Evidence-Based Practice Implementation in Stroke Rehabilitation: A Scoping Review of Barriers and Facilitators
Importance: Despite advancements in stroke rehabilitation research, occupational therapy practitioners still face challenges with implementing research into routine practice. Although the development of evidence-based practices (EBPs) is one critical step along the knowledge translation continuum for the population of people with stroke, research is also needed to identify the most effective strategies for implementing EBPs with stroke survivors who are receiving occupational therapy services. Objective: To synthesize research related to occupational therapy practitioners’ implementation of EBPs in adult stroke rehabilitation. Data sources: We searched four electronic databases-CINAHL, MEDLINE, PubMed, and Academic Search Complete-and the peer-reviewed journal Implementation Science to identify relevant research studies. Study selection and data collection: Studies that met the following inclusion criteria were included in the scoping review: published between January 2003 and January 2018, addressed the adult stroke population, and examined the implementation of occupational therapy interventions. Data were abstracted on the basis of recommendations from the seminal review framework established by Arksey and O’Malley (2005). Thematic analysis identified themes that emerged from the included studies. Findings: Twenty-five articles satisfied our inclusion parameters. Our analyses yielded three overarching themes: barriers to implementation, facilitators of implementation, and implementation strategies. Implementation strategies often consisted of multimodal knowledge translation training programs. Conclusion and relevance: Although the stroke rehabilitation literature appears to have established the barriers to and facilitators of EBP implementation, greater attention to the identification of effective implementation strategies that promote the uptake of EBPs by occupational therapy practitioners is needed. What this article adds: This article summarizes the contextual factors and effective strategies that may influence practitioners’ implementation of stroke research findings in real-world practice.
Gender Differences in the Marital Plans and Union Transitions of First Cohabitations
In an era of changing relationship norms, plans for marriage are an increasingly complex yet important indicator of the link between cohabitation and marriage. Despite qualitative evidence on this complexity, little is known about the nuances of marital plans and gender differences at the population level. This study introduces the concept of “informal” marital plans—cohabitations beginning with some intentions to marry that had yet to be formalized. Drawing on data of heterosexual cohabitors in their first coresidential union from the National Survey of Family Growth (2011–2015, n = 5545), I examine the sociodemographic correlates of marital plans as well as their consequences for men’s and women’s union transitions. The results show significant gender differences in reports of marital plans at the time of moving in together, with women more likely to report engagement and men more likely to report informal marital plans. Although having any marital intentions is positively associated with transitioning to marriage for both genders, engagement is a significantly stronger predictor of marriage than informal marital plans. Pronounced gender differences are found with respect to the dissolution of first cohabitations, as both informal and formal marital plans are more protective against dissolution for men than for women. Distinguishing informal marital plans from engagement provides meaningful new insights into the role of cohabitation in modern American union formation.
Fatherhood and Racial/Ethnic Differences in the Progression of Romantic Relationships
This study examines the influence of fatherhood on the progression of men’s romantic relationships. High levels of relationship flux have resulted in a partner market increasingly characterized by the presence of children, but little is known about how children influence the progression of men’s romantic relationships. Children could reduce the likelihood of marriage and increase chances of cohabitation for single fathers in dating relationships, just as prior literature has found for single mothers. Given high levels of racial/ethnic assortative mating, and variation in the prevalence of single parenthood across racial/ethnic groups, the influence of prior children on men’s relationships may differ by race/ethnicity as well. The authors use data from adult male respondents of the 2002–2015 cycles of the National Survey of Family Growth aged 18–45 regarding the most recent sexual relationship (n = 9,255). Results of propensity score weighted event‐history analyses show that fathers in sexual relationships transition more often and more rapidly into cohabitation than do childfree men, but this pattern varies by race/ethnicity. Children from prior relationships have a strong influence on the progression of non‐Hispanic White men’s relationships, hastening cohabitation, and decreasing transitions to marriage, but prior children have little association with the progression of romantic relationships among Black or Hispanic men. Although fatherhood shapes the progression of men’s romantic relationships, the influence of fatherhood varies across racial/ethnic groups in the United States.
