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BACKGROUND: Community health workers (CHWs) are change agents expected to assist in decreasing the global burden of disease in the communities they serve. However, they themselves have health risk behaviours, which predispose them to non-communicable diseases and thus need to be empowered to make better health choices. There is a gap in literature detailing the challenges faced by CHWs in addressing their own health risk behaviours. AIM: This study aimed to explore the challenges experienced by CHWs in carrying out their daily duties and the motivating factors to join a self-management programme. SETTING: The study was conducted in a low socio-economic urban area of the Western Cape, South Africa. METHODS: This study used a qualitative exploratory design using in-depth interviews to obtain rich data about the personal and professional challenges that CHWs experience on a daily basis. RESULTS: Five themes emerged with regard to professional challenges (social conditions, mental health of patients, work environment, patient adherence and communication). This cadre identified ineffective self-management as a personal challenge and two themes emerged as motivation for participating in a self-management programme: empowerment and widening perspective. CONCLUSION: The challenges raised by the CHWs have a direct impact on their role in communities. This study therefore highlights an urgent need for policymakers and leaders who plan training programmes to take intentional strategic action to address their health challenges and to consider utilising a self-management intervention model to improve their overall health status.

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The purpose of this study was to determine and compare outcomes of two voluntary workplace health management methods: an adapted worksite self-management (WSM) approach and an intensive health monitoring (IM) approach. Research participants were randomly assigned to either the WSM group or the IM group by a computer-generated list (n = 180; 92 WSM and 88 IM). Participants completed baseline, 3 and 12-month follow-up surveys. Individuals receiving workplace WSM and IM improved in self-efficacy and nearly all health behaviors and health status variables after the intervention, compared to before the intervention. Individuals in the WSM group improved in depression symptoms at 3 and 12 months (P < 0.0001, P < 0.0001), and individuals in the IM group did not improve at either time period (P < 0.1488, P < 0.0521). Participants in the WSM group reported more improvement in physical activity and energy, health interfering less with personal life and daily activities and fewer depression symptoms at follow up, compared to participants in the IM group. This study provided additional support for worksite-based health promotion programs to promote healthy lifestyles and improve health status, and documented effectiveness of both methods, with superior performance and greater scalability for the WSM program.

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Many universities seek to improve the health and wellbeing of their faculty and staff through employer wellness programs but racial/ethnic disparities in health care use may still persist. The purpose of this research was to identify racial/ethnic disparities in the use of preventive health services at a Midwestern university. A record review was conducted of self-reported health data from University employees, examining the use of primary care and common screening procedures collected in a Personal Health Assessment conducted by the University's wellness program. Results show that there were significant racial/ethnic differences in the use of primary care and participation in screening. Notably, Asian employees in this sample were less likely to have a primary care provider and participate in routine cancer screenings. The observed racial/ethnic differences in screening behavior were mediated by the use of primary care. Together, these data show that despite equal access to care, racial and ethnic disparities in screening persist and that having a primary care provider is an important predictor of screening behavior. Results suggest that health communications designed to increase screening among specific racial/ethnic minority groups should target primary care use.

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Chronic health conditions and multiple health risk factors afflict Americans and burden employers, but effective, affordable, workplace-based health promotion interventions have not been widely implemented. This is the first study to adapt the empirically validated Chronic Disease Self-Management Program for a general employee population in a workplace setting with an emphasis on disease prevention and health promotion. A quasi-experimental, wellness standard of care comparison, prospective cohort design was used among employee participants at a large University employer. Ninety-one individuals participated in the program. Participants reported significantly increased health behavior frequency and self-efficacy after the intervention, compared with their pre-intervention scores, and improvements were sustained at 3-month follow-up [self-rated abilities for health practices scale (SRA): F = 30.89, P < 0.001; health promoting lifestyle profile-II (HPLP-II): F = 36.30 P < 0.001]. Individuals in the intervention group reported improved self-efficacy and health behaviors compared with the wellness standard of care comparison group at post intervention (SRA: F = 12.45, P < 0.001; HPLP-II: F = 25.28, P < 0.001). Adapting lay-facilitated self-management for the workplace offers promise as a replicable, scalable, affordable model for culture change in organizations.

