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... Nonfatal Shootings: A Comparison of Unintentional and Criminal Incidents Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Anne E. Reynolds, MPH Copyright April 21, 2021 By: Anne E. Reynolds, MPH All rights reserved Approved by: Heidi Hancher-Rauch, PhD, CHES Committee Chair ______________________________ Natalie Kroovand Hipple, PhD Committee Member ______________________________ Elizabeth S. Moore, PhD Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ Running head: NONFATAL SHOOTINGS Nonfatal Shootings: A Comparison of Unintentional and Criminal Incidents Anne E. Reynolds University of Indianapolis 1 NONFATAL SHOOTINGS 2 Abstract Firearm-related injuries continue to be a major public health issue in the United States, but there remains no comprehensive surveillance. This study describes the characteristics of unintentional nonfatal shooting victims and incidents documented by law enforcement January 2017 through December 2019 in Indianapolis, Indiana. Exploratory analyses provided descriptive information about unintentional nonfatal shootings not previously explored. Bivariate analyses and binary logistic regression compared unintentional nonfatal shooting victims (n = 179) and incidents (n = 178) to criminal nonfatal shooting victims (n = 1,464) and incidents (n = 1,304). The odds that a victim suffered an unintentional gunshot wound increased 1.98 times (p = .036), 95% CI [1.05, 3.75], for victims younger than 18 years relative to victims 18-34 years. The odds that a victim suffered an unintentional gunshot wound increased 3.33 times (p < .001), 95% CI [2.23, 4.96], for white victims relative to non-white victims. Unintentional nonfatal shootings require more robust data collection and research conducted through partnership of public health and law enforcement to fully understand how unintentional shootings occur and how they can be prevented. Keywords: unintentional shooting, nonfatal shooting, firearms, gunshot, shooting victim, shooting incident NONFATAL SHOOTINGS 3 Acknowledgements As I approach the completion of this Doctor of Health Science (DHSc) program, I must recognize those who provided guidance, mentorship, and support. To my committee members, Dr. Heidi Hancher-Rauch, Dr. Natalie Kroovand Hipple, and Dr. Elizabeth Moore, you have all been wonderful to work with. Each of you provided guidance from your personal experience and knowledge base that was invaluable. Without your support I would not be finishing this program. To Drs. Hancher-Rauch and Moore, I appreciate your openness to joining my committee even though my research topic is something you have not worked with before. I am thankful for your willingness to learn about criminal justice research along with me. I would like to especially thank Dr. Hipple for her willingness to take a chance and work with me. You readily responded to my email inquiring about your general interest in a project focused on firearm-related injury from a doctoral student without any experience in criminal justice. I appreciate your study brainstorming, openness to share your data, dedication to help me learn about research in the criminal justice arena, and participation on my doctoral committee. Without you all, I would not have been able to conduct this study. I must also thank my family for their support throughout the DHSc program. Continuing full-time employment and spending numerous hours on this study during the week and on weekends was a challenge. Whenever I was having a difficult time, you were always there for me to talk to and express my emotions. I would be remiss in not thanking my best friend, Sam, for being so positive and excited for me to finish this program. You always kept me in check and would not let me forget the goal I was striving to meet. Thank you all for your unwavering support, Anne NONFATAL SHOOTINGS 4 Table of Contents Title Page ....................................................................................................................................1 Abstract ......................................................................................................................................2 Acknowledgements .....................................................................................................................3 Table of Contents ........................................................................................................................4 Chapter 1: Introduction ...............................................................................................................6 Definition of Terms .................................................................................................................8 Significance of Study...............................................................................................................9 Chapter 2: Literature Review..................................................................................................... 10 Chapter 3: Method .................................................................................................................... 20 Subjects ................................................................................................................................. 20 Data ....................................................................................................................................... 21 Independent variables......................................................................................................... 21 Shooting victim variables ............................................................................................... 21 Shooting incident variables ............................................................................................. 23 Procedures ............................................................................................................................. 25 Data collection ................................................................................................................... 25 Data management............................................................................................................... 26 Statistical Analysis ................................................................................................................ 26 Exploratory analyses .......................................................................................................... 26 Inferential analyses ............................................................................................................ 27 Chapter 4: Results ..................................................................................................................... 28 Shooting Victims ................................................................................................................... 28 Unintentional nonfatal shooting victims ............................................................................. 28 Comparing unintentional and criminal nonfatal shooting victims........................................ 29 Bivariate analyses ........................................................................................................... 29 Logistic regression ......................................................................................................... 29 Shooting Incidents ................................................................................................................. 30 Unintentional nonfatal shooting incidents........................................................................... 30 Comparing unintentional and criminal nonfatal shooting incidents ..................................... 30 Bivariate analyses ........................................................................................................... 30 Logistic regression ......................................................................................................... 31 NONFATAL SHOOTINGS 5 Chapter 5: Discussion ............................................................................................................... 31 Limitations ............................................................................................................................ 35 Future Research ..................................................................................................................... 36 Chapter 6: Conclusion ............................................................................................................... 38 References ................................................................................................................................ 39 Table 1 ...................................................................................................................................... 52 Table 2 ...................................................................................................................................... 53 Table 3 ...................................................................................................................................... 55 Table 4 ...................................................................................................................................... 57 Appendix .................................................................................................................................. 58 NONFATAL SHOOTINGS 6 Nonfatal Shootings: A Comparison of Unintentional and Criminal Incidents The Centers for Disease Control and Prevention (CDC) estimated 133,895 nonfatal firearm injuries occurred in the United States in 2017 (CDC, 2019a). Of these, 20,488 (15.30%) were unintentional and 113,407 (84.70%) were violence-related (CDC, 2019b; CDC, 2019c). In Indiana, according to the Indiana Department of Health (IDOH) Trauma Registry, there were 1,255 firearm injuries in the state in 2019. Of these incidents, 201 were unintentional and 845 resulted from assault. The remaining 209 firearm injuries resulted from intentional self-harm, legal intervention, or undetermined intent. Within Marion County, there were 26 unintentional firearm injuries and 329 assault-related firearm injuries in 2019 (IDOH, 2020). However, data from the IDOH are unreliable. When data from the IDOH Trauma Registry were compared to hospital discharge and emergency department (ED) data for the same time period, large discrepancies were seen. Trauma data included more assault-related injuries while more unintentional injuries were included in the hospital discharge and ED data. It was also found that a quarter of Indiana hospitals were not reporting external cause of injury codes in discharge and ED data provided to the IDOH. The management of data in multiple data sources and inconsistent data available in each source are an undeniable example of the lack of comprehensive surveillance data available for firearm injury research. Although summary statistics can be obtained, the data vary between sources and are unreliable. In particular, there is a lack of data available to research nonfatal firearm injuries, especially unintentional shootings. Limitations in data availability and quality are common around the United States because there is no standardized comprehensive injury surveillance system nationwide (Annest & Mercy, 1998; Gotsch, Annest, Mercy, & Ryan, 2001; Hink et al., 2019; Hipple & Magee, 2017). Instead, data are collected by different government agencies in NONFATAL SHOOTINGS 7 different formats (Jagger & Dietz, 1986). With no standardized surveillance system and fragmented data collection methods, scholars have not been able to establish associations between risk factors and the occurrence of unintentional nonfatal shootings or how victim and incident characteristics may be different when comparing unintentional nonfatal shootings with criminal nonfatal shootings (Kellermann et al., 1996). One mechanism that supports data collection in Indiana is a state law mandating medical personnel notify local law enforcement when a patient presents to a hospital ED with a serious injury such as a gunshot wound (Indiana Code 35-47-7-1, 2018). Once an injury is reported to law enforcement, they conduct an investigation to determine what led to the shooting. Regardless of intent, law enforcement is responsible for investigating fatal and nonfatal shootings. There is limited research and data available summarizing unintentional shootings, and even less when the victim suffered nonfatal injuries. It is necessary to learn about unintentional nonfatal shooting victims and incidents because current policies are primarily based on research conducted around fatal incidents. Once the victim population and circumstances are defined, policies and prevention programs can effectively target the population at greatest risk. To expand understanding of nonfatal unintentional shooting victims and incidents, this study used case details about nonfatal firearm injuries captured by the Indianapolis Metropolitan Police Department (IMPD). The purpose of the study was to create profiles about victim characteristics and incident characteristics for unintentional nonfatal shootings to explore the victims and incidents. The profiles were then compared to criminal nonfatal shootings to assess how unintentional victims and incidents differed from criminal victims and incidents. This study aimed to answer the following research questions: 1. What are the characteristics of unintentional nonfatal shooting victims? NONFATAL SHOOTINGS 8 To expand on this research question, the following objectives were addressed: Describe characteristics, including both demographic and injury, of unintentional nonfatal shooting victims; Compare characteristics, including both demographic and injury, of unintentional nonfatal shooting victims to criminal nonfatal shooting victims. 2. What are the characteristics of unintentional nonfatal shootings incidents? To expand on this research question, the following objectives were addressed: Describe incident characteristics including type of shooting, incident location, incident time, and victim actions immediately preceding injury; Compare characteristics of unintentional nonfatal shooting incidents to criminal nonfatal shooting incidents. Definition of Terms This study utilized the following definitions: 1. Aggravated assault: An unlawful attack by one person upon another (Federal Bureau of Investigation [FBI], 2018b, Aggravated assault, para. 8) where a weapon is used with the goal of causing severe or aggravated bodily injury (FBI, 2018a; FBI, 2018b). 2. Shooting victim: An individual with a penetrating wound caused by a projectile from a weapon that uses a powder charge (18 U.S.C. 44, 2018; Beaman, Annest, Mercy, Kresnow, & Pollock, 2000; CDC, 2020; Cherry, Annest, Mercy, Kresnow, & Pollock, 1998; Hipple & Magee, 2017). NONFATAL SHOOTINGS 9 3. Unintentional shooting: A shooting incident that does not occur during an aggravated assault and without intent to cause harm. Incidents of attempted suicide or where intent cannot be determined are excluded. 4. Unintentional firearm injury: An injury lacking intent to cause harm (CDC, 2020) and does not occur during an aggravated assault. 5. Criminal shooting: A shooting incident that occurs during the commission of a crime (i.e. aggravated assault). 6. Intentional firearm injury: An injury sustained during a criminal shooting. 7. Self-defense shooting: An incident during which a victim uses reasonable force against any other person to protect the person or a third person from what the person reasonably believes to be the imminent use of unlawful force (Indiana Code 35-413-2(c), 2020; CDC, 2020). Also referred to as defensive gun use. 8. Self-defense firearm injury: An injury sustained during self-defense gun use. Significance of Study This study is significant because the research provides new information to the public health and criminal justice fields. There is limited gun violence research that has used these available police department data. Local law enforcement records provide detailed information about nonfatal shooting victims and incidents that are not available from the CDC or FBI (Grommon & Rydberg, 2015; Hipple & Magee, 2017). Law enforcement data have the potential to be of higher quality because the information is collected immediately after the incident and on scene from face-to-face interviews whenever possible. Indiana law requires an ED to report gunshot wounds to law enforcement if the injury has not otherwise been reported. The data have NONFATAL SHOOTINGS 10 the potential to provide victim and incident characteristics that are not captured in other public health or criminal justice data sources. This study provides new information to build the understanding of factors associated with unintentional nonfatal shooting incidents and how these victims and incidents are different from criminal nonfatal shooting incidents. Injury prevention programs must address unique victim and incident characteristics (Harvard Injury Control Research Center, 2012; Kellermann et al., 1996). In general, injury prevention programs should facilitate open discussion, adapt successes such as expanded surveillance from other public health areas, address and influence social norms, and be designed to meet the needs of the affected population (Choi, Dekonenko, Aguayo, & Juang, 2020; Dowd, Knapp, & Fitzmaurice, 1994; Harvard Injury Control Research Center, 2012). Results from this study will help injury prevention specialists better tailor injury prevention strategies designed to encompass measures associated with unintentional shootings. Because gun violence research primarily uses homicide data to estimate firearm incidents, this research contributes to the development of policy and programming that more accurately supports injury prevention of unintentional firearm injuries (Hipple & Magee, 2017; Ohsfeldt & Morrisey, 1992). Literature Review For the years 2008-2017, the most recent 10-year period for which data are available, there were nearly 342,500 firearm-related deaths and almost 875,000 nonfatal gunshot wounds treated in EDs across the United States (CDC, 2019e; CDC, 2019f). Nearly 364,000 nonfatal gunshot wounds were treated and the victim released from the ED, while more than 440,000 victims were hospitalized (CDC, 2019f). The distribution of firearm injuries resulting in deaths, hospitalizations, and ED visits are similar and supports the conclusion that deaths only account NONFATAL SHOOTINGS 11 for a small portion of firearm-related injuries (Fowler, Dahlberg, Haileyesus, and Annest, 2015; Frattaroli, Webster, and Teret, 2002; Hipple & Magee, 2017). Because nonfatal injuries are more common than deaths due to firearm shootings, the cost for injury treatment must be considered (CDC, 2019e; CDC, 2019f). Gani, Sakran, and Canner (2017) calculated the average ED and hospital inpatient visit per person with a firearm-related injury at $5,254 and $95,887, respectively. The estimated average annual cost of injury treatment for hospital inpatients is $622 million (Peek-Asa, Butcher, & Cavanaugh, 2017). Further costs are accrued from additional treatment with 15.6% of victims being readmitted to a hospital for additional treatment within six months (Spitzer et al., 2019). The Centers for Medicare and Medicaid Services cover a large portion of hospital inpatient treatment costs for firearm injuries, totaling nearly $242 million in primary treatment with 45.2% of costs associated with hospital readmissions (Peek-Asa et al., 2017; Spitzer et al., 2019). In the United States, from 2001 through 2013, there was an increase in the number of firearm injuries, primarily attributed to an increase in the number of nonfatal incidents. There were 2.5 times as many nonfatal firearm-related injuries as fatalities for the years 2008-2017 (CDC, 2019e; CDC, 2019f; Kalesan et al., 2017). This ratio has remained steady throughout the past 18 years as Annest, Mercy, Gibson, and Ryan (1995) estimated there were 2.6 nonfatal firearm-related injuries for every firearm-related fatality. However, research has focused on fatal incidents and there are less epidemiologic data available that describe the criminological and public health characteristics of nonfatal unintentional firearm injuries in the United States (Frattaroli et al., 2002; Grommon & Rydberg, 2015; Kalesan et al., 2017; Kellermann, Lee, Mercy, & Banton, 1991; Sinauer, Annest, & Mercy, 1996; Webster, Cerd, Wintemute, & Cook, 2016). The lack of information about nonfatal firearm injuries is particularly true of incident NONFATAL SHOOTINGS 12 characteristics such as firearm type and the geographic location where the injury occurred, which are not captured well in available public health and medical data sources (Cherry et al., 1998; Frattaroli et al., 2002; Gross et al., 2017; U.S. General Accounting Office, 1991). As research identifies patterns among victim and incident characteristics, Fowler et al. (2015) note that regular reassessment of these characteristics is necessary to identify shifts in trends among firearm injury victims (Beaman et al., 2000). According to Kellermann et al. (1991), the three circumstances under which firearm injuries generally occur involve interpersonal violence, suicidal behavior, and unintentional weapon discharge. Interpersonal violence is violence between individuals and may include criminal events such as assaults (World Health Organization, 2019). The FBI defines an aggravated assault as an unlawful attack by one person upon another (FBI, 2018b, Aggravated assault, para. 8) where a weapon is used with the goal of causing severe or aggravated bodily injury (FBI, 2018a; FBI, 2018b). Under Uniform Crime Reports (UCR), due to the Hierarchy Rule, criminal shootings may be reported as aggravated assault, robbery, or homicide depending on the entirety of the incident. In the National Incident Based Reporting System (NIBRS), every gun crime is accounted for, however there is no way to know the exact nature of the gun injury (FBI, 2018a; FBI, 2018b; Grommon & Rydberg, 2015; Hipple & Magee, 2017). Non-criminal shooting injuries, which include unintentional injuries and intentional selfinflicted injuries, are of interest to public health researchers because these incidents do not violate criminal law and are not under the purview of law enforcement (Grommon & Rydberg, 2015; Hipple, Huebner, Lentz, McGarrell, & OBrien, 2019). Public health researchers primarily use medical or public health data to assess incident characteristics and victim demographics (Grommon & Rydberg, 2015). Unintentional weapon discharges can result in injury and may NONFATAL SHOOTINGS 13 occur when cleaning a firearm, showing off or playing with a firearm, hunting, or attempting self-defense. Intentional injuries that are not aggravated assaults are likely the result of suicidal behavior, the third circumstance identified by Kellermann et al. (1991). However, it is also possible that incident characteristics cannot be determined and therefore the cause of the injury is undetermined (Beaman et al., 2000; Cherry et al., 1998; Fowler et al., 2015). Both intentional, self-inflicted injuries and those of undetermined intent could be improperly categorized as unintentional, depending on the information provided by the victim (Cook et al., 2017). Unintentional shootings are rarely of interest to the criminal justice community and it is uncommon for criminal justice researchers to utilize public health data when analyzing firearm injuries (Grommon & Rydberg, 2015; Jagger & Dietz, 1986). Lack of interest from the criminal justice community is most likely due to the fact that unintentional shootings, as the name indicates, lack criminal intent. That is, law enforcement is concerned with criminal shootings. Researchers more commonly use data sources such as UCR and NIBRS to learn about criminal shootings at the victim and incident levels (Tillyer, Miller, & Tillyer, 2011). Alternatively, public health researchers seek to understand victims and incidents to prevent firearm-related injury regardless of intent. Data sources frequently used by public health researchers include medical records and trauma registries (Crandall et al., 2013). However, criminal justice and public health researchers collect different data related to victims and incidents. Criminal justice research often focuses on the context and details of shooting incidents. Incident data available in law enforcement data sources and analyzed in criminal justice research include details about the victim, offender(s), relationship between victim and offender, presence of witnesses, and incident location. This information is collected at the scene, if possible, through interviews with multiple people (Grommon & Rydberg, 2015; Jagger & Dietz, 1986). By NONFATAL SHOOTINGS 14 comparison, public health data focus on the aftermath of injury and medical treatment. Data collection occurs at the medical facility and usually only involves the victim. A public health approach to analysis of a criminal justice data source that includes criminal justice and public health data with a focus on unintentional shootings provides a new contribution to both fields (Grommon & Rydberg, 2015; Jagger & Dietz, 1986). Criminal shootings such as aggravated assaults, are commonly identified as the most frequent scenario for nonfatal injuries, while intentional self-inflicted injuries (i.e., suicide attempts) result in the most fatal injuries (Annest et al., 1995; Beaman et al., 2000; Cherry et al., 1998; Coben & Steiner, 2003; Cook et al., 2017; Cummings, LeMier, & Keck, 1998; Fowler et al., 2015; Kellermann et al., 1996). The frequency of criminal shootings and the high fatality of intentional self-inflicted injuries have led researchers to focus on understanding homicides and suicides to improve prevention efforts (Committee on Trauma Research, 1985; Webster et al., 2016). Meanwhile, injuries associated with unintentional weapon discharges have historically been considered accidents, suggesting no pattern could be discerned and the injuries could not be prevented (Committee on Trauma Research, 1985; Kellermann et al., 1991). It is also possible that injuries of undetermined intent could have been more accurately classified if additional information about the incident was available. For these reasons, it is important to gain a more comprehensive picture of unintentional nonfatal shooting injuries and how incident, victim, and injury characteristics are different in these cases from criminal nonfatal shootings. Research into incident characteristics of unintentional firearm injuries commonly assesses fatalities rather than focusing on nonfatal injuries. While some incident characteristics captured by law enforcement may also be collected within medical records, these data are rarely complete and are often anonymized in accordance with the Health Insurance Portability and NONFATAL SHOOTINGS 15 Accountability Act (HIPAA) privacy rule (Beaman et al., 2000; Cherry et al, 1998; Hedegaard, Wake, & Hoffman, 1998; Office for Civil Rights, 2015). While incident characteristics are sometimes captured in the National Electronic Injury Surveillance System (NEISS), the data are not of high enough quality and completeness to analyze for generalizable results (Beaman et al., 2000; Cherry et al., 1998; Powell, Jovtis, & Tanz, 2001). Gotsch et al. (2001) reflected that NEISS data are collected from a single source for surveillance, not research, leading to data quality concerns observed by Beaman et al. (2000) and Cherry et al. (1998). In comparison, medicolegal investigation following a fatality is more likely to uncover incident characteristics (Beaman et al., 2000). Nonfatal firearm injuries are more than twice as common as fatal injuries, yet research continues to combine both outcomes when conducting firearms research (Kalesan et al., 2017). Unintentional firearm injuries and fatalities are more often caused by handguns than long guns, occur in or around a home, and are self-inflicted (Copeland, 1984; Coyne-Beasley & Lees, 2010; Dowd et al., 1994; Frattaroli et al., 2002; Gross et al., 2017; Grossman, Raey, & Baker, 1999; Guetschow, Lilienthal, & Willey, 2018; Ismach et al., 2003; Kellermann et al., 1996; Kongkaewpaisan et al., 2020; Sinauer et al., 1996; Sing, Branas, MacKenzie, & Schwab, 1997; Vassar & Kizer, 1996). Grommon and Rydberg (2015) found that injuries occurring in a home or other private location, regardless of intent, were more severe than injuries that occurred in a public location. These injuries usually occurred when handling or playing with a weapon (Cherry, Runyan, & Butts, 2001; Copeland, 1984; Frattaroli et al., 2002; Grossman et al., 1999; Lee & Harris, 1993). Cherry et al. (2001) found that 35% of injuries were caused by playing with the gun, 12% of injuries occurred when cleaning/repairing/loading/unloading or the gun went NONFATAL SHOOTINGS 16 off, and 10% of injuries occurred during hunting. Ismach et al. (2003) concluded that 74% of injuries investigated could have been prevented with safer gun handling practices. Victim residence and incident location are commonly clustered for firearm-related injuries. Dowd et al. (1994) found that residence and incident location of pediatric firearm injuries in Kansas City, Missouri were concentrated in 35 contiguous census tracts out of the 187 in the city. Researchers reported similar findings in Indianapolis and Philadelphia (Branas, Culhane, Richmond, & Wiebe, 2008; Magee, 2020). In Indianapolis, criminal shooting incidents were concentrated along specific street segments (Magee, 2020). While in Philadelphia, criminal and self-inflicted firearm-related injuries were also geographically concentrated (Branas et al., 2008). Both home and incident addresses associated with assault victims were clustered within specific neighborhoods of Miami and incidents most often occurred within four miles of the victims home address (Zebib, Stoler, & Zakrison, 2017). Unintentional firearm-related injuries have shown a similar pattern with most hunting-related injuries in North Carolina having occurred in the same county where the victim lived (Cole & Patetta, 1988). Trauma data and hospital medical records document that at least 70% of nonfatal firearm injury victims who presented at an ED were transported to the hospital ED by emergency medical services (EMS) or an ambulance (Fowler et al., 2015; Manley et al., 2017). When Fowler et al. (2015) assessed transportation by intent, unintentional nonfatal injury victims commonly arrived by private vehicle (30.4%) compared to EMS (44.6%). This was supported by Grommon and Rydbergs (2015) finding that transportation by EMS was an indicator of more severe injury. Injury severity is associated with wound location (Association for the Advancement of Automotive Medicine [AAAM], 2020). Wound location differs for nonfatal shootings and is NONFATAL SHOOTINGS 17 dependent on criminal intent but does not seem to differ between age groups (Beaman et al., 2000; Williams et al., 2015). Criminal nonfatal shooting victims were more likely to have multiple wound sites in less severe locations than homicide victims (Hipple & Magee, 2017). For example, in Miami, 40.5% of fatal and nonfatal assault victims had multiple wounds (Zebib et al., 2017). Unintentional shooting victims wounds tend to occur in less severe locations, most commonly inflicted on the extremities (Annest et al., 1995; Coupet, Huang, & Delgado, 2019; Dowd et al., 1994; Fowler et al., 2015; Gross et al., 2017; Ismach et al., 2003; Kongkaewpaisan et al., 2020; Mills, Nurius, Matsueda, Rivara, & Rowhani-Rahbar, 2018; Sinauer et al., 1996). While injury severity has been assessed for fatal and nonfatal injuries by intent, few studies have analyzed longitudinal changes in injury severity. Kalesan et al. (2018) found that firearm-related injury severity increased throughout the 20-year period 1993-2014 for all intents. During a similar timeframe, 1996-2015, Manley et al. (2019) found that the number of wounds increased for victims and wounds from large caliber firearms became more common in Memphis, Tennessee. Increasing injury severity, wound quantity, and firearm caliber were first seen in Washington, D.C. and Chicago in the 1980s and 1990s following passage of legislation that regulated imported firearms but exempted those manufactured in the United States (Wintemute, 1996). Injury location and severity also contribute to the victims hospital disposition. Victims with unintentional injuries were treated and released from the ED more often than with criminal nonfatal shootings or intentional selfinflicted injuries (Avraham, Frangos, & DiMaggio, 2018; Coupet et al., 2019; Fowler et al., 2015; Gross et al., 2017; Manley et al., 2017). This finding may be a result of improved trauma and ED care, including the ability to treat more injuries in an ED or outpatient setting (Kalesan et al., 2018). NONFATAL SHOOTINGS 18 Demographic characteristics among nonfatal victims are relatively consistent in the published research. Researchers have found that most firearm injury victims are black males aged 35 years or younger (Coupet et al., 2019; de Anda, Dibble, Schlaepfer, Foraker, & Mueller, 2018; Fitzpatrick et al., 2019; Fowler et al., 2015; Hipple & Magee, 2017; Hipple, Thompson, Huebner, & Magee, 2019; Kalesan et al., 2017; Kalesan et al., 2018; Manley et al., 2017). While researchers have found similar demography when focusing on unintentional injuries, these findings are not consistent (Fowler et al., 2015; Guetschow et al., 2018; Ismach et al., 2003; ). For example, Fowler et al. (2015) estimated that over 70% of unintentional fatal shooting victims were non-Hispanic white and victims were equally likely to be younger or older than 35 years. However, Ismach et al.s (2003) analyses of unintentional fatal and nonfatal shooting victims found victims were mostly black males younger than 35 years. Inconsistencies in unintentional shooting victim demographics are possibly the result of different methodology such as combining unintentional and undetermined intents or geographic location (Gross et al., 2017; Grossman et al., 1999; Hutchinson et al., 2019; Kongkaewpaisan et al., 2020; Mills et al., 2018; Sinauer et al., 1996; Wiebe, 2003). Research conducted around the Midwestern United States supports the need to continue research into nonfatal firearm-related injuries in the region. Midwestern cities such as Indianapolis, Indiana; Chicago, Illinois; St. Louis, Missouri; Kansas City, Missouri; and Kansas City, Kansas have higher rates of violent crimes compared to the nation (FBI, 2019; Fitzpatrick et al., 2019). Fowler et al. (2015) found the Midwest had the second highest rate of fatal firearm injury due to homicide and unintentional incidents by United States region. The rate of firearmrelated injury is impacted by regional culture and state laws about gun ownership and safety (Choi et al., 2020; Coyne-Beasley & Lees, 2010; Gross et al., 2017). The Midwest is a region NONFATAL SHOOTINGS 19 with a deeply rooted gun culture that includes easy access to firearms, permissive regulations for concealed carry, and acceptance of gun possession for self-defense (Lemieux, 2014). While there is no consistent definition of gun culture, researchers have attempted to learn how gun culture developed and persists in the United States. Limieux (2014) used the amount of money spent on military and development of gun movies as a proxy to measure gun culture, but only found gun violence culture present in the Southern region of the country, the region with the highest gun death rates. Social gun culture has also been measured through interviews with gun owners and non-owners about involvement of guns in social activities with family and friends, as well as the perceptions about guns by family and friends. By this measure, gun owners were five times more likely to be exposed to social gun culture compared to non-owners (Kalesan, Villarreal, Keyes, & Galea, 2016). However, gun culture is defined, there is a strong association between firearm ownership and being part of gun culture (Kalesan et al., 2016). Firearm ownership is also associated with higher homicide, suicide, and unintentional firearm fatality rates, and states with more permissive gun laws have higher rates of gun ownership (Kalesan et al., 2016; Limieux, 2014; Miller, Azrael, & Hemenway, 2001; Miller, Azrael, & Hemenway, 2002; Monuteaux, Lee, Hemenway, Mannix, & Fleegler, 2015; Reeping et al., 2019). The percentage of households with a firearm ranges from 30% to 40% among Midwestern states (Kalesan et al., 2016; Monuteaux et al., 2015). These states have higher odds of assault, robbery, and homicide with a firearm compared to Northeastern states (Monuteaux et al., 2015). However, analyses of the impact of gun laws on homicide and suicide rates has resulted in mixed results across the country. States with universal background checks have lower homicide rates while states with shall issue laws have demonstrated higher homicide rates (Siegel, Pahn, Xuan, Fleegler, & Hemenway, 2019). Additionally, the presence of a waiting NONFATAL SHOOTINGS 20 period after firearm purchase has shown to decrease suicide rates (Edwards, Nesson, Robinson, & Vars, 2017). The Giffords Law Centers annual gun law score card rates most Midwestern states a C or poorer for current gun laws (Giffords Law Center, 2020). Lack of laws around universal background checks, gun owner licensing, guns used during domestic violence, assault weapons restrictions, large capacity magazine bans, waiting periods, concealed carry, and community violence intervention funding are believed to consistently contribute to higher gun death rates in Midwestern states (Giffords Law Center, 2020). Given the consistent frequency of gun violence, the quantity of nonfatal injuries compared to fatal injuries and the high cost of treatment, continued research is necessary to understand victim and incident characteristics that support the development of gun violence prevention policy. This study adds to the literature by defining the victim, injury, and incident characteristics seen in the Indianapolis metropolitan area and determining how they are distinct from criminal nonfatal shooting injuries. Method In this retrospective study, data from internal IMPD documents were used to describe nonfatal unintentional firearm injury victims and incidents. Data were also used to explore nonfatal shootings to determine if there were differences in victim characteristics and incident factors between unintentional shootings and criminal shootings. The study period included nonfatal unintentional and criminal shootings occurring between January 2017 and December 2019. The University of Indianapolis Human Research Protections Program determined the study was exempt from institutional review board review because the researcher was provided deidentified data. Subjects NONFATAL SHOOTINGS 21 Study subjects and incidents were identified from internal IMPD documents. To be included in the study, subjects had to be a victim of an unintentional nonfatal shooting or a criminal nonfatal shooting between the years January 2017 and December 2019. Incidents were excluded from the study if they did not meet the definition of an unintentional shooting or criminal shooting. Victims were excluded from the study if they did not meet the definition of a shooting victim or if the injury was fatal. Incident and victim definitions are available in the Definition of Terms section. An a priori sample size estimate was conducted. A total sample size of 770 subjects, 385 in each group, was estimated as necessary to detect a difference between unintentional nonfatal shooting victims and criminal nonfatal shooting victims. Because the comparison groups were independent and proportions were used for comparison, the estimated sample size necessary for each group was calculated as 2 = {(1 )} ( ) . The required sample size was calculated using a z score of 1.96 and a 5% margin of error. As the expected proportions for each group were unknown, the proportion value was estimated conservatively as 0.50 (Berkowitz & Lynch, n.d.). Data Independent variables. Independent variables for this study included variables that described the victim, the victims injuries, and the shooting incident. Shooting victim variables. Demographic and injury variables collected, operational definitions used, and data constructs included: NONFATAL SHOOTINGS 22 Age at the time of the incident was captured as a continuous value. Age was also categorized based on the age-crime curve (DeLisi, 2015; Farrington, 1986; Steffensmeier, Allan, Harer, & Streifel, 1989). Categories used were: o Younger than 18 o 18-34 o 35-54 o 55 and older o Unknown/unspecified Race as specified in the police data source. Shooting victims with race documented as white or Hispanic were categorized as white. The categorization of Hispanics was based on Sandefur, Campbell, and Eggerling-Boecks (2004) findings that approximately 50% of Hispanics identified their race as white in the 1990 and 2000 U.S. Census. Shooting victims with race documented as black or Asian were categorized as non-white. Shooting victims identified as Asian were categorized as non-white based on the U.S. Office of Management and Budgets definition of Asian as a distinct racial category (Revisions to Standards for Classification of Race and Ethnicity, 1997). Shooting victims without documentation of race were categorized as unknown/unspecified. Sex as specified in the police data source was captured as male or female. Number of gunshot wounds as specified in the police data source. Victims were identified as having single, multiple, or an unknown/unspecified number of wounds. NONFATAL SHOOTINGS 23 Severity of shooting victims injuries was categorized using a modified version of the 1990 Abbreviated Injury Scale (AIS) (AAAM, 1990). When a victim had more than one injury, the AIS score was based on the most serious injury. AIS scores of 0-1 were categorized as wounds to extremities while scores of 2-3 were categorized as wounds to the center mass of the body. Victim injury severity was categorized as unknown/unspecified if there was no wound location documented. o 0: Least Severe (wrist, ankle, hand, foot) o 1: Less Severe (arm, leg) o 2: Severe (back, hip, buttocks, genitals/pubic area, abdomen) o 3: Most Severe (head, neck, chest) o Unknown/unspecified Method of transport to the hospital ED included EMS/ambulance, private vehicle/walk-in/other, and unknown/unspecified. Self-inflicted gunshot wound was captured as yes, no, or unknown/unspecified. Shooting incident variables. Incident variables are factors associated with the shooting incident that were captured in internal police documents. Incident variables collected, operational definitions used, and data constructs included: Incident season was assigned based on the incident month using meteorological seasons defined by the National Oceanic and Atmospheric Administration (2016). o Spring: March, April, May o Summer: June, July, August o Fall: September, October, November o Winter: December, January, February NONFATAL SHOOTINGS 24 Incident time was categorized as a.m. or p.m. based on the incident time available on police documents. This time could be the approximate incident time as reported by individuals present at the incident, the time the call was received by the 911 system, or the time police arrived on scene. Given that times were rarely exact and subject to variation, the variable was recoded into a more general time of day. This categorization provided the ability to assess whether there was a difference between the time of day criminal and unintentional nonfatal shootings occurred. Victim action immediately preceding the injury was based on the information available on police documents. Actions included: o Playing/fooling around/showing off o Cleaning/loading/unloading/assembling o Dropped/knocked to floor/mishandled o Demonstrating/transferring/general handling o Carrying on person/holster or pocket mishaps o Other o Unknown/unspecified Activities that were categorized as Other included shootings at a firing range or during target shooting, accessing a firearm from storage, accessing a firearm during an argument or for selfdefense, and shootings while the shooter was intoxicated but there was not enough additional information to otherwise categorize the action. Incident location reflects the type of location where the incident occurred based on the information available in the police documents. Incident locations included: NONFATAL SHOOTINGS 25 o Business o Public street/alley o Inside a residence o Outside a residence o Vehicle o Other o Unknown/unspecified Other incident locations included public parks, construction sites, the wood line between two neighborhoods, inside a barn on residential property, school grounds, garages, and vacant lots. Procedures Data collection. Internal police documents reviewed for this study reflected information collected by IMPD detectives within 24 hours of incident occurrence. In Indiana, firearm injuries most commonly come to the attention of the law enforcement in two ways: a community member notifies law enforcement or an employee of an ED notifies law enforcement that someone has presented to the ED with a firearm injury. Indiana law requires medical personnel report gunshot wounds to local law enforcement (Indiana Code 35-47-7-1, 2018). Once the firearm injury is confirmed, IMPD dispatches aggravated assault detectives to investigate the case. The detectives attempt to conduct an initial interview with the victim at the ED if the victim is there and not at the incident scene. At the start of the investigation, detectives document incident information such as date, time and location, demographic information for relevant individual(s) involved, and a narrative based on available information. Information gathered is recorded in an electronic file with the IMPD within 24 hours of the incident. The electronic files are then shared with a research NONFATAL SHOOTINGS 26 partner. The files are sorted by incident type and documents associated with criminal shootings are entered into the Marion County Nonfatal Shooting Database. Data for this study were gathered two different ways. Unintentional nonfatal shooting victim and incident data were extracted by the primary researcher (A. R.) from internal IMPD documents. Three iterative reviews were conducted to ensure accuracy of data and capture additional variables. A research partner for IMPD provided de-identified data for criminal nonfatal shooting victims and incidents extracted from the Marion County Nonfatal Shooting Database. Data management. Police documents related to unintentional nonfatal shootings are stored in a secure cloud environment. The researcher received redacted data for each unintentional shooting via Box, a password-protected cloud environment. Criminal shooting data were provided to the researcher as a data set extracted from the Marion County Non-fatal Shooting Database. Personal identifiable information was excluded. The data are owned by the IMPD and are shared with a researcher in the Indiana University Department of Criminal Justice as part of a long-term partnership with IMPD. The researcher and owner of the original files were the only individuals with access to the original data. Original data will be retained for 36 months from the date of manuscript defense. This period will allow availability of data to support modifications to the de-identified data sets. De-identified data sets will be retained by the researcher for future research or publication opportunities. Statistical Analysis Exploratory analyses. Descriptive statistics were used to summarize unintentional nonfatal shooting victims and incidents as well as criminal nonfatal shooting victims and NONFATAL SHOOTINGS 27 incidents. Exploratory statistics provided information to answer the first research objective for each research question. Age was analyzed as an ordinal and a continuous data point. The mean and standard deviation were reported for age, as well as frequencies and percentages for age as an ordinal variable. Nominal variables such as race, sex, injury location, action immediately preceding injury, and incident location were reported as frequencies and percentages. Unknown/unspecified responses were included in the descriptive analyses but excluded from reported results. Percentage of unknown/unspecified responses for each variable ranged from 0 to 17.42%. Where appropriate, cross-tabulations were analyzed for nominal data. When crosstabulation tables were larger than two by two and not even, contingency coefficients and associated p statistics were used to assess levels of association. Inferential analyses. Inferential statistics were used to answer the second research objective for each research question. Victim and incident data of unintentional nonfatal shootings were compared to criminal nonfatal shootings. A Mann-Whitney U test was used to assess differences for age as a continuous variable. The ordinal variable for age was analyzed for differences with chi-square test. All nominal variables were analyzed for differences with chisquare test. Statistical significance was measured with Fishers exact p for two-by-two chisquare tests of variables that did not have unknown responses. Pearson chi-square p was reported for larger tables with variables that had unknown responses. The two groups were heterogeneous and when unknown responses were excluded from variables, Fishers exact p statistics were the same as Pearson chi-square p statistics. Assumptions for chi-square tests were met. Binary logistic regression analyses were conducted to assess which variables served as predictors for someone to become an unintentional nonfatal shooting victim. The initial regression model included all shooting victim and incident variables available for unintentional NONFATAL SHOOTINGS 28 and criminal nonfatal shootings. Regression was also performed with variables that were significantly different based on the Fishers exact or Pearson chi-square p value. Finally, regression models were conducted with potential interactions. The model with best fit included all shooting victim and incident variables but excluded unknown/unspecified responses for all variables. Because of small cell size, other responses for the incident location variable were also excluded from the regression model. An = .05 level of significance was used for all testing. Two-tailed tests were used to assess the presence of positive and negative relationships. Analyses were conducted with IBM SPSS Statistics for Windows, Version 27.0 Grad Pack (IBM Corp., Armonk, NY). Results Shooting Victims A total of 1,643 nonfatal shooting victims were included in the study with 179 (10.89%) unintentional and 1,464 (89.11%) criminal victims. The majority of victims were non-white males 35 years and younger. Table 1 presents demographic characteristics of unintentional and criminal nonfatal shooting victims. Injury characteristics of unintentional and criminal nonfatal shooting victims are presented in Table 2. Unintentional nonfatal shooting victims. Data from 179 unintentional nonfatal shooting victims were analyzed. Victim age ranged from 2 to 85 years with a mean age (standard deviation) of 29.54 (14.83) years. Most victims were male (87.15%), non-white (53.63%), and 18-34 years old (59.22%). Fewer than 10% of victims were 55 years or older. Most (74.86%) unintentional victims suffered from a single, self-inflicted gunshot wound. Half of unintentional victims had an AIS score of one. Unintentional shooting victims were more likely to arrive at an ED by non-emergency mode of transportation than by EMS/ambulance. NONFATAL SHOOTINGS 29 Comparing unintentional and criminal nonfatal shooting victims. Bivariate analyses. Data from 1,464 criminal nonfatal shooting victims were analyzed and compared to unintentional nonfatal shooting victims. Criminal victim age ranged from less than 1 to 76 years with a mean age (standard deviation) of 29.35 (11.41) years. Non-white males accounted for less than half of unintentional victims. A larger proportion (67.42%) of criminal victims were non-white males. Non-white males aged 35 years and younger made up the majority (52.87%) of criminal victims while they were less than half of unintentional victims. Age was not significantly different between unintentional and criminal victims (p = .183). However, when age was recoded into ordinal categories, a significant difference was found with differences ranging from 3.86% - 5.70%. Differences between unintentional and criminal nonfatal shooting victims were statistically significant for race (% difference 25.47% - 25.67%, p < .001). Additionally, statistically significant differences victim types were found when comparing gunshot wounds (% difference 18.48% - 20.73%, p < .001), AIS score (% difference 10.32% - 24.80%, p < .001), and wounded body region (% difference 32.19% - 35.12%, p < .001). Exploratory analyses showed an overall significant difference between unintentional nonfatal shooting victims and criminal nonfatal shooting victims. Logistic regression. In the overall logistic regression model, 90.72% of shooting victims were correctly classified as victims of unintentional or criminal shooting incidents. The model included race, age, number of gunshot wounds, wounded body region, and incident location. The regression equation for predicting an unintentional nonfatal shooting was 1 log ( ) = 4.52 + 1.20 + 1.36 + 1.41 1.32 (. ) 2.26 (. ) + 0.45 (. ) + 0.68 (< 18) 0.34 (35 54) + 0.56 ( 55). NONFATAL SHOOTINGS 30 The odds of a victim suffering from an unintentional gunshot wound increased more than threefold when the victim was white. Victims younger than 18 years were 98% more likely to be shot during an unintentional incident, relative to victims age 18-34 years. The odds of a victim suffering from an unintentional gunshot wound increased approximately four times for a single gunshot wound and an extremity wound (OR = 3.90 and 4.11, respectively). Results of the binary logistic regression are available in Table 4. Shooting Incidents A total of 1,482 nonfatal shooting incidents were included in the study with 178 (12.01%) unintentional and 1,304 (87.99%) criminal incidents. Characteristics of unintentional and criminal nonfatal shooting incidents are presented in Table 3. Unintentional nonfatal shooting incidents. There were 179 unintentional nonfatal shooting incidents during the study period. Only one unintentional incident had multiple victims. Unintentional incidents occurred most often (30.34%) in the fall months, September, October, and November with the percentage of the three other seasons ranging from 21.35% - 25.28%. Incidents occurred most often (65.73%) during p.m. hours. A residence was the location of just over half of unintentional incidents. Unintentional incidents were most likely (21.92%) to occur when someone was cleaning, loading, unloading, or assembling a firearm with the percentage of the other actions preceding injury ranging from 6.18% - 20.22%. Comparing unintentional and criminal nonfatal shooting incidents. Bivariate analyses. There were 1,304 criminal nonfatal shooting incidents during the study period. Ten percent of criminal incidents included in the study had multiple victims. Criminal incidents most commonly (29.06%) occurred during the summer months of June, July, and August compared to the fall months when unintentional shooting incidents occurred. NONFATAL SHOOTINGS 31 Seasonal difference was not statistically significant between incident types ranging from 4.19% 6.03% (p = .085). Both unintentional and criminal nonfatal shooting incidents were more likely to occur during p.m. hours. However, time was not statistically different between unintentional and criminal nonfatal shooting incidents (p = .140). Incident location was the only variable that showed a statistically significant difference between criminal and unintentional incidents. Nearly half of unintentional and criminal incidents occurred at a residence. Differences between the remaining incident locations ranged from 0.89% - 21.02%. There was a weak, but statistically significant relationship between incident location and incident type with contingency coefficient C = .34. Therefore, incident type was dependent on location. Logistic regression. Incident location was the only incident variable that was included in the regression model. When incident location was known, business and public street/alley both produced statistically significant results suggesting they influence incident type. Victims shot at a business were less likely to be the victim of an unintentional shooting compared to incidents at residences, and the effect was large (OR = 0.27). Incidents on a public street/alley were least likely to be unintentional (OR = 0.11). Therefore, a victim who was shot at a business or on a public street/alley was less likely to be shot during an unintentional incident than victims shot at a residence. Discussion This study aimed to learn about the characteristics of unintentional nonfatal shooting victims and incidents through descriptive analyses and comparisons to criminal nonfatal shooting victims and incidents. Findings from this study provide details about unintentional nonfatal shooting victims and incidents, an uncommon topic in the literature. The use of police data to assess these victims and incidents also provides new perspective and additional details to the NONFATAL SHOOTINGS 32 existing empirical work. This study identified that victim age, race, number of gunshot wounds, and wound location were significant demographic and injury characteristics for predicting unintentional shootings. Among the incident characteristics analyzed, only incident location was a significant incident-level predictor for unintentional shootings. The largest proportion of unintentional victims were 18-34 years old which supports existing empirical work (Gani et al., 2017; Manley et al., 2017). Although victims younger than 18 years accounted for less than 15% of unintentional shooting victims, this age group was at increased risk of suffering an unintentional gunshot wound. In fact, the odds that a victim suffered an unintentional gunshot wound increased two-fold for victims younger than 18 years compared to victims 18-34 years. The increased risk of injury among victims younger than 18 years has been attributed to higher unintentional injury rates among children younger than 13 years (Choi et al., 2020; Olufajo et al., 2020). This study did not have enough unintentional victims younger than 13 years (n = 3) to assess these victims separately from victims 13-17 years, preventing a direct comparison to existing research about unintentional shootings for the younger than 13 years age group. The inability to tease out juveniles younger than 13 years from those 13-17 years highlights the need for more research about unintentional nonfatal shooting victims younger than 18 years. Because research about unintentional shootings is often conducted with data from public health and medical sources, incident specific information is rarely available to identify specific details about how the victim was shot (Grommon & Rydberg, 2018; Hipple & Magee, 2017). It is important to continue working towards developing comprehensive data about firearm-related injuries. Conducting surveillance under a public safety umbrella that includes data from public health, medical, and law enforcement sources will NONFATAL SHOOTINGS 33 support improved data collection for continued research, including analyses of unintentional nonfatal shooting victims younger than 18 years and younger than 13 years. In this study, unintentional victims were nearly split between white and non-white victims, but the odds of a victim suffering an unintentional gunshot wound were increased threefold among white victims compared to non-white victims. Findings from this study support previous research. Black individuals have the highest rate of firearm injury in the United States, nearly four-fold the rate of white individuals, but the incidence of unintentional nonfatal injuries is similar for black and white victims (Kalesan et al., 2017). This study was limited in scope in that it analyzed shootings that occurred in Marion County - one large urban hub in central Indiana. As a result, study findings provide new insight about race as a risk factor for unintentional shootings in urban areas because research has not assessed unintentional shooting victims of all ages across urbanization levels. Existing research has focused on child victims of unintentional and criminal shootings across population levels (Choi et al., 2020) and unintentional shootings in rural areas (Guetschow et al., 2018). Demographics are known to differ between urban and rural areas. The population of Indianapolis and Marion County, which is representative of demographics in urban areas around the United States, is approximately 61% white and 28% black. In contrast, the six counties that surround Marion County that consist of suburban and rural areas are approximately 93% white and 2% black (U.S. Census Bureau, 2020). Because research has not assessed all unintentional shooting victims across urbanization levels, further research is warranted to confirm that unintentional nonfatal shootings most often affect white victims, regardless of urbanization level. The number and location of gunshot wounds were also significant predictors for unintentional shootings. Unintentional victims most often suffered from a single, self-inflicted NONFATAL SHOOTINGS 34 gunshot wound. The odds of a victim suffering an unintentional gunshot wound increased almost four times for single gunshot wounds. The finding that unintentional shooting victims usually suffer from a single gunshot wound is expected, because there is no intent to harm during an unintentional shooting (CDC, 2020). But the number of gunshot wounds incurred during a shooting has not been explored for unintentional shootings, only criminal shootings. This study provides novel information that unintentional shooting victims most often suffer from a single gunshot wound, a topic that should be further explored. The location of gunshot wounds was also a predictor of incident type. The odds that the victim suffered an unintentional gunshot wound were four times higher compared to victims with gunshot wounds to center mass. The location of gunshot wounds seen in this study supports existing literature that unintentional shooting victims usually have less severe injuries to the extremities (Coupet et al., 2019; Kongkaewpaisan et al., 2020; Mills et al., 2018). Lastly, incident location was found to be a statistically significant predictor for unintentional shootings. Nearly half of the unintentional incidents occurred inside or outside a residence. Residences are consistently found to be the most common location of unintentional shootings (Grossman et al., 1999; Ismach et al., 2003), especially when the victim is a child (Borg et al., 2020; Hemenway & Solnick, 2015), and this study had similar results. Interestingly, the odds that a victim suffered an unintentional gunshot wound were slightly increased for victims shot in a vehicle compared to victims shot at a residence, a finding not previously reported in the literature. The increase in odds was slight (OR = 1.56) and the finding was significant at the = .10 level (p = .073). Although the significance was not present at the = .05 level defined for this study, the increased risk of a type I error is acceptable because the finding relates to policy (Sherman, Strang, & Woods, 2000). Significance at = .10 also NONFATAL SHOOTINGS 35 suggests further research is needed to understand implications. While research has looked at the location of unintentional shooting incidents, location data are often unreliable in public health and medical data sources that are most commonly used for researching unintentional shootings (Grommon & Rydberg, 2015; Gross et al., 2017). Limitations There were limitations to this study associated with the data source, population size, and generalizability. The internal police documents used as the data source were not designed for research purposes; therefore, researchers were not able to assess the reliability of the data. Additionally, the data reflects information known to police within the first 24 hours of the incident and the researcher did not have access to updated information. The data source was also subject to information bias because information documented by police reflect the perspective or interpretation of information provided to the detective. Although there are limitations to the data source, police documents provide details about shooting incidents such as incident location and actions preceding the incident. These incident-specific details are rarely available in public health data sources typically used for research of unintentional shootings (Grommon & Rydberg, 2015). The unintentional nonfatal shooting victim sample size was smaller than the sample size estimated to detect differences between unintentional and criminal victims. The impact of this limitation was controlled because victims represented the population of unintentional nonfatal shooting victims over the study period. The assumption was made that the study analyzed the population because of Indianas legal requirement that medical personnel notify law enforcement of victims with gunshot wounds and other serious injuries that present at a hospital ED for treatment (Indiana Code 35-47-7-1, 2018). NONFATAL SHOOTINGS 36 Finally, results of this study may not be generalizable to other locations with different demographic or geographic makeup. Geographic location has an integrated relationship with shooting incidents as unintentional shootings more commonly affect white residents in rural areas while criminal shootings are most prevalent among black residents in urban areas (Choi et al., 2020; Guetschow et al., 2018; Olufajo et al., 2020). As a result of differences in resident demographics and urbanicity, it is possible that a similar study conducted in a different geographic area would have results unique to the study location. Results could also differ if researchers collect data using a different instrument such as medical records or a trauma registry (Gross et al., 2017; Hutchinson et al., 2019; Mills et al., 2018). Future Research Future research should aim to better understand unintentional nonfatal shooting victims and incidents by conducting follow-up to supplement the data available from the police data source and incorporating data from additional sources. Information provided in the data source should be confirmed, if possible, or updated if new information was identified more than 24 hours after the internal police documents were filed. Follow-up may increase the validity and reliability of the data obtained from this data source and provide additional details of interest not previously available, such as firearm type. Data from EMS records, medical records, or trauma registries should also be incorporated into the dataset. Combining law enforcement data with information about incidents and medical data with information about injuries and treatment would create a data source that supports a more comprehensive understanding of unintentional nonfatal shooting victims and incidents (Hink et al., 2019). The combined data could better be used to analyze injuries with a level of detail not available from law enforcement documentation and assess how the shooters actions prior to the incident impacted injury severity. NONFATAL SHOOTINGS 37 Location of unintentional nonfatal shootings require further study to evaluate the impact of gun policy across the United States. The value of gun policies can be assessed by comparing Indianapolis to other similarly sized metropolitan cities in other states with similar and varied gun policies. Results of this study should also be compared to cities of comparable size to Indianapolis. Comparisons across states will support broader understanding of unintentional nonfatal shootings around the United States and the impact of existing policies to reduce incidents. The Giffords Law Center is a national organization that aims to prevent gun violence through awareness of existing gun laws. Each year, the Giffords Law Center publishes a score card that grades each state based on the presence or absence of state legislation aiming to reduce gun violence. Indiana ranks low on the Giffords Law Centers annual score card because the state does not have laws in place for strict gun control. For example, Indiana does not have legislation requiring universal background checks or gun owner licensing, laws that have been linked to decreases in gun violence (Giffords Law Center, 2020). By comparing results of this study from Indianapolis to similar sized cities in other states that have different legal requirements for gun ownership and use, policy differences can more effectively be assessed for their impact on health outcomes. Research must also assess unintentional nonfatal shootings and victims across urbanization levels. Analyses should compare urban, suburban, and rural areas of Indiana to understand how incident and victim characteristics are similar or different between urbanization levels. Unintentional shootings are more common in rural areas (Choi et al., 2020; Guetschow et al., 2018; Olufajo et al., 2020) and less often studied in urban areas. Research focused on unintentional nonfatal shootings across urbanization levels will support a greater understanding of the risk factors related to unintentional shootings. Risk factors identified in this study such as NONFATAL SHOOTINGS 38 race, injury severity, and the shooters actions before the shooting could be confirmed for the urban population of unintentional shootings while assessing differences with suburban and rural areas. Similarities across all urbanization levels can be addressed at a statewide policy level, while differences can be addressed with local policy and prevention techniques such as increased education. Conclusion Limited research has focused on unintentional shooting victims and incidents. Knowledge of unintentional shooting victim and incident characteristics are primarily based on homicide data and a growing body of research about nonfatal criminal shootings. Findings from this study provide a novel look at unintentional nonfatal shootings and indicate a need for continued research. Development of comprehensive firearm injury surveillance is also needed to support expanded research efforts. Implementation of surveillance and investigation techniques, in conjunction with research, are necessary to inform development of effective policies to prevent unintentional shootings. Public health experts must continue to learn about firearm injury and death across the U.S. (Joseph, Bible, & Hanna, 2020). In the U.S., one out of every 108 people die from a firearm-related injury, and in Indiana firearm-related injuries kill one out of every 90 people (Sehgal, 2020). Continued research and surveillance, particularly when public health and law enforcement work together, will provide a stronger understanding of unintentional nonfatal shooting victims and incidents that will further inform prevention efforts to decrease morbidity and mortality. NONFATAL SHOOTINGS 39 References Annest, J. L., & Mercy, J. A. (1998). Use of national data systems for firearm-related injury surveillance. JAMA, 15(3, Suppl. 1), 17-30. https://doi.org/10.1016/S07493797(98)00057-9 Annest, J. L., Mercy, J. 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BMC Public Health, 17(174). https://doi.org/10.1186/s12889-017-4086-1 NONFATAL SHOOTINGS 52 Table 1 Demographic Characteristics of Unintentional and Criminal Nonfatal Shooting Victims Variable Unintentional Criminal (N = 179) (N = 1,464) n % n % Racea White 83 46.37 303 20.70 Non-White 96 53.63 1,158 79.10 Sexb Male 156 87.15 1,234 84.29 Female 23 12.85 230 15.71 Age (years)c a < 18 25 13.97 121 8.27 18-34 106 59.22 946 64.62 35-54 33 18.44 339 23.16 55 14 7.82 58 3.96 N = 1,640. bN = 1,643. cN = 1,642. 2 p 58.66 < .001 1.00 .380 27.73 < .001 NONFATAL SHOOTINGS 53 Table 2 Injury Characteristics of Unintentional and Criminal Nonfatal Shooting Victims Variables Unintentional Criminal (N = 179) (N = 1,464) n % Yes 140 78.21 No 33 18.44 n % 2 p Self-Inflicted Wounda Gunshot Woundsb Single Multiple 171 95.53 1,095 74.80 8 4.47 336 22.95 AIS Scorec 0 62 34.64 144 9.84 1 90 50.28 585 39.96 2 18 10.06 405 27.66 3 9 5.03 287 19.60 Wounded Body Regiond Extremity 152 84.92 729 49.80 Center mass 27 15.08 692 47.27 EMS/ambulance 70 39.11 Private vehicle/walk-in/other 90 50.28 Transportation to the EDe 38.96 < .001 125.66 < .001 79.70 < .001 NONFATAL SHOOTINGS 54 Note. AIS = Abbreviated Injury Scale; ED = emergency department; EMS = emergency medical services. a N = 173. bN = 1,610. cN = 1,600. dN = 1,600. eN = 160. fN = 179. NONFATAL SHOOTINGS 55 Table 3 Incident Characteristics of Unintentional and Criminal Nonfatal Shootings Variables Unintentional Criminal (N = 178) (N = 1,304) n n % % Seasona Spring 38 21.35 333 25.54 Summer 41 23.03 379 29.06 Fall 54 30.34 324 24.85 Winter 45 25.28 268 20.55 Timeb a.m. 60 33.71 497 38.11 p.m. 117 65.73 806 61.81 Incident Locationc Business 8 4.49 199 15.26 Public street/alley 6 3.37 318 24.39 Residence, inside 70 39.33 310 23.77 Residence, outside 23 12.92 282 21.63 Vehicle 30 16.85 144 11.04 Other 5 2.81 25 1.92 2 p 6.62 .085 3.93 .140 194.73 < .001 NONFATAL SHOOTINGS 56 Unintentional Criminal (N = 178) (N = 1,304) n % n Playing with/fooling around 21 11.80 Cleaning/(un)loading/assembling 39 21.91 Dropped/knocked to floor/mishandled 11 6.18 Demonstrating/transferring/handling 16 8.99 Other 24 13.48 Carrying/holster or pocket mishap 36 20.22 Variables Action Preceding Injuryd a N = 1,482. bN = 1,480. cN = 1,420. dN = 147. % 2 p NONFATAL SHOOTINGS 57 Table 4 Logistic Regression Results Predicting Unintentional Nonfatal Shooting Victims (N = 1,498) Exp (b) 95% CI SE p OR Lower Upper White 1.20 .20 < .001 3.33 2.23 4.96 < 18 .68 .33 .036 1.98 1.05 3.75 35-54 -.34 .26 .187 .71 .43 1.18 55 .56 .38 .140 1.76 .83 3.71 Single GSW 1.36 .41 .001 3.90 1.77 8.63 Extremity wound 1.41 .24 < .001 4.11 2.57 6.57 Business -1.32 .39 .001 .27 .13 .57 Public Street/alley -2.26 .43 < .001 .11 .05 .24 .45 .25 .073 1.56 .96 2.55 2 184.39 < .001 -2 log likelihood 732.06 Predictor Victim characteristics Age (Ref. 18-34) Injury characteristics Incident characteristics Location (Ref. Residence) Vehicle Overall model evaluation Nagelkerke R2 .25 Note. In the dependent variable victim type, unintentional victim = 1; GSW = gunshot wound. NONFATAL SHOOTINGS 58 Appendix Review of Nonfatal Shooting Incidents For this study, 1,582 shooting incidents that occurred during the years 2017 through 2019 were reviewed. Two hundred seventy-eight incidents were unintentional, and 1,304 incidents were criminal. One hundred unintentional incidents were excluded. Twenty-six incidents did not meet the definition of an unintentional shooting and 43 incidents were self-defense. Self-defense incidents were excluded because the victim showed intent to protect themselves or others when using the firearm. Twenty-four unintentional incidents did not have victims meeting the definition of a shooting victim because the wounds were non-penetrating, not from a projectile, or the firearm did not use powder charge. Seven unintentional incidents were excluded as fatal. Data from criminal incidents were provided as-is to the researcher and not individually reviewed. All criminal incidents provided to the researcher were included, for a total of 1,482 shooting incidents. From the 1,482 incidents, 1,646 nonfatal victims were identified; 1,466 victims were injured during criminal incidents and 180 victims were injured during unintentional incidents. One victim with a non-penetrating wound was excluded from the unintentional nonfatal victim data set. Two duplicate victims were excluded from the criminal nonfatal victim data set. A total of 1,643 nonfatal victims from 1,482 shooting incidents were identified for inclusion in analyses. NONFATAL SHOOTINGS 59 Shooting incidents (n = 1,582) Criminal incidents (n = 1,304) Unintentional incidents (n = 278) Incidents excluded (n = 100) Criminal incident (n = 4) Not unintentional (n = 22) Self-defense incidents (n = 43) No shooting victims (n = 24) Fatal (n = 7) Incidents included (n = 1,304) Incidents included (n = 178) Victims reviewed (n = 1,466) Victims reviewed (n = 180) Victims excluded (n = 2) Duplicates (n = 2) Victims included (n = 1,464) Victims excluded (n = 1) Non-penetrating wound (n = 1) Victims included (n = 179) Figure A1. Diagram of Incidents. Diagram of incidents and victims reviewed for inclusion.  ...

