161147  PMID: 22193415
7.  A Novel Look at Racial Health Disparities: The Interaction Between Social Disadvantage and Environmental Health 
American journal of public health  2012;102(12):10.2105/AJPH.2012.300774.
We explored the notion that social disadvantage increases vulnerability to the health effects of environmental hazards. Specifically, we examined (1) whether race modifies the association between blood lead and blood pressure and (2) whether socioeconomic status (SES) plays a role in this modifying effect.
Using the National Health and Nutrition Examination Survey (2001–2008) and linear regression, we estimated the association between blood lead and blood pressure. Using interactions among race, SES, and lead, we estimated this association by levels of social disadvantage.
Black men and women showed a 2.8 (P < .001) and 4.0 (P < .001) millimeters mercury increase in SBP, respectively, for each doubling of blood lead. White adults showed no association. This lead–SBP association exhibited by Blacks was primarily isolated to Blacks of low SES. For example, poor but not nonpoor Black men showed a 4.8 millimeters mercury (P < .001) increase in SBP for each doubling of blood lead.
Our results suggest that social disadvantage exacerbates the deleterious health effects of lead. Our work provides evidence that social and environmental factors must be addressed together to eliminate health disparities.
PMCID: PMC3519308  PMID: 23078461
8.  Providing Support to Relatives and Friends Managing Both Chronic Physical Illness and Depression: the Views of a National Sample of U.S. Adults 
Patient education and counseling  2012;89(1):191-198.
To describe how comorbid depression in chronically ill adults affects the willingness of their family and friends to provide them with illness management support.
We identified a national sample of U.S. adults (n=1027), all of whom had a close relative or friend with a chronic physical illness. We examined whether respondents were less willing to help their relatives/friends with disease management when they reported that these relatives/friends were also diagnosed with depression.
In multivariate models, the odds of respondents being willing to provide disease-management support doubled when the relative/friend was depressed (adjusted odds ratio (AOR) = 1.99; 95% C.I=1.31, 3.02). Respondents were willing to perform an equal number of illness support tasks for relatives/friends with and without depression. However, respondents reported 30% more difficulties discussing health issues (incidence rate ratio (IRR)=1.30; 95% C.I=1.11,1.53), and 44% more barriers to providing support (IRR=1.44; 95% C.I=1.18, 1.75) to depressed relatives/friends.
U.S. adults are more willing to provide disease-management support for chronically ill relatives/friends with depression. However, helping depressed relatives/friends is also more challenging.
Practice implications
By providing resources for potential supporters, health providers could mobilize an important source of disease-management support for patients with chronic illness and depression.
PMCID: PMC3462282  PMID: 22748757
chronic illness; caregiving; diabetes; depression; social support; social network; heart disease; arthritis; behavior change; self-management; health promotion
9.  An Examination of Healthy Aging Across a Conceptual Continuum: Prevalence Estimates, Demographic Patterns, and Validity 
Although the notion of healthy aging has gained wide acceptance in gerontology, measuring the phenomenon is challenging. Guided by a prominent conceptualization of healthy aging, we examined how shifting from a more to less stringent definition of healthy aging influences prevalence estimates, demographic patterns, and validity.
Data are from adults aged 65 years and older who participated in the Health and Retirement Study. We examined four operational definitions of healthy aging. For each, we calculated prevalence estimates and examined the odds of healthy aging by age, education, gender, and race-ethnicity in 2006. We also examined the association between healthy aging and both self-rated health and death.
Across definitions, the prevalence of healthy aging ranged from 3.3% to 35.5%. For all definitions, those classified as experiencing healthy aging had lower odds of fair or poor self-rated health and death over an 8-year period. The odds of being classified as “healthy” were lower among those of advanced age, those with less education, and women than for their corresponding counterparts across all definitions.
Moving across the conceptual continuum—from a more to less rigid definition of healthy aging—markedly increases the measured prevalence of healthy aging. Importantly, results suggest that all examined definitions identified a subgroup of older adults who had substantially lower odds of reporting fair or poor health and dying over an 8-year period, providing evidence of the validity of our definitions. Conceptualizations that emphasize symptomatic disease and functional health may be particularly useful for public health purposes.
PMCID: PMC3536546  PMID: 22367432
Healthy aging; Measurement; Successful aging
10.  Progression of Symptoms and Functioning Among Female Cardiac Patients With and Without Diabetes 
Journal of Women's Health  2011;20(1):107-115.
To determine if older women with both heart disease and diabetes experience worse physical and psychosocial functioning and higher symptom burden over an 18-month period compared with those with heart disease alone.
