Staying healthy: the salience and meaning of health maintenance behaviors among rural older adults in North Carolina

Patient-Centered Outcomes With a Multidisciplinary CKD Care Team Approach: An Observational Study

Rationale & Objective

Multidisciplinary chronic kidney disease (CKD) care has been associated with improved clinical outcomes in comparison to general nephrology care. However, there is little research examining the impact of multidisciplinary care on patient-centered outcomes. We examined if a multidisciplinary approach to CKD care was associated with 4 patient-centered outcomes.

Study Design

Cross-sectional study design using previously established surveys to assess patient-centered outcomes in participants with nondialysis CKD.

Setting & Participants

Adults with CKD stages 1-5 who had not undergone transplant or were not on dialysis.

Exposures

General nephrology care or multidisciplinary care. Patients receiving multidisciplinary care were seen by a pharmacist, social worker, dietitian, and nephrologist, whereas patients receiving general nephrology care only saw a nephrologist.

Outcomes

Four patient-centered outcomes: CKD-specific knowledge, disease-related stress, perception of overall health, and perception of health status compared to 1 year ago.

Analytical Approach

Differences were examined using a Welch 2-sample t test and linear regression model.

Results

Mean age of participants was 60 years with standard deviation of 17 years. 182 (77%) patients were White, and 230 (96%) had formal education greater than or equal to high school. 121 (49%) were women, and 215 (88%) had CKD stage 3-5. 77 (31%) received multidisciplinary care. We did not identify any significant differences in patient knowledge, stress, or perception of health between multidisciplinary and general nephrology care. However, notably, patients in multidisciplinary care were older and had more advanced CKD than those in general nephrology care.

Limitations

Cross-sectional study designs only identify associations. Study was conducted at clinics located within 30 miles of each other, limiting generalizability.

Conclusions

Our results suggest that a team-based approach to care can better support sicker, more vulnerable patients so that they can achieve similar patient-centered outcomes compared to patients who are younger and with less advanced CKD.

COVID-19 Pandemic Among Immigrant Latinx Farmworker and Non-farmworker Families: A Rural-Urban Comparison of Economic, Educational, Healthcare, and Immigration Concerns

COVID-19 has revealed social and health inequities in the United States. Structural inequalities have increased the likelihood of immigrants contracting COVID-19, by being essential workers and through poverty that forces this population to continue working. Rural and urban immigrant families may face different concerns. Using a telephone survey in May 2020 of 105 Latinx families in an existing study, quantitative and qualitative data were gathered on work and household economics, childcare and education, healthcare, and community climate. Analyses show that, although rural and urban groups experienced substantial economic effects, impacts were more acute for urban families. Rural workers reported fewer workplace protective measures for COVID-19. For both groups, fear and worry, particularly about finances and children, dominated reports of their situations with numerous reports of experiencing stress and anxiety. The experience of the pandemic is interpreted as an example of contextual vulnerability of a population already experiencing structural violence through social injustice. Policy implications are highlighted.

Hired Latinx Child Farmworkers in North Carolina: Educational Status and Experience Through a Social Justice Lens

We examine the educational experience of Latinx hired child farmworkers in North Carolina, using a social justice framework. Qualitative (n = 30) and quantitative (n = 202) data collected among children ten to seventeen years of age revealed elevated rates of grade retention and dropout status. Children reported disruption to their schooling caused by international and interstate migration and intrastate movement. Few worked during school time; nevertheless, children reported missed participation in educational enrichment opportunities and little integration into school life. Schools often failed to accommodate language difficulties and problems caused by migration, and an atmosphere of racism prevailed. Educational programs for children in farmworker families were established during the 1960s. However, they do not meet the needs of hired child farmworkers. Policies to reduce child employment in agriculture and to meet their educational needs are necessary to ensure the education needed for future health and well-being. We discuss the applied implications of findings.

"It's Worse to Breathe It Than to Smoke It": Secondhand Smoke Beliefs in a Group of Mexican and Central American Immigrants in the United States

This analysis describes beliefs about secondhand smoke and its health effects held by Mexican and Central American immigrants in North Carolina. Data from 60 semistructured, in-depth interviews were subjected to saliency analysis. Participant discussions of secondhand smoke centered on four domains: (1) familiarity and definition of secondhand smoke, (2) potency of secondhand smoke, (3) general health effects of secondhand smoke, and (4) child health effects of secondhand smoke. Secondhand smoke was generally believed to be more harmful than primary smoke. Mechanisms for the potency and health effects of secondhand smoke involved the smell of secondhand smoke, secondhand smoke being an infection and affecting the immune system, and personal strength being protective of secondhand smoke. Understanding these health beliefs informs a framework for further health education and intervention to reduce smoking and secondhand smoke exposure in this vulnerable population.

COVID-19 Pandemic Among Immigrant Latinx Farmworker and Non-farmworker Families: A Rural-Urban Comparison of Economic, Educational, Healthcare, and Immigration Concerns

COVID-19 has highlighted social and health injustices in the US. Structural inequalities have increased the likelihood of immigrants contracting COVID-19, by being essential workers and through poverty that forces this population to continue working. Rural and urban immigrant families may face different concerns. Using a telephone survey in May 2020 of 105 Latinx families in an existing study, quantitative and qualitative data were gathered on work and household economics, childcare and education, healthcare, and community climate. Analyses show that, although rural and urban groups experienced substantial economic effects, impacts were more acute for urban families. Rural workers reported fewer workplace protective measures for COVID-19. For both groups, fear and worry, particularly about finances and children, dominated reports of their situations with numerous reports of experiencing stress and anxiety. The experience of the pandemic is interpreted as an example of contextual vulnerability of a population already experiencing structural violence through social injustice.

