Measurement of Nontheistic and Theistic Spirituality: Initial Psychometric Qualities of the Inclusive Spiritual Connection Scale

Spirituality represents a key part of life for the majority of U.S. adults and there is a growing body of research supporting relationships between spirituality and numerous health outcomes. Governing healthcare organizations have acknowledged the role religiousness and spirituality play in comprehensive and holistic patient care. While the U.S. shows documented trends towards diverse expressions of spirituality, existing theory-driven measures of spirituality are largely theocentric. The current study concludes a multiphase project that aimed at the outset to develop an inclusive measure of spirituality and establish initial psychometric evidence, validating its use across both theistic and nontheistic spiritual populations. The Inclusive Spiritual Connection Scale (ISCS) was developed based on an expanded conceptualization of spiritual connection to include both theistic and nontheistic expressions of spirituality. The current study builds on a previous study that established preliminary evidence of content validity of the ISCS, from which a 45-item pool was developed. In the present study, data were collected from 736 participants who indicated either theistic or nontheistic sources of spiritual connection. Using a split sample approach (primary developmental sample, n = 368; secondary developmental sample, n = 368) and a test-retest subsample (n =129), the 45-item pool underwent three phases of data analysis to establish initial psychometric evidence of the ISCS for use with theistic and nontheistic populations. Through a series of factor analytic procedures, the 45-item pool was reduced to 13 items, yielding a unidimensional scale of spiritual connection with evidence of sound psychometric properties. The ISCS demonstrated adequate evidence of convergent validity, limited evidence of divergent validity, and strong evidence of reliability. Assessment of measurement equivalence across nontheistic and theistic groups yielded partial evidence of equivalence; however, the baseline levels of spiritual connection appeared to differ between theistic and nontheistic participants. Initial psychometric properties support the ISCS as a reliable and valid tool to assess spiritual connection in spiritually diverse populations, though comparison between spiritual groups requires further validation. The ISCS responds directly to existing gaps in research and possesses the ability to support holistic healthcare care for all US adults regardless of spiritual expression

The Impact of Pre-visit Contextual Data Collection on Patient Activation: Results from a Randomized Control Trial

Background The majority of health indicators are outside of the healthcare system, and current electronic health records (EHR) do not capture those indicators. There is a compelling opportunity to test consumer informatics tools that integrate patient\u27s life circumstances, goals, supports, risks, and care preferences into their EHR for point-of-care discussions. Purpose To determine whether the use of a patient-generated contextual data (PCD) tool designed to enhance the capture and sharing of PCD influenced patient activation. Design, Setting, and Participants A two-armed, non-blind, randomized control trial was conducted between May 2019, and October 2019 at two urban, academically affiliated primary care clinics. 301 patients were enrolled, randomized with stratification by race to study arms. Nearly equal percentages of control and intervention group participants (60.5% vs. 62.4%) and two-thirds of White vs one-third of Black participants completed both assessments (67% vs. 33%). Main outcomes and Measures The main outcome was the pre-/post-visit change in Patient Activation Measure (PAM) score, evaluated using intention-to-treat principles. Analysis was also conducted to determine if patient factors mediated racial differences in baseline PAM scores. Results Using intention-to-treat analysis, there were no significant differences in pre-/post-visit change in PAM scores by arm (p=.079). When allowing for an interaction between race and treatment arm, all interaction terms were not significant (p\u3e0.05). Mediation analysis results indicate income (p=0.025) and difficulty paying monthly bills (p=0.04) when treated as continuous variables, mediated the relationship between race and baseline PAM score. Conclusions and Relevance The findings indicate the PCD Tool did not affect patient activation. Socioeconomic status (SES) mediated baseline racial differences in the PAM score. These data indicate that further study of the relationships among SES and patient activation are needed. The findings also indicate that interventions targeting patient activation need to account for and be sensitive to patient\u27s SES

Evaluation of Structural Change in Primary Care

National health systems are complex and new initiatives are continually being introduced. Well-established instruments exist for evaluating the outcomes of short-term projects and the introduction of new programs within the health system. However, large scale reform involving substantial structural change challenges the ability of existing tools to appropriately evaluate outcomes. In Australia, the National Disability Insurance Scheme (NDIS) and the Health Care Home (HCH) initiatives are examples of structural change although they are not widely recognised as such. This research makes an important contribution to knowledge by exploring structural change and using this exploration to develop new methods for evaluating structural change in the context of primary care in Australia