A confirmatory factor analysis of the beck anxiety inventory in Latinx primary care patients
Research on the Beck Anxiety Inventory (BAI) with ethnic minorities in the U.S. is limited. Because Latinxs constitute 18% of the U.S. population and are the second largest ethnic group in the country, the current study replicated the aforementioned study and examined the BAI factor structure with a Spanish-speaking Latinx sample in the United States. We investigated the original two-factor structure of the BAI with 149 Spanish-speaking Latinx primary care patients. Results from a confirmatory factor analysis indicated that the previous factor structures of the BAI did not represent an adequate fit for our sample. An exploratory factor analysis indicated that possibly an alternate two-factor model of anxiety was the best fit for the data. Cultural considerations are discussed including the possibility of utilizing cultural idioms of distress as a way to assess anxiety among Latinxs.
Examining Caretaker Attitudes Towards Primary Prevention of Pediatric Behavioral Health Problems in Integrated Care
Understanding caretaker attitudes towards the prevention of pediatric behavioral disorders is important for the effective delivery of prevention services. Caretakers of children ages 0–18 (N = 385) read a description of pediatric prevention services in an integrated primary care setting. Attitudes towards these services were assessed. The majority of participants (80%) agreed that prevention is important, 87% reported interest in learning their child’s risk for a behavioral disorder, 84% were interested in learning the results of a screen for behavioral disorders, and 88% were interested in learning parenting strategies. Participants endorsed similarly positive attitudes towards prevention in integrated care. Perceived risks outweighing perceived benefits, younger caregiver age, and identifying as non-Hispanic White predicted less favorable attitudes towards prevention. Other socio-demographic characteristics (e.g., caretaker education) were associated with disorder-specific beliefs about the importance of prevention, but not general attitudes. Findings suggest generally positive attitudes towards preventing behavioral disorders in an integrated care setting.
The Impact of the COVID-19 Pandemic on College Student Mental Health: A Longitudinal Examination of Risk and Protective Factors
The spread of the novel coronavirus has led to unprecedented changes in daily living. College students may face unique challenges associated with these changes. In the present study, college students (N = 205) completed a battery of questionnaires in April of 2020, after having completed similar measures 8, 5, and 2 months prior as part of a larger study. A repeated measures ANOVA suggested significantly greater depression and anxiety symptom severity during the pandemic than at any other time during the 2019-2020 academic year. Static and modifiable factors associated with psychological distress and controlling for pre-existing psychological distress were examined. Cognitive and behavioral avoidance was the most consistent predictor of psychological distress during the pandemic. Online social engagement and problematic Internet use also conferred greater risk. Women and Latinx participants were more likely to experience elevated distress during the pandemic, even when controlling for distress prior to the pandemic.
Psychometric properties of a measure to assess beliefs about modifiable behavior and emotional distress
Assessing beliefs about the helpfulness of modifiable behaviors related to mental health could inform public health efforts to prevent emotional distress. This study examined the psychometric properties of a measure to assess beliefs about the helpfulness of modifiable behaviors involved in the development of anxiety and depression. The relationship between beliefs about modifiable behaviors and actual engagement in modifiable behaviors was also examined. Item pool generation was based on a review of the literature. Experts (N = 10) and participants (N = 50) reviewed the items for content validity. An exploratory factor analysis was conducted on the resultant Beliefs about Behaviors and Emotional Distress Scale (BBEDS) for item reduction in a sample of MTurk participants (Study 1, N = 371). A confirmatory factor analysis was completed in a second MTurk sample (Study 2, N = 373). Construct validity was then examined in a sample of college students (Study 3, N = 215). The questionnaire included 16 items across four domains: health behavior (0.77 ≤ α ≤ 0.84), social support (0.72 ≤ α ≤ 0.76), substance use (0.75 ≤ α ≤ 0.76), and avoidance (0.81 ≤ α ≤ 0.83). The BBEDS had adequate psychometric properties supporting its use to assess beliefs about the helpfulness of modifiable behaviors related to the development of emotional distress. BBEDS scores were associated with engaging in some but not all modifiable behaviors. The BBEDS may be a useful instrument to assess beliefs about the helpfulness of modifiable behaviors implicated in the development of anxiety and depression.