Salutogenic model of health to identify turning points and coping styles for eating practices in type 2 diabetes mellitus

BACKGROUND

It is important for people with Type 2 Diabetes Mellitus (T2DM) to eat healthily. However, implementing dietary advice in everyday life is difficult, because eating is not a distinguishable action, but a chain of activities, embedded in social practices and influenced by previous life experiences. This research aims to understand why and how eating practices are developed over the life-course by investigating influential life experiences - turning points - and coping strategies for eating practices of people with T2DM.

METHODS

The Salutogenic Model of Health guided the study's objective, study design and analysis. Seventeen interviews were performed and analysed based on the principles of interpretative phenomenological analysis. Narrative inquiry and the creation of timelines and food boxes were used as tools to facilitate reflection on turning points and eating practices.

RESULTS

Turning points for unhealthier eating were experiences that strongly disturbed the participants' emotional stability. These experiences included psychosocial trauma, physical health disorders, job loss, and smoking cessation. Turning points for healthier eating were experiences that significantly changed participants views on life and made participants reflective about the effects of current eating practices on future health and life goals. These turning points included confrontation with ill-health, becoming a parent, psychosocial therapy, and getting married. Notably, turning points for healthier eating seemed only to happen when life was relatively stress-free. All participants experienced turning points for healthier eating, yet, not all participants succeeded in improving their diets. Two coping styles were distinguished: active and passive coping. Active coping individuals were able to act in line with their personal intentions, whereas passive coping individuals could not. Differences between active and passive coping styles seemed to be explained by differences in available resources important for adapting and maintaining a healthy diet.

CONCLUSION

Disadvantaged childhood and later life adversities together with the inability to manage the mental stress explained the development unhealthier eating practices. All participants experienced turning points for healthier eating that caused eating to become a priority in their life. Yet, the fact that not all were able to eat as they intended, advocates for nutritional guidance for people with T2DM, with a greater emphasis on reflexivity, psycho-social well-being and social support.

Americans' Health Mindsets: Content, Cultural Patterning, and Associations With Physical and Mental Health

BACKGROUND

Health mindsets are mental frameworks that help people recognize, organize, interpret, and respond to health-relevant information. Although mindsets shape health behaviors and outcomes, no study has examined the health mindsets of ethnically and socioeconomically diverse Americans.

PURPOSE

We explored the content, cultural patterning, and health correlates of diverse Americans' health mindsets.

METHODS

Two studies surveyed approximately equal numbers of African American, Asian American, European American, and Latinx American men and women of lower and higher socioeconomic status (SES). Study 1 (N = 334) used open-ended questions to elicit participants' mindsets about the definitions, causes, and benefits of health. Study 2 (N = 320) used Study 1's results to develop a closed-ended instrument.

RESULTS

In Study 1, open-ended questioning revealed six overarching mindset themes: behavioral, medical, physical, psychological, social, and spiritual. The most prevalent mindsets were psychological definitions, behavioral causes, and psychological benefits. Participants mentioned more cause themes than definition or benefit themes, and mindset theme mentions correlated with worse health. Older participants mentioned more themes than younger, women mentioned more definition themes than men, and low-SES participants mentioned more cause themes than high-SES participants. In Study 2, closed-ended scales uncovered more complex and positive health mindsets. Psychological and spiritual benefit mindsets correlated with good mental health. African Americans and women endorsed the widest array of mindsets, and the spiritual benefit mindset partially explained the superior mental health of African Americans.

CONCLUSIONS

Many Americans hold simplistic, illness-focused health mindsets. Cultivating more complex, benefit-focused, and culturally appropriate health mindsets could support health.

"Be careful!" Perceptions of work-safety culture among hired Latinx child farmworkers in North Carolina

BACKGROUND

Children as young as 10 years of age can be hired to work on farms. Many of these hired child farmworkers are Latinx. Although these children experience high rates of injury, little research has addressed work-safety perceptions among hired Latinx child farmworkers.

METHODS

For this qualitative study, we conducted in-depth interviews in North Carolina in 2016 with 30 Latinx child farmworkers, ages 10 to 17. Our analysis used the work-safety culture conceptual framework to delineate their perceptions of the psychological, behavioral, and situational elements of safety culture.

RESULTS

The child farmworkers describe a weak work-safety culture. Psychologically, they understand that their parents want them to be safe, but they observe that safety is important to only a fraction of their supervisors and coworkers. Behaviorally, they recognize many of the hazards they confront while working, but it is not clear how well they use this knowledge to mitigate these hazards or to change their behaviors to avoid these hazards. Situationally, several children note that the only safety training they receive is the imperative to "be careful." Most receive little formal training, much of the training they receive is informally provided by family members and coworkers rather than supervisors, and their training is geared more toward how to complete a task than how to complete the task safely.

CONCLUSIONS

Child farmworkers perceive that work-safety culture is of limited importance in agriculture. Regulations are needed that improve work-safety culture in agriculture, especially for those vulnerable due to minority age.

Hired Latinx child farm labor in North Carolina: The demand-support-control model applied to a vulnerable worker population

BACKGROUND

US government child labor policies allow children as young as age 10 to be hired as workers on farms not operated by family members. Children may face substantial health risks in an industry known for high worker morbidity and mortality rates, due to high demands for productivity, and low control and little support because of the organization of the workplace. This paper examines how child farmworkers in North Carolina experience their work situation.