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DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY-RELATED CONTENT IN ENTRY-LEVEL OCCUPATIONAL THERAPY PROGRAMS Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Mary Elizabeth Patnaude, MS, OTR/L Copyright May 6, 2019 By: Mary Elizabeth Patnaude, MS, OTR/L All rights reserved Approved by: Lucinda Dale, EdD, OTR, CHT, FAOTA Committee Chair Laura Santurri, PhD, MPH, CPH Committee Member Jane OBrien, PhD, OTR/L, FAOTA Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY Development of a Mapping Tool for Anatomy-related Content in Entry-Level Occupational Therapy Programs Mary Elizabeth Patnaude University of Indianapolis 1 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY Abstract Occupational therapy (OT) practitioners utilize anatomy and anatomy-related knowledge to analyze occupational performance and design intervention plans for prevention, rehabilitation, and wellness. The Accreditation Council for Occupational Therapy Education (ACOTE) provides standards and guidelines about anatomy-related knowledge, but faculty must interpret these standards to design curricula to meet them. The process of curriculum mapping requires that OT educators identify and assess the anatomy and anatomy-related content present in entrylevel programs. In this study, the primary researcher developed a tool as a first step to assist faculty in identifying the amount and scope of anatomy-related content taught in entry-level programs. Official documents of the American Occupational Therapy Association (AOTA) and curriculum mapping studies were used as guidelines for developing the tool. Five expert consultants, who each have a minimum of three years experience teaching in an entry-level occupational therapy program, completed three surveys to validate the tool. The usability of the tool was assessed by applying it to an entry-level Master of Science in OT (MSOT) program. Keywords: Blooms Taxonomy, curriculum design, educational methods, tool development 2 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 3 Acknowledgements I would like to thank the many people who contributed to my success in the DHSc program. I would first like to thank my committee chair, Dr. Lucinda Dale, for all the hours she contributed to this project. Her patience and attention to detail made this project the best it could be. I would also like to thank Dr. Laura Santurri. She has been an attentive advisor, who willingly stepped up to serve on my committee when the direction of the research changed. It was her love of curriculum design that sparked the passion in me for this project. I am also thankful to the other faculty members at the University of Indianapolis who inspired me to be the best I could be. These include Dr. Julianna Gahimer and Dr. Candace Beitman. I am so grateful to my wonderful co-workers at the University of New England. Without their support, I would not have had the endurance to finish this race. I most especially want to thank my mentor and friend, Dr. Jane OBrien. It was her belief in me that opened the door to my career in higher education. She has spent countless hours teaching and guiding me. She stepped up to fill a role on my committee when I needed her, and she has been wonderful! Thanks also to my friend and colleague, Elizabeth Crampsey. She has helped me so much as I grow as an academic. I would also like to thank the occupational therapy faculty at the University of New England, especially the program director, Dr. Kristin Winston, who worked hard to give me time and space to finish this project. I am most grateful to my family. I especially want to thank my wonderful husband, Rev. Jeffrey Patnaude. He has been an advocate, a supporter, and a loving partner throughout all of this. I would like to thank my sons, Richard, Michael, Aaron, David, and Matthew, who have been patient throughout this long process. They were understanding when I missed a performance or a game because I had a deadline. I would like to thank my extended family, DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 4 including my mother, mother-in-law, father-in-law, and siblings. Their prayers and encouragement kept me going, and their help with the kids at times when I was trying to finish a paper or class was invaluable. Many people have contributed to my success in this journey. I thank them all from the bottom of my heart. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 5 Table of Contents Abstract ........ 2 Acknowledgements ...... 3 Table of Contents . 5 Chapter 1: Introduction 7 Chapter 2: Literature Review .. 10 Importance of Anatomy Education in Health Profession Programs. 10 Effective Methods of Anatomy Instruction... 12 Application to Anatomy Curriculum in OT Education 14 Chapter 3: Method 19 Study Design..... 19 Development of Tool 20 Assessment of Face Validity of Tool 21 Assessment of Content Validity of Tool.. 22 Participants 23 Data Collection. 23 Assessment of Usability of Tool.. 24 Chapter 4: Results.... 26 Research Question One.... 26 Research Questions Two and Three. 31 Chapter 5: Discussion and Conclusion. 33 References. 43 Table 1: Anatomy Identified in Blueprint for Entry-Level Education. 50 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 6 Table 2: Research Utilized to Devise Tool Components... 51 Table 3: ACOTE Standards and Identified Courses from Sample MSOT Program.. 52 Appendices Appendix A: Participant Consent Form. 53 Appendix B: Initial Tool Template 55 Appendix C: Word Document Containing Clarified Instructions.. 56 Appendix D: Revised Tool for Round Two 59 Appendix E: Coding of Survey .. 63 Appendix F: Instructions for Completing Tool Version Three.. 65 Appendix G: Final Survey.. 70 Appendix H: Blooms Taxonomy Color Coding 71 Appendix I: Final Completed Tool With Usability.... 72 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 7 Development of a Mapping Tool for Anatomy-related Content in Entry-Level Occupational Therapy Programs Background Occupational therapy (OT) practitioners facilitate engagement in meaningful occupations through analysis of occupational performance. Such analysis forms the basis for all OT models of practice (AOTA, 2010; Christiansen & Baum, 1997). To facilitate participation in occupations, OT practitioners need to understand how activity demands (extrinsic factors) and client performance skills (intrinsic factors) enable or hinder participation in occupation (AOTA, 2010; AOTA, 2014). OT educators must ensure that graduates of accredited programs develop the skills necessary to evaluate these intrinsic and extrinsic factors (AOTA, 2010). Evaluating intrinsic factors requires a deep understanding of body structures and body functions (World Health Organization, 2003). To understand body structures and to analyze factors related to occupational performance, OT students need to be instructed in anatomy (Carroll & Lawson, 2014). The Accreditation Council for Occupational Therapy Education (ACOTE) sets the standards for all OT graduate programs in the United States and identifies one standard naming anatomy (ACOTE, 2013). ACOTE names anatomy in the B.1.1 standard: The student will be able to demonstrate knowledge and understanding of the structure and function of the human body to include the biological and physical sciences. Course content must include, but is not limited to, biology, anatomy, physiology, neuroscience, and kinesiology or biomechanics (ACOTE, 2013, p. s33). There are also ACOTE standards linked to the assessment of intrinsic client factors which require knowledge of anatomy. ACOTE specifies in the B.4.4 standard that OT students be able DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 8 to evaluate person-centered factors and performance skills (ACOTE, 2013). ACOTE provides the outline identifying the content required of graduates of accredited programs, but faculty have the responsibility to develop the curriculum to fulfill these requirements (ACOTE, 2013). Faculty can use the Blueprint for Entry-Level Education (Blueprint) (AOTA, 2010) as a guide for curriculum development when designing OT programs (AOTA, 2010). A panel of expert OT faculty developed the Blueprint to identify the knowledge needed for OT practitioners to understand what clients require to perform meaningful occupations (AOTA, 2010). The Blueprint is based upon the three concepts of occupation, person, and environment (AOTA, 2010). The person-centered factors in the Blueprint related to anatomy content include physiological support, sensory/perceptual support, and motor support. The intrinsic factors identified as person-centered are linked to "skills that should be developed to be able to implement the concepts and the areas of practice that require this knowledge (AOTA, 2010, p. 187). Table 1 outlines the components from the Blueprint which make up the person-centered factors. These skills include assessment, intervention planning, and activity analysis (AOTA, 2010). In the Blueprint, eight key sciences are listed as required to provide students the skills needed to treat the person-centered factors in OT: anatomy, neuroscience, physiology, occupational science, rehabilitation science, exercise science, and anatomy and physiology (AOTA, 2010). Researchers report that knowledge of anatomy is important for students in OT, physical therapy, and medicine (Sbayeh et al., 2016; Thomas, Denham, & Dinolfo, 2011). Through the use of curriculum mapping, OT educators can identify elements of a curriculum and ensure that content is presented with increasing complexity (Krathwohl, 2002; MacNeil & Hand, 2014). This allows faculty to provide course structure whereby simple concepts are mastered as prerequisites to complex knowledge so that students can develop DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY competency and confidence in their learning. Faculty scaffold material to increase the complexity and promote student success (Krathwohl, 2002). Educators may use the hierarchy provided by Blooms Taxonomy as a guide for scaffolding knowledge and as a way to align educational objectives, activities, and assessments (Krathwohl, 2002). Problem Statement OT educators are required by ACOTE to design curricula to meet the accreditation standards (ACOTE, 2013). Through curriculum mapping OT educators can identify gaps and repetitions in content and assess if adequate content is present in OT programs (MacNeil & Hand, 2014). There is currently no tool available for OT faculty to assess where and how anatomy and anatomy-related content is being taught in entry-level programs. A tool to map anatomy and anatomy-related content provides a first step in this process (Litaker et al., 2004). Purpose Statement The purpose of this study was to establish a tool with face and content validity to map anatomy-related content in OT programs. The usability of the tool was assessed by mapping the anatomy-related content in one MSOT program. Research questions. In this study, the primary researcher answered the following research questions: 1. Can a tool with both face and content validity be established to map anatomy-related content in OT programs that meet ACOTE standards? 2. What is the usability of the mapping tool for faculty designing and evaluating OT programs? 3. How is anatomy-related content integrated into one MSOT program? Significance of the Study 9 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 10 OT faculty can use the developed tool to identify the anatomy-related content they use to meet the ACOTE standards regarding basic sciences and assessment of person-centered factors (Schofield, 2014; Sellar et al., 2017). It can be used to tie course objectives to student learning outcomes and provide a method to demonstrate the scaffolding of content. It can also provide a structure for faculty to examine a curriculum while reviewing it for re-accreditation or program assessment. Background and Significance OT practitioners facilitate participation in meaningful occupation through the analysis of occupational performance (AOTA, 2014). Knowledge of anatomy is needed for them to understand client factors such as body structures and body functions (AOTA, 2014; Carroll & Lawson, 2014). In recent studies, researchers have examined the importance of anatomy education in medical and allied health programs, the teaching methods used in those programs, and trends in anatomical education (Carroll & Lawson, 2014; Guzman et al., 2015; Thomas et al., 2011). Importance of Anatomy Education in Health Profession Programs Anatomy and anatomy-related content are integral to the training of OT practitioners and medical students (Carroll & Lawson, 2014; Sbayeh et al., 2016; Schofield, 2014). Schofield (2014) examined the perceptions of OT practitioners regarding the importance of anatomy education. The participants were OT practitioners from Arizona who practiced in outpatient, acute, and pediatric settings and who supervised entry-level OT students. All respondents (n =107) reported that OT students needed anatomy knowledge and that an undergraduate anatomy course was not sufficient to provide it. Eighty-three percent of respondents reported using anatomical knowledge consistently to analyze activities. All respondents reported that DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 11 knowledge of the musculoskeletal and nervous system is essential to OT practice, especially in upper limb rehabilitation (Schofield, 2014). Sbayeh et al. (2016) completed a cross-sectional, questionnaire-based study for medical students, recently graduated doctors, and anatomy educators in Great Britain and Ireland to determine the clinical relevance of anatomy to medical practice. They utilized a Likert scale to measure ratings and found that educating medical practitioners requires an anatomy curriculum that fulfills the needs of developing clinicians (Sbayeh et al., 2016). The anatomy educators reported that more time should be devoted to anatomy education (Sbayeh et al., 2016). Guzman et al. (2015) completed a qualitative study of 363 students at two medical schools in California. They conducted three annual online surveys in which the students provided qualitative responses. The researchers coded the responses as positive if the students perceived anatomy to be beneficial to them in preparing for board exams, third-year clerkships, and clinical evaluation skills (Guzman et al., 2015). Ninety-nine percent of the students reported that anatomy was a highly valued part of their medical school education. Eighty-nine percent of students reported that anatomy helped them prepare for board exams; 95% reported that it helped them prepare for third year clerkships; 65% reported that it prepared them to perform clinical exams (Guzman et al., 2015). Moxham and Plaisant (2007) completed a pre-test and post-test survey of medical students to explore their opinion of the importance of anatomy to clinical medicine. The researchers surveyed 350 medical students before they began studying anatomy, after the course was complete, and in the final year of medical school. In all surveys, all students reported that the practice of medicine could not exist without knowledge of anatomy and that doctors would not be effective without such knowledge (Moxham & Plaisant, 2007). DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 12 Recognizing the need to make anatomy content clinically relevant, educators of future medical doctors sought to discern the level of anatomy education needed to develop competent practitioners (Fitzgerald, White, Tang, Maxwell-Armstrong, & James, 2008). Fitzgerald et al. (2008) conducted a cross-sectional survey study to seek the opinions of newly qualified doctors about the anatomy content received in medical school. One group of students completed an undergraduate level anatomy class only, and one group completed a graduate level anatomy class. The authors asked the students whether they received adequate anatomy education. Eighty percent of those who completed the graduate course answered yes and 46% of those who completed the undergraduate course answered yes (Fitzgerald et al., 2008). These results indicate that medical students perceive that advanced anatomy education is important to be included in their medical training (Fitzgerald et al., 2008). Effective Educational Methods of Anatomy Instruction in Curriculum Design Researchers illustrated the necessity of anatomy education for doctors and OT practitioners (Carroll & Lawson, 2014; Sbayeh et al., 2016). Although knowledge of anatomy is recognized as essential, effective delivery of such knowledge is threatened by several factors: time constraint, cost and availability of cadavers, and lack of qualified instructors (Thomas et al., 2011). The perceptions of students and teachers regarding these methods of instruction were examined to assess the efficacy of them (Agnihotri & Kalyan, 2013). Gabard, Lowe, and Chang (2012) completed a descriptive study to investigate current and future practices related to anatomy instruction in medical and physical therapy schools. They designed a survey, utilizing the Delphi method, to gather expert faculty testimony on current and future practices of anatomy education. They found that although educators reported that cadaver dissection is the most effective method to teach anatomy, it is costly, has limited availability, DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 13 does not allow students to be exposed to technological advances in medicine, and may have adverse health effects (Gabard et al., 2012). All respondents (n = 75) agreed that the type of anatomy instruction used was influenced by budget, time, and availability of qualified instructors. In the future, researchers should study the efficacy of newer educational methods in relationship to clinical competencies would be warranted (Gabard et al., 2012). Thomas et al. (2011) examined the perceptions and preferred educational methods of physical and occupational therapy students in a gross anatomy course, to assess the efficacy of methods such as computer-assisted and small group learning. The researchers surveyed 106 firstyear students enrolled in a gross anatomy class. The traditional lecture and dissection lessons were supplemented with interactive discussions, led by teaching assistants, and online anatomy independent study modules. All students reported that they gained more knowledge from the discussions and multimedia approaches to learning than from lectures. The findings of these researchers support the use of non-traditional, multi-modal, and interactive educational methods of anatomy instruction. Agnihotri and Kalyan (2013) completed a qualitative pilot study surveying 150 anatomy instructors at physiotherapy schools in India, comparing a multimedia instructional approach to problem-based learning. Instructors employed a multimedia approach utilizing computer-based audio-visual resources which students could access from home or in class. They also used problem-based learning, which allowed students to apply anatomy while exploring the diagnoses of actual or simulated patients. All respondents (n = 150) agreed that both approaches were relevant for learning anatomy; they overwhelmingly preferred a combination of traditional lecture, multimedia, and problem-based learning (Agnihotri & Kalyan, 2013). Multi-modal teaching of anatomy content resulted in more active learning, which strengthened the DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 14 relationship between student knowledge and mastery of clinical skills (Agnihotri & Kalyan, 2013). Ogard (2014) completed a descriptive study in a doctor of physical therapy program in Alabama. The researcher compared the efficacy of a newly implemented anatomy curriculum, which reduced the hours of cadaver dissection, to the one used the previous year. In the new curriculum, the students participated in two 3-hour cadaver labs augmented with video dissection, lectures, and active learning. The students in the previous curriculum participated in bi-weekly 150 to 180 minute dissection sessions only. The author compared the two curricula, using student perceptions and exam grades as criteria for evaluation. The students perceived that dissection was the most valuable aspect of the course but there were no significant differences in exam scores. The researcher concluded that methods other than cadaver dissection led to successful student outcomes in anatomy (Ogard, 2014). Application to Anatomy Curricula in OT Education Otegui (2017) believed that reducing anatomy to its most simplistic form, by encouraging students to memorize long lists and charts, harms the discipline and limits its ability to answer deeper questions about the structure and function of humans. To understand and apply anatomy requires an analytical approach which will reassemble the component parts into a whole (Otegui, 2017). Applying methods of curriculum mapping to anatomy content in OT education provides faculty with empirical data regarding how students learn and can inform future curriculum designers (Carroll & Lawson, 2014; MacNeil & Hand, 2014). Mapping has allowed faculty to examine curricula to assess the content covered and to avoid gaps and redundancies (Willett, 2008). Faculty from medical schools, pharmacy schools, schools of social work, and OT programs completed curriculum mapping projects to ensure that DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 15 students received sufficient content to become prepared clinicians (Al-Eyd et al., 2018; Merritt, Blake, McIntyre, & Packer, 2012; Oyewumi, Isaac, Schreiber, & Campisi, 2012; Plaza, Reierson, Slack, Skrepnek, & Sauer, 2007; Sellar et al., 2017; Watts & Hodgson, 2015; Willett, 2008). Willett (2008) surveyed Canadian medical school faculty to describe their efforts to map a curriculum, the challenges they encountered, and the successes they achieved through the process. At the time of the study, 74% of undergraduate medical schools were in the process of building curriculum maps or had already completed them (Willett, 2008). Study respondents reported that the time involved in mapping a curriculum and their lack of experience with the process posed the biggest challenges to them. Despite challenges, faculty reported that mapping the program helped them concentrate on the curriculum (Willett, 2008). Al-Eyd et al. (2018) completed a centralized curriculum mapping process at a new medical school. They developed a tool to link course objectives to program learning outcomes. This map was used to develop, modify, and evaluate the curriculum to maintain integrated content between courses and across semesters. The researchers found that the tool was useful in identifying the areas in which content and learning outcomes were addressed (Al-Eyd et al., 2018). Faculty at the University of Toronto mapped the undergraduate medical school curriculum to determine if the accreditation standards related to otolaryngology were being fulfilled and if any gaps or redundancies existed in it (Oyewumi et al., 2012). This mapping allowed them to evaluate if students received adequate instruction to develop clinical skills. The faculty identified the topics and skills related to otolaryngology and the courses in which they were taught. The researchers mapped the dedicated teaching time for each topic. They classified DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 16 each type of teaching as type I (highly weighted and focused on lecture or seminar), type II (content presented but not the main focus), and type III (content minimally referenced) (Oyewumi et al., 2012). The findings of these researchers led the faculty to establish a systematic way of teaching the content, a system which improved faculty and student satisfaction, and highlighted areas of needed improvement (Oyewumi et al., 2012). Plaza et al. (2007) completed a cross-sectional study to demonstrate a curriculum mapping technique and its use in program evaluation. The authors mapped learning outcomes (domains) set forth by the Center for the Advancement of Pharmaceutical Education. They mapped the courses by year and course number and then shaded the domains addressed in each course. The domains related to patient care, dispensing medications, health promotion, professionalism, and health systems and management. The authors identified the number of competencies within each domain (Plaza et al., 2007). In the study, each cohort of students, from years one to three, rated the extent to which the curriculum focused on each domain. The authors compared the mapping they completed to the results reported by the students (Plaza et al., 2007). The mean rating of domain coverage was the same among students in years one through three for all domains except health systems and management. Students in the first year of the program reported much less coverage in the domain of health systems and management than did the students in years two and three. This technique provided faculty with data important to address the curriculum sequence. Watts and Hodgson (2015) developed a methodology and conceptual framework to map assessment across the social work curriculum at an Australian university. In the first stage of this study, the researchers identified student competencies based on the standards set by the Australian Association of Social Workers Practice. The authors searched the literature and DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 17 identified nine constructs related to social work practice and applied them to teaching and learning (Watts & Hodgson, 2015). The constructs were sorted by the number of criteria related to each domain of social work practice (Watts & Hodgson, 2015). In the second phase, they mapped the curriculum using Blooms Taxonomy to provide a visual representation of the scaffolding of the cognitive level of the content. The authors used findings from these two stages to improve learning outcomes, assessment, and teaching methodologies and to provide faculty development. Merritt et al. (2012) compared the links between the learning objectives in an entry-level OT program to the competencies outlined by the Association of Canadian Occupational Therapy Regulatory Organization. The researchers analyzed the course objectives using Blooms Taxonomy. They examined whether the course objectives were in alignment with the accreditation standards and the OT competencies defined by each programs faculty (Merritt et al., 2012). They found links between learning objectives and 30 essential competencies. They found that the learning objectives were not distributed equally among the standards. This finding led them to recommend that professional regulators, educators, and practitioners work together to ensure that learning objectives and accreditation standards align effectively to produce competent OT practitioners (Merritt et al., 2012). Sellar et al. (2017) mapped the OT curriculum at the University of South Australia. They utilized intended learning outcomes documented in individual courses and linked them to elements in the Australian Minimal Competency Standards for New Graduates (Occupational Therapy Australia, 2010). OT faculty in Australia are required to meet these competency standards in their programs just as faculty in the United States must meet ACOTE standards (ACOTE, 2013; Sellar et al., 2017). These authors used Millers Framework of Competency to DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 18 provide a visual demonstration of the scaffolding of the content by skill (Sellar et al., 2017). Miller (1990) described the scaffolding of skill with the following terms: knowing, knowing how, showing how, and demonstrating. Sellar and colleagues conducted a study "to examine the extent to which the documented undergraduate curriculum supported achievement of the minimum competency standards (Sellar et al., 2017, p. 3). This study included four stages: pilot mapping, establishment of a mapping protocol, individual planning and peer review, and final group review. The authors linked the course intended learning outcomes to the competency standards. They described the number of course objectives linked to the intended learning outcomes and calculated the percentage of links to each minimal competency standard. They quantified the proportion of links at each level of Miller's (1990) pyramid, which included the ability of the student to know, know how, show how, and demonstrate a clinical skill. The authors provided a rigorous examination of the curriculum by creating a tool to map it (Sellar et al., 2017). After the tool was created, faculty in the program mapped either five or six courses. For the sake of objectivity, they chose to map courses for which they were not the instructor. Research assistants mapped all of the courses. The maps were compared. If discrepancies were found among maps, a research assistant met with the faculty member to discuss the content in more depth and resolve the differences. A final group review was done to resolve remaining differences after the research assistants and faculty met (Sellar et al., 2017). This study was conducted prior to a review process to evaluate the future of OT practice in Australia. The authors of this study demonstrated that their curriculum effectively links student learning outcomes to competency standards and would allow them to educate students in becoming competent Australian OT practitioners (Sellar et al., 2017). These researchers reported DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 19 that curriculum mapping is a valuable tool for programmatic assessment and should be completed in future studies (Sellar et al., 2017). Bloom and measurement experts across the United States developed a taxonomy to facilitate the creation of a test bank that accurately measures educational objectives (Krathwohl, 2002). Phillips, Smith, and Strauss (2013) adapted the taxonomy to create multiple-choice exam questions for a radiologic anatomy course. These researchers found that the taxonomy was an effective tool to identify and categorize cognitive skills associated with a deeper understanding of radiological anatomy (Phillips et al., 2013). OT educators are responsible for assuring that anatomy-related content is adequately covered at the right cognitive level and for using the most effective teaching methodologies to develop students into competent practitioners (Carroll & Lawson, 2014; Sellar et al., 2017). Knowledge of anatomy aligns with the person-centered factors utilized by OT practitioners to design effective intervention plans (AOTA, 2010). No tool exists in OT to align anatomy course content with ACOTE standards. The purpose of this study was to establish a tool, with face and content validity, to map anatomy-related content in OT programs. The usability was assessed by utilizing the developed tool to map the anatomy content in one MSOT program. Method Study Design This study was completed in four phases. In phase one, the primary researcher created a tool to map the courses related to anatomy in entry-level OT programs. The researcher assessed the face validity of the mapping tool in phase two. In phase three, a panel of five expert consultants reviewed the tool components to assess and establish content validity. The primary researcher assessed the usability of the tool in phase four by mapping and evaluating an existing DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 20 entry-level MSOT program. Approval to conduct this study was provided by the University of New England Institutional Review Board. The Institutional Review Board of the University of Indianapolis entered into a reliance agreement with the University of New England. Development of Tool The author designed a curriculum mapping tool. The tool was modelled from existing curriculum mapping tools (Plaza et al., 2007; Sellar et al., 2017; Watts & Hodgson, 2015) and the experience of the primary researcher, who has five years experience teaching full-time in an entry level MSOT program. She has developed seven graduate level courses and has participated in a curriculum redesign as a member of the departmental curriculum committee. She completed a doctoral level course in curriculum design. This experience led her to make the decision to include elements of curriculum maps she identified as relevant to OT programs. See Table 2 for a list of the research studies from which the components of the map were selected. The Blueprint (AOTA, 2010) was created to assist OT faculty members in identifying the knowledge needed by OT students. The authors of the Blueprint outlined major topics related to person-centered factors, such as physiological, motor, and sensory support. The authors acknowledged that science forms the basis of OT education and identified anatomy as one of the key sciences. They cited the skills needed to implement anatomy concepts as including assessment, intervention planning, and activity analysis. The primary researcher used the Blueprint (AOTA, 2010) and ACOTE standards (ACOTE, 2013) to operationalize anatomy content as the person-centered factors of physiological, motor, and sensory support. OT students must gain the skills to assess the impact of these factors on occupational performance. To identify the anatomy-related content, the primary researcher chose to include in the tool the one ACOTE standard naming anatomy DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 21 (B.1.1), and the ACOTE standard subcategories relating to basic tenets/ understanding basic clinical science (B.2.2, B.2.6, B.2.7, B.2.9); screening, evaluation, and referral (B.4.2, B.4.4); and intervention planning (B.5.1). The individual course components identified as relevant to OT education included course objectives, educational methods, assessment methods, and OT competencies (Table 2). Course objectives are defined as the area of expertise the students are expected to gain (Harden, 2001). Educational methods can be defined as the ways in which the content is delivered, such as through lectures or demonstration (Thomas & Abras, 2016). Assessment methods are defined as the ways in which learning can be assessed, such as through an objective test (Thomas & Abras, 2016). The primary researcher defined assessment methods using the self-study guide provided by ACOTE (ACOTE, 2018). These are: assignment, project, lab test, presentation, objective test, demonstration, essay test, and other. OT competencies are the skills needed for a practitioner to be entrusted to perform as an entity no longer needing supervision and are defined by OT program faculty as student learning outcomes (Thomas, 2016). For every course fulfilling the ACOTE standard related to anatomy content, the primary researcher developed a color-coded system to visually identify the level of Blooms Taxonomy corresponding to the cognitive level of the verb used in each course objective (Harden, 2001; Krathwohl, 2002; Sellar et al., 2017). Assessment of Face Validity of Tool The author established face validity of the mapping tool by utilizing official documents provided by AOTA (e.g., AOTA, 2010; ACOTE, 2013), curriculum mapping studies (Harden, 2001; Plaza et al., 2007; Sellar et al., 2017), and her professional expertise as a full- time OT faculty member and doctoral student. The Blueprint (AOTA, 2010) was used to operationalize anatomy content as intrinsic or person-centered factors. The major concept of anatomy and key DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 22 concepts of assessment, intervention planning, and activity analysis were identified from the Blueprint (AOTA, 2010). The ACOTE (2013) standards which named anatomy and were related to assessment, intervention planning, and activity analysis were chosen by the primary researcher, based on her interpretation of these concepts. They were basic tenets/understanding basic clinical science (B.1.1, B.2.2, B.2.6, B.2.7, B.2.9); screening, evaluation, referral (B.4.2, B.4.4); and intervention planning (B.5.1). Guidelines for creating the tool were found in several mapping studies. Each component included on the tool was supported by research evidence (see Table 2). The primary researcher synthesized the information from each study. The primary researcher used research evidence and her faculty experience in designing and revising coursework to determine which components to include in the tool. Assessment of Content Validity of Tool Content validity is defined as the amount of congruity between the items on an instrument and the domains from which the items are retrieved (DiIorio, 2005). The congruity can be assessed through gathering insights of experts (Helmer, 1967). Content validity is based on the percent of agreement among experts, and is defined as an 80% agreement among experts (Summers, 1993). Design. The Delphi method, a protocol to systematically obtain and synthesize expert judgment, was utilized to assess the content validity of the developed tool (Helmer, 1967). Researchers found that three rounds of expert reviews were sufficient to establish consensus (Hsu & Sandford, 2007). The Delphi method was utilized in three rounds with a panel of five experts to build consensus (Hsu & Sandford, 2007; McKenzie, Wood, Kotecki, Clark, & Bray, 1999). DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 23 Participants. Researchers have established that a panel of four or five experts is sufficient to determine validity (Beck & Gable, 2001; Hsu & Sandford, 2007; McKenzie et al., 1999). Five OT faculty members with a minimum of three years of experience teaching full-time in an entry-level OT program were recruited through networking with faculty members known to the primary researcher. The primary researcher sent an email asking the individuals to consider being a part of the study. Consent was included in the first survey (see Appendix A). Participation was voluntary and responses remained confidential and secure. Inclusion criteria were identified as being a full-time educator in an entry-level OT program, familiarity with ACOTE standards, and experience with curriculum mapping and Blooms Taxonomy. Experience was defined as having a minimum of three years full-time teaching in an entry-level OT program and the completion of a post-professional class in curriculum design or participation in curriculum mapping for program evaluation and assessment. Exclusion criteria included individuals who could not speak English and who did not have full-time experience teaching in an entry-level OT program, even if they had experience teaching anatomy content. A $250 stipend for participation was provided through a faculty mini-grant from the Center for Excellence in Teaching and Learning at the University of New England to all participants who completed all the surveys. Data collection procedures. Data were collected and managed using three electronic surveys administered through the Research Electronic Data Capture (REDCap) tool hosted at the University of New England. REDCap software is a neutral data collection platform developed at Vanderbilt University in 2004 (Harris et al., 2009). This secure web-based application was designed specifically to retrieve, store, and analyze data in a secure manner for research (Harris DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 24 et al., 2009). For each survey, a link was sent directly from REDCap. The primary researcher sent emails with the link as well. In round one, an open-ended survey was sent to participants with consent (Appendix A) along with the initial tool template (Appendix B). This open-ended questionnaire was utilized to determine consensus among the participants and provide initial measures of content validity (McKenzie et al., 1999). The participants responses to this initial questionnaire were examined by the primary researcher. Using the feedback provided by the experts, the primary researcher clarified instructions provided to the consultants in a word document along with a sample of how the tool should be completed (Appendix C). In round two, the revised tool and the word document were sent to the experts, with a four-point Likert scale to rank each item (See Appendix D). On the scale, 1 represented not relevant and 4 represented very relevant. Using this scale, the participants were instructed to rank each item on its congruence with each ACOTE standard, level of Blooms Taxonomy identified, and relevance to the curriculum mapping process (Appendix C). The mean percentage of agreement among raters for these items was calculated (Beck & Gable, 2001). An 80% congruence was considered acceptable (Summers, 1993). All items with less than an 80% congruence were eliminated. In round three, the final revision of the tool was sent to the participants to provide feedback (Appendix G). This step allowed the experts a final opportunity to revise judgments about the tool (Hsu & Sanford, 2007). The final revisions were incorporated into the completed tool (Appendix I). Assessment of Usability of Tool DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 25 The usability of the mapping tool was assessed by using it to map an existing MSOT program. The courses in the curriculum which fulfilled each ACOTE standard related to anatomy content, as defined by the primary researcher, were identified. The course syllabi were gathered. The course objectives, assessment methods, level of Blooms Taxonomy, and related OT competencies for each course were mapped using the tool. The time taken to complete the mapping process was recorded. The tool contained eight ACOTE standards identified as relating to anatomy content and operationalized by the primary researcher as the person-centered factors identified in the Blueprint (AOTA, 2010). The courses from the sample OT program which fulfill each ACOTE standard in the tool were selected using a 2013 document developed by the program faculty that identified two primary courses fulfilling each ACOTE standard. Ten courses fulfilled these standards. The syllabi for the 10 courses were gathered and organized. The course objectives were examined to confirm that they fulfilled one of the eight ACOTE standards identified in the tool as related to anatomy content. Courses no longer fulfilling the standards were not included in the mapping; as a result one course was excluded and nine remained. The syllabi were organized by semester. The primary researcher identified course objectives from each of the nine courses that fulfilled each ACOTE standard related to anatomy content. These were the objectives chosen to be mapped. The OT competencies reflected the student learning outcomes developed by the faculty to define a successful OT graduate. The sample OT program faculty provided their OT competencies in the graduate student handbook of the MSOT program (OT Department, 2017). For the purposes of this study, the competencies were aligned with course objectives. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 26 The primary researcher completed the tool with the data provided on each course syllabus. She examined each course and plotted the course objectives related to anatomy. She then identified the assessment and educational methods utilized, using information contained in the syllabus. Each course objective was categorized according to Blooms Taxonomy levels and then color-coded accordingly. Appendix H provides the key that was used in the color-coding. Results This study sought to answer three research questions. Can a tool with face and content validity be established to map anatomy-related content, as defined as person-centered factors, in entry-level, pre-professional OT program curricula? What is the usability of this mapping tool by faculty designing entry-level, pre-professional, OT curricula? How is anatomy-related content, as defined by person-centered factors, integrated in one entry-level MSOT program as measured by the mapping tool? Research Question One Can a tool with face and content validity be established to map anatomy-related content in entry-level OT programs? This research question was answered in three phases in five months. Phase one. A curriculum mapping tool was developed based on findings from existing studies. Researchers described curriculum mapping tools developed for various programs (Harden, 2001; Oyewumi et al.; 2012, Plaza et al., 2007; Sellar et al., 2017; Watts & Hodgson, 2015). The tool included course objectives, educational methods, Blooms Taxonomy levels, and OT competencies. See Table 2 for studies linked to each component. The primary researcher used these components as the basis for designing the initial tool template (Appendix B). Phase two. The initial measure of face validity was provided by the primary researchers expertise of five years as a full-time OT educator and 20 years as an OT clinician (Beck & DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 27 Gable, 2001; Cottrell & McKenzie, 2011; McKenzie et al., 1999). Her experience in course development and assessment led her to choose the sections of the tool described in the literature and relevant to OT program design (Thomas, 2016; Thomas & Abras, 2016). The tool was also aligned with the anatomy-related content outlined in the Blueprint (AOTA, 2010) and with subsections of the ACOTE B standards (ACOTE, 2013). The researcher identified the following ACOTE subsections as related to anatomy topics: foundational content requirements; basic tenets of OT, screening, evaluation, and referral; and intervention planning (ACOTE, 2013). The standards addressing the terms and topics in the Blueprint related to anatomy were included in the tool. The standards included: B.1.1, B.2.2, B.2.6, B.2.7, B.2.9, B.4.2, B.4.4, and B.5.1. The initial tool template was created in phase one and completed in phase two (Appendix B). Phase three. In phase three, the primary researcher utilized the Delphi technique to establish content validity (Beck & Gable, 2001; Helmer, 1967). Researchers have utilized the Delphi technique to gather the opinions of expert consultants, to craft policy, and to guide practice in the absence of theoretical foundations (Helmer, 1967). Five full-time OT faculty members served as expert consultants. They were from three programs; two of the programs were in New York, and one of the programs was in Maine. None of the consultants were from the same program as the primary researcher. The consultants areas of clinical practice and teaching expertise were not known because these were not specified as inclusion criteria. Three of the consultants reported having three to five years faculty experience, two consultants reported having six to eight years of faculty experience, and one expert reported having more than nine years of faculty experience. The tool was titled Development of a Mapping Protocol for Anatomy Education in Entry-Level OT Education (Appendix B). DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 28 Round one. The expert consultants reviewed the tool and completed the initial survey (Appendix A). A thematic analysis of the expert reviewers comments revealed key themes. The themes included (1) additional information, (2) additional clarification, and (3) improvement in utility of tool. Theme 1 additional information. Participants expressed confusion as to how the tool related to anatomy and person-centered factors. I am not sure how the tool is person-centered factors yet. She stated that she did not see the connection of anatomy to occupation. I am not sure how your anatomy course is taught, but ours is primarily science core foundations and less focused on occupation. Is there a place to put examples? Requests were made for clarification of Blooms Taxonomy levels. Blooms: How do you expect the user to generate numbers that correspond to Blooms levels? Include a short definition of each level. As a result of these responses, the direction section of the tool was clarified, with more in-depth explanations of the relationship of the person-centered factors to anatomy, and a key with definitions of each level of Blooms Taxonomy. Theme 2 additional clarification. There were comments regarding the need for clarification. These comments led to the revision of the tool for round two. One participant noted, The tool should open with clear instructions that begin with an explanation of what the tool is (i.e., detailed explanation of its intended use) and then detailed instructions on how to use it. One participant expressed a desire to have more clarification on why this tool would be more useful than others already available. There are programs that actually do curriculum mappingexplain why this tool would be superior to other tools available to programs. As a result of these responses, a separate word document was developed with clarification of the rationale for the tool, as well as a sample of how to complete the tool (Appendix D). DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 29 Theme 3 improvement in utility of tool. There were several comments regarding ways in which the tool could be more useful and user friendly. Comments included adding more specificity to the tool and putting all the items together on one page. One participant asked the question, Why are the various keys and instructions on different worksheets? Another indicated that, The words of the ACOTE standards should be included. The primary researcher reviewed the survey with an analysis expert. She focused on the expert consultants comments to revise the tool. The following revisions were made: adding introductory context, clarifying directions, defining the levels of Blooms Taxonomy, and placing instructions on one page. The primary researcher provided a supplementary word document with clarified directions and an example of how to complete the tool (Appendix D). The tool and instructions were revised based on the feedback of the expert consultants. Round two. The revised tool and detailed instructions were sent to the expert consultants, along with a second survey (Appendix C). This survey contained closed and open-ended questions, according to the procedures outlined by the Delphi method. The quantitative data were analyzed through the REDCap program. The open-ended questions were analyzed qualitatively by identifying themes. The themes and a sample of quotes related to them can be found in Appendix E. The responses for the closed-ended questions were converted to a four-point Likert scale where 1 represented not relevant and 5 represented very relevant. Responses were analyzed quantitatively using descriptive statistics. The mean percentages of agreement for each item were calculated among consultants. The threshold to maintain items was 80% congruence (Beck & Gable, 2001; Summers, 1993). Not one of the items was rated at less than 80% congruence, a DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 30 result which suggests that all items were deemed relevant to curriculum mapping by the expert consultants. The qualitative responses were analyzed to identify themes. The themes identified included (1) additional information, (2) clarification, (3) utility of tool, and (4) positive comments. Theme 1 additional information. After the initial revision, one participant still requested additional information by stating, One thing I still feel this lacks is an explanation of why someone would use this tool; maybe a deeper rationale could be included in the introduction? As a result of this response, further clarification was made to the introduction of the tool, providing a more detailed explanation of the rationale for the tool and more clarification about the ways in which anatomy is operationalized. Theme 2 clarification. A comment was made regarding whether this tool is useful for practice-based and lecture-based courses. One participant said, The topics seem relevant. Is it just for anatomy or other courses? The introduction states it is for anatomy. Another participant indicated that, I believe that evaluation and intervention planning are more relevant standards that seem to align more with practice-based courses rather than core foundational science courses. The experts wanted additional clarification about how the tool related to the personcentered factors of anatomy-related education and ACOTE standards. One participant indicated that, The tool should include all ACOTE standards so that a program can map to ensure they have met them all-but maybe I am not understanding the function of the tool. Theme 3 utility of tool. These comments relate to usability of the tool. One participant commented, Under section IV. Educational Methods, you may want to consider sorting those DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 31 under the existing ACOTE-recognized categories of assessment. Another stated, Also, please define OT competencies. Finally, a participant pointed out, I like the concept of Blooms Taxonomy for scaffolding purposes, but maybe include a verb list so programs can ensure the correct level for the objectives. Theme 4 positive comments. There were several comments indicating that the participants agreed with the edits made from the first revision. The revisions definitely explain the tools more clearly. I can see the evolution of this revision from the first draft. This suggested that the tool was evolving in a positive manner. Round three. The tool and instructions were revised based on the feedback given by the expert consultants in round two. The final survey tool review was collected and examined to determine themes of reviewers comments in round three (Appendix G). The themes from the experts feedback included (1) tool completed and (2) final clarification needed. Theme 1 tool completed. Two of the five participants stated that they had Nothing further to add. Theme 2 final clarification needed. The remainder of the comments focused on a request for seeing a more detailed example of the tool. One participant commented that, I would love to see a chart example, fully completed for anatomy, and a summary of the usefulness of the tool- a sort of bring it all home document. Another said, I think the what and how are clear in the instructions, but a more explicit statement of the why is needed, i.e. why would someone use this tool? Research Questions Two and Three The questions regarding the usability of the tool and the way in which it can be used to map a curriculum were interrelated and answered together through the mapping of an MSOT DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 32 program at a private university on the East coast of the United States. The primary researcher spent ten hours completing the usability mapping. The usefulness of this mapping tool was predicated on the user agreeing with the way in which the primary researcher operationalized anatomy content. Anatomy content for the sample program examined is threaded throughout the first three semesters. The ACOTE standards addressing anatomy-related content were fulfilled with 10 courses. The primary researcher examined corresponding course syllabi and consulted with the faculty members teaching the courses. One faculty member confirmed that Therapeutic Use of Self (OTR 614) no longer fulfilled one of the ACOTE standards. This course was eliminated from the mapping. From the nine remaining courses, the primary researcher identified course objectives related to each of the eight ACOTE standards included in the tool. Table 3 lists the courses, objectives, and ACOTE standards. Course objectives for this program were written using the same language as the ACOTE standards, which made it possible to choose the course objectives to be mapped. Seventeen course objectives were identified along with corresponding assessment and educational methods used to address content. This information was documented onto the curriculum map. The cognitive level of the verbs utilized in the course objectives were categorized and color coded according to Blooms Taxonomy (Appendix H). The associated color code was placed next to the course, objective, and semester on the mapping tool. This provided a visual representation of the Blooms Taxonomy cognitive levels for the course objectives throughout the course of the program (see Appendix I). The primary researcher then matched the OT competencies to the course objectives identified from the Graduate Student Handbook of the OT department (OT Department, 2017). For example, one of the competencies DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 33 states that Upon completion of the OT curriculum, the student will integrate knowledge from the liberal arts and sciences into OT practice (OT Department, 2017, p. 8). This competency was assigned a course objective from Functional Anatomy and Kinesiology (OTR 520) that read Apply concepts of biomechanics to movement. The OT competencies were recorded onto the mapping tool. The primary researcher aligned the columns and rows to improve readability of the tool. See Appendix I for the completed pilot map of the tool showing an example of the product. The researcher used color coding to reveal that the Blooms Taxonomy cognitive levels of each course objective increased in complexity from level 1 (demonstrate) to level 6 (create) from the first to the third semesters. It also revealed that five of the course objectives identified two cognitive levels. For example, one of the course objectives contained the verbs evaluate (level 5) and create (level 6). Discussion The primary purpose of this study was to establish a tool to map anatomy-related content in entry-level OT programs accredited by ACOTE. Anatomy was chosen because OT students and practitioners identify it as important to the development of clinical competency and the study of it provides essential knowledge for healthcare practitioners (Moxham & Plaisant, 2007; Schofield, 2014; Sbayeh et al., 2016). Despite the importance of anatomy to student learning (Guzman et al., 2015; Moxham & Plaisant, 2007), access to traditional methods of teaching anatomy, such as cadaver labs, is decreasing and educators are examining alternative methods of teaching students anatomy content (Agnihotri & Kalyan, 2013; Thomas et al., 2011). The primary researcher sought to create a tool to map anatomy-related content in entry-level DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 34 programs accredited by ACOTE because one does not exist (ACOTE, 2013; Carroll & Lawson, 2014; MacNeil & Hand, 2014). ACOTE identifies one standard related to anatomy so the primary researcher operationalized anatomy-related content more broadly to include the application of anatomyrelated concepts in practice. Anatomy was operationalized using the Blueprint to include personcentered factors (AOTA, 2010). Person-centered factors related to anatomy content include intrinsic aspects of the individual, such as perceptual, motor, and sensory skills. Knowledge of anatomy is needed for OT students and practitioners to gain competency in assessment, intervention planning, and activity analysis related to these intrinsic aspects of the individual (AOTA, 2010). Therefore, the operational definition of anatomy for this study included anatomy-related content consisting of person-centered factors (perceptual, motor, and sensory) included for assessment, intervention planning, and activity analysis. Those who disagree with this operational definition of anatomy, or who do not clearly see the link between anatomy and the person-centered factors, would not agree that this tool fulfills the purpose of mapping anatomy-related content. The mapping tool does not provide a measure of the anatomy content taught, such as bones, muscles, joints, and nerves. It implies that anatomy must be understood in order to provide assessment and intervention for person-centered factors. Faculty can use this tool to provide a structure to assess whether anatomy-related concepts are taught as they are identified in the course objectives. In a program without a designated anatomy course, such as the sample MSOT program in this study, faculty must make assumptions about the anatomy-related content. For example, one must agree that in order to analyze the effects of heritable diseases on the occupational performance of clients, as stated in a course objective from Biopsychosocial Dimensions of Adults (OTR 515), one must possess an DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 35 understanding of anatomy in a person without heritable diseases. The sample program integrated anatomy throughout the curriculum. In another example, a course objective was written as stating that a student will identify the muscles of the forearm which extend the wrist with 90% accuracy and implies that students know those specific muscles. In one course from the sample MSOT program, Applied Upper Extremity Intervention (OTR 525), an objective was written as stating that students will apply understanding of upper extremity knowledge to normal and abnormal movement patterns. Students do not have to identify correctly the muscles involved in those movements, but they must apply the anatomy knowledge. This sample MSOT program does not have a stand-alone anatomy course, nor did any of the course objectives measure anatomy content. However, the tool provided a structure to examine where and how anatomy-related content is taught in the curriculum. Future research comparing the mapping of the current sample program (with anatomy content integrated throughout the curriculum) with an OT program with a specific anatomy course would be useful to compare to this pilot mapping. Course instructors utilize verbs in course objectives to identify what students will be able to do by the end of the course. Six cognitive levels of verbs are identified in Blooms Taxonomy. The use of this taxonomy provided a way to demonstrate the scaffolding of the cognitive level of each objective over time (Krathwohl, 2002). The primary researcher devised a color-coded system to provide a visual representation of the scaffolding of the anatomy-related material (Appendix H). The tool was useful in identifying the progression of the course objectives, according to Blooms Taxonomy, to ensure that course content was presented at increasingly complex levels throughout the curriculum. All programs, even those using ACOTE standards as DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 36 course objectives, could use this visual representation to assess the cognitive level and progression of curriculum objectives. When using this tool, faculty can clearly see the progression of the cognitive level of the verbs (Appendix H). For example, in the model MSOT curriculum, the cognitive level of the courses in the first semester are two and three, understand and apply, which are color coded in blue. The cognitive level of the courses in the third semester are level six, create, which is color coded in green. See Appendix I for a visual representation of the progression of the cognitive levels of the course objectives in the model MSOT program. Engaging in the color coding process also helps faculty members determine if the verbs used in the course objectives align. For example, one of the course objectives in the model MSOT curriculum contained the verbs evaluate (level 5) and create (level 6). Requiring students to master two levels in one objective makes it difficult to design effective assessment measures. The tool can be useful as a first step to ensure that a variety of educational and assessment methods are utilized throughout the curriculum. It contains a section in which the faculty can map the educational and assessment methods utilized for each course. Faculty can use this information as a measure of content, and then compare it against resources describing best methods for each type of teaching (Thomas & Abras, 2016). For example, experiential learning, such as simulation, is an effective educational method to teach a demonstration skill, such as performing joint range of motion (Thomas & Abras, 2016). Through the use of the map, it was revealed that in Functional Anatomy and Kinesiology (OTR 520), simulation was used to teach this skill, and a lab test was identified as the most effective assessment method. Lecture was the main educational method identified in two of the practice courses, Biopsychosocial Dimensions of Adults (OTR 515) and Applied Upper DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 37 Extremity Intervention (OTR 525). According to Thomas and Abras (2016), lecture is appropriate in some cases for the cognitive problem-solving needed for practice courses. However, other methods (such as team-based, problem-based, and experiential learning) may be more appropriate. The information gained from this mapping was discussed with the members of the curriculum committee of this program and has been useful in the process of curriculum revision. The mapping process revealed to faculty the types of educational methods employed. Faculty can use this knowledge to better understand how they addressed anatomy-related content in the curriculum. Through the use of the tool, faculty are provided with a way to identify anatomy-related content, as defined by person-centered factors in a curriculum. The usefulness of the tool as a measure of the quality of the curriculum is dependent on the course instructors ability to write measurable course objectives, at the appropriate cognitive level, utilizing the most effective educational and assessment methods for each type of content. For example, a student must know anatomy (Blooms cognitive level 1), in order to apply the knowledge (Blooms cognitive level 3) and evaluate (Blooms cognitive level 5) the anatomy-related concepts as defined as person factors (e.g., physiological, sensory, and motor support) (Krathwohl, 2002) for OT practice. Five mapping studies were used to identify the components utilized in the tool designed for this study (Harden, 2001; Oyewumi et al., 2012; Plaza et al., 2007; Sellar et al., 2017; Watts & Hodgson, 2015). None of the other tools contained all of the components needed to map anatomy content related to specific ACOTE standards. The final mapping tool included: semester, course objective, assessment method, educational method, ACOTE standards, and OT competencies. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 38 This study builds upon the curriculum mapping study done by Sellar et al. (2017) who designed a tool to map OT content in Australia. Their tool utilized the Australian minimal competency standards to operationalize a successful OT student graduate (OT Australia, 2010). These standards include broad categories of skill, such as the ability to gather information and set goals, which are divided into performance criteria, such as the ability to gather information needed for assessment (OT Australia, 2010). Sellar et al. (2017) utilized these standards as student learning outcomes, which they linked to course objectives. The tool in this current study was also designed to link course objectives to student learning outcomes. In the usability mapping, these outcomes were operationalized as those developed by the OT department as the definition of an ideal graduate of the program (OT Department, 2017). Sellar et al. (2017) utilized Millers pyramid as a way for faculty to scaffold the level of learning of the course objectives, whereas the tool in this study utilized Blooms Taxonomy for scaffolding (Krathwohl, 2002). The tool created for this study is unique as it addresses anatomy-related content fulfilling ACOTE standards (ACOTE, 2013). This tool can be used to review course objectives, evaluate assessment and educational methods, to link course objectives to Blooms Taxonomy level, and to identify where in the curriculum students are learning the OT core competencies as defined by the OT program. In this study, the primary researcher used the student learning outcomes developed by the course faculty as the measure of OT competency (OT Department, 2017). To make the tool relevant to each program, faculty would need to operationalize OT competencies in the way which most closely aligns with their program philosophy. A future direction would be to create a tool to assess anatomy content in OT programs accredited by other bodies, such as the Canadian Occupational Therapy Regulatory DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 39 Organization. A similar process could be completed in which the researcher in a Canadian university links accreditation standards to course objectives and the competency standards for new graduates set forth by the university. The primary researcher found it was possible to design a tool to map content related to anatomy in entry-level OT programs in the United States. This tool gives an accurate measure of anatomy-related concepts if the course objectives are written to identify those concepts and if anatomy is operationalized in terms of person-centered factors. If the course objectives are not written to include anatomy, then the tool provides an indirect measure of it, and requires followup with course faculty to identify the exact scope of the anatomy being taught. The tool can still be used, but will require the extra step of seeking clarification from the faculty, a step which is essential to the accreditation review process. The process of completing the pilot-mapping tool was useful for curricular refreshment and re-accreditation. The process revealed that, due to course revisions, one course no longer fulfilled the ACOTE standard for which it was assigned. This information was useful to know when the program completed its interim accreditation report. The tool can be expanded to map an entire curriculum for program development or to inform preparation for re-accreditation. For example, the basic structure could be used and can be expanded to include all of the ACOTE B standards (ACOTE, 2010). This study successfully mapped the course objectives related to the specific ACOTE standards included in the tool. In future studies, every course objective for every course could be mapped. This tool can be adapted to evaluate other areas of OT entry-level programs. Future research expanding the tool to map all of the accreditation standards may be beneficial to faculty examining curriculum decisions. It could also be utilized for other professions, by replacing the DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 40 ACOTE standards with accreditation standards from other disciplines. Using the tool to complete a study comparing and contrasting two ACOTE accredited programs, with very different approaches to delivering anatomy content, would be useful. An example would be to compare the program in this study, which does not have a stand-alone anatomy course, to a program with a stand-alone anatomy course. The results could be examined in relation to student satisfaction and objective measures of success in OT school. All of the researchers in previous mapping studies, with the exception of Harden (2001), had multi-person teams developing the tools (Oyewumi et al., 2012; Plaza et al., 2007; Sellar et al., 2017; Watts & Hodgson, 2015). This structure allowed them to expand the scope of the tools (Plaza et al., 2007; Sellar et al., 2017) and have objective researchers examine curriculum content. For example, Plaza et al. (2007) mapped the entire pharmacy curriculum. This current study was completed by one researcher who chose anatomy to align with her teaching interest and the OT professions need to examine the scope of anatomy education (Carroll & Lawson, 2014; Schofield, 2014). This approach limited the scope of the tool and narrowed its usefulness. The tool gives a visual representation of the courses identified as fulfilling the ACOTE standards, and as a way to begin to evaluate the curriculum. It provides an indirect measure of anatomy and requires follow-up to measure anatomical concepts. The primary researcher chose courses to map anatomy content in an MSOT program for which she was a faculty member. This allowed access to the course materials necessary for mapping but may have led to assumptions not obvious to outside observers. She knew the curriculum well and may have identified content in the hidden curriculum not obvious to others examining the actual curriculum. For example, she teaches several of the courses in the curriculum, and knows that the discussion of heritable diseases such as diabetes, requires DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 41 knowledge of anatomy and physiology. To an independent researcher mapping this course content, those links may not be seen. They would only be noted if they were identified in the course objectives or through a discussion with the course faculty. This personal knowledge may have led the primary researcher in this study to conclude that this tool is a better measure of anatomy-related content than can be objectively measured. If the methodology of this current study had a step in which the researcher requested that faculty confirm the content taught in each course, the tool may have revealed more or less accurate measures of the curriculum content. Use of this tool can serve as an initial step in curriculum assessment. It was designed to map content related to ACOTE standards. For these courses, it provides a visual representation of the scaffolding of the content and the relationship among the course objectives, educational and assessment methods, and the OT competencies. To use the information learned from mapping to inform curriculum decisions to strengthen a program, further analysis would be needed. Study Limitations One limitation of this study was that the expert consultants were chosen through a network of faculty known to the primary researcher. Therefore, the sample may not have been representative of all faculty who teach in OT programs. The inclusion criteria specified only that the faculty teach full-time in an OT program, not that they had specific teaching experience with anatomy. These criteria may have affected the findings because faculty who teach the more advanced concepts related to practice may not equate them to anatomy-related knowledge. In future studies, it would be helpful to include participants with expertise more closely defined as relating to anatomy. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 42 Another limitation is that this study had only one primary researcher. Other curriculum mapping studies examined (Plaza et al., 2007; Sellar et al., 2017; Watts & Hodgson, 2015) had more than one researcher; hence, they had resources to map an entire curriculum. In addition, they were able to utilize objective faculty members and research assistants who did not teach any of the courses being mapped. Thus, they were able to map only the objective course content and not include hidden content. Conclusion The primary researcher in this study found that it was possible to design a useful tool that could be used by faculty to map anatomy-related content in entry-level OT programs accredited by ACOTE. Mapping can be time consuming and overwhelming to faculty members who may not feel competent in this skill. This mapping tool provides a structure for examining the curriculum to assist faculty with curriculum review. The tool can be useful as a first step to ensuring that a variety of educational and assessment methods are utilized throughout the curriculum. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 43 References Accreditation Council for Occupational Therapy Education. (2013). 2011 Accreditation council for occupational therapy education (ACOTE) standards. American Journal of Occupational Therapy, 66, S6-S74. doi: 0.5014/ajot.2012.66S6 Accreditation Council for Occupational Therapy Education. (2018). OT masters degree level self-study guide. 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American Occupational Therapy Association. (2018). Occupational therapy education research agenda: Revised. American Journal of Occupational Therapy, 68(Supplement 2), S1-S2. Beck, C.T., & Gable, R.K. (2001). Ensuring content validity: An illustration of the process. Journal of Nursing Measurement, 9(2), 201-215. Retrieved from DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 44 http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=11696942&site=e host-live&scope=site Carroll, M.A., & Lawson, K. (2014). The intermingled history of occupational therapy and anatomical education: A retrospective exploration. Anatomical Science Education, 7, 494-500. doi: 10.1002/ase.1451 Christiansen, C., & Baum, C. (1997). Understanding occupation: Definition and concepts. In C. Christiansen & C. Baum (Eds.), Occupational therapy: Enabling function and well-being (2nd ed., pp. 2-26). Thorofare, NJ: Slack. Cottrell, R.R., & McKenzie, J.F. (2011). Health promotion education & research methods: Using the five-chapter thesis dissertation model (2nd ed.). Sudbury, MA: Jones and Bartlett. DiIorio, C.K. (2005). Measurement in health behavior: Methods for evaluation and research. San Francisco, CA: Jossey-Bass. Fitzgerald, J. E., White, M. J., Tang, S. W., Maxwell-Armstrong, C. A., & James, D. K. (2008). Are we teaching sufficient anatomy at medical school? The opinion of newly qualified doctors. Clinical Anatomy, 21, 718-724. doi: 10.1002/ca.20662 Gabard, D. L., Lowe, D. L., & Chang, J. W. (2012). Current and future instructional methods and influencing factors in anatomy instruction in physical therapy and medical schools in the U.S. Journal of Allied Health, 41(2), 53-62. Retrieved from: https://une.idm.oclc.org/login?url=https://search-proquestcom.une.idm.oclc.org/docview/1348257253?accountid=12756 Guzman, C.R., Young, S., Rabedeaux, P., Lerner, S., Wimmers, P.F., Byus, C., & Wisco, J.J. (2015). Student perceived value of anatomy pedagogy, Part II: Clinical practice and DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 45 assessment. Journal of Medical Education and Curriculum Development, 2, 21-25. doi: 10.4137/JMECD.S17497 Harris, P.A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J.G. (2009). Research electronic data capture (REDCap) A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Information,42(2), 377-81. Retrieved from: https://projectredcap.org/resources/citations/ Harden, R.M. (2001). AMEE guide no. 21: Curriculum mapping: A tool for transparent and authentic teaching and learning. Medical Teacher, 23(2), 123-137. doi: 10.1080/01421590120036547 Helmer, O. (1967). Analysis of the future: The Delphi method. Retrieved from: file:///C:/Users/mpatnaude1/Downloads/P3558%20(1).pdf Hsu, C.C., & Sandford, B.A. (2007). The Delphi technique: Making sense of consensus. Practical Assessment, Research & Evaluation, 12(10), 1-7. Retrieved from http://pareonline.net/getvn.asp?v=12&n=10 Krathwohl, D.R. (2002). A revision of Blooms Taxonomy: An overview. Theory into Practice, 41(4), 212-218. Retrieved from: http://www.jstor.org/stable/1477405 Litaker, D., Cebul, R.D., Masters, S., Nosek, T., Haynie, R., & Smith, C.K. (2004). Disease prevention and health promotion in medical education: Reflections from an academic health center. Academic Medicine, 79(7), 690-697. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=15234923&site=e host-live&scope=site DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 46 MacNeil, C., & Hand, T. (2014). Examining occupational therapy education through faculty engagement in curriculum mapping and pedagogical reflection. American Journal of Occupational Therapy, 68, s12-s22. doi: 10.5014/ajot.2014.012286 McKenzie, J.F., Wood, M.L., Kotecki, J.E., Clark, J.K., & Brey, R.A. (1999). Establishing content validity: Using qualitative and quantitative steps. American Journal of Health Behavior, 23(4), 311-318. Retrieved from: http://web.b.ebscohost.com/ehost/detail/detail?vid=11&sid=796f865b-4d23-4b83-9261ed646c01c200%40sessionmgr101&bdata=JnNpdGU9ZWhvc3... Merritt, B.K., Blake, A., McIntyre, A.H., & Packer, T.L. (2012). Curriculum evaluation: Linking curriculum objectives to essential competencies. Canadian Journal of Occupational Therapy, 79(3), 175-180. doi: 10.2182/cjot.2012.79.3.7 Miller, G.E. (1990). The assessment of clinical skills/competence/performance. Academic Medicine, 65(9). S63-S67. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=2400509&site=eh ost-live&scope=site Moxham, B.J., & Plaisant, O. (2007). Perception of medical students toward the clinical relevance of anatomy. Clinical Anatomy, 20, 560-564. doi: 10.1002/ca.20453 Occupational Therapy Australia (2010). Australian minimum competency standards for new graduate occupational therapists. Retrieved from: https://www.otaus.com.au/sitebuilder/aboutus/knowledge/asset/files/16/australian_minim um_competency_standards_for_new_grad_occupational_therapists.pdf Ogard, W.K. (2014). Outcomes related to a multimodal human anatomy course with decreased cadaver dissection in a doctor of physical therapy curriculum. Journal of Physical DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 47 Therapy Education, 28(3), 21-26. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=103990012&site=eho st-live&scope=site OT Department (2017). Department of occupational therapy graduate student handbook, University of New England, Portland, ME. Retrieved from: https://www.une.edu/wchp/ot/graduate-program Otegui (2017). The future of anatomy. Argentine Journal of Clinical Anatomy, 9(2), 44-46. Retrieved from http://ajot.aota.org Oyewumi, M., Isaac, K., Schreiber, M., & Campisi, P. (2012). Undergraduate otolaryngology education at the University of Toronto: A review using a curriculum mapping system. Journal of Otolaryngology-Head & Neck Surgery, 41(1), 71-75. doi: 10.2310/7070.2011.110152 Phillips, A.W., Smith, S.G., & Strauss, C.M. (2013). Driving deeper learning by assessment: An adaptation of the revised Blooms Taxonomy for medical imaging in gross anatomy. Academic Radiology, 20(6), 784-789. doi: 10.1016/j.acra.2013.02.001 Plaza, C.M., Reierson, J.R., Slack, M.K., Skrepnek, G.H., & Sauer, K.A. (2007). Curriculum mapping in program assessment and evaluation. American Journal of Pharmaceutical Education, 71(2), 1-8. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=17533429&site=e host-live&scope=site Sbayeh, A, Qaedi Choo, M.A., Quane, K.A., Finucane, P. McGrath, D., O'Flynn, S.,O'Tuatheigh, C.M.P. (2016). Relevance of anatomy to medical education and DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 48 clinical practice: Perspectives of medical students, clinicians, and educators. Perspectives in Medical Education, 5, 338-346. doi: 10.1007/s40037-016-0310-4 Schofield, K.A. (2014). Anatomy in occupational therapy program curriculum: Practitioners perspectives. Anatomical Sciences Education, 7, 97-106. doi: 10.1002/ase.1378 Sellar, B., Murray, C.M., Stanley, M., Stewart, H., Hipp, H., & Gilbert-Hunt, S. (2017). Mapping an Australian OT curriculum: Linking intended learning outcomes with entry-level competency standards. Australian Journal of Occupational Therapy, 1-10. doi: 10.1111/1440-1630.12430 Summers, S. (1993). Establishing the reliability and validity of a new instrument: Pilot testing. Journal of Post Anesthesia Nursing, 8(2), 124-127. Retrieved from http://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=107466435&site=eho st-live&scope=site Thomas, K. J., Denham, B. E., & Dinolfo, J. D. (2011). Perceptions among occupational and physical therapy students of nontraditional methodology for teaching laboratory gross anatomy. Anatomical Science Education, 4, 71-77. doi: 10.1002/ase.208 Thomas, P.A. (2016). Goals and objectives. In A. Thomas, D.E. Kern, M.T. Hughs, & B. Chen (Eds.), Curriculum development for medical education: A six-step approach (3rd ed., pp. 50-64). Baltimore: Johns Hopkins University Press. Thomas, P.A., & Abras, C.N. (2016). Educational strategies. In A. Thomas, D.E. Kern, M.T. Hughs, & B. Chen (Eds.), Curriculum development for medical education: A six-step approach (3rd ed., pp. 65-101). Baltimore: Johns Hopkins University Press. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY Watts, L., & Hodgson, D. (2015). Whole curriculum mapping of assessment: Cartographies of assessment and learning. Social Work Education, 34(6), 682-699. doi: 10.1080/02615479.2015.1048217 Willett, T.G. (2008). Current status of curriculum mapping in Canada and the UK. Medical Education, 42, 786-793. doi: 10.1111/j.1365-2923.2008.03093.xI World Health Organization. (2003). International classification of functioning, disability, and health. Geneva: Author. 49 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 50 Table 1 Anatomy Identified in Blueprint for Entry-Level Education (AOTA, 2010) Person-Centered Factors Skills Area of Practice Physiologic Support Assessment Children and Youth Sensory Perceptual Support Intervention Planning Productive Aging Motor Support Activity Analysis Rehabilitation, Disability, and Participation Environmental Strategies Work and Industry Assistive Technology Mental Illness Self-Management strategies Health and Wellness Use of Virtual Tools DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 51 Table 2 Research Utilized to Devise Tool Components Component Area of Expertise Harden, 2001 X Oyewumi et al., 2012 X Specific Course Mapping X Course Objectives (Intended Learning Outcomes) X Professional Competencies Watts & Hodgson, 2015 X X X Accreditation Standards Scaffolding of Content (Blooms Taxonomy or Millers Level) Sellar et al., 2017 X Year in Which Course Occurs Assessment Methods/ Educational Methods Plaza et al., 2007 X X X X X X X DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 52 Table 3 ACOTE Standards and Identified Courses from Sample MSOT Program COURSE 1 COURSE 2 OTR 520 Functional Anatomy and OTR 525 Applied Upper Extremity Kinesiology Intervention B.2.2 OTR 505 Foundations of OT OTR 502 Analysis of Occupation B.2.6 OTR 502 Analysis of Occupation OTR 513 ACOTE Standard B.1.1 Biopsychosocial Dimensions of Mental Health and Wellness B.2.7 OTR 502 Analysis of Occupation OTR 614 Therapeutic Use of Self B.2.9 OTR 515 Biopsychosocial OTR 513 Dimensions of Adults Biopsychosocial Dimensions of Mental Health and Wellness B.4.2 B.4.4 OTR 529 Integrative Cases of OTR 610 Integrative Cases of Children Adults and Youth OTR 513L Interventions for Mental OTR 515L Interventions for Adults: Health and Wellness Adult Orthopedic and Neurological Intervention B.5.1 OTR 529 Integrative Cases of OTR 610 Integrative Cases of Children Adults and Youth DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 53 Appendix A Participant Consent Form University of New England. Consent for Participation in Research Project Title: Development of a Mapping Tool for Anatomy Education in Entry-Level OT Programs Principal Investigator(s): Mary Elizabeth Patnaude, MS, OTR/L Introduction: Please read this form. You may also request that the form is read to you. The purpose of this form is to give you information about this research study, and if you choose to participate, document that choice. You are encouraged to ask any questions that you may have about this study, now, during or after the project is complete. You can take as much time as you need to decide whether or not you want to participate. Your participation is voluntary. This study is being done as part of the requirements for the primary investigator to earn a Doctor of Health Science degree from the University of Indianapolis. The study participants are five full-time OT faculty with a minimum of three years' experience teaching full-time with some expertise in curriculum design and familiarity with accreditation standards of the Accreditation Council of OT Education (ACOTE). As part of the study, you will be asked to answer a three part survey on the validity of the tool being developed for curriculum mapping. In the first part, you will be asked to complete an open-ended survey on the completed instrument. The instrument will be revised based on this feedback. In the second part, you will be asked to rank each item of the revised survey on a four point Likert scale. The instrument will be revised again. In the third part, you will be asked for your final comments on the instrument. There are no risks or direct benefits for taking part in this study. Participation in this study will cost you approximately 4 hours of your time. Your privacy DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 54 will be protected by the removal of personal information from surveys. Data will be kept confidential by being collected and managed through a secure, web-based application, REDCap, which was specifically designed to store and analyze data in a secure manner for research. It will managed through the University of New England. Your participation is voluntary. Your decision to participate will have no impact on your current or future relations with the university. Your decision to participate will not affect your relationship with Mary Elizabeth Patnaude, MS, OTR/L. You may skip or refuse to answer any question for any reason. If you choose not to participate there is no penalty to you and you will not lose any benefits that you are otherwise entitled to receive. You are free to withdraw from this research study at any time, for any reason. If you choose to withdraw from the research there will be no penalty to you and you will not lose any benefits that you are otherwise entitled to receive. You will be informed of any significant findings developed during the course of the research that may affect your willingness to participate in the research. If you sustain an injury while participating in this study, your participation may be ended. You may choose not to participate. If you have any further questions, you may contact, the researcher conducting this study, Mary Elizabeth Patnaude, MS, OTR/L. For more information regarding this study, please contact mpatnaude1@une.edu. If you choose to participate in this research study and believe you may have suffered a research related injury, please contact Mary Elizabeth Patnaude, MS, OTR/L. If you have any questions or concerns about your rights as a research subject, you may call Olgun Guvench, M.D. Ph.D., Chair of the UNE Institutional Review Board at (207) 221-4171 or irb@une.edu. You will be given a copy of this consent form by request. Signature DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 55 Appendix B Initial Tool Template Basic Tenets/ Understanding Basic Clinical Science Course Course Objectives B.1.1 Semester 1 Semester 2 Semester 3 Screening, Evaluation, and Referral Intervention Planning OT Competencies Assessment Methods Educational Methods * B.2.2 B.2.6 B.2.7 B.2.9 B.4.2 B.4.4 B.5.1 B.5.6 1 2 3 1 2 3 1 2 3 Level of Bloom's Level 1 Remember Level 2 Understand Level 3 Apply Level 4 Analyze Level 5 Evaluate Level 6 Create Directions for completing tool 1) Choose courses in curriculum that primarily fulfill each ACOTE standard listed above 2) Place course in table under appropriate year 3) Type in each course objective 4) Color code each objective using the color coded schema provided 5) Use key provided to identify the educational method utilized to fulfill each course objective Total Percent of Total 0 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 56 Appendix C Word Document Containing Clarified Instructions I. Introduction to Tool 1) This tool is designed to align with the topic of person factors in OT education outlined in the Blueprint for Entry-level Education. The authors of the Blueprint identify the sciences related to this topic, one of which is anatomy, and discuss the skills needed to be developed in order to implement interventions related to person factors. Anatomy is identified as one of the sciences related to physiological, sensory/perceptual, and motor support of or impact on performance. The skills identified include those related to assessment and intervention planning. Therefore, the ACOTE standards chosen to be mapped relate to the science of anatomy and concepts related to anatomy that are utilized in assessment and intervention planning. In addition, this tool will give the user a visual of the scaffolding of content related to Blooms Taxonomy across the curriculum. II. Directions for Completing the Tool 1) Choose courses in the curriculum that primarily fulfill each ACOTE standard. 2) Place course in table under the appropriate semester type in each course objective, assessment method, and educational method utilized in each course. Examples of assessment methods may be lecture exam, practical exam, and presentation. 3) Color code each objective, based on the level of Blooms Taxonomy, using color coded schema provided. 4) Use the key provided to identify the educational methods utilized to fulfill each course objective. 5) Identify the program competencies related to each topic. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY III. 57 Blooms Taxonomy Color Coding: Color-code each cell adjacent to the course objectives, according to the following level of Blooms Taxonomy: Level of Blooms Definition of Level Color of Corresponding Cell Taxonomy Level 1: Remember Recall Information Level 2: Understand Explain Idea or Concept Level 3: Apply Use Information in Another Situation Level 4: Analyze Break Information Into Parts Level 5: Evaluate Justify a Decision or a Course of Action Level 6: Create IV. Generate a New Idea or Concept Educational Methods which may be utilized in OT Curriculum 1) Readings 2) Lectures 3) Online Resources 4) Discussion 5) Problem-Based Learning 6) Team-Based Learning 7) Peer Teaching 8) Real-Life and Supervised Clinical Experiences DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 58 9) Role Models 10) Demonstration 11) Simulation and Artificial Models 12) Role-Plays 13) Standardized Patients 14) Audio or Video Review of Learner 15) Behavioral/Environmental Intervention V. Sample of Completed Tool: The following chart may give you an example of how the tool may be completed. Semester 1 Course Course Objective Assessment Method(s) Educational Method Introduction to Anatomy Demonstrate knowledge and understanding of the structure and function of the human body Lab exam Simulation ACOTE Standard B.1.1 ACOTE Standard Example B.1.1 Demonstrate knowledge and understanding of the structure and function of the human body to include the biological and physical sciences. Course content must include, but is not limited to, biology, anatomy, physiology, neuroscience, and kinesiology or biomechanics. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 59 Appendix D Revised Tool for Round Two Patnaude Dissertation Survey Version 2 Thank you for taking part in this project and for completing the first survey. The following survey was developed based on the feedback given in the first survey. 1) Last Name __________________________________ 2) First Name __________________________________ University of New England Curriculum Tool Validation Part 2 Thank you for completing the first survey to validate the tool. Revisions were made based on the feedback given. Please complete the following survey based on the revisions made. The following documents provide a more in depth explanation of the use of the tool as well as a sample of how the tool may be completed. [Attachment: "Mapping Tool for ACOTE Standards Related to Person Factors in Entry Word Document.docx"] Please review the revised version of the tool before completing the following survey. [Attachment: "Mapping Tool for ACOTE Standards Related to Person Factors in OT.xlsx"] DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 60 The following section will ask for your feedback regarding the revisions made to the tool following the first survey. 3) Please provide your comments thoughts and feedback on the revised title of this tool. __________________________________ 4) Please suggest an alternative title if you feel it would be __________________________________ appropriate. 5) Does the explanation provided contribute to your Yes understanding of the purpose of the tool? No 6) Please comment on whether you feel the directions __________________________________ and explanation for the purpose of the tool are clear? This tool is designed to align with the topic of person factors in OT education as outlined in the Blueprint for Entry-level Education. The authors of the Blueprint identify the sciences related to this topic, one of which is anatomy, and discuss the skills needed to be developed in order to implement interventions related to person factors. Anatomy is identified as one of the sciences related to physiological, sensory/perceptual, and motor support of or impact on performance. The skills identified include those related to assessment and intervention planning. Therefore, the following ACOTE standards were chosen to be mapped related to the science of anatomy and concepts related to anatomy that are utilized in assessment and intervention planning. In addition, this tool will give the user a visual of the scaffolding of content related to Blooms Taxonomy across the curriculum. Please rate each item of the tool. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 7) 8) 9) 10) 11) 12) 13) 14) 1= Not Relevant 2= Somewhat Relevant Semester Number Course Course Objectives Assessment Methods Educational Methods ACOTE Section Headings (Re: Basic Tenets) OT Competencies Blooms Taxonomy Level 1 3= Relevant 4=Very Relevant Keeping in mind the explanation provided above, please rate the relevance of each of the following ACOTE standards to the validity of the tool. 1=Not Relevant 15) 16) 17) 18) 19) 20) 21) 22) 2=Somewhat Relevant 3=Relevant 4=Very Relevant B.1.1 Demonstrate knowledge and understanding of the structure and function of the human body to include the biological and physical sciences. Course content must include, but is not limited to, biology, anatomy, physiology, neuroscience, and kinesiology or biomechanics. B.2.2 Explain the meaning and dynamics of occupation and activity, including the interaction of areas of occupation, performance skills, performance patterns, activity demands, context (s) and environments, and client factors. B.2.6 Analyze the effects of heritable diseases, genetic conditions, disability, trauma, and injury to the physical and mental health and occupational performance of the individual. B.2.7 Demonstrate task analysis in areas of occupation, performance skills, performance patterns, activity demands, context(s) and environments, and client factors to formulate an intervention plan. B.2.9 Express support for the quality of life, well-being, and occupation of the individual, group, or population to promote physical and mental health and prevention of injury and disease considering the context (e.g., cultural, personal, temporal, virtual) and environment. B.4.2 Select appropriate assessments using appropriate procedures and protocols (including standardized formats) and use occupation for the purpose of assessment. B.4.4 Evaluate client(s) occupational performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, rest, sleep, leisure, and social participation. Evaluation or occupational performance using standardized and non-standardized assessment tools includes: the occupational profile, client factors, performance patterns, context, and performance skills. B.5.1 Use evaluation findings based on appropriate theoretical approaches, models of practice, and frames of reference to develop occupation-based intervention plans and strategies (including goals and methods to achieve them) on the basis of the stated needs of the client as well as data gathered during the evaluation process in collaboration with the client and others. Intervention plans and strategies must be culturally relevant, DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 62 reflective of current OT practice, and based on available evidence. Interventions address the following components: occupational profile, client factors, performance patterns, context, performance skills including motor and praxis skills, sensory-perceptual skills, emotional regulation skills, cognitive skills, and communication and social skills. Please review the following ACOTE standards in order the next question. [Attachment: "ACOTE Standards 2012.pdf"] 23) 24) Please add any ACOTE standards you feel are missing from the tool. Please list any items on which you would like further clarification. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 63 Appendix E Coding of Survey Theme Quote Additional The tool should include all ACOTE standards so that a program can map Information to ensure they have met them all- but maybe I am not understanding the function of the tool. Also please define OT competencies. Additional One thing I still feel this lacks is an explanation of why someone would Clarification use this tool; maybe a deeper rationale could be included in the introduction? The topic name seems relevant. Is it just for anatomy or for other courses? The introduction states it is for anatomy. I believe that evaluation and intervention planning are more relevant standards that seem to align more with practice based courses rather than core foundational science courses. I am still a little unclear. Is the purpose of this to look at accreditation standards? Or for mapping student progression or for overall mapping a particular curriculum? You have created a good tool that provides a crosswalk between ACOTE standards and Blooms learning objectives, but the connection of any of this to person factors you reference in the introduction is not clear. i.e. why would an OT educator use this tool? DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY Improvement in Under section IV. Educational Methods, you may want to consider Utility of Tool sorting those under the existing ACOTE-recognized categories of assessment. I like the concept of Blooms Taxonomy for scaffolding purposes, but maybe include a verb list so programs can ensure the correct level for their objectives. Positive The revisions definitely explain the tools more clearly. Comments I can see the evolution of this revision from the first draft. 64 DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 65 Appendix F Instructions for Completing Tool Version 3 Mapping Tool for ACOTE Standards Related to Person Factors in Entry-Level OT Curricula VI. Introduction to Tool This tool is designed to align with the topic of person factors in OT education outlined in the Blueprint for entry-level education. The authors of the Blueprint identify the sciences related to this topic, one of which is anatomy, and discuss the skills needed to be developed in order to implement interventions related to person factors. Anatomy is identified as one of the sciences related to physiological, sensory/perceptual, and motor support of or impact on performance. The skills identified include those related to assessment and intervention planning. Therefore, the ACOTE standards chosen to be mapped in this tool relate to the science of anatomy and concepts related to anatomy that are utilized in assessment and intervention planning. This tool can be adapted for use in other courses, by adding columns with additional ACOTE standards. An additional blank column is included in the tool to facilitate customization (See example below). In addition, this tool will give the user a visual of the scaffolding of content related to Blooms Taxonomy across the curriculum. VII. Directions for Completing the Tool Choose courses in the curriculum that primarily fulfill each ACOTE standard. Place the course in the table under the appropriate semester. Type in each course objective, assessment method, and educational method utilized in each course. Examples of assessment methods may be lecture exam, practical exam, and presentation. Color code each objective, based on the level of Blooms Taxonomy, using color coded schema provided. Use the key provided to identify the educational methods utilized to fulfill each course objective. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 66 Identify the program competencies related to each topic. Although these may be identified more specifically by each academic program, the following list may be helpful. Effective use of: activities and occupations, preparatory methods and tasks, education and training, advocacy, and group intervention. VIII. Blooms Taxonomy Color Coding: Color-code each cell adjacent to the course objectives, according to the following level of Blooms Taxonomy: Level of Blooms Taxonomy Level 1: Remember Level 2: Understand Level 3: Apply Level 4: Analyze Level 5: Evaluate Level 6: Create IX. Definition of Level Color of Corresponding Cell Recall Information Explain Idea or Concept Use Information in Another Situation Break Information Into Parts Justify a Decision or a Course of Action Generate a New Idea or Concept Educational Methods which may be utilized in OT Curriculum Readings Lectures Online resources Discussion Problem-based learning Team-based learning Peer Teaching Real-life and supervised clinical experiences Role models Demonstration DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 67 Simulation and artificial models Course Course Objective Assessment Educational ACOTE Additional OT Method(s) Method Standard Standards Competencies B.1.1 Semester Introduction Demonstrate1) Lab test Simulation Preparatory 1 to Anatomy knowledge methods and understanding of the structure and function of the human body. Role-plays Standardized patients Audio or video review of learner Behavioral/environmental intervention X. ACOTE Assessment Methods 1. Assignment 2. Project 3. Lab Test 4. Presentation 5. Objective Test 6. Demonstration 7. Essay test 8. Other XI. Sample of Completed Tool: The following chart may give you an example of how the tool may be completed. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 68 ACOTE Standards B.1.1 Demonstrate knowledge and understanding of the structure and function of the human body to include the biological and physical sciences. Course content must include, but is not limited to, biology, anatomy, physiology, neuroscience, and kinesiology or biomechanics. B.2.2 Explain the meaning and dynamics of occupation and activity, including the interaction of areas of occupation, performance skills, performance patterns, activity demands, context (s) and environments, and client factors. B.2.6 Analyze the effects of heritable diseases, genetic conditions, disability, trauma, and injury to the physical and mental health and occupational performance of the individual. B.2.7 Demonstrate task analysis in areas of occupation, performance skills, performance patterns, activity demands, context(s) and environments, and client factors to formulate an intervention plan. B.2.9 Express support for the quality of life, well-being, and occupation of the individual, group, or population to promote physical and mental health and prevention of injury and disease considering the context (e.g., cultural, personal, temporal, virtual) and environment. B.4.2 Select appropriate assessments using appropriate procedures and protocols (including standardized formats) and use occupation for the purpose of assessment. B.4.4 Evaluate client(s)' occupational performance in activities of daily living (ADLs), instrumental activities of daily living (IADLs), education, work, play, rest, sleep, leisure, and social participation. Evaluation or occupational performance using standardized and nonstandardized assessment tools includes: the occupational profile, client factors, performance patterns, context, and performance skills. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 69 B.5.1 Use evaluation findings based on appropriate theoretical approaches, models of practice, and frames of reference to develop occupation-based intervention plans and strategies (including goals and methods to achieve them) on the basis of the stated needs of the client as well as data gathered during the evaluation process in collaboration with the client and others. Intervention plans and strategies must be culturally relevant, reflective of current OT practice, and based on available evidence. Interventions address the following components: occupational profile, client factors, performance patterns, context, performance skills including motor and praxis skills, sensory-perceptual skills, emotional regulation skills, cognitive skills, and communication and social skills. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 70 Appendix G Final Survey Confidential Page 1 of 1 Patnaude Dissertation Survey Part 3 Thank you for completing the previous survey. Edits were made to the tool and the instructions for completing the tool in response to the previous survey. This is the final request for comments. Please provide any final thoughts you may have on the current version of this survey. 1) First Name __________________________________ 2) Last Name __________________________________ Please review the revised mapping tool in order to answer the survey question. [Attachment: "Mapping Tool for ACOTE Standards Related to Person Factors in OT_Revised_09_13_18.xlsx"] Please review the revised instructions and sample tool to answer the survey questions. [Attachment: "Mapping Tool for ACOTE Standards Related to Person Factors in Entry_Revised_09_13_18.docx"] 3) After reviewing the revised instrument and instructions, please provide final comments and/or Revisions you would like to be made. DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY 71 Appendix H Blooms Taxonomy Color Coding Color-code each cell adjacent to the course objectives, according to the following level of Blooms Taxonomy: Level of Blooms Taxonomy Definition of Level Level 1: Remember Level 2: Understand Level 3: Apply Level 4: Analyze Level 5: Evaluate Recall Information Explain Idea or Concept Use Information in Another Situation Break Information Into Parts Justify a Decision or a Course of Action Generate a New Idea or Concept Level 6: Create Color of Corresponding Cell DEVELOPMENT OF A MAPPING TOOL FOR ANATOMY Appendix I Final Completed Tool With Usability 72  ...