The Influence of Implicit Theories of Depression on Treatment-Relevant Attitudes
Implicit theories (beliefs about the malleability of self-relevant traits) of emotion are associated with various motivational and emotional responses. Less is known about implicit theories of depression. The present study examined the effects of a manipulation of implicit theories of depression on depression symptom severity, engagement in a self-help task, and treatment-relevant attitudes. Participants experiencing clinically significant levels of depression (N = 142) were randomly assigned to receive education about depression emphasizing either the malleability of depression (incremental condition) or depression as a chronic condition (entity condition). Participants subsequently completed a self-help task for depression. Symptom severity, stigma, prognostic pessimism, psychotherapy and antidepressant credibility, psychological flexibility, and time spent on the self-help task were assessed. Participants in the incremental condition endorsed a greater incremental theory of depression than did those in the entity condition. To the extent that the experimental condition was associated with the adoption of an incremental theory of depression, depression symptom severity and stigma decreased, and treatment-relevant attitudes were more favorable. The experimental condition had no effect on self-help task persistence. Presenting depression as malleable may be associated with more positive attitudes towards treatment, although the impact on actual treatment engagement warrants future investigation.
Modifiable risk and protective factors for anxiety disorders among adults: A systematic review
Anxiety disorders are highly prevalent in the general population and associated with high rates of impairment and disability. This burden highlights the need to identify risk factors that individuals can modify without professional intervention. A systematic review was conducted to identify studies that examined modifiable risk and protective factors for anxiety disorders among adults in the general population. Searches were conducted in PubMed, PsycINFO and MEDLINE using medical subject headings and text words related to risk factors, protective factors, and each anxiety disorder. Screening, data extraction, and quality assessment were performed by three study authors. Modifiable risk and protective factors from 19 studies across seven countries were identified. Risk factors identified included cigarette smoking, alcohol use, cannabis use, negative appraisals of life events, avoidance, and occupational factors. Protective factors included social support, coping, and physical activity. Cigarette smoking was the most studied risk factor. Support was found for cigarette smoking as a risk factor for agoraphobia and panic disorder. Mixed results were found for generalized anxiety disorder and specific phobia. Across disorders, smoking frequency was associated with greater risk. Results indicate an important gap in the literature in that few studies have examined modifiable risk factors for anxiety disorders.
A Primary Care Prevention System for Behavioral Health: The Behavioral Health Annual Wellness Checkup
Behavioral health problems are involved in the majority of primary care visits. These behavior disorders (e.g., depression, anxiety, smoking, insomnia, etc.) are costly, burdensome to both the patient and the healthcare system, and result in greater medical utilization/cost and poorer future health outcomes. Integrated behavioral healthcare has been proposed as a model for more efficiently addressing the burden of behavioral health problems. While this model has demonstrated some promise in the treatment of behavioral health problems, as well as in the reduction in costs and improvement in healthcare outcomes, the primary prevention of behavioral health problems in this delivery model has been relatively neglected. The present paper discusses the potential value of incorporating the prevention of behavioral health problems into the annual physical/wellness checkup and proposes a detailed system for how this might be accomplished. Limitations, future research, and costs associated with increased prevention in a primary care context are discussed.