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To determine: (1) differences in spirituality, religiosity, personality, and health for different faith traditions; and (2) the relative degree to which demographic, spiritual, religious, and personality variables simultaneously predict health outcomes for different faith traditions. Cross-sectional analysis of 160 individuals from five different faith traditions including Buddhists (40), Catholics (41), Jews (22), Muslims (26), and Protestants (31). Brief multidimensional measure of religiousness/spirituality (BMMRS; Fetzer in Multidimensional measurement of religiousness/spirituality for use in health research, Fetzer Institute, Kalamazoo, 1999); NEO-five factor inventory (NEO-FFI; in Revised NEO personality inventory (NEO PI-R) and the NEO-five factor inventory (NEO-FFI) professional manual, Psychological Assessment Resources, Odessa, Costa and McCrae 1992); Medical outcomes scale-short form (SF-36; in SF-36 physical and mental health summary scores: A user's manual, The Health Institute, New England Medical Center, Boston, Ware et al. 1994). (1) ANOVAs indicated that there were no significant group differences in health status, but that there were group differences in spirituality and religiosity. (2) Pearson's correlations for the entire sample indicated that better mental health is significantly related to increased spirituality, increased positive personality traits (i.e., extraversion) and decreased personality traits (i.e., neuroticism and conscientiousness). In addition, spirituality is positively correlated with positive personality traits (i.e., extraversion) and negatively with negative personality traits (i.e., neuroticism). (3) Hierarchical regressions indicated that personality predicted a greater proportion of unique variance in health outcomes than spiritual variables. Different faith traditions have similar health status, but differ in terms of spiritual, religious, and personality factors. For all faith traditions, the presence of positive and absence of negative personality traits are primary predictors of positive health (and primarily mental health). Spiritual variables, other than forgiveness, add little to the prediction of unique variance in physical or mental health after considering personality. Spirituality can be conceptualized as a characterological aspect of personality or a distinct construct, but spiritual interventions should continue to be used in clinical practice and investigated in health research.

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PURPOSE: To determine outcomes for persons with traumatic brain injury (TBI) in terms of employment status, income and public assistance received at 2 years after injury. METHOD: This study was part of a non-experimental, longitudinal survey. Participants included 49 persons with new TBI from one US national Traumatic Brain Injury Model Systems centre. Main outcome measures included employment status, earned monthly income and monthly income from public sources, at the time of injury and at 2-years follow-up. RESULTS: At 2-year follow-up, individuals with TBI reported higher levels of employment and earned income than was previously reported for 1-year post-injury, but continued to experience declines relative to pre-injury baseline. Frequency and amount of major public agency payments continued to be increased relative to baseline. CONCLUSIONS: The costs associated with brain injury remain high for individuals, families and society, as those with TBI move into the more chronic phase of recovery.

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OBJECTIVES: The objectives of the present study were to determine the prevalence of low testosterone among a sample of men with spinal cord injury and to examine the relationship among testosterone, time since injury, and select laboratory values. DESIGN: Participants were 102 men with spinal cord injury participating in inpatient or outpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, and laboratory values. RESULTS: Sixty percent of men with spinal cord injury had low testosterone levels. The median testosterone level for the entire sample was 220 ng/dl (normal reference range = 241-827 ng/dl). Low testosterone was significantly associated with less time since injury, lower hemoglobin, and higher prolactin in the univariate analyses at P < 0.05. CONCLUSIONS: The results indicate that men with spinal cord injury are at risk for low serum testosterone. Testosterone levels were also related to time since injury and hemoglobin and prolactin levels. These findings suggest the need for changes to occur in clinical practice. Guidelines are needed for when and how often testosterone monitoring should be conducted. Future research should address the pathophysiology of low testosterone and the outcomes of testosterone treatment.