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SPORT VARIABLES AND STRESS URINARY INCONTINENCE IN NULLIPAROUS COLLEGIATE ATHLETES Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Rebecca Parr, PT, DPT, OCS Copyright June 29, 2021 By: Rebecca Parr, PT, DPT, OCS All rights reserved Approved by: Edward Jones, PT, DHSc Committee Chair ______________________________ Heidi Ewen, Ph.D., FGSA, FAGHE Committee Member ______________________________ Carol Figuers, MS, PT, EdD Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Sport Variables and Stress Urinary Incontinence in Nulliparous Collegiate Athletes Rebecca E. Parr Interprofessional Health and Aging Studies, University of Indianapolis 1 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Abstract Female athletes have significantly higher prevalence rates of SUI than their nonexercising peers. While exercise appears to be protective against many other disease conditions, it may be linked to the development of SUI in an otherwise healthy population. The purpose of this study was to explore the influence of sports characteristics on SUI in nulliparous female collegiate athletes. A non-experimental study using a cross-sectional design in the form of an online survey explored whether the prevalence of SUI in nulliparous collegiate athletic women was related to the impact and intensity of the sport, training volume, and athlete demographic and training characteristics. Two hundred and nine female nulliparous athletes at Division II universities participated in the study. Nonparametric testing revealed athletes participating in high impact sports demonstrated greater SUI rates and severity than low and moderate impact sports (p=.03). Other variables associated with an increase in SUI were participation in vigorous physical activity >5days/week (p=.037), and a BMI>25 (p=.05). Athletes with a high BMI or those engaging in high intensity and high impact activity most days of the week have a greater need for pelvic floor muscle training, to strengthen and maintain pelvic floor muscle function to prevent SUI. Efforts are needed for education and early prevention to mitigate development of SUI in this population. Keywords: stress urinary incontinence, incontinence, female athlete 2 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 3 Acknowledgements The completion of this study, and the Doctor of Health Science (DHSc) program, would have been impossible if not for the support and encouragement of a few key individuals. I would like to express my heartfelt thanks and appreciation to them as I near the end of my academic journey at the University of Indianapolis DHSC program. I would like to thank my committee chair, Dr. Ed Jones, for his guidance through each stage of the dissertation journey. He was supportive of my ideas and encouraged me throughout the process, even when things deviated from my original plan. I would like to convey my gratitude to my other committee members, Dr. Heidi Ewen and Dr. Carol Figuers, for their insightful comments and suggestions. Their guidance improved this manuscript significantly and helped me clarify my ideas. I would also like to thank Dr. Laura Santurri. She served as a mentor to me throughout the program. Her profound belief in my abilities gave me the strength to complete this degree and my study, even amongst challenges, including the birth of a child and a global pandemic. Finally, I would like to thank my family, especially my parents and my husband, Dustin Parr. Their unwavering support encouraged me to keep going, even when I felt overwhelmed. Without their tremendous understanding and encouragement over the past few years, it would have been impossible for me to complete my study. SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Table of Contents Sport Variables Effect on Stress Urinary Incontinence in Nulliparous Collegiate Athletes Problem Statement Purpose Statement Research Questions Objectives Significance of the Study Literature Review Definitions of Incontinence Incidence and Prevalence of UI in the Population Prevalence of SUI among Athletic Population Anatomy and Physiology of Continence Micturition in Males vs. Females SUI Pathophysiology Risk Factors for SUI Risk Factors for Females Risk Factors for Female Athletes Pelvic Floor Muscle Training in Athletes Conclusion Method Study Design Participants Sample Size Data Operationalization of Variables Instruments Incontinence Questionnaire Urinary Incontinence Short Form International Physical Activity Questionnaire Short Form (IPAQ SF) Procedures Recruitment Informed Consent Data Collection Data Management Statistical Analysis Results General Participant Characteristics Sport Specific Characteristics Urinary Incontinence Characteristics Research Question 1 Research Question 2 Research Question 3: Research Question 4 Discussion 4 6 7 7 7 8 8 9 9 10 10 10 12 12 13 13 14 23 23 24 24 24 24 25 25 26 26 27 28 28 29 29 30 30 32 33 33 34 34 35 35 36 36 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Prevalence and Impact of SUI Impact Level Intensity BMI Disordered Eating Limitations Table 1 Table 2 Figure 1 Figure 2 Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F 5 38 38 39 40 41 42 62 63 64 65 66 67 68 70 73 81 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 6 Sport Variables Effect on Stress Urinary Incontinence in Nulliparous Collegiate Athletes While urinary incontinence (UI) encompasses all types of urine leakage, stress urinary incontinence (SUI) is specific to the involuntary loss of urine during coughing, sneezing, or physical activity (Haylen et al., 2010). SUI affects 16-35% of all adult women, with the primary risk factors being older age, obesity, pregnancy, parity, vaginal delivery, diabetes mellitus, and genetic conditions (Stothers & Friedman, 2011). In young women, the rate is lower as these risk factors are less commonly present (Minassian et al., 2017). While most young women are not affected by SUI, female athletes have significantly higher prevalence rates than their non-exercising peers (Almeida et al., 2016; Carvalhais et al., 2019), with 31.6% reporting urinary leakage (Almousa & Bandin Van Loon, 2019). This is more than double the rate seen in the general female population age 20-29 years (Bedretdinova et al., 2016). When athletes participate in high-impact and/or intensity sport, they are almost three times more likely to experience SUI than non-exercising peers (Almeida et al., 2016; Da Roza et al., 2015). While exercise appears to be protective against many other disease conditions, it may be linked to the development of SUI in an otherwise healthy population. Women who suffered from UI during sport are more likely to have continued and more severe leakage decades later (B & SundgotBorgen, 2010). Female athletes who experience this condition have worse quality of life scores (Alves et al., 2017; dos Santos et al., 2019; Hagovska et al., 2017; Hagovska et al., 2018) and generally limit their physical activity. In a study of physically active women, 90.3% of those with SUI decreased their exercise intensity, and 80.7% avoided certain activities to avoid leakage (Brennand et al., 2018). SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 7 Problem Statement Many female athletes with SUI are nulliparous and lacking traditional risk factors for the development of SUI. Research to date has focused primarily on investigating prevalence rates of UI in athletes. While prevalence rates help establish hypotheses for athletic SUI based on sport characteristics, causation has not been determined. Studies that have investigated potential risk factors have displayed mixed results. For example, some studies have shown high impact sports have a greater influence on SUI than low impact sports (Carvalhais et al., 2018; Da Roza et al., 2015a), while other studies have reported no differences among sports with varying impact forces (B & SundgotBorgen, 2010; dos Santos et al., 2018). While some studies have attempted to determine the risk factors for SUI in the athletic population, initial results have been inconclusive (Brennand et al., 2018; Elks et al., 2020; Wikander et al., 2019). Additional research is required to better understand the prevalence and risk factors for this condition, considering a range of potential factors. Purpose Statement The purpose of this study is to explore the influence of specific sports characteristics on SUI in nulliparous female collegiate athletes. Research Questions This study of nulliparous female collegiate athletes will address the following research questions: 1. Is there a significant difference in stress urinary incontinence between athletes who play a high impact sport compared to athletes who play a low or medium impact sport? 2. Is there a significant difference in stress urinary incontinence between athletes who play high-intensity sports compared to athletes who play lower-intensity sports? SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 8 3. Is stress urinary incontinence related to training volume in athletes? 4. Is stress urinary incontinence related to athlete demographics or training variables? Objectives To answer the research questions, the following objectives will be investigated by the authors: 1. Determine the prevalence of SUI among nulliparous female collegiate athletes, measured with the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form (ICIQ-UI SF) scale. 2. Determine if there is a significant difference in rates and severity of SUI among nulliparous female collegiate athletes who play high, medium, or low impact sports. 3. Determine if there is a significant difference in rates and severity of SUI among varying intensity levels of athletics in nulliparous collegiate athletes, as measured with the International Physical Activity Questionnaire Short Form (IPAQ SF). 4. Determine if there is a significant difference in SUI based on training volume, measured in time spent on sport training (practice or competition) over the past seven days. 5. Determine if there is a correlation between SUI rates to nulliparous female collegiate athlete characteristics, such as BMI or disordered eating. Significance of the Study This study investigated the role of impact, intensity, training volume, and other demographic and training variables as risk factors for nulliparous female athletes with stress urinary incontinence, which could lead to improved screening and preventative treatment for this condition. With early identification, rapid intervention could potentially prevent SUI from SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 9 progressing to more significant incontinence later in life, when females may experience greater risk factors such as increased age, parity, and weight gain (High et al., 2020; Stothers & Friedman, 2011). Understanding the risk factors of SUI among the athletic population could guide coaches and health professionals to develop prevention and treatment strategies for this condition. Utilizing these preventative strategies could reduce the rate of developing SUI among young female athletes and subsequently improve quality of life. Literature Review Female athlete participation in sports has drastically increased since Title IX of the Educational Amendments passed in 1972, eliminating sex-based discrimination in sports (United States Department of Justice, 2015). The number of female collegiate athletes increased from almost 30,000 in 1972 to 280,721 athletes in 2019 (Irick, 2019). As more women are playing sports, greater attention must be paid to health concerns that may differ from their male counterparts, such as urinary incontinence. Definitions of Incontinence The International Continence Society and the International Urogynecological Association define urinary incontinence (UI) as the involuntary loss of urine, encompassing various subtypes (Haylen et al., 2010). Subtypes include urgency incontinence, associated with an incontrollable urge to urinate; stress incontinence, classified as the involuntary loss of urine as a result of physical effort, such as coughing, sneezing, or exercise; mixed incontinence, a combination of stress and urge incontinence; postural incontinence, associated with a change in body position; nocturnal enuresis, loss of urine during sleep; coital incontinence, where loss of urine occurs during coitus; continuous incontinence, in which there is a continuous loss of urine; and SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 10 insensible incontinence, in which the individual is not sure how the incontinence occurred (Haylen et al., 2010). Stress urinary incontinence (SUI) will be the focus of this study. Incidence and Prevalence of UI in the Population The prevalence rates of urinary incontinence vary widely by sampling and data collection strategies and the definition of urinary incontinence used. UI is much more common in females than males, with SUI being the most common form of UI (Milsom & Gyhagen, 2019). SUI affects 10-13% of women, with prevalence peaking during the 5th decade (Milsom & Gyhagen, 2019; Minassian et al., 2017). In women under 40 years of age, fewer than 2 in 1,000 are affected (Aoki et al., 2017). In a study of nulliparous (never having given birth) university students, aged 18-28 years, only 3.2% experienced SUI (Ural et al., 2020). Prevalence of SUI among Athletic Population The prevalence of UI increases significantly in athletes, with rates of SUI varying from 21% to 44% (de Mattos Lourenco et al., 2018; Pires et al., 2020; Teixeira et al., 2018). Among nulliparous athletes, prevalence rates of SUI are 10.3% - 61.1%, with a mean rate of 31.6% (Almousa & Bandin Van Loon, 2019). Urinary incontinence in the athlete appears to vary depending on definitions used and data collection methods (Almousa & Bandin van Loon, 2018). It is also dependent on the sports activity and various other risk factors (Almousa & Bandin Van Loon, 2019; Hagovska et al., 2018; Pires et al., 2020). It is critical to determine the risk factors for developing this condition in young female athletes to design appropriate prevention activities. Anatomy and Physiology of Continence Urinary continence is established through a complex coordination of neural, vascular, muscular, and connective tissue support. Injury to any of these components involved in the urethral closure system can lead to SUI (Bo et al., 2014; Mistry et al., 2020). SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 11 The urinary tract receives automatic parasympathetic and sympathetic innervation from the second through fourth sacral nerve roots (S2-S4) of the spinal cord (Mistry et al., 2020). The pudendal nerve, which also originates from S2-S4, is responsible for voluntary (somatic) control of pelvic floor musculature (Mistry et al., 2020). The bladder neck and urinary sphincters comprise the primary urethral sphincteric closure system. The bladder neck is structurally continuous with the proximal urethra, and two sphincters are present in this space, the internal urethral sphincter (IUS), the external urethral sphincter (EUS) (Mistry et al., 2020). The IUS contains smooth muscle and operates under involuntary control, while the EUS is composed of striated muscle and is under voluntary control (Jung et al., 2012). The urethra lies on top of the endopelvic fascia and anterior vaginal wall (in females) and has a lateral attachment through the arcus tendinous fascia. The arcus tendinous fascia runs from the pubic bone to the ischial spine. The levator ani muscle group lies lateral, and the obturator internus muscle lies posterior to the arcus tenineus fasciae pelvis and endopelvic fascia. The bladder maintains a low-pressure environment during the storage phase by inhibiting the parasympathetic input (Mistry et al., 2020). As the bladder stretches, a spinal reflex activates contraction of the IUS as well as co-activation of EUS via the pudendal nerve (Mistry et al., 2020). The sphincteric system automatically contracts in response to bladder filling (Vignoli, 2018). When the threshold has been reached, a signal of the desire to void is sent to the prefrontal cortex, and an individual determines whether to act on that information (Vignoli, 2018). Due to the training received in childhood, adults can consciously control when urination (micturition) occurs, such as when in a socially appropriate setting (Vignoli, 2018). When micturition is desired, the micturition reflex is activated, an inhibitory message is sent to the somatic center, and a stimulatory message is sent to the parasympathetic center (Mistry et al., SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 12 2020). Thus, the pelvic floor musculature, including the EUS, levator ani group, and IUS, relaxes, and urine can flow outward from the bladder through the urethra. Continence is maintained when the urethral closure pressure is greater than the pressure from the bladder (Bo et al., 2014; Vignoli, 2018). At rest, the urethra maintains closure from the urethral smooth muscular wall and appropriate innervation (Mistry et al., 2020). When pressure increases in the abdomen, such as during a cough, the bladder pressure increases, and the urethral closure must also rise to prevent incontinence (Bo et al., 2014). During these times of added force, pelvic floor musculature also contracts and compresses the urethra to add additional support to maintain continence (Bo et al., 2014; Minassian et al., 2017; Mistry et al., 2020). Micturition in Males vs. Females Voiding mechanisms differ in males versus females due to anatomical differences. The male urethra travels through the penis and is approximately 20 cm, while the female urethra travels above the vaginal opening and is approximately 4 cm long (Abelson et al., 2018). In men, the detrusor muscle of the bladder is very thick and contracts forcefully to move urine through the urethra, as there is significant resistance (Abelson et al., 2018; Vignoli, 2018). In women, there is very little resistance in the urethra; thus, the detrusor muscle is thinner as it does not need to contract much for urine to flow (Abelson et al., 2018; Vignoli, 2018). Instead, micturition is largely achieved by relaxation of the pelvic floor muscles (60% of women) over detrusor muscle contraction (20% of women) (Vignoli, 2018). SUI Pathophysiology SUI has a complex etiology, with various factors influencing its development. More women are affected than men, and there is usually a problem with the closing mechanism of the urinary sphincteric system (Jung et al., 2012). Passive insufficiency from lack of structural SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 13 support could occur when muscles lose stiffness due to excessive stretching or injury, or there is a lack of innervation to the tissues for appropriate contraction to occur (Ashton-Miller et al., 2001). Additionally, overactive opening due to sphincteric mechanism malfunction could also lead to urethral insufficiency (Teleman et al., 2003). Overall, for the urethra to stay closed, the urethral pressure must be equal to or exceed the abdominal pressure. Additionally, there must be appropriate neural and vascular supply to tissues, functioning striated and smooth sphincteric musculature, proper alignment of structures, and an intact vaginal wall for support (Abrams et al., 2017). Risk Factors for SUI Risk Factors for Females A variety of risk factors have been reported for SUI, such as increased number of pregnancies, parity, age, obesity, and physical activity (Milsom & Gyhagen, 2019). Half of all pregnant women develop UI during pregnancy; however, it largely resolves after childbirth, with only 7-15% having continued incontinence at three months postpartum (Abrams et al., 2017). Vaginal birth is also a significant risk factor for SUI. During vaginal childbirth, there may be trauma to the pelvic floor musculature, fascia, nerve, or vasculature from the process of parturition or the position of the baby (Abrams et al., 2017). There may also be direct injury to the urethra during this process, as well as partial denervation to the pudendal nerve, responsible for innervation of the EUS (Abrams et al., 2017). In a longitudinal study, women who had vaginal births compared to women with cesarean births had significantly lower pelvic floor muscle strength and were more likely to develop SUI within twenty years from childbirth (Blomquist et al., 2020). Vaginal childbirth has been shown to have a 71% higher prevalence of UI than delivery by cesarean (Gyhagen et al., 2013). Obesity is also a significant predictor, with SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 14 an 8% increased risk per one BMI unit (Gyhagen et al., 2013). As women age, they lose muscle thickness of the pelvic floor, including the EUS, which may impact closure pressure (Bo et al., 2014). Risk Factors for Female Athletes Female athletes have been found to have a 2.5-2.77 times greater risk of SUI than sedentary women (Da Roza et al., 2015a; Teixeira et al., 2018). There are two main theories observed in the literature for this increased risk, as first reported by Bo (2004). The first theory suggests increased intra-abdominal pressure from athletic activities results in weakness and deformation of the pelvic floor musculature. The second theory suggests athletes have strong pelvic floor muscles, but the intra-abdominal pressure from impact causes incontinence. Studies investigating both hypotheses have shown mixed results, and additional factors have been suggested. At this time, potential risk factors for exercise-related incontinence have been reported to include impaired pelvic muscle strength, diminished muscle endurance, involvement in high impact activities, high-intensity exercise, high training volume, and factors related to impaired energy such as relative energy deficiency syndrome (RED-S) (Almousa & Bandin Van Loon, 2019; B, 2004; Carvalhais et al., 2018, 2019; Da Roza et al., 2015a; Ree et al., 2007; Simeone et al., 2010; Whitney et al., 2019). Muscle Strength. In Bos (2004) first theory, urinary leakage can occur due to weakness of the pelvic floor musculature. Pelvic floor strength has been posited to decrease due to the excessive loading that progressively weakens the pelvic floor musculature (B, 2004), but subsequent studies have reported mixed findings. Some studies support this hypothesis, showing non-exercisers to have greater perineal strength than athletes (da Silva Borin et al., 2013), while some have shown no difference in muscle strength (Carvalhais et al., 2018; Middlekauff et al., SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 15 2016). Still, others demonstrated the opposite, with increased cross-sectional area and thickness of the pelvic floor musculature (Da Roza et al., 2015a, 2015b) and greater maximal pelvic floor strength compared to sedentary women (de Araujo et al., 2015). While athletes had higher pelvic floor strength, which should, in theory, provide greater support to the urethral closure mechanism, they also had a significantly higher rate of UI (de Araujo et al., 2015). Additionally, multiple studies have shown no correlation between urinary leakage and pelvic floor muscle strength (Da Roza et al., 2015; de Araujo et al., 2015; de Melo Silva et al., 2020). Dias and colleagues (2017) performed a simulated study measuring pelvic floor deformation from a nulliparous female with increased muscle distensibility during a drop jump. Their results indicated decreased levator ani stiffness caused only small changes in urethral mobility during the high impact activity, indicating strength or stiffness of the pelvic floor musculature does not play a significant role in impaired urethral closure in athletes (Dias et al., 2017). This evidence contradicts Bos first theory as muscle strength does not appear to be a primary factor in the mechanism for urinary incontinence during athletics; thus, other risk factors must be explored. Muscle Endurance. Pelvic floor muscles are skeletal muscles and contain both type 1 and type 2 muscle fibers. Type 1 fibers contract slowly but have great endurance. These muscle fibers are responsible for maintaining postural tone and compose 70% of the pelvic floor musculature (Marques et al., 2010). The other 30% are type 2, quick contracting fibers. This fiber type contracts rapidly but also fatigues quickly and is designed for turning on during explosive and rapid movements like running and jumping (Marques et al., 2010). While the pelvic floor is comprised predominantly of type 1 slow-twitch fibers, they are not completely resistant to fatigue (Teng et al., 2018). SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 16 Hodges and colleagues (2010) suggested that pelvic floor musculature may experience greater central fatigue versus peripheral fatigue experienced in limb musculature. They suggested this may be due to diminished excitability of the descending pathways from the motor cortex, which serves to prevent fatigue of voluntary pelvic floor muscle function. Thus effort may be reserved for involuntary efforts to maintain continence (Hodges et al., 2010). Middlekauff and colleagues demonstrated an immediate lowering effect on the pelvic floor, indicating decreased support, after both strenuous and nonstrenuous exercise (2016). In a landmark study on nulliparous women with SUI, Ree and colleagues (2007) determined the pelvic floor musculature experienced short-term fatigue following 90 minutes of strenuous physical exercise. Wikander supported this finding, determining powerlifting athletes reported greater leakage after repetitive heavy lifts (2019). A large percentage of elite (55.6-98%) and high school (43%) athletes also experienced UI in the middle or end of training or competition (Carvalhais et al., 2018; Logan et al., 2018; Skaug et al., 2020). In a recent systematic review, both high impact and low impact sports had similar UI prevalence rates, although the type of UI was not reported (Teixeira et al., 2018). Muscle fatigue may explain the presence of UI in low-impact activities. Simeone et al. (2010) posited that maintaining constant pressure on the pelvic floor musculature over long periods sustains a greater risk of incontinence than impact alone. Repeated intra-abdominal pressure may create fatigue in the pelvic floor muscle, reducing the efficacy of the continence mechanism. While muscular fatigue is certainly a potential hypothesis for athletic incontinence, there are no standardized physical examinations or urodynamic methods for measuring fatigue. Thus only indirect signs of fatigue can be evaluated (Teng et al., 2018). SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 17 Impact. Bos (2004) second theory on impact appears to have more support in the literature. In addition to supporting bowel and bladder continence, the pelvic floor musculature also dissipates shock from the lower limbs to the spine (Casey & Temme, 2017). In a novel study by Nygaard and colleagues (1996), nulliparous collegiate athletes who experienced UI during sport had decreased ability to dissipate ground reaction forces in the arches of the feet, which they extrapolated to a diminished ability of the pelvic floor to dissipate shock as well. Alves and colleagues (2017) performed a study investigating the role of impact on nulliparous athletes and determined 55.5% of the women who reported any type of UI played high impact sports while 44.5% played low impact sports. The high-impact athletes in the study reported a greater frequency of UI, which was statistically significantly greater than those playing low-impact sports. The authors also found a greater volume of physical activity was correlated with increased leakage (Alves et al., 2017). A recent systematic review corroborated the higher prevalence of UI in high-impact sports versus low-impact sports (58.10% vs. 12.48%, respectively) (de Mattos Lourenco et al., 2018). Sports with the highest prevalence were trampolining, gymnastics, dancing, volleyball, and basketball (Abrams et al., 2017; Da Roza et al., 2015a; Hagovska et al., 2018; Schettino et al., 2014; Simeone et al., 2010; Vitton et al., 2011). Females who participated in high-impact exercise were eight times more likely to report involuntary urine loss than non-exercisers (Almeida et al., 2016). Movements that appeared to provoke urinary leakage were activities exhibiting greater ground reaction forces such as jumping, running, dismount landings, and highintensity interval training exercise (Almousa & Bandin Van Loon, 2019; Brennand et al., 2018; Vitton et al., 2011). Double unders or triple unders (when a jump rope passes two or three times under the feet when jumping rope), box jumps, and jumping rope were noted as top SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 18 provocative activities (Dobrowolski et al., 2020; Yang et al., 2019). These high-impact activities can create higher forces that can be transmitted to the pelvic floor, stressing tissues and affecting the continence mechanism (Almousa & Bandin Van Loon, 2019; Teixeira et al., 2018). However, athletes in sports exhibiting no impact, such as swimming and weightlifting/powerlifting, also experienced athletic incontinence, which is not consistent with the impact hypothesis (Elks et al., 2020; Wikander et al., 2019). Bo and Borgen (2010) also did not identify differences in UI rates among low, medium, and high impact activities among former elite athletes, which is inconsistent with the impact hypothesis. Thus, impact requires additional investigation as a risk factor for SUI in the athletic population. Intensity. In a sample of nulliparous athletes, intensity was found to be a significant risk factor for UI, with high-intensity activities correlating with greater UI (Hagovska et al., 2018). High intensity was defined as greater than 3,000 MET minutes/week using the International Physical Activity Questionnaire (IPAQ), a validated physical activity intensity assessment (Craig et al., 2003). While Alhababi and colleagues (2019) reported there was no change in SUI prevalence among middle-aged women performing high-intensity exercise versus all intensity levels, they defined high intensity as 32.2 MET hours/week, which falls in the moderate MET range as classified by the IPAQ. Thus, this study may have failed to capture the true effect of high-intensity exercise on SUI. A study of CrossFit athletes conducted during quarantine from the COVID-19 pandemic, when CrossFit gyms were inaccessible, showed CrossFit athletes decreased intensity of their workouts by 64% and had a subsequent 14% decrease in UI (de Araujo et al., 2020). This finding supports intensity of exercise as a risk factor for the development of SUI. SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 19 Intra-abdominal Pressure. High-impact activities, such as running or jumping, creates rapid increases in intra-abdominal pressure (IAP), as does lifting weights (Goldstick & Constantini, 2014). Pelvic floor musculature ideally responds automatically to the increased IAP with a concentric contraction to keep the urethral sphincter closed against the vaginal fascia by mechanical compression (Casey & Temme, 2017). If abdominal pressure rises suddenly, the external urethral sphincter, comprised of mostly type 1 slow-twitch or endurance fibers, may not be able to react in time to match the external pressure, and the urethra will not remain closed. IAP increases with increased speed, intensity, and greater loads to stabilize the spine and protect against high acceleration impact forces (de Gennaro et al., 2019; Dietze-Hermosa et al., 2020). During athletics that involve rapid change of direction movements, running, and tackles, such as rugby, players have reported high (54%) rates of UI. Those experiencing UI reported that urine loss occurs most frequently during competition (90%) and during tackles (88%), and less commonly during running (41%) and weightlifting (18%) (Sandwith & Robert, 2021). Tackling generates a higher IAP than running and is often unexpected, thus type 1 fibers may be unable to react in time. A game situation involving running, tackling, and rapid change of direction movements may overwhelm the pelvic floor, promoting UI (Sandwith & Robert, 2021). Brennand and colleagues (2018) studied women performing recreational exercise and found those performing classic weightlifting, such as deadlifts, clean and jerk, and shoulder press, were less likely to experience leakage than those women performing impact activities. Conversely, Wikander (2019) found a 41% prevalence of UI during powerlifting, a non-impact sport that sustains high intra-abdominal pressures during heavy lifts. Women in this study may have been lifting much heavier weights than the women performing recreational weightlifting in the Brennand et al. (2018) study, which may explain the higher prevalence. Additionally, women SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 20 in Brennand and colleagues study (2018) were mostly parous (83.1%) and older in age (42.9 +/10.9 years), which may not be representative of results in a younger nulliparous population. CrossFit is a popular high-intensity form of exercise that seems to have a large SUI prevalence rate (Elks et al., 2020; High et al., 2020; de Arajo et al., 2020). High and colleagues (2020) performed a large national cross-sectional survey of CrossFit athletes across the United States, and 26.1% of respondents reported SUI with prevalence ranges from 23-29% in the 20 to 30 years-old age group. De Arajo and colleagues (2020) similarly found a 30% prevalence rate. This is significantly higher than the national statistics for nonathletes. Seventy-seven percent of CrossFit athletes and 78% of Olympic weightlifting and powerlifting athletes with SUI reported heavy weightlifting activities between 101-200 lbs. to be problematic for leakage (Elks et al., 2020; Skaug et al., 2020). Wikander (2019) noted many women cited the use of a weight belt to be a factor provoking SUI symptoms; weight belts are commonly used for maximal lifts. Furthermore, only 2.2% of female powerlifters experienced UI outside of heavy lifting activities (Wikander et al., 2019). Overall, a rapid increase in IAP, causing an external overload to the sphincteric system, appears to a probable cause of SUI (Wikander et al., 2019). Disordered Eating. Low energy availability has been hypothesized to be a contributing factor to UI in female athletes. This condition is often attributed to intense exercise and/or disordered eating, resulting in decreased estrogen levels (Rebullido & Stracciolini, 2019). Estrogen receptors are found in the pelvic floor structures, and a hypoestrogen state may influence the function of the continence system (Rebullido & Stracciolini, 2019). Disordered eating also robs the body of energy and nutrition to strengthen muscles, ligaments, and fascia (Goldstick & Constantini, 2014; Logue et al., 2018). Several eating disorders, such as bulimia SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 21 nervosa, induce repeated vomiting, creating high intra-abdominal pressure on the pelvic floor (Goldstick & Constantini, 2014). In the female athlete, disordered eating can be considered a subclinical eating disorder, and many times the athletes do not meet the full diagnostic criteria as outlined in the DSM V (Knapp et al., 2014). Beals and Manore (2000) examined the behavioral and psychological characteristics commonly present in athletes with a subclinical eating disorder. They determined subclinical eating disorders by scores on the Eating Disorder Inventory (EDI), the Body Shape Questionnaire (BSC), and the Eating Disorder Inventory Symptom Checklist (EDI-SC). Scores were correlated with a 7-day weighted food record and activity logs and a 30-120 min in depth interview (Beals & Manore, 2000). Eight criteria emerged for diagnosing this condition: 1) Preoccupation with food or body weight, 2) distorted body image, 3) body weight influencing self-esteem, 4) intense fear of weight gain at normal or underweight, 5) weight loss attempts through a pathological method, 6) using rules to govern food consumption with self-hate if a rule is broken, 7) absence of medical disorder explaining low body weight or weight loss, and 8) menstrual dysfunction. Due to the impaired bioavailability of nutrients, decreased estrogen, and repeated intraabdominal pressure associated with disordered eating, even low-impact athletes have a higher risk for incontinence (Goldstick & Constantini, 2014). In a study on elite Portuguese athletes and nonathletes, athletes who exhibited disordered eating had a three times higher rate of UI than nonathletes (Carvalhais et al., 2019b). Whitney and colleagues (2019) found similar results in adolescent female athletes. Conversely, several studies have failed to link disordered eating with SUI in a variety of impact and nonimpact sports (Carvalhais et al., 2019b; Gram & B, 2020; Skaug et al., 2020, SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 22 2020). Each of the studies reviewed utilized different methods for measuring disordered eating. These mixed results may be influenced by the variety of definitions and measures used. Training Volume. The pelvic floor can withstand repeated impact over a period of time but has been shown to fatigue in endurance studies (Ree et al., 2007; Simeone et al., 2010). Therefore, it is reasonable to hypothesize a high load of training volume in which athletes are subjected to long durations of repeated stresses on the pelvic floor may reach a continence threshold. In a sample of nulliparous high school athletes, participation in vigorous athletics for a greater number of seasons was the chief factor associated with incontinence (Logan et al., 2018). This finding has been reproduced in a study of amateur and elite volleyball players but not in cheerleading and gymnastics (da Silva Pereira et al., 2020; Skaug et al., 2020). Increased practice time has also been associated with UI. Athletes who spent a greater amount of time training in a week experienced more significant SUI (da Silva Pereira et al., 2020; Skaug et al., 2020). Training 4 days or more each week was associated with 2.3 times higher odds of SUI than those who trained less (Skaug et al., 2020). The risk of developing UI has been shown to increase by 15.3% for each additional hour practiced in a sample of rugby players (Sandwith & Robert, 2021). Nygaard and colleagues (2015) investigated lifetime physical activity and determined women with greater longevity of physical exercise were statistically significantly more likely to experience SUI. Interestingly, women in this study who had significant vigorous exercise during their teen years had a much higher rate of SUI in adulthood. The authors speculated that these time periods could be vulnerable for soft tissue injury, as many hormonal, skeletal, and muscular changes occur rapidly (Nygaard et al., 2015). SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 23 In a retrospective study on adolescent girls with UI, 85% of those with pelvic floor laxity played vigorous sports, supporting Nygaards theory (Bauer et al., 2018). Pelvic Floor Muscle Training in Athletes During a pelvic floor muscle contraction, the pelvic floor musculature lifts upward and inward, closing the urethra and stabilizing the bladder neck and urethra from descent (Bo, 2004). When the pelvic floor musculature is contracted prior to a cough (the knack), bladder neck descent was reduced, and continence was improved (Miller et al., 2001). Pelvic floor muscle training (PFMT) has been shown to reduce SUI symptoms and is recommended as the initial treatment for individuals with this disorder (Belushi et al., 2020; B, 2004; Lasak et al., 2018). This exercise training improves the strength, endurance, and/or power of the pelvic floor muscles as well as control and timing of pelvic floor contractions to improve continence (Belushi et al., 2020; Lasak et al., 2018; Miller et al., 2001). In a study of elite volleyball athletes with SUI, a 12-week PFMT program decreased the amount of urine loss by almost 30% and significantly improved pelvic floor muscle strength (Pires et al., 2020). This program had three phases: improving the athletes awareness of the pelvic floor, isolated strength training, and sport-specific training (Pires et al., 2020). Ferreira et al. (2014) also demonstrated a decreased amount and frequency of urinary leakage in 45% of nulliparous female elite athletes after PFMT. These results suggest that the addition of a PFMT program may be an important complement to an athletes training regimen to improve symptoms of SUI in athletes. Conclusion Urinary incontinence is prevalent in the athletic population, and mechanisms for stress incontinence differ for athletes than the non-athletic population. The pathophysiology of UI SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 24 appears to be complex and multifactorial. Sport variables such as training intensity, impact, and training volume, along with individual variables such as disordered eating or muscular fatigue, should be investigated in further depth to determine the most significant risk factors for the nulliparous athlete. Additionally, pelvic floor muscle training has been shown to be beneficial in combating SUI. Incorporating a PFMT program into sport-specific training may be helpful to prevent the development of SUI, although no studies have investigated this currently. Method Study Design A non-experimental study using a cross-sectional design in the form of an online survey explored whether the prevalence of stress urinary incontinence in nulliparous collegiate athletic women was affected by the impact and intensity of the sport, training volume, and athlete demographic and training characteristics. The study took place from January 2021 to February 2021. The Institutional Review Board at the University of Indianapolis deemed this study exempt from IRB review. The IRB study number is 01329. Participants Convenience sampling was used to recruit female collegiate athletes from three division II colleges/universities in the Midwestern United States. Inclusion criteria included nulliparity, age 18-29 years, and current participation in a Division II college sport. Exclusion criteria included individuals with a history of current or prior pregnancy or prior childbirth. Sample Size An a priori sample size estimate was calculated using G*Power, version 3.1.9.7 (Faul et al., 2009). The calculation was based on one-way ANOVA using the following parameters: twotailed test, two degrees of freedom, three groups, alpha of .05, power of .80, and moderate effect SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 25 size of .25. As effect sizes have not been reported in the literature on this topic, a medium effect size was chosen. Based on this calculation, it was estimated a minimum sample size of 159 participants was needed for the study. Data Data was collected using Qualtrics (Qualtrics, Provo, UT), an online survey platform. Participant demographics (height, weight, age), history of disordered eating, incontinence status, physical activity intensity, and sport/activity characteristics (type of sport, years of sport participation, and volume of sport training) were collected in February 2021. BMI was calculated using the athletes self-reported height and weight. Operationalization of Variables Impact. The impact of an activity involves the magnitude of ground reaction forces being transmitted through the body and was categorized by the investigator as low impact, medium impact, or high impact. Impact was classified by the protocol used by de Mattos et al. (2018): High impact: activities that demand jumps (>4x bodyweight); Medium impact: activities that involve sprints and rotational movements (2-4x bodyweight); Low: activities that require lifting some weight (<1-2x bodyweight). Training Volume. The volume of sport training was defined as the measure of sports activity performed in the prior week. Volume was calculated by multiplying the time in minutes of physical activity each day by the weekly frequency of practice (Alves et al., 2017). Incontinence. SUI was defined as the involuntary loss of urine during coughing, sneezing, or physical activity, in accordance with International Continence Society guidelines (Haylen et al., 2010). Thus, a classification of SUI status required a total score of >0 on the ICIQ SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 26 UI-SF total score, indicating some form of UI in addition to an answer of cough or sneeze or when physically active/exercising on question 6 on the ICIQ UI-SF, to indicate SUI. Disordered Eating. Disordered eating status was defined and listed in the survey according to the criteria outline in Beals and Manore (2000). Criteria include: 1) Preoccupation with food or bodyweight, 2) distorted body image, 3) body weight influencing self-esteem, 4) intense fear of weight gain at normal or underweight, 5) weight loss attempts through a pathological method, 6) using rules to govern food consumption with self-hate if a rule is broken, 7) absence of medical disorder explaining low body weight or weight loss, and 8) menstrual dysfunction. Participants checked either yes or no or unsure as a response to these survey items. Body mass index (BMI) was calculated by the participants self-reported height and weight information. After calculating BMI, scores were divided into two categories for analysis, <25 and 25. Scores of 25 or greater are consistent with the National Institutes of Healths overweight category while scores 18.5 to 24.9 fall into the healthy weight category (National Heart, Lung, and Blood Institute, n.d.). Scores of less than 18.5 were considered underweight (National Heart, Lung, and Blood Institute, n.d.). Instruments Incontinence Questionnaire Urinary Incontinence Short Form The ICIQ UI-SF was used to classify incontinence. The ICIQ UI-SF has three diagnostic questions that are scored; the first two relate to the frequency and severity of urine leakage, and the third asks about the impact of urine leakage on quality of life (Appendix B) (Bristol Urological Institute, 2020). The last question is unscored and asks under what circumstances urine leaks (Bristol Urological Institute, 2020). This question was used to classify the type of incontinence. The ICIQ UI-SF is scored by the sum of all questions (0=no leak; 1-5=slight; 6- SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 27 12=moderate; 13-18=severe; 19-21=very severe). The primary investigator was granted permission from the Bristol Urological Association to use the ICIQ-UI-SF for this research study (Appendix A). The ICIQ UI-SF is a valid and reliable measure for assessing incontinence in the adult female population. It displays excellent test-retest reliability with ICC ranging from .91-.96 (Gotoh et al., 2009; Lim et al., 2017) and excellent intra-rater reliability with ICC ranging from .84- .96 (Hajebrahimi et al., 2004; Tubaro et al., 2006). Internal consistency measures range from adequate to excellent with Cronbachs alpha ranging from .60-.97 (Al-Shaikh et al., 2013; Avery et al., 2004; Gotoh et al., 2009; Hajebrahimi et al., 2012; Huang et al., 2008; Lim et al., 2017; Tubaro et al., 2006). The ICIQ UI SF displays excellent validity as well. Prior studies have shown excellent criterion validity Pearsons r=.48-.62 and Spearmans .55-.74 (Gotoh et al., 2009; Karantanis et al., 2004; Klovning et al., 2009), excellent convergent validity Pearsons r=.93 and Spearmans =.63 ( Hajebrahimi et al., 2012; Karmakar et al., 2017), content validity k=.70 (Hajebrahimi et al., 2012), construct validity ICC=.84 between urodynamic testing (Hajebrahimi et al., 2012) and face validity (Avery et al., 2004; Huang et al., 2008). International Physical Activity Questionnaire Short Form (IPAQ SF) To assess the intensity of physical activity, the IPAQ SF was used. This form is free, publicly available, and validated in adult populations aged 18 to 65 years of age (Craig et al., 2003). In a large, multi-country validity and reliability study, the IPAQ SF displayed excellent test-retest reliability (Spearmans .76) and moderate concurrent (Spearmans .58) and criterion validity (Spearmans .30) (Craig et al., 2003). While validity measures are only moderate, this scale has similar validity as other scales that monitor physical activity (Danquah SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 28 et al., 2018). As these types of questionnaires rely on self-report of activity, recall bias is a potential source of error. Using an accelerometer to estimate physical activity would be much more exact (Lee et al., 2011) but was cost-prohibitive for this study and unsuitable for the survey methodology. The IPAQ Short Form has seven questions with four questions regarding time and level (low, medium, high) of physical activity (Appendix C) (The IPAQ Group, 2020). The questionnaire defines low, medium, and high intensity according to metabolic equivalent, or MET. METS are used to estimate the energy used by the body during physical activity and thus can be used as an estimate of intensity (Ainsworth et al., 2000). The IPAQ SF score provided the cumulative MET-minutes per week. This was calculated by multiplying the activity level MET with the amount of time spent performing the activity weekly for walking, moderate activity, and vigorous activity data (The IPAQ Group, 2020). Scores were divided into high, moderate, or low depending on the MET minute per week score. High intensity required vigorous intensity activity on at least three days per week achieving a minimum of 1500 MET minutes per week or seven or more days of any combination of walking, moderate-intensity or vigorous intensity activities achieving a minimum total of 3000 MET minutes per week. This study utilized the former definition for its definition of high intensity and those failing to achieve the definition for high intensity were classified as low to moderate intensity for this study. Procedures Recruitment Participants were recruited from three universities with Division II athletics in the Midwestern United States. Athletic directors at each university were contacted by the investigator with information about the study and a request for approval to recruit their student- SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 29 athletes. Athletic directors or athletic training staff forwarded the study invitation to all female student athletes at the university. The email invitation described the details of the study, provided the contact information of the lead investigator for any questions, and included a link to the study (Appendix F). Four reminder emails were sent to increase the response rate (Dillman, 2011). An incentive, consisting of five $50 gift cards, was used to increase the response rate (Dillman, 2011). At the end of the survey, participants were redirected to another survey, thanking them for participation and asking about interest in entering a gift-card raffle. Participants who indicated an interest were directed to a form wherein they could provide an email address. Participants who declined were directed to an exit page. This method allowed the research responses to remain anonymous and keep the raffle entries from links to identifying data. Informed Consent Potential participants were required to consent to participate via a consent form located on a secure online data collection portal before being given access to the survey (Appendix D). Participants had the option to indicate consent and proceed to the survey or deny consent and exit the survey. The participant was required to select the option that they consented to the study before being allowed access to the survey. Data Collection Potential participants received a link to the survey via email to be completed at their convenience over a period of five weeks (Appendix E). After the participant read the informed consent form and agreed to be in the study, she was asked to provide demographic information such as height, weight, and age along with sport-specific information, such as sport played and years of sport participation. Two validated questionnaires, the ICIQ UI-SF and IPAQ SF, were also used to collect data on urinary incontinence and physical activity frequency and intensity. SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 30 Data Management Data was gathered on Qualtrics (Qualtrics, Provo, UT), a secure cloud-based data collection portal with access only by the primary investigator. Data was exported from Qualtrics into IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY) on a passwordprotected private laptop securely stored at the investigators home. Data was backed up by a password protected external hard drive as well as in the University supplied Google Drive. Email addresses for the gift card were not linked to individual answers on the survey. Statistical Analysis All data was analyzed using IBM SPSS Statistics for Windows, Version 27.0 (IBM Corp., Armonk, NY). Descriptive statistics were examined to show the distribution and central tendencies of the variables within the data. Frequencies and percentages were reported for nominal data. Means and standard deviations were reported for normally distributed interval or ratio data, while medians and interquartile ranges were reported for non-normally distributed data. The normality of data was determined using the Shapiro-Wilk test. All comparisons were two-tailed, and test significance values less than .05 were considered statistically significant. RQ1: Is there a significant difference in stress urinary incontinence between athletes who play a high impact sport compared to athletes who play a low or medium impact sport? Hypothesis: Athletes who play a high-impact sport will have significantly greater ICIQ UI SF scores than athletes who play low and mid-intensity sports. To answer this question, a one-way ANOVA was conducted to determine if there was a significant difference in ICIQ UI SF scores between impact groups. Assumptions for this test included independent groups, a normal distribution for each group with equality of variance, and SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 31 interval or ratio scale of measurement. Central tendency values, Fishers skewness and kurtosis, and Shapiro-Wilk values were examined. While the data failed the Shapiro-Wilk test for normality, variances were equal among groups. The one-way ANOVA is a robust measure and has been found to be accurate in a variety of conditions, including deviance from normal distribution and with measures of skewness and kurtosis ranging from -1 to 1, thus low, moderate, and high impact groups were compared using this method (Blanca et al., 2017). Due to the small sample size of the low impact group, the low and moderate impact groups were then grouped together and compared to the high impact group using a nonparametric Mann Whitney U test. RQ2: Is there a significant difference in stress urinary incontinence between athletes who play high-intensity sports compared to athletes who play lower intensity sports? Hypothesis: Athletes who play high-intensity sports will display significantly greater scores on the ICIQ UI SF than athletes who play lower intensity sports. Since the ICIQ UI SF scores and intensity scores were not normally distributed, a nonparametric Mann-Whitney U test was performed to determine if there was a between-group difference between the high and low-intensity groups. Assumptions for this test included two categorical, independent groups, a dependent variable at the interval level, and independence of observations. RQ3: Is stress urinary incontinence related to training volume in athletes? Hypothesis: Athletes who have a high training volume will have a significantly greater ICIQ UI SF score than athletes with a low or moderate training volume. Training volume and ICIQ UI SF score data both violated normality assumptions, so a nonparametric test was required for this hypothesis. This comparison included two categorical, SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 32 independent groups, a dependent variable at the interval level, and independence of observations so a Mann Whitney U was performed to answer this research question. RQ4: Is stress urinary incontinence related to athlete demographics or training variables? Hypotheses: Athletes with a BMI of 25 or greater will have greater ICIQ UI SF scores than athletes with BMI scores <25. Athletes with greater years of sports training will have greater ICIQ UI SF score than athletes with fewer years of sports training. Athletes who report disordered eating will have greater ICIQ UI SF scores than athletes without disordered eating. As ICIQ UI SF scores, BMI, and years of sports training data failed to meet normality standards, nonparametric tests were performed. While the Disordered Eating variable technically had three groups, only the definitive yes and no groups were analyzed. Thus, each of these variables had two independent groups, independence of observations, and a continuous dependent variable, so Mann-Whitney U tests were used to analyze the data to answer this research question. Results There were 251 survey responses, which exceeded the a priori sample size estimates of 159. One participant did not consent and was thus not directed to the questionnaire. Thirty-four participants completed less than 60% of the survey and these incomplete responses were eliminated from the data. An additional nine responses demonstrated contradictory results in response to the urinary incontinence questions (e.g., answering urine never leaked and then that they leaked multiple times per day). Therefore, their data were excluded from analyses. This removal of responses did not significantly alter the power of the study. Of the remaining responses, some participants had missing data fields and some extreme outliers were present, which were then removed during data cleaning. Interpolation was used to SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 33 estimate responses to the missing fields based on their sports teams characteristics. With this method, the data file was divided by sport and the mean values for each sport were used in place of the missing data point. Of the valid responses, 209 athletes data were analyzed. Eleven sports were represented, with nine athletes participating in two sports. If athletes participated in more than one sport, they were prompted to list all sports they participated in on the survey. The investigator compared the impact level of all sports in which the athlete participated and in all cases the impact level was the same across both sports. Individuals participating in both track and cross country were labeled as cross country as it was likely those athletes participating in both sports were more likely to be distance runners and not field athletes, thus cross country was likely a better grouping. Tennis and lacrosse have similar movements and activities thus the one athlete that responded to playing both was randomly allocated to the lacrosse group. Table 1 lists the sport frequencies with the re-grouping of dual-sport athletes. General Participant Characteristics Descriptive statistics of athletes characteristics are presented in Table 2. The sample of 209 athletes had a mean (standard deviation) age of 20.19 (1.47) years. Mean BMI was 23.74 (3.35), with mean weight and height of 145.76 (23.1) lbs. and 65.76 (3.35) inches, respectively. One hundred twenty (57.4%) athletes reported disordered eating. Sport Specific Characteristics Twenty-four athletes (11.5%) participated in low impact sports, 84 (40.2%) in moderate impact level, and 101 (48.3%) in high impact level sports. Among the sample, athletes reported a mean of 11.49 (3.95) years of participation in their sport. They reported performing vigorous activities 5.06 (1.45) days/week for 1.8 (0.79) hours and moderate activity 3.62 (2.21) days for SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 34 1.23 (0.82) hours on average. The mean energy expenditure was calculated from these responses according to the IPAQ protocol and totaled 6010.07 (3380.66) MET minutes/week. Urinary Incontinence Characteristics Two hundred and eight respondents answered questions regarding urinary leakage. Of the sample, 94 (45%) were determined to have some form of urinary incontinence while 74 (35.4%) met the criteria stress urinary incontinence. Of the 74 athletes presenting with SUI, the mean ICIQ UI SF score was 5.01, with individual component scores of 1.45 for frequency, 2.03 for amount, and 1.47 for quality of life. These results are indicated in Table 2 and represent frequency ranges from once per week to two-to-three times/week, small leakage amounts, and a small self-rated effect on quality of life. Research Question 1: Is there a significant difference in stress urinary incontinence between athletes who play a high impact sport compared to athletes who play a low or medium impact sport? A Levenes test showed the variances for ICIQ UI SF score were equal, F(2,204)=1.582, p=.208. A one-way ANOVA was performed to analyze this question, F (2,204)=2.48, p=.086. However, a post-hoc power analysis revealed this test was underpowered. Low and moderate impact sports were then grouped together and compared against high impact sports using a nonparametric test. The Mann-Whitney U test, Z=-2.176, p=.03 indicated the groups differed significantly at an alpha .05 level. The effect size was small (d=.31). Figure 1 demonstrates the difference in median ICIQ UI SF score among these two groups, with the high-impact athletes demonstrating higher ICIQ UI SF scores. SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 35 Research Question 2: Is there a significant difference in stress urinary incontinence between athletes who play high-intensity sports compared to athletes who play lower intensity sports? Due to the number of significant outliers in the data on walking, the alternative definition of intensity using the IPAQ was used, using only vigorous activity to calculate intensity. This definition specified high-impact as vigorous intensity activity on at least three days/week for greater than 1500 MET minutes/week. Using these criteria for vigorous activity, 25 athletes were classified as low intensity and 84 were classified as high intensity. Statistical analysis indicated there were no differences between the groups at an alpha .05 level (p=.584). When the groups were divided into high and low-intensity groups by the median MET minute result (5400 MET minutes), the Mann Whitney U approached significance, p=.057, with higher intensity displaying higher scores. The effect size was small (d=.27) indicating that a larger sample would be needed. When high intensity exercise was examined in conjunction with exercise frequency, statistically significant results emerged. Athletes performing intense physical activity six or seven days of the week had greater SUI than athletes performing high intensity exercise less than six days per week (p=.037). The high frequency of exposure to IAP from intense exercise may result in a synergic overload to the pelvic floor musculature, decreasing the ability to support the continence mechanism (Khowailed et al., 2020). Research Question 3: Is stress urinary incontinence related to training volume in athletes? Training volume was defined as the number of hours per week spent performing moderate or vigorous physical activity. The median of 13.5 hours/week was used to divide the groups into high and low training volume for the statistical analysis. The results of the Mann Whitney U test, (Z=-1.37, p=.17) determined that the groups failed to differ significantly at an SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 36 alpha .05 level. Components of training volume were also examined separately to determine if there was a relationship with ICIQ UI SF scores. Only >five days/week of vigorous activities appeared to be related. The Mann Whitney U test, Z=-2.09, p=.037 indicated athletes exercising vigorously more than five days per week differed significantly at an alpha .05 level from those exercising less than or equal to five days/week. The effect size was small (d=.29). Research Question 4: Is stress urinary incontinence related to athlete demographics or training variables? BMI was divided into two groups <25 and 25. Years of sports training was a continuous variable and was classified into high and low by splitting the data based upon the median values. Disordered eating was grouped into two groups from the survey, disordered eating and normal eating, based on self-report. As the dependent variable ICIQ UI SF score data failed normality assumptions, Mann Whitney U tests were performed to analyze the relationships among BMI, years of sport training, and disordered eating on ICIQ UI SF scores. The Mann Whitney U test (Z=-1.96, p=.05) indicated the BMI groups differed significantly with athletes who had higher BMI values having greater ICIQ UI SF scores. The effect size was small (d=.31). There were no differences between disordered eating groups (Z=-.59, p=.56) or between years of sports training groups (Z=-.33, p=.74). Discussion Stress urinary incontinence is prevalent throughout the female athletic population; however, its etiology is poorly understood. Prior research attempts have been focused on determining the risk factors for SUI in the athletic population (Brennand et al., 2018; Elks et al., 2020; Wikander et al., 2019). Therefore, the purpose of this study was to explore the influence of sports characteristics on SUI in nulliparous female collegiate athletes. Multiple measures, SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 37 including standardized assessments and self-report estimates were examined. These entailed athlete BMI, disordered eating status, sport impact level, intensity of physical activity, weekly training volume, and years of sport training. The ICIQ UI SF score was utilized to classify athletes with SUI and to quantify the frequency and severity of SUI. Nine participants answered the survey questions on urinary incontinence inconsistently and could not be used in the data analysis. Six athletes answered urine never leaks to the question asking under what circumstances urine leaks, however, then answered that they did have urine leakage when asked about their frequency, amount, and the effect on their quality of life. Additionally, three participants answered that urine never leaked and that quality of life was not altered but then reported leakage during coughing and sneezing. One continent participant answered that her quality-of-life score was a 1/10 in terms of urinary incontinence, which could indicate misunderstanding the question or possibly that she was worried about urinary leakage but was not currently affected. Finally, two participants reported no UI but answered the question when does urine leak as leaks before you can get to the bathroom. For these two instances, their ICIQ scores were not used due to the inconsistency of responses. These answers may indicate participant data entry errors or a confusion of the young athletes on what constitutes urine leakage. Incomplete answers have been noted in prior research in this population (L. Forner, personal communication, March 23, 2021. McKenzie et al., 2016). Contradictory responses have also been noted; Rodrguez-Lpez and colleagues asked athletes Do you think you have or have had UI? and only 9% answered affirmatively, although 22.7% indicated they had experienced urine leakage during training (Rodrguez-Lpez et al., 2020). It is likely these athletes do not truly understand UI. Prior studies have indicated that the majority of young women display poor knowledge about pelvic floor function and health (Cardoso et al., SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 38 2018; Falvey et al., 2021; Howard-Thornton et al., 2011; Parden et al., 2016). Thus, athletes in this current study may not have fully understood the terminology utilized or that the leakage they may have experienced was technically UI. Prevalence and Impact of SUI The prevalence of UI in the sample was 45% with SUI occurring in 35.4%. This is consistent with previous studies in which 48% of nulliparous athletes had UI and 37.5% SUI (dos Santos et al., 2018). SUI appears to be the most prevalent subtype of UI of the nulliparous athlete population (Alves et al., 2017; Da Roza et al., 2015b; Skaug et al., 2020). The mean ICIQ UI SF score was 5.01 in the sample with scores ranging from 1/21 to 15/21. This score indicates mild severity of incontinence (Klovning et al., 2009), with frequency ranges from once per week to two-to-three times/week (score 1.45), small leakage amounts (2.03), and a small self-rated effect on quality of life (1.47). Prior studies corroborate this finding, reporting mean scores of 4.7- 5.3 among nulliparous female athletes (Gram & B, 2020; Hagovska et al., 2017). Impact Level A statistically significant difference was found in the high and low/moderate impact sport groups. These findings are consistent with prior research indicating ICIQ UI SF scores were significantly different amount high and low impact sports (dos Santos et al., 2018). Sports with higher impact levels appear to have higher UI prevalence rates and greater impacts of UI on quality of life (Da Roza et al., 2015a; Dobrowolski et al., 2020). During a high impact activity such as jumping, the pelvic floor deforms in response to the compression of the falling organs against the decelerating pubic bone (Dias et al., 2017). The organs, including the bladder, bounce back and become compressed against the vaginal wall SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 39 and levator ani musculature, increasing the pressure between the urine and bladder wall (Dias et al., 2017). Performing impact activity, such as a long jump, creates a ground reaction force up to 16x higher than body weight (Almousa & Bandin Van Loon, 2019). As the pelvic floor musculature acts as a shock absorber for the lower extremities, it follows that an increase in impact could overload the continence system (Casey & Temme, 2017). Thus, women who participate in high impact sports display greater rates of SUI. Intensity There were no statistical differences between the high and low intensity groups using the definition of high intensity from the IPAQ. Most athletes fell into the high intensity group (n=84) versus the low intensity group (n=25). The small number of athletes in the low intensity group may have led to a diminished power to detect a change. The effect size was small (d=.27), indicating a greater sample size would be required to detect a change than was originally calculated. Additionally, the athletes in this study had higher MET minutes of vigorous activity than found in prior studies. While Hagovska and colleagues (2017) found a significant difference in SUI among intensity levels in their study, their athletes average vigorous intensity MET minutes were 2811.32060.3, which is considerably lower than the 47052963.38 MET minutes the athletes in this study reported. There were additional details regarding the studies that were different, with one major result being the difference in the type of athlete. Hagovska and colleagues (2017) surveyed club sport athletes while investigators in this study surveyed collegiate athletes. Athletes participating at the collegiate level are likely to have exercise practices that support high intensity to promote fitness and performance. In a prior study using the IPAQ, collegiate athletes reported 39522549.41 MET minutes/week, which is closer to the results found in this study. Using the IPAQ definition of high intensity as vigorous activity at SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 40 least three days/week for greater than 1500 MET minutes/week may not be sufficiently high to detect any true differences at the collegiate level. Training Volume There were no statistical differences on SUI with training volume. This is consistent with some prior studies (Cardoso et al., 2018; Jcome et al., 2011) but not all (Alves et al., 2017; Da Roza et al., 2015a; da Silva Pereira et al., 2020; Sandwith & Robert, 2021). Da Silva Pereira and colleagues (2020) found a significant difference in UI comparing the physical activity and sport specific training weekly among amateur and professional athletes, however professional athletes exercised twelve hours/week while amateur athletes performed six hours/week. Athletes in Alves and colleagues study exercised 5.4 3.5 (high impact) and 6.24+4.12 (low impact) hours/week. The athletes in the current study performed physical activity 14.99 7.98 hours/week (median 13.5). Therefore, the athletes in this study may have been exercising at a sufficiently high physical activity level that differences were not noted between groups. Rugby athletes in Sandwith and Roberts (2021) study reported similar training hours per week (14.9 4.4 hours/week) as the athletes in this study, but with a conflicting finding. They determined the risk of UI increased 15.3% with each additional hour of training (Sandwith & Robert, 2021). While demographic and training variables were similar in these studies, all athletes in Sandwith and Roberts study played rugby, a high impact sport, which may explain the different results. In this study, when training volume was isolated to high intensity exercise only, a significant difference was found for those training >5 days/week (p=.037). It is possible that training volume in isolation is not a risk factor for SUI, but rather the cumulative effect of intensity and/or impact with training volume. BMI SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 41 Being overweight is a known risk factor for females in the general population (Nygaard et al., 2015), however prior studies have not identified links between BMI and UI (Da Roza et al., 2015a). BMI levels tend to be lower in athletes and previous literature only examined BMI ranges in the normal range of <25 (Da Roza et al., 2015a; Torstveit & Sundgot-Borgen, 2012). Thus, values may have been too low to reflect a true difference in the relationship for UI. In the current study, several athletes had BMI values 25, which was statistically significantly related to SUI. BMI grossly exaggerates the overweight category in athletes that have significant muscle mass and many have less subcutaneous fat than BMI-matched non-athletic peers (WallnerLiebmann et al., 2013). BMI does accurately reflect the increased weight relative to height of the athlete, which can affect pelvic floor function. Consequently, even though an athlete has greater fat free mass, the greater weight on the system may predispose an athlete toward incontinence. Disordered Eating Disordered eating has displayed mixed results in connection with SUI in the literature (Carvalhais et al., 2019a; Goldstick & Constantini, 2014; Gram & B, 2020; Skaug et al., 2020, 2020, 2020), and did not appear to be related to SUI in the current study. Of interest was the high rate of disordered eating in the sample (57.4%). These findings are significantly greater than rates found in prior studies, however different criteria were used to assess disordered eating (Carvalhais et al., 2019b; Whitney et al., 2019). The current research was performed during the COVID-19 pandemic, which may explain some of the increased prevalence. Several studies have reported a negative impact on mental health and an increase in disordered eating since the start of the COVID-19 pandemic in March 2020 (Buckley et al., 2021; Chan & Chiu, 2021; Nutley et al., 2021; Ramalho et al., 2021; Rodgers et al., 2020). Qualitative reports indicated participants felt the COVID-19 pandemic directly contributed to SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 42 increasing disordered eating behavior due to increased stress, frustration, and feelings of isolation (Nutley et al., 2021). Rodgers and colleagues (2021) proposed eating disorders may have been exacerbated by restrictive food diets to decrease contracting COVID-19 or minimizing its effects during the pandemic. Years of Training There were no significant results between years of training and SUI. While greater years of training was associated with SUI in high impact athletes (Cardoso et al., 2018; Da Roza et al., 2015a), this sample pool consisted of low, moderate, and high impact sport types. In studies conducted in elite athletes that included all impact levels, reports are mixed, with some studies indicating no relationship between UI and years of training (Rodrguez-Lpez et al., 2020; Skaug et al., 2020) while others found that greater years of training were related to greater SUI prevalence (Keyla M. dos Santos et al., 2019). Participating in a sport over multiple years does not appear to have a clear relationship to SUI. Limitations There were several limitations of this study, particularly the cross-sectional nature, unknown effect size in a priori sample calculations, and challenges related to the COVID-19 pandemic. The cross-sectional design of this survey is a significant limitation as causality cannot be determined, nor can long-term effects of exercise on stress urinary incontinence. Additionally, data from all 2020-2021 athletes were gathered in the spring, so athletes playing fall sports may not have been at peak activity levels, thus impacting results. As effect sizes have not been reported in the literature on this topic, a moderate effect size of .25 was used to calculate an a priori sample size. The study sample (n=209) collected exceeded the a priori calculation (n=159), however due to the effect size noted in this study, a SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 43 larger study population is recommended for future studies. Future studies should determine sample size calculations based upon small effect sizes noted in this study. Collecting data during a pandemic could also have affected the nature of the results. As in-person research was halted, the study was required to be disseminated in an online format. There were several variant answers from respondents on the IPAQ and ICIQ-UI-SF that were improbable or impossible. Hagovska and colleagues noted in their 2017 study that many participants had difficulty with the questionnaire and a research member was available on site to give clear instructions and assist in ensuring accurate data. Utilizing an in-person group administration method by an independent research assistant would have been preferable, and was the initial choice of administration method, but was not possible during the COVID-19 pandemic. This method would have allowed participants to ask clarifying questions and the research assistant could check for completeness of responses. The COVID-19 pandemic also greatly affected athletics. Universities and high schools closed in person sports in March 2020 (McGuine et al., 2020; B. Gerlach, personal communication, April 8, 2021). Training routines were interrupted, affecting the quality, quantity, and type of training (Andreato et al., 2020). Mental health of athletes suffered, with an increase in disordered eating (Buckley et al., 2021; Chan & Chiu, 2021; Nutley et al., 2021; Ramalho et al., 2021; Rodgers et al., 2020). Limited training was allowed from August 2020 until January 2021, when all sports had resumed training and competition (B. Gerlach, personal communication, April 8, 2021). As the survey was disseminated the last week in January 2021, data may be different than previously published studies due to these pandemic-related changes in collegiate athletics. Additionally, the use of a face mask during exercise may have changed athletes perceptions of activity intensity, which was a subjective report in this survey. Studies SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 44 have shown that exercising with a face mask can lead to a hypercapnic hypoxia condition (Islam et al., 2020). Thus, the amount of vigorous intensity exercise responses noted in the sample may be inflated due to the greater cardiorespiratory demands of exercising with a mask. Real World Implications This study confirms that SUI is highly prevalent in nulliparous female athletes. Athletes most at risk, such as those with a high BMI or those engaging in high intensity and high impact activity most days of the week, have a greater need for pelvic floor muscle training, to strengthen and maintain pelvic floor muscle function to prevent SUI. Sport teams should incorporate pelvic floor muscle training into their strength and conditioning routines. Pelvic health specialists should work closely with the collegiate sports medicine, athletic training, and strength and conditioning teams to develop an appropriate program. Additionally, while SUI affects over one-third of nulliparous female athletes, many do not seem to understand the condition. The athletes in this study, as well as those in prior studies, noted confusion about what constituted urinary incontinence and whether leakage that only occurred during sport activities was truly urinary incontinence (Hagovska et al., 2017, L. Forner, personal communication, March 27, 2021). More education should be disseminated to this at-risk population for improved pelvic floor dysfunction identification, classification, and prevention efforts. A pelvic health physical therapist may be a key asset to female sports teams to provide the recommended education and training to coaching staff, athletic training staff, and athletes. Future Directions Athletes in this study and in prior studies, have consistently shown poor comprehension and inconsistent responses to existing standardized questionnaires. Investigating health literacy in the female student-athlete population should be considered for future studies and is important SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 45 from a public health perspective. A qualitative study examining an athletes perception of urinary leakage during physical activity, or perception of meaning of survey questions, could provide a first step in understanding cognitive dissonance related to the questionnaire language and actual experiences. As SUI is highly prevalent in this demographic, it is critical to establish a tool that is successful in collecting accurate data. Including questions regarding sport specific activities would be beneficial for assessing provocative activities related to UI. Second, this study as well as others have noted inconsistencies in using self-report physical activity data due to the subjective nature (Hagovska et al., 2017). Using accelerometers would improve the accuracy of responses. Accelerometers can estimate energy expenditure, which is required for intensity calculations (Li et al., 2016). Accelerometers provide more precise measures of low and moderate intensity physical activity, as these are often underreported by the IPAQ SF (Oyeyemi et al., 2014). Additionally, highly active individuals tend to under-report physical activity using the IPAQ SF (Rsk et al., 2017). Thus, use of a wearable accelerometer to categorize physical activity quantity and intensity would be preferred to selfreport in a future study. Conclusion Female collegiate athletes display high rates of SUI. Athletes participating in high impact sports, high intensity activity >5 days a week, and those with BMI over 25 appear most at risk. 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American Journal of Obstetrics and Gynecology, 215(3), 316.e1-316.e7. https://doi.org/10.1016/j.ajog.2016.02.031 Miller, J. M., Perucchini, D., Carchidi, L. T., DeLancey, J. O. L., & Ashton-Miller, J. (2001). Pelvic floor muscle contraction during a cough and decreased vesical neck mobility. Obstetrics & Gynecology, 97(2), 255260. https://doi.org/10.1016/S00297844(00)01132-7 Milsom, I., & Gyhagen, M. (2019). The prevalence of urinary incontinence. Climacteric, 22(3), 217222. https://doi.org/10.1080/13697137.2018.1543263 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 58 Minassian, V. A., Bazi, T., & Stewart, W. F. (2017). Clinical epidemiological insights into urinary incontinence. International Urogynecology Journal, 28(5), 687696. https://doi.org/10.1007/s00192-017-3314-7 Mistry, M. A., Klarskov, N., DeLancey, J. O., & Lose, G. (2020). A structured review on the female urethral anatomy and innervation with an emphasis on the role of the urethral longitudinal smooth muscle. 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Rug-pee study: The prevalence of urinary incontinence among female university rugby players. International Urogynecology Journal, 32(2), 281285. https://doi.org/10.1007/s00192-020-04510-2 Schettino, M. T., Mainini, G., Ercolano, S., Vascone, C., Scalzone, G., DAssisi, D., Tormettino, B., Gimigliano, F., Esposito, E., Di Donna, M. C., Colacurci, N., & Torella, M. (2014). Risk of pelvic floor dysfunctions in young athletes. Clinical and Experimental Obstetrics & Gynecology, 41(6), 671676. Simeone, C., Moroni, A., Petten, A., Antonelli, A., Zani, D., Orizio, C., & Cosciani Cunico, S. (2010). Occurrence rates and predictors of lower urinary tract symptoms and incontinence in female athletes. Urologia, 77(2), 139146. Skaug, K. L., Engh, M. E., Frawley, H., & B, K. (2020). Prevalence of pelvic floor dysfunction, bother and risk factors and knowledge of the pelvic floor muscles in Norwegian male and female powerlifters and Olympic weightlifters. Journal of Strength and Conditioning Research. https://doi.org/10.1519/JSC.0000000000003919 Stothers, L., & Friedman, B. (2011). Risk factors for the development of stress urinary incontinence in women. Current Urology Reports, 12(5), 363. https://doi.org/10.1007/s11934-011-0215-z SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 60 Teixeira, R. V., Colla, C., Sbruzzi, G., Mallmann, A., & Paiva, L. L. (2018). Prevalence of urinary incontinence in female athletes: A systematic review with meta-analysis. International Urogynecology Journal, 29(12), 17171725. https://doi.org/10.1007/s00192-018-3651-1 Teleman, P. M., Gunnarsson, M., Lidfeldt, J., Nerbrand, C., Samsioe, G., & Mattiasson, A. (2003). Urethral pressure changes in response to squeeze: A population-based study in healthy and incontinent 53- to 63-year-old women. 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Title Ix of the education amendments of 1972. https://www.justice.gov/crt/title-ix-education-amendments-1972 Ural, . M., Gck, S., Ekici, A., & Topuolu, A. (2020). Urinary incontinence in female university students. International Urogynecology Journal. https://doi.org/10.1007/s00192-020-04360-y SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 61 Vignoli, G. (2018). Physiology of micturition in female. In G. Vignoli (Ed.), Urodynamics for urogynecologists: A pocket guide for clinical practice (pp. 115). Springer International Publishing. https://doi.org/10.1007/978-3-319-74005-8_1 Vitton, V., Baumstarck-Barrau, K., Brardjanian, S., Caballe, I., Bouvier, M., & Grimaud, J. C. (2011). Impact of high-level sport practice on anal incontinence in a healthy young female population. Journal of Womens Health (2002), 20(5), 757763. https://doi.org/10.1089/jwh.2010.2454 Whitney, K. E., Holtzman, B., Parziale, A., & Ackerman, K. E. (2019). Urinary incontinence is more common in adolescent female athletes with low energy availability. Orthopaedic Journal of Sports Medicine, 7(3), 2325967119S00115. https://doi.org/10.1177/2325967119S00115 Wikander, L., Cross, D., & Gahreman, D. E. (2019). Prevalence of urinary incontinence in women powerlifters: A pilot study. International Urogynecology Journal, 30(12), 2031 2039. https://doi.org/10.1007/s00192-019-03870-8 Yang, J., Cheng, J. W., Wagner, H., Lohman, E., Yang, S. H., Krishingner, G. A., Trofimova, A., Alsyouf, M., & Staack, A. (2019). The effect of high impact crossfit exercises on stress urinary incontinence in physically active women. Neurourology and Urodynamics, 38(2), 749756. https://doi.org/10.1002/nau.23912 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 62 Table 1 Collegiate Sport Participation, Adjusted for Multiple Sports Frequency Percent Sport Basketball 10 4.8 Cheerleading 2 1.0 Soccer Lacrosse Tennis 37 19 15 17.7 9.1 7.2 Volleyball 18 8.6 Cross Country Track & Field 20 26 9.6 12.4 Softball Golf Swimming and/or Diving 38 6 18 18.2 2.9 8.6 Total 209 100.0 Note: Of the 12 athletes that participated in >1 collegiate sport, 11 participated in Track & Field and Cross Country, while one participated in Tennis and Lacrosse. Both Track & Field and Cross Country and Tennis and Lacrosse were classified as the same impact level, thus were coded as Cross Country and Tennis, respectively for the data analyses. SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Table 2 Characteristics of Study Participants Mean Demographics (n = 209) Age (years) 20.19 Weight (lbs) 145.76 Height (in) 65.76 BMI 23.74 Std Dev 1.47 23.1 3.35 3.35 Prevalence of Urinary Incontinence (n=208) Percentage Any type UI (n = 94) 45.00% SUI (n = 74) 35.40% Disordered Eating Yes (n = 120) No (n = 75) Unsure (n = 13) 57.4% 35.9% 6.2% Sport Impact Level Low (n = 24) 11.5% Moderate (n = 84) 40.2% High (n = 101) 48.3% _______________________________________________________________ 63 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Figure 1 64 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Figure 2 65 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Appendix A Permission for Use for ICIQ-UI SF 66 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Appendix B The ICIQ UI SF instrument 67 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Appendix C The International Physical Activity Questionairre 68 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 69 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 70 Appendix D Online Survey Consent Form Sport Variables and Stress Urinary Incontinence Among Nulliparous Collegiate Athletes Start of Block: Informed Consent Consent You are invited to participate in a research study. This study is focused on the training variables that may be related to urinary leakage in the female athlete. The purpose of this study is to better understand how different aspects of sport training can influence urinary leakage (pee accidents) that occur during exercise. We are inviting you to participate in this study because you are a female collegiate athlete. If you agree to participate in this study, you will be asked to complete a one-time web-based survey regarding your physical exercise, sport, and urinary leakage. We will also ask some demographic questions. The survey should take no longer than 10 minutes to complete. You will receive an initial invitation to participate along with reminders, when possible, to complete this survey. Participation in the survey is optional, and if you wish to cease participation, you are free to do so without penalty. If you do not wish to participate in this study, simply do not complete the study. If you do not wish to answer any questions, you may stop the survey at any time. The survey does not collect any personal identifiers and, therefore, the information gathered will be anonymous. You will not benefit personally from participating in this study. However, we hope that others may benefit in the future from what we learn as a result of this study. This study does not expose you to any more risk than you would experience in everyday life, however some questions may make you feel uncomfortable. CONSENT TO PARTICIPATE IN RESEARCH STUDY Sport Variables and Stress Urinary Incontinence Among Nulliparous Collegiate AthletesStudy Principal Investigator (PI): Ed Jones, PT, DHScUIndy Email: joneser@uindy.eduUIndy Telephone: 317-788-8013 Ed Jones, PT, DHSc from the Krannert School of Physical at the University of Indianapolis (UIndy) and Rebecca Parr, PT, DPT, OCS from the Department of Interprofessional Health & Aging Studies at the University of Indianapolis (UIndy) are conducting a research study. You were selected as a possible participant in this study because you are a female athlete playing a collegiate sport in the 2020-2021 season. Your participation in this research study is voluntary. Why is this study being done?The results of the research may help researchers understand the variables that lead to urinary leakage during sport which could lead to improved screening and preventative treatment for this condition. With early identification, rapid intervention could potentially prevent SUI from progressing to a more significant problem later in life. What will happen if I take part in this research study? If you volunteer to participate in this study, the researcher will ask you to do the following: Perform a ten-minute online survey How long will I be in the research study? Participation will take a total of about ten minutes SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 71 Are there any potential risks or discomforts that I can expect from this study? Questions regarding urinary leakage or disordered eating may make you feel uncomfortable or embarrassed. You can skip items if you would prefer not to answer a question. All information will be collected in an anonymous manner (no names or IP addresses collected) and only research team members will have access to data. Are there any potential benefits if I participate? While there are no direct benefits from participating in this study, you may experience personal benefits from participating in a study that have the potential to improve the lives of others. What other choices do I have if I do not wish to participate?Participation is voluntary. If you choose not to participate in this study, there is not a penalty. Will I be paid for participating? You may enter a drawing to win one of five $50 gift cards Will information about me and my participation be kept confidential? The results of this study may be published in a scholarly book or journal, presented at professional conferences or used for teaching purposes. However, only aggregate data will be used. Personal identifiers will not be collected and thus cannot be used in any publication, presentation or teaching materials.Will the data from my study be used in the future for other studies?It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies, without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. What are my rights if I take part in this study? You can choose whether or not you want to be in this study, and you may withdraw your consent and discontinue participation at any time. Whatever decision you make, there will be no penalty to you, and no loss of benefits to which you were otherwise entitled. You may refuse to answer any question/s that you do not want to answer and still remain in the study. Who can I contact if I have questions about this study? If you have any questions, comments or concerns about the research, you can talk to the one of the researchers. Please contact: The principal investigator Ed Jones, PT, DHSc at joneser@uindy.eduThe study coordinator Rebecca Parr, PT, DPT, OCS at parrr@uindy.edu Additionally, you can contact the Director of the Human Research Protections Program (HRPP):If you have questions about your rights as a research participant, or you have concerns or suggestions and you want to talk to someone other than the researchers, you may contact the Director of the Human Research Protections Program, by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. How do I indicate my informed consent to participate in this study? If you consent to participate in this study, then you affirm that you satisfy inclusion criteria and your consent is voluntary. Inclusion criteria include being age 18 years of age or older, a female athlete engaged in collegiate athletics and no current or prior pregnancy. To indicate your voluntary consent and proceed with the questionnaire, select one of the following options: SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 72 I voluntarily consent to participate in this study (1) I do NOT consent to participate in this study (2) Skip To: End of Survey If You are invited to participate in a research study. This study is focused on the training variabl... = I do NOT consent to participate in this study SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 73 Appendix E Online Survey Sport What competitive sport do you play for your college/university? o Basketball (14) o Cheerleading/STUNT (15) o Soccer (16) o Lacrosse (17) o Tennis (18) o Volleyball (19) o Cross Country (20) o Track & Field (21) o Softball (22) o Golf (23) o Swimming and/or Diving (24) o I play more than one competitive sport (25) o I do not play a competitive sport for my college/university (26) Skip To: End of Survey If What competitive sport do you play for your college/university? = I do not play a competitive sport for my college/university Display This Question: If What competitive sport do you play for your college/university? = I play more than one competitive sport Multiple Sports What sports do you play for your university? ________________________________________________________________ YearsSport How many years have you participated in that particular sport? (not just in college) ________________________________________________________________ SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 74 Page Break Q4 The next few questions will ask about your physical activity in the last week (7 days). Please think of all the time you spent being physically active, both in your sport practice/competition and outside of sport activities. Page Break DaysVigEx Think about all the vigorous activities that you did in the last 7 days. Vigorous activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only of those activities that you did for at least 10 minutes at a time. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, fast bicycling, running, or aerobics? o 1 day (1) o 2 days (2) o 3 days (3) o 4 days (4) o 5 days (5) o 6 days (6) o 7 days (7) o I did not do any vigorous activity (8) Skip To: DaysModEx If Think about all the vigorous activities that you did in the last 7 days. Vigorous activities refe... = I did not do any vigorous activity HoursVigEx 1. How much time did you usually spend doing vigorous exercise on one of those days? Please type the length of time in hours, e.g. 2 hours and 30 minutes would be entered as "2.5" ________________________________________________________________ Page Break SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 75 DaysModEx Think about all the moderate activities you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those activities you did for at least 10 minutes at a time. During the last 7 days, how many days did you do moderate physical activities like bicycling at regular pace or doubles tennis? Do not include walking. o 1 day (1) o 2 days (2) o 3 days (3) o 4 days (4) o 5 days (5) o 6 days (6) o 7 days (7) o I did not do any moderate activities (8) Skip To: DaysWalk If Think about all the moderate activities you did in the last 7 days. Moderate activities refer to... = I did not do any moderate activities HoursModEx How much time did you usually spend doing moderate exercise on one of those days? Please type the length of time in hours, e.g. 2 hours and 30 minutes would be entered as "2.5" ________________________________________________________________ DaysWalk Think about all the time you spent walking in the last 7 days. This includes at work, at home, at school, walking to travel from place to place, and any other walking that you have done SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 76 solely for recreation, sport, exercise, or leisure. During the last 7 days, on how many days did you walk for at least 10 minutes at a time? o 1 day (1) o 2 days (2) o 3 days (3) o 4 days (4) o 5 days (5) o 6 days (6) o 7 days (7) HoursWalk How much time did you usually spend walking on one of those days? Please type the length of time in hours, e.g. 2 hours and 30 minutes would be entered as "2.5" ________________________________________________________________ HoursSit This question is about the time you spent sitting on weekdays in the last 7 days. Include time spent at work, at home, while doing coursework and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch TV. During the last 7 days, how much time did you spend sitting on 1 WEEK DAY? Please type the length of time in hours, e.g. 2 hours and 30 minutes would be entered as "2.5" ________________________________________________________________ Page Break SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 77 UIFreq These next questions will ask you about any urine leakage ("pee accidents") that you may experience. How often do you leak urine? o Never (0) o About once a week or less often (1) o Two or three times a week (2) o About once a day (3) o Several times a day (4) o All the time (5) UIAmount We would like to know how much urine you think leaks. How much urine do you usually leak (whether you wear protection or not)? o None (0) o A small amount (2) o A moderate amount (4) o A large amount (6) UIQOL How much does leaking urine interfere with your everyday life? Please select a number between 0 (not at all) and 10 (a great deal) 0 Please select a number between 0 (not at all) and 10 ( a great deal) () 10 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES UIWhen When does urine leak? Please mark all that apply to you) Never-urine does not leak (1) Leaks before you can get to the toilet (2) Leaks when you cough or sneeze (3) Leaks when you are asleep (4) Leaks when you are physically active/exercising (5) Leaks when you have finished urinating and are dressed (6) Leaks for no obvious reason (7) Leaks all the time (8) Page Break 78 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES DisEat Do any of the below statements seem like you? I am preoccupied with food or body weight I have a distorted body image My body weight influences my self-esteem I have an intense fear of weight gain I have attempted to lose weight through an extreme method I use rules to govern my eating and I hate myself if I break a rule I have menstrual dysfunction, such as missing periods o Yes (1) o No (2) o Unsure (3) Page Break 79 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES Age These next questions will collect demographic information. What is your age in years? ________________________________________________________________ Weight What is your weight in pounds? ________________________________________________________________ Height What is your height in inches? e.g. 5'5 would be 65 inches ________________________________________________________________ End of Block: Informed Consent 80 SPORT VARIABLES AND STRESS INCONTINENCE ATHLETES 81 Appendix F Recruitment Email Subject line of email: Research Study on Student-Athletes, Chance to Win a $50 Gift Card Hello University of ****** Student-Athlete, We hope you will participate in this research study, Sport Variables and Stress Urinary Incontinence Among Nulliparous Collegiate Athletes Study. The purpose of this study is to explore the influence of sports characteristics on stress urinary incontinence in female collegiate athletes. As a female collegiate athlete, you are in a unique position to provide information on these variables whether or not you experience urinary leakage, which can be used to help other athletes in the future. Your participation in this research study is strictly voluntary but is very important in contributing to our understanding of issues affecting female collegiate athletes. Key Points It should only take 10 minutes For your time, you will be entered to win a $50 gift card Your participation in this survey is completely voluntary and all your responses are anonymous. None of the responses will be connected to identifying information. Please complete this survey by Friday, February 26, 2021. Take the survey now If you have any questions about this survey, or difficulty in accessing the site or completing the survey, please contact Dr. Rebecca Parr, the study coordinator, at parrr@uindy.edu Thank you for your participation in this important research. Sincerely, Dr. Rebecca Parr University of Indianapolis Doctor of Health Science Program (269) 274-7043 parrr@uindy.edu  ...