TRUE TO SIZE: CREATING AN INTERDISCIPLINARY SUICIDE AWARENESS AND PREVENTION EVIDENCE-BASED PROJECT IN A NONPROFIT ACADEMIC MEDICAL CENTER

Suicide is a serious health problem that continues to increase despite significant efforts to reduce suicide in vulnerable populations. High rates of suicide negatively impact individuals, families, and communities nationwide. The purpose of this project was to prepare the inpatient and outpatient clinical workforce at National Jewish Health (NJH) to care for patients who are suicidal. This project included reviewing the literature on suicide awareness and prevention training across the continuum of healthcare, implementing an evidence-based training model, and evaluating the effectiveness of training. This project started in 2017 and throughout, this researcher was the lead for the Suicide Prevention Workgroup, Doctor of Nursing Practice student, and participated in every phase of evidence-based practice (EBP) development. The purpose of the Suicide Prevention Workgroup was to improve the quality of interventions, comply with regulations, and measure outcomes. The REAIM (2019) framework was used to guide a review of the literature and appraise validated training models. The Stetler (2001) model of research utilization implementation facilitated operational training details across the organization. Upon completion of the training, participants were asked to complete the Zero Suicide Workforce Survey (Suicide Prevention Resource Center, 2017) that measured iv knowledge, confidence, and practice of suicide prevention. Analyses of the survey included investigating correlations between confidence in skill ability and intervention and conducting independent-samples t-tests on different disciplines. Future implications of this project could provide healthcare organizations with best evidence-based practice for suicide awareness and prevention training that reaches all patients regardless of their admission status

COPING MOTIVES AS A MODERATOR OF THE ASSOCIATION BETWEEN MINORITY STRESS AND ALCOHOL USE AMONG EMERGING ADULTS OF MARGINALIZED SEXUALITIES AND GENDERS

Alcohol use and negative consequences are higher among individuals of marginalized sexualities and genders (MS/G), and emerging adults within this category face particular risks. According to Meyer’s (2003) minority stress model, the higher prevalence of alcohol use and negative consequences among MS/G is an attempt to cope with proximal/internal and distal/external minority stressors. The purpose of this study was to examine whether coping motives moderated the relationship between internal minority stress and alcohol use outcomes. We hypothesized that higher internal minority and emerging adult stressors would be positively associated with higher levels of drinking-related outcomes, and that coping would moderate this association, with those higher in coping motives reporting a stronger positive relationship between internal minority stress and alcohol use outcomes. 122 MS/G college students (ages 18-25) completed an online survey assessing their alcohol use and associated negative consequences, internal and external minority stressors, and drinking motives. Results of hierarchical linear regressions revealed that while coping motives positively, associated with alcohol-related negative consequences (β = .38, p \u3c .001) and quantity of alcohol consumption (β = .22, p \u3c .01), there was not a significant interaction between coping motives and internal minority stressors. However, both coping motives (β = .22, p \u3c .01) and internal minority stressors (β = .22, p \u3c .01) were positively associated with frequency of binge drinking, with a significant interaction between internal minority stress and coping (β = .07, p \u3c .05). These results suggest that MS/G college students who endorse greater coping motives consume greater quantities of alcohol and are at greater risk for alcohol-related negative consequences. Only binge drinking was significantly associated with internal minority stress and moderated by coping, raising the possibility that internal minority stress is significantly related to alcohol use only at higher levels of alcohol consumption

Neuropsychological Outcomes After Cardiac Surgery: A Pilot Feasibility Study

Approximately half of patients who have cardiac surgery will experience deficits in attention, memory, and thinking speed after their operation. Given that heart surgery is one of the most common medical procedures in Canada, it is necessary to better understand the natural history of cognitive impairment after such surgery. Yet, there is no globally accepted method for measuring cognitive function in patients who undergo heart surgery. To address this, we assessed whether it was feasible to use a web-based approach to measure cognition in heart surgery patients before and after their operation. Findings showed that remote administration of cognitive testing was feasible. Relative to healthy age and sex-matched controls, cardiac patients showed impairment on the Creyos battery before and after surgery, specifically on tasks that relied on verbal processing skills. This study will help identify vulnerable patients and inform future interventional trials to promote cognitive recovery and improve patient quality of life