METHODS

In-depth interviews conducted in 2016 with 30 Latinx child farmworkers, ages 10 to 17, were analyzed using concepts from the demand-control-support model. All had worked as either migrant or seasonal hired farmworkers within the past year.

RESULTS

Children reported planting, cultivating, and harvesting crops including fruits, vegetables, and tobacco. The crew leader supervisory system, piece-rate pay, and coworker pressure produced significant demands to work quickly and take risks including lifting heavy loads, operating mechanical equipment, and working in excessive heat. Children had little control over work to counter demands they experienced; and they labored in a state of fear of firing, wage theft, and other sanctions. Support was variable, with younger children more likely to experience family and coworker support than older children.

CONCLUSIONS

The high demands with limited control and, for some, little support, that these children experience place them at risk and show the possibility of injury and exploitation. Future research should systematically document the occupational injury and illness of hired child farmworkers, and consider whether changes in labor policy are warranted.

Child Work Safety on the Farms of Local Agricultural Market Producers: Parent and Child Perspectives

Agriculture is a hazardous industry, yet there are few regulations on the ages at which children may engage in farm work. Local agricultural market producers (LAMPs) are a growing subset of farmers within "sustainable agriculture" who engage in direct-to-consumer and direct-to-retailer enterprises. This study explores the occupational health and safety perceptions of parents and children for children who work on their families' LAMP farms. In-depth interviews were conducted with 12 parent-child dyads from LAMP farms in Illinois and North Carolina. Four themes emerged from these 24 interviews; parents and children perceived that: (1) the nature of small farms makes them safer than industrial agricultural operations; (2) child safety on farms is common sense; (3) avoiding hazardous tasks keeps children safe; and (4) parents know best (compared to regulations) about ways to keep their children safe. Some of these themes echo the results of earlier studies conducted with more conventional farms. Further research is needed to develop programs to improve child occupational safety on LAMP farms.

Good job, bad job: Occupational perceptions among Latino poultry workers

OBJECTIVES

Immigrant workers frequently take jobs that are physically demanding, provide low wages, and result in injuries (e.g., poultry production and processing). Through a qualitative approach, this paper elicits poultry workers' evaluations of their jobs and set them in the larger context of their lives.

METHODS

Semi-structured interviews were conducted with 65 poultry workers in western North Carolina. Workers were asked to discuss job characteristics, physical and psychological impacts of their employment, and perceived health risks.

RESULTS

Immigrant workers valued the stability, benefits, upward mobility, and pay offered. They disliked the physical demands, the potential perceived effects of the job on their health, and the interactions with bosses and peers.

CONCLUSIONS

Workers' willingness to endure dirty, dangerous, and demanding (3-D) conditions of poultry must be understood in the context of other employment options, structural violence, and their focus on immediate family needs that positive aspects of these jobs can fulfill. Am. J. Ind. Med. 59:877-886, 2016. © 2016 Wiley Periodicals, Inc.

Participation levels in 25 Community-based participatory research projects

This analysis describes the nature of community participation in National Institutes of Health and Centers for Disease Control and Prevention funded community-based participatory research (CBPR) projects, and explores the scientific and social implications of variation in community participation. We conducted in-depth interviews in 2012 with professional and community researchers from 25 CBPR projects in the Southeast US. Interview topics focused on participants' experiences with the nature and conduct of their CBPR project. Projects were rated on community participation in 13 components of research. Projects varied substantially in community participation. Some projects had community participation in only two to three components; others had participation in every component. Some professional researchers were deliberate in their inclusion of community participation in all aspects of research, others had community participation in some aspects, and others were mainly concerned that community members had the opportunity to participate in the study. Findings suggest a need for a standardized rubric for community-based research that facilitates delineation of approaches and procedures that are effective and efficient. Little actual community participation may also result in negative social impacts for communities.

What Does It Mean for Something to Be "Scientific"? Community Understandings of Science, Educational Attainment, and Community Representation Among a Sample of 25 CBPR Projects

Community-based participatory research (CBPR) seeks to conduct relevant, sustainable research that is tailored to the needs of the communities with which it is engaged through equitable collaboration between community representatives and professional researchers. Like other participatory approaches to research and planning, CBPR has been criticized for the potential to engage a biased sample of community representatives and, thereby, undermine the fundamental purpose of the approach. Moreover, the varying educational levels and areas of expertise, especially regarding science literacy, among those participating in CBPR has raised concern about the ability for true collaboration to exist within CBPR projects. This article presents findings from a qualitative study of 25 CBPR research projects and explores matters of science literacy, community representation, and the nature of CBPR. Ultimately, it is suggested that those who engage in CBPR should carefully consider the potential for biased community representation and seek to purposely and mindfully avoid any partiality.

Physical Activity Perceptions and Influences among Older Adults in Rural Nova Scotia

This study identified factors that influenced physical activity (PA) participation among older adults from rural settings in Nova Scotia Canada and explored how the rural context may influence PA participation and promotion. Data were collected via individual semistructured interviews with 20 older adults (Mage = 77.5 years) from rural areas of Cape Breton and subjected to thematic analysis procedures (Braun & Clarke, 2006). Four themes representing factors that influence the prioritization of PA were identified: (1) historical context of activity, work, and productivity; (2) already busy with day-to-day activities; (3) being/staying on the go; and (4) cautionary approach. These findings suggest that PA promotion should be contextually salient, and highlight the need for a shared understanding between rural older adults and PA promoters regarding what constitutes being "physically active". Effective promotion of PA among rural older adults may require a shift away from contemporary methods of PA promotion.