... CLINICAL REASONING, CRITICAL THINKING DISPOSITION, AND SELFREFLECTION: PREDICTORS OF ACADEMIC SUCCESS AND CLINICAL READINESS? Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Michael Obert, PT, MPT, OCS Copyright 2/24/2020 By: Michael Obert, PT, MPT, OCS All rights reserved Approved by: Stephanie Kelly, PT, PhD, Committee Chair Karen Huhn, PT, PhD Committee Member Elizabeth Moore, PhD, Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: CLINICAL REASONING AND ACADEMIC SUCCESS 1 Clinical Reasoning, Critical Thinking Disposition, and Self-Reflection: Predictors of Academic Success and Clinical Readiness? Michael Obert University of Indianapolis CLINICAL REASONING AND ACADEMIC SUCCESS 2 Abstract Identifying students who may struggle in a professional physical therapy (PT) program can inform admission decisions and direct development of strategies to help students be successful in the program. Many researchers have studied the relationship between various preadmission variables and success in a PT program. To date, the preadmission variables studied have accounted for 37% or less of the variance in predicting PT program success. The purpose of this study was to determine if preadmission variables and the following variables had an impact on PT student program success and clinical readiness: Health Science Reasoning Test Numeracy (HSRT-N) scores, California Critical Thinking Disposition Inventory (CCTDI) scores, SelfReflection and Insight Scale (SRIS) scores. This study also explored the relationship between the SRIS and HSRT-N and CCTDI. Forty-two DPT students were included in this prospective cohort study. The only statistically significant difference (p = .043) between PT students who experienced academic success and PT students who experienced academic difficulty was in their SRIS-Insight scores. Students who experienced academic success had higher mean SRIS-Insight scores than those who experienced academic difficulty. The SRIS and its subscales did have 17 statistically significant low to moderate correlations (r = .30-.67, p < .05) with HSRT-N and CCTDI scores and subscale scores. Results suggest that SRIS-Insight scores may be useful in identifying students at-risk for academic difficulty and SRIS scores may serve as a useful instrument in PT education. Keywords: Health Science Reasoning Test-Numeracy, California Critical Thinking Disposition Inventory, Self-Reflection and Insight Scale, preadmission criteria, academic success, academic difficulty, clinical readiness, physical therapy education CLINICAL REASONING AND ACADEMIC SUCCESS 3 Acknowledgements As I near the end of my doctoral program, I am grateful for the opportunity for personal and professional growth that this program has afforded me. I would like to take the opportunity to thank those who have supported me along the way. First, I would like to thank my wife, Jessica, and our two daughters, Payton and Presley. Your support, love, understanding and encouragement have served as my key points of motivation to complete this project, and ultimately this degree. I could not have done this alone, and truly appreciate all that you have done for me. Next, I would like to thank my committee members, Dr. Stephanie Kelly, Dr. Elizabeth Moore and Dr. Karen Huhn. I truly appreciate you sharing your knowledge, time and expertise with me to help make this a fruitful project. Your guidance helped this project evolve from a simple idea into something unique and tangible. I truly appreciate your patience, understanding, encouragement and family-first mentality. You all have served as great role models to me for the rest of my career. Finally, I would like to thank the faculty and students in the Doctor of Physical Therapy Program at Mount St. Joseph University. I am incredibly grateful to be surrounded by such an encouraging and inspiring group of people on a daily basis. I truly appreciate you sharing your expertise and words of encouragement along the way, and look forward to paying it forward. With my deepest gratitude, Michael Obert CLINICAL REASONING AND ACADEMIC SUCCESS 4 Table of Contents Title Page.1 Abstract2 Acknowledgements..3 Chapter 1: Introduction6 Background. 6 Problem Statement...7 Purpose of the Study.7 Chapter 2: Literature Review...8 Preadmission Variables and Academic Success...8 Academic Success and Difficulty...11 Type of Program.12 Clinical Reasoning.12 Self-Reflection...15 Critical Thinking Disposition.16 Chapter 3: Method..18 Study Design..18 Instrumentation..21 Participants.24 Data24 Procedures..25 Statistical Analysis.29 Chapter 4: Results..30 CLINICAL REASONING AND ACADEMIC SUCCESS 5 Demographics30 Objective 1.31 Objective 2.31 Objective 3.32 Objective 4.32 Objective 5.33 Chapter 5: Discussion and Conclusion..33 Discussion..33 Study Limitations...43 Conclusion.43 References..47 Table 1: Descriptive Statistics and Comparison between Preadmission Criteria and Academic Standing.54 Table 2: Descriptive Statistics and Comparison between Health Sciences Reasoning Test with Numeracy and Academic Standing55 Table 3: Descriptive Statistics and Comparison between California Critical Thinking Disposition Inventory and Academic Standing56 Table 4: Descriptive Statistics and Comparison between SRIS and Academic Standing57 Table 5: Health Sciences Reasoning Test with Numeracy Correlations with Self-Reflection and Insight58 Table 6: California Critical Thinking Disposition Inventory Correlations with Self-Reflection and Insight Scale...59 Appendices.60 CLINICAL REASONING AND ACADEMIC SUCCESS 6 Clinical Reasoning, Critical Thinking Disposition, and Self-Reflection: Predictors of Academic Success and Clinical Readiness? Professional physical therapy (PT) programs are faced with the important task of identifying students who have the potential to succeed in a demanding program. More importantly, once a cohort of students has matriculated into a program, PT faculty are charged with the task of ensuring their students are ready to enter into the clinical setting (Commission on Accreditation in Physical Therapy Education, 2014) and that at least 80% of the matriculated students graduate in a timely manner (CAPTE, 2016). There is a financial loss for schools when a student is not retained as well as a loss for the student who incurs a debt that does not result in a PT career. Clinical reasoning and critical thinking are important factors for safe and effective clinical practice and professional growth (Jensen, Gwyer, Shepard, & Hack, 2000; Resnik & Jensen, 2003). Critical thinking has been defined as purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which that judgment is based (Facione, 1990, p. 3). Clinical reasoning is the application of the critical thinking process to a patient scenario that includes evidence of reflection (Jensen et al., 2000; Koharchik, Caputi, Robb, & Culleiton, 2015). For these reasons, it is of the utmost importance that critical thinking, clinical reasoning, and reflection are incorporated into professional PT programs. Previous studies have focused on preadmission criteria as predictors of academic success in PT programs. Potential predictors have included measures of previous performance and aptitude such as undergraduate grade point average (GPA) and performance on the Graduate Record Examination (GRE). Other predictors evaluated are affective measures, learning styles, CLINICAL REASONING AND ACADEMIC SUCCESS 7 interviews, undergraduate school selectivity, age, and ethnicity. To date, studies have only accounted for 37% or less of the variance to explain student academic success or difficulty in a PT program (Andrews, Johansson, Chinworth, & Akroyd, 2006; Jewell & Riddle, 2005; Ruscingo, Zipp, & Olson, 2010; Shiyko & Pappas, 2009; Templeton, Burcham, & Franck, 1994; Utzman, Riddle, & Jewell, 2007; Wheeler & Arena, 2009). While it may be impossible to explain 100% of the variance from a predictive equation, there are additional factors that have not been explored. A study attempting to predict performance on the National Physical Therapy Licensing Examination (NPTE) found that adding a measure of clinical reasoning improved the predictive ability of the model (Huhn & Parrott, 2017). It is possible that clinical reasoning, critical thinking disposition, and self-reflection could be some of the missing factors that could help programs predict who will be successful and prepared to enter the clinical setting. Purpose of the Study The purpose of the study was to explore the relationship between clinical reasoning skills, critical thinking disposition, and self-reflection in students prior to beginning coursework in a professional PT program and academic success and clinical readiness after the first year of the program. Preadmission criteria were also evaluated in order to compare the results of this study to the current body of evidence. The objectives of the study were: 1. To determine if there is a relationship between preadmission criteria and a) student academic standing in the first year of a program, and b) clinical readiness at the end of the first year of study. 2. To determine if there is a relationship between clinical reasoning, as measured with the Health Sciences Reasoning Test-Numeracy (HSRT-N), and a) student academic standing in the first year of a program, and b) clinical readiness at the end of the first year of study. CLINICAL REASONING AND ACADEMIC SUCCESS 8 3. To determine if there is a relationship between willingness to think critically, as measured by the California Critical Thinking Disposition Inventory (CCTDI), and a) student academic standing in the first year of a program, and b) clinical readiness at the end of the first year of study. 4. To determine if there is a relationship between self-reflection, as measured by the SelfReflection and Insight Scale (SRIS), and a) student academic standing in the first year of a program, and b) clinical readiness at the end of the first year of study. 5. To determine if there is a relationship between SRIS scores and scores on the HSRT-N and CCTDI. Literature Review CAPTE grants accreditation to PT programs that meet certain quality standards. Programs are expected to graduate at least 80% of matriculated students in a timely manner (CAPTE, 2016) and ensure clinical readiness of their students prior to clinical internships (CAPTE, 2014). Many studies have attempted to identify predictors of student academic success within a program to aid in the selection of students who have the most potential to succeed in a program. Others have sought the same information to identify students who may struggle within a program in order to provide an intervention to help them succeed. Clinical reasoning is a recurrent theme that CAPTE emphasizes should be incorporated into the PT curriculum (CAPTE, 2014), but to date there have been no studies to evaluate if clinical reasoning skills prior to admission have an impact on student success within a PT program. There is also little research on the impact of critical thinking disposition and self-reflection on academic performance in a PT program. Preadmission Variables and Academic Success CLINICAL REASONING AND ACADEMIC SUCCESS 9 In a total of 12 studies, researchers attempted to identify both academic and nonacademic predictors of academic success and results ranged from being able to account for 16% (Templeton et al., 1994) to 37% (Thieman, Weddle, & Moore, 2003) of the variance. The commonly utilized cognitive variables included total undergraduate GPA (uGPA) or components of uGPA including science or prerequisite course GPA (Andrews et al., 2006; Day, 1986; Dockter, 2001; Fell, Mabey, Mohr, & Ingram, 2015; Huhn & Parrott, 2017; Jewell & Riddle, 2005; Ruscingo et al., 2010; Shiyko & Pappas, 2009; Templeton et al., 1994; Thieman et al., 2003; Utzman et al., 2007; Wheeler & Arena, 2009). The total GRE scores (tGRE) and component scores including analytic (aGRE), verbal (vGRE), and quantitative (qGRE) were evaluated in many of the studies as potential predictors of student success in a PT program (Andrews et al., 2006; Day, 1986; Huhn & Parrott, 2017; Jewell & Riddle, 2005; Shiyko & Pappas, 2009; Thieman et al., 2003; Utzman et al., 2007; Wheeler & Arena, 2009). Besides the fact that the overall predictive variance was generally low, there are other challenges to applying the findings of these studies to current programs. The variances for the individual predictors were often either not reported, or in studies that assessed multiple PT programs, some of the variables were predictive in some programs but not others. Non-cognitive variables were also evaluated with respect to their ability to predict student academic success in a DPT program. Age was a common factor for several studies (Andrews et al., 2006; Day, 1986; Dockter, 2001; Ruscingo et al., 2010; Shiyko & Pappas, 2009; Thieman et al., 2003; Wheeler & Arena, 2009) although only three of the studies found that age had predictive value for academic success, and again the percentage of variance was low ranging from approximately eight to ten percent (Dockter, 2001; Shiyko & Pappas, 2009; Thieman et al., 2003). Race and gender were explored as potential predictors (Andrews et al., 2006; Day, 1986; CLINICAL REASONING AND ACADEMIC SUCCESS 10 Shiyko & Pappas, 2009; Wheeler & Arena, 2009) with only one of these studies showing that white race was a positive predictor variable for program GPA (Day, 1986). Other studies explored further admission variables such as a written essay or verbal interview with all of them reporting that some combination of these variables added to a predictive model (Dockter, 2001; Shiyko & Pappas, 2009; Thieman et al., 2003). Two studies found that undergraduate school selectivity had an impact on predicting student success (Andrews et al., 2006; Wheeler & Arena, 2009). While there were some studies that reported a high variance that was accounted for in predicting students academic success in a PT program, there were some methodological flaws that may limit their use. The study that was able to predict 37% of the variance for the students program GPA only had one out of 122 students from four cohorts who did not complete the program and the one student who did not complete the program withdrew in good standing (Thieman et al., 2003). The fact that all students either graduated or withdrew while in good standing, may limit this studys applicability to the current study, which aimed to identify those students who may struggle in the first year. The next highest variance accounted for that was reported in these studies was 33%, but this study excluded 13 students who did not graduate (Fell et al., 2015), which also limits its applicability to the current study. Of the studies that reported attrition and included students who had experienced academic difficulty, the highest variance accounted for was 24% that included a combination of vGRE, qGRE, and uGPA added to the predictive model (Utzman et al., 2007). This study, however, included students from a combination of masters programs, transitional DPT programs, and DPT programs. The researchers reported there was high variability in using their equation for each of the 20 programs included in the study (Utzman et al., 2007). CLINICAL REASONING AND ACADEMIC SUCCESS 11 The academic variables, including uGPA (Andrews et al., 2006; Day, 1986; Dockter, 2001; Fell et al., 2015; Huhn & Parrott, 2017; Jewell & Riddle, 2005; Ruscingo et al., 2010; Shiyko & Pappas, 2009; Templeton et al., 1994; Thieman et al., 2003; Utzman et al., 2007; Wheeler & Arena, 2009), tGRE (Shiyko & Pappas, 2009; Thieman et al., 2003), vGRE (Jewell & Riddle, 2005; Shiyko & Pappas, 2009; Utzman et al., 2007), and qGRE (Jewell & Riddle, 2005; Shiyko & Pappas, 2009; Utzman et al., 2007; Wheeler & Arena, 2009) were the most frequently reported significant predictors of success in a professional PT program (p < .05). However, success was defined differently in many of these studies. The most frequently reported non-academic variables that were significant predictors of academic success were undergraduate school selectivity (Andrews et al., 2006; Wheeler & Arena, 2009), age, and admission interviews and essays (Dockter, 2001; Shiyko & Pappas, 2009; Thieman et al., 2003). Academic Success and Difficulty Academic success and difficulty were defined differently in many of these studies, which provides a challenge for utilizing their results. A few studies aimed to predict the final program GPA (Day, 1986; Fell et al., 2015; Thieman et al., 2003) while others looked at predicting firstyear GPA (Dockter, 2001; Ruscingo et al., 2010; Shiyko & Pappas, 2009). While the equations from these studies could be useful, the authors did not identify if there was a difference between students who experienced academic difficulty and students who did not. One study demonstrated that using a combination of uGPA and undergraduate school selectivity was able to predict attrition, although the variance accounted for was not stated (Andrews et al., 2006). Three other studies defined academic difficulty similar to the current study that included students who went on probation or were dismissed from the program for academic reasons. These studies reported that a combination of school selectivity (Wheeler & Arena, 2009), component GRE scores, and CLINICAL REASONING AND ACADEMIC SUCCESS 12 uGPA were able to predict students with academic difficulty (Jewell & Riddle, 2005; Utzman et al., 2007; Wheeler & Arena, 2009). Type of Program Another challenge with interpreting and implementing results of these studies is that there were many different types of programs included. One study included students from a two-year bachelors program (Templeton et al., 1994), five of the studies included students from masters programs only (Andrews et al., 2006; Day, 1986; Dockter, 2001; Jewell & Riddle, 2005; Thieman et al., 2003), five studies included DPT programs only (Fell et al., 2015; Huhn & Parrott, 2017; Ruscingo et al., 2010; Shiyko & Pappas, 2009; Wheeler & Arena, 2009), and one study included students from masters, transitional DPT, and DPT programs (Utzman et al., 2007). The current standard in PT education is a DPT program, and even across DPT programs, there is some variance where some programs are a traditional graduate program and others are direct-entry programs or 3+3 programs. While many of the masters programs that were included in this review were graduate programs, the depth and rigor of DPT programs have increased compared to masters programs, so their results may not be generalizable to students in a current DPT program. Clinical Reasoning One missing factor that has not often been used to predict student academic performance is clinical reasoning. It is well accepted in healthcare that clinical reasoning is an important factor for becoming a clinician. Commission on Accreditation in Physical Therapy Education has emphasized the importance of incorporating clinical reasoning into PT education (CAPTE, 2014). Clinical reasoning is one component on the Clinical Performance Instrument (American Physical Therapy Association, 2006) which is used to evaluate student performance in the CLINICAL REASONING AND ACADEMIC SUCCESS 13 clinical setting. Students are not expected to enter a PT program with good clinical reasoning skills, as clinical reasoning is something that is taught in PT programs and is expected to improve over time. Since clinical reasoning is the application of the critical thinking process to patient scenarios (Jensen et al., 2000; Koharchik et al., 2015), it may be useful to assess students critical thinking skills with a health care focus. The HSRT-N is a critical thinking skills test with a health care focus, and could potentially provide insight into the critical thinking skills of the students at the beginning of a program. Low scores on the HSRT-N could potentially lead to challenges with their development of clinical reasoning skills while in the program. Jensen, Gwyer, Shepard, and Hack (2000) identified clinical reasoning skills as one of the components of expert practice in PT. Reflective practice is one of the key components of clinical reasoning (Jensen et al., 2000). Given the importance of clinical reasoning skills for the development and success of PT students and PTs, it may be advantageous to evaluate clinical reasoning skills, as well as the key components of critical thinking, critical thinking disposition and self-reflection as potential predictors of success in PT education. Students may have good critical thinking skills, but if their critical thinking disposition is such that they are not readily willing to engage in the critical thinking process, it may be challenging to develop their critical thinking skills, and thus their clinical reasoning skills. Additionally, those who are not willing to engage in components of clinical reasoning, such as critical thinking and self-reflection, may have difficulty with improving their clinical reasoning skills. Therefore, it is also important to address students disposition toward critical thinking. Clinical reasoning skills have been shown to evolve over time for students in a DPT program (Gilliland, 2014, 2017; Huhn, Black, Jensen, & Deutsch, 2013). In a qualitative study, first-year students used more simple strategies which involved faulty reasoning patterns CLINICAL REASONING AND ACADEMIC SUCCESS 14 compared to third-year students who used more sophisticated strategies (Gilliland, 2014). Students also tended to focus more on surface concepts and anatomy early in the development of their clinical reasoning. As they progressed through a program, their clinical reasoning process incorporated more information from the medical diagnosis and biomechanical factors, but they still did not incorporate the patients life context into their decision-making (Gilliland, 2017). While a focus on movement and biomechanics is an additional key factor for expert practice (Jensen et al., 2000), students were missing the reflective part of the clinical reasoning process. In another study, clinical reasoning skills as measured by the Health Sciences Reasoning Test (HSRT) improved from the beginning of a DPT program to the end of the didactic portion of a program. However, there were no significant changes noted in the HSRT scores during the clinical internships at the end of the curriculum (Huhn et al., 2013). Clinical reasoning skills were assessed in only one of the studies predicting academic success. The aim of this particular study was to evaluate the relationships between clinical reasoning skills as measured by the HSRT, cognitive admission variables, and success on the National Physical Therapy Licensing Examination (NPTE). While it was not the primary focus of the study, the authors reported a moderate correlation between the HSRT scores and first-year GPA (r = .33, p < .001) and that first-year GPA had the strongest relationship with NPTE pass rates (r = .60, p < .001). The HSRT also had a strong relationship with the NPTE (r = .43, p < .001) and the addition of the HSRT to a predictive model improved the strength of the model (AIC 2 = 10.7; p = .001) (Huhn & Parrott, 2017). The HSRT has also been deemed to have construct validity for use with PT students as scores were able to discriminate between novice and expert clinicians, particularly the deductive (p = .01) and analysis (p < .001) subscales (Huhn, Black, Jensen, & Deutsch, 2011). Results of these studies indicate that the HSRT may CLINICAL REASONING AND ACADEMIC SUCCESS 15 have validity for the current study, and the fact that first-year GPA had a strong correlation with NPTE pass rates indicates the importance of success in the first year. For the purpose of the current study, the developers of the HSRT recommended the use of the HSRT-N (Numeracy), which is a newer version of the HSRT and can be correlated to the HSRT results in the literature (D. August, personal communication, March 21, 2018). Self-Reflection Since self-reflection is considered a vital component of clinical reasoning and expert practice (Jensen et al., 2000), it would be valuable to explore self-reflection as a potential predictor of academic performance. Students clinical reasoning skills and self-reflection improved over time in a DPT program in one longitudinal mixed methods study (Furze et al., 2015). Beginners used more compartmentalized thinking and did not focus on the whole patient, whereas intermediates began to implement the context of the patient on decision making and had notable improvements in self-reflection. Finally, entry-level students had a much more encompassing approach that included the patients context into their clinical reasoning process (Furze et al., 2015). Roche and Coote (2008) reported that in the beginning stages of a PT students development, reflection was more performance-based. Toward the end of the program, students reported that reflection had a positive effect on clinical practice. Reflection allowed them to have a more open mind with treatment choices, helped them improve their pattern recognition, and provided justification for their treatment choices (Roche & Coote, 2008). Finally, one study utilized the Self-Reflection and Insight Scale (SRIS) that showed improvements in scores following a critical thinking course within a DPT program (Huhn, 2017). There is also a connection between self-reflection and learning, where self-reflection and learning have mediated the effects of anxiety in nursing students (Pai, Ko, Eng, & Yen, 2017). If CLINICAL REASONING AND ACADEMIC SUCCESS 16 students struggle in their ability to self-reflect, it is possible they could struggle through a DPT program that includes a significant level of learning and also emphasizes the clinical reasoning process. Early identification of these students could help faculty implement measures to improve their self-reflection and clinical reasoning skills. Unfortunately, there is a lack of empirical evidence aimed at measuring reflection in a PT setting. The majority of studies identified in this literature review used qualitative methods to assess clinical reasoning, while Furze et al. (2015) developed the Clinical Reasoning Reflection Questionnaire (CRRQ) for use in their study; however, it has not been validated. While the SRIS has only been utilized with PT students in one study (Huhn, 2017), it can be used to measure cognitive flexibility, reflection, and self-regulation and has been used in multiple settings including with nursing students, where self-reflection and insight had a positive effect on critical thinking (p < .001) (S. Y. Chen, Chang, & Pai, 2018). Positive scores on the SRIS have also demonstrated a positive correlation with competence in Taiwanese nursing students (Eng & Pai, 2015). While there are limited standardized tools to measure self-reflection in PT education, the SRIS has demonstrated adequate metrics for use in healthcare education, and was used for this study as a measure of self-reflection. Critical Thinking Disposition While it has been shown that clinical reasoning and self-reflection develop over time, it is also important to understand the students attitude towards thinking and willingness to change a thought process over time in order to be successful in a PT program. The CCTDI, which classifies scores as strong negative, negative, inconsistent or ambivalent, positive, or strong positive (Insight Assessment, 2018a), has been used for this particular purpose with PT students. One study reported that PT students scores on the CCTDI were low compared to the normative CLINICAL REASONING AND ACADEMIC SUCCESS 17 values for health sciences majors, although this particular study assessed bachelors-level PT students (Bartlett & Cox, 2000). Another study sought to explore the relationship between the CCTDI, the California Critical Thinking Skills Test (CCTST), and attrition in PT students. The authors only reported descriptive statistics of the CCTDI in this study that were inconsistent. The students CCTST scores were low as a whole (20th percentile), and this may have partially explained why there was no significant correlation with CCTST scores and attrition (Domenech & Watkins, 2015). On the contrary, other studies have demonstrated that CCTST and CCTDI scores significantly improved (p < .05) over time, particularly the truth-seeking and selfconfidence subscales of the CCTDI (Bartlett & Cox, 2002; Wessel & Williams, 2004). These studies have demonstrated that PT students have the potential to score low on their critical thinking disposition, but that it can improve over time. The CCTDI was utilized for the current study to explore the relationship between critical thinking disposition and student academic success in the first year of a DPT program. It is important to assess disposition towards critical thinking because one can have good critical thinking skills, but if they are not willing to use those skills, they may not be successful in a program that emphasizes critical thinking and clinical reasoning. While there have been many studies that have aimed to predict student success in a PT program, both for admissions and retention purposes, there is a lack of research evaluating the impact of clinical reasoning, self-reflection, and critical thinking disposition on student academic performance. The aim of the current study was to explore the relationship of preadmission variables, clinical reasoning skills as measured by the HSRT-N, self-reflection as measured by the SRIS, and critical thinking disposition as measured by the CCTDI with success in the first year of a DPT program and clinical readiness at the end of the first year. Findings of this study CLINICAL REASONING AND ACADEMIC SUCCESS 18 may help inform admissions decisions in addition to identifying students who may benefit from early intervention to help them succeed in a DPT program. Method Study Design This prospective cohort study explored the relationship between preadmission variables, HSRT-N scores, CCTDI scores, and SRIS scores collected prior to beginning a DPT program to student academic success in the first year of a program and clinical readiness at the end of the first year of study. The study took place at Mount St. Joseph University (MSJ) within the Department of Physical Therapy between June, 2018 and May, 2019. Prior to participant recruitment, the study was approved by the Human Research Protections Program (HRPP) at the University of Indianapolis who entered into a reliance agreement with the institutional review board (IRB) at MSJ. First year curriculum and Hallmark Practical I. The first-year curriculum in the MSJ DPT program consists of foundational knowledge courses with a progression to foundational clinical courses. The first two semesters in the program include gross anatomy, exercise physiology, neuroscience, biomechanics, and kinesiology. Students are also introduced to the research series and professional socialization in these semesters. The third and final semester continues the professional socialization series along with introduction to professional issues. The core of the third semester is the foundational clinical courses including basic examination and evaluation, basic patient care skills, therapeutic exercise, and modalities. It is in the third semester where the students begin to apply their foundational knowledge in patient-based scenarios and learn the basic skills required by physical therapists. CLINICAL REASONING AND ACADEMIC SUCCESS 19 At the end of the third semester, students participate in Hallmark Practical I (HMP I), which is a summative year-end practical in which the students perform an examination, evaluation, and treatment of a simulated patient. Students are graded on each component of the simulated case and separate rubrics are utilized for each of the four clinical courses based on the appropriate components of the initial examination and treatment. Student performance is also evaluated on a separate rubric that is used to determine clinical readiness. The rubric was designed by faculty, although it does not have established reliability and validity. Students are graded in four categories including clinical reasoning, professionalism, communication, and safety. For each category student performance is rated as either unsatisfactory, emerging, or proficient. Students must achieve a minimum of emerging in each of the four categories to successfully pass HMP I. Students who successfully complete the first year and receive a passing score on HMP I are deemed clinically ready and be able to begin their integrated clinical experiences the following month. Operationalization of variables. For the current study, participants were placed in the academic difficulty group if they experienced one of the following: academic probation, warning letter, or academic dismissal. Students were placed in the academic success group if they did not experience academic difficulty as defined here. Academic probation is defined as having a cumulative GPA less than 3.0 on a 4.0 scale. A warning letter is sent to any students who have earned less than a 3.0 in any given semester, but whose cumulative GPA is still at or above a 3.0. Academic dismissal is defined as any student who is not able to continue in the DPT program either for failure of a course or consecutive semesters with a cumulative GPA less than 3.0. All participants who did not fall into the academic difficulty group were considered as having achieved academic success in the first year of the program. Clinical readiness was determined CLINICAL REASONING AND ACADEMIC SUCCESS 20 using HMP I scores. Students who obtained a level of emerging or proficient were considered clinically ready. The critical thinking component of clinical reasoning was measured using the HSRT-N, which gives an overall score as well as scores in seven subscales: Analysis, Interpretation, Inference, Evaluation, Explanation, Deduction, and Induction. Analysis measures the ability to identify patterns and assumptions when making decisions. Interpretation is the ability to determine or assign meaning to a given situation. Inference is the ability to draw conclusions from a given set of information. Evaluation is the ability to assess the quality and credibility of information and their sources. Explanation is the ability to provide a rationale for decisions. Deduction is the ability to determine what to believe or do in situations that are clearly defined. Induction is the ability to determine the most likely outcome given a situation that may not be clearly defined (Insight Assessment, 2018b). Critical thinking disposition was measured using the CCTDI, which provides results as an Overall score as well as scores in seven subscales: Truth-seeking, Open-mindedness, Analyticity, Systematicity, Confidence in reasoning, Inquisitiveness, Maturity of judgment. Truth-seeking is the desire to gain the best understanding of every situation even when the evidence conflicts with personal beliefs. Open-mindedness is the tendency to consider and tolerate the beliefs or opinions of others that differ from ones own beliefs. Analyticity is the tendency to predict what will happen next based on a certain situation. Systematicity is making a habit of approaching situations in a very structured and systematic way. Confidence in reasoning is the tendency to trust ones own thought process and problem-solving skills. Inquisitiveness is the desire to learn more. Maturity of judgment is the tendency to make decisions in a timely manner even when multiple correct solutions may apply (Insight Assessment, 2018a). CLINICAL REASONING AND ACADEMIC SUCCESS 21 Self-reflection was measured using the SRIS, and scores are reported using an overall score, self-reflection score, and insight score. Self-reflection is the inspection and evaluation of ones thoughts, feelings and behavior (Grant, Franklin, & Langford, 2002, p. 821) and insight is the clarity of understanding of ones thoughts, feelings and behavior (Grant et al., 2002, p. 821). Instrumentation Health Sciences Reasoning Test with Numeracy. The HSRT-N was developed from an earlier tool, the HSRT which is a test designed to measure clinical thinking skills and the decision-making processes. The test can be taken electronically or on a paper form and can be administered in a 50-minute time frame. Insight Assessment who is the proprietor of the test scored the tests and provided results in the form of an overall score and five subscores: Analysis, Inference, Evaluation, Induction, and Deduction (Insight Assessment, 2018b). The HSRT has demonstrated the ability to track changes in clinical reasoning skills over time in a DPT program (Huhn et al., 2013) and has also shown discriminative ability between novices and experts (Huhn et al., 2011), ability to predict NPTE success, and aid in admissions decisions (Huhn & Parrott, 2017). A previous study demonstrated there was a difference in scores between undergraduate and graduate students on the HSRT, where the mean in undergraduate programs was 18.3 and the mean in graduate programs was 22.5 (Huhn & Parrott, 2017). In a validation study, the mean score for novice physical therapists was 22.49 (3.2) and the mean score for experts was 24.06 (3.92). The total score in addition to the Deduction and Analysis subscale scores demonstrated discriminative ability between novices and experts at a p < .01 level. Reliability for the five CLINICAL REASONING AND ACADEMIC SUCCESS 22 subscales have also been reported and are as follows: Induction (r = .76), Deduction (r = .71), Inference (r = .52), Analysis (r = .54), and Evaluation (r = .77) (Huhn et al., 2011). Developers of the HSRT recommended the use of a newer version of this test, the HSRTN (numeracy). The HSRT-N is a 38-question test that is taken electronically and scored on a 100-point scale. There are currently no published studies using the HSRT-N in physical therapist education programs, however, the scores on the HSRT-N can be directly correlated with scores from the HSRT with the correlation of scores for both versions approaching 1.00 (D. August, personal communication, March 21, 2018). Percentiles are also comparable across the two versions, and the HSRT-N adds three additional scales, Numeracy, Explanation, and Interpretation (D. August, personal communication, March 21, 2018). Based on the recommendation of the developers, the HSRT-N was used for the study, and permission was granted by Insight Assessment to use the HSRT-N for the study. California Critical Thinking Disposition Inventory. The CCTDI is a questionnaire designed to measure ones disposition and willingness to engage in critical thinking. The test can be taken in either an electronic or paper format and is estimated to take less than 30 minutes to complete. The test has been calibrated for various professions, adults, and students in grades ten and above. The CCTDI is another proprietary test through Insight Assessment who performed the scoring of the tests. The CCTDI measures seven scales: truth-seeking, open-mindedness, analyticity, systematicity, confidence in reasoning, inquisitiveness, and maturity of judgment (Insight Assessment, 2018a). A few studies have used the CCTDI in PT education. The alpha reliability of the overall CCTDI has been reported as .91 with the Cronbachs alpha for the seven subscales ranging from .71 to .80. The subscales have also been correlated with the psychological constructs of CLINICAL REASONING AND ACADEMIC SUCCESS 23 openness to experience and ego resiliency which helps establish validity of the instrument. (Domenech & Watkins, 2015). Two studies have reported lower scores in the self-confidence and truth-seeking subscales in PT students (Bartlett & Cox, 2000; Domenech & Watkins, 2015) while a third reported statistically significant changes in the total scores and all subscales over one year, with the greatest changes occurring in the same subscales over the didactic portion of the program (Bartlett & Cox, 2002). One final study which evaluated CCTDI scores with PT students demonstrated that overall change scores at two different time points were not statistically significant, but there were statistically significant changes in the subscales of truthseeking, self-confidence, and systematicity (Wessel & Williams, 2004). Finally, one study evaluated PT students change in CCTDI scores from before taking a clinical reasoning course to after completing a clinical reasoning course. The author reported statistically significant (p < .05) improvements in CCTDI total scores, as well as the subscales of truth-seeking, systematicity, confidence in reasoning, and inquisitiveness (Huhn, 2017). While there is a paucity of research that has utilized the CCTDI with PT students, the limited results have demonstrated usefulness and the ability to measure change over time with the population of interest (Bartlett & Cox, 2000, 2002; Domenech & Watkins, 2015; Huhn & Parrott, 2017; Wessel & Williams, 2004). Permission was granted by Insight Assessment to use the CCTDI for the study. Self-Reflection and Insight Scale. The SRIS (see Appendix A) is a 20-question inventory with users responding on a six-point Likert scale from disagree strongly to agree strongly. The SRIS includes two subscales: self-reflection and insight. This instrument has demonstrated reliability with test-retest correlation being r = .77 for self-reflection and r = .78 for insight. The SRIS has also demonstrated good internal consistency with both subscales with a Cronbachs alpha of .91 for self-reflection and .87 for insight (Grant et al., 2002). One study CLINICAL REASONING AND ACADEMIC SUCCESS 24 utilized the SRIS to evaluate change in PT students self-reflection and insight before and after participating in a course in critical reasoning. Results showed a statistically significant increase (p = .001) in total scores from pre-course to the completion of the course (Huhn, 2017). While the SRIS has not been frequently utilized with PT education to date, it has been used with adequate metrics with nursing students (S. Y. Chen et al., 2018; Shu Yueh Chen, Lai, Chang, Hsu, & Pai, 2016; Eng & Pai, 2015), across cultures with various versions in different languages (Akun & etin, 2017; Shu Yueh Chen et al., 2016), and in the field of psychology where results of the SRIS have served as a significant predictor of psychological well-being (Harrington & Loffredo, 2010). With these factors considered, the SRIS was utilized in the current study as a potential predictor of success. Permission was granted by the developer of the SRIS to use this assessment for the study (A. Grant, email communication, February 10, 2018). Participants A convenience sample was recruited from the incoming MSJ student cohort in June, 2018. The inclusion criteria for this study were being a first-year DPT student in the MSJ program and not having prior experience in a DPT program. The exclusion criteria were not being a first-year student in the MSJ DPT program or having taken prior classes in any DPT program. Forty-four potential participants met the inclusion criteria of being a first-year DPT student in the MSJ program and not having prior experience in a DPT program. No students were excluded from potential participation due to the exclusion criteria. Data Data were collected from three sources: the registrars office at MSJ, an online survey taken by study participants at the beginning of the DPT program, and from the DPT program at the end of the academic year. Data collected from the registrars office included GPA at the end CLINICAL REASONING AND ACADEMIC SUCCESS 25 of the first year or at the time of dismissal from the program. This data was sent to the research assistant who compiled and de-identified data utilizing pre-assigned code numbers into a spreadsheet prior to sending to the principle investigator. Preadmission and demographic information were obtained from the DPT program through the same research assistant. The research assistant compiled and de-identified the data utilizing pre-assigned code numbers prior to sending the data to the principle investigator. Data collected through the online survey included SRIS scores, HSRT-N scores, and CCTDI scores. The online survey was taken through two different platforms. The SRIS was taken through Qualtrics while the HSRT-N and the CCTDI were taken through the platform used by Insight Assessment. After grades were entered at the conclusion of the first year, data was downloaded from Qualtrics by the primary investigator into an Excel file. Data were also collected and compiled by Insight Assessment at that time and emailed to the primary researcher. Data from the three assessments were in the form of the pre-assigned code numbers in order to maintain confidentiality of the participants. Student data from the various sources was matched by the primary investigator through the use of the unique study identification number and organized into an Excel file. Procedures Assignment of study identification number. A research assistant in the DPT program randomly assigned a four-digit code to every student in the first year DPT cohort and maintained this information in a spreadsheet on a secure flash drive under lock and key. At no time did the primary investigator have access to this file. The research assistant gave students their code during the meeting to introduce the students to the research study. They were told they would need to use this code if they agreed to participate in the study. This method of code assignment CLINICAL REASONING AND ACADEMIC SUCCESS 26 allowed the participants to maintain confidentiality and the primary investigator to remain blinded to the participants throughout the study. The research assistant would also be able to retrieve each participants code in case one of the participants forgot his or her code. Recruitment. Potential participants were informed that this study was approved by the HRPP and IRB and were recruited at MSJ during their first week of orientation to the DPT program. A typed letter describing the purpose of the study and rationale for recruitment was distributed to each of the students (see Appendix A). A research assistant who was not involved in the study distributed the letters to minimize coercion. The same person also gave a verbal explanation of the purpose of the study and answered questions regarding the process to the best of their ability. Potential participants were informed that if they chose to participate, their student records including preadmission data and grades within the program would be accessed, although this information would be de-identified to ensure confidentiality. Potential participants were also instructed that their choice to either participate or not participate in the study would have no bearing, positive or negative, on their placement or success in the program. Potential participants were informed that they could withdraw from the study at any time with no repercussions to them. Potential risks and benefits of the study were also included in the letter. Potential risks of participation in the study were anticipated to be minimal and could include emotional distress associated with taking the tests and questionnaires and receiving their results on these forms. Potential benefits of participation were also minimal and could include possible insights into the students own clinical reasoning skills, critical thinking disposition, and self-reflection. Potential participants were assured that their personal identifying information would remain anonymous. Consenting participants were given the opportunity to meet with the primary investigator prior to participation in the study and address any questions or concerns that would not impact the CLINICAL REASONING AND ACADEMIC SUCCESS 27 validity of the study. Students were required to complete several different tasks during the first few weeks as part of orientation. Students were told they would be given time during their orientation to participate if they wished and it would not require any time outside their regular class time. Informed consent. An informed consent document was placed at the beginning of the online survey taken through Qualtrics. Potential participants were required to select either yes or no indicating whether or not they gave consent to participate in the study. Selecting yes indicated consent to participate in the study, and the data from the proceeding tests would be collected. Individuals selecting no would be taken to the end of the survey and no further information would be collected. When the survey moved out of the Qualtrics platform to the Insight Assessment platform, prior to starting the next part of the survey participants were required to respond yes or no indicating their continued consent to participate in the study. Selecting yes to each of these questions and completing all of the assessments indicated informed consent to participate in the study. Potential participants were informed that this study was approved by the HRPP and IRB. Data collection. All first year DPT students were given time during orientation in the first few weeks of the program to participate in the study by completing the online survey using a computer in the computer lab on campus. A specific time was set up within the first few weeks of the program when students were required to gather in the computer labs. During this preset time, students were instructed that they could participate in the study and complete the surveys, or they could use the time to study, do other coursework, or complete their additional orientation tasks. Having all students in the same room helped ensure confidentiality of those who chose to participate and those who chose not to participate in the study. The link to the online survey was CLINICAL REASONING AND ACADEMIC SUCCESS 28 posted for all students to see. The link navigated them to the Qualtrics survey. To proceed to the survey students had to consent to being in the study by clicking yes on the informed consent form. Those who proceeded in the survey first took the SRIS. At the end of the SRIS instrument, there was a link to the second part of the study. This link took participants to the Insight Assessment site where participants again had to consent to be in the study to move forward in the surveys. Participants who marked yes were asked to complete the HSRT-N and CCTDI. Consenting participants completed the three instruments consecutively with the option of a short break in between tests. The research assistant was available via phone or email to help troubleshoot any technical problems with completing the instruments. Insight Assessment was also available to provide technical support for the HSRT-N and CCTDI via phone if needed during testing. Participants took the SRIS first, followed by the CCTDI, and finally the HSRT-N. The SRIS and CCTDI are questionnaires with a Likert scale system and were deemed not to provide an overt amount of mental fatigue. Insight Assessment recommends having participants take the CCTDI prior to the HSRT-N for this reason, and have not reported any problems with testing fatigue (C. Smitt, personal communication, April 16, 2018). Following completion of the online survey, the primary researcher provided a list of the study identification numbers of study participants to the research assistant. Data was not analyzed at that time, only a list of study identification numbers for those completing the three instruments was provided. The research assistant used the codes to collect the preadmission data. They entered the data into an Excel spreadsheet and only used the assigned student identification number, no student identifiers were put into the file. Upon completion, the research assistant put the Excel file onto a secure, encrypted flash drive and kept it under lock and key. At the conclusion of the first year, the research assistant de-identified and coded data regarding first CLINICAL REASONING AND ACADEMIC SUCCESS 29 year GPA, academic status, and HMP I performance. The de-identified data was placed in an Excel file and given to the primary researcher via the secure, encrypted flash drive. The primary researcher was responsible for combining data from all sources and matching the data using the assigned study identification numbers. Once all data were collected, it was exported to a statistical software program for analysis. Health Sciences Reasoning Test and California Critical Thinking Disposition Inventory. The HSRT-N and CCTDI can both be taken via a browser-based or app format. Participants had access to an in-app tutorial prior to taking these tests to help with navigating and completing the HSRT-N and the CCTDI. All scoring for the HSRT-N and CCTDI was completed by Insight Assessment. Any participants requiring accommodations to complete the tests were to notify the research assistant, and additional time would be allotted for those participants to complete the tests. Insight Assessment sent the coded scores from the HSRT-N and CCTDI to the primary investigator. Again, data was sent only using study identification codes and no personal identifying information was listed. Completing the three instruments previously described satisfied the requirements of participation. Thereafter, students continued through their first year in the program with no other requirements for participation in the study. At the conclusion of the first year, all enrolled students in this cohort who were not dismissed or did not withdraw participated in a summative year-end practical, HMP I. Student academic performance in the first year and their performance on HMP I are both used within the MSJ DPT program to determine clinical readiness for participation in clinical internships following the first year. Statistical Analysis CLINICAL REASONING AND ACADEMIC SUCCESS 30 All statistical tests were performed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY). Descriptive statistics were conducted on the entire sample. Nominal data are presented as frequencies and percentages, ordinal data as medians and interquartile ranges, while interval and ratio data are reported as means and standard deviations or medians and interquartile ranges, dependent on whether the data were normally distributed. Nominal data were compared using Fishers exact tests, ordinal data were compared using Mann-Whitney U tests, normally distributed interval and ratio data were compared using independent t tests while non-normally distributed interval and ratio data were compared using Mann-Whitney U tests. Correlations were conducted using Pearson tests for normally distributed data and Spearman rho tests for ordinal and non-normally distributed data. Correlation coefficients were interpreted as follows: a correlation of 0-.30 were considered very low to no correlation, .30-.50 were considered low, .50-.70 were considered moderate, .70-.90 were considered high and .90-1.00 were considered very high (Hinkle, Wiersma, and Jurs, 1979). The Shapiro-Wilk test was used to assess the normality of the data and the Levenes test was used to determine if there was homogeneity of variance. Data were considered normally distributed if the Shapiro-Wilk test statistic did not differ from a normal distribution at a significance level of .05. All tests were two-tailed and a significance level of less than .05 was considered statistically significant. Results Demographics Forty-four students participated in the study. Two participants began taking the assessments, but did not complete all of them; therefore, they were excluded from data analysis. Of the remaining 42 students, the majority were female (n = 27, 64.3%) and Caucasian (n = 38, CLINICAL REASONING AND ACADEMIC SUCCESS 31 90.5%). The median age was 23 years (25th percentile 22, 75th percentile 24). Demographic details can be found in Table 1. Thirty-five (83.3%) students were in the academic success group while 7 (16.7%) students were in the academic difficulty group. There were no statistically significant differences (p > .05) in student demographics between academic standing groups (success and difficulty). Sample descriptive statistics for outcome data: preadmission criteria, HSRT-N scores, CCTDI scores, and SRIS scores can be found in Tables 1-4, respectively. Four of the 42 students who participated in the study did not complete the first year of the program; three were dismissed due to academic difficulty, and one withdrew voluntarily from the program while in good academic standing. Data from the student who withdrew voluntarily from the program was included in the study. The remaining 38 students who completed the first year of the program, passed HMP I and were deemed clinically ready, and thus only correlation analysis was performed for clinical readiness. Objective 1: Preadmission Criteria, Academic Standing and Clinical Readiness There were no significant differences between groups in academic standing in any of the preadmission criteria including uGPA, pre-requisite GPA, tGRE, vGRE, qGRE, aGRE and interview scores, thus the null hypothesis is accepted. See Table 1 for descriptive and comparative statistics. Statistically significant, but low positive correlations were found between HMP I professionalism scores and qGRE scores (r = .35, p = .031), and HMP I communication scores and interview scores (r = .41, p = .011). All other correlations were insignificant. Objectives 2: Health Sciences Reasoning Test with Numeracy, Academic Standing and Clinical Readiness CLINICAL REASONING AND ACADEMIC SUCCESS 32 There were no significant differences between groups in academic standing in any of the HSRT-N scores or CCTDI scores. See Table 2 for descriptive and comparative statistics. Interpretation scores had a moderate positive correlation with HMP I clinical reasoning scores (r = .51, p = .001), and low positive correlations with HMP I professionalism scores (r = .34, p = .035) and HMP I safety scores (r = .34, p = .039). There was also a low positive correlation between Inference scores and HMP I safety scores (r = .44, p = .006), and Evaluation scores and safety scores (r = .43, p = .007), and Numeracy and HMP I clinical reasoning scores (r = .40, p = .013). All other correlations between HSRT-N scores and HMP I scores were insignificant. Objective 3: California Critical Thinking Disposition Inventory, Academic Standing and Clinical Readiness There were no significant differences between groups in academic standing in any of the CCTDI scores. See Table 3 for descriptive and comparative statistics. All correlations between CCTDI scores and HMP I scores were insignificant. Objective 4: Self-Reflection and Insight Scale, Academic Standing and Clinical Readiness Self-reflection and Insight and Academic Standing scores including total score, selfreflection, and insight scores were analyzed. Three extreme outliers were identified in the SRIS-I scores. These scores were analyzed for data input accuracy, which all were deemed to be entered correctly. Individual responses on the SRIS were then analyzed to determine if the participants had consistent answers. Two of the three demonstrated consistent answers; therefore, their data were included in the analysis. The third participant had inconsistent answers to similar questions. Since the validity of the participants scores was uncertain, the data were analyzed both including and excluding the participants data to avoid researcher bias. CLINICAL REASONING AND ACADEMIC SUCCESS 33 When including all data points, there were no significant differences between groups in academic standing for the SRIS total, SRIS-SR, or SRIS-I scores. With the extreme outlier excluded, the non-significant differences remained for SRIS total and SRIS-SR. However, there was a statistically significant difference between groups in academic standing for the SRIS-I scores, with the academic success group having a higher mean score. See Table 4 for descriptive and comparative statistics for outcomes with all data points and the one significant difference with the outlier removed. All correlations between SRIS scores and HMP I scores were insignificant. Objective 5: Correlation between Assessments Health Sciences Reasoning Test with Numeracy and Self-Reflection and Insight Scale. There were three correlations between HSRT-N subscales and SRIS subscales that had a low correlation, all others were negligible. The low correlations were between HSRT-N subscale evaluation and SRIS total, HRST-N subscale evaluation and SRIS-SR, and HSRT-N subscale induction and SRIS-I. See Table 5 for all correlations between HSRT-N and SRIS scores. California Critical Thinking Disposition Inventory and Self-Reflection and Insight Scale. There were fourteen correlations that were at a least low correlation, including seven moderate correlations, between the CCTDI scores and SRIS scores. The truth-seeking and maturity of judgment subscales were the only CCTDI scores that did not have at least a low correlation with any of the SRIS scores. See Table 6 for all correlations between CCTDI scores and SRIS scores. Discussion The current study found no significant predictors of first-year GPA and only one statistically significant difference in Insight scores (p = .043) between students who were CLINICAL REASONING AND ACADEMIC SUCCESS 34 successful and students who demonstrated difficulty in the first year of a DPT program. Previous studies have reported that GRE scores or components of GRE scores (Day, 1986; Shiyko & Pappas, 2009; Utzman et al., 2007; Wheeler & Arena, 2009), undergraduate GPA (Andrews et al., 2006; Day, 1986; Fell et al., 2015; Jewell & Riddle, 2005; Ruscingo et al., 2010; Shiyko & Pappas, 2009; Thieman et al., 2003; Utzman et al., 2007; Wheeler & Arena, 2009), prerequisite GPA (Dockter, 2001; Fell et al., 2015; Thieman et al., 2003), age at admission (Dockter, 2001; Ruscingo et al., 2010; Shiyko & Pappas, 2009; Thieman et al., 2003), race (Day, 1986), interview scores (Shiyko & Pappas, 2009), undergraduate school selectivity (Andrews et al., 2006; Wheeler & Arena, 2009), HSRT scores (Huhn & Parrott, 2017), and even first-year GPA (Dockter, 2001) have demonstrated some predictive value for various levels of success in a PT program, either defined as GPA within a PT program at various time points, probationary status or success on the NPTE licensure exam. Jewell and Riddles (2005) study was most closely related to this study where preadmission criteria including undergraduate GPA, math and science GPA, and GRE scores were analyzed as potential predictors of probationary status. While this was with a masters-level PT program, vGRE scores, qGRE scores and undergraduate GPA were predictive of probationary status, but only vGRE scores remained in the model when tested with a validation set. This study only looked at the preadmission criteria and did not look at measures of clinical reasoning, critical thinking disposition or self-reflection. Results of the current study did not match Jewell and Riddles (2005) findings in regards to preadmission data. This study aimed to evaluate the relationship between clinical reasoning skills, as measured by the HSRT-N, and academic success and clinical readiness. The HSRT, which is the earlier version of the HSRT-N, has been used with students in DPT programs. One study CLINICAL REASONING AND ACADEMIC SUCCESS 35 evaluated change in HSRT scores in DPT students at three different time points in two DPT programs: (1) at the beginning of the program, (2) prior to terminal clinical experiences, and (3) prior to graduation (Huhn et al., 2013). In that study, HSRT total scores, deduction scores and analysis scores changed from time 1 to time 2, but not time 2 to time 3 (Huhn et al., 2013). This demonstrates the greatest change in clinical reasoning skills changed during the didactic portion of the program; however, time 1 to time 2 in each of the programs was two to three years in length. Because there was not an additional HSRT measure in the middle of the didactic portion there is no way to tell at which point during the didactic portion of the curriculums that the HSRT scores and clinical reasoning improved, or improved the most. Another study demonstrated that HSRT scores had a moderate correlation to first-year GPA in the program and added to a predictive model for NPTE scores (Huhn & Parrott, 2017). Findings from the current study did not demonstrate the same relationship between the HSRT-N and first-year GPA. The reason for this may be the fact that the program in the current study does not use a traditional plus/minus grading scale which is used in the vast majority of PT programs. It is possible that the lack of a plus/minus grading scale may not be as discriminative for GPA, and thus may be the reason that the current study did not find predictors of first-year GPA. The first year of the program in the current study includes primarily foundational background knowledge and introductory levels of examination, evaluation and intervention. The curriculum advances in the second year with more diagnosis or practice-pattern-specific management for patients with orthopedic, neurologic and cardiopulmonary conditions in addition to the geriatric and pediatric populations. While the first year involves teaching clinical reasoning, the second year has an emphasis on a much higher level of the clinical reasoning process which includes pattern recognition and the students previous clinical experience. Both CLINICAL REASONING AND ACADEMIC SUCCESS 36 pattern recognition and clinical experience have been defined as components of the clinical reasoning process (Hendrick, Bond, Duncan, & Hale, 2009). Since the first year in this program does not involve as high of a level of clinical reasoning as it is more focused on gaining foundational knowledge to apply later, perhaps the HSRT-N would be better served as an instrument to be used in the second year of the program. The program under study is similar to the programs in the previous study (Huhn et al., 2013) where each program begins with a year of didactic work, followed by shorter or introductory clinical experiences, followed by further didactic coursework prior to terminal clinical experiences. It is possible that clinical reasoning and thus HSRT or HSRT-N scores demonstrate the greatest growth in the higher-level patient management courses where the students have at least some clinical experience on which to reflect. No studies have evaluated these changes in HSRT scores from one year to the next in PT education. The results also indicated that besides the preadmission criteria of qGRE and interview scores, the HSRT-N subscales were the only other variables that had at least low correlations with HMP I grades, the strongest of those being between Interpretation scores from the HSRT-N and Clinical Reasoning grades (r = .51, p = .001). The fact that the HSRT-N had at least low correlations with HMP I performance may indicate that the HSRT-N may be better used for assessing practical examination performance or performance during clinical experiences later in the curriculum. Previous studies looking at the CCTDI in PT students demonstrated inconsistent or ambivalent scores (Domenech & Watkins, 2015) and low scores in the truth-seeking and confidence in reasoning (Bartlett & Cox, 2000); however, the second study was in undergraduate PT students. Another study demonstrated improvements in CCTDI and subscale scores over the CLINICAL REASONING AND ACADEMIC SUCCESS 37 course of the middle year of a masters-level PT program with the greatest improvements in truth-seeking and confidence in reasoning scores (Bartlett & Cox, 2002). A third study looked at CCTDI scores in a masters-level PT program which did not show change over time in overall scores, but did show changes in truth-seeking, confidence in reasoning and systematicity over time (Wessel & Williams, 2004). The current study did not demonstrate any differences in CCTDI scores between students who experienced academic success or difficulty. Contrary to these previous studies, the mean CCTDI scores for this study were generally in the positive range including confidence in reasoning, with only systematicity and truth-seeking scores being in the inconsistent range. Results from the current study and previous studies indicate that students entering a PT program may have lower critical thinking disposition in the areas of truth-seeking, confidence in reasoning and systematicity. Truth-seeking is defined as the habit of always desiring the best possible understanding of any given situation; it is following reasons and evidence where ever they may lead, even if they lead one to question cherished beliefs (Insight Assessment, 2018a). Confidence in reasoning is defined as the habitual tendency to trust reflective thinking to solve problems and make decisions (Insight Assessment, 2018a). Systematicity is defined as the tendency or habit of striving to approach problems in a disciplined, orderly, and systematic way (Insight Assessment, 2018a). While there were no significant differences in this study between students who were successful and those who experienced difficulty, the consistently low CCTDI subscale scores in PT students may give some insight to faculty in areas that need to be more explicitly addressed when teaching clinical reasoning and critical thinking. The fact that both CCTDI scores and HSRT scores have demonstrated improvement over time in a PT program supports the thought that clinical reasoning is being taught in PT education programs. The CLINICAL REASONING AND ACADEMIC SUCCESS 38 CCTDI just may not be an appropriate tool to help determine who will be successful in a PT program, or at least in the first year of a professional program. The SRIS Insight scores were the only significant difference between the academic success and difficulty groups in this study. Those who experienced academic difficulty in the first year of the DPT program in this study had significantly lower insight scores than those in the academic success group. Again, insight is defined as the clarity of understanding of ones thoughts, feelings and behavior (Grant et al., 2002, p. 821). As insight scores have demonstrated a positive correlation with cognitive flexibility (Grant et al., 2002), this may lead to some insight as to the challenges experienced in the first year of a DPT program. Cognitive flexibility refers to ones understanding that there may be more than one solution to a problem, their willingness to adapt their thought processes in these situations, and their self-efficacy to do so (Grant et al., 2002). While insight and cognitive flexibility have not specifically been studied and reported in the physical therapy literature, these constructs have been evaluated in other health care programs. One study was performed with sixth-year medical students in which two groups of students participated in a clinical reasoning seminar. Both groups of students talked through cases with a tutor in order to develop hypotheses and differential diagnosis, refine hypotheses and develop a final diagnosis. The intervention group were explicitly encouraged to practice insight throughout the case discussion. While there was no statistically significant difference between groups in the accuracy of the final diagnosis, the intervention group was significantly more likely to list the correct diagnosis in their initial differential diagnoses (Nendaz, Gut, LouisSimonet, Perrier, & Vu, 2011). CLINICAL REASONING AND ACADEMIC SUCCESS 39 Cognitive flexibility has also been associated with diagnostic expertise in clinicians. Those who demonstrate cognitive flexibility have demonstrated the ability to use both analytic and responsive approaches to the diagnostic process, are more willing to refine hypotheses as more information is gathered about a patient, and are better able to interpret that information from multiple perspectives (Bordage, Grant, & Marsden, 1990). This may show that those who do practice insight and cognitive flexibility more are able to see a broader picture of potential diagnoses or answers, and approach a problem from multiple perspectives. The ability to practice insight or be more flexible in thinking could lead to success both in a DPT program, but also as a practicing clinician, especially when patients or patient cases do not present like the typical textbook cases. Interestingly, while insight scores have demonstrated a positive correlation with cognitive flexibility, they have also demonstrated a negative correlation with anxiety, stress, depression and alexithymia, which is the ability to identify and express ones feelings (Grant et al., 2002). Other studies have demonstrated positive correlations between insight scores and psychological well-being (Harrington, Loffredo, & Perz, 2014; Stein & Grant, 2014). A previous study has demonstrated that entry-level DPT students have higher stress and anxiety levels than age and gender matched working individuals, although in this study the levels of anxiety did not predict performance (Frank & Cassady, 2005). The SRIS scores also did not correlate with academic performance in medical students in another study (Carr & Johnson, 2013). Contrary to these findings, Schwartz, Evans and Agur (2015) evaluated stress and anxiety in relation to academic performance in PT students during timed and untimed anatomy tests. Findings of this study indicated that anxiety was higher and test performance was lower in the timed tests versus the untimed tests, which supports the notion that increased anxiety can negatively affect academic CLINICAL REASONING AND ACADEMIC SUCCESS 40 performance (Schwartz et al., 2015). Lower SRIS-I scores in the difficulty group in this study may indicate lower levels of cognitive flexibility, and higher levels of stress or anxiety that may have impacted their performance during the first year of the program. Similarly, a previous study in nursing education demonstrated that stress and insight scores were significantly correlated with nursing students clinical competence, where lower levels of stress and higher insight scores led to increased competence (Eng & Pai, 2015). A previous study in PT education that utilized the SRIS had their students take the SRIS at a similar time point in the program as the current study (Huhn, 2017). Scores were compared between the two studies and similar mean scores were found where the SRIS total scores were within .82 points, SRIS-SR scores were within 2.02 points and SRIS-I scores were within 1.2 points of one another. The similarity in scores may demonstrate the usefulness of the SRIS as a reliable tool in PT education. The SRIS and its subscales demonstrated some significant positive correlations with both the HSRT-N and CCTDI along with their subscales in this study. This may further support the thought that self-reflection is associated with the critical thinking and clinical reasoning process. The previous study using the SRIS in PT education (Huhn, 2017) found a significant improvement in SRIS total scores and SRIS Self-Reflection scores following a six-week critical reasoning course. Findings of this study may demonstrate self-reflection and insight are precursors or key components of the clinical reasoning process. The difference between groups in SRIS-I scores also lends to the fact that there are several other components that contribute to ones ability to successfully transition into graduate level PT education, and other factors such as mental health, stress, anxiety and depression should be considered. The SRIS has the potential to be a useful instrument in identifying students that may struggle in the first year during this CLINICAL REASONING AND ACADEMIC SUCCESS 41 stressful transition. While the author does not believe that those who appear to be under stress should be eliminated from the applicant pool, identifying those early who may be under greater levels of stress would potentially be helpful in directing them to appropriate resources to develop strategies for coping skills and stress management that they need in order to improve their chances of success. Finally, there were some low to moderate positive correlations between scores on HMP I and some of the other variables in this study. However, it should be noted that all students who completed the first year and HMP I did receive passing scores, meaning that they met the expectations. The correlations essentially demonstrated that higher performers on the HMP I had higher scores on the preadmission variables or the questionnaires and tests used in this study, although those who scored lower on HMP I still performed adequately. Not all of these correlations have a clear connection as far as similar constructs. Part of the reason why this may be so challenging to compare these two is that the rubric does not have clearly defined criteria for each of the areas measured. It is up to the individual faculty who graded the student to determine what constitutes clinical reasoning, professionalism, communication and safety. The preadmission criteria of qGRE scores had a low positive correlation to professionalism scores, to which there is not a clear connection. Other correlations make more sense, most significantly the moderate positive correlation between clinical reasoning scores and interpretation scores, and the low positive correlation between clinical reasoning scores and numeracy scores on the HSRT-N. As the HSRT-N is designed to measure clinical reasoning skills, having higher scores on the HSRT-N prior to starting the program may have aided the students in developing stronger clinical reasoning skills throughout the first year. Interview scores had low positive correlations with communication scores. Since the interviews consist of assessing the potential PT students CLINICAL REASONING AND ACADEMIC SUCCESS 42 communication skills, it makes sense that the higher the student scored on the interview would lend to stronger communication during HMP I. The most interesting finding is the three significant low positive correlations with safety scores that included interpretation, inference and evaluation scores on the HSRT-N. Safety on HMP I is determined by both the students safety with body mechanics during the examination and intervention, as well as relative to the patient in terms of their choices of intervention, appropriateness of the intervention based on the specific patient and their characteristics and as far as setting up the treatment area and guarding during transfers or gait. In order to maintain safety of the patient and therapist, the student must put together all of the pieces of the patient case to make the best decision. This decision-making process would clearly include interpreting the data and figuring out what is important and giving meaning to the data, inferring safety and patient response based on the information given and evaluating the quality of the information given to make their decisions. While there are some clear connections between some of the correlations with HMP I and other variables in this study, the lack of clear connections between other variables, the lack of clearly defined constructs of measurement, faculty variability, and the lack of established reliability and validity of the rubric encourages caution to be taken when interpreting the significance of these results. It also should be taken into consideration that all of the students who participated in HMP I did perform to the level of expectation. Therefore, if a student was able to complete the first year of the program (in this particular cohort), they had developed the knowledge and skills to be deemed clinically ready. This still may indicate that performing strongly on the qGRE, the interview, and certain subscales of the HSRT-N could lead to higher performance on HMP I and possibly in the clinical setting. CLINICAL REASONING AND ACADEMIC SUCCESS 43 Study Limitations There are several limitations to note in the current study. The study was underpowered due to a small sample size and may serve better as a pilot study for the use of the HSRT-N, CCTDI and SRIS. The HSRT-N has not been used in any published studies at this point with PT education. While results of the HSRT-N are well-correlated with HSRT scores, results of this study did not demonstrate its usefulness for the proposed purpose. Its use may still be warranted in PT education due to previous findings with the HSRT in studies with larger sample sizes and at different time points within the curriculum. The current study also did not produce any significant findings in regards to preadmission variables, however, the results of previous studies still warrant their use for admissions committees and future studies. The difference in insight scores between groups should be taken with caution due to the small sample size, in addition to the fact that there were no significant differences with all data points included. However, excluding the data point in question did have positive effects on the distribution of the data. Along with increasing the test statistic of the Shapiro-Wilk, excluding the data point in question brought the mean 0.16 points closer to the median and lessened the standard deviation by 0.38, which indicates a more normally distributed data set. It is possible that the participants score could have either decreased or increased had they answered the questions consistently. There is no way of knowing what effect consistent answers by this participant would have on the scores, so again the results should be taken with caution. Conclusion This study did not identify any predictors of academic success or clinical readiness in the first year of a DPT program, but did demonstrate that those who experienced academic difficulty did have lower insight scores on the SRIS. While reflection has been associated as a key CLINICAL REASONING AND ACADEMIC SUCCESS 44 component of clinical reasoning (Jensen et al., 2000), this study did not find any differences between groups in academic standing on the overall SRIS or SRIS Self-Reflection scores. Combining these results, with the fact that there were no significant differences between groups in academic standing in the HSRT-N scores or the CCTDI scores, may indicate the first year of a DPT program might be too early to use measures of clinical reasoning or critical thinking to determine who is at risk for academic difficulty. Clinical reasoning is a skill that is taught in DPT programs and is expected to grow over time. However, looking at precursors to or components of clinical reasoning, such as insight, self-reflection, or critical thinking skills and disposition, may still give faculty insight as to how to assess and develop clinical reasoning skills. Perhaps the second year of the program where many DPT programs advance to more integrated clinical reasoning with higher levels of patient management courses would be a more appropriate time to assess clinical reasoning skills and disposition. This could potentially advise faculty on who may struggle with clinical reasoning on terminal clinical experiences and the NPTE. The SRIS had significant correlations with the HSRT-N and CCTDI, which may indicate its usefulness as an additional tool to provide a more holistic view of the students clinical reasoning development. With previous studies demonstrating higher levels of stress and anxiety in DPT students compared to other age-matched individuals (Frank & Cassady, 2005), and negative effects of stress and anxiety on test performance (Schwartz et al., 2015), insight scores may be a useful tool to use at the beginning of a program to assess who may be at risk for academic difficulty due to challenges with cognitive flexibility, stress and anxiety. It also may be useful to introduce a measure of stress and anxiety early in a program in order to help at-risk students get the assistance or professional help they need to be successful. CLINICAL REASONING AND ACADEMIC SUCCESS 45 Additionally, previous studies have demonstrated that some of the variables in this study have demonstrated predictive ability for student success in a PT program or on the licensure exam, but these variances were generally less than 50%. This leaves over half of the variance unaccounted for. Considering these factors, there is clearly more than ones ability to take a test, perform well in undergraduate coursework and successfully manage transition from undergraduate school or previous work life to a demanding professional curriculum. The variability among DPT programs also presents a challenge for utilizing the results of this and previous studies in identifying students who may struggle. Faculty should be advised that there is no perfect recipe to determine who will be successful in a DPT program, but they can potentially utilize the predictive variables in this study and previous studies to help identify different areas of weakness in students in order to provide them the resources to help them be successful. Future research should consider evaluating levels of stress or anxiety, self-reflection and insight, and critical thinking or clinical reasoning skills both prior to and at varying time points within the curriculum. It is also possible that assessing some of these measures prior to starting the program may paint a very different picture of the students levels of stress, anxiety, disposition, and other factors related to clinical reasoning than at different points in the middle of the program. Students may not have realistic or accurate expectations of the rigors of a program prior to beginning coursework. Many PT faculty perform these tasks informally throughout the curriculum as part of the faculty and advising duties that are expected of them. However, adding formal measures may be beneficial to better quantify and analyze these factors. While many PT programs have science pre-requisites that are required for admission into a program, students come from varying backgrounds of undergraduate degrees and previous work experience. Perhaps students who did not earn degrees in a science-related field are more CLINICAL REASONING AND ACADEMIC SUCCESS 46 likely to have difficulty in a science-heavy curriculum. Prior studies have shown that undergraduate school selectivity has contributed to predictive models for success in PT programs (Wheeler & Arena, 2009), so it is possible that the area of study could also lead to success or challenges in a demanding PT curriculum. Since it is not expected that quantitative measures can predict 100% of the variance associated with student academic success or difficulty, it could be useful perform qualitative analysis with students who struggle in a PT program. It is possible that there are some unique personal or generational components that have not been explored, and the personal stories of these students may give researchers and faculty insights into additional components that could be explored. Lastly, while PT programs are required to meet CAPTE criteria within the curriculum, it is possible that the variance between programs in how the curriculum is set up, how the content is delivered and when students participate in their clinical experiences could also be factors contributing to success or difficulty within a PT program. Students come in with different learning styles as well, which may contribute to success based upon the learning styles and teaching strategies used in their particular PT program. 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Anatomical Sciences Education, 8(6), 518-524. doi:10.1002/ASE.1508 Shiyko, M. P., & Pappas, E. (2009). Validation of pre-admission requirements in a doctor of physical therapy program with a large representation of minority students. Journal of Physical Therapy Education, 23(2), 29-36. Stein, D., & Grant, A. M. (2014). Disentangling the relationships among self-reflection, insight, and subjective well-being: The role of dysfunctional attitudes and core self-evaluations. J Psychol, 148(5), 505-522. doi:10.1080/00223980.2013.810128 Templeton, M. S., Burcham, A., & Franck, L. (1994). Predictive study of physical therapy admission variables. Journal of Allied Health, 23(2), 79-87. Thieman, T. J., Weddle, M. L., & Moore, M. A. (2003). Predicting academic, clinical, and licensure examination performance in a professional (entry-level) master's degree program in physical therapy. Journal of Physical Therapy Education, 17(2), 32-37. Utzman, R. R., Riddle, D. L., & Jewell, D. V. (2007). Use of demographic and quantitative admissions data to predict academic difficulty among professional physical therapist students. Physical Therapy, 87(9), 1164-1180. CLINICAL REASONING AND ACADEMIC SUCCESS 53 Wessel, J., & Williams, R. (2004). Critical thinking and learning styles of students in a problembased, master's entry-level physical therapy program. Physiotherapy Theory & Practice, 20(2), 79-89. doi:10.1080/09593980490453039 Wheeler, E., & Arena, R. (2009). The impact of feeder school selectivity on predicting academic success in an allied health professional program. Journal of Allied Health, 38(3), e79e83. CLINICAL REASONING AND ACADEMIC SUCCESS 54 Table 1 Descriptive Statistics and Comparison between Preadmission Criteria and Academic Standing Total Sample Academic Academic (N = 42) Success Difficulty (N = 35) (N = 7) M (SD) M (SD) M (SD) p Undergraduate GPA 3.55 (.18) 3.53 (.19) 3.61 (.15) .347 Prerequisite GPAa 3.30 (.31) 3.37 (.30) 3.28 (.32) .636 Total GRE 303.95 (7.30) 304.20 (7.78) 302.71 (4.31) .629 Verbal GRE 151.76 (4.54) 151.69 (4.61) 152.14 (4.48) .811 Quantitative GRE 152.19 (4.08) 152.51 (4.17) 150.57 (3.41) .255 Analytical GREa 4.0 (0.50) 4.0 (1.0) 4.0 (1.0) .899 Interview Scorea 0.75 (0.25) 0.75 (0.25) 0.75 (0.25) .540 Note: GPA = grade point average; GRE = Graduate Record Examination score a Scores reported as median and interquartile range CLINICAL REASONING AND ACADEMIC SUCCESS 55 Table 2 Descriptive Statistics and Comparison between Health Sciences Reasoning Test with Numeracy and Academic Standing Total Sample Academic Academic (N = 42) Success Difficulty (N = 35) (N = 7) M (SD) M (SD) M (SD) p HSRT-N Total 82.23 (5.81) 82.43 (5.37) 81.29 (8.09) .640 Analysis 83.14 (8.00) 83.29 (7.47) 82.43 (10.97) .799 Interpretationa 72.00 (16.00) 72.00 (16.00) 72.00 (22.00) .931 Inference 82.62 (7.31) 83.06 (7.05) 80.43 (8.83) .392 Evaluation 72.81 (9.41) 73.09 (9.67) 71.43 (8.52) .676 Explanationa 82.00 (14.00) 82.00 (14.00) 82.00 (9.00) .770 Inductiona 88.00 (9.00) 88.00 (9.00) 85.00 (6.00) .470 Deduction 79.00 (8.97) 79.06 (8.22) 78.71 (12.91) .928 Numeracy 75.43 (8.94) 75.51 (0.75) 75.00 (9.75) .892 Note: HSRT-N = Health Sciences Reasoning Test with Numeracy a Scores reported as median and interquartile range CLINICAL REASONING AND ACADEMIC SUCCESS 56 Table 3 Descriptive Statistics and Comparison between California Critical Thinking Disposition Inventory and Academic Standing Total Sample Academic Academic (N = 42) Success Difficulty (N = 35) (N = 7) M (SD) M (SD) M (SD) p CCTDI Overall 302.62 (22.79) 302.71 (22.66) 302.14 (25.29) .953 Truth-Seeking 38.50 (4.93) 38.34 (5.08) 39.29 (4.38) .650 Open-Mindedness 44.74 (3.99) 44.49 (4.15) 46.00 (3.06) .366 Inquisitiveness 46.05 (5.75) 46.29 (5.55) 44.86 (7.03) .555 Analyticity 45.43 (3.90) 45.34 (3.81) 45.86 (4.63) .755 Systematicity 40.48 (6.38) 40.83 (6.48) 38.71 (5.94) .430 Confidence in Reasoning 44.17 (6.40) 44.09 (6.62) 44.57 (5.56) .857 Maturity of Judgment 43.43 (4.56) 43.49 (4.64) 43.14 (4.48) .858 Note: CCTDI = California Critical Thinking Disposition Inventory CLINICAL REASONING AND ACADEMIC SUCCESS 57 Table 4 Descriptive Statistics and Comparison between SRIS and Academic Standing Total Sample Academic Academic Mean (N = 42) Success Difficulty difference (N = 35) (N = 7) M (SD) M (SD) M (SD) SRIS total 89.52 (9.73) 90.46 (10.22) 84.86 (5.05) 5.60 .167 SRIS Self- 53.69 (7.55) 54.09 (8.09) 51.71 (3.59) 2.37 .232 SRIS Insight 35.83 (4.56) 36.37 (4.71) 33.14 (2.48) 3.23 .088 SRIS Insight 36.10 (4.28)a 36.71 (4.34)b 33.14 (2.48) 3.56 .043* p Reflection outlier excluded Note: Abbreviations: SRIS, Self-Reflection and Insight Scale. a N = 41 with outlier excluded b N = 34 with outlier excluded * indicates statistical significance at p < .05 CLINICAL REASONING AND ACADEMIC SUCCESS 58 Table 5 Health Sciences Reasoning Test with Numeracy Correlations with Self-Reflection and Insight Scale Variable SRIS total Self-Reflection Insight HSRT-N total .19 .10 .25 Analysis .13 .12 .08 Interpretation -.08 -.10 -.01 Inference .14 .03 .25 Evaluation .41* .37* .26 Explanation -.02 .02 .02 Deduction -.05 -.08 .10 Induction .26 .17 .39* Numeracy -.01 < .01 -.01 Note: Abbreviations: HSRT-N = Health Sciences Reasoning Test with Numeracy; SRIS = SelfReflection and Insight Scale. * indicates statistical significance at p < .05 CLINICAL REASONING AND ACADEMIC SUCCESS 59 Table 6. California Critical Thinking Disposition Inventory Correlations with Self-Reflection and Insight Scale Variable SRIS Total Self-Reflection Insight CCTDI Overall .62** .49* .51* Truth-Seeking .15 .23 -.06 Open-Mindedness .30* .32* .12 Analyticity .26 .13 .33* Systematicity .50* .24 .67** Confidence-in-Reasoning .55** .47* .39* Inquisitiveness .64** .55** .45* Maturity of Judgment .19 .15 .14 Note: CCTDI = California Critical Thinking Disposition Inventory; SRIS = Self-Reflection and Insight Scale. * indicates statistical significance at p < .05 ** indicates statistical significance at p < .001 CLINICAL REASONING AND ACADEMIC SUCCESS 60 Appendix A Recruitment Letter Thank you for taking the time to hear about this research study. The proposed study will be used to evaluate potential predictors of academic success and clinical readiness in the first year of a doctor of physical therapy (DPT) program. If potential predictors are found with this study, DPT faculty could use the results in the future to help identify students who will be successful in their program, as well as to identify students who may struggle. Identifying students who may struggle could allow the faculty to implement strategies early on in the DPT program to help the students succeed. Michael Obert (MO) will be the primary investigator in the proposed study. For this study, all potential participants will be given a unique identifying code prior to the start of the study. All data obtained by MO will be in the form of these codes in order to ensure anonymity throughout and after the study. Your participation in this study is voluntary. Choosing to participate or not participate in the study will have no impact, positive or negative, on your status in the DPT program. Should you choose to participate, you will be asked to complete three surveys in the first few weeks of the DPT program. If you choose to participate your academic records, including GRE scores, undergraduate and science GPA, first-year GPA, and demographic information will also be accessed and recorded in a de-identified manner. At the conclusion of the first year in the DPT program, MO will analyze the de-identified data to determine if there are relationships between these variables. You will also have the right to withdraw from the study at any time without any repercussions. The completion of all three surveys is estimated to take approximately 60-75 minutes. Potential risks of participation in the study are anticipated to be minimal and could include CLINICAL REASONING AND ACADEMIC SUCCESS 61 emotional distress associated with taking the tests and questionnaires and receiving your results on these forms. Potential benefits of participation are also minimal and could include possible insights into your own clinical reasoning skills, critical thinking disposition, and self-reflection. After hearing about the study, you may set up an appointment with MO via email (Michael.obert@msj.edu) to discuss any questions or concerns you may have prior to making a decision. He will answer any questions that do not affect the validity of the study. Thank you very much for your time and consideration for the proposed study, Michael Obert Michael.obert@msj.edu 513-244-4305 CLINICAL REASONING AND ACADEMIC SUCCESS Appendix B 62  ...

