Informal care can be better than adequate: Development and evaluation of the Exemplary Care Scale.

Purpose: To evaluate a new measure assessing excellent, or exemplary, informal care--an aspect of caregiving that has received little attention. The Exemplary Care Scale (ECS) was developed on the basis of insights from previous research with items generated by the authors in consultation with a multidisciplinary research team. Design: 310 informal caregivers and 283 of their elderly care recipients completed the ECS and other measures pertaining to quality of care and its presumed correlates. Results: Factor analyses indicated that the ECS consists of 2 factors reflecting provision of exceptional care (Provide) and respect for care recipient autonomy, wishes, and the like (Respect). The ECS factor structure was equivalent among caregivers and care recipients. Both factors were empirically distinct from existing measures of poor quality and adequate care. Each ECS factor was associated with other care-related constructs in predictable ways, implying construct validity. Conclusions: The ECS, in conjunction with existing measures, provides a more comprehensive assessment of the quality-of-care continuum and should prove useful to researchers and practitioners interested in quality of informal care provided to chronically ill or disabled people. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Endorsement of proactively aggressive caregiving strategies moderates the relation between caregiver mental health and potentially harmful caregiving behavior.

This research tested the proposition that the oft-reported relation between caregiver mental health outcomes (i.e., resentment, depression) and potentially harmful caregiver behavior (PHB) would be mediated or moderated by caregiver endorsement of proactively aggressive caregiving strategies (PA). Caregiver resentment was the strongest predictor of PHB in the sample of 417 informal caregivers who resided with their care recipients; in fact, resentment mediated the impact of caregiver depression, thus suggesting that depressed affect was associated with PHB only if depressed caregivers resented their caregiving burdens. As predicted, caregiver endorsement of PA moderated the relation between resentment and PHB, such that links between these two constructs were strongest when caregivers were high in both resentment and PA. Endorsement of PA also mediated the relations between demographic or contextual variables (i.e., income, care recipient dementia) and PHB. Implications of these results for research and intervention are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Chronic pain in a community-based sample of men with spinal cord injury: prevalence, severity, and relationship with impairment, disability, handicap, and subjective well-being

OBJECTIVE: To assess the prevalence, severity, and correlates of chronic pain in a community-based sample of men with spinal cord injury (SCI). DESIGN: Survey. SETTING: Community. PARTICIPANTS: Seventy-seven men with SCI randomly selected from a sampling frame solicited from the community. METHOD: Participants completed standardized questionnaires assessing many areas of life, were interviewed in their homes, and underwent a physical examination at a hospital. There they were interviewed by an anesthesiologist regarding chronic pain, and a nurse administered objective pain measures. RESULTS: Seventy-five percent of the men reported chronic pain. Chronic pain was associated with more depressive symptoms, more perceived stress, and poorer self-assessed health. Greater intensity of pain was related to less paralytic impairment, violent etiology, and more perceived stress. Area of the body affected by pain was related to independence and mobility. CONCLUSIONS: Because of the high prevalence of chronic pain in the population with SCI and its relation to disability, handicap, and quality of life, health care providers need to give this issue the same priority given to other SCI health issues. Analysis of individual pain components provides better information than assessing overall pain. It is futile to treat SCI pain without giving full attention to subjective factors.     

The balance of give and take in caregiver–partner relationships: An examination of self-perceived burden, relationship equity, and quality of life from the perspective of care recipients following stroke.