Health-promoting practices and the factors associated with self-reported poor health in caregivers of children orphaned by AIDS in southwest Uganda

Informal caregivers worldwide are faced with the dilemma of maintaining their health and meeting the caregiving demands of their loved ones. This study explores the health outcomes of caregiving, caregivers' health-promoting practices and the challenges to providing care among caregivers to children orphaned by AIDS in southwest Uganda. A descriptive design and interview questionnaires were used to collect data from 204 caregivers. The average age of the caregivers was 41.36 (±10.9) years and most of them (53%) were grandmothers to the orphans. The majority (65%) of the caregivers were caring for at least three orphans, had been in the caregiver role for more than five years (61%), and stated that their health had been negatively impacted by caregiving (61%). According to self-reports, the most common new health problems since taking up the caregiving role were chronic ill health (97%), social isolation (95%) and mental stress (92%). The health-promoting practices most often engaged in were eating a balanced diet (67%), seeking spiritual support (58%), and performing self-care activities (44%). The challenges to caregiving most often reported were poverty (88%) and a lack of time to seek personal medical care (59%). The predictors of self-reported poor health among the caregivers were stress (odds ratio [OR] = 3.43; p ≤ 0.01), caring for three or more orphans (OR = 2.19; p ≤ 0.01), female gender (OR = 1.77; p ≤ 0.01), and having spent more than five years as a caregiver to an orphan (OR = 1.35; p ≤ 0.01). The findings suggest that caregivers commonly experience poor health and their health-promoting practices are inadequate. There is a need for organised and formal health-promotion programmes for caregivers of children orphaned by AIDS, especially in rural areas of developing countries. Interventions for health promotion can be achieved through integrated programmes that provide health education, social services, respite from caregiving and counselling.

Perceptions that influence the maintenance of scientific integrity in community-based participatory research

Scientific integrity is necessary for strong science; yet many variables can influence scientific integrity. In traditional research, some common threats are the pressure to publish, competition for funds, and career advancement. Community-based participatory research (CBPR) provides a different context for scientific integrity with additional and unique concerns. Understanding the perceptions that promote or discourage scientific integrity in CBPR as identified by professional and community investigators is essential to promoting the value of CBPR. This analysis explores the perceptions that facilitate scientific integrity in CBPR as well as the barriers among a sample of 74 professional and community CBPR investigators from 25 CBPR projects in nine states in the southeastern United States in 2012. There were variations in perceptions associated with team member identity as professional or community investigators. Perceptions identified to promote and discourage scientific integrity in CBPR by professional and community investigators were external pressures, community participation, funding, quality control and supervision, communication, training, and character and trust. Some perceptions such as communication and training promoted scientific integrity whereas other perceptions, such as a lack of funds and lack of trust could discourage scientific integrity. These results demonstrate that one of the most important perceptions in maintaining scientific integrity in CBPR is active community participation, which enables a co-responsibility by scientists and community members to provide oversight for scientific integrity. Credible CBPR science is crucial to empower the vulnerable communities to be heard by those in positions of power and policy making.

Rural definition of health: a systematic literature review

BACKGROUND

The advent of patient-centered care challenges policy makers, health care administrators, clinicians, and patient advocates to understand the factors that contribute to effective patient activation. Improved understanding of how patients think about and define their health is needed to more effectively "activate" patients, and to nurture and support patients' efforts to improve their health. Researchers have intimated for over 25 years that rural populations approach health in a distinct fashion that may differ from their non-rural counterparts.

METHODS

We conducted a systematic review of the literature to assess the extent and strength of evidence for rural definition of health. Studies were eligible for inclusion if they were published in English, reported on original research and presented findings or commentary relevant to rural definition of health, were published over the last 40 years, and were based on observations of rural U.S., Canadian, or Australian populations. Two reviewers were assigned to each selected article and blinded to the other reviewer's comments. For discordant reviews, a third blinded review was performed.

RESULTS

Of the 125 published articles identified from the literature, 34 included commentary or findings relevant to a rural definition of health. Of these studies, 6 included an urban comparison group. Few studies compared rural and urban definitions of health directly. Findings relevant to rural definition of health covered a broad range; however, good health was commonly characterized as being able to work, reciprocate in social relationships, and maintain independence. This review largely confirmed many general characteristics on rural views of health, but also documented the extensive methodological limitations, both in terms of quantity and quality, of studies that empirically compare rural vs. urban samples. Most notably, the evidence base in this area is weakened by the frequent absence of parallel comparison groups and standardized assessment tools.

CONCLUSIONS

To engage and activate rural patients in their own healthcare, a better understanding of the health beliefs in rural populations is needed. This review suggests that rural residents may indeed hold distinct views on how to define health, but more rigorous studies are needed to confirm these findings.

Recruiting underserved mothers to medical research: findings from North Carolina

Representative samples are required for ethical, valid, and useful health research. Yet, recruiting participants, especially from historically underserved communities, can be challenging. This paper presents findings from in-depth interviews with 40 mothers about factors that might influence their willingness to participate or allow their children to participate in medical research. Saliency analysis organizes the findings. Frequent and important salient themes about research participation included concerns that it might cause participants harm, hope that participants might gain a health benefit, and recognition that time and transportation resources could limit participation. Ultimately, we propose that a theoretical model, such as the Theory of Planned Behavior (TPB), will facilitate more systematic evaluation of effective methods for recruitment and retention of participants in medical research. Future research should explore the utility of such a model for development of effective recruitment and retention strategies.