... THE EFFECTS OF BACKWARD CYCLING ON POSTERIOR PROTECTIVE STEPPING RESPONSES IN PEOPLE WITH PARKINSON DISEASE Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Suzanne ONeal, PT, DPT, NCS Copyright 6/25/2020 By: Suzanne ONeal, PT, DPT, NCS All rights reserved Approved by: Stephanie A. Miller, PT, PhD Committee Chair Elizabeth S. Moore, PhD Committee Member Megan Eikenberry, PT, DPT, NCS Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: BACKWARD CYCLING AND PARKINSON DISEASE The Effect of Backward Cycling on Posterior Protective Stepping Responses in People with Parkinson Disease Suzanne ONeal University of Indianapolis 1 BACKWARD CYCLING AND PARKINSON DISEASE 2 Abstract The purpose of this study was to assess the effects of backward cycling on posterior protective stepping responses in people with Parkinson disease. Secondary aims were to assess changes in gait parameters, balance, and aerobic capacity and to assess the acceptability of backwards cycling as an intervention. Twenty-two people (18 males, 4 females) with a history of idiopathic Parkinson disease in Hoehn & Yahr stages II or III completed a 6-week backward cycling program. Each participant cycled for 30 minutes at a moderate intensity twice a week for 12 total sessions. Pre-test, post-test, and 1-month follow up assessments were completed. Data collected included the Mini-BESTest, 6 Minute Walk Test, posterior stepping response variables (number of steps, time to steady, and maximal excursion), and gait parameters in both the forward and backward directions (gait velocity, right and left step length, and right and left step width). Statistical analysis was performed to assess difference across time and within groups. A repeated measures ANOVA with Bonferroni post hoc analysis was used for normally distributed data. A Friedman ANOVA with a Wilcoxon signed-ranks post hoc test was used for non-normally distributed data. Significant within-group differences were shown in forward and backward gait velocity (p = .017, p = .001), forward right and left step length (p = .011, p = .007), number of steps during a posterior stepping response (p = .019), and the Mini-BESTest (p = .003). Pair-wise post hoc analysis revealed differences between baseline measurements and 1-month follow up in forward right and left step length (p = .049, p = .039), backward gait velocity (p = .007), number of steps during a posterior stepping response (p = .013), and the Mini-BESTest (p < .001). These results show that a backward cycling program is feasible and can have a positive effect on posterior protective stepping responses as well as quality of gait and balance. Keywords: Parkinson disease, balance, gait, stepping responses, cycling BACKWARD CYCLING AND PARKINSON DISEASE 3 Acknowledgements I would like to express my gratitude to the University of Indianapolis for creating such a wonderful environment for me to thrive. My sincerest thanks go out to my committee members Dr. Stephanie A. Miller, Dr. Elizabeth Moore, and Dr. Megan Eikenberry. Dr. Miller, it was an honor getting to work under your mentorship. Despite your many hats, you always had time to answer my many questions in the most motivating way possible. You were one of the main reasons I chose the University of Indianapolis and you did not disappoint. Dr. Moore, I feel so lucky to have learned from you. You are truly an expert in your field and I so appreciate all the time you took helping me with my seemingly endless data. Dr. Eikenberry, I cannot thank you enough for not only sharing your expertise, but also for always being my cheerleader and support crew. To the Physical Therapy Program at Midwestern University, thank you so much for your support in my research. Thank you to my research assistants who put in countless hours of data collection and leading interventions, all while juggling a rigorous curriculum. Thank you to Kacey Kline, PTA for your endless administrative support and scheduling hundreds of hours of research sessions. Finally, to the local Parkinson community, thank you all for continuing to inspire me. I feel so incredibly lucky to be part of such a supportive group. BACKWARD CYCLING AND PARKINSON DISEASE Table of Contents List of tables.7 List of figures...7 Introduction......8 Literature review..9 Parkinson disease.....9 Parkinson disease and falls.....11 Parkinson disease interventions......13 Strength training.14 Treadmill training...14 Dance..15 Cycling...16 Backward cycling.......17 Reactive stepping responses.......18 Intervention summary.....18 Exercise safety in the home19 Method...20 Study design.......20 Participants.21 Data collection........21 Operationalization..22 Instruments.23 Montreal Cognitive Assessment.....23 MDS-UPDRS III....23 GAITRite.....24 Mini-BESTest.....24 Posterior stepping responses..25 Six-minute walk test.......25 Procedures......26 Recruitment....26 Eligibility determination....26 4 BACKWARD CYCLING AND PARKINSON DISEASE Confidentiality..26 Informed consent..27 Screening......27 Montreal Cognitive Assessment....27 MDS-UPDRS III.......27 Demographic and medical history data....28 Testing..28 Mini-BESTest........28 Posterior stepping response.....28 Gait analysis.....29 Six-minute walk test......30 Intervention.......31 Statistical analysis.33 Results...35 Primary objective..35 Posterior stepping response..35 Secondary objectives........36 Backward gait measurement....36 Forward gait measurement...........37 Balance.....37 Aerobic capacity.......38 Acceptability.......38 Discussion....38 Limitations........43 Strengths.......44 Conclusion............44 References....46 Tables...60 Figures......62 Appendix......63 5 BACKWARD CYCLING AND PARKINSON DISEASE List of Tables Table 1 Baseline Characteristics60 Table 2 Group pre-test, post-test, and 1-month follow up results.61 6 BACKWARD CYCLING AND PARKINSON DISEASE List of Figures Figure 1 Flow of participants in study.62 7 BACKWARD CYCLING AND PARKINSON DISEASE 8 The Effect of Backward Cycling on Posterior Protective Stepping Responses in People with Parkinson Disease Parkinson disease (PD) is a progressive, neurodegenerative disorder characterized by the cardinal signs of bradykinesia, tremors, rigidity, and postural instability (Goodman & Fuller, 2015). People living with PD often experience recurrent falls, which can be detrimental to function and quality of life (Allen, Schwarzel, & Canning, 2012). Reactive stepping responses are commonly affected by the disease progression due to decreased limits of stability and bradykinetic movements (Horak, Dimitrova, & Nutt, 2005; Schoneburg, Mancini, Horak & Nutt, 2013). Medications are commonly used to manage the symptoms of PD; however, this approach has limited effects on stepping responses (de Kam et al., 2014), and in some cases, has been shown to worsen reactive stepping responses (Horak et al., 2005). There are few studies assessing the effects of exercise on posterior stepping responses in people with PD. Two known studies investigating the outcomes of interventions on stepping responses in persons with PD have resulted in improved function, including increased limits of stability and quicker reaction times to perturbations. However, the studies either utilized specialized equipment for the actual intervention (Shen & Mak, 2012) or a high-frequency protocol in which repetitions of up to 230 were used (Jobges et al., 2014), decreasing their feasibility for use in the clinic or home. There are several studies which suggest that exercise improves mobility and balance in people with PD; however, no study specifically addresses or measures change in posterior stepping responses (Nadeau et al., 2017; Ridgel, Phillips, Walter, Discenzo, & Loparo, 2015; Uygur et al., 2015). Electromyographic (EMG) studies have revealed similar muscle activation patterns between backwards cycling and posterior stepping responses (Chvatal, Torres-Oviedo, BACKWARD CYCLING AND PARKINSON DISEASE 9 Safavynia, & Ting, 2011; Eisner, Bode, Nyland, & Caborn, 1999). There are no known published studies assessing the effects of backwards cycling in people with PD. The purpose of this study was to assess the effect of backwards cycling on participant function, including posterior protective stepping responses, and to determine if backward cycling would be an acceptable form of intervention based on the number of adverse events and retention rate. The following primary objective was addressed: to determine if backward cycling has an effect on posterior protective stepping responses in people with PD. In addition, the following secondary objectives were addressed: (a) to determine if backward cycling significantly affects forward and backward gait parameters, balance, and aerobic capacity; and (b) to assess the acceptability of backwards cycling as an intervention through recording adverse events and retention rate. Stationary bicycles are common in both physical therapy settings as well as in the community; therefore, this type of equipment is readily available and easy to access. If a backwards cycling exercise program can improve posterior protective stepping responses in people with PD, then results of this study may help guide clinicians to choose more appropriate, effective, and safe home program exercises for the PD population. Literature Review Parkinson Disease Parkinson disease is the second-most common neurodegenerative disorder in the United States, affecting more than 800,000 adults (Goodman & Fuller, 2015). The number of people living with PD is expected to steadily rise to 1.06 million by 2030, 1.24 million by 2040, and 1.34 million by 2050 (Kowal, Dall, Chakrabarti, Storm, & Jain, 2012). In 2010, the disease carried a national economic burden of over $14.4 billion dollars (Goodman & Fuller, 2015), which is $8.1 billion higher than a comparable population without PD (Kowal et al., 2012). BACKWARD CYCLING AND PARKINSON DISEASE 10 Additionally, hip fractures resulting from falls carry an economic burden of $192 million per year in the United States; many falls occurring from a backward perturbation or during backward walking (Hackney & Earhart, 2009a) in the PD population. People with PD are more at risk for fractures due to a higher prevalence of osteoporosis and lower bone mineral density (Coomber, Alshameeri, Masia, Mela, & Parker, 2017) and also carry a higher mortality rate than the healthy population (Coughlin & Templeton, 1979). People with PD also have more risk of recurrent fractures due to the increased fall risk (Zuckerman, 1996). Parkinson disease becomes increasingly common with age and affects one in every 100 people over the age of 75 years (Goodman & Fuller, 2015). The combination of the motor deficits resulting from PD along with age-related changes of decreased muscle strength, impaired balance, and visual deficits can severely affect mobility (Christofoletti, McNeely, Campbell, Duncan, & Earhart, 2016). The impact of PD also involves the caregiver, with over 40% of caregivers reported declining health as a result of the burden of care (Schrag, Hovris, Morley, Quinn, & Jahanshahi, 2006). Additionally, over 50% of caregivers reported depression due to their caregiving roles; it has been shown that depression is associated with higher caregiver burden and lower healthrelated quality of life (Martinez-Martin et al., 2007; Schrag et al., 2006). Certain common PD factors, including falls, have been correlated with increased caregiver burden. One major predictor of institutionalization, such as in a nursing home, is caregiver distress (Schrag et al., 2006). It can be inferred that alleviating the impact of PD on the caregiver can decrease their burden as well as improve health-related quality of life and delay institutionalization for the person living with PD. BACKWARD CYCLING AND PARKINSON DISEASE 11 Parkinson Disease and Falls Recurrent falls are a problem for people with PD and can lead to injury, reduced activity levels, increased caregiver burden, and increased fear of falling (Allen et al., 2012). People with PD have a two-fold risk of falling compared to the healthy population and recurring fall rates have been shown to be high, with one study reporting 70% falling at least once a year and another reporting 87% experiencing at least one fall in 20 years (Allen et al., 2012; Ashburn, Stack, Pickering, & Ward, 2001; Hely, Reid, Adena, Halliday, & Morris, 2008). Falls in PD can have significant effects on quality of life due to fractures, hospitalizations, loss of functional ability, and activity restrictions (McVey et al., 2009). An analysis of Medicare claims showed that people with PD were 1.3 times more likely to sustain an injury from a fall that required medical attention and that these injuries drove up medical costs (Grimbergen, Munneke, & Bloem, 2004). In fact, in people with PD, 30% of emergency room admissions were trauma based, with falls being the most frequent cause (Martignoni et al., 2004). A retrospective study by Wielinski et al. (2005) reported that 21.6% of patients with PD who fell sustained a fracture and of those, 40.6% required surgery. Additionally, 65% of patients who fell sustained some type of injury other than a fracture, with 75.5% of this cohort needing health care services. People with PD are particularly vulnerable to backwards falls due to a smaller stability margin (Horak et al., 2005). Several reasons for increased risk for falls exist for the PD population, including poor postural responses, proprioceptive deficits, freezing of gait, and the decreased ability to dual task (Grimbergen, Munneke, & Bloem, 2004). During a reactive stepping response, the time to initiate a step is normal in people with PD, however more time is required to reach maximum movement force. Additionally, the overall force production is reduced in people with PD due to bradykinesia. This results in a person with BACKWARD CYCLING AND PARKINSON DISEASE 12 PD not adequately being able to return their center of mass within their limits of stability, increasing the risk for a fall (Schoneburg et al., 2013). Another study resulted in a similar conclusion in that people with PD have a backward preponderance for falls following postural perturbations, as well as abnormal co-contraction of both the agonist and antagonist muscles in the legs and trunk (Grimbergen et al., 2004). McVey et al. (2013) reported that as the disease progresses from mild to moderate, posterior stepping responses also worsen, resulting in the need for more steps to recover balance and more inconsistency in choice of stepping foot. Dopaminergic medication is frequently used to improve motor symptoms resulting from PD, however it has been shown that backwards stepping abnormalities are not improved by pharmacological management (de Kam et al., 2014). Bryant, Rintala, Hou, Lai, and Protas (2011) reported no statistically significant change in forward and backward gait speed, cadence, and stride length between people with PD off medications and on medications. All participants were either taking a carbidopa/levodopa or carbidopa/levodopa/entacapone combination. The dose of medications among the participants ranged from 100 to 300 mg, with a mean of 152.38 mg. A study by de Kam et al. (2014) focused on stepping responses and reported that people with PD had poorer stepping responses with forward and backward perturbations than healthy controls, and that the addition of dopaminergic medications did not improve these stepping responses. Grimberger et al. (2004) confirmed this finding, stating that postural reactions are particularly resistant to dopaminergic medications. In some cases, stepping responses actually worsened significantly on levodopa medication (Schoneburg et al., 2013), increasing the risk for falls and injury. Lastly, the use of levodopa and other dopaminergic medications can eventually lead to dyskinesias, which can compound any existing motor impairments, increasing risk for falls (Kleiner-Fisman et al., 2006). BACKWARD CYCLING AND PARKINSON DISEASE 13 Deep brain stimulation (DBS) has increased in frequency since its introduction in the 1990s and has shown to be most effective at alleviating levodopa-responsive symptoms such as tremor, on-off fluctuations, and dyskinesias (Weaver et al., 2009). Deficits in gait and balance, however, are least likely to be affected by DBS and in some cases, could worsen (Okun, 2012). Weaver et al. (2009) compared a group receiving dopaminergic medications to people receiving DBS and found that the DBS group had significantly more adverse events compared to the medicine group, including falls, gait disturbance, depression, and dystonia. Additionally, recent studies demonstrated that although DBS can have an immediate effect on motor symptoms in PD, there is then a gradual decline in the effectiveness on gait disturbances and postural instability (Potter-Nerger & Volkmann, 2013; St. George, Nutt, Burchiel, & Horak, 2010; van Nuenen et al., 2008). Due to the ineffectiveness of medications and DBS on improving postural instability, including stepping responses, interventions are needed to improve this reactive strategy to decrease risk for falls and injury. Parkinson Disease Interventions There exists a large range of interventions used in the clinic in order to address motor symptoms of PD, including treadmill training, general exercise, and dance. A meta-analysis on the effect of exercise and motor training in people with PD revealed that several types of interventions had a positive effect on balance; however, the effect was small and a conclusion could not be made on whether exercise could reduce falls in the PD population (Allen, Sherrington, Paul, & Canning, 2011). A recent systematic review of PD interventions to maximize physical function and minimize secondary complications found insufficient evidence to support the use of one approach due to the wide variety of interventions used (Tomlinson et al., 2014). This allows one to infer that not one intervention is superior over the other. BACKWARD CYCLING AND PARKINSON DISEASE 14 Strength training. It has been shown that people with PD have decreased muscle strength and power compared to a healthy population, which can lead to postural instability and falls (van der Kolk & King, 2013). Studies have shown positive effects of strength training in improving muscular strength and endurance (Corcos et al., 2013; Toole, Hirsch, Forkink, Lehman, & Maitland, 2000; van der Kolk & King, 2013), however evidence remains unclear on the effect of strength training on balance and falls (Cruickshank, Reyes, & Ziman, 2015). Treadmill training. Treadmill training, either with use of a safety harness or without it, is a common intervention in rehabilitation settings. Its use with people with PD in the clinic has shown consistency in improvements with forward gait speed (Cakit, Saracoglu, Genc, & Erdem, 2007; Herman, Giladi, Gruendlinger, & Hausdorff, 2007; Herman, Giladi, & Hausdorff, 2008; Mehrholz et al., 2015) and stride length (Mehrholz et al., 2015; Miyai et al., 2002; Protas et al., 2005). Treadmill training has also demonstrated positive effects on outcome measures, such as the Unified Parkinsons Disease Rating Scale (UPDRS) (Ganesan, Sathyaprabha, Gupta, & Pal, 2014; Herman et al., 2007), Berg Balance Scale (Cakit, Saracoglu, Genc, & Erdem, 2007; Ganesan et al., 2014), and Dynamic Gait Index (Cakit et al., 2007). Most of the aforementioned outcome measures do not include reactive balance assessments nor a backwards walking component. Herman, Giladi, and Hausdorff (2008) reviewed 14 studies involving treadmill training and PD. None of the 14 studies assessed backwards walking or backwards stepping abilities. Additionally, only one study included backwards walking in the intervention (Protas et al., 2005); the rest of the studies only included a forward walking intervention. Several studies used the UPDRS as an assessment of motor function and while the UPDRS does include a postural stability assessment in the form of a posterior pull test, a total UPDRS score does not BACKWARD CYCLING AND PARKINSON DISEASE 15 give a sense of reactive abilities. One could score poorly on the postural stability section, and still rate highly on the overall test. Only one study could be found which included a backwards walking assessment. Tseng, Yuan, and Jeng (2015) looked at the effect of treadmill training on backwards walking in people with PD and found significant improvements in backward gait velocity and stride length, despite the intervention being only forward walking. To this date, no known studies have assessed the effectiveness of treadmill training and stepping responses. Forward walking treadmill training has resulted in increased stride length; however, a past study has concluded that effective stepping responses are independent of the length of the step (King, Luchies, Stylianou, Schiffman, & Thelen, 2005); therefore, no conclusion can be made on the effects of treadmill training on posterior stepping responses. Dance. There have been several studies assessing the effect of dance on gait and balance in people with PD. One recent systematic review assessed dance as an intervention for PD and reviewed a total of five studies. The authors concluded that no meaningful change was experienced with forward gait velocity; there was no mention on backward gait within this review (Sharp & Hewitt, 2014). Another systematic review looked at Argentine tango and PD and reviewed 13 studies. Of these 13 studies, four included a backward gait assessment. Positive results in backward gait were seen after a dance program in people with PD, however there was no significant or clinically meaningful change seen in backward gait velocity in three of the four studies which included a backwards gait component (Duncan & Earhart, 2014; Hackney & Earhart, 2009b; Hackney & Earhart, 2009c); Hackney and Earhart (2009b) did report significant difference in backward stride length. Hackney, Kantorovich, Levin, and Earhart (2007) compared a tango program to a more traditional strength/flexibility exercise program and found BACKWARD CYCLING AND PARKINSON DISEASE 16 no significant differences between groups. No specific stepping response measure was used in any of the mentioned studies. Stepping responses were instead included as a subsection within the Mini-BESTest, therefore no conclusion can be made on the effectiveness of dance on stepping responses. Cycling. Several studies have reported the positive effects of a cycling exercise program on motor function in people with PD (Nadeau et al., 2017; Ridgel et al., 2015; Uygur et al., 2015). Improvements after a cycling regime included improved aerobic capacity, walking speed, cadence, and improvement of motor function, as measured by the UPDRS Motor III subsection (Nadeau et al., 2017; Ridgel et al., 2015; Ridgel, Vitek, & Alberts, 2009). Nadeau et al. (2017) reported improvements in forward gait speed and walking cadence however backwards gait and stepping responses were not measured in this study. Most cycling studies did not specifically focus on assessing posterior stepping responses, but instead, the assessment was embedded within the UPDRS Motor III as part of the total score. This makes it impossible to determine how effective an intervention was at improving this specific movement. One study by Uygur et al. (2014) included a stepping test in their study in the form of the 4-Square Step Test (4SST). The 4SST requires quick directional changes as it requires participants to step forward, backward and sideways in consecutive fashion (Dite & Temple, 2002). The cycling group demonstrated significant improvements in walking velocity and the 4SST, supporting the notion of transfer of cycling exercise to stepping ability in people with PD (Uyger et al., 2014). The 4SST, however, is a test of proactive stepping responses, therefore, there continues to be lack of evidence regarding exercise and posterior, or reactive, stepping responses. To this date, no known interventional studies exist which focuses on the effect of cycling on backwards gait and stepping responses. In the work by Barroso et al. (2014), the BACKWARD CYCLING AND PARKINSON DISEASE 17 researchers concluded there are shared neuromuscular mechanisms between cycling and walking due to similar muscle synergies. Clinically, this may mean that cycling exercises can transfer to locomotion abilities. Backwards cycling. Only a few studies could be found pertaining to backwards cycling, all involving healthy adult samples. Cycling in general has been shown to have similar neural control as walking with similar central pattern generator-like output (Zehr, Hundza, Balter, & Loadman, 2009). Two studies assessed the recruitment pattern of the muscles in the lower extremity during backward cycling. Results of both studies were similar in that they showed greater rectus femoris activation in the early quadrant of pedal revolution, followed by activation of the medial and lateral hamstrings in the later quadrants of pedal revolution (Eisner et al., 1999; Neptune, 2000). An EMG study of normal backward stepping responses revealed early activation of the rectus femoris, followed by relaxation, with introduction of the biceps femoris and semitendinosus (Chvatal et al., 2011). Hence, there seems to be similarities of muscle recruitment patterns between backward cycling and backward stepping, giving this intervention potential in terms of improvements in posterior stepping responses. Another study comparing forward and backward cycling found that backward cycling produced higher electromyography (EMG) readings (Zehr et al., 2009). A cycling program is feasible to carry out in the community (McGough et al., 2016) and although backwards cycling requires greater muscle involvement, in terms of amplitude and duration, it does not require more metabolic demand compared to forward cycling (Bressel, Heise, & Bachman, 1998). This can support the feasibility of a cycling program in the clinic setting. There are no known interventional studies assessing the effects of backwards cycling in either the healthy population or people with PD. BACKWARD CYCLING AND PARKINSON DISEASE 18 Reactive stepping responses. Few known articles include interventions and assessments focused on reactive stepping responses in people with PD. A study by Protas et al. (2005) included repetitive task-specific, compensatory step training in which individuals with PD were asked to step to recover balance after a perturbation. Perturbations were presented in all directions (forward, backwards, and to each side) and outcomes included a gait analysis and a step test. The step test required the person to step up and down an 8.8 cm step for five repetitions as quickly as possible. Significant improvements were demonstrated in the step test as well as gait speed and cadence. The step test, however, is a proactive balance test, therefore difficult to ascertain if the intervention improved reactive posterior stepping responses. Furthermore, only forward walking was assessed during the gait analysis, therefore no conclusion can be made on improvements in the backward direction. Jobges et al. (2004) also included a reactive stepping intervention and assessment. The intervention consisted of repetitive pulls and pushes in the backward and sideways directions. The participants completed two 20-minute sessions each day with approximately 180 to 230 perturbations per session. The intervention group showed significant increase in compensatory step length and decreased initiation time to step, however the twice a day schedule (which would be difficult to reproduce in the clinic) with the high number of repetitions decreases the feasibility of this intervention. Barajas and Peterson (2018) assessed reactive step training in people with PD and found improvements in the margin of stability however the intervention utilized a hydraulic force platform, which would not be feasible in the home or traditional clinic setting. Van Ooteghen, Frank, and Horak (2017) also utilized a hydraulic platform and safety harness, again limiting its feasibility for use in the home or clinic. Additionally, the participants were instructed to avoid BACKWARD CYCLING AND PARKINSON DISEASE 19 stepping if possible. (Van Ooteghen, Frank, & Horak, 2017, p. 3). This may not fully reflect an actual protective stepping response. Intervention summary Most of the aforementioned interventions focused on forward movement directions, therefore effectiveness of these interventions in improving backwards stepping is unable to be determined. A meta-analysis completed by Allen, Sherrington, Paul, and Canning (2011) assessed the effect of exercise on balance and falls with people with PD and revealed that all included studies in the analysis did not include a backwards gait component, nor a stepping response component. Dance interventions do include multi-directional stepping, however its effectiveness on posterior stepping responses is still unknown. No other known studies have specifically focused on interventions to improve protective stepping responses in people with PD. Several studies focused on improved gait parameters, however low to moderate correlations between gait and stepping responses has been shown and that no consistency between direction of gait and direction of postural responses exist. This may infer that gait deficits in a particular direction is not predictive of postural responses in that direction. (Sutter, Seidler, Duncan, Earhart, & McNeely, 2017). Exercise and Safety in the Home Exercise adherence at home is an important aspect of rehabilitation, however perceived barriers can decrease compliance among individuals. Researchers found that perceived barriers to exercise can be predictive of exercise compliance (Ellis et al., 2013); therefore, one focus for therapists should be to minimize these perceived barriers. Several perceived barriers to exercise have been identified in the PD population, including fear of falling, difficulty carrying out the BACKWARD CYCLING AND PARKINSON DISEASE 20 exercise, and being tedious for others (Ellis et al., 2013; Pickering, Fitton, Ballinger, Fazakarley, & Ashburn, 2012). Treadmill training is a common intervention in the clinic setting to improve motor symptoms with people with PD; however, there are limited studies confirming the safety of use of a treadmill in the home or community by people with PD (Bello et al., 2013; Canning et al., 2012; Carda et al., 2012; Nadeau, Pourcher & Corbeil, 2013). Most studies showing no adverse effects with use of a treadmill utilized either a safety harness (Bello et al., 2013; Carda et al, 2012) or limited their participants to those in the Hoehn and Yahr (H&Y) PD stages of I and II (Canning et al, 2012; Nadeau, Pourcher, & Corbeil, 2013). A safety harness would likely not be a feasible option for home use. For those people living with later stages of PD who are starting to experience postural instability (Stages III & IV), independent treadmill training in the home and community may not be a safe option for motor training. A pilot study involving treadmill training which included five people with PD in H&Y stages II or greater, resulted in four falls and seven near falls, for a total of 11 adverse events (Skidmore et al., 2008). For safety reasons, there is a need for alternative exercises for people in later stages of PD to safely perform at the home and community to improve balance and stepping responses outside of the clinic. A meta-analysis on the effects of exercise and motor training in people with PD revealed that several types of interventions had a positive effect on balance (Allen, Sherrington, Paul, & Canning, 2011); however, interventions mostly consisted of exercises in standing (e.g., treadmill training, highly challenging balance training, walking over ground), which may decrease its safety in the PD population. Stationary cycling has been shown to be both feasible and safe for people with PD (McGough et al., 2016); therefore, riding a stationary bike may be more appropriate for the home and community setting. Stationary cycling can also address identified BACKWARD CYCLING AND PARKINSON DISEASE 21 perceived barriers to exercise, including fear of falling and being less tedious for caregivers. Backwards stationary cycling could be a safe option for people with PD to exercise as it can allow a person to improve postural instability in a position that does not increase fall risk. Method Study Design This was a quasi-experimental, pretest-posttest single group design pilot study with onemonth follow-up. The study was approved by both the University of Indianapolis Human Research Protections Program (HRPP) and the Midwestern University Office of Research and Sponsored Programs (ORSP), and was conducted at the Midwestern Universitys Physical Therapy Institute. Participants Participants were recruited from local neurologic rehabilitation centers, Parkinson disease-specific exercise groups, and Parkinson disease-specific support groups. To be included in the study, individuals had to meet the following inclusion criteria: (a) be between the ages of 20 and 80 years, (b) have been diagnosed with idiopathic PD, (c) be in stages II or III of the Hoehn and Yahr (H&Y) PD Staging Scale (Goetz et al., 2004), (d) be able to walk unassisted without an assistive device for at least 20 feet, (e) not currently enrolled in physical therapy, and (f) be able to understand and speak English. Exclusion criteria were (a) the presence of PDdementia (PD-D), as assessed by a score of less than 21/30 on the Montreal Cognitive Assessment (MoCA) (Dalrymple-Alford et al., 2010), (b) diagnosis of parkinsonism or a Parkinson plus syndrome, (c) the presence of another neurologic disorder, and (d) any other injury or issue which would limit the ability to participate in any capacity, including pregnancy. Hoehn and Yahr staging was determined by the administration of the Movement Disorder BACKWARD CYCLING AND PARKINSON DISEASE 22 Society Unified Parkinsons Disease Rating Scale Part III: Motor Examination (MDS-UPDRS III). Data Collection Data were collected at baseline, within one-week of the conclusion of the 6-week intervention (one-week post-test), and one-month post-intervention (one-month follow-up) by trained research assistants not involved with the intervention. The MoCA and UPDRS-III data were collected to determine study eligibility and were performed by the primary investigator (S. O.). All data were input into a Microsoft Excel spreadsheet under a unique study identification number. Demographic and past medical history related to PD were collected at baseline including age, gender, number of years since diagnosis, and medication schedule. In addition, the following outcomes data were collected at baseline: forward and backward gait analysis measurements, including gait velocity, step length, and step width, posterior stepping response (PSR) measures, including the maximal stepping excursion (PSR-MSE), time to steady (PSRTTS), and number of steps (PSR-StepNo) to steady, Mini-Balance Evaluation Systems Test (MBT), and the six-minute walk test (6MWT). With the exception of the MBT and 6MWT, three trials of each outcome variable were conducted and the mean score was calculated. All outcome measures were reassessed within one week following the 6-week intervention program, and at a one-month follow-up, except for the MoCA and UPDRS-III. All data were entered into an electronic data collection sheet on a password-protected laptop. The primary investigator and research assistants were the only individuals with access to the laptop and password. Data were recorded using a randomly assigned unique identification number linked to each participant. The only link between the identification number and the participants name was kept on a document created on a password-protected computer in a file BACKWARD CYCLING AND PARKINSON DISEASE 23 location separate from the data file. The laptop was kept in a locked office when not in use. The primary investigator had possession of the office key. Operational Variables Participants were designated as H&Y stage II if they had bilateral involvement and were able to recover balance during the pull test (embedded within the MDS-UPDRS III) in two steps or less. Participants were designated as H&Y stage III if there was mild to moderate involvement and three or more steps were required, or assistance was needed to recover from the pull test. Posterior stepping responses was defined as stepping responses measured during administration of reactive postural responses within the MBT. Data collected related to posterior stepping responses was time to steady, maximal stepping excursion, and number of steps needed to steady. An adverse event was defined as any negative result of the intervention, including any injury or medical event directly related to the intervention. Instruments Montreal Cognitive Assessment. The MoCA is a brief, validated instrument for mild cognitive impairment and tests various cognitive abilities including executive function, attention, and memory (Gill, Freshmen, Blender, & Ravina, 2008). The MoCA has been shown to be a valid and reliable tool for the screening of cognitive impairments in people with PD, with good intrarater and interrater reliability (ICC = .79 and .81, respectively) and good convergent validity with a neuropsychological battery (r = .72) (Gill et al., 2008). The MoCA has also been shown to be able to detect PD-D with a cut-off score of less than 21/30. (Dalrymple-Alford et al., 2010). Movement Disorder Society Unified Parkinsons Disease Rating Scale Part III. The MDS-UPDRS III is a comprehensive, clinical rating scale for people with PD and is the most widely used PD-specific measure to assess both motor and non-motor functions (Goetz et al., BACKWARD CYCLING AND PARKINSON DISEASE 24 2008). Section III of the MDS-UPDRS is the motor examination section and can be used to determine the H&Y stage of an individual with PD (Scanlon, Katzen, Levin, Singer, & Papapetropoulos, 2007). It has demonstrated excellent test-retest reliability in both the total score and for the motor subsection score only (ICC = .92 and .90, respectively) (Siderowf et al., 2002). This measure has been shown to have strong concurrent validity with the original UPDRS scale (r = .96) as well as high internal consistency ( = .79 to .93) (Goetz et al., 2008). Posterior stepping responses. Posterior stepping responses were measured during administration of the MBT subsection of reactive postural control, in which the push and release test is used. The push and release test has been shown to hold its sensitivity over repeated trials (Jacobs, Horak, Tran, & Nutt, 2006) and it has been shown to be more accurate in identifying fallers than the pull test (Valkovic, Brozova, Botzel, Ruzicka, & Benetin, 2008). It also has good interrater reliability (ICC = .84) (Jacobs et al., 2006). The variables collected during the posterior stepping response were the maximal stepping excursion (PSR-MSE), the number of steps needed to steady (PSR-StepNo), and the time to steady (PSR-TTS). In the past, stepping responses have been measured by use of force plates and motion analysis systems. The force plates center of pressure changes and the motion analysis system could capture data such as step length and step height (McVey et al., 2009). One recent study looked at maximum step length, as measured by the Maximum Step Length Test (MSLT), and measured the stepping distance by a measuring tape (Duncan, McNeely, & Earhart, 2017). In this study, the maximal stepping excursion during the posterior stepping response (PSR-MSE) was measured by a measuring tape. Time to steady was measured in seconds and the number of steps was measured by visual counting. GAITRite. The GAITRite system is a portable walkway used for gait analysis to collect objective data on spatiotemporal gait parameters (Bilney, Morris, & Webster, 2003). The BACKWARD CYCLING AND PARKINSON DISEASE 25 GAITRite system has good to excellent test-retest reliability (ICC = .79 to .98) (van Uden & Besser, 2004), excellent concurrent validity with paper-and-pencil gait analysis methods on spatial measures (right step length ICC = .97; left step length, ICC = .99), and excellent concurrent validity with video-based methods on temporal measures in healthy populations (right step time ICC = .97; left step time ICC = .95) (McDonough et al., 2001). This system also demonstrated good test-retest reliability for gait speed, cadence, and stride length (ICC = .92 to .97). Mini-Balance Evaluation Systems Test. The MBT is a 14-item comprehensive balance measure that assesses four systems of balance: anticipatory postural adjustments, reactive postural responses, sensory orientation, and dynamic gait (Duncan et al., 2012). In a review of psychometric properties of the MBT, it demonstrated good-to-excellent criterion validity with the BESTest (r = .96), the Berg Balance Scale (r = .79 to .94), the Brief BESTest (r = .94) and the Fullerton Advanced Balance Scale ( = .87) (Di Carlo, Bravini, Vercelli, Massazzi, & Ferriero, 2016). It also demonstrated moderate concurrent validity with the activities-specific balance confidence scale (r = .53 to .66) and moderate-to-high correlation with the timed up and go test (r = -.66 to -.89). It has excellent test-retest reliability (ICC = .92 to .98) and interrater reliability (ICC = .86 to .99). The MBT has an established minimal detectable change (MDC) score (3.5 points) as well as a minimal clinically important difference (MCID) value (4 points) (Di Carlo, Bravini, Vercelli, Massazza, & Ferriero, 2016). Six-minute walk test. The 6MWT is a submaximal test of endurance which measures the distance a person can walk in six minutes. It has excellent test-retest reliability for people with PD (ICC = .96) and has an established MDC value for PD of 82 meters (Steffen & Seney, 2008). Construct validity has been demonstrated in patients with heart failure (r = .63 to .79) (Demers, BACKWARD CYCLING AND PARKINSON DISEASE 26 McKelvie, Negassa, & Yusuf, 2001), however, no known studies have established validity of the 6MWT with the PD population. Procedures Recruitment. Participants were recruited using a combination of convenience and snowball sampling. Recruitment locations were local neurologic rehabilitation centers, Parkinson disease-specific exercise groups, and Parkinson disease-specific support groups. Recruitment methods included informational emails and phone calls (Appendix A). The informational emails had general information regarding the study, inclusion criteria, and instructions to contact the primary investigator for any questions or to express interest in the study. Potential participants contacted the primary investigator directly by phone or email. Eligibility determination. All interested participants were screened by phone or email to determine if preliminary criteria for the study were met, including diagnosis of PD, the ability to walk without assistance for 20 feet, and the absence of any other neurologic condition or injury. A standard script with questions was used (Appendix B). If interested individuals did not meet study criteria, they were informed of this during the phone call or email and no follow-up appointment was made. All interested individuals who met the preliminary inclusion criteria during eligibility determination were scheduled a baseline testing appointment where they were screened to determine if they met the H&Y stage and PD-D status inclusion requirements. Confidentiality. Prior to baseline testing, each participant was assigned a randomly generated unique identification number that was used to record data. The unique identification number allowed confidentiality of data as well as to blind the primary investigator of each participants results. Unique identification numbers were generated using an online number randomizer program. All data were stored electronically on a password-protected laptop. When BACKWARD CYCLING AND PARKINSON DISEASE 27 not in use, the laptop was stored in a locked filed cabinet, and the key kept by the primary investigator. Informed Consent. At the start of the baseline appointment, the primary investigator explained all details of the study, answered any questions, and obtained written informed consent. It was explained that further testing by the MDS-UPDRS III and MoCA would be necessary to confirm eligibility and that signing of the informed consent did not guarantee participation in the study. After consent was obtained, administration of the MoCA and MDSUPDRS III proceeded. Screening The screening process was conducted by the primary investigator and took place at the Midwestern University Physical Therapy Institute (MWU PTI). During this appointment, after written informed consent was obtained, the MoCA and MDS-UPDRS III were administered. If eligibility was confirmed, the baseline measures were then collected. Individuals who did not meet the H&Y and PD-D inclusion criteria during the screening process were not enrolled in the study and all data collected were destroyed. Montreal Cognitive Assessment. Each participant was assessed for PD-D by completing the MoCA. The primary investigator administered the MoCA to each participant in a private examination room. The primary investigator followed all testing protocols set by the developers of the measure. All participants scored at least a 21/30 continued with baseline testing. Movement Disorders Society Unified Parkinsons Disease Rating Scale. The primary investigator administered section III of the MDS-UPDRS. The primary investigator is certified in administration of the MDS-UPDRS through the Movement Disorders Society. This test also BACKWARD CYCLING AND PARKINSON DISEASE 28 allowed the primary investigator to determine the H&Y stage for each participant. Two participants did not meet the criteria of the H&Y stage (they were staged at I), therefore did not continue with baseline testing. Demographic and medical history data. Following informed consent and screening, data on demographics and past medical history related to PD were collected. Data collected included gender, age, years since diagnosis, PD-related medications and dosage, and first signs and symptoms. Testing. Following confirmation of eligibility, baseline testing began. All baseline tests were administered in the same order for each participant and at each stage of assessment: MBT, PSR, gait analysis using the GAITRite, and the 6MWT. After participating in a 6-week backward cycling intervention program, participants were retested within one week of their last cycling visit and again approximately one month after their last cycling visit. The same testing procedures were used for both post-intervention testing sessions. For all time periods, data were recorded in a de-identified electronic data sheet. All adverse events occurring at any time during the 6-week intervention program were also recorded. Mini-BESTest. The MBT was administered by a trained research assistant. Prior to this study, interrater and intrarater reliability was established for all research assistants involved in the data collection aspect of this study. Interrater reliability was excellent (ICC = .96) and intrarater reliability was good-to-excellent (ICC = .81 to 1.00). The test was conducted using the instructions included within the test. A gait belt was donned on each participant for safety. The total score was calculated out of a maximal score of 28 and recorded. Posterior stepping response. Posterior stepping responses were measured during administration of the MBT subsection of reactive postural control. For this test, the participant BACKWARD CYCLING AND PARKINSON DISEASE 29 was instructed to stand with feet shoulder width apart and arms down at sides. The administrator then placed both hands on the participants shoulder blades, and asked him or her to lean back into the administrators hands beyond their backward limit. They were then instructed to do whatever was necessary, including taking a step, to avoid a fall once the administrators hands were removed. Prior to performing this component of the MBT, the participants heels were lined up on a taped placed on the ground. The participant first listened to the instructions, as stated on the MBT. The participant was then instructed to stop and stay in place after steadying. A research assistant then placed a piece of tape directly behind the heel that was the furthest back. The participant was then instructed to return to the start line and this was repeated for two more trials, for a total of three. A research assistant then measured (in centimeters) the distance between the start tape and the three pieces of tape on the ground. This was recorded as the PSRMSE. All three trials were also videotaped to allow the research assistant to watch each trial to collect data on time to steady and the number of steps. For PST-TTS data, the time started as soon as the tester removed their hands from the participants shoulder blades and stopped as soon as the participant successfully stopped their backward momentum. The time, in seconds, was then recorded. If the patient needed assistance to prevent a fall, no time was entered. For the PSR-StepNo, the research assistant watched the video and counted the number of steps needed to steady. Gait analysis. Forward and backward gait parameters were assessed utilizing the GAITRite. The password-protected research laptop contained the GAITRite software, therefore before the gait trials, the laptop was connected to the GAITRite mat. Participants were entered into the system as Participant along with their first name and their unique identification number as their last name. Date of birth was also entered per system requirement. BACKWARD CYCLING AND PARKINSON DISEASE 30 To assess forward walking, the participant was instructed to stand at the end of the walkway, facing the walkway. A gait belt was donned if deemed necessary. A research assistant stood behind the participant, as to not influence walking speed. Another research assistant controlled the laptop connected to the GAITRite in order to capture the data of each trial. The participant was instructed to walk at a comfortable pace beyond the other end of the walkway. Three trials were completed and trial data were saved within the GAITRite program. To assess backwards walking, the participant was instructed to stand at the end of the walkway, facing away. A research assistant was positioned behind the participant (to the side of the mat) as to not influence walking speed. The participant was instructed to walk backwards along the walkway at a self-selected pace and then instructed to stop once beyond the end of the walkway. Three backwards walking intervals were completed and trial data were saved within the GAITRite program. The participant was allowed to rest up to two minutes in between each walking interval if needed. Variables recorded for this study were gait velocity (centimeter/second), mean step length (cm), and mean step width (cm), and were obtained through the GAITRite software. Side-specific variables, including right and left step length and step width, were provided through the software. Six-minute walk test. Prior to testing, measures of exercise responses w taken, which included heart rate (HR), blood pressure (BP), and oxygen saturation (SO2). The same exercise measures were also taken immediately after completion of the 6MWT. A walkway of a 50-foot length was marked off with a red cone at each end. Instructions were used according to the recommendations set by the American Thoracic Society (2002): The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this hallway. Six minutes is a long time to walk, so you will be exerting yourself. BACKWARD CYCLING AND PARKINSON DISEASE 31 You will probably get out of breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. You will be walking back and forth around the cones. You should pivot briskly around the cones and continue back the other way without hesitation. Now Im going to show you. Please watch the way I turn without hesitation. Are you ready to do that? I am going to use this counter to keep track of the number of laps you complete. I will click it each time you turn around at this starting line. Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes, but dont run or jog. A gait belt was used if deemed necessary. The research assistant stood at a location near the starting point for the duration of the test, as to not influence the walking pace. If a participant required close supervision, an additional research assistant walked alongside, but behind the participant as to not influence walking pace. The assistant announced when each minute had passed, and did not provide other verbal cues throughout the test. After completion of the test, the participant was seated in a chair and exercise response measures were taken and recorded. The participant was instructed to rest until exercise measures returned back to within 10% of baseline results (Noonan & Dean, 2000). The total number of feet the participant ambulated was calculated and recorded on a de-identified electronic data sheet. Intervention Upon completion of baseline testing, participants were scheduled to return to the MWU PTI for 12 total sessions over a six-week period, at an average frequency of two times per week. Each participant received an electronic copy of their schedule, and a hard copy if they wished, as well as contact information in case they needed to cancel or reschedule. Participants were instructed to come to each session dressed comfortably with appropriate athletic shoes. The BACKWARD CYCLING AND PARKINSON DISEASE 32 MWU PTI provided water as needed throughout each session, as well as a small exercise towel. For the intervention, a Schwinn Airdyne stationary bicycle (SAB) was used. The SAB has been used in the treatment of various medical conditions, including being part of cardiac rehabilitation (Butler, Palmer & Rogers, 1992), the treatment of Guillain-Barre Syndrome (Arsenault et al., 2016), and traumatic brain injury (Sartor-Glittenberg & Brickner, 2014). It also has been used to determine aerobic capacity in people with multiple sclerosis (Beier, Bombardier, Hartoonian, Motl, & Kraft, 2014). Despite no known publications describing the use of the SAB with the Parkinson population, its safety has been demonstrated among other neurologic disorders. Additionally, the SAB provides consistent pedaling resistance both in the forward and backward directions. This was not the case with some other types of upright, stationary bicycles in which resistance of pedaling was only felt in forward pedaling. During the first session, the participant was introduced to the SAB by a research assistant. The seat height for each participant was set at a height which allowed 25 to 30 of knee flexion when the pedal was at the bottommost point. This represented the most desirable position to ease forces placed on the knee during cycling (Asplund & St. Pierre, 2004). The knee flexion angle was determined by having the participant sit on the SAB, move one pedal to the bottommost position, and measuring the knee angle with a goniometer. Prior to cycling, exercise response measures were taken, including HR, BP, respiratory rate (RR), and SO2, and recorded. The seat height for each participant was also recorded in order to maintain consistency during each session. Each participant was asked to pedal backwards at a self-selected pace for five minutes in order to warm up. After this period, the participant was instructed to pedal at a moderate intensity for 30 minutes. Participants were allowed to take a short rest break if they felt necessary, or when the researchers felt it was necessary during the 30-minute interval; however, BACKWARD CYCLING AND PARKINSON DISEASE 33 the timer was stopped during the duration of any rest breaks to ensure that the total work time equated to 30 minutes. All rest breaks, including number required and the duration of each break, was recorded. Immediately following onset of the exercise interval, the participant was asked to rate their intensity by use of a visual Borg Rating of Perceived Exertion scale (Borg RPE). The Borg RPE is a 15-point scale from 6 to 20, with 6 being the lightest intensity and 20 being maximal intensity (Borg, 1982). The Borg RPE was chosen for this study as research has demonstrated that people with PD may demonstrate abnormal cardiac responses to exercise, including decreased HR (Werner, DiFrancisco-Donoghue, & Lamberg, 2006). The Borg RPE has been shown to be a reliable and valid measure of exercise intensity (Day, McGuigan, Brice, & Foster, 2004; Foster et al., 2001; Herman, Foster, Maher, Mikat, & Porari, 2006). For this study, moderate intensity was defined as an RPE rating of 12-14. The RPE obtained and recorded every 5 minutes of cycling to ensure moderate intensity was maintained throughout the session. If the reported RPE rating was greater than 14, the participant was asked to decrease speed until they rated their exertion as a 14 or below. If the participant reported a rating of less than 12, they were asked to increase their speed until the rating fell within the desired range. A bottle of water was within reach of the participant at all times. After completion of 30 minutes, the participant was given a choice of either decreasing the intensity and pedaling at a selfselected pace for five additional minutes for a cool-down period, or to walk for five minutes. Following completion of the cool-down period, the participant was seated in a chair and exercise response measures was taken. The participant was instructed to rest until all measures returned to within 10% of baseline measures. A trained research assistant monitored each session and recorded all necessary data, including pre-exercise response measures, perceived exertion rating, and post-exercise response measures (Appendix C). BACKWARD CYCLING AND PARKINSON DISEASE 34 Statistical Analysis Data were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY). All comparisons were two-tailed using a significance level of less than .05 to be considered statistically significant. Descriptive statistics were conducted on participant demographics and baseline and post-intervention data. Nominal and ordinal data are presented as frequencies and percentages. Normally distributed interval and ratio data are reported as means and standard deviations while non-normally distributed data are reported as medians and interquartile ranges. Normal distribution of data was determined using the Shapiro-Wilk test. Sphericity was determined by the Mauchlys test of sphericity. For outcome measures in which three trials were conducted, the calculated mean score of the three trials was used for analyses. To determine if there were statistically significant differences in the outcome variables over time both parametric and non-parametric tests were conducted. For normally distributed data with assumption of sphericity, repeated measures ANOVAs were conducted. This included forward and backward gait velocity, forward step length, forward step width, and backward right step length. For data that did not meet the assumption of sphericity, the Greenhouse-Geisser test was used (PSR-MSE, backward left step length, backward left and right step width). If significance was demonstrated, post-hoc tests with Bonferroni correction was run to locate the source of difference. For data not normally distributed, a Friedman ANOVA test was run to determine difference in the repeated measures at each time frame (MBT, PSR-TTS, and PSR-StepNo). If significance was found, pairwise Wilcoxon signed-ranks post-hoc tests were conducted using the Bonferroni correction to adjust the significance level (p < .017) to control for possible alpha inflation. BACKWARD CYCLING AND PARKINSON DISEASE 35 Effect size estimates for each normally distributed variable are reported using partial-eta squared (2p). For pairwise comparisons, effect size estimates are reported using Cohens d. Due to data not being normally distributed, effect sizes for MBT, PSR-TTS, and PSR-StepNo were calculated based on the formula recommended by Cohen (1988) and Rosenthal (1994). Effect sizes were transformed to Cohens d based on calculations reported by Cohen (1988) and Rosenthal (1994), (as reported by Lenhard & Lenhard, 2016). Effect sizes for Cohens d were interpreted based on guidelines proposed by Cohen (1988, 1992) with 0.20 - < 0.50 = small effect; 0.50 - < 0.80 = medium effect; > 0.80 = large effect. Results Twenty-six participants were enrolled in the study. Prior to starting the intervention, two participants opted out, one due to not being able to commit the time and the other due to a death in the family. Twenty-four people started the intervention program with one person discontinuing after two intervention sessions due to leg cramping. Twenty-three participants completed the intervention program and subsequent posttest. For one-month follow-up testing, one participant was not able to be reached; therefore, 22 participants completed the one-month follow-up test. Baseline demographics are presented in Table 1. Primary Objective The primary objective was to determine if backward cycling had an effect on posterior protective stepping response in people diagnosed with PD. Results are presented in Table 2. Posterior stepping response. A Friedman ANOVA revealed there was a significant decrease in the number of steps needed to steady following a backward loss of balance (PSRStepNo) across the three time periods, X2 (2, N = 22) = 7.96, p = .019 with a medium effect size (d = 0.74), representing a moderate magnitude of change. Pairwise post hoc analyses using the BACKWARD CYCLING AND PARKINSON DISEASE 36 Wilcoxon signed-ranks test revealed a significant median decrease between baseline and onemonth follow-up of 0.50 steps, with a large effect size (d = 0.81), representing a large magnitude of change. A Friedmans ANOVA revealed no significant difference in PSR-TTS across three measures, X2(2, N = 19) = 5.15, p = .076; however, a medium effect size (d = 0.58) was determined, representing a moderate magnitude of change. A repeated measures ANOVA revealed no significant difference in mean MSE over time, F(2, 40) = 3.48, p = .065, with a small effect size (2p = 0.15), representing a small magnitude of change. Secondary Objectives The secondary objectives were to determine if backward cycling significantly affects backward gait parameters, forward gait parameters, balance, and aerobic capacity; and to assess the acceptability of backwards cycling as an intervention through recording adverse events and retention rate. Backward gait parameters. A repeated measures ANOVA revealed a significant increase in mean backward gait velocity over time, F(2, 42) = 7.91, p = .001 with a medium effect size (2p = 0.27), representing a moderate magnitude of change. Post hoc analysis identified a statistically significant increase between baseline and one-month follow-up, mean difference 12.60 cm/s, p = .011 with a small effect size (d = 0.26), representing a small magnitude of change. No significant difference was found between baseline and one-week testing, with a mean difference of 6.92 cm/s and small effect size (d = 0.34), representing a small magnitude of change. No significant difference was found in mean left step length over time, F(2, 42) = 1.11, p = .327 with a negligible effect size (2p = 0.05) representing a trivial amount of BACKWARD CYCLING AND PARKINSON DISEASE 37 change. No significant difference was found in mean right step length over time, F(2, 40) = 2.56, p = .090 with a small effect size (2p = 0.11), representing a small magnitude of change. No significant difference was found in mean left step width over time, F(2, 42) = 1.05, p = .342 with a negligible effect size (2p = 0.05) representing a trivial amount of change. No significant difference was found in mean right step width over time, F(2, 42) = 0.78, p = .425 with a negligible effect size (2p = 0.04), representing a trivial amount of change. Forward gait parameters. A repeated measures ANOVA revealed a significant increase in mean forward gait velocity over time, F(2, 42) = 4.52, p = .017, with a small effect size (2p = 0.18), representing a small magnitude of change; left step length, F(2, 40) = 5.65, p = .007, with a medium effect size (2p = 0.22), representing a moderate magnitude of change; and right step length, F(2, 42) = 4.99, p = .011, with a small effect size (2p = 0.19), representing a small magnitude of change. Post hoc analyses identified a statistically significant increase between baseline and one-month follow-up in left step length, mean difference 3.39 cm, p = .039, with small effect size (d = 0.31), and right step length, mean difference 3.01 cm, p = .049, with a small effect size (d = 0.29), both effect sizes representing a small magnitude of change. No significant difference was found in left step width, F(2, 42) = 1.69, p = .197 with a negligible effect size (2p = 0.07) and mean difference of 0.47 cm between baseline and one-week testing, with a negligible effect size (d = 0.14), both effect sizes representing a trivial amount of change. No significant difference was revealed in right step width, F(2, 42) = 0.84, p = .437, with a negligible effect size (2p = 0.04), and a mean difference of 0.01 cm and negligible effect size (d = 0), both effect sizes representing a trivial amount of change. Balance. A Friedmans ANOVA revealed that there was a significant increase in MBT scores over time, X2(2, N = 22) = 11.4, p = .003 and a large effect size (d = 0.91), representing a BACKWARD CYCLING AND PARKINSON DISEASE 38 large magnitude of change. Pairwise post hoc analysis using the Wilcoxon signed-ranks test revealed a statistically significant difference between baseline and 1-month follow-up (Z = -3.50, p < .001). The median difference of 3.00 points resulted in a very large effect size (d = 1.24), representing a very large magnitude of change. There was no significant difference between baseline and 1-week post-test, Z = -2.24, p = .025, however, there was a medium effect size (d = 0.72), representing a moderate magnitude of change. Aerobic capacity. A repeated measures ANOVA revealed no significant difference in mean 6MWT distance over time, F(2, 42) = 1.10, p = .342, with a small effect size (2p = 0.15), representing a small magnitude of change. Acceptability. One adverse event was recorded and involved a participant experiencing leg cramping during the first two intervention sessions therefore, this participant opted to discontinue the intervention. Twenty-four participants started the intervention program, and 23 participants completed the entire intervention program, for a 95.8% retention rate. Discussion The purpose of this study was to explore the use of backwards cycling in people with PD. The objectives were to determine the effects on participant function and to determine if backward cycling would be an acceptable form of intervention based on the number of adverse events and retention rate. It is known that people with PD have postural instability and consequential fall risk, and this fall risk can increase as the disease progresses (Gray & Hildebrand, 2000). Postural instability in the backward direction is particularly prevalent in the PD population (Carpenter, Allum, Honegger, Adkin, & Bloem, 2003; Horak, Dimitrova, & Nutt, 2005). A survey by Ashburn, Stack, Ballinger, Fazakarley, and Fitton (2008) which included 124 people living with PD, revealed that out of the eight bone fractures which occurred due to BACKWARD CYCLING AND PARKINSON DISEASE 39 falling, six out of eight (75%) were due to backward or sideward landings. Protective stepping responses, or reactive postural control, refer to a persons ability to produce an effective stepping strategy to realign the bodys center of mass with the limits of stability (Schoneburg et al., 2013). It is known that these stepping responses are slower and smaller in people with PD, therefore increasing risk for falls (Shoneburg et al., 2013). To date, this is the first study to assess a backward cycling program for the PD population. For posterior protective stepping responses, we selected to highlight the number of steps, maximal excursion distance, and time to steady. At baseline, participants required a mean of 2.48 steps to steady from a posterior loss of balance (LOB). This is consistent with a previous study, which included moderately affected people with PD, and reported a mean of 2.43 steps needed to recover from a posterior LOB (McVey et al., 2013). After completion of a 6-week backward cycling program, the number of steps significantly decreased from a median of 2.00 steps to 1.50 steps. This median change persisted through the 1-month follow-up. Both baseline to 1-week post-test comparisons and baseline to 1-month follow-up comparisons demonstrated a medium to large effect size (d = 0.63 and d = 0.81 respectively). This significant reduction in the number of backwards steps following a posterior LOB may be relevant in the PD population, as retropulsion has been shown to be a fall risk factor (Lindholm, Hagell, Hansson, & Nilsson, 2014) as well as a self-identified deficit in people with PD (Ashburn et al., 2008). Additionally, the reduction in number of steps needed to maintain balance after this backwards cycling program may be of interest to clinicians who work with the PD population with goals of improving posterior reactive stepping responses in people who exhibit more than one step. There was downward trend observed in the maximum stepping excursion, meaning the participants were able to steady themselves in a shorter distance following a posterior loss of BACKWARD CYCLING AND PARKINSON DISEASE 40 balance; however, this was not a significant change from baseline. The mean maximal stepping excursion at baseline of 54.80 cm decreased to 43.12 cm at one-week post-test (medium effect size, d = 0.56), with a slight upward trend at 1-month follow-up of 46.23 cm. One factor that could explain this variable not reaching significance is that participants were able to steady themselves with less steps, therefore possibly being able to step with an increased step length in order to do so. In other words, a person may be able to catch themselves in less steps due to being able to step longer. While this could significantly improve the number of steps, this could limit how much change the MSE could potentially achieve. Additionally, at baseline, the median number of steps was two, leaving little room for improvement as one step is the minimum value for this test. Therefore, if the number of steps is near a ceiling, the MSE may not have room for an appreciable change. While not statistically significant, this effect may be clinically relevant. It is known that retropulsion is an independent risk factor for falls in people with mild PD (Lindholm, Hagell, Hansson, & Nilsson, 2015); therefore, a backward cycling program shows potential as being an effective intervention to improve posterior protective stepping responses. The time to steady variable also showed a downward trend, meaning that participants were able to steady themselves after a loss of balance in less time. The median time to steady at baseline was 0.89 seconds and decreased to 0.35 seconds at one-week follow-up, with a medium effect size (d = 0.72). This change was maintained at the one-month follow-up, with a median of 0.41 seconds to steady, and a medium effect size (r = 1.24) compared to baseline. Therefore, following the backward cycling intervention, the participants were quicker to steady themselves, and this improvement maintained through the 1-month follow-up, with little to no change. Although the change was not statistically significant, the medium effect size in reduction of time BACKWARD CYCLING AND PARKINSON DISEASE 41 to steady may be relevant to clinicians working with the PD population who have goals in improving stepping responses. In terms of the posterior protective stepping responses overall, following a posterior LOB, participants were able to steady themselves in less distance, less steps, and in less time. There have been studies showing improvements in stepping abilities and responses (Barajas & Peterson, 2018; Jobges et al., 2004; Protas et al., 2005) however what is lacking is an intervention in which a person with PD can perform on their own outside of therapy care. All of these previous studies utilized an intervention in which external perturbations were used, produced by either a person or expensive equipment. These types of interventions are not feasible for a person at home or in the community. A stationary bicycle, however, is common in homes, community fitness and recreation centers, therefore readily available. Additionally, the type of stationary bicycle used in this study is relatively inexpensive compared to other recumbent-type bicycles found in therapy clinics. Therefore, this intervention is a feasible, safe mode of exercise that people living with PD can perform at home or community in order to improve and/or maintain posterior protective stepping responses to optimize their safety. In terms of effects on gait variables, backward cycling resulted in significant improvements in backward gait velocity, forward gait velocity, and forward step length. The mean difference for both forward and backward gait velocity improved from baseline to oneweek post-test but continued improving from one-week post-test to one-month follow up. This seems to indicate that there was continued improvement four weeks beyond cessation of the intervention. This continued improvement may be due to two factors. First, one unintended result of this study is that at 1-month follow-up testing, several participants reported including backward cycling in their own exercise program. This continuation of this particular intervention BACKWARD CYCLING AND PARKINSON DISEASE 42 may have had a continued positive effect on several study variables between post-test and onemonth follow-up. Secondly, it is known that exercise has been shown to have a neuroprotective effect on the brain as well as result in exercise-induced neuroplasticity (Mak, Wong-Yu, Shen, & Chung, 2017). Additionally, exercise has been shown to increase the binding potential of dopamine receptors in early PD as well as a neurorestorative effect (Petzinger et al., 2013). This would result in improved motor function, including automatic movements (Petzinger et al., 2013). Therefore, the continuation of improvement following the intervention could be due to lasting motor function improvements due to the neuroplastic and neurorestorative effects of exercise. The mean difference in backward gait velocity from baseline to 1-month follow-up was 12.85 cm/s, or 0.13 m/s. Although no MDCs have been established for backwards walking in PD, this value approached the MDC for forward gait velocity in this population (MDC=0.18 m/s) (Steffen & Seney, 2008). This may be of interest to clinicians who are treating patients with PD who have goals in improving backward gait, which has been shown to be affected in PD (Hackney & Earhart, 2009). Additionally, walking ability has been identified as a primary concern for people with PD, and that gait speed is a particularly important factor (Hass et al., 2014). Balance significantly improved following a backwards cycling program. Participants MBT scores from baseline (Median = 23) to one-week post-test (Median = 25) improved by a median difference of 2 points, and this improvement continued through the one-month followup, with a median MBT score of 26. This 3-point difference from baseline to one-month followup closely approached the MDC established for PD, of 3.5 points (Di Carlo et al., 2016). Overall, there seems to be a ceiling effect due to the relatively high baseline score of the MBT. The mean BACKWARD CYCLING AND PARKINSON DISEASE 43 age of the study participants was 68.8 years with a median MBT score of 23 at baseline. The normative mean MBT value for the 60-69 age group is 24.7 (OHoski et al., 2014), therefore, the baseline value was close to the normative value, leaving little room for improvement. Additionally, we selected to include people in H&Y stage II and III, however it is stage III where people with PD start demonstrating postural instability, with stage II being defined as bilateral involvement without impairment of balance (Goetz et al., 2004). By including stage II, this skewed the MBT scores towards a higher total. In our study, the mean MBT scores for participants in H&Y stage II was 23.55 and the mean for participants in H&Y stage III was 21.75. Therefore, the inclusion of H&Y stage II may have introduced a ceiling effect, therefore limiting the potential magnitude of change. Looking further into the MBT subscales, one reason for the increase in the MBT could be attributed to improvements within the reactive postural control subsection. Calculating the means of these subscores, baseline for reactive postural control was 4.17 points, which increased to 4.95 points at one-week post-test and this increase remained at one-month follow-up with a mean of 5.10 points. In terms of aerobic capacity, no significant changes were found, despite participants exercising at a moderate intensity each session. This may be due to the frequency of the intervention delivery. The American College of Sport Medicine Guidelines for Exercise Testing and Prescription recommends an exercise frequency of at least 3 days per week when exercising at a moderate intensity in order to improve or maintain aerobic capacity (Whaley, Brubaker, & Otto, 2006). The participants in this study only exercised at a frequency of twice per week. For clinicians with goals of improving aerobic capacity, an increase in frequency may be needed or BACKWARD CYCLING AND PARKINSON DISEASE 44 inclusion of aerobic exercise in a patients home exercise program would be warranted to complement the therapy sessions. Overall, results from our study are consistent with other studies looking at the effects of forward cycling and PD in terms of gait variables, with significant improvements in forward gait velocity, cadence, and balance (Nadeau et al., 2017; Uyger et al., 2015). Interestingly, our study with a focused backward direction intervention produced improved gait variables in the forward direction as well. This type of result has been reported in other studies. One study looking at the effects of forward treadmill training reported improvements in backward gait variables, including backward gait velocity, and stride length, following a forward treadmill training program (Tseng, Yuan, & Jeng, 2015). Another study using repetitive compensatory step training in the backward and lateral direction also showed significant improvements in forward gait velocity, cadence, and step length (Jobges et al., 2003). These aforementioned studies seem to support the notion that the direction of the intervention may not limit improvements in other directions. However, findings from our previous studies study either do not contain evidence supporting that the intervention can improve stepping responses or the intervention is not feasible in the home and clinic. The safety of the use of a treadmill at home by people with PD has come into question, with a study showing several adverse events during a home treadmill exercise program with people with PD (Skidmore et al., 2008). The feasibility of a compensatory stepping program at home is also challenged, due to the need for external perturbations. The safety of the use of a stationary bicycle in the PD population has been shown in the past (McGough et al., 2016) and it is further supported by our study. In addition, our study demonstrates that with backwards cycling is safe, feasible, and potentially effective at not only improving protective stepping responses, but also gait and balance. BACKWARD CYCLING AND PARKINSON DISEASE 45 This six-week backward cycling program resulted in one adverse event. One participant experienced leg cramps after two intervention sessions and decided to discontinue the program. The participant reported his leg cramping in both quadricep muscles. There are two possible explanations for the cramping experienced by this participant: muscle overload/fatigue or an electrolyte deficit (Bergeron, 2008). Following the first session, the participant was instructed to stay hydrated during the days between sessions as well as consider an electrolyte sport drink; however, the cramping persisted. During backward pedaling, it has been shown that the rectus femoris works both eccentrically and concentrically (Neptune, Kautz, & Zajac, 2000). It has also been shown that although backward cycling does not require more metabolic demand compared to forward cycling; there is greater muscle involvement terms of amplitude and duration (Bressel, Heise, & Bachman, 1998). Therefore, the act of pedaling backwards may have been too great of a load for this participant, therefore may have required a slower, gradual increase in duration of the pedaling to condition the leg muscles. It is important to note that if a new intervention like backwards cycling is introduced into a patients treatment therapy, therapists should encourage cessation of an external exercise program until exercise tolerance is increased, possible gradual increase of the duration of the exercise, and to promote proper hydration. Every participant was able to get on and off the upright bicycle with no more than supervision. The main complaints during the intervention was discomfort of the bicycle saddle; however, this discomfort waned as the intervention sessions continued. Several participants reported they continued backward cycling in their own fitness centers immediately following completion of the research program, further supporting the acceptability of the intervention. Limitations BACKWARD CYCLING AND PARKINSON DISEASE 46 Several limitations exist within this study. The sample size was relatively small therefore potentially underpowered. It also lacked a control group, which could negatively affect internal validity. The addition of a control group would allow comparisons to more traditional forms of exercise interventions. Additionally, the 6-week duration of the intervention program was relatively short. A systematic review of exercise interventions for people with PD included 14 studies, 10 (71%) of which had intervention durations of greater than six weeks (Goodwin et al., 2008). We selected this duration, as well as the frequency of twice a week, intentionally in order to create a feasible program within any outpatient therapy setting. Although attempts to schedule participants in peak medication times was the goal for both the assessments and interventions, this was not able to be consistent due to scheduling logistics and availability. Many participants, however, were scheduled on the same day and time each week, therefore some amount of consistency was able to be achieved. Strengths This study introduced a multi-faceted method of objectively measuring posterior protective stepping responses. Taking this approach, therapists can gain more insight into the specific issue affecting individuals from effectively steadying themselves following a posterior LOB. For example, a patient may be able to steady themselves, however if the maximal excursion distance is excessive, this may continue to be a fall risk, therefore specific interventions are needed to improve this. Additionally, this study supports an intervention that utilizes relatively inexpensive equipment that has potential at improving posterior stepping responses. This is in stark contrast to most studies regarding stepping responses, which utilize expensive hydraulic force plates. Clinical Relevance BACKWARD CYCLING AND PARKINSON DISEASE 47 Adherence to a home exercise program in people with PD is an important factor as consistent exercise has been associated with improved quality of life, motor function, mobility, and decreased caregiver burden (Oguh, Eisenstein, Kwasny,& Simuni, 2014). Factors have been identified for reasons why patients were not complaint with their home exercise programs, including fear of falling, difficulty carrying out the exercise, and being tedious for others. In this present study, backward cycling was feasible, with a high retention rate, and was also safe, with only one adverse event (muscle cramps) being reported. Additionally, each participant was able to get on/off the bicycle and pedal with no more than supervision, therefore has the potential to be an intervention that can be done independently. The intervention also has potential to be effective at improving posterior stepping responses without need of expensive equipment nor the need for another person to produce an external perturbation, therefore increasing the feasibility of home and community use. Conclusion This study supports the use of a backwards cycling program as a feasible, safe intervention that can be effective at improving posterior proactive stepping responses in people with PD. Secondarily, a backwards cycling program may also improve overall balance and gait parameters in both the forward and backward direction. Future research is needed to determine the effects of a longer duration program (10-12 weeks) and to determine the optimal dosage in terms of frequency and duration. Additionally, a control group for comparisons to other commonly used interventions would be warranted. Due to the effectiveness and safety, backward cycling could be considered as an intervention for both the clinic and community setting. BACKWARD CYCLING AND PARKINSON DISEASE 48 References Allen, N. E., Schwarzel, A. K., & Canning, C. G. (2012). Recurrent falls in Parkinsons disease: A systematic review. Parkinsons Disease, 2013, 1-16. doi:10.1155/2013/906274 Allen, N. 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Motor Control, 13, 368-386. doi:10.1123/mcj.13.4.368 BACKWARD CYCLING AND PARKINSON DISEASE 63 Table 1 Baseline Characteristics (N=23) Characteristic Minimum - Maximum Gender, n (%) Male 19 (82.6) Female 4 (17.4) Age, mean (SD) 68.22 (7.74) 56-78 Years since PD diagnosis, mean (SD) 6.39 (4.44) 1-14 Hoehn and Yahr stage, n (%) Stage II 11 (47.8) Stage III 12 (52.2) MDS-UPRDS III, mean (SD) 30.70 (13.10) 10-63 MoCA, mean (SD) 26.74 (2.77) 21-30 Note. PD = Parkinson disease; MDS-UPDRS III = Movement Disorders Society-sponsored revision of the Unified Parkinsons Disease Rating Scale part III motor examination; MoCA = Montreal Cognitive Assessment BACKWARD CYCLING AND PARKINSON DISEASE 64 Table 2 Comparison of Baseline, 1-Week, and 1-Month Follow-up Measures Baseline PSR-MSE (cm) 1-week follow1-month follow-up up M (SD) M (SD) M (SD) Posterior Stepping Response 54.80 (25.13) 43.12 (15.56) 46.32 (13.02) .065 PSR-TTS (sec) 0.89 (1.37) 0.35 (0.52) 0.41 (0.79) .076 PSR-step number 2.00 (1.50) 1.50 (1.08) 1.50 (1.08) .019* Gait velocity (cm/sec) 71.57 (19.36) Backward Gait 78.49 (21.20) 84.43 (24.90) .001** Left step length (cm) 41.66 (8.04) 42.92 (9.36) 43.76 (11.15) .327 Right step length (cm) 43.42 (9.47) 44.35 (11.59) 46.29 (12.28) .090 Left step width (cm) 18.90 (4.53) 18.50 (5.03) 18.16 (4.70) .342 Right step width (cm) 19.03 (4.79) 18.71 (4.92) 18.40 (4.60) .425 Gait velocity (cm/sec) 111.48 (20.27) Forward Gait 118.42 (21.22) 120.03 (23.96) .017* Left step length (cm) 63.52 (9.93) 66.58 (10.07) 66.91 (10.61) .007** Right step length (cm) 63.72 (8.36) 66.26 (9.23) 66.73 (9.22) .011* Left step width (cm) 10.23 (3.00) 10.70 (3.83) 10.84 (3.67) .197 Right step width (cm) 10.55 (3.22) 10.55 (3.75) 10.94 (3.60) .437 6MWT (ft) Functional Outcome Measures 1188.14 (217.02) 1221.36 (252.89) 1239.18 (247.33) .361 MBT 23.00 (4.25) Variable 25.00 (2.75) 26.00 (3.00) p .003** BACKWARD CYCLING AND PARKINSON DISEASE Note. PSR-MSE = posterior stepping response maximal stepping excursion; PSR-TTS = posterior stepping response time to steady; 6MWT = 6 Minute Walk Test; MBT = MiniBESTest * p < .05 ** p<.01 Reported as median (interquartile range) 65 BACKWARD CYCLING AND PARKINSON DISEASE Assessed for eligibility (n = 28) Ineligible (n = 2) Did not meet H&Y criteria (n = 1) Enrolled in study, baseline measures completed (n = 26) Opted out of intervention after baseline measures (n = 2) Could not commit the time (n = 1) Death in family (n = 1) Scheduled for intervention (n = 24) Discontinued intervention (n = 1) Experienced leg cramps Completed program, completed 1week follow-up (n = 23) Lost to 1-month follow up (n = 1) Unable to contact to schedule Completed 1-month follow up-up (n = 22) Figure 1. Flow of participants in study. 66 BACKWARD CYCLING AND PARKINSON DISEASE 67 Appendix A Hello, The Midwestern University Physical Therapy Program is seeking volunteers for a research study being conducted at the Midwestern University Physical Therapy Institute. The study is looking for people living with Parkinsons disease to complete a 12-session backward cycling exercise program. Details: Study title: The effects of backward cycling on posterior protective stepping responses in people with Parkinson disease Purpose: To assess if cycling backwards on a stationary bicycle has any effect on stepping responses, balance, gait, and aerobic capacity. Eligibility criteria: Be 20-80 years of age Diagnosis of idiopathic Parkinson disease Currently in stages II or III of the Hoehn and Yahr Parkinsons disease rating scale Be able to walk unassisted without an assistive device for at least 20 feet Not currently enrolled in physical therapy Be able to understand and speak English This study is of no cost to any participant. All data will be kept confidential in a passwordprotected laptop only accessible to the primary investigator, co-investigator, and research assistants. If you have any questions or are interested in this study, please contact Suzanne ONeal, PT, DPT, NCS at soneal@midwestern.edu or 623-572-3938. Thank you very much, Suzanne ONeal, PT, DPT, NCS primary investigator Assistant Professor Physical Therapy Program Midwestern University 19555 N 59th Avenue Glendale, AZ 85308 soneal@midwestern.edu 623-572-3938 This research study has been reviewed and approved by the Midwestern University Institutional Review Board (AZ #1128) BACKWARD CYCLING AND PARKINSON DISEASE Appendix B 68 BACKWARD CYCLING AND PARKINSON DISEASE Appendix C Intervention Data Sheet Session #: Date: Pre-Vitals Heart Rate: Blood Pressure: Respiratory Rate: Oxygen Saturation: Number of rest breaks: Duration of each break: Rate of Perceived Exertion (RPE) Target: 12-14 Within first minute 5 minutes 10 minutes 15 minutes 20 minutes 25 minutes Total exercise time (if different from 30 minutes): Post-Vitals Heart Rate: Blood Pressure: Respiratory Rate: Oxygen Saturation: 69  ...

