Alexa Stuifbergen

University of Texas at Austin, Austin, Texas, United States

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Publications (89)90.54 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background: Cognitive impairment is among the most debilitating outcomes of multiple sclerosis (MS). Although several neuropsychological tests and self-report cognitive measures have been used to assess cognitive impairment, they may not be sensitive to change over time, or may not be feasible to administer in a clinical setting. The purpose of this study was to assess the reliability and validity of the 8-item PROMIS Cognitive Abilities and Cognitive Concerns Scales in a large community-based sample of people with MS. The PROMIS Cognitive Abilities and Cognitive Concerns Scales derive from the National Institutes of Health-funded Patient Reported Outcomes Measurement Information System (PROMIS), an item repository that capitalizes on recent psychometric advances to produce short, psychometrically sound health measures. Methods: Mailed survey data were collected from 322 individuals recruited from two National Multiple Sclerosis Society chapters in a southwestern state. Results: Both cognitive scales demonstrated high internal consistency reliability and were moderately correlated with self-reported depressive symptoms, self-efficacy, barriers to health promotion, health, and functional status (all correlation coefficients >0.35). In hierarchical regression analysis, the PROMIS Cognitive Concerns score added significant unique variance to the prediction of MS Incapacity Status after controlling for self-reported depressive symptoms, exercise, spiritual growth, and global health. Those who were unemployed owing to their disabilities had significantly lower PROMIS Cognitive Abilities scores and higher Cognitive Concerns scores than those who were working or those who were retired or not working for other reasons. Conclusions: The PROMIS Cognitive Abilities and Cognitive Concerns Scales are short, psychometrically sound measures that assess an important dimension of functioning and health for people with MS.
    International journal of MS care. 01/2014; 16(1):1-8.
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    ABSTRACT: Background Multiple sclerosis (MS) is a debilitating, progressive disease with no known cure. Symptoms vary widely for persons with MS and measuring levels of fine motor, gross motor and cognitive function is a large part of assessing disease progression in both clinical and research settings. While self-report measures of function have advantages in cost and ease of administration, questions remain about the accuracy of such measures and the relationship of self-reports of functioning to performance measures of function. Objective The purpose of this study was to compare scores on a self-report measure of functional limitations with MS with a performance-based measure at five different time points. Methods Sixty participants in an ongoing longitudinal study completed two measures of function annually over a five-year period - the self-report Incapacity Status Scale and the MS Functional Composite (MSFC), a performance test. Pearson correlations were used to explore the association of self-report and performance scores. Results There were moderate to strong correlations among the ISS total (r= -.53 to -.63, p<.01) and subscale scores of gross (r=.79 to .87; p<.01)) and fine (r= .47 to .69; p<.01) motor function and the corresponding MSFC performance measure. The pattern of change over time in most scores on self-report and performance measures was similar. Conclusion Findings suggest that the self-report measure examined here, which has advantages in terms of feasibility of administration and patient burden, does relate to performance measurement, particularly in the area of gross motor function, but it may not adequately reflect cognitive function.
    Disability and Health Journal. 01/2014;
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    ABSTRACT: Women's racial/ethnic-specific attitudes toward physical activity have been pointed out as a plausible reason for their low participation rates in physical activity. However, very little is actually known about racial/ethnic commonalities and differences in midlife women's attitudes toward physical activity. The purpose of this study was to explore commonalities and differences in midlife women's attitudes toward physical activity among 4 major racial/ethnic groups in the United States (whites, Hispanics, African Americans, and Asians). This was a secondary analysis of the qualitative data from a larger study that explored midlife women's attitudes toward physical activity. Qualitative data from 4 racial/ethnic-specific online forums among 90 midlife women were used for this study. The data were analyzed using thematic analysis, and themes reflecting commonalties and differences in the women's attitudes toward physical activity across the racial/ethnic groups were extracted. The themes reflecting the commonalities were: 1) physical activity is good for health, 2) not as active as I could be, 3) physical activity was not encouraged, 4) inherited diseases motivated participation in physical activity, and 5) lack of accessibility to physical activity. The themes reflecting the differences were: 1) physical activity as necessity or luxury, 2) organized versus natural physical activity, 3) individual versus family-oriented physical activity, and 4) beauty ideal or culturally accepted physical appearance. Developing an intervention that could change the social influences and environmental factors and address the women's racial/ethnic-specific attitudes would be a priority in increasing physical activity of racial/ethnic minority midlife women.