Occupational safety beliefs among Latino residential roofing workers

BACKGROUND

This analysis describes beliefs about work safety and personal protective equipment (PPE) among Latino roofing workers, it delineates their perceptions of work environment characteristics that affect work safety and PPE use, and it describes how they experience work injuries and the consequences of these injuries.

METHODS

In-depth interviews were completed with 10 current and former Latino residential roofers. Interview transcripts were subjected to systematic qualitative analysis.

RESULTS

Participants' valued productivity over safety, and this had a negative influence on their safety behavior and reduced their PPE use. They understood that roofing was hazardous. They limited use of PPE when they felt it reduced productivity and when it was uncomfortable. Work environment characteristics that affected safety included company size, the physical demands of the job, lack of training, the need for work, general life stress, and distractions at work. An injury had to result in lost work time to be considered significant. Access to health care is limited by employers not providing Workers' compensation.

DISCUSSION

Future research is needed to substantiate these descriptive results and to delineate factors that are associated with safety behavior and use of PPE. Interventions, based on a lay health educator model, are needed to improve safety in this population. Safety regulations need to be evaluated and their enforcement needs to be improved.

A qualitative analysis of how elders seek and disseminate health information

This study documents older adults' sources of health information, describes the purposes for health information seeking, and delineates gender and ethnic variation in health information seeking. Sixty-two African American and White adults aged 65 and older completed qualitative interviews describing their use of complementary therapies. Interviews identified how individuals obtained and shared health information. Friends, not family, were the dominant source of health information. Participants ranged from active seekers to passive consumers of health information. Information seeking was common for benign symptoms. More women than men discuss health information with others. Friends are the primary source of health information for rural older adults. There is substantial passivity in the pursuit of health information. Identifying health information sources of rural older adults can support the dissemination of information to those who share it with others.

Variation in the interpretation of scientific integrity in community-based participatory health research

Community-based participatory research (CBPR) has become essential in health disparities and environmental justice research; however, the scientific integrity of CBPR projects has become a concern. Some concerns, such as appropriate research training, lack of access to resources and finances, have been discussed as possibly limiting the scientific integrity of a project. Prior to understanding what threatens scientific integrity in CBPR, it is vital to understand what scientific integrity means for the professional and community investigators who are involved in CBPR. This analysis explores the interpretation of scientific integrity in CBPR among 74 professional and community research team members from of 25 CBPR projects in nine states in the southeastern United States in 2012. It describes the basic definition for scientific integrity and then explores variations in the interpretation of scientific integrity in CBPR. Variations in the interpretations were associated with team member identity as professional or community investigators. Professional investigators understood scientific integrity in CBPR as either conceptually or logistically flexible, as challenging to balance with community needs, or no different than traditional scientific integrity. Community investigators interpret other factors as important in scientific integrity, such as trust, accountability, and overall benefit to the community. This research demonstrates that the variations in the interpretation of scientific integrity in CBPR call for a new definition of scientific integrity in CBPR that takes into account the understanding and needs of all investigators.

Assessment of everyday beliefs about health: the lay concepts of health inventory, college student version

This research investigated lay conceptualisations about health using a progressive mixed-method approach, culminating in a new self-report measure of lay concepts of health. In Study 1, 223 community and college-aged adults provided everyday descriptors of healthy people. These open-ended qualitative responses were narrowed to 259 distinct descriptors, and subsequently rated on their importance to health by a second lay sample (Study 2). The health descriptors rated as most important were then subjected to exploratory factor analysis in Study 3, resulting in five distinguishable factors. Proposed scale items were then administered again (to college students, in Study 4), and a confirmatory factor analysis (CFA) was performed. The CFA supported a four-factor model, comprised of Social-Emotional Health, Positive Health Practices, Absence of Stress and Anxiety, and Adequate Rest, presented as the college student version of the Lay Concepts of Health Inventory. The measure, as well as limitations and recommendations for future research, are presented.

Health maintenance and low socio-economic status: A family perspective

The socio-economic status of people has a profound influence on health, as higher rates ofmorbidity and mortality are reported for individuals with lower socio-economic status. Dueto the increased burden of disease, research exploring how families maintain their health ina low socio-economic situation is an urgent priority. The objective of the study was to gainan understanding of the reality families are confronted with in terms of their health due totheir socio-economic status. The study was contextual, qualitative and exploratory usingpurposive sampling methods. The sample size was governed by data saturation and realisedas 17 families (n = 17). The participants for the study were families residing in SoshanguveExtension 12 and 13, South Africa. The data collection method was self-report using a semi-structured interview. Content analysis was done according to Tesch’s approach using opencoding. Five themes based on the theoretical basis of the study, including age, sex and geneticconstitution, individual lifestyle factors, social and community networks, living and workingconditions and general socio-economic status were used. Maintaining the health of peopleliving in a physically and psychosocially disadvantaged position requires a different approachfrom registered professional nurses. No community-specific intervention can be planned andimplemented to reduce the burden of communicable and non-communicable disease in thecommunity without evidence based on a family perspective.

Concepts of diabetes self-management in Mexican American and African American low-income patients with diabetes

The goal of the study was to explore low-income minority patients' concepts of diabetes self-management and assess the extent to which patient beliefs correspond to evidence-based recommendations. African American and Mexican American patients with type 2 diabetes were recruited from safety net clinics that serve the uninsured and under-insured in Chicago and San Francisco to participate in focus group discussions. Grounded theory was used to identify themes related to diabetes self-management. Strategies participants mentioned for diabetes self-care were medication use, diet, weight loss and exercise. Eating more fruit and vegetables and consuming smaller portions were the most commonly mentioned dietary behaviors to control diabetes. African Americans expressed skepticism about taking medications. Mexican Americans discussed barriers to acquiring medications and use of herbal remedies. Mexican Americans frequently mentioned intentional exercise of long duration as a management strategy, whereas African Americans more frequently described exercise as regular activities of daily living. Blood glucose self-monitoring and reducing risks of diabetes complications were rarely mentioned as diabetes self-management behaviors. African American and Mexican American patients have different concepts of diabetes self-management, especially with regard to medication use and physical activity. Consideration of these differences may facilitate design of effective self-management interventions for these high-risk populations.