... Effects of Childhood Experiences on Pregnancy and Birth Outcomes Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Jennie M. Le, MS, ASCP(MB), CGMBS. Copyright June 28, 2021 By: Jennie M. Le, MS, ASCP(MB), CGMBS All rights reserved Approved by: Elizabeth S. Moore, PhD Committee Chair ______________________________ Gretchen Bandoli, PhD, MPH, MBA Committee Member ______________________________ Lochana Siriwardena, PhD Committee Member ______________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis ______________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis ______________________________ CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 1 Effects of Childhood Experiences on Pregnancy and Birth Outcomes Jennie M. Le Department of Interprofessional Health and Aging Studies, University of Indianapolis Center for Better Beginnings, University of California, San Diego Author Note Jennie M. Le https://orcid.org/0000-0002-1791-6109 Corresponding concerning this paper should be addressed to Jennie M.Le, Department of Interprofessional Health and Aging Studies, University of Indianapolis, Indianapolis, Indiana, United States. Email: lejm@uindy.edu CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Acknowledgements I am thankful for the support that I have consistently received from family, my research committee at the University of Indianapolis (UIndy), the University of California at San Diego Health (UCSD Health), and my colleagues at the Rady Childrens Institute Genomics for Medicine (RCIGM). I thank my family, my husband Si Chi and daughter Caroline, for their endless love, understanding, and encouragement throughout my learning years at the Interprofessional Health & Aging Studies (IHAS), UIndy. My great thanks extend to my research committee, Dr. Elizabeth Moore, Dr. Gretchen Bandoli, and Dr. Lochana Siriwardena. Each advisor generously offered collective expertise, sagacious wisdom, and steady guidance to help me complete my Doctoral project. I am deeply thankful to Dr. Karen Garman, Dr. Tina Chambers, Dr. Charlotte Hobbs, and Dr. Stephen Kingsmore at RCIGM and UCSD Health for supporting my participation in the MotherToBaby study for this project. My great appreciations also extend to Dr. Laura Santurri and the IHAS dedicated professors and staff, who equip me with the skills and knowledge for a doctorate health professional. Finally, I am grateful to collaborate and continue to share learning experiences with my colleagues at the UIndy throughout this program and for the time to come. With deepest gratitude, Jennie M. Le, MS, ASCP(MB), CGMBS 2 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 3 Abstract A growing body of research reports an association between adverse childhood experiences (ACEs) and severe physiological and psychological health problems. Recent studies suggested that positive childhood experiences (PCEs) may bestow a protective buffer against the negative impacts of ACEs. The current study examined the effect of ACEs/PCEs on pregnancy outcomes, including unhealthy gestational weight gain (UWG), gestational diabetes (GD), preterm birth, and small or large birth weight for gestational age (SGA or LGA). The study sample included 556 women who enrolled in the MotherToBaby, delivered a live singleton from 2015-2021, and completed the Positive and Adverse Childhood Experiences survey between September 2020 and February 2021. Women who reported 3 ACEs or physical/emotional abuse had increased aOR = 1.68, 95% CI [1.12, 2.51]) or aOR = 1.79, 95% CI [1.24, 2.59] for UWG. Although sexual abuse or household dysfunction had elevated point estimates with increased odds for GD, SGA, and LGA or UWG, preterm birth, and LGA, the associations were not statistically significant with large confidence intervals. Additionally, due to the small sample size within stratified outcomes, we were unable to assess the effect modification of PCEs. Further research may advance an understanding of associations between timing, frequency, and types of ACEs/ PCEs and pregnancy health which could facilitate ACE awareness, reduce medical costs in maternal health care, and provide a better beginning for infant development. Keywords: adverse childhood experiences, positive childhood experiences, MotherToBaby, pregnancy health, gestational diabetes, gestational weight gain, gestational age, preterm birth, birth weight for gestational age. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 4 Table of Contents Acknowledgements ......................................................................................................................... 2 Abstract .......................................................................................... Error! Bookmark not defined. Table of Contents ............................................................................................................................ 4 List of Tables ................................................................................. Error! Bookmark not defined. List of Figures ................................................................................ Error! Bookmark not defined. Adverse and Positive Childhood Experiences on Pregnancy Health and Birth Outcomes ... Error! Bookmark not defined. Problem Statement .............................................................Error! Bookmark not defined. Purpose Statement ..............................................................Error! Bookmark not defined. Significance of the Study ...................................................Error! Bookmark not defined. Literature Review ......................................................................................................................... 14 Childhood Experiences Theory and Model .......................Error! Bookmark not defined. The Life Course Theory .........................................Error! Bookmark not defined. Developmental Psychopathology Model ...............Error! Bookmark not defined. Adverse Childhood Experiences and Adult Outcomes ..................................................... 17 Physical, Sexual, and Emotional Abuse ............................................................... 18 Physical and Emotional Neglect ........................................................................... 19 Household Dysfunction ........................................................................................ 19 Socioeconomic and Demographic Factors............................................................ 20 Genetic and Biological Factors of Childhood Experiences ............. Error! Bookmark not defined. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 5 Epigenetic Effect ................................................................................................... 21 Neurobiological and Metabolic Functioning .........Error! Bookmark not defined. Inflammatory and Autoimmune Functioning ....................................................... 22 Health Behaviors Associated with Adverse Childhood Experiences ..... Error! Bookmark not defined. Smoking .................................................................Error! Bookmark not defined. Drinking .................................................................Error! Bookmark not defined. Drug Use ................................................................Error! Bookmark not defined. Sexual Risk ............................................................Error! Bookmark not defined. Summary ................................................................Error! Bookmark not defined. Effects of Positive Childhood Experiences....................................................................... 25 Supportive Environment ........................................Error! Bookmark not defined. Resilience ...............................................................Error! Bookmark not defined. Summary ................................................................Error! Bookmark not defined. Health Effects Associated with Adverse Childhood Experiences ... Error! Bookmark not defined. Pregnancy Health ...................................................Error! Bookmark not defined. Birth Outcomes ......................................................Error! Bookmark not defined. Summary ................................................................Error! Bookmark not defined. Instruments for Childhood Experiences Study ..................Error! Bookmark not defined. The Positive Childhood Experiences Questionnaire............ Error! Bookmark not defined. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 6 The Adverse Childhood Experience Questionnaire ............. Error! Bookmark not defined. Summary ............................................................................Error! Bookmark not defined. Method ........................................................................................... Error! Bookmark not defined. Study Design ......................................................................Error! Bookmark not defined. Participants .........................................................................Error! Bookmark not defined. Procedure .......................................................................................................................... 35 Data Collection and Management ..................................................................................... 35 Study Data ......................................................................................................................... 36 Operational Variables ....................................................................................................... 37 Instruments for MTB-PACE Study .................................................................................. 38 Assessment of Positive Childhood Experiences ................................................... 38 Assessment of Adverse Childhood Experience .................................................... 39 Data Analysis .................................................................................................................... 40 Research Question 1 ............................................................................................. 40 Research Question 2 ..............................................Error! Bookmark not defined. Research Question 3 ..............................................Error! Bookmark not defined. Results ........................................................................................................................................... 42 Characteristics of the MTB-PACE Participants ............................................................... 42 Demographic Characteristics of MTB-PACE Participants................................... 43 Health Conditions and Health Information of the MTB-PACE Participants ....... 43 Research Question 1 Result .............................................................................................. 44 Objective 1a: Prevalence of ACEs/PCEs among MTB-PACE Participants ......... 44 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 7 Objective 1b: Factor Analysis of ACEs Questionnaires.Subtypes Prevalence..... 45 Research Question 2 Result .............................................................................................. 45 Objective 2: Associations between ACEs and Pregnancy or Birth Outcomes ..... 45 Research Question 3 Result ...............................................Error! Bookmark not defined. Objective 3: Examination of the Effect Modification of PCEs on ACEs-related Pregnancy and Birth Outcomes ............................................................................ 47 Discussions ................................................................................................................................... 48 Unhealthy Gestational Weight Gain ................................................................................. 49 Gestational Diabetes ......................................................................................................... 51 Preterm birth ......................................................................Error! Bookmark not defined. Small Birth for Gestational Age ....................................................................................... 53 Large Birth for Gestational Age ....................................................................................... 54 Summary55 Study Limitations ...............................................................Error! Bookmark not defined. Conclusions ................................................................................................................................... 55 References ...................................................................................... Error! Bookmark not defined. List of Tables ................................................................................................................................ 76 Table 1. Demographics and Characteristics of All MTB-PACE Participants and by the Number of ACEs Reported (N = 556) .............................................................................. 76 Table 2. Health Conditions and Health Information of All MTB-PACE Participants and by the Number of ACEs (N = 556) ................................................................................... 78 Table 3. PACE Prevalence of MTB-PACE Participants .................................................. 80 Table 4. Factor Analysis of ACE-Q: Rotated Factors and Correlation ............................ 83 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 8 Table 5. PACEs Prevalence of MTB-PACE Participants (N = 556) ................................ 84 Table 6. Associations between Total/Subtype ACEs and Pregancy and Birth Outcomes (N = 556) ........................................................................................................................... 85 Table 7. Examination of PCEs Effect Modification on Pregnancy and Birth Outcomes (N = 556) 88 List of Figures ............................................................................................................................... 90 Figure 1. MTB-PACE Study Sampling ............................................................................ 90 Figure 2. Diagram of Three Factor Analysis of ACE-Q................................................... 91 Appendix A ................................................................................................................................... 92 Positive and Adverse Childhood Experiences Questionnaire ........................................... 92 Positive Childhood Experiences Questionnaire (PCEs-Q). .................................. 92 Adverse Childhood Experiences Questionnaire (ACEs-Q) .................................. 92 Appendix B ................................................................................................................................... 94 Use of PACEs Questionnaire ............................................................................................ 94 Appendix C ................................................................................................................................... 97 Table 8. Estimated Sample Size for the Study.................................................................. 97 Table 9. PACEs Prevalence and Health Outcomes of MTB-PACE Participants ............. 98 Table 10. Post-hoc Analysis of MTB-PACE Study.....100 Appendix D ................................................................................................................................. 104 Determination Letters ..................................................................................................... 103 Appendix E ................................................................................................................................. 104 SES Scores 104 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 9 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 10 List of Tables Table 1: Demographics and Characteristics of All MTB-PACE Participants and by the Number of ACEs Reported (N = 556) Table 2: Health Conditions and Health Information of All MTB-PACE Participants and by the Number of ACEs (N = 556) Table 3: Survey Responses of MTB-PACE Participants Table 4: Factor Analysis of ACE-Q: Rotated Factors and Correlation Table 5: PACEs Prevalence of MTB-PACE Participants (N = 556) Table 6: Associations between Total /Subtypes ACEs and Pregnancy and Birth Outcomes Table 7: Examination of the Modification Effect of PCEs on Pregnancy and Birth Outcomes (N = 556) Table 8: Estimated Sample Size for the Study Table 9: PACEs Prevalence and Health Outcomes of MTB-PACE Participants Table 10: Post-hoc Analysis of MTB-PACE Study CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES List of Figures Figure 1: MTB-PACE Study Sampling Figure 2: Diagram of Three-Factor Analysis of ACE-Q 11 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 12 Adverse and Positive Childhood Experiences on Pregnancy Health and Birth Outcomes More than half of Americans have at least one adverse childhood experience (ACE) which approximately 1 in 6 people report experiencing four or more ACEs during childhood (Centers for Disease Control and Prevention [CDC], 2020). ACEs relate to both psychological and physical experiences that occur before the age of 18 years. As defined in early ACE research, these experiences included physical abuse, emotional abuse, sexual abuse, neglect, household dysfunction, exposure to domestic violence, mental illness, substance abuse, incarceration, and parental divorce or separation (Felitti et al., 1998; Hughes et al., 2017). Females and individuals of certain racial and ethnic minority groups in the United States (U.S.) are more likely to experience four or more ACEs (CDC, 2020). ACEs are considered risk factors for many severe health problems in the U.S. that cost families, the economy, and society a total of hundreds of billions of dollars each year (CDC, 2020; Felitti et al., 1998; Hughes et al., 2017). Research suggests that ACEs may have direct physiological alterations of the brains architecture, functions, and development, activation of the neural endocrine stress response and inflammation, and disruption of the autoimmune and metabolic function (Buss et al., 2017; Teicher et al., 2016). Moreover, ACEs may act on adverse outcomes through behavioral pathways including smoking, alcohol binge drinking, sexual risk-taking, drug-using, and violence perpetrating (Currie et al., 2020; Hughes et al., 2017; Mersky et al., 2018; Pear et al., 2017; Petruccelli et al., 2019). Preventing or mitigating the impacts of ACEs could potentially reduce as many as 1.9 million cases of heart diseases and 21 million cases of depression in the U.S. (CDC, 2020). ACEs may also negatively impact pregnancy and birth outcomes (Berrens et al., 2017; Bethell et al., 2019; Cao-Lei et al., 2016; Hughes et al., 2017; Ranchod et al., 2016; Smith et al., CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 13 2016). ACEs can deleteriously affect pregnancy through complications such as perinatal unhealthy weight gain, gestational diabetes, high blood pressure, and preeclampsia (Olsen, 2018). Adverse pregnancy outcomes, such as preterm birth, small birth size, low birth weight, and fetal death, were reported with greater frequency among pregnant women exposed to a high level of ACEs (Appleton et al., 2019; Nerasi et al., 2018; Olsen, 2018; Selk et al., 2016). Positive childhood experiences (PCEs) may modify the effects of ACEs in a doseresponse manner (Appleton et al., 2019; Bethell et al., 2019). Individuals who experienced four or more ACEs yet were nurtured in a safe and supportive environment that enhanced their sense of security and belongingness had lower odds of developing depression and poor mental health relative to individuals without a supportive environment (Bethell et al., 2019, Beutel et al., 2017; Crouch et al., 2019; Howell et al., 2020). Problem Statement Over the past two decades, studies have reported effects of ACEs on the physiological and psychological health of children and adults (Felitti et al., 1998; Hughes et al., 2017; Olsen et al., 2018), yet there are gaps in the research of ACEs and PCEs. First, most studies of ACEs and PCEs examined the impact of childhood experiences on the health outcomes of adults but did not study the prevalence of ACEs and PCEs among pregnant women. Second, it is unclear whether individual ACEs or types of ACEs differentially predict adverse pregnancy and birth outcomes, or whether a cumulative ACE score best summarizes the effects of childhood exposures (Merrick et al., 2017). Finally, among a few studies examining the effects of ACEs on women, little research has focused on PCEs that may modify the effects of ACEs on pregnancy health risks and birth outcomes. The current dissertation aims to address the research gaps by analyzing CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 14 preexisting data collected through the MotherToBaby (MTB) Pregnancy studies and MTBPACE addendum study. Purpose Statement The purpose of this study is to examine the prevalence of childhood experiences (ACEs and PCEs) and the associations between ACEs/PCEs and adverse pregnancy and birth outcomes among a sample of women who enrolled in the MTB pregnancy studies and later participated in the MTB-PACE study. The current study addressed the following research questions: 1. What is the prevalence of childhood experiences (ACEs and PCEs) self-reported by pregnant women who participated in the MTB-PACE study? 2. What are the associations between ACEs scores, individually and cumulatively, and adverse pregnancy (i.e., unhealthy weight gain and gestational diabetes), and birth outcomes (i.e., gestational age at delivery, and birth weight for gestational age) in the MTB-PACE participants? 3. Do PCEs modify the associations between ACEs scores and adverse pregnancy (i.e., unhealthy weight gain and gestational diabetes) or birth outcomes (i.e., gestational age at delivery, and birth weight for gestational age)? To answer the research questions, we examined the following objectives: 1. a) To calculate frequencies and percentages of self-reported childhood experiences (ACEs and PCEs) by women who participated in the MTB-PACE study. b) To analyze subtypes of the ACEs questionnaire results using factor analysis. 2. To determine associations between subtype ACEs/total ACEs scores and adverse pregnancy and birth outcomes using factor analysis of ACEs results to categorize ACEs subtypes and multivariate logistic regression to analyze the associations. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 15 3. To determine whether PCEs scores modify the associations between ACEs and adverse pregnancy and birth outcomes using multivariate logistic regressions on two stratified samplings of MTB-PACE participants, one with cumulative PCEs scores of 5 or higher and another with PCEs scores of 4 or lower. Significance of the Study A conceptual clarification of complex factors associated with ACEs, examining from different levels and subtypes, with and without PCE modifiers, that influence the risks of maternal and intergenerational health through adverse pregnancies and poor childbirth outcomes, may effectively contribute to the scientific and clinical knowledge in maternal and child medicine. A better understanding of the associations between ACEs/PCEs and perinatal outcomes facilitates clinical implications in the care of pregnant women. The ACEs/PCEsrelated findings also improve the standard prenatal care involving routine screening, counseling, and personalized medical treatment of pregnant womens conditions. The results help enhance self-efficacy and social support to mitigate adverse effects on the health and well-being of the mothers-to-be and their babies. Additionally, ACEs/PCEs awareness may directly affect the resource allocations in implementing early detection and a pragmatic intervention to improve health outcomes among maternal and pediatric patients who suffered from ACEs. Identifying ACEs early in life and during prenatal care can reduce medical costs of perinatal and postnatal complications and effectively improve maternal health and birth outcomes, thus providing a better beginning for infant development (Narayan et al., 2018). Literature Review Adverse childhood experiences (ACEs) are among pervasive, unaddressed public health issues in the U. S. categorized by a high prevalence rate across 25 states (CDC, 2020a; Hughes et CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 16 al., 2017). Before 18 years old, 61% of children in the U.S. have experienced one or more ACEs (CDC, 2020a; Hughes et al., 2017). Adverse childhood trauma includes experiences of physical, emotional, sexual abuse; physical, emotional neglect; exposures to household dysfunction such as domestic violence, mental illness, substance abuse, incarceration, and parental divorce or separation (Felitti et al., 1998; Petruccelli et al., 2019). Researchers developed models to plausibly explain the long-lasting effects of ACEs on the psychological, physiological health, and adverse health behaviors of individuals (Buss et al., 2017; Cameranesi et al., 2019; Teicher et al., 2016; Wong et al., 2018). ACEs exposures may endure neurobiological changes, alter the epigenetic variants, increase biological stress to the autoimmune system, and disrupt the metabolic regulations causing serious health problems (Buss et al., 2017; Teicher et al., 2016). Further, individuals with ACEs may engage in adverse health behaviors, substance abuse, and perpetration of violence (Currie et al., 2020; Hughes et al., 2017; Mersky et al., 2018; Pear et al., 2017; Petruccelli et al., 2019). In addition to the enduring effect on the health and well-being of the individual, the impact of ACEs propagated to the next generation through pregnancy and birth outcomes (Berrens et al., 2017; Bethell et al., 2019; Cao-Lei et al., 2016; Hughes et al., 2017; Racine et al., 2018a; Racine et al., 2018b; Ranchod et al., 2016; Smith et al., 2016). A growing number of studies reported that pregnancy complication and poor delivery outcomes were disproportionately related to pregnant women experiencing ACEs (Appleton et al., 2019; Campbell et al., 2018; Diesel et al., 2014; Huffhines et al., 2016; Mason et al., 2016; Ranchod et al., 2016; Schoenake et al., 2019). Childhood Experiences Theory and Model CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 17 The Life Course Theory In the early 20th century, pioneer psychologists utilized the Life Course Theory (LCT) in studies of young people who experienced enormous social changes during the Great Depression, World Wars I and II, the Cold War, the Vietnam War, and the Civil Rights movements (Elder, 1998; Shanahan et al., 2003). The emergence of LCT marked a new era for the longitudinal, prospective, and retrospective studies of the life history of individuals in social psychological research (Elder, 1998; Shanahan et al., 2003). LCT reflects the nature of the interconnection between the socio-historical experiences and biographical context through five principles: lifespan development, human agency, time and place, life sensitivity, and social relationships (Black et al., 2009; Elder, 1998; Shanahan et al., 2003). The authors articulated that human development is dynamic as people live and make choices within the historic and social context of their times and places (Black et al., 2009; Elder, 1998; Shanahan et al., 2003). Individuals shape the trajectories of development and behaviors through personal experiences to remarkable events or traumatic occurrences during sensitive periods across the lifespan; however, these trajectories are influenced by the dependence and relationships of social networks (Black et al., 2009; Elder, 1998; Shanahan et al., 2003). In longitudinal studies of human development, LCT also examined the life consequences as a result of the accumulation of disadvantages (Elder, 1998). Early transitional experiences followed by subsequent trauma, even years later in life, can have an enduring and long-lasting effect on the health and well-being of individuals (Elder, 1998). LCT has opened a new perspective that challenges researchers to properly account for the effects of experiences throughout the lifespan of an individual (Elder, 1998). CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 18 Developmental Psychopathology Model Developmental Psychopathology (DP) is a coherent model that integrates developmental science and psychopathology in studying human development (Eme, 2017). Drawn from multidisciplinary findings, DP focuses on four interrelated principles considering normality and abnormality: the reciprocal and transactional processes, the psychopathological pathways, and the multiple-level aspect of human development (Eme, 2017). Considering abnormality as a deviation from normality due to adverse exposures, Eme (2017) emphasized the importance of mutual inclusion of normal and abnormal pathways in the pathological study. The reciprocal and transactional factors contributing to the developmental cascades further explain the cumulative and long-lasting effects of childhood adversity into adulthood (Eme, 2017). Sequential and timing effects of adverse and positive environments on development may involve multiple pathways and outcomes; DP conveys a framework of various pathways leading to the same effect while a single developmental factor can associate with different outcomes (Eme, 2017). Moreover, Eme (2017) examined human development via multilevel analyses including the neurobiological, psychological, and socio-environmental contexts. Like LCT, DP provides an expansive approach for researchers to examine the pathological and psychological effects of adversity throughout an individuals lifespan. Adverse Childhood Experiences and Adult Outcomes Although there are different definitions of what may constitute childhood adversity among researchers, Felitti and colleagues (1998) are the pioneers who introduced an ACEs measure using metrics of abuse (physical, emotional, sexual), neglect (physical and emotional), and household dysfunction (such as mental illness, substance abuse, incarceration, parental divorce or separation). In further research, experiences of racism, financial hardship, being CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 19 bullied, serious childhood illness or injury, exposures to household criminality, and environmental criminality expanded the metrics used to measure ACEs (Hughes et al., 2017; Kim et al., 2019; Lydsdottir et al., 2017). A preliminary study of ACEs prevalence in pregnant women in the Southern U.S. estimated that one-fourth of ACEs is associated with abuse, onefourth with neglect, and approximately half relates to household dysfunction (Nguyen et al., 2019). Research studies have consistently found that ACEs are associated with increased risks of many adverse health outcomes in adults. A systematic review of 199 papers, published from 1990 to 2014 conducted by Li et al. (2016), estimated the pooled odds ratio of 2.03 to 2.70, 95% CIs [1.37, 3.01] and [2.10, 3.47] between any type of abuse/neglect endured during childhood and depression/anxiety disorder in adults. In one study, having four or more ACEs was associated with a 2 to 5-fold increased risk of experiencing an adverse physical or psychological effect in adulthood (Madigan et al., 2017). Overall, ACEs were frequently reported on a wide array of adversities such as abuse, neglect, household dysfunction, and socioeconomic factors. Physical, Sexual, and Emotional Abuse Abuse can occur in various forms and a wide range of family dynamics. Abuse can involve physical harm or injury (physical abuse), exposure to sexual material or situations (sexual abuse), and harmful verbiage that can severely affect ones mental health or social development (emotional abuse) (HelpGuide, n.d.). Rich-Edwards and colleagues (2011) studied two large cohorts of 2,128 pregnant women in urban and suburban areas in Boston, Massachusetts, and found associations between prenatal depression and either physical abuse (OR = 1.48, 95% CI [1.15, 1.90]) or sexual abuse (OR = 1.68, 95% CI [1.24, 2.28]). Childhood sexual abuse was associated with risks for physical and psychological problems during CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 20 pregnancy including a high frequency of hospitalization due to complications of premature contractions, cervical insufficiency, and premature birth (Leeners et al., 2010). Also, findings of a longitudinal study conducted by Choi and colleagues (2017) indicated that childhood emotional abuse was associated with a risk of having prenatal distress and postpartum depression in a prospective cohort of 150 South African women. Physical and Emotional Neglect Neglect is a common type of child abuse that is not always easily identified. Parents who physically neglect their child fail to adequately provide basic needs including food, clothing, hygiene, or supervision while those who emotionally neglect their child fail to provide a safe, nurtured, and loving environment (HelpGuide, n.d.). In a large cohort study of the Kaiser Health Plan members in California, Dong et al. (2004) found the prevalence of childhood physical and emotional neglect was 24.7% among adults. In addition to physical, emotional, and sexual abuses, physical and emotional neglect was among common experiences in cohort studies of women with ACEs (Choi et al., 2017; Hughes et al., 2017; Kim et al., 2019; Merrick et al., 2017). Household Dysfunction Children living in a dysfunctional household with parental mental illness, substance abuse, incarceration, divorce, or separation experience a high level of ACEs (Felitti et al., 1998). In a longitudinal study of a cohort of 3,389 pregnant Swedish women with ACEs, Angerud and colleagues (2018) found that parental separation, household substance abuse, or household mental illness was among the most prevalent (18.6% to 28.5%), and was associated with a high risk of having prenatal and postnatal depression in these women. There is still a research gap in CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 21 examining the association between ACEs-related household dysfunction and adverse pregnancy and birth outcomes. Socioeconomic and Demographic Factors Childhood adversities are commonly experienced by people from diverse backgrounds, races, and ethnicities. Previous studies indicated people who have low childhood socioeconomic status (SES) or belong to demographic subgroups were more likely to experience ACEs (Danielson et al., 2018; Kim et al., 2019; Zarse et al., 2019). In a longitudinal study of approximately 1,800 women who lived at or below 200% of the federal poverty line in Wisconsin, U.S., Mersky and Lee (2019) found an association between a high level of ACEs and adverse pregnancy health. The authors concluded that cumulative ACEs scores were associated with a slightly increased odds of pregnancy loss (OR = 1.12, 95% CI [1.08, 1.17]), preterm birth (OR = 1.07, 95% CI [1.01, 1.12]), and low birth weight (OR = 1.08, 95% [1.03, 1.15]) among the low SES women in this population (Mersky & Lee, 2019). In a cohort study of Mother-Baby Minnesota, 79% of 133 pregnant women who selfidentified as Black reported four-fold higher odds of having physical abuse, five-fold higher odds of experiencing childhood sexual abuse, and seven-fold higher odds of witnessing domestic violence as a child, compared to White and other ethnic groups (Kim et al., 2019). Gillespie and colleagues (2017) supported a well-established discrepancy in preterm birth rates between different racial groups, with approximately 1 in 11 White women having a preterm birth compared to 1 in 7.5 non-Hispanic African American women. When further queried, they found that childhood stresses (abuse, neglect, household dysfunction, serious childhood illness, and adverse environmental experience) were associated with birth timing in the sample, and elevated levels of cortisol mediated the association (Gillespie et al., 2017). Additionally, in a nearly four- CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 22 year prospective cohort study on 9470 women with singleton gestations from eight clinics across the U.S., Grobman and colleagues (2017) found that non-Hispanic Black women, compared to non-Hispanic White counterparts, experienced an association between ACEs and a significantly higher risk for hypertension-related pregnancy, preterm birth, and delivering a small-forgestational-age infant (Grobman et al., 2017). These findings indicate SES and race/ethnicity are among important factors for consideration in ACEs research and health-related policy-making (Walsh et al., 2019). Genetic and Biological Factors of Childhood Experiences Researchers have examined the enduring effects of ACEs on psychological and physiological functions and the impact of ACEs across the lifespan of individuals (Buss et al., 2017; Cameranesi et al., 2019; Teicher et al., 2016; Wong et al., 2018). The pathways on which ACEs modulate can be viewed through the dynamic effects of genetics, the architecture and function of the brain, the neuroendocrine responses, the metabolism regulation, and the inflammatory and autoimmune functioning in the body (Buss et al., 2017; Dieckmann et al., 2020; Luiz et al., 2018; Monk et al., 2016; Rubinstein et al., 2020; Teicher et al., 2016). Epigenetic Effect A growing body of epigenetic research indicates many genetic variants are likely to be susceptible to methylation of the deoxyribonucleic acid (DNA) with trauma exposures. ACEs may impair the early psychosocial environment during sensitive periods of development through epigenetic signatures (Argentieri et al., 2017; Blacker et al., 2019; Bush et al., 2018; Brodsky et al., 2018; Cao-Lei et al., 2016; Frach et al., 2020; Gouin et al., 2017; Kaufman et al., 2018; Kertes et al., 2016; Monk et al., 2016). Methylation of the cytosine nucleotide alters geneexpression regulations without changes to the DNA sequence for many genes involved in the CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 23 stress response pathways (Cao-Lei et al., 2016). It was also reported that elevated global placental DNA methylation was associated with large births for gestational age (Dwi Putra et al., 2020), and childhood physical abuse correlated with modestly increased DNA methylation of placental genes FKBP5, one of the glucocorticoid-related genes associated with fetal movement and heart rate (De Castro-Catala et al., 2017). However, limited research studies have focused on the intergenerational effects of ACEs propagated through an epigenetic modification that affects pregnancy health risks and birth outcomes. Neurobiological and Metabolic Functioning There is evidence that ACEs affect adverse health outcomes through neurological and metabolic pathways in humans. Buss and colleagues (2017) articulated that childhood trauma and ACEs may cause enduring neurobiological damages that irreversibly change the trajectories of the brains function and development. Alterations in the brain can elevate a biological stress response, interfere with the autoimmune system, and disrupt metabolic regulations leading to psychological and physiological effects (Buss et al., 2017; Teicher et al., 2016). Additionally, autonomic responses, pain, and mood are significantly associated with increased ACEs scores among affected individuals, particularly back pain, migraines for adults, and post-traumatic stress disorder (PTSD) in adult women (Zarse et al., 2019). Inflammatory and Autoimmune Functioning Research results indicated ACEs affect health outcomes in children and adults through interconnected inflammatory and autoimmune functions. Hantsoo et al. (2019) also found that high levels of ACEs were associated with alterations in the composition of the gut microbiota and these changes elevated stress responses through the acute inflammatory and immune pathways. Other research studies suggested ACEs increased disruption to the adaptive stress CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 24 response leading to susceptibility of diseases such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) regardless of age and SES (Luiz et al., 2018; Rubinstein et al., 2020). Further, Bandoli and Chambers (2017) found an increased risk of preterm birth among women with RA (risk ration [RR] = 2.10, 95% CI [1.54, 2.87]) and Crohns disease (RR = 1.87, 95% CI [1.25, 2.81]) in a cohort study of 3034 pregnant women. Later, the authors found RA, SLE, and inflammatory bowel disease (IBD) associated with preterm birth and small for gestational age (SGA) in a birth cohort of 2,963,888 Californian women (Bandoli et al., 2020). However, to our knowledge, no one has assessed whether there is a differential effect of chronic conditions and adverse pregnancy outcomes by ACEs exposure. Health Behaviors Associated with Adverse Childhood Experiences Smoking Tobacco use including smoking, heavy smoking, and early smoking initiation has a strong relationship with ACEs (Anda et al., 1999; Bellis et al., 2014). Compared to individuals without ACEs, those with ACEs score of four or higher had an adjusted odds ratio of 3.96, 95% CI [2.74-5.73] for smoking (Bellis et al., 2014). A respective cohort study by Anda et al. (1999) surveying 9,215 adults in a primary care setting in Southwestern U.S. indicated that individuals with ACEs score of five or higher were associated with a substantially high odds of 5.4, 95% CI [4.1, 7.1] for early smoking initiation before age of 14 years, and the OR = 2.8, 95% CI [1.9, 4.2] for heavy smoking with 20 cigarettes per day. Furthermore, Pear and colleagues (2017) found in a U.S. National Longitudinal study of 2,999 mothers from diverse races and ethnicities that ACEs were significantly associated with increased risks of prenatal smoking in household alcoholism (RR = 1.25, 95% CI [1.13, 1.38]). CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 25 Drinking Maternal ACEs were also associated with alcohol use and increases fetus health risk (Currie et al., 2020). In a prospective cohort study of 1,663 pregnant women in a Canadian community, Currie and colleagues (2020) found that maternal ACEs accounted for two to threefold increased odds of binge drinking of five or more drinks among middle and upper-middleincome women. The authors found maternal ACEs accounted for a two to three-fold increase in the odds of binge drinking that may put the infant at a high risk of being born with fetal alcohol spectrum disorders (Currie et al., 2020). The likelihood of binge drinking is highest among firsttime expectant mothers who lack social support. Alcohol use by pregnant women was also strongly linked with delivering small babies-for-gestational-age, even among infants who had not met full criteria for fetal alcohol spectrum disorders (Myers et al., 2018). Drug Use Illicit drug use and adverse drug-related health problems associated with ACEs have been examined in research. Currie and Tough (2020) indicated a greater level of illicit drug use was reported by pregnant women with higher ACEs scores compared to those with less illicit drug use. In a secondary analysis of prospective cohort data from a three-year study of 1,680 pregnant women in Canada, Currie and Tough (2020) found that women with two to three ACEs had more than a two-fold increase in illicit drug use, while those with four or higher ACEs had an approximately four-fold increase in illicit drug use during pregnancy. The authors articulated that exposures to childhood abuses were more consistently associated with illicit drug use than exposures to household dysfunction among the women in this sample (Currie & Tough., 2020). Although researchers have studied antidepressant use during pregnancy (Campagne, 2019; CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 26 Currie & Tough, 2020), little is known about the prevalence of antidepressant use among pregnant women affected by ACEs. Sexual Risk Previous studies indicated that ACEs were associated with sexual risk behaviors and increased odds of reproductive health problems. In a three-year study of a cohort of 5,060 women in the Southwestern U.S., Hillis and colleagues (2001) found risks of engaging in sexual activity before the age of 15 years were associated with a high ACEs score in abuses (OR = 2.8, 95% CI [2.1, 4.0]) and household dysfunction (OR = 2.5, 95% CI [1.8, 3.6]). Risky sexual behaviors including early sexual activity and engaging in unprotected sex were elevated in individuals who had high ACE scores and strongly connected to unplanned pregnancy among adolescents (Bellis et al., 2014). Consistently, in a cross-sectional study of 1,500 British adults from a diverse population, Bellis et al. (2014) found that women with ACE scores of four or higher were at higher risk (OR = 4.46, 95% CI [2.73, 7.30]) for unplanned pregnancy before 18 years of age compared to those with ACE scores of three or lower. Summary The neuroendocrine and autonomic effects caused by ACEs tend to be impactful during the sensitive period of childhood development. The effects are strongly connected to a wide array of adverse health behaviors through adulthood including smoking, binge drinking, sexual risk-taking, and illicit drug abuse (Currie et al., 2020; Hillis et al., 2001; Hughes et al., 2017; Mersky et al., 2018; Pear et al., 2017; Petruccelli et al., 2019; Strathearn et al., 2019). The health risk behavior of women suffering from ACEs is important in the study of the effects of ACEs on adverse pregnancy and birth outcomes. Effects of Positive Childhood Experiences CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 27 Supportive Environment Research studies showed PCEs provided a protective buffer against the deleterious effects of ACEs (Bethell et al., 2019; Beutel et al., 2017; Jaffee et al., 2017). Individuals with four or more ACEs, who were nurtured in a safe, secure, and engaging environment reported relatively lower odds of developing depression or poor mental health (Bethell et al., 2019, Beutel et al., 2017; Crouch et al., 2019). In a cohort study of 101 low-income pregnant U.S. women from various racial/ethnic groups, Narayan and colleagues (2017) found high levels of PCEs related to receiving basic needs and feeling safe and belonging were associated with lower prenatal stress and psychopathology. Furthermore, Merrick et al. (2020) studied another cohort of 101 low-income, pregnant women, using ACE and PCE surveys and reported that benevolent experiences in early childhood tend to have a stronger effect against the impact of ACEs on psychopathological health compared to those occurring in later childhood. Further studies are in need to examine the effective and sufficient support provided to women with ACEs at critical timing in life (Malat et al., 2017). Resilience Several researchers showed that resilience can be a positive factor that buffers the adverse impact of ACEs on affected individuals (Bellis, et al., 2018; Beutel et al., 2017; Howell et al., 2020; Young-Wolff et al., 2019; Youssef et al., 2017). While women with low social support or coping abilities tend to be negatively affected by ACEs, resilient individuals are more likely to overcome adverse behaviors and improve ailments from undiagnosed somatoform symptoms (Howell et al., 2020; Young-Wolff et al., 2019). Youssef and colleagues (2017) examined the dose-response relationship between ACEs, depressive symptoms, and resilience and found young adults with medium and high levels of resilience had experienced less CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 28 depressive symptoms associated with ACEs. In a cross-sectional study of a cohort of 101 lowincome women at 3 to 39-weeks of pregnancy who participated in the Women, Infant, and Children (WIC) program in the Midwestern U.S., Howell and colleagues (2020) found cumulative ACEs were associated with depression and inversely associated with resilience in these women. These findings encourage further research to effectively improve resilience in people who suffer from severe ACEs (Howell et al., 2020; Youssef et al., 2017). Summary A growing body of research has conveyed a positive impact of PCEs on protecting individuals against the adverse effects of ACEs. Living in a supportive environment or experiencing social supportive relationships may reduce stress responses, facilitate the adaptation to childhood trauma experiences, and improve maternal health and birth outcomes among ACEsaffected women. However, there is little evidence as to what extent the association between ACEs and adverse pregnancy outcomes among pregnant women is modified by PCEs. Health Effects Associated with Adverse Childhood Experiences Pregnancy Health As briefly mentioned in previous sections, research studies have proliferated in examining the adverse impact of ACEs on pregnancy outcomes. Gestational diabetes and excessive gestational weight gain are among pregnancy-related complications frequently reported in women with ACEs (Campbell et al., 2018; Center for Child Counseling.,2020; Diesel et al., 2014; Hollingsworth et al., 2012; Huffhines et al., 2016; Mason et al., 2016; Ranchod et al., 2016; Schoenaker et al., 2019). Unhealthy Gestational Weight Gain. Ranchod and colleagues (2016) found an association between ACEs and the risk of unhealthy gestational weight gain in the data analysis CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 29 of 2,873 women participating in the National Longitudinal Survey of Youth from 1979 to 2012. The authors found physical abuse was associated with a 20% increased risk (RR = 1.2, 95% CI [1.1, 1.4]) of excessive gestational weight gain; while household dysfunction such as mental illness and alcoholism was associate with a 30% (RR = 1.3, 95% CI [1.0, 1.7]) and 60% (RR = 1.6, 95% CI [1.1, 2.2]) increased risk of prenatal obesity (Ranchod et al., 2016). Notably, Diesel et al. (2014) found no association between ACEs score and maternal excessive weight gain in a retrospective cohort study of 472 low-income pregnant women, aged 23 years, from a prenatal clinic in Northeastern U. S. Gestational Diabetes. In a longitudinal cohort study of 45,550 registered nurses from 14 states in the U.S., Mason et al. (2016) indicated that sexual and physical abuse was associated with 30% to 42%, 95% CIs [1.14, 1.49] and [1.21, 1.66] greater risk of GD. Additionally, cumulative exposure to both severe sexual and physical abuse in childhood was associated with an increased risk of GD compared to a single abuse (Mason et al., 2016). However, Mason and colleagues (2016) found no association between these abuses and prenatal obesity among these women. Consistently, in another longitudinal population-based cohort study of 6,317 Australian women, aged 18 to 23 years, Schoenaker et al. (2019) showed an association between abuse and household dysfunction and gestational diabetes mellitus. The relative risk of having GD was 1.73 to 1.76, 95% CIs [1.02, 3.01] and [1.04, 2.99] among the women with ACEs scores of three or higher (Schoenaker et al., 2019). Finally, Madigan and colleagues (2017) indicated that a cumulative ACEs score of four or higher was associated with two folds increased risk of having prenatal diabetes among a cohort of 501 urban women. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 30 Birth Outcomes In addition to the description in previous sections about the intergenerational effects of ACEs, a growing body of research has focused on the adverse impact of ACEs on childbirth outcomes. Poor birth outcomes including preterm birth and low birth weight are frequently reported among pregnant women with a high level of ACEs (Appleton et al., 2019; Gillespie et al., 2017; Nerasi et al., 2018; Olsen, 2018; Selk et al., 2016; Smith et al., 2016). Preterm Birth. Sexual abuse was associated with increased odds (OR = 1.22, 95% CI [1.10, 1.35]) for preterm birth in a large cohort of 51,434 pregnant women (Selk et al., 2016). Margerison-Zilko et al. (2016) found childhood sexual abuse and violence experiences were associated with preterm delivery at 35-36 weeks of pregnancy in another cohort study of 3,019 mothers with singletons at 52 clinics in the Midwestern U.S. Gillespie et al. (2017) also found physical and emotional abuses or household dysfunction (interpersonal loss) were inversely associated with gestational age at birth in a cohort of 89 pregnant African American women at two Ohio, U.S. hospitals. Additionally, a study that examined 75 cases of mothers with singleton and 148 controls in Edmonton, Canada indicated that exposure to two or more ACEs was associated with a twofold higher risk of preterm birth (Christiaens et al., 2015). Also, Madigan and colleagues (2017) found a two-fold increased risk of preterm birth among a cohort study of hundreds of women with a cumulative ACEs score of four or higher. Further, in a study of a larger cohort of 2,303 women with a singleton pregnancy, Smith and colleagues (2016) estimated that each additional ACEs score was associated with a decrease of 0.06 weeks of gestational age among pregnant women from clinics in Northeastern U.S. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 31 Moreover, researchers identified multiple pathways interconnected in the associations between ACEs and adverse pregnancy outcomes (Bublitz et al., 2017; McDonnell et al., 2016; Salah et al., 2019). A connection was demonstrated by McDonnell et al. (2016) from the WIC cohort study of 398 pregnant women aged 16 to 46 years in the Midwestern U.S. The authors indicated that childhood household dysfunction was significantly negatively associated with gestational age at first pregnancy, while gestational age was positively associated with infant birth weight (McDonnell et al., 2016). Furthermore, Salah et al. (2019), from a one-year cohort study of 593 pregnant women in Tunisia, found that collective childhood exposures to violence were associated with the risk of preterm birth as well as low birth weight among these women. Finally, the plausible mechanism explaining the link between GD and the risk of preterm birth through elevated interleukin-15 was suggested by Bublitz et al. (2017). Birth Weight. Appleton et al. (2019) found that maternal ACEs with sexual abuse, emotional abuse, and household dysfunction also significantly and inversely correlated with the infant birth weight of 100 female New Yorkers. Consistently, Madigan et al. (2017) indicated a cumulative ACE score of four or higher was associated with a two-fold increased risk of low birth weight in a cohort study of 501 mother-infant dyads. In a larger cohort study of more than 2,000 women at many clinics in the Northeastern U.S., Smith and colleagues (2016) found that each additional ACE score in pregnant women was associated with a decrease of 16.33 grams in infants birth weight. Additionally, research studies sought to understand the interaction effects of ACEs and PCEs on birth outcomes. Appleton and colleagues (2019), in a prospective birth cohort study of 126 mothers at around 27-week gestation at the Albany Medical center in New York, U.S., examined the main and interaction effects between ACE categories (i.e., sexual abuse, emotional CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 32 abuse, and parental divorce/separation) and social support concerning infant cephalization. Infant cephalization is defined as the ratio between the head circumference of an infant at birth and the birth weight as well as the infants birth size at delivery. According to Appleton et al. (2019), positive social support can be tangible support (e.g., financial or transportation help), belonging support (e.g., social activities or emotional expression), or appraisal support (e.g., advice and information). The authors found that maternal ACEs can deleteriously increase infant cephalization index; however, social support (tangible and belonging) during pregnancy may provide a protective buffer against its enduring effects (Appleton et al., 2019; Holdsworth & Appleton, 2019). Summary Childhood trauma and ACEs have a lasting effect on the health and well-being of the individual; moreover, the impact of ACEs may pass on to the next generation through adverse pregnancy and poor childbirth outcomes. Adverse conditions in pregnancy, such as GD and UWG can contribute to poor birth outcomes including preterm birth, low birth weight, and SGA. Nevertheless, childhood positive experiences and social support may provide some protective buffer promoting a trauma adaptation to improve maternal health outcomes. However, there remains a research gap to examine whether ACE subtypes differently associate with adverse pregnancy and birth outcomes, or whether a cumulative ACE score better predicts the adverse pregnancy and birth outcomes of childhood exposures. Instruments for Childhood Experiences Study The Positive and Adverse Childhood Experience questionnaire (PACE-Q) is the instrument used to collect PACE data from the MotherToBaby participants. PACE combines the Positive Childhood Experience questionnaire (PCEs-Q) and the Adverse Childhood Experience CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 33 questionnaire (ACEs-Q) in one measure to collect information about participants childhood experiences. The Positive Childhood Experiences Questionnaire The PCEs-Q, a 7-item assessment tool, is used to capture the positive experiences that a person feels when supported by family and society (Bethell et al., 2019). PCEs-Q adapts questions from validated subscales including the Child and Youth Resilience Measure-28, the Psychological Caregiving subscale, the Education subscale, the Culture subscale, and the Peer Support subscale (Bethell et al., 2019; Liebenberg et al., 2013). In the cross-sectional cohort study of 6,188 Wisconsin, non-institutionalized adults in 2015 using PCE-Q, Bethell and colleagues (2019) found PCEs-Q having reliable consistency, Cronbachs alpha of .77, and an adequate convergent and divergent validity when using individual and cumulative scores (with a single Eigenvalue of 2.95 and factor loading across seven items ranges from 0.57 to 0.72). The authors suggested PCEs-Q can be used to assess the positive childhood experiences in individuals associated with resilience and cultural sensitivity (Bethell et al., 2019). The questionnaire records the degree and frequency a child felt able to talk to family about feelings, felt family support during a difficult time, enjoyed joining community events, felt belong to the school, and felt safe and protected at home (Bethell et al., 2019). Researchers have increasingly utilized PCEs-Q together with ACEs-Q in studies to examine the modifying effects of PCEs that may protect against the deleterious impact of ACEs on affected individuals (Appleton et al., 2019; Bethell et al., 2019; Jaffee et al., 2017). The Adverse Childhood Experience Questionnaire Based on published surveys, the ACEs questionnaire (ACEs-Q) has adapted into the current universally used survey to advance the clinical implication of ACEs in public health CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 34 promotion (Behell, 2017; Mersky et al., 2017; Zarse et al., 2019). The questionnaires consist of three parts: core questions, optional modules, and state-added questions (Behell, 2019). The ACEs-Q has 11 items assessing the collective information, in cumulative score 0, 1, 2-3, or 4-8 ACEs, of childhood exposures including physical, sexual, emotional abuse, and household dysfunctions such as mental illness, domestic violence, substance abuse, and parental incarceration, divorce, or separation (Behell, 2019). After two decades of using ACEs-Q for studies on large, diverse population samplings across the U.S. and around the world, it has demonstrated high internal consistency (Cronbachs alpha = .77 to .81), test-retest reliability of r = .90 to .91, and strong convergent validity, r = .73, when compared to the validated Childhood Trauma Questionnaire (Mersky et al., 2017; Schmidt et al., 2020). ACEs-Q has been a simple and quick tool for use to quantify the types and the convergence of individual adverse exposures (Mersky et al., 2017; Zarse et al., 2019). Although limited in the assessment of the duration, severity, and timing of personal ACEs in affected individuals, the ACEs-Q has been widely used as the core-risk assessment of ACEs-related mental health, health behaviors, medical illness, and premature death in children and adults worldwide (Zarse et al., 2019). Summary ACEs pose long-lasting effects on psychological, biological, and physiological health, along with adverse health behaviors for individuals. However, the negative effect of ACEs is beyond the lifespan of individuals. ACEs have the potential to affect intergenerational health through adverse pregnancy and poor childbirth, from the womens mental and gestational health to birth outcomes. The impact of ACEs on pregnancy and birth outcomes may be associated with multiple complex factors, individually and cumulatively, from genetics, environmental factors, demographic characteristics, health behavior, medical condition, and SES of pregnant women. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 35 Early detection of ACEs before and during pregnancy may provide opportunities for mitigation, whereby successful intervention could reduce the medical cost due to complications, improve maternal health, and childbirth outcomes thus provide a better beginning for the health and development of the infants (Narayan et al., 2018). Method Study Design The current study analyzed data that were collected as part of the MTB-PACE study. MTB-PACE study is an addendum of the MTB Pregnancy Studies which is a research program under the largest conductor of pregnancy registries in North America focusing on factors that may affect pregnancy (MotherToBaby, 2021). Mothers-to-be enroll in one of the MTBPregnancy Studies via the program website after which data are collected through telephone interviews and medical records of participants. After delivering a baby, the mothers are invited to participate in the MTB-PACE study in which data are collected through a web-based survey. The purpose of the current study was to examine the prevalence of childhood experiences (ACEs and PCEs), the associations between ACEs/ PCEs and pregnancy and birth outcomes, and the potential effect modification of PCEs on pregnancy health and birth outcomes among a sample of MTB-PACE participants who completed the PACE addendum between September 1, 2020 to February 15, 2021. Participants Pregnant women who enrolled in the MTB Pregnancy Studies and delivered a live born singleton infant between 2015 and 2021were offered participation in the MTB-PACE study. For the MTB Pregnancy Studies, the population of interest was expecting women 18 years or older who lived in the U.S. and Canada. For the MTB-PACE addendum study, participants were MTB CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 36 women who had delivered a live birth within the past five years, who signed informed consent and completed the PACE survey. Women who did not provide informed consent, who consented but did not complete the PACE questionnaire, or who had multiplex infants were excluded from the current studys data analyses. A minimum study sample size was estimated using G* Power, version 3.1.9.7 (Faul et al., 2007). The data were extracted from literature including studies by Mason et al. (2016), Selk et al. (2016), and Ranchod et al. (2016). Using z tests, logistic regressions with a priori alpha level of .05, and a power level of .80, an estimated sample for each pregnancy/birth outcome and ACE type were calculated, ranging from 74 to 354. Based on the expected prevalence of particular outcomes, the appropriate number of participants enrolled in the study was recommended for the data analysis to be sufficiently powered (Appendix C, Table 8). Procedures The MTB Pregnancy Studies and MTB-PACE study met the requirements defined by federal regulation of human subject research (National Institute of Health, n.d.). The MTBPregnancy Studies received approval from the Institutional Review Board (IRB), the MTBPACE study was approved by the IRB as the addendum of MTB Pregnancy Studies, and the current study was exempt from IRB human research (Appendix D). Informed consent documents were prepared in various languages for both verbal and written formats: oral consent was employed in MTB Pregnancy Studies for phone interviews and signature consent was included in the data collection surveys of the MTB-PACE study. Data Collection and Management The current study was affiliated with a research facility within the MotherToBaby network located in Southwestern U. S., the Center for Better Beginnings at the University of CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 37 California at San Diego, California (UCSD Health). Data on participants demographics, characteristics, health conditions, and selected pregnancy and birth outcomes were retrieved from the MTB-Pregnancy Studies. Self-reported data and health records of the MTB-Pregnancy Studies participants were collected prenatally, while data related to birth outcomes were collected following delivery, and ACEs and PCEs data were collected post-delivery for the MTB-PACE addendum study using PACE-Q. Study participants demographics, health information, and PACEs responses were confidentially managed using a secure, online, and password-protected data collection portal of MTB database and only accessible to authorized personnel approved by IRB and MTB Research. Collected data were assigned unique, independently de-identified codes. Missing, unclear, or incomplete responses alerted researchers to contact responders for confirmation using the secured link between de-identified data and contact information. For the current study, a webdata dictionary workbook describing MTB Pregnancy Studies and MTB-PACE study (with links to projects, worksheets, tables, codes, measure units, variables) and limited-use, de-identified datasets in Excel files were provided by the UCSD Health research management. The data strictly complied with the UCSD Health retention policy and participants consent upon completion of the research study. Study Data Data collected on maternal demographics and characteristics of MTB-Pregnancy Studies participants included age (younger than 30, 30-35, 36-40, and older than 40 years), race (White, Black, Asian, Indian/Native American, and Other), ethnicity (Hispanic / Latina, NonHispanic / NonLatina), education (high school or less, college, and above college degree), SES (low and high), and location (provinces in Canada and states in the U.S., from Midwest, Northeast, CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 38 Southeast, Southwest, and West U. S.). Data collected on health conditions of MTB-Pregnancy Studies participants included preexisting diabetes type I or II (yes, no), hypertension (yes, no), asthma (yes, no), rheumatoid arthritis (RA) (yes, no), systemic lupus erythematosus (SLE) (yes, no), and inflammatory bowel disease (IBD) such as Crohns disease and ulcerative colitis (yes, no). Additionally, MTB-Pregnancy Studies data collection included participants health information such as prenatal body mass index (BMI) in kg/m2 and categorized as weight status (underweight/normal weight, overweight, and obese), passive and active smoking (yes, no), recreational drug use (yes, no), alcohol use (yes, no), and anxiety/depression (yes, no). Collected pregnancy and birth outcomes data from the MTB-Pregnancy Studies included unhealthy gestational weight gain (yes, no), GD (yes, no), preterm birth babies born before 37 weeks of gestation (yes, no), and birth weight for gestational age in percentile including SGA (yes, no), and LGA (yes, no). Finally, collected data on ACEs and PCEs of the MTB-PACE participants consisted of responses to questions in the PACE survey. Operational Variables The operational variables in the current study comprised both the independent variable (ACEs and PCEs) and dependent variables (adverse pregnancy and birth outcomes). The current study examined the psychological and physiological trauma which MTB-PACE participants experienced before the age of 18 years. These experiences included eight categories: physical, sexual, emotional, substance abuse, domestic violence, mental illness, incarceration, and parental divorce or separation (Felitti et al., 1998; Hughes et al., 2017). The SES of participants was determined based on the Hollingshead four-factor index including four domains of marital, employment, educational, and occupational status (Hollingshead, 1975). Participants with a total score of 3 or less for four domains were considered to have high SES, while those with a score CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 39 higher than 3 were of low SES (Appendix D). Prenatal BMI, calculated by the ratio of weight in kg and height in meter square, was categorized by underweight/ normal weight, overweight, and obese. According to CDC (2019b), depending on their pre-pregnancy BMI, women in a particular weight category should gain a specific amount of weight for a singleton or multiplex pregnancy to be considered having a healthy gestational weight gain. UWG was identified as yes if maternal weight gain was out of the range or no if it was within the range recommended by CDC guidelines (CDC, 2019b). Preterm birth was defined as gestational age less than 37 weeks at delivery. Based on CDC growth curves of boy and girl infants delivered by study participants (CDC, 2009), SGA is the birth weight of the baby for gestational age < 10th percentile while LGA is the infants birth weight > 90th percentile for gestational age. Instruments for MTB-PACE Study The PACE-Q was used to collect data for the MTB-PACE study. PACE-Q combined the 7-item Positive Childhood Experience Questionnaire (PCEs-Q) and the 11-item Adverse Childhood Experience Questionnaire (ACEs-Q) in one measure to collect information about participants childhood experiences (Bethell et al., 2017; Bethell et al., 2019; CDC, 2020b). ACEs-Q and PCEs-Q have been widely used by researchers across the U.S. to study childhood exposures (Bethell et al., 2017; Bethell et al., 2019; CDC, 2020b; Liebenberg et al., 2013; Mersky et al., 2017). Assessment of Positive Childhood Experiences The childhood experiences that a person felt supported by family and society were assessed by the PCEs-Q (Bethell et al., 2019). PCEs-Q measures positive childhood experiences in individuals associated with resilience and cultural sensitivity (Bethell et al., 2019). The questionnaires assessed the degree and frequency of positive experiences through a 5- point CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 40 Likert scale including never; rarely; sometimes; often; or very often that an individual felt able to talk to family about feelings, felt family support during a difficult time, enjoy joining community traditions, felt belong to the school, and obtained genuine interest from at least two adults other than parents. The PCEs-Q also assessed the likelihood as never; a little of the time; some of the time; most of the time; or all of the time that an individual felt safe and protected at home. The PCEs-Q score ranged from 0-7 in which the answers never, rarely, sometimes, a little of the time, or some of the time to an item gave a PCEs score of 0 while the answers of often, very often, or all of the time gave a PCEs score of 1 to the item (Bethell et al., 2019). The response preferred not to answer was considered a missing value in PCEs-Q data. Finally, responses to PCEs-Q were summarized by the number of PCEs (0-2, 3-4, 5, 6-7), and PCEs variables in the stratification analysis were categorized by high ( 5) versus low ( 4) cumulative PCEs scores. Assessment of Adverse Childhood Experience The ACEs-Q is a measure widely used across the U.S to assess the collective information of childhood exposures prior to age 18 years. ACEs-Q has 8 subtypes including physical abuse, sexual abuse, emotional abuse, and household dysfunction (substance abuse, incarceration, mental illness, violence, divorce or separation) (Behell, 2017; CDC, 2020b; Mersky et al., 2017). ACEs-Q is a simple tool with a yes or no response to identifying individual adverse exposures such as living with a depressed, mentally ill, suicidal, alcoholic, or incarcerated household member. ACEs-Q also queries whether or not an individual has experienced parental divorce or separation. The questionnaires assess the level and frequency of physical abuse or emotional abuse as never; once, or more than once that an individual got a slap, hit, kick, beat, or physically hurt; swear, insult, or emotionally put down by a parent or adult. The same 3- CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 41 point Likert scale was used to assess sexual abuse experiences as to how often an individual was sexually touched, forced to touch, or have sex with anyone at least 5 years older (Behell, 2017; CDC, 2020b). ACEs-Q total score ranged from 0-8 in which the answers no and never had an ACEs score of 0 while the responses yes, once, and more than once had an ACEs score of 1 to the item (Bethell et al., 2017). The summation of items 2 and 3 had a score of 0 with the answer no and a score of 1 with the answer yes to alcoholism, illegal street drug, or abused prescription medications. Additionally, the score of the sexual abuse subtype was 0 with negative responses (no or never) to all items 9-11 in the ACEs-Q, or else, it had a score of 1. Finally, the response preferred not to answer was considered a missing value in the subsequent data analyses. Finally, responses to ACEs-Q were categorized by the number of ACEs as 0-1, 2, 3, and 4-8, and ACEs variables in the association analyses were total ACEs score (0-8) (Bethell et al., 2019; CDC, 2019), or cumulative ACEs scores of 3 or higher with ACEs scores of 2 or less as a reference (Schoenaker et al., 2019). Data Analysis IBM SPSS Statistics for Window, Version 27.0 (IBM Corp., Armonk, NY) was used to statistically analyze data for research questions 1, 2, and 3 following methods described by Field (2018). All tests were two-tailed and an alpha level less than .05 was considered statistically significant. Research Question 1 What is the prevalence of childhood experiences (ACEs and PCEs) self-reported by pregnant women who participated in the MTB-PACE study? For research question 1, descriptive statistics were used to describe the demographics, characteristics, health conditions, health information, and the prevalence of ACEs and PCEs CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 42 among MTB-PACE participants. The demographic data categorized age, race/ethnicity, education, and SES. Health conditions and health information included prenatal BMI, preexisting diabetes, depression and anxiety, smoking, alcohol, and recreational drug use. Other chronic health conditions included asthma, RA, SLE, and IBD such as Crohns disease and ulcerative colitis. These data were summarized in numbers and percentages for categories of ACEs and PCEs in a characterization table. Additionally, factor analysis and Monte Carlo parallel verification were employed to analyze the 11-item ACE questionnaires. Three ACEs subtypes with the highest correlation between ACEs items, Scree plot, Eigenvalues, and rotation matrix were categorized using the Generalized Least Squares extraction and Quartimax with Kaiser Normalization. Research Question 2 What are the associations between ACEs scores, individually and cumulatively, and adverse pregnancy (i.e., UWG and GD), and birth outcomes (i.e., preterm birth, SGA, and LGA) in the MTB-PACE participants? For research question 2, multivariate logistic regression analyses examined the associations of the predictor variable (i.e., subtype and total ACEs score) on adverse pregnancy (i.e., the presence/absence of UWG or GD), and birth outcomes (i.e., the presence/absence of preterm birth, SGA, or LGA) among women who participated in MTB-PACE study. Regression models used total ACEs score (i.e., the cumulative scores of 8 ACEs types in the 11-item ACEsQ), dichotomized ACEs score 3, and ACEs subtype score (i.e., the dichotomized ACEs score, 1 for presence and 0 for absence, in each subtype categorized in the factor analysis results). Finally, the response preferred not to answer was considered a missing value and was replaced using imputation program in IBM SPSS Statistics for Windows, Version 27.0. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 43 The goodness of fit of the logistic regression models was examined through the Hosmer and Lemeshow test and the relationships between predictor and independent variables were identified and interpreted. Odd ratios and 95% confidence intervals were calculated, with a twotail alpha at a significance level of .05 for participants with and without exposure to the particular ACE type(s), using the chi-square test (Field, 2018; Tabachnick & Fidell, 2019). The association models were adjusted for potential confounding effects such as maternal age, race/ethnicity, education, and SES of participants (Field, 2018; Tabachnick & Fidell, 2019). Research Question 3 Do PCEs modify the associations between ACEs scores and adverse pregnancy (i.e., UWG and GD) or birth outcomes (i.e., preterm birth, SGA, and LGA)? For research question 3, multivariate regression analyses described in the analysis of research question 2 were used to examine the potential effect modification of PCEs. The effect modification analysis of PCEs scores was evaluated by visual inspection of the estimated effects at 95% CI within two strata of participants with low versus high total PCEs scores. The PCEs strata included women with low PCEs scores of 4 and lower and those with high PCEs scores of 5 or higher, while the ACEs strata were participants with ACEs scores of 3 or higher in which ACEs scores of 2 or lower were categorized as a reference. Results Characteristics of the MTB-PACE Participants From September 2020 to February 2021, a total of 595 women 18 years or older, who delivered a baby between 2015 and 2021 identified by the MTB Pregnancy Studies registry, were invited to participate in the MTB-PACE study. Among the 595 women, 39 (6.6%) were excluded from the analysis for the following reasons: 17 (2.9%) declined participation, 7 (1.2%) CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 44 had multiple births and 15 (2.5%) did not have complete delivery information. A total of 556 women met the inclusion criteria for the MTB-PACE study and their data were analyzed for the current study (Figure 1). Demographic Characteristics of MTB-PACE Participants Table 1 presents the demographics and characteristics of all participants and also by ACE score categories by the number of ACEs (0-1, 2, 3, and 4-8) reported from the PACE-Q. The MTB-PACE participants were predominantly well-educated (with college or above college education), White, non-Hispanic/Latina women between 30 to 35 years of age who lived in the Western U.S. The majority of participants (N = 477, 90.5%) had a high SES as measured by the Hollingshead four-factor index. Health Conditions and Health Information of the MTB-PACE Participants Table 2 shows frequency of the health conditions and information of all MTB-PACE participants and by the number of ACEs (0-1, 2, 3, and 4-8). Among 556 participants, 239 (43.0%) of the women had one preexisting health condition and 81 (14.6%) had two preexisting health conditions related to inflammatory/autoimmune diseases ranging from 0.9% for diabetes type I and SLE to 14% for asthma. Prenatal BMI categorized as obese and overweight were commonly reported by 22.5% and 13.3 % of MTB-PACE women. Additionally, 46 (8%) of the participants self-reported having a history of depression and anxiety. Health information related to tobacco use, either passively or actively, recreational drug use, or alcohol intake (4 or more drinks/occasion) were each endorsed by less than 6% of participants. Among the 67% of the MTB-PACE women with UWG, 78.2% had weight gain categorized as excessive, while the remaining women had less than ideal weight gain for their prenatal BMI, according to the recommendation by CDC (2019b). Finally, 5.9% of the women had GD, 8.1% had a preterm CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 45 birth, 6.3% delivered an SGA infant, and 6.9% had an LGA infant for gestational age (Table 9, Appendix C). Research Question 1 Result Objective 1a: Prevalence of ACEs/PCEs among MTB-PACE Participants Prevalence of ACEs among MTB-PACE participants is summarized in Table 3. A total of 285 (51.3%) MTB-PACE participants reported more than one adverse childhood experience. The most common experience was emotional abuse which was reported in more than half of the participants, followed by household mental illness which was reported by 37.6% of them. Approximately 25% of women experienced physical or sexual abuse, and 20% of the women experienced parental divorce or separation, alcoholism, or domestic violence. The least commonly reported ACEs were recreational drug use or the incarceration of a household member. When evaluated cumulatively as a count of the 8-ACE sub-domains, about half of the participants reported 0-1 ACEs, 15.5% reported 2 ACEs, 14.7% reported 3 ACEs, and 21.0% reported 4-8 ACEs (Table 5). Prevalence of PCEs among MTB-PACE participants is characterized in Table 3. More than 90% of the women reported having more than one positive childhood experience. Feeling safe, protected, or supported at home were among the most common experiences endorsed by more than three-fourths of MTB-PACE participants. Also, feeling supported by friends, feeling mentored, enjoying community events were reported by more than 70% of the participants, while only half of the women reported feeling like they belonged at their high school or feeling able to talk to their family. Further characterized cumulative PCEs of all 7 questions, 47.8% of the participants had the highest cumulative PCE scores of 6-7, 13.3% had PCE score of 5, 23.2% had PCE scores of 3-4, and 15.6% had PCE scores of 0-2 (Table 5). Table 5 also shows that women CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 46 who reported the highest number of ACEs also were more likely to report the lowest number of PCEs. On the contrary, women who reported the highest number of PCEs also were more likely to report the lowest number of ACEs. Objective 1b: Factor Analysis of ACEs Questionnaires and Prevalence of ACEs Subtypes Factor analysis and the Monte Carlo parallel verification suggested that a 3-factor model is suitable for the 11-item ACE questionnaire. Using the Generalized Least Squares extraction, Quartimax with Kaiser Normalization rotation, Eigenvalues were determined from 1.27 to 3.42. The rotated factor matrix and the correlation between ACE items are summarized in Table 4 and Figure 2 with the factor loading of > 0.30 as a threshold evaluation. Three factors were categorized for 11 ACE items. The first factor was Household dysfunction, a 5-item ACEs category that included family member substance abuse, parental divorce or separation, and parental incarceration. The second factor was physical/emotional abuse, which included three ACE items on witnessing or experiencing physical abuse or experiencing emotional abuse. Finally, sexual abuse was the third factor consisting of the remaining 3 ACE items on inappropriate childhood sexual experiences. The correlations between the three factors suggested they were weakly related to one another with coefficients from 0.21 (Sexual abuse and Physical/Emotional abuse) to 0.32 (Household dysfunction and Physical/Emotional abuse), and 0.30 (Household dysfunction and Sexual abuse). Research Question 2 Result Objective 2: Associations between ACEs and Pregnancy or Birth Outcomes Overall, women with ACEs scores of 3 or more had increased odds of having unhealthy pregnancy (UWG and GD) or birth outcomes (LGA) in comparison to those with ACEs score of CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 47 0-2; however, only the association between ACEs scores and UWG was statistically significant (Table 6). Unhealthy Gestational Weight Gain. Among 67% of women in the cohort who had UWG, 78.2% were categorized as excessive according to CDC guidelines for pregnant women. The prevalence of UWG, 61%-80%, monotonically increased with the number of ACEs (Appendix C, Table 9). In multivariable models (Table 7), each additional ACE was associated with a 16% increase in odds of UWG with 95% CI [1.05, 1.29]. Findings were similar when ACEs count was dichotomized into high vs. low ACEs (adjusted OR = 1.68, 95% CI [1.12, 2.51]). When analyzed by ACE subtype, the odds of UWG were elevated for women who endorsed physical/emotional abuse and household dysfunction, although confidence intervals in the latter estimate included the null. Finally, there was no association observed between sexual abuse and UWG. Gestational Diabetes. Approximately 6% of the women in the cohort were diagnosed with GD. The prevalence of GD was fairly equal in various ACEs counts (4.3% -5.5%) but almost double (9.8%) for women with an ACEs score of 3 (Appendix C, Table 9). No increase in odds associated with household dysfunction or physical/emotional abuse in the study cohort was observed. Although there was some evidence that women with ACE scores of 3 or higher had increased odds of having GD (aOR of 1.36, 95% CI [0.64, 2.88]), compared to those with ACE scores of 0-2, and women who experienced sexual abuse had 40% higher odds for GD (95% CI [0.62, 3.14]); however, the confidence intervals were large and overlapped the null. Preterm Birth. Among 8.1% of women in the cohort who delivered a preterm baby, the preterm birth prevalence was monotonically elevated with counts of ACEs. The prevalence of preterm birth ranged from 5.8%-9.3% for ACEs scores of 2 or higher, compared to 8.9% for the CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 48 reference (Appendix C, Table 9). The odds of preterm birth were elevated among women with household dysfunction (aOR= 1.48, 95% CI [0.78, 2.82]), although again this was not statistically significant. Other ACEs count and ACE subtypes such as physical/emotional abuse or sexual abuse did not show an increased risk for preterm birth. Birth Weight for Gestational Age. Approximately 6.3% of women in the cohort delivered a small baby for GA, and 6.9% had LGA offspring. The highest prevalence of birth (SGA and LGA) was for women with ACEs score of 4 or higher; however, women with ACEs score of 3 appeared least likely to have SGA (2.4%) while a similar prevalence of LGA observed for ACE scores of 2 or 3 compared to other ACEs (Appendix C, Table 9). The odds of having SGA was slightly increased 18% with 95% CI [0.55, 2.66] for women who experienced sexual abuse, non-statistically significant. However, no association between ACEs count and other ACEs subtypes and SGA was observed. Finally, each additional ACE was associated with a 17% increase in odds of having LGA. The odds ratios for ACEs exposures and LGA ranged from 1.31 to 1.89 for other ACEs count and subtypes but all the confidence intervals were wide and included the null. Research Question 3 Result Objective 3: Examination of the Effect Modification of PCEs on ACEs-related Pregnancy and Birth Outcomes Due to the small number of outcomes in stratified analyses of the specific cohort of women in ACE subtypes, examination of the effect modification for ACEs was analyzed as a cumulative variable as well as dichotomized ACEs of 3 or higher (ACEs 0-2 as reference). The effect modification of ACEs subtype by PCEs level could not be accurately assessed due to the small sample sizes in the stratification. As illustrated in Table 7, there was no evidence of PCEs CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 49 modifying the association between ACEs exposure and adverse pregnancy and birth outcomes. Point estimates between the two PCEs strata (PCEs scores 5 versus 4) were quite similar, and confidence intervals for the stratum-specific estimates widely overlapped for all of the pregnancy (UWG and GD) and birth outcomes (preterm birth, SGA, and LGA) in the study. Discussions The current study examined the characteristics of the MTB-PACE cohort and the prevalence of pregnancy and birth outcomes including UWG, GD, preterm birth, and birth weight for GA. The MTB-PACE participants were predominantly White (86.2%), non-Hispanic (92.3%), had high SES (88.8%), and reported having a college or above college education (87.0%). They had normal gestational age at delivery (M = 39.2 weeks, SD = 0.11) and delivered babies with normal birth weight for gestational age (M = 49.2 percentile, SD = 1.75). More than half of the participants had UWG, while only 8.1% of the women had a preterm birth, 5.8% had GD, 6.3% delivered a SGA infant, and 6.9% delivered a LGA infant. Previous studies have examined the association between ACEs and adverse pregnancy outcomes (Appleton et al., 2019; Christiaens et al., 2015; Madigan et al., 2017; Margerison-Zilko et al., 2016; Ranchod et al., 2016; Schoenaker et al., 2019; and Selk et al., 2016), although there was heterogeneity in the designs, settings, and prevalence among ACE studies. Our findings of approximately half of participants experiencing no adverse childhood experience was similar to findings reported in previous studies by Ranchod et al. (2016), Schoenaker et al. (2019), and Smith et al. (2016). Over half of the women (51.3%) reported exposure to two or more ACEs. This frequency was primarily driven by emotional abuse, which was endorsed by over half (51.1%) of the respondents. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 50 Factor analysis of 11 ACE items of ACEs-Q suggested that three subtypes household dysfunction, physical/emotional abuse, and sexual abuse best categorized the ACEs data. The orthogonal analysis was consistent with the factor loadings and correlation result found in a previous study of a large number of non-institutionalized adults in five U.S. states conducted by Ford et al. (2014) and later employed in the ACEs-related pregnancy studies of approximately 2,000 Canadian women by Racine et al. (2018). Due to small total counts of outcomes in each ACEs item, the current study examined three subtypes of ACEs and categorizations of exposure with ACEs scores of 3 or higher during subsequent analyses of pregnancy and birth outcomes. Prevalence of PCEs in the MTB-PACE cohort aligns with a study by Bethell et al. (2019) in which approximately half of the participants had high scores of 6 or 7 on all items of the PCEs-Q. Due to the relatively small sample size within PCEs categorizations of exposure in the current study, the potential effect modifications of ACEs on pregnancy and birth outcomes was examined by two PCEs strata, one with relatively high PCEs scores (i.e., 5 cumulative scores) compared to those with lower PCEs scores (i.e., 4 or less). Unhealthy Gestational Weight Gain According to CDC guidelines of gestational weight gain for pregnant women, 67% of women in the cohort were categorized as having UWG. Among these, 78.2% of women had excessive gestational weight gain while 21.8% of UWG cases had inadequate weight gain during pregnancy. Examination of the association between cumulative total ACEs and ACEs 3 and pregnancy outcome revealed statistically significantly increased odds (aOR = 1.16, CI [1.05, 1.29], aOR = 1.68, CI [1.12, 2.51]) of having UWG, respectively. When further examined by ACE subtypes, household dysfunction and physical/emotional abuse increased odds (aOR = 1.29, CI [0.90, 1.56] and aOR= 1.79, CI [1.24, 2.59]) for UWG. Ranchod et al. (2016) found that CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 51 household alcoholism and physical abuse significantly increased the risk for excessive gestational weight gain; however, the authors examined alcoholism as a specific item in household dysfunction and physical abuse separately from emotional abuse without the inclusion of inadequate gestational weight gain. The mechanism of UWG is unclear and may be influenced by the participants characteristics, health conditions, and maternal lifestyle of MTB-PACE participants. Researchers reported the negative impact of ACEs exposures in which chronic stress in childhood may affect the normal function of the hypothalamic-pituitary-adrenal (HPA) axis interfering with individuals appetite regulation. Eating comfort food or using food as a coping strategy to ease emotional and physical distress is common (Ranchod et al., 2016) while having increased childhood trauma and elevated prenatal anxiety put women at risk for excessive gestational weight gain (Diesel et al., 2014). This may plausibly explain the susceptibility for excessive gestational weight gain with little effect modification of PCEs in the current cohort. This includes the potential effect of health characteristics in which more than one-third of the women entered pregnancy overweight and obese, more than half reported having emotional abuse, and the high prevalence of depression/anxiety among women with low ACEs scores of 0-2 (or high PCEs scores). Although healthy eating may be disrupted by stressful experiences, the mechanism associated between ACEs/PCEs and inadequate gestational weight gain, if causal, remains to be elucidated. Additional work to determine causality and explore the underlying etiology of excess and inadequate gestational weight gain and ACEs/PCEs is needed. Furthermore, clinical implications involving screening for ACEs exposures, providing nutritional and/or physical education, and promoting healthy eating through individualized counseling or support groups may further help pregnant women maintain a healthy weight gain during and after pregnancy. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 52 Gestational Diabetes There were approximately 40% increased odds of having gestational diabetes among MTB-PACE women who experienced sexual abuse or ACEs scores of 3 or higher. The results; however, were not statistically significant at an alpha level of .05. Although with a different study design, sample, and setting, a recent data analysis of more than 3,000 Rhode Island women between 2016-2018 by Bala et al. (2020) found that there was a non-statistically significant increase in odds between ACEs scores of 1-2 or 3+ and GD. According to the study by Racine et al. (2018), sexual abuse was not associated with maternal health outcomes including GD among the pregnancy cohort in the All Our Babies/Families study. Mason et al. (2016) found that forced sexual abuse and severe physical abuse were associated with increased GD risk; however, unlike the current study, the authors examined physical abuse separately from emotional abuse. In Schoenaker et al. (2019), the association between ACEs (physical abuse and household substance abuse) and GD risk was elevated only among women with prenatal depression symptoms, while Stanhope et al. (2020) found there were no increased odds for GD associated with ACEs 4 among a large cohort of Hispanic women. In our sample, there were no increased odds for GD associated with household dysfunction or physical/emotional abuse and no evidence of positive modification of PCEs. Versteegen and colleagues (2021) found a significant association between depression and GD and a non-significant association between ACEs/social support and GD among 300 pregnant women in the Albany Infant and Mother study at a New York prenatal care clinic. Possible explanations for these inconsistent findings may be due to the small sample size in ACEs subtypes and outcomes, the intensity of exposures which likely vary within and between studies, the instruments used, and the potential mediation effect of depression among many individuals. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 53 Further research with a larger and more diverse sample, considering the severity of exposures, may provide a better understanding of the effect of ACEs, ACEs subtypes, and the potential effect modification of ACEs by PCEs level and the risk of GD. Preterm birth Household dysfunction and sexual abuse had some evidence of increased odds for giving birth before gestational week 37 among MTB-PACE women but all of the associations included the null. Associations between sexual abuse and elevated odds for preterm birth were found in past studies by Margericon-Zilko et al. (2016) and Selk et al. (2016). However, MargericonZilko and colleagues (2016) observed the effects of ACEs when sexual abuse was reported in both childhood and adulthood, and Selk et al. (2016) found the associations only for forced sexual activity in childhood or adolescence. Additionally, Mersky & Lee (2019) found that total ACEs were significantly associated with preterm birth, although when modeled as a categorical variable, the increased risk was only observed among women with a high level of childhood adversity. Salah et al. (2019) found that collective violence exposures in childhood were associated with a significant decrease in gestational age. In a large case-control study by Christiaens et al. (2015), lifetime physical/emotional abuse in both childhood and adulthood was associated with spontaneous preterm birth, and odds for delivering a preterm infant were elevated among women experiencing 2 ACEs. Finally, in a longitudinal study of pregnant women in 4 hospitals in Pakistan, Shaikh et al. (2021) found that ethnic and health disparity rather than ACEs were associated with preterm birth among Pakistani women. The discrepancy in the cohort studied, study design, instrument use, and findings between the current study and published papers indicated the complexity and diversity of ACEs exposures that may have a negative impact on preterm birth. In addition to non-statistical significance, there was no CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 54 indication of ACEs effects on preterm birth associated with physical/emotional abuse or 3 ACEs in the current study, and the MTB-PACE sample did not demonstrate the modification effect of PCEs 5 compared to PCEs 4 on preterm birth. The possible reasons may be due to insufficient power for stratified analysis and the potential effect of frequency, intensity, and timing of ACEs exposures on preterm birth. Small Birth for Gestational Age In the current study, there were increased odds of delivering a SGA baby in women who experienced sexual abuse, but the association was not statistically significant. We did not observe increased odds for SGA outcome among the study sample with ACEs scores of 3 or higher, and the association between ACEs and SGA in the current study was not modified by PCEs. To our knowledge, there is little research examining the association between ACEs and SGA. Appleton et al. (2019) found ACEs associated with a significant increase of infant cephalization index, which is defined as the percentage of head circumference divided by infant birth weight, among pregnant women who had high cumulative ACEs score. Furthermore, Appleton et al. (2019) indicated that a protective effect of social support (tangible and emotional) against the negative impact of ACEs 3 on infant cephalization. Additionally, Mersky and Lee (2019) found that total ACEs were significantly associated with low birth weight among women with severe childhood exposures, although low birth weight is commonly a result of prematurity, not growth restriction. Salah et al. (2019) found that witnessing community violence was significantly associated with a low birth weight of fewer than 2,500 grams, while Smith et al. (2016) suggested each additional ACEs score was associated with a decrease of 16.33 grams in infants birth weight. The outcomes of these past studies and current study are slightly different from one and another in which diverse physiological mechanism(s) may likely contribute to the CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 55 findings. Further research considering health conditions including the types and timing of social support may strengthen the understanding of the association between PACEs and SGA. Large Birth for Gestational Age Little research has studied the impact of ACEs/PCEs on birth outcomes related to having a LGA baby (>90th percentile). Examination of the association between cumulative ACEs or dichotomized ACEs scores and LGA offspring indicated an increase of 17% to 89% odds of delivering an LGA baby but the confidence intervals slightly overlapped the null. ACE subtypes showed increased odds, aOR = 1.31 [0.66, 2.61] for household dysfunction, aOR = 1.69 [0.81, 3.55] for physical/emotional abuse, and aOR = 1.77 [0.85, 3.71] for sexual abuse; however, the associations were not statistically significant at an alpha level of .05 with wide-ranged CIs. Furthermore, women who experienced PCEs scores of 5 showed similar odds for LGA compared to those with PCEs scores of 4. The non-statistical significance in the current study may be due to the small sample size within ACEs subtypes, ACEs outcomes, and PCEs strata. Additional research may advance an understanding of the potential mediation of excessive weight gain and GD and the intergenerational effect of PACEs associated with LGA. Summary The current study estimated associations between total ACEs and ACE subtypes and adverse pregnancy and birth outcomes among a cohort of 556 MTB-PACE participants. Although most associations were not statistically significant and we did not find evidence of effect modification of ACEs by PCEs levels, most of our ACEs subtypes, outcomes, and PCEs strata were small and underpowered for the analyses. Post-hoc analyses on small strata comparing high PACEs to the reference may explore the extreme measures of PACEs effect on pregnancy and birth outcomes among MTB-PACE participants. Moreover, a longitudinal study CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 56 on a nationally representative population of women may further strengthen the understanding of the association between PACEs and pregnancy health and birth outcomes. Study Limitations This study has several limitations. The sample sizes were small for examining the effects of PACEs on rare pregnancy and birth outcomes using ACEs subtypes or PCEs strata in the association analyses. The non-random sampling in the current study underrepresented Black, non-Hispanic/non- Latina women or those from relatively disadvantaged backgrounds. As a result, the study findings may have limited generalization to these populations. Another limitation is the MTB-PACE data collection. The data collected in the MTB-PACE study is subject to recall bias because the information primarily relied on how accurately participants recall their experiences in childhood, in many cases, the time frame could be decades-long. Women may respond to the survey questions differently, depending on their emotional states, health conditions, and their already known pregnancy outcomes at the time of the survey (Cammack et al., 2018). Finally, the survey instruments used in the study may have a limitation in the lens of standardized assessment. Although PACE-Q demonstrates good internal consistency, scoring algorithm, and excellent test-retest reliability, information about content and convergent validity of PACE-Q is still limited in the research literature. Conclusions Despite the above caveats, this study contributes to the clinical knowledge and currently limited body of research concerning the prevalence and effects of adverse and positive childhood experiences on pregnancy (UWG and GD) and birth outcomes (preterm birth, SGA, and LGA). The current study analyzed three principal components of ACE-Q consisting of household dysfunction, physical/emotional abuse, and sexual abuse within a cohort of 556 women and CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 57 examined the associations of total ACEs, ACEs subtypes, 3 ACEs, and the effect modification of PCEs on pregnancy and birth outcomes. Further research using a longitudinal study design on a large and diverse sample of pregnant women, considering frequency, timing, and severity of childhood exposures would provide a better understanding of the associations between ACEs and PCEs and pregnancy and birth outcomes. The findings may facilitate PACE awareness, improve clinical implications, promote social support, reduce medical costs in the health care of pregnant women, and provide a better beginning for infant development. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 58 References Anda, R. F., Croft, J. B., Felitti, V. J., Nordenberg, D., Giles, W. 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Cogent Medicine, 6, Article e1581447. https://doi.org/10.1080/2331205X.2019.1581447 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 77 Table 1 Demographics and Characteristics of All MTB-PACE Participants and by the Number of ACEs Reported (N = 556) Demographics Number of ACE N (%) 0-1 2 3 4-8 n = 271 n = 86 n = 82 n = 117 (48.7%) (15.5%) (14.7%) (21.0%) Age (years) < 30 116 (20.9) 51 (18.8) 15 (17.4) 21 (25.6) 29 (24.8) 30-35 285 (51.3) 152 (56.1) 48 (55.8) 35 (42.7) 50 (42.7) 36-40 125 (22.5) 57 (21.0) 20 (23.3) 21 (25.6) 27 (23.1) > 40 30 (5.4) 11 (4.1) 3 (3.5) 5 (6.1) 11 (9.4) White 479 (86.2) 250 (92.3) 73 (84.9) 65 (79.3) 91 (77.8) Black 24 (4.3) 3 (1.1) 6 (7.0) 4 (4.9) 11 (9.4) Asian 34 (6.1) 11 (4.1) 6 (7.0) 9 (11.0) 8 (6.8) Indian/Native American 5 (0.9) 2 (0.7) 1(1.2) 0 (0.0) 2 (1.7) Other 13 (2.3) 5 (1.9) 0 (0.0) 3 (3.7) 5 (4.3) Missing 1 (0.2) Race 1 (1.2) Ethnicity Hispanic/Latina NonHispanic/NonLatina Missing 41 (7.4) 13 (4.8) 9 (10.5) 7 (8.5) 12 (10.3) 513 (92.3) 258 (95.2) 77 (89.5) 73 (89.0) 103 (88.0) 2 (0.4) 2 (2.4) CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Demographics 78 Number of ACE N (%) 0-1 2 3 4-8 n = 271 n = 86 n = 82 n = 117 (48.7%) (15.5%) (14.7%) (21.0%) Education High school or less 71 (12.8) 20 (7.4) 9 (10.5) 15 (18.3) 27 (23.1) College 211 (37.9) 105 (38.7) 36 (41.9) 25 (30.5) 45 (38.5) Above college 273 (49.1) 146 (53.9) 41 (47.7) 41 (50.0) 45 (38.5) Missing 1 (0.2) 1 (1.2) SES Low (score > 3) 17 (3.1) 6 (2.2) 7 (8.1) 0 (0.0) 4 (3.4) High (score 3) 494 (88.8) 245 (90.4) 73 (84.9) 77 (93.9) 99 (84.6) 45 (8.1) 20 (7.4) 6 (7.0) 5 (6.1) 14 (12.0) Canada 48 (8.6) 27 (10.0) 6 (7.0) 7 (8.5) 8 (6.8) Midwest U.S. 77 (13.9) 35 (12.9) 8 (9.3) 16 (19.5) 18 (15.4) Northeast U.S. 79 (14.2) 37 (13.7) 12 (14.0) 17 (20.7) 13 (11.1) Southeast U.S. 84 (15.1) 39 (14.4) 11(12.8) 15 (18.3) 19 (16.2) Southwest U.S. 50 (9.0) 24 (8.9) 10 (11.6) 5 (6.1) 11 (9.4) West U.S. 218 (39.2) 109 (40.2) 39 (45.3) 22 (26.8) 48 (41.1) Missing Location Note. MTB-PACE = MotherToBaby addendum study using Positive and Adverse Childhood Experience survey; ACE = adverse childhood experiences; SES = social economic status. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 79 Table 2 Health Conditions and Health Information of All MTB-PACE Participants and by the Number of ACEs Reported (N = 556) Characteristics Number of ACE N (%) 0-1 2 3 4-8 n = 271 n = 86 n = 82 n = 117 (48.7%) (15.5%) (14.7%) (21.0%) Health Conditions Preexisting conditions Diabetes (Type I and II) 5 (0.9) 0 (0.0) 1(1.2) 1 (1.2) 3 (2.8) Hypertension 9 (1.6) 4 (1.5) 0 (0) 1 (0.6) 4 (3.7) Asthma 75 (13.5) 31 (11.8) 9 (10.5) 11 (13.4) 24 (22.4) RA 44 (7.9) 24 (9.1) 7 (8.1) 4(4.9) 9 (8.4) SLE 4 (0.7) 2 (0.8) 1 (1.2) 0 (0.0) 1 (0.9) Crohns disease 50 (9.0) 32 (12.2) 5 (6.1) 5 (6.1) 8 (7.5) Ulcerative colitis 31 (5.6) 15 (5.7) 0 (0.0) 5 (3.1) 11 (10.3) Underweight/Normal weighta 356 (64.0) 196 (72.3) 58 (67.4) 47 (57.3) 55 (47.0) Overweightb 125 (22.5) 49 (18.1) 18 (20.9) 26 (31.7) 32 (27.4) Obesec 74 (13.3) 26 (9.6) 10 (11.6) 8 (9.8) 30 (25.6) Missing 1 (0.2) Prenatal BMI 1 (1.2) CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Characteristics 80 Number of ACE N (%) 0-1 2 3 4-8 n = 271 n = 86 n = 82 n = 117 (48.7%) (15.5%) (14.7%) (21.0%) Health Information Smoking (passive/active) 33 (5.9) 8 (3.0) 6 (7.0) 6 (7.3) 13 (10.3) Recreational Drugs 14 (2.5) 4 (1.5) 3 (3.5) 2 (2.4) 5 (4.3) Alcohol (4 drinks/occasion) 11 (2.0) 7 (2.6) 0 (0.0) 3 (3.7) 1 (0.9) Depression/Anxiety 46 (8.3) 10 (3.7) 15 (17.4) 5 (6.1) 15 (12.8) Note. ACE = adverse childhood experiences; RA = rheumatoid arthritis; SLE = systemic lupus erythematosus; BMI = body mass index, a underweight/normal weight (BMI < 24.9), b overweight (25.0 < BMI < 29.9), c obese (BMI 30). CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 81 Table 3 Survey Responses of MTB-PACE Participants Evera Missingb Imputedc n (%) n (%) n (%) Positive childhood experiences. 1. How often did you feel your family stood by you during difficult times? 2. How often did you feel that you were able to talk to your family about your feelings? 3. 430 (77.3) 289 (52.0) For how much of your childhood was there an adult 460 (83.0) 2 (0.4) communitys tradition? 401 (72.5) 3 (0.5) 5. How often did you feel supported by your friends? 397 (71.4) 6. How often did you feel that you belonged at your in your household who made you feel safe and protected? 4. How often did your enjoy participating in your high school? 7. 289 (52.3) 3 (0.5) How often were there at least two adults, other than your parents, who took a genuine interest in you? 398 (71.6) Note. . MTB-PACE = MotherToBaby addendum study using Positive and Adverse Childhood Experience survey; a Responses = yes, once, more than once, often, very often, most of the time, or all of the time; bMissing (blank) data only, cMissing (blank) data and no answer. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 82 Evera Missingb Imputedc n (%) n (%) n (%) 207 (37.6) 1 (0.2) 5 (0.9) Adverse childhood experience Household Dysfunction 8. Did you live with anyone who was depressed, mentally ill, or suicidal? 9. Did you live with anyone who was a problem drinker or alcoholic? 10. Did you live with anyone who used illegal street drugs or who abused prescription medications? 11. 107 (19.2) 22 (4.0) 2 (0.4) 23 (4.1) 1 (0.2) 107 (19.2) 2 (0.4) Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? 12. Were your parents separated or divorced? Note. a Responses = yes, once, more than once, often, very often, most of the time, or all of the time; bMissing (blank) data only, cMissing (blank) data and no answer. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Evera n (%) Missingb n (%) 83 Imputedc n (%) Physical/Emotional Abuse 13. How often did your parents or adults in your home ever slap, hit, kick, punch, or beat each other up? 14. 107 (19.2) 1 (0.2) Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. 15. 128 (23.1) 1 (0.2) 3 (0.5) How often did a parent or adult in your home ever swear at you, insult you, or put you down? 282 (51.1) 4 (0.7) 125 (22.5) 5 (0.9) 85 (15.3) 8 (1.4) 35 (6.3) 4 (0.7) Sexual Abuse 16. How often did anyone at least 5 years older than you, or an adult, touch you sexually? 17. How often did anyone at least 5 years older than you, or an adult, try to make you touch them sexually? 18. How often did anyone at least 5 years older than you, or an adult, force you to have sex? Note. a Responses = yes, once, more than once, often, very often, most of the time, or all of the time; bMissing (blank) data only, cMissing (blank) data and no answer. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 84 Table 4 Factor Analysis of ACE-Q: Rotated Factors and Correlation ACE-Q Factor loading 1 2 3 Factor 1: Household dysfunction ACE 1a (PACE-Q8) b .06 .25 .38 ACE 2 (PACE-Q9) .05 .13 .53 ACE 3 (PACE-Q10) .21 .05 .63 ACE 4 (PACE-Q11) .05 .05 .56 ACE 5 (PACE-Q12) .11 .10 .43 Factor 2: Physical/Emotional abuse ACE 6 (PACE-Q13) .05 .60 .30 ACE 7 (PACE-Q14) .10 .85 .08 ACE 8 (PACE-Q15) .09 .56 .29 Factor 3: Sexual abuse ACE 9 (PACE-Q16) .82 .14 .20 ACE 10 (PACE-Q17) .89 .07 .18 ACE 11 (PACE-Q18) .62 .04 .18 Correlation Factor Factor Factor 1 2 3 1.00 .32 .30 .32 1.00 .21 .30 .21 1.00 Note. ACE-Q = Adverse Childhood Experience questionnaire. PACE = Positive and Adverse Childhood Experiences. aACE item correspondent to b PACE question in the survey. Extraction Method: Generalized Least Squares; Rotation Method: Quartimax with Kaiser Normalization; Factor loadings greater than .30 appear in bold. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 85 Table 5 PACEs Prevalence of MTB-PACE Participants (N = 556) Number of ACEa Characteristics N (%) 0-1 2 3 4 n = 271 n = 86 n = 82 n = 117 (48.7%) (15.5%) (14.7%) (21.0%) PCE scoresb 0-2 87 (15.6) 11 (4.1) 17 (19.8) 15 (18.3) 44 (37.6) 3-4 129 (23.2) 35 (12.9) 24 (27.9) 26 (31.7) 44 (37.6) 5 74 (13.3) 33 (12.2) 22 (25.6) 11 (13.4) 8 (6.8) 6-7 266 (47.8) 192 (70.8) 23 (26.7) 30 (36.6) 21(18.0) Note. PACE = Positive and Adverse Childhood Experiences; MTB-PACE = MotherToBaby addendum study using Positive and Adverse Childhood Experiences survey; ACE = adverse childhood experiences; PCE = positive childhood experiences. aACE score of 1 is answer yes on each of ACE items 1, 2-3, 4, or 5; ACE item 6, 7, or 8; and ACE item 9-11. b PCE score of 1 is answer yes on each of PCE items 1-7. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 86 Table 6 Associations between Total/Subtype ACEs and Pregnancy and Birth Outcomes (N = 556) Outcomes N (%) Unadj OR [95% CI] Adj OR [95% CI] Pregnancy Outcomes Unhealthy weight gain Total ACE 372 (67.0) 1.20 [1.09, 1.33]** 1.16 [1.05, 1.29]* ACE scores 3 151 (75.9) 1.89 [1.28, 2.79]** 1.68 [1.12, 2.51]* Household Dysfunction 208 (70.5) 1.42 [0.99, 2.02] 1.29 [0.90, 1.56] Physical/Emotional Abuse 228 (73.5) Sexual Abuse 93 (70.5) 1.27 [0.83, 1.94] 1.07 [0.68, 1.66] Total ACE 32 (5.8) 1.00 [0.83, 1.20] 0.98 [0.81, 1.20] ACE scores 3 14 (5.8) 1.40 [0.68, 2.89] 1.36 [0.64, 2.88] Household Dysfunction 16 (5.4) 0.87 [0.43, 1.78] 0.83 [0.40, 1.73] Physical/Emotional Abuse 18 (5.8) 1.03 [0.50, 2.12] 1.00 [0.48, 2.08] Sexual Abuse 10 (7.6) 1.48 [0.68, 3.21] 1.40 [0.62, 3.14] ACE Subtype 1.94 [1.36, 2.78]** 1.79 [1.24, 2.59]** Gestational Diabetes ACE Subtype Note. Unadj OR = unadjusted OR; adj OR = adjusted OR. ACE = adverse childhood experiences; Total ACE (of 8 types); ACE subtype = score of ACE item in each subtype; ACE scores 0-2 (reference) and 3 or more; Frequency calculated in ACE 3 group (N = 199). *p <.05, **p <.005. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Outcomes N (%) Unadj OR [95% CI] 87 Adj OR [95% CI] Birth Outcomes Preterm birth Total ACE 45 (8.1) 1.01 [0.87, 1.19] 1.00 [0.85, 1.18] ACE scores 3 16 (8.0) 0.99 [0.52, 1.86] 0.94 [0.48, 1.84] Household Dysfunction 28 (9.5) 1.51 [0.81, 2.82] 1.48 [0.78, 2.82] Physical/Emotional Abuse 24 (7.7) 0.90 [0.49, 1.65] 0.84 [0.45, 1.58] Sexual Abuse 12 (9.1) 1.18 [0.59, 2.36] 1.07 [0.52, 2.21] Total ACE 35 (6.3) 0.97 [0.81, 1.17] 0.97 [0.80, 1.17] ACE scores 3 10 (5.0) 0.70 [0.33, 1.49] 0.69 [0.32, 1.49] Household Dysfunction 18 (6.1) 0.93 [0.47, 1.85] 0.94 [0.47, 1.88] Physical/Emotional Abuse 18 (5.8) 0.83 [0.42, 1.65] 0.81 [0.40, 1.64] Sexual Abuse 9 (6.8) 1.12 [0.51, 2.45] 1.18 [0.52, 2.66] Total ACE 38 (6.8) 1.16 [0.98, 1.35] 1.17 [0.99, 1.39] ACE scores 3 18 (9.1) 1.67 [0.86, 3.24] 1.89 [0.94, 3.79] Household Dysfunction 22 (7.5) 1.24 [0.63, 2.41] 1.31 [0.66, 2.61] Physical/Emotional Abuse 26 (8.4) 1.69 [0.83, 3.46] 1.69 [0.81, 3.55] Sexual Abuse 13 (9.8) 1.74 [0.86, 3.51] 1.77 [0.85, 3.71] ACE Subtype SGA ACE Subtype LGA ACE Subtype CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Outcomes N (%) Unadj OR [95% CI] 88 Adj OR [95% CI] Note. ACE = adverse childhood experiences. Unadj and Adj = Models were unadjusted or adjusted with confounders. ACE subtype = score of 0 (reference) and one on either ACE item in each subtype. Total ACE scores (8 types) for outcome; ACE scores 0-2 (reference) and 3 or more; Frequency calculated in ACE 3 group (N = 199); Models adjusted for maternal age, race/ethnicity, and education, and SES; .Models adjusted for maternal age, race/ethnicity, and education. *p <.05, **p <.005. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 89 Table 7 Examination of Effect Modification of PCEs on Pregnancy and Birth Outcomes (N = 556) Outcomes PCE scores 4 PCE scores 5 n = 216 (38.8%) n = 340 (61.2%) Adjusted OR [95% CI] Adjusted OR [95% CI] Pregnancy Outcomes Unhealthy weight gain Total ACE 1.22 [1.03, 1.44]* 1.06 [0.99, 1.14] ACE scores 3 1.59 [0.85, 3.00] 1.42 [1.11, 1.83]* Total ACE 1.04 [0.74, 1.46] 1.03 [0.91, 1.16] ACE scores 3 1.33 [0.31, 5.68] 1.88 [1.26, 2.80]** Gestational Diabetes Note. ACE = adverse childhood experiences; Total ACE scores of 8 types; ACE score 2 or less as reference. Regression model was adjusted for maternal age, race/ethnicity, and education; Regression model was adjusted for maternal age, race/ethnicity, education, and socioeconomic status. *p <.05, **p <.005. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Outcomes PCE scores 4 PCE scores 5 n = 216 (38.8%) n = 340 (61.2%) Adjusted OR [95% CI] Adjusted OR [95% CI] 90 Birth Outcomes Preterm birth Total ACE 0.97 [0.75,1.24] 1.00 [0.89,1.13] ACE scores 3 0.84 [0.31,2.28] 0.93 [0.60,1.45] Total ACE 0.89 [0.69,1.14] 0.75 [0.62,0.90]** ACE scores 3 0.54 [0.20,1.44] 0.24 [0.10,0.55]** Total ACE 1.15 [0.89,1.48] 1.07 [0.94,1.28] ACE scores 3 1.85 [0.62,5.56] 1.25 [0.79,1.99] SGA LGA Note. ACE = adverse childhood experiences; GA = gestational age; SGA = small gestational age (<10th percentile); LGA = large gestational age (>90th percentile); GD = gestational diabetes; preterm birth = gestational age < 37 weeks. Total ACE scores of 8 types. ACE score 2 or less as reference.Regression models were adjusted for maternal age, race/ethnicity, and education; Regression models were adjusted for maternal age, race/ethnicity, education, and socioeconomic status. *p <.05, **p <.005. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Figure 1 MTB-PACE Study Sampling 91 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Figure 2 Diagram of Three Factor Analysis of ACE-Q Note. ACE = adverse childhood experiences. 92 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 93 Appendix A Positive and Adverse Childhood Experiences Questionnaire Positive Childhood Experiences Questionnaire (PCEs-Q) 1. How often did you feel your family stood by you during difficult times? Would you say never, rarely, sometimes, often, very often, or prefer not to answer? 2. How often did you feel that you were able to talk to your family about your feelings? Would you say never, rarely, sometimes, often, very often, or prefer not to answer? 3. For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, all of the time, or prefer not to answer? 4. How often did your enjoy participating in your communitys tradition? Would you say never, rarely, sometimes, often, very often, or prefer not to answer? 5. How often did you feel supported by your friends? Would you say never, rarely, sometimes, often, very often, or prefer not to answer? 6. How often did you feel that you belonged at your high school? Would you say never, rarely, sometimes, often, very often, or prefer not to answer? 7. How often were there at least two adults, other than your parents, who took a genuine interest in you? Would you say never, rarely, sometimes, often, very often, or prefer not to answer? Adverse Childhood Experiences Questionnaire (ACEs-Q) 1. Did you live with anyone who was depressed, mentally ill, or suicidal? Yes, No, or Prefer not to Answer? 2. Did you live with anyone who was a problem drinker or alcoholic? Yes, No, or Prefer CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 94 not to Answer? 3. Did you live with anyone who used illegal street drugs or who abused prescription medications? Yes, No, or Prefer not to Answer? 4. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? Yes, No, or Prefer not to Answer? 5. Were your parents separated or divorced? Yes, No, or Prefer not to Answer? 6. How often did your parents or adults in your home ever slap, hit, kick, punch, or beat each other up? Never, Once, More than once, or Prefer not to Answer? 7. Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking. Never, Once, More than once, or Prefer not to Answer? 8. How often did a parent or adult in your home ever swear at you, insult you, or put you down? Never, Once, More than once, or Prefer not to Answer? 9. How often did anyone at least 5 years older than you, or an adult, touch you sexually? Never, Once, More than once, or Prefer not to Answer? 10. How often did anyone at least 5 years older than you, or an adult, try to make you touch them sexually? Never, Once, More than once, or Prefer not to Answer? 11. How often did anyone at least 5 years older than you, or an adult, force you to have sex? Never, Once, More than once, or Prefer not to Answer? CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Appendix B Use of PACEs Questionnaire 95 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 96 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 97 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 98 Appendix C Table 8 Estimated Sample Size Associated with Outcome and ACE Type using G*Power Article Number Outcome/ OR G* Power of casesa ACE Type [95% CI] Sample sizeb Gestational diabetes, N = 3,181 (3.0%)c Mason et al. (2016) 258 Severe physical abuse 1408 Physical abused 318 Forced sexual abuse 892 Sexual abusee 1.43 [1.22,1.67] 297 - 636 1.31 [1.15,1.50] 154 - 245 Excessive Gestational weight gain, N = 2,356 (38.0%)c Ranchod et al. (2016) 990 Household Mental illness 1.10 [0.9, 1.20] 448 1013 Household alcoholism 1.20 [1.10, 1.3] 454 1084 Physical abuse 1.20 [1.10, 1.4] 212 Preterm birth, N = 4,110 (8.0%)c Selk et al. (2016) 518 Forced sexual abuse 1.24 [1.13, 1.37] 90 908 Touch-only sexual abuse 1.03 [0.95, 1.11] 67 317 Severe physical abuse 1.11 [0.99, 1.25] 117 Note. ACE = adverse childhood experiences; preterm birth = gestational age between 20 to 37 weeks. a Cases associated with outcome and ACE type. b Sample size estimated at = .05 and = 0.8, c Number and percentage of outcome , d Sever, moderate, and mild physical abuse, e Forced and touch-only sexual abuse. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 99 Table 9 PACEs Prevalence and Health Outcomes of MTB-PACE Participants (N = 556) Outcomes Number of ACE N (%) 0-1 2 3 4-8 n = 271 n = 86 n = 82 n = 117 (48.7%) (15.5%) (14.7%) (21.0%) 165 (60.9) 57 (66.3) 57 (69.5) 94 (80.3) 15 (5.5) 4 (4.9) 8 (9.8) 5 (4.3) 24 (8.9) 5 (5.8) 5 (6.1) 11 (9.3) Pregnancy Unhealthy weight gain Missing Gestational diabetes Missing 372 (67.0) 1 (0.2) 32 (5.9) 3 (0.5) Birth Preterm birth Missing 45 (8.1) 2 (0.4) Birth weight for GA SGA 35 (6.3) 20 (7.4) 5 (5.8) 2 (2.4) 8 (7.5) LGA 38 (6.9) 16 (5.9) 4 (4.7) 4 (4.9) 14 (12.1) Missing 3 (0.6) CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Outcomes 100 Number of PCE N (%) 0-2 3-4 5 6-7 n = 87 n = 129 n = 74 n = 266 (15.6%) (23.2%) (13.3%) (47.8%) 67 (77.0) 90 (69.8) 48 (64.9) 167 (62.8) 8 (9.2) 2 (1.6) 5 (6.8) 17 (6.4) 6 (6.9) 13 (10.1) 6 (8.1) 20 (7.5) Pregnancy Unhealthy weight gain Missing Gestational diabetes Missing 372 (67.0) 1 (0.2) 32 (5.9) 3 (0.5) Birth Preterm birth Missing 45 (8.1) 2 (0.4) Birth weight for GA SGA 35 (6.3) 10 (11.5) 9 (7.0) 4 (5.4) 12 (4.5) LGA 38 (6.9) 7 (8.1) 12 (9.3) 3 (4.1) 16 (6.0) Missing 3 (0.6) Note. ACE = adverse childhood experiences; PCE score of 1 is answer yes on each of PCE items 1-7. preterm birth = GA < 37 weeks; SGA = small birth weight (<10th percentile) for GA; LGA = large birth weight (>90th percentile) for GA. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES 101 Table 10 Post-hoc Power Analysis of MTB-PACE Study Outcomes N (%) Adj OR [95% CI] Pregnancy Outcomes G* Power Estimation Unhealthy weight gain Total ACE 372 (67.0) 1.16 [1.05, 1.29]* 1.00 ACE scores 3 151 (75.9) 1.68 [1.12, 2.51]* 1.00 Household Dysfunction 208 (70.5) 1.29 [0.90, 1.56] 1.00 Physical/Emotional Abuse 228 (73.5) 1.79 [1.24, 2.59]** 1.00 Sexual Abuse 93 (70.5) 1.07 [0.68, 1.66] 0.96 PCE scores 5 215 (63.2) 1.42 [1.11, 1.83]* 0.95 PCE scores 4 157 (72.7) 1.59 [0.85, 3.00] 1.00 Total ACE 32 (5.8) 0.98 [0.81, 1.20] 0.41 ACE scores 3 14 (5.8) 1.36 [0.64, 2.88] 0.17 Household Dysfunction 16 (5.4) 0.83 [0.40, 1.73] 0.19 Physical/Emotional Abuse 18 (5.8) 1.00 [0.48, 2.08] 0.22 Sexual Abuse 10 (7.6) 1.40 [0.62, 3.14] 0.12 PCE scores 5 22 (6.5) 1.88 [1.26, 2.80]** 0.26 PCE scores 4 19 (8.8) 1.33 [0.31, 5.68] 0.24 ACE Subtype Gestational Diabetes ACE Subtype CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Outcomes N (%) Adj OR [95% CI] Birth Outcomes 102 G* Power Estimation Preterm birth Total ACE 45 (8.1) 1.00 [0.85, 1.18] 0.72 ACE scores 3 16 (8.0) 0.94 [0.48, 1.84] 0.26 Household Dysfunction 28 (9.5) 1.48 [0.78, 2.82] 0.48 Physical/Emotional Abuse 24 (7.7) 0.84 [0.45, 1.58] 0.41 Sexual Abuse 12 (9.1) 1.07 [0.52, 2.21] 0.21 PCE scores 5 26 (7.6) 0.93 [0.60,1.45] 0.44 PCE scores 4 19 (8.8) 0.84 [0.31,2.28] 0.32 Total ACE 35 (6.3) 0.97 [0.80, 1.17] 0.46 ACE scores 3 10 (5.0) 0.69 [0.32, 1.49] 0.10 Household Dysfunction 18 (6.1) 0.94 [0.47, 1.88] 0.22 Physical/Emotional Abuse 18 (5.8) 0.81 [0.40, 1.64] 0.22 Sexual Abuse 9 (6.8) 1.18 [0.52, 2.66] 0.11 PCE scores 5 16 (4.7) 0.24 [0.10,0.55]** 0.17 PCE scores 4 19 (8.8) 0.54 [0.20,1.44] 0.26 38 (6.8) 1.17 [0.99, 1.39] 0.54 ACE Subtype SGA ACE Subtype LGA Total ACE CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Outcomes 103 N (%) Adj OR [95% CI] 18 (9.1) 1.89 [0.94, 3.79] G* Power Estimation 0.26 Household Dysfunction 22 (7.5) 1.31 [0.66, 2.61] 0.31 Physical/Emotional Abuse 26 (8.4) 1.69 [0.81, 3.55] 0.38 Sexual Abuse 13 (9.8) 1.77 [0.85, 3.71] 0.19 PCE scores 5 19 (5.6) 1.25 [0.79,1.99] 0.24 PCE scores 4 19 (8.8) 1.85 [0.62,5.56] 0.27 ACE scores 3 ACE Subtype Note. ACE = adverse childhood experiences. Total ACE scores (8 types) for outcome; ACE scores 0-2 (reference) and 3 or more; Frequency calculated in ACE 3 group (N = 199); ACE subtype = score of 0 (reference) and one on either ACE item in each subtype. Models adjusted for maternal age, race/ethnicity, and education, and SES; .Models adjusted for maternal age, race/ethnicity, and education. *p <.05, **p <.005. CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Appendix D Determination Letters 104 CHILDHOOD EXPERIENCES ON PREGNANCY AND BIRTH OUTCOMES Appendix E 105  ...