Assessing the cost-effectiveness of facility-based emergency care in low resource settings

Background Emergency conditions comprise nearly half of the total global burden of disease, and disproportionately affect low-resource settings (LRS). This burden of life-threatening yet treatable conditions can be ameliorated by effective, timely emergency care (EC) interventions, so significantly that the Disease Control Priorities project estimates over half of deaths in the lowest-income countries could be addressed though the implementation of effective EC. Interest in developing better facility-based EC is expanding rapidly, yet there is a large gap in the cost-effectiveness literature to support informed resource allocation. Distinguishing the "value for money" of EC is crucial, especially in contexts of extreme resources limitations. Developing robust and setting-specific data on the cost of implementing EC cultivates the ability to understand the impacts of, and plan improvements in, EC in LRS. The aim of this thesis was to investigate the cost-effectiveness of interventions forming a systematic approach to EC in health facilities in LRS. Aims and Objectives The primary aim of this research was to investigate the cost-effectiveness of implementing the WHO emergency care toolkit to reduce mortality related to emergency conditions in health facilities in an LRS. To achieve this aim, the following objectives were established: synthesise evidence relating to the costeffectiveness of EC in LRS, enumerate context specific costs of delivering facility-based EC, and retrospectively study the impact of implementing a low-cost set of EC interventions in low-resource EC naïve health facilities on cost and outcome (mortality), to derive a measure of cost effectiveness. Methods The dissertation is comprised of 3 studies. First, Chapter 3 undertakes a systematic review of literature on EC interventions in LRS, using PRISMA guidelines and the Consolidated Health Economics Evaluation Reporting Standards (CHEERS) checklist. Secondly, to enumerate context specific costs of delivering facility-based EC, data were collected over a 4-week period in Uganda using direct activity-based costing and presented in Chapter 6. Measures of central tendency were derived by condition and by intervention. Variations in cost between conditions were explored using a Kruskal-Wallis H test and a post-hoc Nemenyi test were performed to make pairwise comparisons between conditions. Third, in Chapter 7 a cost-effectiveness analysis model was developed using Microsoft Excel to calculate both the costs and effects of scalable investments strengthening facility-based EC on morbidity and mortality. Costs and consequences associated with piloting the WHO Emergency Care Toolkit package of interventions in Uganda were analysed using the decision tree model. Pre- and post-intervention groups were compared from a societal perspective. Cost and health outcomes were discounted using a microsimulation and parameter uncertainty assessed using Monte-Carlo simulation probabilistic sensitivity analyses. Results 35 studies were included in the final review; most were methodologically weak and focused on singleintervention analyses rather than intervention packages or system changes. This body of literature represented only 24 of 137 low- and middle-income countries (LMICs) globally, and was heterogeneous in methods, settings, and presentation of results of the identified studies. Accordingly, formulating a general conclusion about the wider implication of the findings on the cost–effectiveness of EC is problematic. The overall median (IQR) cost of care across all conditions was $15.53 (14.44 to 19.22). A Krauskal-Wallis test yielded statistically significant difference in cost values between sentinel conditions (H=94.89, p=1.20E-19). At a P value of < .05, the post-hoc Nemenyi test revealed paediatric diarrhoea has a statistically significant lower median cost compared to all other conditions, but did not yield any significant differences in median cost between the remaining four sentinel conditions. In running the decision tree model with a 1753 patient cohort, sampled 10000 times, the intervention averted 509 DALYs over standard care. The model found implementing the WHO Toolkit saved$664,231 ($658,552 to$669,910), and yielded an additional 27 lives saved, or an additional 1,826 life years. Conclusions and relevance This dissertation makes important conceptual, analytical and empirical contributions in exploring the application of local economic evidence-informed priority setting to ensure that decisions made around EC are guided by the populations they serve. In conducting one of the first cost-effectiveness analyses of investments that create a systematic approach to facility-based EC, we found that this is a very low-cost, high-yield intervention. In many cases it may not only be cost-effective, but actually cost saving. This finding is especially relevant in LRS contexts where associated additional costs may be considered affordable given the high burden of emergency conditions