The experiences of women of reproductive age regarding health-promoting behaviours: a qualitative study

Background

Health promotion is critical for community and family health. Health-promoting behaviours provide solutions for maintaining and promoting health. Although several studies have addressed the frequency and different types of health-promoting behaviours in women, little information is available about their experiences. This study aimed to explore the experiences of women of reproductive age regarding health-promoting behaviours.

Methods

In the present study, which was conducted in Tehran, Iran, 15 females, who were selected purposefully, participated in individual in-depth, semi-structured interviews. The interviews were recorded, transcribed verbatim, and analysed using conventional content analysis.

Results

Nine main categories were derived from the analysis, including establishing an appropriate eating pattern, establishing a balanced rest/activity pattern, spirituality, stress management, personal sensitivity and responsibility, establishing an appropriate pattern of social interactions, practicing safe and healthy recreations, feeling improvement in physical-functional health, and feeling improvement in emotional and psychological health. The first 7 categories represent the nature and types of real health-promoting behaviours in women of reproductive age, whereas the last 2 constitute feeling and understanding of the implementation of these behaviours.

Conclusion

The study findings show that the women experience improvement in physical-functional, emotional, and psychological health by implementing health-promoting behaviours. It is therefore necessary to introduce strategies in the context of the community culture for improving different aspects of health-promoting behaviours in women of reproductive age to maintain and improve their overall health.

How people interpret healthy eating: contributions of qualitative research

OBJECTIVE

To identify how qualitative research has contributed to understanding the ways people in developed countries interpret healthy eating.

DESIGN

Bibliographic database searches identified reports of qualitative, empirical studies published in English, peer-reviewed journals since 1995.

DATA ANALYSIS

Authors coded, discussed, recoded, and analyzed papers reporting qualitative research studies related to participants' interpretations of healthy eating.

RESULTS

Studies emphasized a social constructionist approach, and most used focus groups and/or individual, in-depth interviews to collect data. Study participants explained healthy eating in terms of food, food components, food production methods, physical outcomes, psychosocial outcomes, standards, personal goals, and as requiring restriction. Researchers described meanings as specific to life stages and different life experiences, such as parenting and disease onset. Identity (self-concept), social settings, resources, food availability, and conflicting considerations were themes in participants' explanations for not eating according to their ideals for healthy eating.

IMPLICATIONS

People interpret healthy eating in complex and diverse ways that reflect their personal, social, and cultural experiences, as well as their environments. Their meanings include but are broader than the food composition and health outcomes considered by scientists. The rich descriptions and concepts generated by qualitative research can help practitioners and researchers think beyond their own experiences and be open to audience members' perspectives as they seek to promote healthy ways of eating.

Older adults' self-management of daily symptoms: complementary therapies, self-care, and medical care

OBJECTIVES

To describe older adults' use of complementary therapies, self-care practices, and medical care to treat daily symptoms and to delineate gender, ethnic, age, and education differences.

METHOD

A total of 200 African American and White participants (age 65+) selected using a site-based procedure complete a baseline interview and up to six sets of three daily follow-up interviews at monthly intervals. The percent of older adults using a therapy and the frequency with which therapies are used are considered.

RESULTS

The use of complementary therapies to treat daily symptoms, though important, is substantially less than the use of self-care practices and medical care. Participants differed by age, ethnicity, and education in the use of therapies.

DISCUSSION

In considering the percentage of individuals who use a therapy and the frequency with which therapies are used, this analysis adds a new dimension to understanding how older adults manage daily symptoms. Older adults are selective in their use of health self-management.

Concepts of healthful food among low-income African American women

OBJECTIVE

Describe beliefs about what makes foods healthful among low-income African American women.

METHODS

In one-on-one interviews, 28 low-income African American mothers viewed 30 pairs of familiar foods and explained which food in the pair was more healthful and why. Responses were grouped into codes describing concepts of food healthfulness.

RESULTS

Nutrient content, physical effects of food, and food categories were used to judge the healthfulness of foods. Fruits, vegetables, and dairy foods were considered the most healthful and starchy foods the least healthful because they were believed to cause weight gain. Beliefs about which foods contain which nutrients and which foods have particular physical effects varied widely across participants.

CONCLUSIONS AND IMPLICATIONS

Participants demonstrated awareness of which foods are healthful but lacked understanding of why those foods are more healthful than others. Knowledge about the health effects of foods may be necessary to motivate individuals to choose healthful foods.

Dietary resilience as described by older community-dwelling adults from the NuAge study "if there is a will -there is a way!"

Many older adults experience age-related changes that can have negative consequences for food intake. Some older adults continue to eat well despite these challenges showing dietary resilience. We aimed to describe the strategies used by older adults to overcome dietary obstacles and to explore the key themes of dietary resilience. The sample was drawn from the five-year Québec Longitudinal Study "NuAge". It included 30 participants (80% female) aged 73-87 years; 10 with decreased diet quality and 20 with steady or increased diet quality; all had faced key barriers to eating well. Semi-structured interviews explored how age-related changes affected participants' experiences with eating. Thematic analysis revealed strategies used to overcome eating, shopping, and meal preparation difficulties. Key themes of dietary resilience were: prioritizing eating well, doing whatever it takes to keep eating well, being able to do it yourself, getting help when you need it. Implications for health professionals are discussed.