Use of Enhanced Data Visualization to Improve Patient Judgments about Hypertension Control
Objective. Uncontrolled hypertension is driven by clinical uncertainty around blood pressure data. This research sought to determine whether decision support—in the form of enhanced data visualization—could improve judgments about hypertension control. Methods. Participants (Internet sample of patients with hypertension) in 3 studies (N = 209) viewed graphs depicting blood pressure data for fictitious patients. For each graph, participants rated hypertension control, need for medication change, and perceived risk of heart attack and stroke. In study 3, participants also recalled the percentage of blood pressure measurements outside of the goal range. The graphs varied by systolic blood pressure mean and standard deviation, change in blood pressure values over time, and data visualization type. Results. In all 3 studies, data visualization type significantly affected judgments of hypertension control. In studies 1 and 2, perceived hypertension control was lower while perceived need for medication change and subjective perceptions of stroke and heart attack risk were higher for raw data displays compared with enhanced visualization that employed a smoothing function generated by the locally weighted smoothing algorithm. In general, perceptions of hypertension control were more closely aligned with clinical guidelines when data visualization included a smoothing function. However, conclusions were mixed when comparing tabular presentations of data to graphical presentations of data in study 3. Hypertension was perceived to be less well controlled when data were presented in a graph rather than a table, but recall was more accurate. Conclusion. Enhancing data visualization with the use of a smoothing function to minimize the variability present in raw blood pressure data significantly improved judgments about hypertension control. More research is needed to determine the contexts in which graphs are superior to data tables.
COVID-19 cases and testing in 53 prison systems
COVID-19 has entered United States prison systems at alarming rates. Disparities in social and structural determinants of health disproportionately affect those experiencing incarceration, making them more vulnerable to COVID-19. Additionally, prisons are sites of congregate living, making it impossible to practice social distancing, and most prisons have relied only on incremental measures to reduce risk and spread of COVID-19. To more fully understand the impact that COVID-19 is having on incarcerated populations, it is critical to have systematic data on testing, test positivity, cases, and case fatality. Using data from the COVID Prison Project, we present data on 53 prison systems COVID-19 testing, test positivity, case, and case fatality by state and compare these data with each state’s general population. We do this for the early stages of the pandemic, utilizing data through July 15, 2020. Many states are not reporting full information on COVID testing with some also not reporting on case fatality. Among those reporting data, there is a wide variation between testing, test positivity, and case rates within prison systems and as compared to the general population. However, when more tests are deployed more cases are identified with the majority of state prisons having higher case rates than their general population. These findings underscore the need for the implementation and study of COVID-19 mitigation and surveillance strategies to flatten the COVID-19 curve in prisons across the country. We call for future research to build on these data from the COVID Prison Project to protect the health of our nations’ often forgotten residents.
Beyond the Classroom: The Intergenerational Effect of Incarceration on Children’s Academic and Nonacademic School-Related Outcomes in High School
The author uses strategic comparison regression and the Longitudinal Study of Adolescent to Adult Health (n = 11,767) to explore the effect of parental incarceration on academic and nonacademic outcomes in high school. This method compares youth whose parents were incarcerated before the outcomes are measured with those whose parents will be incarcerated after. The author examines most recent grades and a range of nonacademic outcomes, such as truancy, involvement in school activities, and suspension. Results indicate that the associations between parental incarceration and grades are largely accounted for by selection, but associations between parental incarceration and nonacademic processes persist. Maternal incarceration holds particular importance for behavioral outcomes (fighting and truancy), and paternal incarceration holds particular importance for behavioral, connectedness, and disciplinary outcomes. Researchers examining the intergenerational consequences of incarceration should examine school contexts beyond the classroom and explore the pathways through which this disadvantage occurs.