... ESTABLISHING FACE AND CONTENT VALIDITY OF A NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Timothy E. Kent, LAT, ATC Copyright 6/26/2020 By: Timothy E. Kent, LAT, ATC All rights reserved Approved by: Christine Lauber, EdD, LAT, ATC Committee Chair Elizabeth S. Moore, PhD Committee Member Luzita Vela, PhD, LAT, ATC Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Establishing Face and Content Validity of a Novel Athletic Training Script Concordance Test Tim Kent University of Indianapolis 1 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 2 Abstract Background/Significance: Script concordance tests, based on script theory, have been proposed to objectively measure clinical reasoning in medical professionals. As the result of much research, best practices exist guiding the construction of script concordance tests and have been implemented within multiple professions. However, use of a script concordance test as a measure of clinical reasoning in athletic training has not yet been investigated. Purpose: The purpose of this study was to systematically develop a script concordance test specific to athletic training, demonstrating validity and internal reliability. Methods: Five content experts responded to an initial survey to delineate a test blueprint and a subsequent survey to establish face validity of the resultant script concordance test. Twenty expert clinicians then completed the tests. Analyses of validity and internal reliability were calculated from the expert panelist responses to create a final optimized version of the test. Results: Item level and scale level content validity indices of 1.0 were both established for a novel script concordance test in athletic training. A 100-item test displayed a Cronbachs alpha value of .48. Item analysis and subsequent removal of all performing items resulted in a 75-item test with a Cronbachs alpha value of .73. A further item analysis with subsequent removal of worst performing vignettes resulted in a 60-item final version of the script concordance test possessing a Cronbachs alpha value of .77. Conclusions: Through purposeful selection of content experts, a novel script concordance test measuring clinical reasoning in athletic training was developed, displaying face validity. Purposeful selection of a reference expert panel resulted in the script concordance test demonstrating internal consistency reliability. The validated script concordance test poses implications for further research in clinical reasoning specific to the athletic training profession. Keywords: script concordance test, athletic training, validity NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 3 Acknowledgements Praise the Lord! For all of my family. For my wife, Sarah, and children, Rayleigh, Adelyn, and Elliot, who have made both known and unknown sacrifices incalculable in number while steadfastly remaining supportive of me over the course of this endeavor. For my mother, Martha, and late father, Eldon, who instilled in my from a very early age the importance of education and have been my foundation in myriad ways in the pursuit thereof at each successive stage of my life. Praise the Lord! For my dissertation committee. For Dr. Christine Lauber, Dr. Elizabeth Moore and Dr. Luzita Vela, who were kind enough to selflessly volunteer themselves to the additional burdens that have no doubt accompanied sharing their expertise and continually keeping me focused and encouraged throughout this process. Praise the Lord! For all of my friends. For John Taylor, Chris Magott, and Matt Wallace, who each, at successively integral developmental points in my life, offered honest, kind, and absolute friendship, modeling for me the type of individual that I have aspired to become. Praise the Lord! For all of my colleagues. For the athletic training experts kind enough to devote countless hours of their time, allowing this project to come to fruition. For Dr. Monica Matocha and Dr. Brian Coulombe of the Texas Lutheran University Athletic Training Program, who picked up my loose ends and displayed patience with me throughout this endeavor. Praise the Lord! For all of my past students, whose cumulative struggles and successes towards learning and entering the profession of athletic training provided me the inspiration for this venture. With my deepest gratitude and sincerity I thank all of those, named and unnamed, who have graced my life to this point and somehow left a lasting mark on either who I am or these papers directly. For without them, neither this manuscript nor I would exist, as is. Praise the Lord! Graciously, Timothy E. Kent July 6, 2020 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 4 Table of Contents Abstract ........................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 3 Literature Review.......................................................................................................................... 12 Clinical Reasoning .................................................................................................................... 13 Analytical (system two) reasoning. ....................................................................................... 13 Non-analytical (system one) reasoning. ................................................................................ 15 Dual process reasoning. ......................................................................................................... 16 Script theory. ......................................................................................................................... 17 Clinical Expertise ...................................................................................................................... 18 Script Concordance Tests .......................................................................................................... 20 Design. ................................................................................................................................... 21 Length. ................................................................................................................................... 22 Scoring. .................................................................................................................................. 22 Reference panel. .................................................................................................................... 24 Evidence of Validity and Reliability ......................................................................................... 25 Content validity. .................................................................................................................... 25 Construct validity. ................................................................................................................. 26 Internal consistency reliability............................................................................................... 27 Athletic Training ....................................................................................................................... 29 Method .......................................................................................................................................... 31 Study Design ............................................................................................................................. 31 Participants ................................................................................................................................ 31 Content experts. ..................................................................................................................... 31 Expert panel. .......................................................................................................................... 32 Data Collection.......................................................................................................................... 32 Quantitative data. ................................................................................................................... 32 Qualitative data. ..................................................................................................................... 33 Script Concordance Test ........................................................................................................... 33 Procedures ................................................................................................................................. 34 Informed consent. .................................................................................................................. 34 Creation of the script concordance test.................................................................................. 34 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 5 Data Analysis ............................................................................................................................ 35 Results ........................................................................................................................................... 36 Face Validity ............................................................................................................................. 37 Content Validity ........................................................................................................................ 38 Item Analysis............................................................................................................................. 40 Internal Consistency .................................................................................................................. 40 Discussion ..................................................................................................................................... 41 Establishing Face and Content Validity .................................................................................... 41 Establishing Internal Consistency Reliability ........................................................................... 43 Limitations ................................................................................................................................ 45 Conclusions and Implications ................................................................................................... 46 References ..................................................................................................................................... 47 Appendices .................................................................................................................................... 66 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 6 List of Tables Table 1 Content Expert Characteristics ................................................................................... 58 Table 2 Expert Panel Demographics........................................................................................ 59 Table 3 Expert Panel Experience ............................................................................................. 60 Table 4 Stepwise Item Analysis and Removal ........................................................................ 62 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 7 List of Figures Figure 1 Process of establishing face and content validity ........................................................ 64 Figure 2 Process of maximizing Cronbachs alpha through item analysis ................................ 65 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 8 Script Concordance Testing in Athletic Training There are currently over 25,000 athletic trainers working in the United States, and the profession is expected to see in excess of a 20% job growth rate over the next decade (Bureau of Labor Statistics, 2015). As integral members of an inter-professional health team, athletic trainers are tasked with adhering to the five core competencies, as outlined by the Institute of Medicine (IOM, 2003), in the pursuit of improved patient outcomes. A third of these core competencies is that allied health providers employ evidence-based practice, combining research with individual clinical expertise to guide patients toward the best care possible (IOM, 2003). Integral to evidence-based practice is the clinicians role in decision-making based on individual expertise, also known as clinical reasoning. Currently, clinical reasoning is understood to be a complex cognitive practice utilizing both analytical and non-analytical thought processes (Norman & Eva, 2010). Research has shown that greater than half of diagnostic errors in medicine are resultant from faulty cognitive processes, or clinical reasoning (Singh et al., 2013). Increased clinical reasoning ability is proposed to be largely the result of increased experience (Thornton, 2010). Evidence exists demonstrating that experienced physicians construct and access knowledge schemas differently than novices, and that altering the manner by which novices clinically reason has modestly decreased medical error rates, an indicator of increased patient outcomes (Eva, Hatala, Leblanc, & Brooks, 2007). In addition to potential implications clinical reasoning has on clinicians abilities to provide better patient care, the established charge of the IOM also tasks healthcare education programs with teaching clinical reasoning to their students. In athletic training (AT), the inclusion of utilizing clinical reasoning to formulate appropriate clinical diagnoses in the current NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 9 National Athletic Trainers Association (NATA, 2011) education competencies and upcoming curricular content as outlined in the Commission for Accreditation of Athletic Training Education 2020 Professional Standards (CAATE, 2019) underscore the importance of this task. It therefore, becomes imperative that AT program administrators have a manner by which to evaluate whether they are successfully doing so. Combined with the evidence that increased clinical reasoning can lead to increased patient outcomes (Keeney, 2008; Rivas et al., 2016), it becomes increasingly evident that practicing athletic trainers and AT education programs alike would both benefit from the ability to measure clinical reasoning. Yet there remain few objective ways in which clinical reasoning can ultimately be measured. Two of the most common measures, the objective structured clinical examination (OSCE) and long case examination, are laborious to administer and difficult to objectively score (See, Tan, & Lim, 2014). A more recently established alternative manner to measure clinical reasoning adopted across multiple allied health domains is the script concordance test (SCT). Script concordance tests have increasingly been validated in various areas of medicine over the last decade and adopted as measures of clinical reasoning among a spectrum of allied health profession education programs (Lubarsky, Durning, & Bernard, 2014). Problem Statement To this date, a valid and reliable SCT test specific to AT has not been systematically created. Adding AT to the list of health professions that have a valid and reliable SCT would provide the profession with a useful tool to measure clinical reasoning in students and clinicians. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 10 Purpose Statement The purpose of this study is to construct a valid and reliable online SCT specific to AT demonstrating content validity and internal reliability. Researchers have demonstrated that construct validity and reliability can be established on SCTs across a variety of health sciences disciplines and health professions education. To create a valid and reliable SCT, care must be taken in the development of its items and selection of the expert panel used to help establish its validity (Lubarsky, Dory, Duggan, Gagnon, & Charlin, 2013). Research Question Can an online SCT specific to AT be created that demonstrates both content validity and internal reliability? To answer this research question, the following objectives were addressed. Objectives This study aimed to satisfy the following unique objectives: 1. To utilize an expert in each of the five domains of AT a priori to create a test blueprint consisting of five pertinent cases from each domain. 2. To create a 100 question SCT constituted of 25 individual cases containing four items each. 3. To query a sample of five athletic trainers, representative of varied working environments, whom will establish face validity of newly created 100 question SCT. 4. To establish content validity, as measured with the item-level content validity (I-CVI) and scale-level content validity indices (S-CVI), of newly created 100 question SCT a posteriori among aforementioned five content experts. 5. To administer the newly created 100 question SCT to an expert panel of 20 certified athletic trainers. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 11 6. To analyze internal reliability, as measured with Cronbachs alpha, of expert panelists responses to refine an optimized scoring key. Significance of the Study By demonstrating that an online SCT specific to AT possesses both content validity and internal reliability, a potential tool for measuring clinical reasoning ability specific to athletic trainers can be established. Once shown to be valid and reliable, the SCT could be utilized in further research to establish that its proposed construct in measuring clinical reasoning holds true when applied to the broad discipline of AT. Establishment of such would allow for the practical use of a SCT in a number of manners across the profession. First, these results would position a SCT as a uniquely practical, valuable, and validated way to measure clinical reasoning amongst athletic trainers. Further implications would range from establishing a measure of the effect that clinical reasoning has on patient outcomes, and AT programs effectiveness in teaching clinical reasoning to their students. Ultimately, the SCT could subsequently be utilized in any type of research which aimed at measuring clinical reasoning as either an independent or dependent variable in relationship to another phenomenon. More pointedly, creating a SCT in this manner would create an opportunity to inform EBP in developing clinical reasoning in AT students and clinicians, ultimately increasing patient outcomes. Definition of Terms Athletic trainer healthcare professional who renders health services encompassing the prevention, examination, diagnosis, treatment, and rehabilitation of emergent, acute or chronic injuries and medical conditions under the direction of or in collaboration with a physician (Board of Certification [BOC], 2017) NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 12 Certified having passed the BOC exam for entry level AT competence and currently in good standing with the BOC (BOC, 2017) Clinical reasoning construct of learning involving cognitive activity by a clinician to integrate information from a clinical encounter into a pre-existing system of knowledge organization (Kreiter & Bergus, 2009) Content validity the extent to which a test item is representative and relevant to a targeted medical domain (Humbert et al., 2011) Script concordance test a test used in health professions education to assess the ability to interpret medical information under instances of uncertainty (Lubarsky et al., 2013) Script theory an explanation of how humans understand real world events through an almost effortless use of organized schemas representative of past repeated experiences (Charlin, Boshuizen, Custers, & Feltovich, 2007) Literature Review The SCT was developed as a means of measuring clinical reasoning based on the construct of script theory (Charlin, Brailovsky, Leduc & Blouin, 1998). To fully understand the relationship between clinical reasoning and script theory one must first be generally knowledgeable of clinical reasoning, and second, specifically knowledgeable of the overlapping theories of how clinical reasoning occurs. Incorporating script theory as a basis for the development of clinical expertise allows the SCT to gain legitimacy as a tool for measuring clinical reasoning. An accounting of research on the optimal procedures in test construction and evidence supporting validity and reliability allow for the construction of a SCT as a means for measuring clinical reasoning in AT. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 13 Clinical Reasoning Clinical reasoning has long been studied by clinicians and medical educators. However, because it is not objectively tangible, widespread consensus on exactly what clinical reasoning is, or what identifiable characteristics comprise clinical reasoning, does not exist (Norman, 2005). Researchers have shown that across all levels of health professions education, large disagreement exists in not only identifying a singular definition or integral characteristics of clinical reasoning, but even simply in defining common terms utilized when discussing clinical reasoning (Young et al., 2019). Characteristics of clinical reasoning, such as role reflection, deliberate practice, intuition, experience, reflection, metacognition, and flexibility in thinking have even shown to differ among health professions (Huhn, Gilliland, Black, Wainwright, Christensen, 2019). However, a universally accepted facet of clinical reasoning in medicine is that it is a manner of cognition utilized by clinicians in the diagnosis and management of patient ailments (Braude, 2012). Central to the concept of clinical reasoning is the cognitive operation of decision making. Clinical reasoning involves utilizing broad cognitive strategies of deliberation and evaluation to ultimately result in a decision upon a course of action (Daly, 2018). The precise manners by which these cognitive strategies and ultimate decision occur are still widely debated. Analytical (system two) reasoning. It has long been proposed that cognitive processes undergirding clinical reasoning are largely analytical in nature and can generally be divided into two primary categories, decision theory and problem solving (Loftus, 2012). Decision theory is a comparatively straight forward theoretical model of clinical reasoning that proposes that probability decisions are made by clinicians based on known data points to determine optimal responses to a given situation. This theory draws largely from Bayesian rules and statistical NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 14 modeling of predicting outcomes (Karni, 2011). Utilizing Bayesian concepts, decision makers are continually tasked with choosing among multiple strategies reflecting ones inferences regarding an eventual outcome and the likelihood of each outcome actually materializing in any given situation. In this cognitive strategy, new information affects a decision makers inferences by adding known information to the internal probability calculations of eventual outcomes the decision maker weighs, according to Bayes rule (Karni, 2013). Because decisional theory is based on probability, utilizing decision theory as a means of clinical reasoning is best suited at the population level rather than at the individual patient level (Loftus, 2012). Using decision theory often does not allow a decision maker to take into account individualized preferences, data points, beliefs, and health risks of a singular patient when making a decision regarding that patient, as it draws on population level data to determine probabilities (Edwards & Richardson, 2008; Cox, 2012). Problem solving as a cognitive strategy, on the other hand, is utilized by clinicians when determining an appropriate action in response to a specific given situation. Also analytical in nature, it finds its roots in the hypothetico-deductive process of forming plausible hypotheses for a given scenario and systematically testing those hypotheses to come to an ultimate decision (Loftus, 2012). The hypothetico-deductive explanation of clinical decision-making finds its medical roots from physicans reflections of their decision-making processes following controlled standardized patient encounters during their medical education (Elstein, Schulman, & Sprafka, 1978). It has been pointed out, however, that true clinical encounters do not typically involve the straightforward patient presentations that are commonplace in this specific educational setting (Donner-Banzhoff, 2018). NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 15 Non-analytical (system one) reasoning. Resulting from the acknowledgement of the importance of individual patient differences and commonly confounding clinical situations, recent models of clinical reasoning incorporating non-analytical alternatives to hypotheticodeductive reasoning are commonly utilized in conjunction with metacognition as means of explaining clinical reasoning, especially in expert clinicians (Marcum, 2012). The two most widely accepted non-analytic alternatives to hypothetico-deductive reasoning are the use of exemplars and utilization of illness scripts in pattern recognition (Norman, 2005). These two methods of cognition are similar in that they premise that clinicians draw upon their experiences to intuitively, tacitly, or reflexively generate reasoned responses to a clinical scenario (Loftus, 2012). Schmidt and Rikers (2007) labelled these non-analytical alternatives to hypotheticodeductive reasoning as structure theories. Exemplars are often described as clinical examples of conditions or patients that are representative of those conditions key clinical features or patients presentations (Monteiro, Norman, & Sherbino, 2018). Exemplars act as encapsulated analytic knowledge that health professionals call upon to help guide their decisions. Importantly, exemplars reside in episodic memory, never altered afterwards (Papa & Li, 2015), such as a clinician recalling a patients signs and symptoms of the very first ACL tear they diagnosed. In describing clinical reasoning through the use of exemplars, decision making at its most simple explanation involves retrieval and application of such knowledge (Monteiro, Norman, & Sherbino, 2018). Much like exemplars, the use of illness scripts allows clinicians to call on cognitively stored knowledge structures to understand a patient presentation or diagnosis and ultimately make a decision regarding it (Custers 2015). However, these illness scripts are constantly being refined with each new experience (Papa & Li, 2015). Related to the aforementioned case, the signs and symptoms NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 16 indicating an ACL tear would be adjusted from those of the initial patient to those most frequently seen and relevant of the entirety of a clinicians experiences. Both the use of exemplars and illness scripts are theorized to allow a clinician to make use of preconceived associations and connections that have developed over time to non-analytically make medical decisions regarding patient care (Monteiro, Norman, & Sherbino, 2017). Dual process reasoning. Most recently, those studying the way in which clinical reasoning occurs have borrowed from the field of cognitive psychology and come to some consensus that the reasoning process involves a combination of analytical and non-analytical processes, labeled dual process theory (Pelaccia, Tardif, Triby, & Charlin, 2011). Dual process theory posits that either analytical or non-analytical strategies become dominant in the reasoning and decisional processes, based upon the specific characteristics of a case and their conformity to the clinicians encapsulated knowledge structures (Rotgans et al., 2019). It has become one of the most currently accepted descriptions of the complex interplay of cognitive strategies comprising clinical reasoning (Marcum, 2012). When clinicians possess well-developed exemplars or illness scripts, the non-analytical cognitive mechanisms become dominant, leading to comparatively intuitive and quicker decisions. The refinement of exemplars and illness scripts to be accurate enough to allow for effective clinical reasoning through non-analytical processes, takes multiple patient exposures, and is thus typically utilized by experienced clinicians (Custers, 2015). When a clinician, whether through lack of experience or novelty of a patient case, does not possess adequate exemplars or illness scripts matching the case at hand, the analytical cognitive strategies instead become predominant in the reasoning and decision processes. This manner of reasoning has typically been regarded as deliberate, systematic, and slow in comparison to the non-analytic alternative (Rotgans et al., 2019). NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 17 Script theory. Script theory operates under the premise that scripts, or cognitive schemas, are continuously created as the brains way of organizing data from the results of realworld interactions (Charlin et al., 2007). In medicine, these cognitive schemas are routinely referred to as illness scripts and are called upon during the non-analytical processes of clinical reasoning (Schmidt & Rikers, 2007). An individual illness script is comprised of three distinct components: the Fault, the Enabling Conditions, and the Consequences (Keemink, Custers, van Dijk, & ten Cate, 2018). The Fault is a representation of the underlying pathophysiological processes of any given disease or injury. The Enabling Conditions include contextual and individual patient characteristics influencing the probability of a patient becoming diseased or injured. Finally, the Consequences are the resultant clinical signs and symptoms that are manifested from the Fault (Custers, 2015). Script theory views illness scripts as dynamic, routinely being adapted as new clinical information is gathered with each patient encounter, a process described as script instantiation (Lubarsky, Dory, Audetat, Custers, & Charlin, 2015). In this application of illness scripts, script theory connects analytical and non-analytical processes. Clinicians call on analytical processes to both continually refine and redevelop scripts based on probability calculations and non-analytical processes to access encapsulated knowledge in the reasoning and decision processes (Custers, 2015). As a result, much attention has been afforded to script theory and its application towards clinical reasoning in the last decade. Thornton (2010) surmised that proper utilization of script theory is a contributor to clinical expertise, allowing a practitioner to make decisions while simultaneously interpreting, both intuitively and analytically, multiple sources of knowledge pertaining to those decisions, including scripts derived from past clinical experiences. The uniqueness of script theory is that it allows for the concurrent process of making intuitive and interpretive decisions. In effect, script NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 18 theory acts as a concurrent dual process theory (Marcum, 2012). Though commonly referred to as two distinct cognitive processes, there is evidence that analytical and non-analytical ways of thinking are not actually dichotomous, but actually overlap and occur simultaneously (Evans, 2008). Through application of this concurrent process and accordant to script theory, clinicians subconsciously call upon previously established illness scripts to intuitively guide their reasoning process each time they encounter a patient whose presentation matches a prior constructed illness script. Utilizing non-analytical processes lessens the amount of analytical hypothetico-deductive analysis needed to conclude the appropriate action in response to the patient encounter unless insufficient illness scripts exist. In the cases where insufficient illness scripts exist, the new encounter is considered predominantly analytically, while simultaneously being internalized through metacognition to construct a new or refine an existing illness script (Lubarsky et al., 2015). Schmidt and Rikers (2007) expanded on this phenomenon, hypothesizing that as these illness scripts are routinely and repeatedly instantiated, lower level details of each script are packaged together into more general higher level concepts with like explanatory power, a process they described as knowledge encapsulation, forming a basis of clinical expertise. Clinical Expertise Experienced clinicians have been shown to be better than inexperienced clinicians in extracting relevant information from a patients history and are able to generate more accurate hypotheses earlier in a patient encounter. These differences have been theorized to be in part due to the differentiation in the integration of the various cognitive processes involved in clinical reasoning (Charlin et al., 2007). Scripts of clinical experts are thought to be more elaborately structured and well-developed than those of their less experienced peers, resulting from numerous opportunities to clinically apply each script and subsequent fine tuning. Because NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 19 development of illness scripts is dependent on understanding and interpretation of Enabling Conditions, script theory leverages contextual factors in the reasoning process that are commonly overlooked through purely knowledge driven explanations of clinical expertise (Woods & Mylopoulos, 2015). More precisely developed scripts, attuned to contextual factors, should allow experienced clinicians to better utilize the amorphous mix of clinically relevant and irrelevant information commonly elicited early in patient encounters (Charlin et al., 2007). Ultimately, this results in experienced clinicians demonstrating expertise by more easily accessing knowledge pertinent to making decisions in practical situations when compared to their inexperienced peers (Custers, 2015). Durning, Artino, Pandaro, van der Vleuten, and Schuwirth (2011) provided evidence that experienced clinicians reasoned differently than novices by demonstrating that not only do contextual factors influence the process of clinical reasoning, but that experienced clinicians were also cognitively aware of this influence. This cognitive awareness, also known as metacognition, is now believed to be a contributory factor in how clinical experts are able to discern what illness scripts are applicable to a given patient encounter, and to what degree they should be cognitively considered and accepted to dictate a given response (Marcum, 2012). Accordingly, it is argued that context does not just impact clinical reasoning, it is the very integration of context to individual patient cases that becomes the act of clinical reasoning (Woods & Mylopoulos, 2015). Effectively, the development of more accurate, holistic scripts creates clinical expertise. Together, changes in illness script construction and the clinicians understanding of how and why these changes came to be, help to differentiate the cognitive processes between those with and without clinical expertise (Schmidt & Rikers, 2007). NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 20 In effect, when compared to those lacking clinical expertise, clinicians demonstrating expertise possess an improved script-based framework consisting of encapsulated knowledge allowing them to more quickly and accurately rely on non-analytical cognitive processes to guide behavior. When presented with situations of uncertainty that do not closely match the encapsulated knowledge from existing illness scripts, experts rely on metacognition to provide a check to their overreliance on non-analytical reasoning, prompting them to revert back to an analytical approach to problem solving (Pelaccia, Tardif, Triby, & Charlin, 2011). However, a strong illness script may increasingly lead to cognitive biases (framing, availability, and satisfaction of search among others) by a clinician, especially if they do not properly utilize metacognition to control such biases (Norman, Monteiro, Sherbino, Ilgen, Schmidt & Mamede, 2017) The SCT is widely purported to objectively measure a clinicians ability to clinically reason in this manner (Charlin et al., 1998). Script Concordance Tests The utilization of SCTs to measure clinical reasoning is a relatively new concept to medicine, having stemmed from the creation of the Diagnosis Script Questionnaire by Charlin et al. (1998). Script concordance tests are designed specifically to measure a clinicians relative weighting of clinical information as it pertains to possible differential hypotheses given a scenario (Charlin et al., 1998). The process of interpreting uncertain situations forces the test taker to access non-analytic thinking strategies, as complete analytic explanations are not available per design of the test. Similarly, the addition of information in each SCT item allows for some analytic interpretation by the test taker but forces a value judgement on the importance of that information. Clinicians with better defined illness scripts and metacognitive processes access embedded knowledge to make that value judgement, theoretically aligning their responses NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 21 through common utilization of their expertise in ill-defined situations. Since the inception of the SCT in 1998, different iterations of the test have been utilized to measure clinical reasoning within various medical specialties including dermatology (Bursztejn et al., 2011), otolaryngology (Iravani, Amini, Doostkam, & Dehbozorgian, 2016), oncology (Lambert, Gagnon, Nguyen, & Charlin, 2009), and geriatrics (Piovezan et al., 2012), among others. However, SCTs have also been utilized in more general medical fields such as nursing (Humbert et al., 2011), pharmacy (Boulouffe, Charlin, & Vanpee, 2010), radiology (Brazeau-Lamontagne, Charlin, Gagnon, Samson, & van der Vleuten, 2004), and general medicine (Dawson, Comer, Kossick, & Neubrander, 2014). Though the SCT was originally developed as a diagnostic exam, over the last 20 years it has been used to measure more than just diagnostic decision making. In addition to querying diagnostic reasoning, SCTs are also routinely utilized to measure therapeutic treatment, and investigational decisions, as demonstrated by Humbert, Besinger, and Miech (2011) in the general field of emergency medicine, and See et al. (2014) in a more specialized field of pulmonary medicine. Cohen et al. (2009) utilized a SCT to measure clinical reasoning in physical therapists, specific to assessment and intervention decisions regarding seating and mobility needs, showing the tests ability to measure reasoning processes in specific subsets of individual medical fields. When considering the varied ways in which SCTs have been used, it becomes evident that use for measuring clinical reasoning amongst the specific domains of AT is appropriate, given the SCT is constructed well. Fortunately, much research has been conducted on how to create a SCT that truly measures clinical reasoning. As a result, evidence-based practices in the construction of SCTs currently exist. Design. The design of the SCT differs from most traditional test formats. Examinees are first presented with a series of brief clinical scenarios. Each scenario is followed by a set of NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 22 three-part questions. The initial portion of each of these questions provides examinees with a plausible hypothesis typically centered on diagnoses, investigative or therapeutic options, given the provided clinical description. In the second part of each question examinees are presented with a new piece of information that may or may not affect the provided hypothesis. The third portion of each question then asks examinees to respond on a Likert scale to what degree the new piece of information affects the provided hypothesis. Each individual scenario and associated prompts is referred to as a case, and is intended to give examinees sufficient clinical information to guide meaningful decisions with a deliberate degree of uncertainty (Lubarsky et al., 2013). Length. There is consensus that the ideal length of a SCT is approximately 20 scenarios, each containing three individual prompts (Dory, Gagnon, Vanpee, & Charlin, 2012; Fournier, Demeester, & Charlin, 2008; Lubarsky, Charlin, Cook, Chalk, & van der Vleuten, 2011; Lubarsky et al., 2013). However, due to the inherent ambiguous nature of the exam, there are often questions in the original iteration of a SCT that are needed to be discarded due to large variance in answers. As such, Dory et al. (2012) recommend test creators originally start with 25 cases, with four items per case. Following such recommendations would allow for elimination of poorly performing questions discerned through analysis, still leaving an optimized version of the test adhering to best practice length recommendations. The results are then compared with a panel of experts results on the same test to determine a final score (Dory et al., 2012). Scoring. The seminal version of the SCT utilized seven answer options per individual prompt, arranged in a Likert-scale for examinees to choose from, and was scored by an aggregate scoring method (Charlin et al., 1998). Unlike multiple choice tests, where answers are absolutely correct or incorrect, SCTs are purposefully constructed to represent situations of uncertainty. The test inherently works under the assumption that there are multiple acceptable answers to a NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 23 question or situation, but that experts will typically cluster their answers modally around one answer option. An aggregate scoring method, where test takers receive partial credit as a percentage of the number of panel members who chose the same answer choice, is intended to reward examinees who mirror responses of the expert panel that did not agree with the modal answer (Fournier et al., 2008). After roughly a decade of research, numerous systematic reviews concluded that each individual prompt should only consist of five Likert-like scale choices, and continue to be measured with an aggregate scoring system (Dory et al., 2012; Fournier et al., 2008; Lubarsky et al., 2011; Lubarsky et al., 2013). Within the last 10 years, however, the strength of those recommendations has been called into question and arguments have been made for changing both the size of the Likert scale and the aggregate scoring technique. As an alternate to the widely accepted five-point Likert-like scale option, a three-point Likert-like scale option has been proposed (Lineberry, 2014). As SCTs are intended to measure situations of uncertainty, the number of questions typically including a modal answer choice at either extreme of a five-point Likert-like scale are few. Lineberry, Kreiter, and Bordage (2013) demonstrated that as a result, consistently answering a SCT with central tendency and avoiding extreme answers can artificially inflate an examinees score. A three-point Likert scale option may also eliminate ethnic bias, which has been shown to occur in other tests similar to SCTs where specific ethnicities are more likely to avoid extreme answers (Lineberry et al., 2013). However, in a comparison of a five-item and three-item Likert scales, Wilson, Pike, and Humbert (2014) found that a five-point scale exhibited greater reliability and correlation with experience. To add to the uncertainty regarding the optimal size Likert scale for scoring SCTs, there is also unsettled debate about the method of scoring SCTs. As an alternative to the typical NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 24 aggregate scoring method, a single best option scoring method, known as consensus scoring, has been proposed and shown to replicate the results of the prior described aggregate scoring method (Bland, Kreiter, & Gordon, 2005). Lineberry et al. (2013) made additional philosophical claims against the aggregate scoring method. They premised that it became impossible to determine reliability of SCTs with the use of Cronbach alpha, and that it is conceptually inappropriate as a measure of panel error. Examinees scores cannot be reconciled as estimates of true expert opinion according to classical test theory, without a single best answer (Lineberry et al., 2013). Proponents of the aggregate scoring system claim that as a measure of clinical reasoning, it is appropriate to assume that individual experts may organize their knowledge differently into distinctly different illness scripts, leading to multiple acceptable decisions for a given question (Lubarsky, Gagnon, & Charlin, 2013). They point to evidence that the variability of answers making up the reference panel is a key contributor to the discriminatory power of SCTs (Charlin et al., 2006). A final point of contention in the scoring of SCTs is the elimination of individual items that do not correlate highly with the overall test score. Dory et al. (2012) found that eliminating specific items that do not correlate with the overall score of the SCT may be used to optimize internal consistency of the test. This generally has meant eliminating between 20% and 75% of the test (Dory et al., 2012). Lubarsky et al. (2013) proposed performing an a posteriori post hoc analysis of questions to increase psychometric properties of the SCT. However, elimination of questions to optimize score reliability comes at the intrinsic cost of compromising the content validity of the SCT (Lubarsky et al., 2013). Reference panel. One last consideration in the scoring of SCTs is the creation of the reference score panel itself. Gagnon, Charlin, Coletti, Sauve, and van der Vleuten (2005) NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 25 examined the results of 38 panel members responses to create 1000 random samples of reference panelists of varying sizes in an attempt to determine ideal panel size composition. They found that in order to establish adequate reliability in the experts results, 15 panel members are required. As panel size increases past 20, a negligible gain in reliability estimates results (Gagnon et al., 2005). In addition to size, qualification of the panel members has also been called into question. Yet, there exists no substantive evidence that systemic differences in panel composition result in changes of discernment between levels of clinical reasoning (Dory et al., 2012). The prevailing recommendation is that the scoring panel should be composed of practitioners with good overall experience in the subject area of the test (Fournier et al., 2008). What exactly constitutes good overall experience is widely interpretable. Much of the debate regarding whether aggregate scoring or consensus scoring is a more appropriate scoring method for SCTs actually stems from the underlying inconsistencies found in most reference panels. Lineberry et al. (2014) argued that the discriminatory power of the SCT between experts and novices might be more a function of other known confounding variables, such as generational differences and exposure (or lack thereof) to trends than of expertise. Lubarsky et al. (2013) agreed that identifying experts for a reference panel is still a non-evidence-based encounter and qualitative in nature. Evidence of Validity and Reliability Content validity. Most research on SCTs has initially concentrated on establishing the content validity of SCTs in specific fields of medicine. To date, SCTs have been validated as being able to discriminate levels of clinical reasoning in varied areas of medicine. Researchers have established the validity in a number of general medical fields such as nursing (Humbert et al., 2011), pharmacy (Boulouffe et al., 2010), radiology (BrazeauLamontagne et al., 2004), and NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 26 general medicine (Dawson et al., 2014). In contrast, validity has been established in much more specific medical content areas including dermatology (Bursztejn et al., 2011), otolaryngology (Iravani et al., 2016), oncology (Lambert et al., 2009), and geriatrics (Piovezan et al., 2012), among other disciplines. All of these authors came to the same conclusion; a SCT within its given discipline, when constructed according to the evidence-based best practice guidelines, was able to discriminate between the clinical reasoning ability of students or novices, and experts (Boulouffe et al., 2010; BrazeauLamontagne et al., 2004; Bursztejn et al., 2011; Dawson et al., 2014; Humbert et al., 2011; Iravani et al., 2016; Lambert et al., 2009; Piovezan et al., 2012). Construct validity. Because clinical reasoning is concurrently viewed as both a process and a result, attempts at demonstrating construct validity have varied in method. At the root of each of these methods is an attempt to link an output to a cognitive construct that in some way utilizes previous knowledge, differentiated by amount of experience (Kreiter & Bergus, 2009). Collard et al. (2009) found that SCT scores correlated highly with multiple choice question (MCQ) scores early in students academic careers, but weaker as students progressed through their schooling. This occurrence helps to establish a dichotomy between absolute knowledge and the development of clinical reasoning that occurs over time. In a contrasting approach, Brailovsky, Charlin, Beausoleil, Cote, and van der Vleuten (2001) moderately correlated SCT scores with other measures of clinical reasoning in medical students, including short answer management problems (r = .45, p = .013), simulated office oral exams (r = .45, p = .015). Similarly, Humbert et al. (2011) utilized convergent validity to establish construct validity of SCTs. In this instance, they found that scores on a SCT specific to emergency medicine significantly correlated (r = .56, p < .001) to scores on the United States Medical Licensing Examination Step 2-Clinical Knowledge exam (Humbert et al., 2011). Finally, a number of NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 27 studies have investigated the scores between cohorts of clinicians varying in level of clinical experience, routinely finding a progression in SCT scores as clinical experience progresses within each cohort of clinicians (Erickson, Wagner, Morgan, Hepps, Gorman & Rouse, 2016; Humbert & Miech, 2014; Kazour, Richa, Zoghbi, El Hage & Haddad, 2017). Internal consistency reliability. Charlin et al. (2006) demonstrated that the level of questions utilized in a SCT also affects both the tests construct validity and its internal consistency. SCTs comprised of items judged to be of moderate variability in expert panelist responses were found to be both internally consistent with the ability to discriminate clinical experience among examinees., Conversely, SCTs comprised of questions of high variability in expert panelist responses were shown to be only discriminating of clinical experience in examinees, while SCTs created from questions of low variability were shown to be only internally consistent. Evidence of internal consistency has consistently been established through the use of Cronbach alpha (Dory et al., 2012). However, the adequacy of utilizing Cronbachs alpha, specifically as the sole indicator of internal consistency, has recently been questioned due to its incompatibility with classical test theory. Lineberry et al. (2013) argue that though Cronbachs alpha values may demonstrate internal consistency, this does not ensure a singular construct leading to that consistency. As a specific alternative to determining SCT reliability, utilization of generalizability theory and/or utilization of consensus scoring to satisfy classical test theory assumptions regarding internal consistency have been proposed (Lineberry et al., 2013). A more comprehensive review of how to best determine internal reliability, especially for multi-dimensional higher order constructs such as clinical reasoning, provides a much less clear understanding of how internal consistency measurement in SCT may occur (Crede & Harms, 2015). NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 28 The fact that many constructs are integrated into the explanation of clinical reasoning creates problems of testing its internal consistency, in and of itself. It has been suggested that because higher order constructs inherently include multiple constructs to explain a singular phenomenon, measuring internal consistency in these cases becomes irrelevant (Hanisch et al., 1998). Effectively, the argument exists that because individual clinicians utilize different prior clinical experiences to form their own specific exemplars and illness scripts, those scripts will likely not be highly homogenous in construct. A recent study (Reeves, Baker, Casanova, Cheatham, & Pickering, 2020) reviewing the Quality of Life Scale (QOLS) supports this assumption. Though internal consistency of the QOLS has been previously validated with Cronbach alpha multiple times across multiple samples (Burckhardt & Anderson, 2003), when examined through the use of a factorial analysis, the scale was found to lack internal consistency (Reeves, Baker, Casanova, Cheatham, & Pickering, 2020). The fact that quality of life is a multidimensional scale would explain this anomaly. Like Reeves et al. (2020), researchers have begun to use a myriad of methods attempting to combat the heterogeneity of multi-dimensional constructs while simultaneously demonstrating internal reliability (Crede & Harms, 2015). Among these methods include generalizability studies such as suggested by Lineberry et al. (2013), exploratory factor analysis, and item response theory (Ward, French, Barbosa-Leiker, & Iverson, 2016). However, these analyses have widely been pursuit without any existing standardized public guidelines (Crede & Harms, 2015). Though consensus on how exactly to best demonstrate internal consistency in cases of multidimensional constructs like clinical reasoning does not currently exist, the aforementioned evidence of construct validity coupled with high Cronbachs alpha does have merit in doing so until such methods are accepted. Establishing internal reliability of a SCT can be approached NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 29 much like a qualitative researcher would attempt to triangulate data to validate subjective findings. A high Cronbachs alpha for any particular SCT, when considered together with the well-established research regarding validity and reliability of SCTs in general, provides a convincing basic framework establishing that when constructed with questions of moderate variability, SCTs validly and reliably measure the construct of clinical reasoning independent from factual knowledge itself (Lubarsky et al., 2011). Athletic Training There exists scarce reference to any objective measure of clinical reasoning specific to the field of AT. A thorough search of the literature resulted in one such measure, the diagnostic thinking inventory for AT (DTI-AT). The DTI-AT was adapted from the diagnostic thinking inventory (DTI), another purported measure of clinical reasoning (Kicklighter, Barnum, Geisler, & Martin, 2016). However, further use of the DTI-AT is not evident in a comprehensive search of the literature. That is not to say that athletic trainers have not investigated clinical reasoning, though. Researchers investigating clinical reasoning within athletic training have instead utilized more generic measures of clinical reasoning that is not specific to AT content. For example, Heinerichs, Vela, and Drouin (2013) utilized the universal DTI and Reflection in Learning Scale (RLS) when evaluating a learner-centered technique on clinical reasoning in athletic training students. However, the preponderance of literature investigating the validity of the DTI generally pales in comparison to that investigating the validity of SCTs. The same search of literature resulted in the absence of any published use or validation of a SCT in AT. Though a paucity of research specific to clinical reasoning within the athletic training profession exists, athletic trainers have meanwhile been called to increasingly utilize EBP within clinical practice by the IOM. Clinical reasoning, a result of clinical expertise and gained through NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 30 clinical experience, is one key component of EBP. Knight (2008) publicly called for the AT profession to develop clinicians who are adept at clinical reasoning nearly a full decade ago. At that time, he claimed that critical thinking was an objective of many AT programs across the country, though most taught quasi-critical thinking at best. Geisler and Lazenby (2009) further acknowledged the need for AT programs to determine what reasoning processes students were utilizing as they progressed through their curricula. Yet there is a slowly increasing amount of research in the field of athletic training investigating clinical reasoning. Kicklighter, Geisler, Barnum, Heinerichs and Martin (2018) qualitatively investigated factors that were perceived to influence athletic trainers development of reasoning abilities. Barrett, Denegar, and Mazerolle (2018) perused the challenges facing athletic training educators in teaching clinical reasoning skills. Conversely, Geisler (2016) opined on strategies athletic training educators can employ to increase clinical reasoning in students. The common thread tying together the research of clinical reasoning in the field of athletic training is that it predominantly excludes a medium by which reasoning ability specific to the field can be measured. Kicklighter et al. (2016), the first to examine a medium for measuring AT students reasoning processes with the newly created DTI-AT remain the only published study doing so. This gap in measuring clinical reasoning specific to athletic training acts as a barrier to further research in this area. However, there is expansive literature in existence that already supports the use of SCTs as accurate and valid measures of clinical reasoning. Among this large body of evidence, there have been no published attempts to establish the ability of a SCT to measure clinical reasoning within the AT field through a rigorous research process. By first establishing the ability for SCTs to validly measure clinical NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 31 reasoning within AT, further research on the implications and utilization of SCTs in the profession can ensue. Method Study Design A non-experimental validity and reliability study was conducted at Texas Lutheran University during the 2018-2020 academic years. The study was approved by the Institutional Review Board at Texas Lutheran University and the Human Research Protections Program at the University of Indianapolis prior to participant recruitment. Information from AT content experts was used to create an online version of a SCT specific to AT and the questions on the proposed SCT were analyzed for content validity at the item and scale level. Participants Two distinct groups of participants were utilized in this study: 1) a group of content experts, and 2) an expert panel of athletic trainers. An initial purposive sample of content experts was recruited directly by the primary investigator (T. K.). Snowball sampling of this initial group allowed recruitment of additional potential experts. A similar combination of purposive and snowball sampling was used to identify athletic trainers for the expert group. Content experts. A group of five experts, one from each of the five knowledge and skill practice domain areas identified by the Athletic Trainer Practice Analysis Study, 7th edition (Henderson, 2015) representing both genders and multiple ethnicities were utilized to create a test blueprint of the online SCT. Content experts were purposively recruited by the primary investigator. Inclusion criteria for the content experts included, a) 10 or more years of clinical experience or an established line of research within an identified content area, b) self-reported use of evidence-based practice, and c) employment in a position specific to each respective NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 32 content domain. Exclusion criteria from the expert panel included a) the inability to read written English, as the SCT was administered in English, and b) the self-reported presence of any type of learning disability. Expert panel. The panel utilized to create the reference score for a SCT consisted of 20 expert athletic trainers representative of both genders and multiple ethnicities. The use of 20 experts in the construction of a reference score on a SCT has been shown to result in consistent reliability estimates, while an increase in reliability with more than 20 experts becomes negligible (Gagnon et al., 2005). The expert panel was purposively recruited by the primary investigator. Inclusion criteria for the reference panel included a) current good standing with the BOC, b) certification for 10 or more years, and c) 10 or more years of clinical experience as an athletic trainer, and d) self-reported use of evidence-based practice. Fournier et al. (2008) advised that the expert panel should be constructed of representatives possessing good overall experience in the field to which the SCT pertains. The previously described selection criteria aimed at identifying such individuals. Exclusion criteria from the expert panel included a) the inability to read written English, as the SCT was administered in English and b) the self-reported presence of any type of learning disability. Data Collection Quantitative data. Data were collected using the Qualtrics XM Platform tool. Participants accessed the online Qualtrics questionnaire via a hyperlink provided to by the primary investigator. All participants completed the questionnaire which asked about their demographic characteristics, including gender and ethnicity, as well as their certification status, years of certification, and years of clinical experience. Proposed content experts were queried on NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 33 their position description as well as their use of evidence-based practices. The primary investigator downloaded results from Qualtrics into a Microsoft Excel spreadsheet. Qualitative data. Content experts communicated directly with the primary investigator in order to discern face and content validity. In instances where content experts did not agree with face or content validity of an item, their qualitative reasoning for objection was obtained. This communication occurred through email correspondence, telephone and face-to-face conversations. The primary investigator documented communication from content experts through the use of written recordings and memos to chronicle the evolution of the SCT towards face validity. Script Concordance Test Twenty-five individual cases pertaining to AT with four question stems apiece were developed by the primary investigator and used throughout this study. Each question had a fivepoint Likert-like scale response option (Lubarsky et al., 2013). Each stem on the SCT presented an ill-defined and authentic scenario for which the expert panelist must possess factual knowledge to answer. However, factual knowledge alone must not be sufficient to answer each question; prompts must also be ambiguous enough to force respondents to select their chosen answer from other acceptable options (Lubarsky et al., 2011). This cognitive process is the foundation of clinical reasoning. Each item was constructed according to the key features approach described by Lubarsky et al. (2013). NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 34 Procedures Informed consent. Professional contacts of the primary investigator were initially contacted as potential participants in the study via an email including a brief description of the study and hyperlink to an informed consent. The informed consent form describing the title and purpose of the study, explanation of the procedures, potential risks and benefits, assurance of confidentiality, and rights of voluntary participation prefaced involvement in the study. The informed consent was administered through Qualtrics prior to access of the questionnaire. Possible participants were unable to proceed through the study without first completing the informed consent. Possible participants were given time to examine the implications their consent had upon them as individuals and request a video conference with the primary investigator to ask any questions they may have had before consenting. Creation of the script concordance test. After obtaining informed consent, the primary investigator provided a questionnaire of self-reported inclusion/exclusion criteria to potential content experts (Appendix A). Once selected, the five content experts were prompted to provide a listing of five cases with associated key features they believed to be most pertinent in their specific practice domain (Appendix B), as outlined by the Athletic Trainer Practice Analysis Study, 7th edition (Henderson, 2015). The primary investigator subsequently created five SCT cases (four questions per case) for each of the AT domains from the solicited feedback of the content experts. The resultant SCT was returned to the content experts. Experts determined if they deemed each question to be clear and representative of AT content through a variant of the SCT item quality grid (Appendix C) adapted from Fournier et al. (2008), allowing for the assessment of face and content validity by the primary investigator. The newly created SCT was then administered electronically to the 20 members of the expert panel. Upon completion of the NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 35 SCT, each expert panelists results were downloaded from Qualtrics by the primary investigator. Expert panelists answers were screened for unanimity; one question for which all expert panelists gave the same response was not included in subsequent analyses. The primary investigator then analyzed each of the expert panelists responses to establish the maximum internal consistency reliability through the use of item analysis. Questions demonstrating internal consistency reliability > .70 were then used to create the final version of the SCT and associated scoring key. Data Analysis Through the use of IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY), descriptive statistics were conducted on both the content expert group and expert panel. Nominal data were presented as frequency and percentage, ordinal data as median and interquartile range, and interval and ratio data as mean and standard deviation, or median and interquartile range, depending on whether or not the data were normally distributed. In determining content validity, both S-CVIs and I-CVIs were calculated in Microsoft Excel using formulas provided by Polit and Beck (2006). Individual questions not demonstrating an I-CVI of 1.00 were rewritten until a final version of the SCT demonstrating S-CVI of 1.00 and I-CVI of 1.00 for all questions could be constructed, per recommendations by Polit and Beck (2006). Cronbachs alpha tests were conducted to estimate the internal consistency of the SCT. An item analysis displaying item-total correlation was completed. Cronbachs alpha was conducted to determine the initial internal consistency of individual questions on overall internal consistency reliability. The coefficients were used to determine the final iteration of the SCT, NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 36 consisting of 20 cases and 3 questions, as recommended by Lubarsky et al. (2013). The final version of the SCT aimed to maximize Cronbachs alpha level. Results The five content experts who helped create the framework for the resultant SCT were mostly male (N = 3, 60%) and non-Hispanic White (N = 4, 80%) with one expert self-identifying as Hispanic/Latino. The group had been practicing as certified athletic trainers for a mean of 17.6 years, with a range from 15 to 22 years. Three of five (60%) content experts were employed in a collegiate setting, one (20%) in an industrial setting, and one (20%) in a hospital/outreach setting. Expertise was established for four of the five (80%) content experts through selfreporting of specific and routine engagement as part of their formal job-related duties in their specified practice domain. Expertise was established for one (20%) content expert through a self-reported established research agenda in their specified practice domain. Five of the five (100%) experts indicated fluency in English, to satisfy the final inclusion criteria. A breakdown of individual content expert characteristics can be found in Table 1. The 20 expert panelists represented both male and female genders and multiple ethnicities. A demographic breakdown of the expert panel is found in Table 2. The expert panelists had been certified for a mean of 15.35 years, with a range of 10 to 35 years. Similarly, they had a mean of 15.2 years of clinical experience, ranging from 10 to 35 years. Individual accounts of expert panelists experience is provided in Table 3. Finally, all 20 of the eventual expert panelists self-reported use of evidence-based practice in one or more of the five domains of athletic training. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 37 Face Validity Five expert panelists were emailed directly by the principal investigator with a brief description of the content and purpose of a script concordance test, an example of a SCT vignette and specific instructions for developing a framework for eventual SCT questions. These instructions prompted each content expert to list five frequently seen or especially important clinical situations within their content area of expertise, with four relevant options a clinician might consider in response to the aforementioned situations. Content experts emailed their responses (constituting the test blueprint) directly to the primary investigator who then fleshed out each situation with details to create an initial version of the SCT. An initial 100 item draft version of the SCT was created in accordance with input from the content experts, consisting of five vignettes of four items each per domain. The primary investigator then emailed each of the content experts a copy of the SCT questions from their domain to begin the process of establishing face validity. Content experts evaluated each of the items created by the primary investigator in response to their original prompts. Content experts were asked to affirm whether they believed each question was written and worded clearly and whether the content of each item was representative of typical athletic training content. Qualitative feedback from the expert panelists, gathered through email in this phase of the study, was used to make initial minor edits to each of the questions. The feedback from the content experts centered around two themes: including additional background information and including varying athletic training work settings into the original prompts. Most of the initial edits were in an effort to expand on the patients background within individual vignette prompts. An example of this was assigning patients who were involved in NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 38 athletics a position (such as pitcher), instead of a generic description as a baseball player. Adding age and gender of patients when they were deemed possible considerations in the decisionmaking process were another common initial edit. Edits expanding background were applied across the prompts within each domain. However, there was one instance of distinct edits that were recommended within an individual domain, as well. Adding information specifying chief complaints of patients were initial edits made specifically within the Therapeutic Interventions domain, in an effort to direct the purpose of the intervention response options. The second category of primary edits focused on diversifying the settings and patients in which the athletic trainer test-taker would be hypothetically practicing within individual vignettes. The original iteration, created by the primary investigator, focused all of the questions towards traditional athletic settings. However, multiple content experts recommended that the SCT would be more generalizable to athletic training practice if prompts included varying athletic settings that were representative of the varied athletic training practice settings. Many questions were edited in response to this suggestion. The resultant prompts included police academy, occupational workplace, recreational athletics, and industrial settings. Similar in tone to the recommendation to diversity setting was the recommendation to diversify patient ages across the lifespan. The majority of patients initially created by the primary investigator were adolescent or young adult, matching the population typical to the traditional athletics work setting. As settings were diversified, patients ages were diversified, as well, to range from youth to the elderly. Content Validity After the initial round of edits was made to establish face validity, the revised SCT was sent in its entirety, directly via email, to all five content experts to establish content validity. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 39 Content experts were asked to rate each vignette using an item quality grid adapted from Fournier et al. (2008). The item quality grid probed the content experts on whether they believed individual vignettes required a decision to be made, included knowledge typical to athletic training practice, were necessary to interpret each response possibility, and contained options relevant to the prompt. Additionally, the item quality grid queried content experts on adequate mechanics of each question, namely that each was clearly and correctly written and followed a key feature approach. Finally, content experts were asked to respond whether the SCT in its entirety utilized Likert-like scales that were clearly defined and unambiguous, included responses that should span the Likert-like scale, and should vary in uniformity from respondents. The constructive feedback received from the content experts on the item quality grid all was in response to the criterion The scenario is clearly understandable and correctly written. In sum, 19 of the 25 vignettes at this stage in the creation of the SCT were deemed by at least one content expert to not be clearly understandable or correctly written. In an effort to remedy the lack of clarity and correctness, the primary investigator emailed each content expert requesting that they suggest edits for each question they had indicated did not meet the clear and correct criterion. These suggestions were easily divided into two categories: providing more clarity and correcting inaccurate descriptions. The suggestions centered on providing more clarity were largely semantic in nature, including suggestions such as changing spineboard to spineboard with a cervical collar, using ultrasound to using ultrasound over her piriformis, and has mild overpronation to mildly overpronates, bilaterally. Three questions (12, 18, and 24) were deemed to be incorrectly written. Question 12 necessitated changing two response items: is not breathing to has no pulse and is unconscious to is not breathing. Revision of question 18 required changing a pain scale in one response from 1/10 to 2/10. Question 24 required an NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 40 edit to properly describe a degree of confidentiality, changing keeping information of his HIV status strictly confidential to sharing knowledge of his HIV positive status with nobody. As changes were made to the 19 questions, the newly edited questions were sent back to the respective content experts who had indicated they were initially unclear or incorrect, to confirm each revised question was now deemed clear and correct. The resultant 100 item SCT test (Appendix D) was deemed to positively meet all criteria described within the item quality grid by each of the five content experts, displaying an item level content validity index of 1.0, and a scale level content validity index of 1.0, as suggested by Polit and Beck (2006) for a panel size of five. A summary of processes used to establish face and content validity is found in Appendix E. Item Analysis The test taken by the 20 individuals of the expert panel was composed of 100 individual items, organized into five vignettes of four items apiece, per each of the five athletic training practice domains. Any item from an existing vignette that already had an item removed was disqualified from further removal. This process was repeated until exactly one item was removed from each vignette. This process is depicted in Figure 2. An account of each stepwise removal including the item removed and resultant Cronbachs alpha value is included in Table 4. After item optimization, a 75 question SCT (appendix E), constructed of 25 individual vignettes with three items apiece was created. Internal Consistency Prior to item analysis, an initial Cronbachs alpha of .48 was obtained based on 99-items. After item optimization, a Cronbachs alpha coefficient of .73 was calculated, an increase of .25 from the original iteration of the exam. Following the initial item analysis and optimization of the SCT, a secondary analysis was performed to compare all possible iterations of the SCT that NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 41 included only four of the five vignettes for each respective domain area. This analysis essentially compared the internal consistency of every 60-item iteration of the SCT with equal distribution of questions from each domain area. A possible 3,250 iterations of a final SCT existed and were compared. The newly optimized and final 60-item version of the SCT (Appendix F) demonstrated an internal consistency Cronbachs alpha coefficient value of .77. This value represented a .04 increase over the initially optimized version and a .29 increase over the original version of the SCT. Discussion The goal of this study was to establish face and content validity of a SCT specific to athletic training that demonstrated maximal internal consistency. The current study operated under the assumption that a SCT specific to athletic training would demonstrate construct validity in measuring clinical reasoning if it were constructed in accordance with established test construction criteria set forth by Charlin et al. (2006), Dory et al. (2012), Fournier et al. (2008), Gagnon et al. (2005) and Lubarsky et al. (2013). When constructed according to these guidelines construct validity in SCTs has been established regardless of medical discipline. Establishing Face and Content Validity The first step of establishing face and content validity involved creating a test blueprint to ensure all domains of athletic training were included within the resultant script concordance test. Test blueprints are advised to ensure knowledge domains intended to be tested are comprehensively addressed within the questions of the exam (Lubarsky et al., 2013). It has been suggested that test developers be familiar with not only the content domain of the SCT, but also the purpose and target audience (Lubarsky et al., 2013). The approach taken in developing a test blueprint for this study leveraged the strengths of two groups to satisfy this suggestion. Content NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 42 experts in each domain of athletic training were identified, ensuring familiarity in content from each domain of athletic training. In order to be considered a content expert, individuals must have had direct vocational or research ties to one of the five domains of athletic training, with a requisite ten years of experience. These criteria were aimed at ensuring those creating the blueprint for the test had a breadth and depth of knowledge about the content included in their specified domain. To further ensure familiarity with the content area of the domain, each content expert was provided with a copy of the BOC Practice Analysis, 7th edition (Henderson, 2015), which comprehensively lists the task statements, knowledge, and skills requisite of entry level athletic trainers. The primary investigator, a certified athletic trainer, was familiar with the purpose of a SCT and the target audience, and ultimately then wrote the SCT from the solicited blueprint of the content experts. Care was taken in selection of the content experts to include individuals of both genders and multiple ethnicities in an attempt to minimize any gender, ethnic, or cultural biases that might become prevalent with a homogenous question writing group. Once a SCT had been developed by the primary investigator from the blueprint of the content experts, it was sent back to each content expert to determine if the wording chosen by the principal investigator was clear and that the resultant questions were representative of athletic training, as intended by the experts in the test blueprint. Utilizing qualitative feedback from the content experts, verbiage changes were applied to the questions in need to increase the clarity or representativeness of those questions. This method has been used in similar healthcare research to establish face validity of a novel measure (Miller, Bakas, Weaver, Buelow & Sabau, 2015). A second round of more formal feedback was solicited utilizing a modified version of the item quality grid (Fournier, 2008) from the expert panel to further establish face and content validity, through the application of content validity indices. Polit and Beck (2006) suggested that NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 43 content validity can be measured at two levels: individual items and overall scale. For an instrument to demonstrate content validity, each item must be deemed content valid, along with the entire scale. It is suggested item level content validity is achieved when an individual item is deemed content relevant by 80% of those rating it. However, when there are five or less evaluators, as is the case for the content experts, chance inflates the likelihood of this occurring, and a more stringent criterion of 100% accordance is advised (Polit and Beck, 2006). Feedback from the item quality grid responses of each content expert was utilized to reword questions not meeting the 100% criterion until all content experts were in unanimous agreement. Scale level content validity is calculated based on the percentage of items within a measure rated as content valid by all of the raters. As 100% item level agreement was necessary for an item to be included, due to the expert panel size of five, calculating scale level agreement became a formality, as it was assured to be 100%, as well. Again, Miller et al. (2015) provide an example of successful integration of this methodology in establishing content validity in a novel measure within healthcare. Establishing Internal Consistency Reliability Internal consistency reliability was established through a stepwise progression of discarding vignettes and individual questions until an acceptable Cronbachs value indicating internal consistency was achieved. Taber (2017) chronicled the widespread use of Cronbachs alpha as a measure of internal consistency reliability in the development of scientific research instruments among peer reviewed and published research. Dory et al. (2012) indicated it is expected that removal of 25% of the original questions in a SCT may be necessary to establish acceptable internal consistency, but up to a 75% question removal rate might be needed. Consideration of these rates were taken into account in the creation of the athletic training NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 44 specific SCT; the initial version of the exam started with 100 questions, while the end product included only 60 questions, a 40% reduction. This planned reduction in questions proved both necessary and beneficial, as the original 100 item SCT demonstrated a Cronbachs alpha of only .48. There is a lack of uniformity in describing the quality of Cronbachs alpha values as they relate to internal consistency. This ambiguity is clearly seen as Taber (2017) demonstrates peer reviewed and published research have described this level of Cronbachs alpha (.48) on the continuum ranging from not satisfactory to sufficient and even as acceptable, even though a value of .70 or greater is typically considered the threshold of desired internal consistency of a new measure. Dory (2012) suggests an internal consistency of .80 is optimal. However, Taber (2017) argued that this level of internal consistency is only intended for scales that measure items of a singular conceptual construct. However, a SCT would not represent a scale measuring items of a singular conceptual construct as Taber (2017) described, as the complexity of the development of clinical reasoning would represent many overlapping constructs. In addition to the many constructs that may result in clinical expertise and subsequent athletic training, discipline-specific knowledge could be considered a singular construct. Furthermore, each of the five practice domains included within the created SCT could actually represent five multiple constructs in nature. The eventual optimized 60 question SCT demonstrated a Cronbachs alpha of .77, nearing Dorys (2012) recommendations and exceeding the general consensus in desirability. Interestingly, from the remaining items after the initial optimization, there were fifteen, 60-question versions of the exam that could be created with a Cronbachs alpha equal to or greater than .75, and 685 possible versions that could be created with a Cronbachs alpha equal to or greater than .70. This provides a number of acceptable versions of the SCT that could NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 45 be used to measure development of clinical reasoning ability over time without subjecting learners to a testing effect of repeating the same exam. Most studies reporting validation of new SCTs bypass the step of establishing face and content validity and progress straight to demonstrating internal consistency reliability of the new measure. By doing so, researchers made the assumption that because SCTs have content validity in other disciplines, they will also have content validity in new disciplines. This study aimed to more definitively establish the overall reliability of a script concordance test in athletic training by rigorously regimenting the process of test creation allowing for establishment of face and content validity. Only then was internal consistency reliability considered and established. The final product resulted in a script concordance test comprised of 20 vignettes and a total of 60 items that were equally distributed among the five domains of athletic training. This test demonstrated item level and scale level content validity indices of 1.00 and a Cronbachs alpha of .77, indicating it demonstrated face validity, content validity and internal consistency. Limitations There are a number of limitations to be considered in the establishment of face and content validity and internal consistency reliability of the eventual SCT. Perhaps the most important limitation is the lack of consensus on what criteria constitute clinical expertise. Though a threshold of experience is necessary to develop clinical expertise, this threshold is ambiguous. Additionally, a threshold of experience alone does not guarantee clinical expertise, as other factors such as use of evidence, metacognition and continuing education may all supplement the development of clinical expertise. The process of purposive and snowball sampling presents another important limitation. The personal contacts of the primary investigator who were initially sampled come from a fairly homogenous educational background. Thus, the NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 46 opinions and rationale utilized by each expert panelist to answer each question may be skewed towards the leanings of these specific educational backgrounds, and not fully generalizable other educational backgrounds. Finally, the lack of test-retest results by the expert panel decrease the overall reliability of the resultant SCT. Conclusions and Implications This research lays out a framework for establishing face and content validity of a newly developed SCT. This developmental step and component of validity is often assumed and bypassed in the development of novel SCTs. Additionally, a framework for optimizing internal consistency reliability through item and case analysis/reduction was demonstrated that both adhered to best practice guidelines and resulted in an ideal level of internal consistency reliability. Future research should focus on comparing the results of two groups, experienced athletic trainers and novice athletic trainers, to confirm the SCTs ability to discriminate clinical reasoning ability. Once established, the profession of athletic training would have a valid and reliable tool to measure clinical reasoning ability specific to athletic training. The implications of creating such a tool are profound. 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The life changes in epilepsy scale: development and establishment of content and face validity. Clinical Nurse Specialist, 29(2), 95-99. http://doi.org/ 10.1097/NUR.0000000000000109 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 55 Monteiro, S., Norman, G., & Sherbino, J. (2018). The 3 faces of clinical reasoning: Epistemological explorations of disparate error reduction strategies. Journal of Evaluation in Clinical Practice, 24(3), 666-673. http://doi.org/ 10.1111/jep.12907 National Athletic Trainers Association. (2011). Athletic training education competencies. Retrieved from https://www.nata.org/sites/default/files/competencies_5th_edition.pdf Norman, G. R. (2005). Research in clinical reasoning: Past history and current trends. Medical Education, 39(4), 418-427. http://doi.org/10.1111/j.1365-2929.2005.02127.x Norman, G. R., & Eva, K. W. (2010). Diagnostic error and clinical reasoning. Medical Education, 44, 94 100. http://doi.org/10.1111/1365.2923.2009.03507.x Norman, G. 