A Case Study on the Perception of Aging and Participation in Physical Activities of Older Chinese Immigrants in Australia

This qualitative study explores how older Hong Kong Chinese Australians perceive aging and to what extent this perception affects their participation in physical activities. The main methods used were in-depth interviews with 22 participants ranging in age from 60 to 91 years. Interviews were translated from Chinese (Cantonese) and transcribed into English. Content analysis was used to find recurring themes from the interview data. The main findings indicate that the perception of aging is to some extent influenced by culture. Some participants defined aging as being measured in years, and others defined it by the state of one’s physical health, appearance, and capacity to continue fulfilling one’s social roles. These perceptions strongly influenced their preferences for and participation in physical activities. Acknowledging the fact that Chinese-speaking people are not culturally homogeneous, this article makes some recommendations to health service providers with regard to the development of appropriate physical activity programs.

Representations of Old Age in Falls Prevention Websites: Implications for Likely Uptake of Advice by Older People

Introduction:

The representations of old age in falls prevention websites were explored and considered for their potential impact on older people's uptake of the advice.

Method:

Websites were searched for using the strategy of a previous systematic-style review and evaluated using the principles of discourse analysis.

Findings:

In the analysis of 33 websites, three main subject positions afforded to older readers were identified: (1) Passive recipients: victims of the ageing process, ignorant, ill-informed and vulnerable; (2) Rational learners: responsive to information, rational problem solvers and compliant with prescriptive advice; and (3) Empowered decision makers: actively engaged with and evaluative of information, autonomous and responsible for their course of action.

Discussion:

Falls prevention websites were rarely designed according to evidence-based recommendations concerning fit with positive self-identity and empowerment of active self-management of health. Although the representation of older people as passive and inert was most evident, the image of empowered decision makers was most likely to engage older people in preventing falls.

Conclusion:

Occupational therapists should ensure that they represent older people in a positive and respectful manner in falls prevention information, both that available through the internet and in written form.

Balance, balancing, and health

In this article we explore the concept of balance in the context of health. We became interested in balance during a grounded theory study of lay conceptualizations of cancer risk in which participants were concerned with having a good life, which relied heavily on balancing processes. This led us to the qualitative literature about balance in the context of health, which was large and in need of synthesis. We identified 170 relevant studies and used Thomas and Harden's technique of thematic synthesis to identify key balance-related themes and develop these into more abstract analytic categories. We found that balance and balancing were salient to people in three health-related contexts: health maintenance, disease or disability management, and lay or professional caregiving. In each of these contexts, balance or imbalance could be a state or a process. In addition, those using the word balance had either an internally or externally focused orientation to the world around them. Clinicians and public health practitioners might benefit from using these insights in their research and communication.

Alternative view of health behavior: the experience of older Korean women

In this study we explored the perspectives of older Korean women on the principles and meanings of health behavior. Participants were 12 women age 65 and older, with no serious illnesses requiring hospitalization, who were living independently. We used an interpretative phenomenological approach for data collection and analysis. Seven themes emerged: (a) eating well in accordance with one's physical requirements; (b) maintaining one's inherited health; (c) controlling one's illness properly; (d) maintaining good relationships with close relatives and friends; (e) being modest and free from greed; (f) staying in harmony with nature; and (g) regaining energy and vitality. These experiences were mainly based on the traditional Korean concept of health promotion, "food is medicine," rather than on Western concepts of health promotion. In providing optimal geriatric nursing care for Korean older women, the results will be significant because they are based on older women's traditional Korean perspectives of health promotion rather than existing perspectives of Western medicine.

Differentiating approaches to diabetes self-management of multi-ethnic rural older adults at the extremes of glycemic control

PURPOSE OF THE STUDY

This study identified approaches to diabetes self-management that differentiate persons with well-controlled from poorly controlled diabetes. Previous research has focused largely on persons participating in self-management interventions.

DESIGN AND METHODS

In-depth qualitative interviews were conducted with 48 adults, drawn from a population-based sample aged 65 years or older with diabetes. The sample was stratified by sex and ethnic group (African American, American Indian, and White) from the low (A1C <6%) and high (A1C >8%) extremes of the glycemic control distribution. Case-based text analysis was guided by a model, including six self-management domains and four resource types (self-care, informal support, formal services, and medical care).

RESULTS

A "structured" approach to self-management differentiated respondents in good glycemic control from those in poor glycemic control. Those in good glycemic control were more likely to practice specific food behaviors to limit food consumption and practice regular blood glucose monitoring with specific target values. This approach was facilitated by a greater use of home aides to assist with diabetes care. Respondents in poor glycemic control demonstrated less structure, naming general food categories and checking blood glucose in reaction to symptoms.

IMPLICATIONS

Results provide evidence that degree of structure differentiates self-management approaches of persons with good and poor glycemic control. Findings should provide a foundation for further research to develop effective self-management programs for older adults with diabetes.