Data from older women with heart disease (≥60 years, n = 1008, 18% with diabetes) were used to assess the impact of diabetes on physical functioning (Sickness Impact Profile [SIP]-Physical and Six-Minute Walk test [6MWT]), psychosocial functioning (SIP-Psychosocial and depressive symptoms), and physical symptom burden (cardiac and general) at baseline and 4, 12, and 18 months later. Generalized estimating equation models compared trends in outcomes over time between groups with and without diabetes.
Across all four time points, women with heart disease and diabetes had greater functional impairment, as indicated by higher SIP scores, than those without diabetes (43%–71% higher SIP-Physical scores and 32%–65% higher SIP-Pyschosocial scores; all p ≤ 0.002). 6MWT distance was 17%–30% less in the diabetes group across time points (all p ≤ 0.002). Depressive symptoms were 27%–39% higher in the diabetes group (all p < 0.03) except at month 4. Women with diabetes scored 15%–29% higher on a physical symptom index across time points (all p < 0.05) than those without diabetes; no significant differences were observed in cardiac symptoms until month 18 (diabetes group 29% higher, p = 0.02). Subgroups with and without diabetes in this sample experienced significantly different trends over time in SIP-Physical scores (p = 0.02) and 6MWT distance (p = 0.05), such that the disadvantage of the diabetes group at baseline was greater 18 months later.
Women with comorbid diabetes and heart disease are vulnerable to poor health-related quality of life, particularly in terms of physical functioning and symptoms, and require special efforts from clinical care providers to ameliorate a potential downward trend in these outcomes over time.
PMCID: PMC3052276  PMID: 21091196
11.  Successful Aging in the United States: Prevalence Estimates From a National Sample of Older Adults 
To estimate the prevalence of successful aging in the United States, with the broad aim of contributing to the dialogue on Rowe and Kahn’s concept of successful aging.
Using data from the Health and Retirement Study, the prevalence of successful aging was calculated for adults aged 65 years and older at four time points: 1998, 2000, 2002, and 2004. Successful aging was operationalized in accordance with Rowe and Kahn’s definition, which encompasses disease and disability, cognitive and physical functioning, social connections, and productive activities.
No greater than 11.9% of older adults were aging “successfully” in any year. The adjusted odds of successful aging were generally lower for those of advanced age, male gender, and lower socioeconomic status. Between 1998 and 2004, the odds of successful aging declined by 25%, after accounting for demographic changes in the older population.
Few older adults meet the criteria put forth in Rowe and Kahn’s definition of successful aging, suggesting the need for modification if the concept is to be used for broad public health purposes. Disparities in successful aging were evident for socially defined subgroups, highlighting the importance of structural factors in enabling successful aging.
PMCID: PMC2981444  PMID: 20008481
Health disparities; Healthy aging; Prevalence; Successful aging
Inadequate recruitment into Alzheimer disease (AD) clinical trials is an important threat to the validity and generalizability of the studies. The majority of dementia patients are first evaluated by community-based physicians; however, physician perceptions of clinical research are largely unknown.
A survey was distributed to 3,123 physicians in three states; 370 were returned. Survey items assessed attitudes, perceived benefits of and barriers to referral to clinical research and physicians use of the internet for medical information.
The mean age of the respondents was 50.6 ± 10.8y; 70% were male, 78% Caucasian, 61% were primary care providers; 63% used the internet ≥3 times/week. No demographic or medical specialty differences existed between those who were likely (n=193) and unlikely (n=162) to refer patients to clinical trials. Differences were discovered in perceived benefits reported by physicians who were more likely to refer, while differences in perceived barriers existed in primary care compared with specialists. Referral to clinical trials is predicted by close proximity to a research center (OR:4.0,95%CI:1.1–15.6) and availability of internet information regarding diagnostic evaluation (OR:2.3,95%CI:1.1–4.7). Primary barriers included concerns about exposure of patients to uncomfortable procedures (OR:4.7,95%CI:1.2–18.7) and lack of time to discuss research participation (OR:6.8,95%CI:1.4–32.3).
Proximity to a research center and availability of diagnostic clinical tools are strong predictors of clinical trial referral. Concern over risks to patients and lack of time are strong barriers. These results suggest that dementia outreach education targeted to physicians should emphasize the importance of clinical trials with a focus on discussing research participation in a time-efficient manner and increasing awareness of risk reduction and the safety of research protocols. Providing easy access to up-to-date, user-friendly educational materials on dementia diagnosis and research via the internet are likely to improve referrals of patients to AD clinical trials from community physicians.
PMCID: PMC2787738  PMID: 19561438
Alzheimer’s disease; Clinical Trials; Recruitment; Referral; Dementia; Physician

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