Purpose: We examined the sense of being a burden to others or self-perceived burden (SPB) in people with stroke. Method: A mail survey was completed by 57 former inpatients and their partner caregivers. The care recipient survey included measures of functional status, quality of life, marital satisfaction, equity in the relationship, and psychological distress, as well as SPB using the Self-Perceived Burden Scale (SPBS; Cousineau, McDowell, Hotz, & Hébert, 2003). The caregiver survey included similar measures in addition to a caregiver burden measure. Results: SPB was found to be a prevalent and distressing concern. SPBS scores correlated with measures of functional status and mood; however, the correlations were highest for measures of family roles and work/productivity. Using equity theory as a basis to examine the SPB construct, care recipients who perceived themselves as overbenefiting from the relationship had significantly higher SPB scores than those whose relationship was viewed as equitable or underbenefiting. Conclusions: For some receiving care from a partner after stroke is associated SPB. This sense of burden is related to changes in help-seeking behavior, quality of life, and distress. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Physicians'' experiences and beliefs regarding informal consultation

CONTEXT: Efforts to control medical expenses by emphasizing primary care and limiting specialty care may influence how physicians use informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of and beliefs about informal consultation. DESIGN: Survey mailed in July 1997. PARTICIPANTS: Of a random sample of Massachusetts general internists, pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%) responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about informal consultation. RESULTS: Generalist physicians requested more informal consultations than specialists (median, 3 vs 1 per week; P<.001) and were asked to provide fewer (2 vs 5 per week; P<.001). In multivariate analyses, physicians in a health maintenance organization, multispecialty group, or single-specialty group requested more informal consultations than those in solo practice (82%, 40%, and 28% more, respectively; all P<.001) and were more often asked to provide them (43%, 63%, and 14% more, respectively; all P<.05). Physicians with at least 30% of their income from capitation requested 38% more and were asked to provide 46% more informal consultations than those with little or no income from capitation (both P<.001). Generalists' overall approval of informal consultation was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale; P<.001), and approval was strongly associated with beliefs about how informal consultation affects quality of care (P<.001). CONCLUSIONS: Use of informal consultation is common, varies by specialty, practice setting, and capitation, and therefore may increase with current trends toward group practice and managed care. Because overall approval of informal consultation is strongly associated with beliefs about how it affects quality of care, this issue should be carefully considered by physicians who participate in informal consultation.     

Peer review of the quality of care. Reliability and sources of variability for outcome and process assessments

CONTEXT: Peer assessments have traditionally been used to judge the quality of care, but a major drawback has been poor interrater reliability. OBJECTIVES: To compare the interrater reliability for outcome and process assessments in a population of frail older adults and to identify systematic sources of variability that contribute to poor reliability. SETTING: Eight sites participating in a managed care program that integrates acute and long-term care for frail older adults. PATIENTS: A total of 313 frail older adults. DESIGN: Retrospective review of the medical record with 180 charts randomly assigned to 2 geriatricians, 2 geriatric nurse practitioners, or 1 geriatrician and 1 geriatric nurse practitioner and 133 charts randomly assigned to either a geriatrician or a geriatric nurse practitioner. MAIN OUTCOME MEASURES: Interrater reliabilities for structured implicit judgments about process and outcomes for overall care and care for each of 8 tracer conditions (eg, arthritis). RESULTS: Outcome measures had higher interrater reliability than process measures. Five outcome measures achieved fair to good reliability (more than 0.40), while none of the process measures achieved reliabilities more than 0.40. Three factors contributed to poorer reliabilities for process measures: (1) an inability of reviewers to differentiate among cases with respect to the quality of management, (2) systematic bias from individual reviewers, and (3) systematic bias related to the professional training of the reviewer (ie, physician or nurse practitioner). CONCLUSIONS: Peer assessments can play an important role in characterizing the quality of care for complex patients with multiple interrelated chronic conditions, but reliability can be poor. Strategies to achieve adequate reliability for these assessments should be applied. These strategies include emphasizing outcomes measurement, providing more structured assessments to identify true differences in patient management, adjusting systematic bias resulting from the individual reviewer and their professional background, and averaging scores from multiple reviewers. Future research on the reliability of peer assessments should focus on improving the ability of process measures to differentiate among cases with respect to the quality of management and on identifying additional sources of systematic bias for both process and outcome measures. Explicit recognition of factors influencing reliability will strengthen efforts to develop sound measures for quality assurance.     