Ways of healthy aging: a case study of elderly people in a Northern Thai village

This ethnographic study was conducted to explore ways of healthy aging and the influence of culture on health-related behaviors in a rural community in Northern Thailand. In-depth interviews, focus group discussions, participant observations and field notes were used to understand the lives of seven healthy Thai older adults aged 75 years and over. Data were collected from March 2007 to February 2008, with ongoing ethnographic analysis involving coding, identifying patterns, generalizing and making reflective notes to elucidate the cultural patterns of behavior. All informants perceived health as interrelated with their life styles, which was, in turn, closely related to their cultural roots, suggesting that culture influences the health of all members of smaller, closely knit communities, including the elderly, by integrating physical, social and spiritual health for older adults and their families.

A case study of physical activity among older adults in rural Newfoundland, Canada

The purpose of this study was to assess rural older adults' perceptions of leisure-time physical activity and examine these perceptions from a historical perspective. Semistructured interviews were conducted with 10 inhabitants (mean age 82 years) of Fogo Island, Newfoundland and Labrador, Canada. Interviews were transcribed verbatim and subjected to inductive analysis. Member-checking interviews were conducted with 5 participants. Findings indicated that beginning in childhood, participants were socialized into a subculture of work activity. As a result of these historical and social forces, leisure-time physical activity did not form part of the participants' lives after retirement. Strategies for successful aging involved keeping busy, but this "busyness" did not include leisure-time physical activity. Results demonstrated the importance of developing a broader understanding of how past and present-day contexts can influence participation in leisure-time physical activity.

Connection between the meaning of health and interaction with health professionals: caring for immigrant women

The meaning of health perceived by adult immigrant women in Canada is discussed from the perspectives of immigration, culture, and lived experience to understand their encounters with health care professionals. Authors base their findings on the thematic analysis of focus group data. Immigrant women viewed health as the outcome of a web of interactions between conditions of mental, physical, social, emotional, environmental, and spiritual well-being, appealing to both biomedical and phenomenological ideologies. Our analyses of qualitative data revealed that the disagreements noted by immigrant women when interacting with health care professionals were due to the discrepancies between their cultural views of health and the dominant biomedical perspective.

Goal setting as a shared decision making strategy among clinicians and their older patients

OBJECTIVE

Older adults are less likely than other age groups to participate in clinical decision-making. To enhance participation, we sought to understand how older adults consider and discuss their life and health goals during the clinical encounter.

METHODS

We conducted six focus groups: four with community-dwelling older persons (n=42), one with geriatricians and internists (n=6), and one with rehabilitation nurses (n=5). Participants were asked to discuss: patients' life and health goals; communication about goals, and perception of agreement about health goals. Group interactions were tape-recorded, transcribed, and analyzed using content analysis.

RESULTS

All participants were willing to discuss goals, but varied in the degree to which they did so. Reasons for non-discussion included that goal setting was not a priority given limited time, visits focused on symptoms, mutual perception of disinterest, and the presumption that all patients' goals were the same.

CONCLUSION

Interventions to enhance goal setting need to address key barriers to promoting goals discussions. Participants recognized the benefits of goal setting, however, training and instruments are needed to integrate goal setting into medicine.

PRACTICE IMPLICATIONS

Setting goals initially and reviewing them periodically may be a comprehensive, time-efficient way of integrating patients' goals into their care plans.

The conceptualization of perceived insufficient milk among Mexican mothers

This study sought to provide a comprehensive picture of maternal conceptualization of Perceived Insufficient Milk (PIM) using qualitative methods (semistructured interviews, free lists, and rankings) in Mexico. Two hundred and seven first-time mothers of infants younger than 6 months and mothers-to-be who were (or intended to be) breastfeeding were interviewed in waiting areas at a hospital and a health clinic in Mexico City, Mexico, from September 2000 to January 2001. Pattern searching and triangulation of the 3 qualitative methods indicated that women viewed crying as the chief symptom of PIM. Maternal diet and liquid intake were cited as both the most salient causes and treatments for PIM. The main coping strategy in the event of PIM was formula feeding. These findings highlight the need for addressing maternal concerns in relation to PIM, especially regarding the role of crying as the initiator of the PIM cycle.

Physical activity among rural older adults with diabetes

PURPOSE

This analysis describes physical activity levels and factors associated with physical activity in an ethnically diverse (African American, Native American, white) sample of rural older adults with diabetes.

METHOD

Data were collected using a population-based, cross-sectional stratified random sample survey of 701 community-dwelling elders with diabetes completed in 2 rural North Carolina counties. Outcome measures were as follows: first, physical activity in the past year, and second, days physically active in the prior week (0-7). Potential correlates included personal and health characteristics and were evaluated for statistical significance using logistic regression models.

FINDINGS

About half (52.5%) of the participants stated that they had engaged in physical activity in the past year. Among those, 42.5% stated that they had no days with at least 30 minutes of continuous physical activity in the prior week, while 21.5% reported daily physical activity. Common activities were walking and housework. Correlates of physical activity in the past year and days active in the prior week included measures of physical health and mobility.

CONCLUSIONS

Physical activity in this ethnically diverse sample of rural elders with diabetes is limited. Effort must be invested to increase physical activity in these groups.

Is health promotion relevant across cultures and the socioeconomic spectrum?

Is health promotion a White middle-class phenomenon that people from other cultures and classes do not regard as important? When implementing health-promotion initiatives, are healthcare providers making assumptions that are not valid for other cultural or socioeconomic groups? How do people of various cultures and classes perceive health and health promotion? To explore these questions, this article reviews some of the relevant literature on culture and class in relation to health promotion, exploring issues foundational to the effectiveness of health-promotion programs and pertinent to delivering health-promotion interventions to ethnic, racial, and cultural minorities and poor populations. Health promoters are encouraged to consider the social determinants of their patients' health and tailor programs on the basis of their patients' motivations and resources.