Institutional capacity to provide psychosocial care in cancer programs: Addressing barriers to delivering quality cancer care
This study investigates barriers and promoters to delivering quality psychosocial services in 58 cancer programs across North America. Oncology care providers (n = 2008) participated in a survey in which they identified barriers and promoters for delivering psychosocial care at their respective institutions. Multilevel modeling was used to examine (a) the extent to which provider and institutional characteristics were associated with the most common barriers, and (b) associations between perceived barriers and institutional capacity to deliver psychosocial services as measured by the Cancer Psychosocial Care Matrix. Across 58 Commission on Cancer‐accredited programs in North America, the most frequently reported barriers were inadequate number of psychosocial care personnel, lack of funding, inadequate amount of time, lack of systematic procedures, and inadequate training for oncology providers. Overall, there were few significant differences in reported barriers by type of institution or type of provider. In general, the most frequently reported barriers were significantly associated with the institution’s capacity to deliver quality psychosocial care. In particular, the lack of a systematic process for psychosocial care delivery significantly predicted lower levels of institutional capacity to deliver quality psychosocial care. When identifying barriers, respondents reported a greater number of institutional barriers than barriers related to individual provider or patient characteristics. These results present a compelling case for cancer programs to implement and monitor systematic procedures for psychosocial care and to integrate these procedures in routine clinical practice.
Enhancing vocational training in corrections: A type 1 hybrid randomized controlled trial protocol for evaluating virtual reality job interview training among returning citizens preparing for community re-entry
The Michigan Department of Corrections operates the Vocational Villages, which are skilled trades training programs set within prisons that include an immersive educational community using virtual reality, robotics, and other technologies to develop employable trades. An enhancement to the Vocational Villages could be an evidence-based job interview training component. Recently, we conducted a series of randomized controlled trials funded by the National Institute of Mental Health to evaluate the efficacy of virtual reality job interview training (VR-JIT). The results suggested that the use of VR-JIT was associated with improved job interview skills and a greater likelihood of receiving job offers within 6 months. The primary goal of this study is to report on the protocol we developed to evaluate the effectiveness of VR-JIT at improving interview skills, increasing job offers, and reducing recidivism when delivered within two Vocational Villages via a randomized controlled trial and process evaluation. Our aims are to: (1) evaluate whether services-as-usual in combination with VR-JIT, compared to services-as-usual alone, enhances employment outcomes and reduces recidivism among returning citizens enrolled in the Vocational Villages; (2) evaluate mechanisms of employment outcomes and explore mechanisms of recidivism; and (3) conduct a multilevel, mixed-method process evaluation of VR-JIT implementation to assess the adoptability, acceptability, scalability, feasibility, and implementation costs of VR-JIT.
System involvement among young adults experiencing homelessness: Characteristics of four system-involved subgroups and relationship to risk outcomes
Young adults experiencing homelessness (YAEH) have been found to have high rates of prior involvement with foster care and juvenile justice, but little is known about whether YAEH differ in their risk behaviors based on exposure to different systems. This study used a dataset of 1426 YAEH from 7 different US cities to examine the historical risk and resilience characteristics of those involved in foster care alone, juvenile justice alone, both systems (dual status), and no system involvement. Logistic regression was used to examine whether different types of childhood system involvement predicted risk behaviors in young adulthood including substance use, trade sex, suicide attempts, unplanned pregnancy, and involvement in the adult criminal justice system. Notably, 57% of youth had been exposed to one of the systems – 20% foster care only (n = 291), 18% juvenile justice only (n = 254), and 18% dual status (n = 261). YAEH without a history of system involvement had significantly lower childhood trauma scores and lower rates of lifetime mental health diagnoses compared to all three system involved groups, with dual status youth having the highest rates of both. In relation to risk outcomes, youth with dual status histories had higher odds of trading sex and those with juvenile justice involvement, either alone or as dual status, had higher odds of being arrested after age 18 and of problematic substance use. Results suggest YAEH with prior involvement in child-serving systems have unique risk characteristics that vary by type of system involvement, with dual-system involved youth at particularly high risk. Findings highlight the need for foster care and juvenile justice systems to work collaboratively in providing preventive interventions prior to system exit.