    Journal of midwifery & women's health 07/2013; 58(4):440-50. · 1.13 Impact Factor
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    ABSTRACT: The accumulation of limitations over the life course requires that women readapt to environmental barriers they encounter over time. The purpose of this qualitative case study was to detail the life experiences associated with living with mobility, cognitive, and sensory loss experienced by a woman and her sister who participated in an ongoing ethnographic study of mobility impairment in women. In-depth interviews were subjected to thematic, life course analysis. A family case study was interpreted as an exemplar for aging with early-onset disability into multiple morbidity, which was described as a series of loss, recovery, and reengagement. Within the case study, the participant suggested that because her functional limitations were not accommodated earlier in life due to societal and family-level disadvantage, these limitations were more difficult to adjust to in later years.
    Research in Gerontological Nursing 01/2013; 6(1):57-69. · 0.66 Impact Factor
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    ABSTRACT: OBJECTIVES: To explore Asian American midlife women's attitudes toward physical activity using a feminist perspective. DESIGN: A qualitative online forum study. SETTINGS: Internet communities/groups for midlife women and ethnic minorities. PARTICIPANTS: A total of 17 Asian American women recruited through the Internet using a convenience sampling method. METHODS: A 6-month qualitative online forum was conducted using 17 online forum topics. The data were analyzed using thematic analysis. RESULTS: Three major themes related to Asian American midlife women's attitudes toward physical activity were extracted from the data: keeping traditions, not a priority, and not for Asian girls. Because Asian American midlife women were busy in keeping their cultural traditions, they rarely found time for physical activity. The women gave the highest priority to their children, and physical activity was the lowest priority in their busy lives. Also, the women were rarely encouraged to participate in physical activity during their childhoods, and they perceived that their weak and small bodies were not appropriate for physical activity. CONCLUSIONS: Several implications for future development of physical activity promotion programs for this specific population have been suggested based on the findings.
    Journal of Obstetric Gynecologic & Neonatal Nursing 07/2012; · 1.03 Impact Factor
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    ABSTRACT: Despite an increasing number of studies of midlife women's physical activity, little is known about how attitudes toward physical activity of midlife women from diverse ethnic groups influence the women's physical activity. To explore ethnic differences in midlife women's attitudes toward physical activity and determine the relationships between the attitudes and their actual participation in physical activity while considering other influencing factors. The Midlife Women's Attitudes Toward Physical Activity model was used to guide the study. This was a cross-sectional Internet survey study of 542 midlife women. The instruments included questions on background characteristics and health and menopausal status; the Physical Activity Assessment Inventory; a modified Barriers to Health Activities Scale; the Questions on Attitudes Toward Physical Activity, Subjective Norm, Perceived Behavioral Control, and Behavioral Intention; and the Kaiser Physical Activity Survey. The data were analyzed using ANOVA, correlation, hierarchical multiple regression, and path analyses. There were significant ethnic differences in the attitude scores (F = 2.58, p < .05), but no ethnic differences in the physical activity scores. Interestingly, there were significant ethnic differences in the occupational physical activity scores (F = 5.68, p < .01). Attitude scores accounted for 5% of total variances of the physical activity scores (F(ch) = 43.52, p < .01). The direct paths from the attitude scores (p < .01), the self-efficacy scores (p < .01), and the barrier scores (p < .05) to the physical activity scores were statistically significant. Ethnic differences in the women's attitudes toward physical activity need to be considered in promoting physical activity of midlife women.