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PURPOSE: Few studies have considered the impact of masculine role variables on outcome and adjustment to SCI among men. The present study examined the relations among SCI, views of masculinity, psychological adjustment, and rehabilitation outcomes among men with SCI. METHOD: The sample included 20 men with SCI receiving inpatient rehabilitation, with a mean age of 45 years. Data included demographic variables as well as Conformity to Masculine Norms Inventory (CMNI), Gender Role Conflict Scale (GRCS), Functional Independence Measure (FIM), and Satisfaction with Life Scale ratings, and change in marital status. RESULTS: The findings revealed that satisfaction with life was positively related to scores on the CMNI Violence scale, FIM change from admission to discharge was positively related to the CMNI Emotional Control scale and negatively related to the CMNI Dominance scale. Change in marital status was inversely related to the CMNI Emotional Control and Primacy of Work scales and the GRCS Restricted Emotionality and Power, Success, and Competition scales. CONCLUSIONS: The findings show that certain aspects of the traditional masculine role (i.e., ability to modulate strong emotions) may be adaptive in the rehabilitation process, whereas other aspects (i.e., a dominant interpersonal style) may present a barrier to effective rehabilitation.

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PURPOSE: This study evaluated a personal assistance services (PAS) training programme that aimed to improve the consumer and personal assistant relationship and increase consumer and personal assistant knowledge on health and wellness issues. METHOD: A total of 87 consumers and 53 personal assistants were enrolled in this longitudinal intervention study. Consumers and personal assistants in the intervention group participated in a six-hour in-person PAS training programme. RESULTS: Consumers and personal assistants who participated in the training had increased knowledge at both three and six months post-training compared to consumers and personal assistants who were in the non-treatment group. There were no differences in consumer/personal assistant relationship variables. CONCLUSIONS: Future studies should examine the impact of PAS training programmes on health behaviours needed to decrease secondary conditions.

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PRIMARY OBJECTIVE: Traumatic brain injury (TBI) is a significant health problem disproportionately affecting men and is often associated with changes in masculine role functioning in life domains such as vocational functioning, sexual and inter-personal functioning and personal independence. These changes could have serious implications for men's adjustment following injury. The aim of this study was to examine the relations among traditional masculine role adherence, psychosocial adjustment and rehabilitation outcomes in men with TBI. RESEARCH DESIGN: A correlational design was chosen to examine the relations among variables. Spearman correlations and Wilcoxon Rank Sum tests were used to examine relationships between masculine role variables and outcome variables. METHODS AND PROCEDURES: The study included 33 men with TBI who had been discharged from inpatient rehabilitation within 5 years. Participants completed surveys on traditional masculine gender role adherence and gender role conflict and additional data, including measures of functional outcome, life satisfaction, psychosocial outcomes and earnings, were obtained through the TBI Model System longitudinal data collection system. MAIN OUTCOMES AND RESULTS: The results revealed significant associations between masculine role adherence and satisfaction with life, follow-up earnings and FIM change from admission to discharge. CONCLUSIONS: In the current study, particular masculine role variables corresponded to different functional and psychological outcomes. Understanding these differences provides new directions for treatment and offers important information about aspects of traditional masculine roles that may enhance or hinder adjustment to injury.

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OBJECTIVE: Although previous research has shown an association between spinal cord injury (SCI) and testosterone production, these studies have yielded inconsistent results. The present study documented the prevalence of low testosterone among men with SCI. DESIGN: Participants were 92 men with SCI participating in inpatient rehabilitation. Data included total serum testosterone level, demographic and injury information, neurologic level and degree of incomplete function, American Spinal Injury Association Impairment Scale grade, and additional laboratory values, including prealbumin, albumin, hematocrit, and aspartate aminotransferase. RESULTS: The median testosterone level for men who sustained injuries <4 mos earlier was 160 ng/dl. Testosterone categories were significantly associated with age, time since injury, hematocrit, albumin level, and aspartate aminotransferase in the univariate analyses. Age, time since injury, and hematocrit levels were significant predictors of low testosterone in the multivariate analysis. CONCLUSION: The prevalence of low testosterone among men with acute SCI seems to be high. The results suggest the need for routine screening for low testosterone among men with SCI and consideration given to testosterone replacement therapy. Future research is needed to investigate the etiology, pathogenesis, and potential avenues for treatment of low testosterone among men with SCI.