The relative contribution of ethnicity versus socioeconomic status in explaining differences in disability and receipt of informal care

Data from a comparative study of 1975 African American, Puerto Rican, and non-Hispanic White persons age 60 and older in a large Northeastern city were used to investigate the relative contribution of ethnicity and socioeconomic status (SES) to explaining differences in the need for and receipt of informal care. It was hypothesized that differences in disability would be related largely to SES, whereas ethnicity would account for most of the differences in the amount of informal care. The results of a path analysis argue in favor of a cultural rather than a socioeconomic explanation for between-group differences. SES had no direct effect on disability when controlling for ethnicity. Ethnicity did explain between-group differences in the amount of care. Even when controlling for disability, elders in the two minority groups received more informal care than did older White persons. The findings illuminate the important role played by ethnicity in explaining an older person's need for and receipt of long-term care assistance.     

Perceived social support, social skills, and quality of relationships in bulimic women.

The impaired relationship between bulimics and their environment may be an important factor in the onset and perpetuation of bulimia. This study explored specific aspects of the bulimic's social network and interpersonal relationships as well as individual difference variables that might mediate her ability to support or perceive this as adequate. Ss were 21 bulimic women and 21 control Ss who completed self-report measures assessing perceived social support, the quality of relationships, social skills, and psychopathology. Bulimics reported less perceived support from friends and family, more negative interactions and conflict, and less social competence. Differences in negative interactions remained significant after controlling for overall psychopathology, and level of conflict was an important predictor of group membership. In addition, bulimics were rated as less socially effective by observers unaware of their group membership. Results highlight the need for further investigation of the quality and type of interactions in bulimic women's lives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ageing and quality of life. 2: Understanding successful ageing

Older people are being maintained in their own homes for longer periods and at increasing levels of frailty since the widespread introduction of community care policies across Europe. In order to sustain a good quality of life such individuals are more reliant on support from both informal (family) and formal sources. If appropriate assistance is to be provided then there is a need for a better understanding of how older people maintain their self-esteem. This article provides additional empirical support for the processes of accommodation and immunization and illustrates how knowledge of these concepts is important to the development of improved services for older people.     

How shall we judge ourselves? Training evaluation in clinical psychology programs.

Examined the procedures, practices, and problems associated with clinical training evaluation. 62 directors of American Psychological Association (APA)-accredited clinical psychology doctoral programs completed a questionnaire assessing their use of informal and formal training evaluation procedures, the impact of these procedures, methods of data collection and dissemination, and obstacles to meaningful evaluation. Informal, qualitative evaluation measures (e.g., personal impressions, reputations) were used most frequently, and formal, quantitative comparison measures (e.g., pre–post comparisons) were employed least frequently. Supervisors' written evaluations, APA-accreditation reports, feedback from internship supervisors, and quantitative evaluation of supervisors by supervisees were perceived as having the greatest impact in determining the quality of clinical training. In over 75% of the programs, one person was responsible for the collection and dissemination of training evaluation data, typically to other faculty members. Inadequate evaluation methods and measures, time restraints, and lack of personnel were rated the most serious obstacles to successful evaluation. Clinical training evaluation appears to be in a preparadigmatic stage characterized by diversity, creativity, and informality. The classification of available measures and the establishment of a coordinated national program of training evaluation are discussed as possible correctives. (27 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Spouse criticism and support: Their association with coping and psychological adjustment among women with rheumatoid arthritis.

Examined whether psychological adjustment of women with rheumatoid arthritis would be related to the support and criticism the patient received from the husband. Interviews were conducted with the husbands of 103 women with rheumatoid arthritis. Spouse interviews were content coded for critical remarks. Wives completed a revised version of the Ways of Coping Scale and a scale of the perceived supportiveness of the spouse. Husbands completed rating scales assessing their perceived vulnerability to illness and the degree of burden they experienced in providing assistance to their wives. Path analyses revealed that patient adjustment was significantly related to the attitude of the spouse. Patients with a highly critical spouse engaged in more maladaptive coping behaviors and reported a poorer psychological adjustment. Independent of spousal criticism, patients who perceived their spouse as being supportive engaged in more adaptive coping. A path model was fit to the data that suggested that the spouse may affect adjustment indirectly through influencing the patient's selection of adaptive or maladaptive coping responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Continuous quality improvement in primary care: what's happening?