    Nursing research 06/2012; 61(5):342-52. · 1.80 Impact Factor
  • Ana Todd, Alexa Stuifbergen
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    ABSTRACT: There is evidence that early detection from breast cancer screening is an effective means to reduce overall mortality from breast cancer. Findings from multiple research studies suggest that women with chronic disabling conditions are less likely to participate in breast cancer screening due to the multiple barriers they face. Barriers include those related to finances, environment, physical limitations, health carers' attitudes and lack of knowledge, and psychosocial issues. The purpose of this article is to provide an overview of the existing evidence of the barriers to breast cancer screening experienced by women with physical disabilities. Rehabilitation nurses that work with women who have chronic disabling conditions can be instrumental in eliminating these barriers to breast cancer screening through their efforts to promote health which is consistent with the philosophy of maximizing the health potential and quality of life of these women whose needs are often overlooked.
    Rehabilitation nursing: the official journal of the Association of Rehabilitation Nurses 03/2012; 37(2):74-9. · 0.78 Impact Factor
  • Heather Becker, Sook Jung Kang, Alexa Stuifbergen
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    ABSTRACT: To explore whether measures of resources, barriers, and health-promoting behaviors would add significantly to the prediction of health-related quality of life among survivors with disabilities that occurred prior to their cancer diagnosis once contextual factors were controlled for. A descriptive correlational study. Adult cancer survivors with preexisting disabling conditions who had completed active treatment were recruited from throughout the United States. Most of the 145 respondents were breast cancer survivors with preexisting neuromuscular conditions such as polio and multiple sclerosis. The average time since cancer diagnosis was nine years. Respondents completed a mailed survey. Health-promoting behaviors, self-efficacy, barriers to health promotion, social support, functional limitations, cancer-related variables, depression, and quality of life. The sample reported poorer physical well-being than other cancer survivors without preexisting disabling conditions. Health-promoting behaviors and psychosocial factors, such as depressive symptoms and self-efficacy, added significantly to the prediction of physical, social, emotional, and functional components of health-related quality of life after contextual factors entered the equations. The findings underscore the importance of providing this population with the means to promote their health to the greatest extent possible, given the multiple threats to their health status. Nurses may be able to help survivors with preexisting disabling conditions reduce the negative influence of poorer health status and functional limitations on quality of life by providing interventions that reduce depression and build perceived ability to engage in health-promoting behaviors.
    Oncology Nursing Forum 03/2012; 39(2):E122-31. · 1.91 Impact Factor
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    ABSTRACT: Objective: To explore the feasibility and effects of a computer-assisted cognitive rehabilitation intervention - Memory, Attention, and Problem Solving Skills for Persons with Multiple Sclerosis (MAPSS-MS) - for persons with multiple sclerosis on cognitive performance, memory strategy use, self-efficacy for control of symptoms and neuropsychological competence in activities of daily living (ADL). Design: A randomized controlled single-blinded trial with treatment and wait list control groups. Setting: Southwestern United States. Subjects: Convenience sample of 61 persons (34 treatment, 27 wait list control) with multiple sclerosis (mean age 47.9 years, SD 8.8). Intervention: The eight-week MAPSS-MS intervention program included two components: (a) eight weekly group sessions focused on building efficacy for use of cognitive compensatory strategies and (b) a computer-assisted cognitive rehabilitation program with home-based training. Outcome measures: A neuropsychological battery of performance tests comprising the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS) and self-report instruments (use of memory strategies, self-efficacy for control of multiple sclerosis and neuropsychological competence in ADL) were completed at baseline, two months (after classes), and at five months. Results: Both groups improved significantly (P < 0.05) over time on most measures in the MACFIMS battery as well as the measures of strategy use and neuropsychological competence in ADL. There was a significant group-by-time interaction for scores on the measures of verbal memory and the use of compensatory strategies. Conclusions: The MAPSS-MS intervention was feasible and well-accepted by participants. Given the large relative increase in use of compensatory strategies by the intervention group, it holds promise for enhancing cognitive function in persons with multiple sclerosis.