Why Are So Many Indigenous Peoples Dying and No One Is Paying Attention? Depressive Symptoms and “Loss of Loved Ones” as a Result and Driver of Health Disparities
Indigenous peoples have not only experienced a devastating rate of historical loss of lives, they are more likely to experience mortality disparities. The purpose of this article is to examine Indigenous women’s lived experiences of grief and loss in two Southeastern tribes and the relationship between depressive symptoms and recent loss of a loved one. Our exploratory sequential mixed-methods research was informed by the Indigenous based Framework of Historical Oppression, Resilience, and Transcendence (FHORT). We summarized key qualitative themes from ethnographic data from 287 female participants across the two tribes, collected through focus groups, family interviews, and individual interviews. We then quantitatively examined how these themes predicted depressive outcomes among 127 respondents. Specifically, we examined associations between depressive symptoms and components of historical oppression—historical loss, loss of lives, and the presence of PTSD symptoms—along with resilience and transcendence.
Cardiovascular Health among U.S. Indigenous Peoples: A Holistic and Sex-Specific Systematic Review
The purpose of this systematic review is to examine mental, sociocultural, behavioral, and physical risk and protective factors related to cardiovascular disease (CVD) and related outcomes among U.S. Indigenous peoples. A total of 51 articles met the inclusion criteria of research focusing factors for CVD among U.S. Indigenous peoples (Mental n = 15; Sociocultural, n = 17; Behavioral/Physical, n = 19). This review reveals clear risks for CVD, which tended to be elevated for females. Mental health problems (depression, anxiety, PTSD/trauma, alcohol, and other drug (AOD) abuse) were clearly associated with CVD, along with enculturation, social support, and the social environment – including discrimination and trauma. Poor diet and obesity, diabetes, hypertension, cholesterol were behavioral or physical factors. Overall, identified research was limited and in beginning stages, lacking more information on etiology of the interconnections across sex and the mental, sociocultural, and behavioral determinants of CVD.
Outcomes From a Sequential Multiple Assignment Randomized Trial of Weight Loss Strategies for African American Adolescents With Obesity
Background: Minority adolescents are at highest risk for obesity and extreme obesity; yet, there are few clinical trials targeting African American adolescents with obesity. Purpose: The purpose of the study was to develop an adaptive family-based behavioral obesity treatment for African American adolescents using a sequential multiple assignment randomized trial (SMART) design.Methods: Fit Families was a SMART where 181 African American adolescents (67% female) aged 12-17 were first randomized to office-based versus home-based behavioral skills treatment delivered from a Motivational Interviewing foundation. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based behavioral skills treatment or contingency management with voucher-based reinforcement for adolescent weight loss and for caregiver adherence to the program. All interventions were delivered by community health workers. The primary outcome was treatment retention and percent overweight. Results: All adolescents reduced percent overweight by -3.20%; there were no significant differences in percent overweight based on treatment sequence. Adolescents receiving home-based delivery in Phase 1 and contingency management in Phase 2 completed significantly more sessions than those receiving office-based treatment and continued skills without CM (M = 8.03, SD = 3.24 and M = 6.62, SD = 2.95, respectively). The effect of contingency management was strongest among older and those with lower baseline confidence. Younger adolescents experienced greater weight reductions when receiving continued skills (-4.90% compared with -.02%). Conclusions: Behavioral skills training can be successfully delivered to African American adolescents with obesity and their caregivers by community health workers when using a home-based service model with incentives. More potent interventions are needed to increase reductions in percent overweight and may need to be developmentally tailored for younger and older adolescents.
Exploring the relationship between cumulative trauma and recidivism among older adults: Does race and offense history matter?
There is a dearth of knowledge on the role of cumulative trauma, stress, and minority oppression on recidivism among incarcerated elder population. The current study fills a gap in the literature by exploring the association between race, trauma, offense history, and recidivism among incarcerated elders. This study used a cross-sectional correlational design with 607 adult males aged 50 and older in a Northeastern state correctional system. Results of a series of moderation analyses revealed that drug offense history had a significant moderating effect on the relationship between trauma and recidivism. However, minority status or violent offense history was not found to be a significant moderator of the trauma and recidivism relationship. These findings suggest prevention and intervention efforts would benefit from incorporating trauma-informed approaches and principles of restorative justice that facilitate individual, family, and community healing.