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OBJECTIVE: To evaluate differences in outcome in persons with violent versus nonviolent traumatic brain injury (TBI) etiology. DESIGN: Two-group (violent vs nonviolent) 1-year follow-up study. SETTING: Midwestern medical center TBI Model System serving a predominantly rural catchment area. PARTICIPANTS: Forty-five (n = 19 violent TBI etiology; n = 26 nonviolent TBI etiology) inpatients with primary diagnosis of TBI followed up as outpatients 1 year after injury. MAIN OUTCOME MEASURES: Substance use, income source, employment status, Wechsler Adult Intelligence Scale--Revised (abbreviated version), Logical Memory I and II from the Wechsler Memory Scale--Revised, Wide Range Achievement Test--Third Edition Reading subtest, Trail-Making Tests A and B, Rey Auditory Verbal Learning Test, Community Integration Questionnaire, Neurobehavioral Functioning Inventory. RESULTS: Members of the violent group were more likely to be men, of a racial minority, unemployed, and have low income. Substance abuse was common among both groups prior to injury, with significant declines at 1 year. Follow-up also revealed significant group differences in verbal intelligence, social integration, productivity, and source of income, but nonsignificant difference in employment. In all comparisons, more favorable outcomes were found for the nonviolent group. CONCLUSIONS: Persons with violent injury etiology have poorer premorbid functioning and are likely to have less favorable outcomes than the general population with TBI. Therefore, persons with violent TBI etiology may require more intensive aftercare programming to promote improved rehabilitation outcomes.

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This study was a needs assessment to inform the design and evaluation of a home-based telerehabilitation network for rural elderly patients. We conducted a literature review of telerehabilitation studies and a needs-assessment by interviewing 43 professionals, including homecare nursing staff, members of volunteer organizations and service agencies, social workers, discharge planners, researchers, and rehabilitation therapists. The survey addressed perceived needs, advantages, and disadvantages with the use of telemedicine technologies for rehabilitation services. All respondents agreed that there are unmet needs among elderly people who are discharged from hospital settings, and identified several problems including: medication noncompliance, isolation, limited access to specialists and community-based services. Our findings defined a framework for the development of a client-oriented rural telehealth network that will be used to guide patients discharged to homecare following stroke, through a complex array of health, mental health, and social services, spanning all levels of care.

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PURPOSE: To describe the design and development process for an information network that meets the complex needs for information exchange by persons with disabilities. This paper describes the needs assessment and design processes that drove the selection of specific system features, and discusses the range of entities with whom persons with disabilities must exchange information. The authors delineate the design goals and their associated specifications for a network of local resource information that serves the needs of persons with disabilities. A model program has been specified and is currently under development. It will enable users to exchange personal, health, and resource information with service entities and with other members of the disability community who depend on detailed information to support their performance of everyday tasks. As an outcome this activity, a highly portable, replicable, sustainable, scalable, and secure model of consumer-driven information exchange will become available to persons with disabilities and to those who provide services to them. The impact of this system will be amplified when it is launched and replicated in interested communities nationwide.

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The purpose of this study was to determine telehealth professionals' current experience with technology, expectations of future technical improvements, and how the technology might impact the delivery of care, including communication with patients and patient safety. We developed a semi-structured interview protocol with eight open-ended questions. A sample of telehealth professionals of the Missouri Telehealth Network (MTN) was selected to represent all major clinical specialties. Interviews were conducted during face-to-face encounters or over the phone. A content analysis was performed using the interview transcripts. A total of 32 telehealth professionals were interviewed (representing 80% of all professionals who were registered MTN users at the time of the study). Twenty-six of them are care providers (physicians, nurses, etc.), and the remaining six are administrators or educators. Self-reported experience with telemedicine ranged from 1 to 7 years (mean 3.72 years). Telehealth professionals find the technology acceptable and easy to integrate in the care delivery process. However, many professionals believe there is room for improvement and would like it to reach a more consistent, reliable, but yet flexible state. They recommended that emphasis be placed on improvement of the audio features, establishment of connections, and avoidance of interruptions. Thirty-two percent of the respondents did not know whether practicing telemedicine over the telehealth network would increase the risk of security and privacy violations. The study findings suggest that telehealth professionals need to be educated about the security features of a telehealth network. In addition, continuous quality improvement, including internal and external benchmarking, is applicable to telemedicine settings and can both improve the quality of teleconsultations and minimize errors.