    Clinical Rehabilitation 02/2012; 26(10):882-93. · 2.19 Impact Factor
  • Heather Becker, Alexa Stuifbergen, Janet Morrison
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    ABSTRACT: Cognitive impairment has a major impact on the lives of people with Multiple Sclerosis (MS). Yet, it is often under-diagnosed, and more effective assessment methods are needed. In particular, brief measures that focus on cognitive functioning in daily life situations, are sensitive to modest change over time, and do not require a highly skilled assessor merit exploration. The purpose of this exploratory study was to investigate the performance of individuals with MS on three relatively new measures: the PROMIS Cognitive Concerns and Abilities Scales and the Everyday Problems Test (EPT), and to compare scores on these measures with scores on neurocognitive performance measures typically used to assess cognitive functioning in people with MS. Twenty-nine individuals with MS who reported cognitive concerns participated in the study. Most were non-Hispanic White women, with relapsing-remitting MS, diagnosed approximately 18 years ago. All three measures yielded reliability coefficients of .80 or above and also demonstrated sensitivity to change following an educational intervention. Scores on the revised EPT were moderately correlated with scores on five standard neuropsychological measures. Compared with the PROMIS Cognitive Concerns scale, scores on the self-reported PROMIS Cognitive Abilities scale tended to correlate more highly with the neurocognitive performance measures, although the correlations were generally small. While results of this exploratory study are promising, future research should be conducted with larger and more diverse samples of people with MS to determine the broader utility of these measures.
    International journal of MS care. 01/2012; 14(2):71-76.
  • Alexa K Stuifbergen, Tracie Culp Harrison
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    ABSTRACT: Use of complementary and alternative therapies (CATs) is common with both the general population and with people who have multiple sclerosis (MS). The purpose of this study was to describe the reported use and perceived effectiveness of different CATs in a large sample (N = 621) of people with MS. One-third of the participants reported that they were presently using one or more CATs, and 50% had tried one or more CATs in the past. Most CATs were perceived as being helpful. People who were presently using CATs differed little from those who were not with regard to demographic- and illness-related variables. Use of CATs was positively associated with the practice of other health-promoting behaviors. The frequent use of different CATs suggests that clinicians should systematically and nonjudgmentally inquire about CAT use among their patients.
    Rehabilitation nursing: the official journal of the Association of Rehabilitation Nurses 01/2012; 28(5):141-7, 158. · 0.78 Impact Factor
  • Claudia C Beal, Alexa Stuifbergen, Deborah Volker
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    ABSTRACT: Delayed arrival at the emergency department after the onset of ischemic stroke symptoms is an important reason for low tissue plasminogen activator administration rates. There is evidence that women arrive at the hospital later than do men, but little is known about women's experiences in the period between symptom onset and hospital arrival. The purpose of this naturalistic investigation using narrative methodology was to gain understanding of women's early symptom experience of ischemic stroke. The sample consisted of 9 women aged 24 to 86 years with an ischemic stroke within 1 year of diagnosis. Data were collected using in-depth interviews in which participants were asked to tell the story of their stroke from the moment they noticed the symptoms until they arrived at the hospital. Data were analyzed using sequential methods of narrative analysis. The participants experienced stroke onset as the inability to carry out their accustomed activities in usual ways and as a process occurring over time rather than a discrete event. There was a tendency to objectify the body. Two participants considered stroke as a possible cause for their symptoms, and the other women attributed symptoms to everyday bodily experiences and/or other health conditions. Most participants did not perceive themselves at risk for stroke, although all but 1 woman had risk factors. For some women, stroke onset was different from their previous ideas about this event, and this was especially the case if a woman had prodromal symptoms. Decision making during early stroke flowed from women's evaluation of symptoms and the meaning of symptoms, and meaning was informed by a woman's life situation. The findings from this study may yield variables for future studies of cognitive, emotional, and behavioral predictors of hospital arrival time. There is a need for research on women's prodromal symptoms.