OBJECTIVES: Despite much health care interest in quality and Continuous Quality Improvement, there is little quantitative information about it. The purpose of this study was to measure the attitudes, activities, and organizational cultures concerning Continuous Quality Improvement in a group of Midwestern primary care clinics. METHODS: Three surveys of the clinicians, nurses, and other staff in 44 primary care clinics in the metropolitan area of Minneapolis and St. Paul were conducted. These surveys assessed: (1) attitudes about quality improvement, (2) previous efforts in these clinics to use process improvement teams, and (3) the extent to which the clinics' organizational cultures were perceived as supporting quality. The Provider Attitude Survey was completed by clinicians and nurses; the Process Improvement Progress was completed by members of the best Continuous Quality Improvement teams, if any; and the Quality Systems Inventory was completed by all personnel. RESULTS: Most of the clinical personnel reported support for various Continuous Quality Improvement concepts, but their understanding and experience were limited. Only 20 (45%) clinics had had at least one Continuous Quality Improvement team in the past, only five of the 12 teams with adequate information had completed an improvement cycle, and only seven reported improving a process with it. The mean clinic scores for quality culture were no better than those in other types of organizations. CONCLUSIONS: Despite relatively favorable attitudes and some Continuous Quality Improvement activities, there appears to be a need to help clinics build skill and experience for the required care improvements.     

Role of maternal functioning and parenting skills in adolescent functioning following parental divorce.

While divorce has been associated with impaired child functioning, the mechanisms within the divorce process leading to such an outcome have rarely been examined. The following hypothesis was examined: Divorce is associated with poor parental adjustment or disrupts parenting behavior, or both, which leads to poor adolescent functioning. Subjects were 121 and 93 young adolescents from intact and recently divorced families, respectively, and their mothers and teachers. Mothers completed measures assessing parental conflict and depression, observers coded parenting skills during a mother–adolescent interaction, and teachers completed measures assessing adolescent functioning. Although the magnitude of differences was not large, analyses of variance indicated that the divorced sample was functioning poorer than the married sample on all measures except interparental conflict. Path analysis suggested that parental functioning and parenting skills play a role in adolescent functioning following divorce. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Longitudinal risk factors for intimate partner violence among men in treatment for alcohol use disorders.

Objective: This study examined static and time-varying risk factors for perpetration of intimate partner violence (IPV) among men in treatment for alcohol use disorders. Method: Participants were 178 men diagnosed with alcohol abuse or dependence and their partners. Most (85%) of the men were European American; their average age was 41.0 years. Participants completed measures assessing initial alcohol problem severity, baseline beliefs related to alcohol use, antisocial personality characteristics, alcohol and drug use, relationship adjustment, and IPV. Results: According to couples' reconciled reports, 42% of participants perpetrated IPV at baseline. Among this group, the IPV recurrence rate was 43% at 6-month follow-up and 36% at 12-month follow-up. For participants without IPV perpetration at baseline, new incidence of IPV was 15% and 7% at the 6-month and 12-month follow-up points, respectively. Fixed marker predictors of IPV rates included baseline alcohol problem severity variables, baseline beliefs related to alcohol use, and antisocial personality characteristics. Variable risk factor predictors included alcohol and drug use variables, relationship adjustment factors, and anger. Alcohol use variables and anger were associated with new incidents of IPV among those without reported IPV at baseline only. Conclusions: Findings suggest that assessing and monitoring IPV occurrence by both partners is important for men in treatment for alcohol use disorders. Results indicate vulnerability factors that may identify individuals at risk for IPV and provide targets for IPV prevention among those with alcohol use disorders. These findings can aid in the development of more comprehensive models that more precisely predict IPV. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Symptom perception in children with asthma: Cognitive and psychological factors.