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Persons with disabilities represent a growing population in both the European Union (EU) and the United States (USA). The ability to work is a key component in achieving independence and full inclusion in society, and employability is increasingly seen as an important outcome variable for studies in health and disability. However, persons with disabilities face considerable challenges in returning to work due to barriers related to transportation, job changes after disability, lack of support services in the workplace, and related barriers. Telework, or work from a distance, may help to mitigate these obstacles, while expanding the range of work options available for persons with disabilities. The EU has made substantial policy progress to support telework, but persons with disabilities have had only limited long-term success in telework initiatives due to lack of work support services. The USA has generally strong support services but lacks telework policy infrastructure. The EU and the USA can benefit from collaborative work to enhance their complementary strengths.

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OBJECTIVE: To evaluate differences in demographics, injury severity, and vocational outcomes for persons with TBI based on rural vs. urban residency. PARTICIPANTS: 78 individuals with TBI (28 from rural counties, 50 from urban counties) who requested services from the Missouri Division of Vocational Rehabilitation (VR) over a two year period. MEASURES: Demographics (i.e., age, race, education), injury severity (i.e., loss of consciousness, post traumatic amnesia, length of hospitalization, neuropsychological test scores), VR services provided (e.g., transportation, maintenance, on-the-job training, etc.), and VR outcomes (successfully vs. unsuccessfully employed; cost per case). PROCEDURE: All participants completed a standard neuropsychological evaluation and completed VR services (i.e., were followed from enrollment to case closure). Rural and urban residency was determined using U.S Office of Management and Budget definitions of metropolitan and non-metropolitan areas. ANALYSIS: Chi-squares, Fisher's Exact tests, Wilcoxon Rank Sums test, and MANOVAs. RESULTS: Few if any differences were found between the groups in demographics (i.e., more African Americans in urban areas), injury severity (i.e., more rural residents with multiple TBIs), or neuropsychological test scores. However, individuals from urban areas received significantly more maintenance funds (46% vs. 21%), transportation services (36% vs. 11%), and on-the-job training (28% vs. 7%), and had more spent on them ($1,816 vs $1,242). Although statistically non-significant (p < 0.15), 24% of individuals from urban areas were successfully employed at VR case closure, compared to only 7% of individuals from rural areas. CONCLUSIONS: Individuals with TBI from rural and urban settings have generally similar demographic, injury severity, and neuropsychological abilities, although they appear to differ in terms of vocational outcomes and number of VR services received, possibly related to limited availability of resources in rural areas.

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Decreased length of inpatient rehabilitation stay, greater long-term injury survival rates, broader access to information technologies, and the growing role of the Internet create potential for new models of rehabilitation that are more community- and person-centered rather than historically hospital- and provider-centered services. In recent years, information-based rehabilitation technologies have grown rapidly, expanding the possibilities for numerous interventions to promote independent living. These programs have centered primarily on providing rehabilitation health services over a distance ("telerehabilitation"). Telerehabilitation can be conceived as part of a broader approach that includes elements of direct rehabilitation services, service coordination, community resources, and information relay between numerous individuals, service providers, and community members ("rehabilitation informatics"). Because of the complexity of these information types and sectors, this broader conceptual approach of rehabilitation informatics borrows heavily from fields such as adaptive computing, robotics, computer networking, and high-level systems programming. As such, innovation in rehabilitation informatics will require new models of training that span these domains. This paper proposes a rationale for the new field of rehabilitation informatics, and offers a multidisciplinary training model for the next generation of rehabilitation informaticians.

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OBJECTIVE: To characterize financial and vocational outcomes among persons with traumatic brain injury (TBI) in terms of employment status, earned and private income, and public assistance received at the time of injury and at 1 year after injury. DESIGN: Nonexperimental, longitudinal study. SETTING: Inpatient TBI rehabilitation unit and participants' community of residence. PARTICIPANTS: Thirty-five persons with new TBI from 1 national Traumatic Brain Injury Model Systems center. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status, earned and private monthly income, and public assistance received monthly at the time of injury and at 1-year follow-up. RESULTS: From the time of injury until 1-year follow-up, the percentage of persons employed decreased from 69% to 31%; the percentage unemployed increased from 11% to 49%; the average earned monthly income declined 51% (from US dollars 1,491 to US dollars 726); and the mean total public assistance received per month increased 275% (from US dollars 153 to US dollars 421). CONCLUSION: Assuming that this study sample is representative of national statistics for TBI, during the first year after injury, TBI is associated with an estimated $642 million in lost wages, US dollars 96 million in lost income taxes, and US dollars 353 million in increased public assistance.

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