    The Journal of cardiovascular nursing 07/2011; 27(3):240-52. · 1.47 Impact Factor
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    Eun-Ok Im, Bokim Lee, Wonshik Chee, Alexa Stuifbergen
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    ABSTRACT: To explore attitudes toward physical activity of White midlife women in the United States using a feminist perspective. A cross-sectional qualitative study using a thematic analysis. Internet communities for midlife women. Twenty-nine White midlife women in the United States recruited using a convenience sampling method. We used 17 topics on attitudes toward physical activity and ethnic-specific contexts to administer an online forum. We analyzed the data using thematic analysis. We found three themes: thinking without action, gendered and sedentary culture, and motivating myself. The women knew and understood the necessity of physical activity for their physical and mental health but in most cases had not been able to take action to increase their physical activities. Although the culture that circumscribed the women's physical activity was sedentary in nature, the women tried to motivate themselves to increase their physical activities through several creative strategies. The findings strongly suggest that although women were doing their best, American culture itself needs to be changed to help women increase physical activity in their daily lives.
    Journal of Obstetric Gynecologic & Neonatal Nursing 05/2011; 40(3):312-21. · 1.03 Impact Factor
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    ABSTRACT: The purpose of this study was to explore African American midlife women's attitudes toward physical activity. Using a feminist perspective, a 6-month online forum was conducted with 21 African American midlife women recruited on the Internet. The data were analyzed using thematic analysis. Four themes emerged: (a) culturally acceptable body, (b) missed opportunity to learn, (c) physical activity as a luxury, and (d) want to do by myself. The women had positive body images regardless of their actual weight. The women considered physical activity "a luxury" in their busy lives and thought that they had already missed opportunities to learn. The women wanted to participate in physical activities alone because of their bad childhood experiences and hesitance to go out in public with sweaty, messy hair. The findings suggested that unique programs that promote physical activity should be developed that consider the women's ethnic-specific attitudes.
    Western Journal of Nursing Research 03/2011; 34(3):317-39. · 1.22 Impact Factor
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    ABSTRACT: The purpose of this article is to report the influence of gender on aging with childhood onset paralytic polio. The hermeneutic phenomenological exploration of gender was done using multiple qualitative interviews with 25 women, age 55 to 75 years of age, who had polio since before 14 years of age. We noted three themes: (a) the movement of her body, (b) integrating body and gender, and (c) gender discrepancies. Findings are discussed in the context of gendered expectations and the women's bodies.
    Journal of Gerontological Social Work 02/2011; 54(2):138-58.
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    ABSTRACT: Initial evidence suggests that computer-assisted cognitive rehabilitation may improve cognitive performance among people with multiple sclerosis (MS). Most studies of computer-assisted cognitive training have incorporated an individualized in-office/clinic approach for training. The purpose of this study was to explore the feasibility of home-based computer-assisted training and systematically examine the perceptions of people with MS regarding home use of the program. Qualitative data (written and verbal) obtained as part of a larger randomized clinical trial of a cognitive rehabilitation intervention were analyzed. The computer training component of the intervention included prescribed tracks and exercises on the Internet-based Neuropsychonline program. The majority of the participants used the program the recommended number of times per week and for the minimum number of minutes over the 8-week intervention. Although participants had notable negative perceptions and complaints about the program during the training experience, most of them acknowledged during training that use of the program helped them recognize cognitive limitations, create and practice strategies to increase cognitive function, and improve the quality of their daily life. Data from focus groups 3 months after the training included similar criticisms regarding lack of feedback and difficulties with the program as well as acknowledgment of the positive effects and a desire for continued access to the program. The findings suggest that while home training is feasible, careful preparation for use of the program is required.
    International journal of MS care. 01/2011; 13(4):189-198.