Objective: This study tested the differential effects of several cognitive and psychological variables on children's perception of asthma symptoms by use of an Asthma Risk Grid. Children's subjective and objective assessments of PEFR (peak expiratory flow rate) were characterized as representing perceptual accuracy, symptom magnification, and/or underestimation of asthma symptoms. Design: The study included 270 children with asthma (ages 7–17) and their primary caregivers who completed measures assessing cognitive and psychological factors and a 5 to 6 week symptom perception assessment. Main Outcome Measures: Children's symptom perception scores by use of the Asthma Risk Grid. Results: Children's attentional abilities had more of a bearing on their symptom monitoring abilities than their IQ estimates and psychological symptoms. The more time children took on Trails and Cancellation Tasks and the fewer errors they made on these tasks, the more likely they were to perceive their asthma symptoms accurately. More time on these tasks was associated with more symptom magnification scores, and fewer errors were related to fewer symptom magnification scores. More errors and higher total scores on the Continuous Performance Task were associated with a greater proportion of scores in the danger zone. Conclusion: Statistical support was provided for the utility of attentional-based instruments for identifying children who may have problems with perceptual accuracy, and who are at risk for asthma morbidity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Creating informal play opportunities: Are parents' and preschoolers' initiations related to children's competence with peers?

Preschoolers' social competence may depend on the frequency with which informal play activities are initiated by parents, children, and playmates. In this study, measures of children's peer relations in informal and school contexts and the frequency of parents', children's, and peers' play initiations were obtained with 83 preschool children and their families on 2 occasions. Frequent parent initiations were associated with higher levels of prosocial behavior, lower levels of nonsocial behavior, and, among boys, greater peer acceptance in preschool. Children who were more initiating of informal peer contacts displayed less anxious behavior in school and were better liked by their classmates. Finally, the degree to which parents involved children in the process of arranging informal play activities was positively related to the frequency with which children initiated their own peer contacts. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Overview of health-related quality-of-life measures for pediatric patients: application in the assessment of pharmacotherapeutic and pharmacoeconomic outcomes

Health-related quality of life (HRQOL) is an important dimension in assessing health care. Several methodologic considerations are related to the manner in which these data are obtained in children. Few multidimensional generic measures of quality of life (QOL) have been developed for children and adolescents. Most published research concerns the development of tools to be used in a disease-specific manner for clinical trials. Although several authors point out numerous advantages in assessing HRQOL in clinical practice, several barriers must be overcome for this to occur. In the current era of economic restraint, HRQOL measures must be integrated into pharmaco-economic analyses to assess fully the impact of a drug on health care resources and outcomes.     

The role of psychiatric comorbidity in the prediction of readmission for detoxification

BACKGROUND: The burden of caring for terminal cancer patients has a negative effect on the informal caregivers' quality of life. OBJECTIVES: To investigate the effects of a transmural home care intervention program for terminal cancer patients on the direct caregivers' (the patient's principal informal caregiver) quality of life, compared with standard care programs. The intervention program intended to optimize the cooperation and coordination between the intramural and extramural health care organizations (transmural care). METHODS: Direct caregivers of terminal cancer patients (estimated prognosis of less than 6 months) could be included in this quasi-experimental study. The direct caregivers' quality of life was measured in a multidimensional way 1 week before (T1), 1 week after (T2), and 4 weeks after (T3) the patient's discharge from the hospital (discharge being the starting point of the intervention), then again at 3 months after the patient's death (T4). Factor analyses on the four outcome measures yielded one factor. This was considered the primary outcome measure and was named the Overall Quality of Life Index (OQOLI). RESULTS: Multiple regression analyses showed that the intervention contributed significantly positively to the direct caregivers' OQOLI at T2 (beta=.30; p < .05) and T4 (beta=.28; p < or = .05), compared with standard care. CONCLUSION: Transmural care forms a significantly positive contribution to the OQOLI of direct caregivers of terminal cancer patients 1 week after the patient's discharge from the hospital and 3 months after the patient's death. Good terminal care also appears to be important for direct caregivers as well, with respect to perceived quality of life.