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    Martha Gene Meraviglia, Alexa Stuifbergen
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    ABSTRACT: The purpose of this study was to explore the health-promoting (HP) behaviors of low-income cancer survivors before and after their diagnosis of cancer. This qualitative study used a purposive sampling strategy to identify low-income, ethnically diverse cancer survivors. Participants were recruited from an urban outpatient cancer clinic serving only low-income clients. Thirteen, ethnically diverse low-income cancer survivors participated in 60- to 90-minute interviews discussing their experience with HP behaviors before and after their diagnosis with cancer, their cancer experience, and their perspectives on being a cancer survivor. Conventional content analysis of transcripts and field notes by 2 coders identified words, context, frequency, emphasis, and consistency of participants' comments. Statements were further examined to identify patterns and main themes and to interpret the meaning of what was said. Participants described their use of various HP behaviors primarily walking, maintaining a positive mental attitude, and changing their diet. Participants discussed their perspectives on having a diagnosis of cancer as well as the meaning of being a cancer survivor. They described spiritual growth through prayer, renewing their faith, maintaining a hopeful outlook, and expressing thankfulness toward God. Participants expressed interested in learning about effective physical exercises, healthy eating, and stress management strategies. Results suggest that low-income cancer survivors engage in various HP behaviors and want to learn more behaviors to use after cancer treatment. Findings provide useful information for clinical nurse specialists when providing information about HP behaviors for use during and after cancer treatment as well as the meaning of cancer survivor for low-income cancer survivors.
    Clinical nurse specialist CNS 01/2011; 25(3):118-24. · 0.74 Impact Factor
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    Ana Todd, Alexa Stuifbergen
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    ABSTRACT: PURPOSE: Recent literature indicates that women with various types of chronic disabling conditions are less likely to participate in routine breast cancer screening compared to those without disabling conditions. The purpose of this study is to identify the barriers and facilitators related to breast cancer screening among women with MS. METHODS: After receiving approval from the IRB, a semi-structured interview in a private setting was conducted with 36 women with MS, whose mean age was 55. Interviews were audio-taped and transcribed verbatim. The interview questions informed by the Health Belief Model, addressed knowledge, experience, barriers and facilitators related to breast cancer screening. Qualitative descriptive techniques were used to analyze the data. The majority of the women in the sample were White, 67% were married, 47% had at least a bachelor's degree and about 31% were unemployed due to their disability. FINDINGS: Findings show that 70% of these women had received annual mammograms and 50% had performed monthly breast self-exams. Of the women who had not received mammograms, most (80%) had mobility limitations. Some of the women in this study described various environmental and intrapersonal barriers to breast cancer screening. Among these were barriers related to transportation, difficulty in positioning for the exam, health care provider attitudes, not remembering, fear, discomfort, and "having enough to handle." Facilitators included annual reminders and helpful health care providers.
    International journal of MS care. 01/2011; 13(2):49-56.
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    ABSTRACT: Despite a lack of studies on Hispanic midlife women's physical activity, the existing studies have indicated that Hispanics' ethnic-specific attitudes toward physical activity contributed to their lack of physical activity. However, little is still clearly known about Hispanic midlife women's attitudes toward physical activity. The purpose of this study was to explore Hispanic midlife women's attitudes toward physical activity using a feminist perspective. The study was a 6-month qualitative online forum among 23 Hispanic women who were recruited through Internet communities/groups. The data were collected using 17 online forum topics on attitudes toward physical activity and ethnic-specific contexts. The data were analyzed using thematic analysis. Three major themes emerged from the data analysis process: (a) "family first, no time for myself," (b) "little exercise, but naturally healthy," and (c) "dad died of a heart attack." Although some of the women perceived the importance of physical activity due to their family history of chronic diseases, the study participants thought that physical activity would be a waste of time in their busy daily schedules. These findings provided directions for future health care practice and research to increase physical activity among Hispanic midlife women.
    Women & Health 09/2010; 50(6):563-79. · 1.05 Impact Factor
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    ABSTRACT: Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life. The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions. The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics. Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly. Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.
    Disability and Health Journal 07/2010; 3(3):133-45. · 1.50 Impact Factor

Publication Stats

1k Citations
90.54 Total Impact Points


  • 1990–2014
    • University of Texas at Austin
      • • School of Nursing
      • • Department of Educational Psychology
      Austin, Texas, United States
  • 2011
    • Baylor College of Medicine
      Houston, Texas, United States
  • 2008–2009
    • University of Missouri
      Columbia, Missouri, United States
  • 2005
    • Western Michigan University
      Kalamazoo, Michigan, United States
  • 2000
    • Rangsit University
      Bang Kadi, Pathum Thani, Thailand
  • 1997
    • University of Arkansas at Little Rock
      Little Rock, Arkansas, United States