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Journal of the American Geriatrics Society, 60(10), 1946-1950. http://doi.org/10.1111/j.1532-5415.2012.04152.x NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 56 Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know whats being reported? Critique and recommendations. Research in Nursing and Health, 29, 489-497. Reeves, A. J., Baker, R. T., Casanova, M. P., Cheatham, C. W., & Pickering, M. A. (2020). Examining the factorial validity of the Quality of Life Scale. Health and Quality of Life Outcomes,18(32), 1-17. https://doi.org/10.1186/s12955-020-01292-5 Rivas, F. J., MartnIglesias, S., del Cerro, J. L., Arenas, C., Lpez, M. and Lagos, M. (2016), Effectiveness of Nursing Process Use in Primary Care. International Journal of Nursing Knowledge, 27(1), 43-48. doi:10.1111/2047-3095.12073 Rotgans, J. I., Schmidt, H. G., Rosby, L. V., Tan, G. J., Mamede, S., Zwaan, L. Low-Beer N. (2019). Medical Education, 53(2), 143-152. http://doi.org/ 10.1111/medu.13681 Schmidt, H. G., & Rikers, R. M. (2007). How expertise develops in medicine: Knowledge encapsulation and illness script information. Medical Education, 41(12), 1133-1139. http://dx.doi.org/10.1111/j.1365-2923.2007.02915.x See, K. C., Tan, K. L., & Lim, T. K. (2014). The script concordance test for clinical reasoning: Re-examining its utility and potential weakness. Medical Education, 48(11), 10691077. http://doi.org/10.1111/medu.12514 Singh, H., Giardina, T. D., Meyer, A. N., Forjuoh, S. N., Reis, M. D., & Thomas, E. J. (2013). Types and origins of diagnostic errors in primary care settings. JAMA Internal Medicine, 173(6), 418 425. http://doi.org/10.1001/jamainternmed.2013.2777 Taber, K. S. (2017). The use of Cronbachs alpha when developing and reporting research instruments in science education. Research in Science Education, 48(6), 1273-1296. http://doi.org/10.1007/s11165-016-9602-2 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 57 Thornton, T. (2010). Clinical judgement, expertise and skilled coping. Journal of Evaluation in Clinical Practice, 16(2), 284-291. http://doi.org/10.1111/j.1365-2753.2010.01386.x Wilson, A. B., Pike, G. R., & Humbert, A. J. (2014). Analyzing script concordance test scoring methods and items by difficulty and type. Teaching and Learning in Medicine, 26(2), 135-145. http://dx.doi.org/10.1080/10401334.2014.884464 Ward, L. D., French, B. F., Barbosa-Leiker, C., & Iverson, A. E. (2016). Application of exploratory factor analysis and item response theory to validate genomic nursing concept inventory. Journal of Nursing Education, 55(1), 9-17. http://doi.org/ 10.3928/0148483420151214-05 Woods, N. N., & Mylopoulos, M. (2015). How to improve the teaching of clinical reasoning: from processing to preparation. Medical Education, 49(10), 952-953. http://doi.org/ 10.1111/medu.12823 Young, M., Thomas, A., Gordon, D., Gruppen, L., Lubarsky, S., Rencic, J., Durning, S.J. (2019) The terminology of clinical reasoning in health professions education: Implications and considerations, Medical Teacher, 41(11), 1277-1284. http://dx.doi.org/10.1080/0142159X.2019.1635686 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 58 Table 1 Content Expert Characteristics Characteristics Expert 1 Expert 2 Expert 3 Expert 4 Expert 5 Illness Evaluation Immediate Prevention Assessment and Therapeutic Administration and and Emergency Intervention and Professional Wellness Diagnosis Care Male Male Male Female White White White White 15 21 22 15 Collegiate Collegiate Collegiate Industrial Injury and Practice Domain of Expertise Healthcare Responsibility Promotion Gender Ethnicity Female Hispanic or Latino Years Certified 15 Employment Hospital or setting clinic Establishment Job related Job related Job related Research Job related of Expertise duties duties duties line duties Table 1 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 59 Table 2 Expert Panel (n=20) Demographics Characteristics Number Percentage Female 7 35% Male 13 65% Black 1 5% Hispanic or Latino 3 15% White 16 80% Gender Ethnicity Table 2 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 60 Table 3 Expert Panel (n=20) Experience Expert Panelist Years of Certification Years of Clinical Experience 1 16 16 2 10 10 3 10 10 4 10 10 5 22 22 6 10 10 7 15 15 8 15 15 9 14 12 10 35 35 11 21 21 12 13 12 13 11 11 14 15 15 15 12 12 16 22 22 17 10 10 18 10 10 19 16 16 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 20 20 Table 3 61 20 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Table 4 Stepwise Item Analysis and Removal Analysis Number Item Removed Resultant Cronbach's Alpha 1 60 .48 2 61 .52 3 81 .56 4 2 .58 5 65 .61 6 77 .63 7 20 .65 8 11 .66 9 90 .67 10 45 .68 11 14 .69 12 94 .70 13 7 .71 14 38 .71 15 73 .72 16 27 .72 17 35 .73 18 54 .73 19 85 .73 62 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 20 29 .73 21 21 .73 22 41 .73 23 49 .73 24 70 .72 25 97 .73 Table 4 63 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 64 Figure 1 Individual content experts create 5 vignette test blueprint Test blueprints are sent to PI PI creates initial version of SCT according to test bluepring 100 items (5 vignettes of 4 items each) Content experts evaluate vignettes from own domain PI makes minor edits based on feedback Each content expert evaluates entire SCT with item quality grid PI edits individual vignettes to be "clearly understandable and correctly written" All content experts evaluate for I-CVI and SCVI of 1.0 Figure 1. Process of establishing face and content validity Face and content valid 100 item SCT results NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Figure 2 4. Remove indicated item 1. Run item analysis in SPSS 3. Determine which item's removal (from remaining vignettes without an item already removed) would increase Cronbach's alpha the most 2. Compare Cronbach's alpha of all versions of test with one additional item removed Figure 2. Process of maximizing Cronbachs alpha through item analysis 65 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 66 Appendix A Content Expert Inclusion/Exclusion Questionnaire 1. In what year were you initially granted permission to practice as a certified athletic trainer by the Board of Certification, Inc. (BOC)? (choose drop down year: 1989 - present) (if after 2002, go to end of survey) (if 2002 or prior, go to question 2) 2. How many years of clinical experience do you possess as a certified athletic trainer? (choose drop down number: 0 - 29) (if 10 or greater, go to question 3) (if less than 10, go to question 6) 3. Are you currently engaged in clinical practice as a certified athletic trainer? (select: Yes/No) (if yes, go to question 4) (if no, go to question 6) 4. In which of the domains of athletic training (if any), as identified by the Athletic Trainer Practice Analysis, 7th edition, do you regularly and purposefully integrate evidence based practices into your current clinical practice? (select all that apply: Injury and Illness Prevention and Wellness Examination, Assessment and Diagnosis Immediate and Emergency Care Therapeutic Intervention NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 67 Healthcare Administration and Professional Responsibility None of the above) (if none of the above, go to end of survey) (otherwise, go to question 5) 5. Which of the domains of athletic training (if any) do you specifically and routinely engage in as part of your formal job related duties? (select all that apply: Injury and Illness Prevention and Wellness Examination, Assessment and Diagnosis Immediate and Emergency Care Therapeutic Intervention Healthcare Administration and Professional Responsibility None of the above) (if none of the above, go to end of survey) (otherwise, go to question 7) 6. Which of the domains of athletic training (if any), as identified by the Athletic Trainer Practice Analysis, 7th edition, do you have a currently established research line in? (select all that apply: Injury and Illness Prevention and Wellness Examination, Assessment and Diagnosis Immediate and Emergency Care Therapeutic Intervention Healthcare Administration and Professional Responsibility None of the above) (if none of the above, go to end of survey) NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST (otherwise, go to question 7) 7. Are you fluent in your ability to read and write English? (select: Yes/No) (if yes, go to question 8) (if no, go to end of survey) 8. Do you possess one or more diagnosed learning disabilities? (select: Yes/No) (end of survey) 68 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 69 Appendix B Content Expert Prompt Thank you for choosing to participate as a content expert in the area of (insert domain). Your input will be instrumental in the experimental creation of a valid and reliable script concordance test specific to athletic training aimed at measuring clinical reasoning. As part of this study you are asked to identify five possible cases to be utilized in a script concordance test. Each case will be composed of three components: 1) clinical situation, 2) relevant options, and 3) key features. A brief description of each of these components and an example of one entire case follows. Should you find it beneficial to understand the final construct that will result from your input, an actual example of a script concordance test question that might stem from the given example can also be found below. Clinical Situations Identify five authentic frequently seen or especially important clinical situations within the domain of (insert domain), as identified by the Athletic Training Practice Analysis, 7th edition (see attached for reference). Each clinical situation need not be overly complex or unusual, but should contain some amount of uncertainty. Relevant Options Please identify four relevant hypotheses, investigational strategies, or therapeutic options that may result from each individual clinical situation. Relevant options may vary from specific to general in nature. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 70 Key Features Please identify four specific pieces of data that you would look for in each situation to help you progress towards a solution. Example for Therapeutic Intervention domain Case 1 Clinical Situation: Patient who is a baseball player presents to athletic trainer in order to perform post-operative shoulder rehab Relevant Options: (therapeutic options) initiate passive range of motion exercises, control pain, strengthen surrounding musculature, develop a home care program Key Features: type of surgery performed, current pain levels, MMT results, psychosocial barriers Example of Possible Resulting SCT question A 21 year old baseball player returns to your university in January stating he had shoulder surgery over Christmas break. He was instructed to contact the athletic training staff to continue his post-operative rehabilitation. If you were thinking of .and you find this option becomes initiating passive range of the patient had a labral -2 motion exercises debridement -1 0 +1 +2 -2: strongly contraindicated / -1 contraindicated / 0 neither more or less indicated / +1 indicated / +2 strongly indicated (Please provide your cases under the prompts on the following page) NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Case 1 Clinical Situation: (insert text here) Relevant Options: (insert text here) Key Features: (insert text here) Case 2 Clinical Situation: (insert text here) Relevant Options: (insert text here) Key Features: (insert text here) Case 3 Clinical Situation: (insert text here) Relevant Options: (insert text here) Key Features: (insert text here) Case 4 Clinical Situation: (insert text here) Relevant Options: (insert text here) Key Features: (insert text here) Case 5 Clinical Situation: (insert text here) Relevant Options: (insert text here) Key Features: (insert text here) 71 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 72 Appendix C Item Quality Grid Injury and Illness Prevention and Wellness Promotion Scenario 1 Criteria Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 2 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 3 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Criteria 73 Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 4 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 74 Scenario 5 Criteria Yes No Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Examination, Assessment, and Diagnosis Scenario 1 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 2 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 75 The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 3 Criteria Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 4 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 5 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Criteria 76 Yes No Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Immediate and Emergency Care Scenario 1 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 2 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 77 The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 3 Criteria Yes No Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 4 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 5 Criteria NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 78 The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Therapeutic Intervention Scenario 1 Criteria Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 2 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 79 Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 3 Criteria Yes No Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 4 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 5 Criteria The scenario describes a challenging situation requiring a decision NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 80 The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Healthcare Administration and Professional Responsibility Scenario 1 Criteria Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 2 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 81 Options presented in each question are relevant to scenario Scenario 3 Criteria Yes No Yes No Yes No The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 4 Criteria The scenario describes a challenging situation requiring a decision The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Scenario 5 Criteria The scenario describes a challenging situation requiring a decision NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 82 The scenario includes knowledge typical of athletic training practice The scenario is necessary to understand individual questions The scenario is clearly understandable and correctly written Questions are developed following a key feature approach Options presented in each question are relevant to scenario Script Concordance Test Criteria Likert scale anchors are clearly defined and unambiguous Questions are built to allow answers to be spread equally throughout Likert scale Questions are built to allow answers to range from high to low variability Yes No NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 83 Appendix D Domain 1 Injury Prevention and Wellness Promotion 1. An ACL deficient pitcher with documented blood pressure of 140/95 is completing the pre-participation physical exam and screening process at your institution. If you were thinking of: Requiring him to complete an electrocardiogram (ECG) before releasing him for participation And you find: He has no past medical or family history of heart He currently has minimal participation effusion in his knee balance program for him -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 conditions Releasing him for full Starting a prophylactic This option becomes: He scored equally for both limbs on the Y balance test during screening Referring him to a He has documented sickle cardiologist cell trait -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 84 2. A 16-year-old female soccer player has time to complete one 30-minute injury prevention plan before practice, daily. She asks you to create a plan that would be most beneficial for her. If you were thinking of: And you find: Creating an ACL She has no previous prevention plan history of ACL injury Creating a plan focused on agility exercises This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 She lacks 8 degrees of dorsiflexion in her dominant ankle Assessing her valgus She is currently 7 days landing angle before removed from a grade 1 proceeding ankle sprain Creating an ACL She is the starting prevention plan goalkeeeper -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 85 3. While monitoring football practice during the 6th day of the fall season, you become aware that there is a line of storms approximately 10 miles away. If you were thinking of: Removing all personnel from the field Removing all personnel from the field And you find: This option becomes: The line of storms is moving away from your -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 location The line of storms is moving parallel to your location Providing a sports drink in place of water for the The team is practicing for players at the half-way 45 minutes today point of practice Providing a sports drink in place of water for the The team is practicing for players at the half-way 2 hours today point of practice -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 86 4. You are tasked with fitting the football team at your high school with protective devices prior to the upcoming football season. If you were thinking of: And you find: This option becomes: Providing a shoulder stabilizer harness for a The player is a wide player with recurrent receiver -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 glenohumeral instability Providing cantilevered pads for a linebacker Providing ACL braces for a player without history of knee injury Providing a smaller helmet for a player who requests one He has a previous history of grade 3 AC sprain, without surgical repair The player is an offensive lineman His current helmet aligns correctly at all bony landmarks, but wiggles on his head -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 87 5. A 51-year-old female employee at your place of work asks you to create a tailored wellness plan for her. If you were thinking of: And you find: Focusing on having her She walks for 30 minutes increase physical activity at least 5 times weekly Testing her resting blood This option becomes: -2 -1 0 +1 +2 She has a BMI of 31.4 -2 -1 0 +1 +2 Focusing her plan on Her primary complaint is -2 -1 0 +1 +2 psychological wellness that she is unhappy with -2 -1 0 +1 +2 glucose levels the amount of work-elated stress she experiences Testing her She has not been to the cardiorespiratory doctor for an annual endurance physical in the last 10 years. -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 88 Domain 2 Examination, Assessment and Diagnosis 1. A 29-year-old womens soccer player reports to your athletic training clinic 30 minutes after planting to change direction and feeling her knee give out. Her chief complaint is knee pain. If you were thinking of the following diagnosis: And you find: This diagnosis becomes: She is point tender over Grade 3 ACL sprain the medial border of the -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 involved patella Grade 3 ACL sprain Meniscus tear Patellar subluxation She has full active knee extension She has moderate knee effusion She has a negative Lachmans test -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 89 2. A 15-year-old patient who pitches for a little league team reports to your athletic training clinic with a chief complaint of medial elbow pain and a decrease in throwing velocity. If you were thinking of the following diagnosis: Wrist flexor strain And you find: He has 4/5 strength with elbow flexion This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 He has pain with no laxity UCL sprain during valgus stress testing His pain has gradually Medial epicondylitis increased over the past 3 weeks He reports the pain UCL sprain occurring during one specific pitch -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 90 3. A 38-year-old male assembly line worker reports to you with a chief complaint of shoulder pain on his dominant arm. If you were thinking of: Performing the empty can test Performing the apprehension/relocation test And you find: This option becomes: His pain is isolated to the anterior -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 glenohumeral joint He has a history of one glenohumeral dislocation, 6 years previous His pain is Performing the exacerbated with Hawkins Kennedy test active external rotation He reports a FOOSH Performing the AC (fall on an compression test outstretched hand) mechanism of injury -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 91 4. A 21-year-old female volleyball player reports to you with a chief complaint of pain and clicking in her left knee. If you were thinking of: Referring her to an orthopedic specialist Referring her to an orthopedic specialist And you find: This option becomes: She has not attempted any intervention to remedy her -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 complaints yet Hey symptoms have persisted for the past 4 months She has a past medical Referring her to an orthopedic specialist history of surgical repair to her medial meniscus in the same knee 4 years previous Referring her to an Her pain and clicking can orthopedic specialist be consistently reproduced -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 92 5. A 49-year-old male recreational athlete reports to you with a chief complaint of chronic low back pain. If you were thinking of the following diagnosis: Spinal stenosis Lumbar disc herniation Mechanical low back pain Sciatica And you find: A positive straight leg raise test A positive straight leg raise test A negative straight leg raise test A negative straight leg raise test This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 93 Domain 3 Immediate and Emergency Care 1. You have been tasked with creating an emergency action plan (EAP) for a newly constructed high school. If you were thinking of: And you find: Creating individualized The new high school has EAPs for each athletics 15 different athletics facility location facility locations Including EMS as part of The local EMS department the emergency personnel is volunteer only Designating your local The local hospital is not hospital as the emergency categorized as a trauma care facility center This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 The high school only Having an ambulance on sponsors the sports of site for all home contests basketball, soccer, baseball, and softball -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated 2. You are responding to a patient who has been involved in a bleacher collapse accident. Upon visual triage of the situation, the patient is lying prone with an obvious open tibial fracture. NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST If you were thinking of: Providing initial spinal immobilization through the use of a spineboard Providing initial spinal immobilization through the use of a spineboard And you find: The patient is not 94 This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 complaints of neck or back -2 -1 0 +1 +2 breathing The patient has full sensation in all extremities Providing initial immobilization of the open tibial fracture through the The patient is unconscious use of a vacuum splint Providing initial immobilization of the open tibial fracture through the use of a vacuum splint The patient has no pain -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 95 3. A female softball catcher jogs over to you during practice after diving for a ball, with an obviously dislocated glenohumeral joint. If you were thinking of: And you find: Attempting to relocate her Her dislocation is shoulder posterior Attempting to relocate her She has a diminished shoulder distal radial pulse Attempting to relocate her shoulder Attempting to relocate her shoulder This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 This is her first occurrence of glenohumeral dislocation Your initial attempt to relocate the shoulder was unsuccessful -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 96 4. A 19-year-old football player comes to you on the sideline asking you to take care of a fresh turf burn abrasion measuring 2 inches x 6 inches that he just received. If you were thinking of: Cleansing the wound with sterile saline Mechanically debriding the wound with gauze And you find: The patient has a history of resistant staphylococcus -2 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 The wound to be clean with small rubber pellets embedded The patient cannot see you top of the wound again until 24 hours later the wound -1 aureus infection Wrapping moist gauze on Utilizing tap water to rinse This option becomes: The tap water at your facility goes through a water softener -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 97 5. A 27-year-old male racquetball player presents to you with an apparent blow out fracture of his right orbit occurring 30 minutes prior. If you were thinking of: And you find: This option becomes: Referring him immediately to the emergency He has no vision deficits -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 department Referring him next day to a He has bilateral periorbital physicians office hematoma (raccoon eyes) Referring him same day to He has a small hyphema a minor emergency clinic present in the involved eye Referring him immediately to the emergency department Restricted upward gaze in the involved eye -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 98 Domain 4 Therapeutic Intervention 1. You are tasked with creating a plan of care for a 41-year-old female with piriformis syndrome in her left buttock/leg. Her chief complaint is of pain after long bouts of sitting. If you were thinking of: And you find: Using a foam roller over her Her radiating symptoms piriformis travel to the posterior knee Using e-stim Using ultrasound Administering 400mg ibuprofen 4 times a day This option becomes: -2 -1 0 +1 +2 Her pain scale is a 3/10 -2 -1 0 +1 +2 She has a 24% body fat -2 -1 0 +1 +2 -2 -1 0 +1 +2 She has a history of gastroesophageal reflux disease -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 99 2. You are tasked with creating a plan of care for a 22-year-old male tennis player with rotator cuff tendonopathy. His chief complaint is worsening pain (6/10) with overhead motions over the last 3 days. If you were thinking of: And you find: Educating him about the He had a corticosteroid advantages of corticosteroid injection to the same area injections 10 months ago Initiating isometric He has 4/5 strength for all exercises shoulder motions Decreasing serving activity He has full strength in all for 4 days planes of motion Implementing scapular He has mild scapular stabilizer exercises winging, bilaterally This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 100 3. You have a 17-year-old patient diagnosed with patellofemoral pain syndrome and decreased thigh girth in the affected leg. If you were thinking of: And you find: Integrating body weight full The patient has mild pain squats into a rehabilitation (1/10) with a single full plan weight body squat Utilizing McConnell taping The patient has a q-angle as part of a treatment plan of 23 o This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 Integrating jump landing training into a The patient is male rehabilitation plan Focusing a treatment plan on increasing muscular strength Her chief complaint is pain with activity (3/10) -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 101 4. A 37-year-old female training for a half marathon was diagnosed with posterior tibialis tendonitis on her left leg 2 weeks prior. She continues to complain of pain during and after activity. If you were thinking of: And you find: She has mild pes planus, Fitting her for orthotics equal bilaterally Utilizing ice massage before She takes regular medicine activity for high cholesterol Integrating strengthening of intrinsic foot muscles into a rehabilitation plan She has mild overpronation Suggesting the use of OTC She prefers to use naproxen sodium (Aleve) homeopathic remedies for into a treatment plan pain control This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 102 5. A 55-year-old male firefighter diagnosed with a grade one inversion ankle sprain reports to you with moderate swelling about the entire ankle. He reports a current pain scale of 3/10 and appears to be non-weight bearing, using crutches and a walking boot. If you were thinking of: And you find: Advising him to discontinue His injury date was 2 days use of the boot previous Utilizing intermittent compression as part of a treatment plan Initiating active assistive range of motion exercises Utilizing continuous ultrasound as part of a treatment plan This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 He has a past medical history of diabetic neuropathy in the opposite limb He has 10 degrees of decreased dorsiflexion in the involved ankle His injury date was 4 days previous -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 103 Domain 5 Healthcare Administration and Professional Responsibility 1. You and one colleague work at a university that sponsors football, volleyball, mens and womens soccer during the fall semester. Each of these teams practices at a different on campus location, but are all serviced out of one common athletic training facility. The only team you have a set schedule for at this point is the football team, which will be practicing at 8 a.m. daily. You are asked to coordinate staffing priorities for the upcoming training camp practices. If you were thinking of: Staffing an athletic trainer on site for both football and womens soccer practice And you find: All four teams will be practicing concurrently Staffing one athletic trainer A player on the mens at football practice and one soccer team has a history athletic trainer centrally at of supraventricular the athletic training facility tachycardia Staffing both athletic trainers on site for football practice This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 The four teams practices are spread over 12 hours of the day in four 3 hour blocks Staffing both athletic The football team will not trainers centrally at the be wearing equipment athletic training facility today NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 104 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated 2. You have been working at your local police department for the last year, 8 hours a day, Monday through Friday as the sole athletic trainer. Over the last 2 months you have found yourself busier than you were at the beginning of the year, as word of your availability to the department has become more widespread. Part of your annual program assessment is to examine data and see if the current level of staffing and supplies are adequate or not. If you were thinking of: Requesting for the addition of a staff member And you find: This option becomes: You interacted with 15 patients a day, on average, -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 over the course of the year Using the number of average days a policeman was on restricted duty after No institutional data on injury until their return to this statistic exists from full duty to help you years previous determine staffing adequacy Requesting a budget increase You used 80% of the total budget allotted to you for the first year NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Using a peer comparison to There are only two help you determine budget comparable peers for you adequacy to utilize as benchmarks -2 105 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated 3. During your annual program review you identify a few small operational practices that could be changed to increase the privacy and safety of the patients at your athletic training facility. If you were thinking of: And you find: Calling your medical Your medical directors director to discuss these spouse has just been changes before diagnosed with a terminal implementing them cancer This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 Standing orders signed by Implementing these changes your medical director without first consulting directing you to partake in your medical director continual quality improvement Communicating with your medical director through email Your medical director typically only gives a brief yes or no response to emails NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Scheduling an in person Your medical director can meeting with your medical only meet during the director to discuss the summer while you are off changes contract -2 106 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated 4. A male basketball player at your institution who you have built great rapport with after a long post-surgical ACL rehabilitation, confides in you that he just found out that he tested positive for human immunodeficiency virus (HIV). He asks you to keep this information private as he internalizes what it means to him and his future. If you were thinking of: Referring him to the teams clinical psychologist for counseling And you find: He is dating the clinical psychologists daughter Alerting other members of He routinely comes into the athletic training staff of the clinic for ongoing his HIV positive status blister care Alerting the teams clinical psychologist of his HIV positive status He has recently developed suicidal ideation in This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 107 response to his newfound HIV positive status He has been practicing Keeping information of his HIV status strictly confidential unprotected sex with a player on the womens basketball team at your -2 -1 0 +1 +2 institution for the last month -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated 5. As the director or athletic training services at a public university, a subordinate female staff member (Kelly) alleges to you that another subordinate male staff member (Ron) made a derogatory and sexist comment to her in the presence of patients. If you were thinking of: And you find: Getting Rons side of the A patient, unsolicited, story before making any corroborates Kellys other decisions description of the events This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 Ron and Kelly have since Scheduling a joint meeting talked about the incident with Kelly and Ron on their own, and come to a mutual understanding NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST Scheduling a joint meeting Kelly asks you to just with Ron and a human forget the whole thing resources representative even happened 108 -2 -1 0 +1 +2 -2 -1 0 +1 +2 One other female athletic Alerting your Title IX director of this incident training staff member reports Ron speaking in a similar manner to her on one occasion -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 109 Appendix E Domain 1 Injury Prevention and Wellness Promotion 1. An ACL deficient pitcher with documented blood pressure of 140/95 is completing the pre-participation physical exam and screening process at your institution. If you were thinking of: Requiring him to complete an electrocardiogram (ECG) before releasing him for participation Starting a prophylactic balance program for him And you find: This option becomes: He has no past medical or family history of heart -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 conditions He scored equally for both limbs on the Y balance test during screening Referring him to a He has documented sickle cardiologist cell trait -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 110 2. A 16-year-old female soccer player has time to complete one 30 minute injury prevention plan before practice, daily. She asks you to create a plan that would be most beneficial for her. If you were thinking of: And you find: Creating an ACL She has no previous prevention plan history of ACL injury Creating a plan focused on agility exercises This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 She lacks 8 degrees of dorsiflexion in her dominant ankle Creating an ACL She is the starting prevention plan goalkeeeper -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 111 3. While monitoring football practice during the 6th day of the fall season, you become aware that there is a line of storms approximately 10 miles away. If you were thinking of: Removing all personnel from the field Removing all personnel from the field And you find: This option becomes: The line of storms is moving away from your -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 location The line of storms is moving parallel to your location Providing a sports drink in place of water for the The team is practicing for players at the half-way 2 hours today point of practice -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 112 4. You are tasked with fitting the football team at your high school with protective devices prior to the upcoming football season. If you were thinking of: And you find: This option becomes: Providing a shoulder stabilizer harness for a The player is a wide player with recurrent receiver -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 glenohumeral instability Providing ACL braces for a player without history of knee injury Providing a smaller helmet for a player who requests one The player is an offensive lineman His current helmet aligns correctly at all bony landmarks, but wiggles on his head -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 113 5. A 51-year-old female employee at your place of work asks you to create a tailored wellness plan for her. If you were thinking of: And you find: Focusing on having her She walks for 30 minutes increase physical activity at least 5 times weekly Testing her resting blood This option becomes: -2 -1 0 +1 +2 She has a BMI of 31.4 -2 -1 0 +1 +2 Focusing her plan on Her primary complaint is -2 -1 0 +1 +2 psychological wellness that she is unhappy with glucose levels the amount of work related stress she experiences -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 114 Domain 2 Examination, Assessment and Diagnosis 1. A 29-year-old womens soccer player reports to your athletic training clinic 30 minutes after planting to change direction and feeling her knee give out. Her chief complaint is knee pain. If you were thinking of the following diagnosis: Grade 3 ACL sprain Meniscus tear Patellar subluxation And you find: She has full active knee extension She has moderate knee effusion She has a negative Lachmans test This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 115 2. A 15-year-old patient who pitches for a little league team reports to your athletic training clinic with a chief complaint of medial elbow pain and a decrease in throwing velocity. If you were thinking of the following diagnosis: Wrist flexor strain And you find: He has 4/5 strength with elbow flexion This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 He has pain with no laxity UCL sprain during valgus stress testing He reports the pain UCL sprain occurring during one specific pitch -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 116 3. A 38-year-old male assembly line worker reports to you with a chief complaint of shoulder pain on his dominant arm. If you were thinking of: And you find: He has a history of one Performing the apprehension/relocation test Performing the Hawkins Kennedy test Performing the AC compression test This option becomes: glenohumeral dislocation, -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 6 years previous His pain is exacerbated with active external rotation He reports a FOOSH (fall on an outstretched hand) mechanism of injury -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 117 4. A 21 year old female volleyball player reports to you with a chief complaint of pain and clicking in her left knee. If you were thinking of: Referring her to an orthopedic specialist Referring her to an orthopedic specialist And you find: This option becomes: She has not attempted any intervention to remedy her -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 complaints yet Hey symptoms have persisted for the past 4 months Referring her to an Her pain and clicking can orthopedic specialist be consistently reproduced -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 118 5. A 49-year-old male recreational athlete reports to you with a chief complaint of chronic low back pain. If you were thinking of the following diagnosis: Spinal stenosis Lumbar disc herniation Sciatica And you find: A positive straight leg raise test A positive straight leg raise test A negative straight leg raise test This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 119 Domain 3 Immediate and Emergency Care 1. You have been tasked with creating an emergency action plan (EAP) for a newly constructed high school. If you were thinking of: And you find: Including EMS as part of The local EMS department the emergency personnel is volunteer only Designating your local The local hospital is not hospital as the emergency categorized as a trauma care facility center This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 The high school only Having an ambulance on sponsors the sports of site for all home contests basketball, soccer, baseball, and softball -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 120 2. You are responding to a patient who has been involved in a bleacher collapse accident. Upon visual triage of the situation, the patient is lying prone with an obvious open tibial fracture. If you were thinking of: Providing initial spinal immobilization through the use of a spineboard And you find: The patient has full This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 complaints of neck or back -2 -1 0 +1 +2 sensation in all extremities Providing initial immobilization of the open tibial fracture through the The patient is unconscious use of a vacuum splint Providing initial immobilization of the open tibial fracture through the use of a vacuum splint The patient has no pain -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 121 3. A female softball catcher jogs over to you during practice after diving for a ball, with an obviously dislocated glenohumeral joint. If you were thinking of: And you find: Attempting to relocate her She has a diminished shoulder distal radial pulse Attempting to relocate her shoulder Attempting to relocate her shoulder This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 This is her first occurrence of glenohumeral dislocation Your initial attempt to relocate the shoulder was unsuccessful -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 122 4. A 19-year-old football player comes to you on the sideline asking you to take care of a fresh turf burn abrasion measuring 2 inches x 6 inches that he just received. If you were thinking of: Cleansing the wound with sterile saline And you find: The patient has a history of resistant staphylococcus -2 The patient cannot see you top of the wound again until 24 hours later the wound -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 aureus infection Wrapping moist gauze on Utilizing tap water to rinse This option becomes: The tap water at your facility goes through a water softener -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 123 5. A 27-year-old male racquetball player presents to you with an apparent blow out fracture of his right orbit occurring 30 minutes prior. If you were thinking of: And you find: This option becomes: Referring him immediately to the emergency He has no vision deficits -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 department Referring him next day to a He has bilateral periorbital physicians office hematoma (raccoon eyes) Referring him same day to He has a small hyphema a minor emergency clinic present in the involved eye -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 124 Domain 4 Therapeutic Intervention 1. You are tasked with creating a plan of care for a 41-year-old female with piriformis syndrome in her left buttock/leg. Her chief complaint is of pain after long bouts of sitting. If you were thinking of: And you find: Using e-stim Her pain scale is a 3/10 -2 -1 0 +1 +2 Using ultrasound She has a 24% body fat -2 -1 0 +1 +2 -2 -1 0 +1 +2 Administering 400mg ibuprofen 4 times a day This option becomes: She has a history of gastroesophageal reflux disease -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 125 2. You are tasked with creating a plan of care for a 22-year-old male tennis player with rotator cuff tendonopathy. His chief complaint is worsening pain (6/10) with overhead motions over the last 3 days. If you were thinking of: And you find: Initiating isometric He has 4/5 strength for all exercises shoulder motions Decreasing serving activity He has full strength in all for 4 days planes of motion Implementing scapular He has mild scapular stabilizer exercises winging, bilaterally This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 126 3. You have a 17-year-old patient diagnosed with patellofemoral pain syndrome and decreased thigh girth in the affected leg. If you were thinking of: And you find: Integrating body weight full The patient has mild pain squats into a rehabilitation (1/10) with a single full plan weight body squat This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 Integrating jump landing training into a The patient is male rehabilitation plan Focusing a treatment plan on increasing muscular strength Her chief complaint is pain with activity (3/10) -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 127 4. A 37-year-old female training for a half marathon was diagnosed with posterior tibialis tendonitis on her left leg 2 weeks prior. She continues to complain of pain during and after activity. If you were thinking of: And you find: Utilizing ice massage before She takes regular medicine activity for high cholesterol Integrating strengthening of intrinsic foot muscles into a rehabilitation plan She has mild overpronation Suggesting the use of OTC She prefers to use naproxen sodium (Aleve) homeopathic remedies for into a treatment plan pain control This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 128 5. A 55-year-old male firefighter diagnosed with a grade one inversion ankle sprain reports to you with moderate swelling about the entire ankle. He reports a current pain scale of 3/10 and appears to be non-weight bearing, using crutches and a walking boot. If you were thinking of: Utilizing intermittent compression as part of a treatment plan Initiating active assistive range of motion exercises Utilizing continuous ultrasound as part of a treatment plan And you find: This option becomes: He has a past medical history of diabetic neuropathy in the opposite -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 limb He has 10 degrees of decreased dorsiflexion in the involved ankle His injury date was 4 days previous -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 129 Domain 5 Healthcare Administration and Professional Responsibility 1. You and one colleague work at a university that sponsors football, volleyball, mens and womens soccer during the fall semester. Each of these teams practices at a different on campus location, but are all serviced out of one common athletic training facility. The only team you have a set schedule for at this point is the football team, which will be practicing at 8 a.m. daily. You are asked to coordinate staffing priorities for the upcoming training camp practices. If you were thinking of: And you find: Staffing one athletic trainer A player on the mens at football practice and one soccer team has a history athletic trainer centrally at of supraventricular the athletic training facility tachycardia Staffing both athletic trainers on site for football practice This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 The four teams practices are spread over 12 hours of the day in four 3 hour blocks Staffing both athletic The football team will not trainers centrally at the be wearing equipment athletic training facility today -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 130 2. You have been working at your local police department for the last year, 8 hours a day, Monday through Friday as the sole athletic trainer. Over the last 2 months you have found yourself busier than you were at the beginning of the year, as word of your availability to the department has become more widespread. Part of your annual program assessment is to examine data an see if the current level of staffing and supplies are adequate or not. If you were thinking of: And you find: This option becomes: Using the number of average days a policeman was on restricted duty after No institutional data on this injury until their return to statistic exists from years full duty to help you previous -2 -1 0 +1 0 +1 0 +1 +2 determine staffing adequacy Requesting a budget increase You used 80% of the total budget allotted to you for the -2 -1 +2 first year Using a peer comparison to There are only two help you determine budget comparable peers for you to adequacy utilize as benchmarks -2 -1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 131 3. During your annual program review you identify a few small operational practices that could be changed to increase the privacy and safety of the patients at your athletic training facility. If you were thinking of: And you find: Calling your medical Your medical directors director to discuss these spouse has just been changes before diagnosed with a terminal implementing them cancer Communicating with your medical director through email This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 Your medical director typically only gives a brief yes or no response to emails Scheduling an in person Your medical director can meeting with your medical only meet during the director to discuss the summer while you are off changes contract -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 132 4. A male basketball player at your institution who you have built great rapport with after a long post-surgical ACL rehabilitation, confides in you that he just found out that he tested positive for human immunodeficiency virus (HIV). He asks you to keep this information private as he internalizes what it means to him and his future. If you were thinking of: Referring him to the teams clinical psychologist for counseling Alerting the teams clinical psychologist of his HIV positive status And you find: He is dating the clinical psychologists daughter This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 He has recently developed suicidal ideation in response to his newfound HIV positive status He has been practicing Keeping information of his HIV status strictly confidential unprotected sex with a player on the womens basketball team at your institution for the last month -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 133 5. As the director or athletic training services at a public university, a subordinate female staff member (Kelly) alleges to you that another subordinate male staff member (Ron) made a derogatory and sexist comment to her in the presence of patients. If you were thinking of: And you find: This option becomes: Ron and Kelly have since Scheduling a joint meeting talked about the incident with Kelly and Ron on their own, and come to -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 a mutual understanding Scheduling a joint meeting Kelly asks you to just with Ron and a human forget the whole thing resources representative even happened One other female athletic Alerting your Title IX director of this incident training staff member reports Ron speaking in a similar manner to her on one occasion -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 134 Appendix F Domain 1 Injury Prevention and Wellness Promotion 1. An ACL deficient pitcher with documented blood pressure of 140/95 is completing the pre-participation physical exam and screening process at your institution. If you were thinking of: Requiring him to complete an electrocardiogram (ECG) before releasing him for participation Starting a prophylactic balance program for him And you find: This option becomes: He has no past medical or family history of heart -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 conditions He scored equally for both limbs on the Y balance test during screening Referring him to a He has documented sickle cardiologist cell trait -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 135 2. While monitoring football practice during the 6th day of the fall season, you become aware that there is a line of storms approximately 10 miles away. If you were thinking of: Removing all personnel from the field Removing all personnel from the field And you find: This option becomes: The line of storms is moving away from your -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 location The line of storms is moving parallel to your location Providing a sports drink in place of water for the The team is practicing for players at the half-way 2 hours today point of practice -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 136 3. You are tasked with fitting the football team at your high school with protective devices prior to the upcoming football season. If you were thinking of: And you find: This option becomes: Providing a shoulder stabilizer harness for a The player is a wide player with recurrent receiver -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 glenohumeral instability Providing ACL braces for a player without history of knee injury Providing a smaller helmet for a player who requests one The player is an offensive lineman His current helmet aligns correctly at all bony landmarks, but wiggles on his head -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 137 4. A 51-year-old female employee at your place of work asks you to create a tailored wellness plan for her. If you were thinking of: And you find: Focusing on having her She walks for 30 minutes increase physical activity at least 5 times weekly Testing her resting blood This option becomes: -2 -1 0 +1 +2 She has a BMI of 31.4 -2 -1 0 +1 +2 Focusing her plan on Her primary complaint is -2 -1 0 +1 +2 psychological wellness that she is unhappy with glucose levels the amount of work related stress she experiences -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 138 Domain 2 Examination, Assessment and Diagnosis 1. A 29 year old womens soccer player reports to your athletic training clinic 30 minutes after planting to change direction and feeling her knee give out. Her chief complaint is knee pain. If you were thinking of the following diagnosis: Grade 3 ACL sprain Meniscus tear Patellar subluxation And you find: She has full active knee extension She has moderate knee effusion She has a negative Lachmans test This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 139 2. A 15-year-old patient who pitches for a little league team reports to your athletic training clinic with a chief complaint of medial elbow pain and a decrease in throwing velocity. If you were thinking of the following diagnosis: Wrist flexor strain And you find: He has 4/5 strength with elbow flexion This diagnosis becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 He has pain with no laxity UCL sprain during valgus stress testing He reports the pain UCL sprain occurring during one specific pitch -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 140 3. A 38-year-old male assembly line worker reports to you with a chief complaint of shoulder pain on his dominant arm. If you were thinking of: And you find: He has a history of one Performing the apprehension/relocation test Performing the Hawkins Kennedy test Performing the AC compression test This option becomes: glenohumeral dislocation, -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 6 years previous His pain is exacerbated with active external rotation He reports a FOOSH (fall on an outstretched hand) mechanism of injury -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 141 4. A 21-year-old female volleyball player reports to you with a chief complaint of pain and clicking in her left knee. If you were thinking of: Referring her to an orthopedic specialist Referring her to an orthopedic specialist And you find: This option becomes: She has not attempted any intervention to remedy her -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 complaints yet Hey symptoms have persisted for the past 4 months Referring her to an Her pain and clicking can orthopedic specialist be consistently reproduced -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 142 Domain 3 Immediate and Emergency Care 1. You have been tasked with creating an emergency action plan (EAP) for a newly constructed high school. If you were thinking of: And you find: Including EMS as part of The local EMS department the emergency personnel is volunteer only Designating your local The local hospital is not hospital as the emergency categorized as a trauma care facility center This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 The high school only Having an ambulance on sponsors the sports of site for all home contests basketball, soccer, baseball, and softball -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 143 2. A female softball catcher jogs over to you during practice after diving for a ball, with an obviously dislocated glenohumeral joint. If you were thinking of: And you find: Attempting to relocate her She has a diminished shoulder distal radial pulse Attempting to relocate her shoulder Attempting to relocate her shoulder This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 This is her first occurrence of glenohumeral dislocation Your initial attempt to relocate the shoulder was unsuccessful -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 144 3. A 19-year-old football player comes to you on the sideline asking you to take care of a fresh turf burn abrasion measuring 2 inches x 6 inches that he just received. If you were thinking of: Cleansing the wound with sterile saline And you find: The patient has a history of resistant staphylococcus -2 The patient cannot see you top of the wound again until 24 hours later the wound -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 aureus infection Wrapping moist gauze on Utilizing tap water to rinse This option becomes: The tap water at your facility goes through a water softener -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 145 4. A 27-year-old male racquetball player presents to you with an apparent blow out fracture of his right orbit occurring 30 minutes prior. If you were thinking of: And you find: This option becomes: Referring him immediately to the emergency He has no vision deficits -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 department Referring him next day to a He has bilateral periorbital physicians office hematoma (raccoon eyes) Referring him same day to He has a small hyphema a minor emergency clinic present in the involved eye -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 146 Domain 4 Therapeutic Intervention 1. You are tasked with creating a plan of care for a 41-year-old female with piriformis syndrome in her left buttock/leg. Her chief complaint is of pain after long bouts of sitting. If you were thinking of: And you find: Using e-stim Her pain scale is a 3/10 -2 -1 0 +1 +2 Using ultrasound She has a 24% body fat -2 -1 0 +1 +2 -2 -1 0 +1 +2 Administering 400mg ibuprofen 4 times a day This option becomes: She has a history of gastroesophageal reflux disease -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 147 2. You are tasked with creating a plan of care for a 22-year-old male tennis player with rotator cuff tendonopathy. His chief complaint is worsening pain (6/10) with overhead motions over the last 3 days. If you were thinking of: And you find: Initiating isometric He has 4/5 strength for all exercises shoulder motions Decreasing serving activity He has full strength in all for 4 days planes of motion Implementing scapular He has mild scapular stabilizer exercises winging, bilaterally This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 148 3. You have a 17-year-old patient diagnosed with patellofemoral pain syndrome and decreased thigh girth in the affected leg. If you were thinking of: And you find: Integrating body weight full The patient has mild pain squats into a rehabilitation (1/10) with a single full plan weight body squat This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 Integrating jump landing training into a The patient is male rehabilitation plan Focusing a treatment plan on increasing muscular strength Her chief complaint is pain with activity (3/10) -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 149 4. A 37-year-old female training for a half marathon was diagnosed with posterior tibialis tendonitis on her left leg 2 weeks prior. She continues to complain of pain during and after activity. If you were thinking of: And you find: Utilizing ice massage before She takes regular medicine activity for high cholesterol Integrating strengthening of intrinsic foot muscles into a rehabilitation plan She has mild overpronation Suggesting the use of OTC She prefers to use naproxen sodium (Aleve) homeopathic remedies for into a treatment plan pain control This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 150 Domain 5 Healthcare Administration and Professional Responsibility 1. You have been working at your local police department for the last year, 8 hours a day, Monday through Friday as the sole athletic trainer. Over the last 2 months you have found yourself busier than you were at the beginning of the year, as word of your availability to the department has become more widespread. Part of your annual program assessment is to examine data and see if the current level of staffing and supplies are adequate or not. If you were thinking of: And you find: This option becomes: Using the number of average days a policeman was on restricted duty after No institutional data on injury until their return to this statistic exists from full duty to help you years previous -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 determine staffing adequacy Requesting a budget increase You used 80% of the total budget allotted to you for the first year Using a peer comparison to There are only two help you determine budget comparable peers for you adequacy to utilize as benchmarks NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 151 -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated 2. During your annual program review you identify a few small operational practices that could be changed to increase the privacy and safety of the patients at your athletic training facility. If you were thinking of: And you find: Calling your medical Your medical directors director to discuss these spouse has just been changes before diagnosed with a terminal implementing them cancer Communicating with your medical director through email This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 Your medical director typically only gives a brief yes or no response to emails Scheduling an in person Your medical director can meeting with your medical only meet during the director to discuss the summer while you are off changes contract -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 152 3. A male basketball player at your institution who you have built great rapport with after a long post-surgical ACL rehabilitation, confides in you that he just found out that he tested positive for human immunodeficiency virus (HIV). He asks you to keep this information private as he internalizes what it means to him and his future. If you were thinking of: Referring him to the teams clinical psychologist for counseling Alerting the teams clinical psychologist of his HIV positive status And you find: He is dating the clinical psychologists daughter This option becomes: -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 He has recently developed suicidal ideation in response to his newfound HIV positive status He has been practicing Keeping information of his HIV status strictly confidential unprotected sex with a player on the womens basketball team at your institution for the last month -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated NOVEL ATHLETIC TRAINING SCRIPT CONCORDANCE TEST 153 4. As the director or athletic training services at a public university, a subordinate female staff member (Kelly) alleges to you that another subordinate male staff member (Ron) made a derogatory and sexist comment to her in the presence of patients. If you were thinking of: And you find: This option becomes: Ron and Kelly have since Scheduling a joint meeting talked about the incident with Kelly and Ron on their own, and come to -2 -1 0 +1 +2 -2 -1 0 +1 +2 -2 -1 0 +1 +2 a mutual understanding Scheduling a joint meeting Kelly asks you to just with Ron and a human forget the whole thing resources representative even happened One other female athletic Alerting your Title IX director of this incident training staff member reports Ron speaking in a similar manner to her on one occasion -2: strongly contraindicated / -1: contraindicated / 0: neither more or less indicated / +1: indicated / +2: strongly indicated  ...

... PERCEPTIONS OF ADULTS POST-STROKE AND THEIR PHYSICAL THERAPISTS ON COMMUNITY MOBILITY Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Maryleen K. Jones, PT, MPT, CLT, NCS Copyright June 25, 2020 By: Maryleen K. Jones, PT, MPT, CLT, NCS All rights reserved Approved by: Stephanie A. Miller, PT, PhD Committee Chair Steven Wiley, PT, PhD Committee Member Lisa Borrero, PhD Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Perceptions of Adults Post- Stroke and Their Physical Therapists on Community Mobility Maryleen K. Jones, PT, MPT, CLT, NCS jonesmk@uindy.edu University of Indianapolis June 25, 2020 Word Count: 24,556 Perceptions of Adults Post-Stroke and Their Physical Therapists on Community Mobility Abstract Purpose: Stroke is a leading cause of limited mobility status among adults. Although survivors of stroke may recover some ability to complete functional mobility, successful community mobility remains limited. The aim of this study was to explore the alignment of perceptions regarding community mobility between adults post-stroke and their physical therapists after discharge from physical therapy. Participants: Six pairs of adults post-stroke and their physical therapists. Method: A mixed methods approach utilizing individual semi-structured interviews followed by open coding with concurrent triangulation to the Environmental Analysis of Mobility Questionnaire 2.0 was employed to formulate overarching themes of perspectives pertaining to community mobility encounters and avoidances. Results: Qualitative analysis revealed three themes that facilitated community mobility: 1) collaborative goals, 2) support systems, and 3) meaningful interventions. Five themes were found to detract from community mobility: 1) societal perceptions, 2) safety, 3) levels of function, 4) upper extremity function, and 5) third party influences. EAMQ 2.0 data supported interventions that addressed encounters within the temporal, terrain, and distance dimensions. The adults post-stroke reported higher avoidance scores on the physical load dimension of the EAMQ, while this dimension was unaddressed by physical therapists. Conclusions: Commonalities between groups built upon collaboration toward an optimal outcome for enhanced community mobility after stroke. A clear understanding of a patients perspective may allow for the physical therapist to better select interventions to address their environmental mobility needs. Clinical Relevance: Utilization of a battery of outcome measures, inclusive of the EAMQ 2.0 may provide physical therapists with a robust picture necessary to develop a plan of care encompassing community mobility. Addressing all dimensions of community mobility in addition to incorporation of the perceptions of an adult post-stroke may enhance the tailoring of post-stroke rehabilitation episodes of care and lead to enhanced outcomes. Keywords: stroke, survivor perception of community mobility, therapist perception of community mobility, mixed methods Perceptions of Community Mobility 1 PERCEPTIONS OF ADULTS POST-STROKE AND THEIR PHYSICAL THERAPISTS ON COMMUNITY MOBILITY Table of Contents Title Page .........................................................................................................................................1 Abstract ............................................................................................................................................2 List of Tables3 List of Figures..4 Chapter 1: Introduction ....................................................................................................................5 Problem Statement .................................................................................................................6 Overview ................................................................................................................................6 Purpose of Study ...................................................................................................................7 Project Rationale ....................................................................................................................8 Chapter 2: Literature Review ...........................................................................................................9 Definitions ...........................................................................................................................10 Community Mobility Participation ......................................................................................12 Assessment of Community Mobility ...................................................................................17 Therapist Perceptions of Community Mobility ...................................................................21 Patient Perceptions of Community Mobility ......................................................................22 Consideration for Combined Views.....................................................................................23 Purpose of Study ..................................................................................................................23 Chapter 3: Method .........................................................................................................................26 Study Design ........................................................................................................................26 Population and Study Sample ..............................................................................................28 Inclusion Criteria .................................................................................................................28 Exclusion Criteria ................................................................................................................28 Participant Recruitment .......................................................................................................29 Data Collection ...................................................................................................................29 Instruments...........................................................................................................................31 Perceptions of Community Mobility 2 Ethical Considerations .........................................................................................................32 Data Management ................................................................................................................32 Data Analysis .......................................................................................................................34 Chapter 4: Results ..........................................................................................................................37 Demographics of Adults Post-Stroke..................................................................................37 Demographics of Physical Therapists.................................................................................37 Facilitators of Community Mobility ...................................................................................38 Detractors of Community Mobility ...................................................................................46 EAMQ 2.0 Data ..................................................................................................................54 Chapter 5: Discussion and Conclusion ..........................................................................................54 Discussion of Results .........................................................................................................54 Study Limitations and Implications for Future Research ..................................................59 Contribution to the Profession61 Conclusion .........................................................................................................................62 Acknowledgements63 Budget and Motivation...66 References ......................................................................................................................................67 Appendices.....................................................................................................................................79 Appendix A: Recruitment Flyer...........................................................................................79 Appendix B: Environmental Analysis of Mobility Questionnaire ......................................81 Appendix C: Semi-Structured Interview Questions for Adults Post-Stroke .......................90 Appendix D: Semi-Structured Interview Questions for Physical Therapists ......................92 Appendix E: Transcript Approval Form ..............................................................................94 Appendix F: Informed Consent ...........................................................................................95 Perceptions of Community Mobility 3 List of Tables Table 1: Adult Post-Stroke Demographics ....................................................................................75 Table 2: Physical Therapists Demographics .................................................................................76 Table 3: Quantitative Data from EAMQ 2.0 ................................................................................77 Perceptions of Community Mobility 4 List of Figures: Figure 1: Visual Representation of Qualitative Themes ...............................................................78 Perceptions of Community Mobility 5 Perceptions of Community Mobility by Adults Who Have Experienced a Stroke and Their Physical Therapists According to the Centers for Disease Control and Prevention (CDC), it is estimated that each year over 610,000 people experience their first stroke.1 Eleven to 35% of first-time survivors of stroke have moderate to severe ongoing disability, resulting in the need for physical assistance to complete tasks.1,2 Survivors of mild stroke may also continue to experience limitations in function and participation in pre-stroke activities such as community mobility one year after stroke.4,5,6 Difficulty accessing the community after a stroke may be the result of limitations in mobility. Although individuals view community mobility as a vital activity after stroke,7 studies have shown that older adults who survive stroke and have residual impairment demonstrate a significant tendency to avoid activities, including mobility, within the context of their communities.8,9,40 Factors influencing the recovery of community mobility after stroke include physical therapy interventions that address gait speed and/or walking efficiency, barrier identification and negotiation, and/or functional endurance.8, 9,12,27,29 Non-motor factors also associated with return to community mobility after stroke are self-perceived health or fitness status, 12,30,31 depression levels, 8,31 social support,12,31 and self-awareness.31 Understanding the perceptions of recovery of older adult survivors of stroke may enhance the ability of physical therapists to augment the patients participation in activities after the conclusion of therapy including return to community mobility. Physical therapists utilize the International Classification of Functioning, Disability and Health (ICF) to identify contextual and health-related factors perceived to influence the patients Perceptions of Community Mobility 6 ability to participate in meaningful activities, as well as, standardized assessments to evaluate a patients mobility and walking function. The use of standardized assessments allow clinicians to monitor change over time and determine discharge readiness; however, summative scores from these assessments may not take into account the patients contextual influences or their personal goals.24,25,26 Optimal patient-centered care incorporates shared decision-making between the patient and the physical therapist.13 Although separate explorative studies on the perceptions of persons with stroke and physical therapists with respect to aspects of stroke recovery have been published,12,27-29 investigation as to the alignment between perceptions of older adults with stroke and their physical therapists has not been fully investigated. Exploring perceptions regarding community mobility from multiple views immediately after discharge from outpatient physical therapy along with comparing all perspectives may provide physical therapists with a better understanding of the necessary skills and requirements that older adults who experience a stroke need to optimally participate in community mobility. This information should fill a critical gap in the literature that could lead to more effective promotion of quality, wellrounded, meaningful, and goal-oriented care. PROBLEM STATEMENT Overview The ability to perform community mobility is viewed as an important and meaningful activity by older adults who experience a stroke.22,27,28 Community mobility and community ambulation are often used interchangeably with an assumption that the terms have the same meaning. However, Patla and Shumway-Cook identify community mobility as a complex task Perceptions of Community Mobility that is multidimensional requiring adaptability for safe negotiation of varied constructs.41,42 Due to the multidimensional aspects that are associated with community mobility, a clarification of the term community mobility as it relates to a meaningful context of a participant, such as the older adult who experiences a stroke is necessary. Clarification of the terms by the physical therapists who assist in maximizing a patients ability to participant in community mobility is needed. Presently, a gold standard for assessing community mobility does not exist. Measurement of community mobility is often dependent upon the measurement of gait speed, endurance, and ability to negotiate steps and curbs.8,9,41,42 The perceptions that are held, regarding community mobility, by older adults who experience a stroke may serve as indicators regarding the extent that they participate in community mobility activities. Furthermore, the perceptions that are held by physical therapists may differ from the older adult who has experienced a stroke,22,28 indicating a need to explore the alignment between the two individual perceptions in order to optimize understanding of the recovery process after stroke. The purpose of this study is to explore how perceptions of community mobility align between older adults recovering from stroke and their physical therapist. Specifically, the study will address the following objectives: 1. To explore the perceptions of community mobility in adults post-stroke via qualitative interviews. 2. To determine self-perceived community mobility of adults post-stroke as measured with the Environmental Analysis of Mobility Questionnaire (EAMQ 2.0). 3. To explore the perceptions of physical therapists regarding the community mobility of their adult patient with stroke via qualitative interviews. 4. To explore and compare the perceptions of community mobility that may exist between 7 Perceptions of Community Mobility 8 adults post-stroke and their physical therapists as triangulated to the EAMQ 2.0 and emergent themes developed from the qualitative interviews. Exploring perceptions regarding community mobility from multiple views immediately after discharge from outpatient physical therapy along with comparing all perspectives may provide physical therapists with a better understanding of the necessary skills and requirements that adults who experience a stroke need to optimally participate in community mobility. This information may fill a critical gap in the literature that could lead to more effective promotion of quality, wellrounded, meaningful, and goal-oriented care. Rationale of the project Based on the findings in the literature that various factors such as gait speed, poor endurance, balance, decreased self-efficacy, depression, lack of social support 7-10,15,27,28,31,35,37,4043 have been linked to decreased participation in community based activities further investigation of the perceptions regarding community mobility is warranted. Comparing and contrasting the perceptions between patient and physical therapist may elicit sub textual nuances that may serve as facilitators or barriers to community mobility and thus influence the decision-making process of the physical therapist with respect to interventions targeting participation in community mobility. A review of the current body of literature reveals a broad range of definitions and qualifiers of what constitutes community mobility by both therapists and adults post-stroke with resultant mobility impairments. An investigation of the differences and commonalities of the perceptions held by both the adult post-stroke and their physical therapists may assist in defining meaningful community mobility within the physical therapy profession. Conducting a mixed methods study that explores both perceptions of the adult who has survived and experienced Perceptions of Community Mobility 9 mobility impairments as a result of stroke and their physical therapists will allow for a greater understanding of the recovery process with potential understanding of the barriers or facilitators that impact optimal meaningful participation at a community level. Triangulating the findings of the qualitative investigation with the EAMQ 2.0, a validated and reliable measure that specifically addresses the dimensions of community mobility may elicit descriptive information pertaining to the dimensions of community mobility. Contextual descriptions related to quantitative information that is used for decision making by physical therapists may allow for salient interventions directed at maximizing community level mobility for adults post-stroke. LITERATURE REVIEW The ICF model of care focuses on ones ability to participate in meaningful tasks in both a personal and social context.32 During the rehabilitation process, physical therapists work with survivors of stroke to regain and maximize independence with a focus on enhancing participation in meaningful activities. Survivors of stroke identify ambulation as an important link to restoration of health and social interaction; therefore, ambulation is a primary focus during the rehabilitation process.31 Multiple factors have been identified as necessary components of optimal mobility including: endurance, gait speed, gait mechanics, balance and postural transitions, obstacle negotiation, path finding, and terrain negotiation.8,9,28,31,41,42 In addition to factors pertaining to the physical domains of the environment, identified factors that are associated with successful management of dual tasking, degree of traffic density, and variable ambient conditions have also been cited as necessary for successful mobility in ones community.8, 9,41,42 All of the factors are viewed by both patients and therapists to be vital for optimal participation in meaningful activities.12,28,33,42 Participation in meaningful societal Perceptions of Community Mobility 10 activities is reported by The Institute of Medicine Workshop on Disability in America as being a component of function critical and integral to a persons quality of life.34 Definitions Community ambulation and community mobility are often used interchangeably without truly reflecting the multiple constructs that the broad term mobility encompasses versus the single construct of ambulation. Definitions been previously reported for both are gait speeds of .40 m/s to .80 m/s, functional mobility, or sufficient balance for terrain negotiation.8,9,10,35 If the physical therapy profession wishes to realize the professional vision of transforming society by optimizing movement to improve the human experience,57 uniform and accurate terminology must be utilized. During the course of this paper the term community ambulation will be used when discussing various constructs that the original authors, such as Perry10 and Lord7 have termed community ambulation, with the addition of other physical constructs such as curb and stair negotiation. The term community mobility will be used when describing the aims of the proposed study as well as other dimensions or constructs that are included in optimal societal participation such as ambient conditions, terrain variations, physical loads and traffic density in hopes of providing a robust description of the many dimensions that optimal movement and negotiation of ones community encompasses. Community mobility encompasses a range of dimensions that impacts ones ability to carry out their instrumental activities of daily living (IADLs) and maintaining social relationships and status.42 Instrumental Activities of Daily Living are inclusive of activities such as shopping, transportation, household tasks, managing financial affairs and medication management. Instrumental Activities of Daily Living are essential for individuals to function Perceptions of Community Mobility 11 independently among others within the community context and adapt to their environments in a timely manner according to the situation that occurs concurrently.45 Community mobility that involves IADLs may be interpreted as a complex task that involves ambulation. A complex task requires an individual to adapt a task at hand to the environmental demands or dimensions as described by Patla and Shumway-Cook.42,50 A complex task requires additional physiological resources beyond those needed to ambulate in less complex environments such as the familiar environment of their home or the predictable environment of the clinic.5,7,28,29,35 The term community mobility will be used throughout the remainder of this paper in order to encompass all potential variables that may impact or be a factor of negotiation of community environments. For persons who live with impairments as a result of stroke, participation in societal activities can be highly dependent upon the environment. The Institute of Medicine Workshop on Disability in America recognizes Keysors assessment that some environments that are more facilitative are associated with less disability, whereas other environments that are less facilitative are associated with more disability34, pg.165 This statement brings to light that human adaptation to an environment is both a dynamic and a complex process where the environment itself may enhance or diminish participation. This phenomenon, particularly after stroke, merits further understanding and investigation. 34 Recovery of the ability to perform community mobility by adults post-stroke enhances quality of life, improves general health and independence with activities of daily living (ADLs) and IADLs and decreases caregiver burden.33,41,45 Lord et al 7-defined community ambulation as locomotion outdoors that includes activities outside the home necessary to live independently, such as visits to the supermarket, pharmacy, and bank, which supports the relationship to IADLs. Descriptive destinations Perceptions of Community Mobility 12 requiring community mobility, that were deemed essential by older adults in a study by Brown et al33 included grocery stores, pharmacies, doctors offices, financial institutions, and department stores such as Wal-Mart or Target.33 A subcategory of essential locations for some participants included doctors offices located in a hospital complex, religious facilities, and gas stations. Nonessential locations were identified as restaurants, beauty and barber shops, senior centers, hospitals, and shopping malls.33 Ability to perform mobility tasks in these community locations are reported to enhance quality of life and are believed to be necessary contributors to independence.28,33,39,40 Under the ICF model of functioning, disability, and health meaningful participation in patient centered activities is the ultimate goal. The ICF model guides physical therapist to investigate, evaluate, and address the various personal and environmental factors that impact a patients ability to participate in meaningful activities which are often community based.32, 40 Using the ICF model therapists may intervene, collaborate and develop strategies with their patients to optimize their performance and ability to participate in meaningful activities, which often include community participation. Community Mobility Participation The relationship of community mobility to quality of life and health status has been minimally investigated. Schmid et al37 determined that a persons ability to transition from the ambulation categories of household ambulation (<.4 m/s) to community ambulation (>.8 m/s) had a meaningful impact on the participation levels and quality of life of older adults who survived a stroke. Although a small amount of literature supports metrics of gait as qualifiers of quality of life,37 the extent of impact that gait speed has on ones quality of life as related to Perceptions of Community Mobility 13 community mobility remains lacking. Although this study supports that increased gait speed improves quality of life for survivors of stroke as measured by the Stroke Impact Scale, it should be noted that these findings support only the temporal dimension of mobility, and that factors influencing actual access to essential community locations were not reported. Several studies by Robinson et al8,40 and Shumway-Cook et al9,42 indicate that older adults with mobility impairments have fewer encounters and avoid dimensions within their environments that they feel pose a challenge to their mobility. Furthermore, although survivors of stroke that possess the capability of completing single encounters in their community environments, results indicated that participants had decreased satisfaction with the encounter due to inability to complete multiple activities during the community encounter, thus indicating a limitation to the extent survivors of stroke participate in community mobility. 40 Quality of life for a survivor of stroke may vary in conceptualizations such as well-being, health status, participation and extent of participation in meaningful activities, and achievements such as return to employment.4 In order to fully understand a survivor of strokes perception on quality of life and its potential relationship to community mobility, exploration of the perceptions of community mobility requires deeper descriptions of the value, expectations, concerns and cultural contexts that are placed on community mobility. Self-efficacy relates to a persons confidence in their ability to perform a specific task or behavior38. Bandura38 described four factors that may influence ones self-efficacy with respect to a situation or a specific task. These factors include: previous experience with a specific task, observation of successful performance of the task, social persuasion with respect to the task, including persuasion from family, professionals, and society, and ones psychological state.38 Several studies have explored factors that are associated with attainment of community Perceptions of Community Mobility 14 ambulation after stroke and level of community mobility within the older adult population.2, 4, 6, 7, 8, 10, 15, 19,24,30,37,40,42 Self-efficacy is a consistent emergent theme related to quality of life as well as level of participation in mobility activities.8,9,40,47,48 Specifically, self-efficacy can be predictive of the number of community based walking related activities an adult post-stroke may complete post-stroke.8 Although community ambulation has been associated with both tangible and objective measures, intangible personal factors that influence self-efficacy may be relevant to a patients plan of care and should be a consideration of the physical therapists.13,40,44 Several independent studies provide supporting evidence for the role and importance that self-efficacy plays in successful community ambulation for older adults and older adults who have experienced a stroke.8,39,40,42,44 Durcan, Flavin, and Horgan39 identified balance selfefficacy as being independently associated with independent community ambulation (a gait speed of .8m/s over a 10 meter distance), however other environmental dimensions of accessing the community and performing mobility tasks within the community setting as well how selfefficacy impacts those constructs were not addressed. Robinson, Shumway-Cook, NoritakeMatsda, and Ciol40 reported that the traditional constructs of ambulation are most often prioritized by physical therapist, including gait speed, performance during functional gait tasks, balance tasks, muscle length and strength, range of motion, and visual-spatial ability. However, these constructs are not predictive of a survivor of strokes level of participation in community mobility. Suggesting that capability to participate and actual participation in community mobility tasks are separate determinates of ones degree and level of participation. In efforts to fully utilize the ICF framework, it appears that PTs must also consider contextual personal factors such as self-efficacy when preparing patients for community mobility tasks. Reported measures of self-efficacy that demonstrate responsiveness to the level of community mobility by older Perceptions of Community Mobility 15 adults who experience a stroke are the Falls Efficacy Scale and Activities-specific Balance Confidence (ABC) Scale.8, Further investigation of subjective and objective measure of participation in community mobility tasks by Robinson et al,8 showed that self-efficacy related to balance and falls had a strong association with participation in community-based walking activities. Conversely, decreased self-efficacy and depression were associated with an increase in perceived difficulty with and frequency of community-based walking activities.8, 40,39 An additional study conducted by Schmid et al attributed avoidance of mobility and activities after stroke appears to be related to anxiety and depression.47 A systematic review of self-efficacy as related to stroke rehabilitation indicated that self-efficacy was associated with quality of life, participation in ADLs and IADLs, physical functioning and lower depression rates post-stroke. 48 Although there have been several studies that have explored the role of self-efficacy in recovery from stroke as well as its impact on the quality of life of a person who experienced a stroke, the literature is void of evidence as to how the self-efficacy of a person who experienced a stroke impacts their perceptions related to community mobility, and if the patients self-efficacy impacts the perception of a physical therapist treating persons who experience stroke. Furthermore, self-efficacy may be a factor that is potentially sensitive to environmental constructs such as the degree that accessible modifications exist within a particular community, which may be related to a cultural context within the particular community. 46 These findings provide merit to the need to investigate the perceptions of both therapists and persons who experience a stroke with respect to the methods of preparation the rehabilitation process provides a person who experiences a stroke towards maximizing participation in the community. Review of the literature does not reveal a specific community mobility self-efficacy scale that is Perceptions of Community Mobility 16 validated for use with adults post-stroke. Sanford et al utilized a modified version of the FES with respect to ten mobility tasks and had participants rate their level of confidence in performing the tasks.58 The modified version was found to be a sufficient measure of selfefficacy for improvement of mobility in older adult patients identified with mobility impairments.58 Consideration of using a modified version of a validated mobility questionnaire that encompasses the multiple constructs and dimensions of community mobility, such as the EAMQ 2.0 is merited. Use of such a measure may allow a PT to have potential insight into the level of self-efficacy their patient has with respect to the factors that impact community mobility. Community mobility is a reported hallmark of participation for the older adult who has experienced a stroke7. Achievement of community mobility after stroke may be dependent upon assessment and task specific training of tasks required for community mobility. Assessment of the dimensions associated with community mobility were evaluated and defined by Patala and Shumway-Cook.41 Identified dimensions were distance, time, ambient conditions, terrain characteristics, physical load, attentional demands, postural transitions, and density.41 In multiple studies conducted by Shumway-Cook et al 9,41,42 in sample population consisting of older adults and survivors of stroke dimensions of the community environment that were avoided 100 percent by both populations consisted of longer distances (>10 blocks), ambient conditions that were wet, physical load of carrying objects. Dimensions that were avoided greater than 50% consisted of temporal features of crossing a busy street, terrain dimensions of two flights of stairs or more, curbs, and postural transitions that included reaching activities. Interestingly over 65% of the populations avoided traveling into the community alone, demonstrating that independent community mobility may not be easily obtained and possibly related to confidence, self-efficacy Perceptions of Community Mobility 17 or perceived difficulty of the tasks.8,42 Further investigation into the reasons behind this finding is warranted.9,42 Furthermore, review of the literature indicates that a void exists with respect to the various dimensions related to community mobility that are specifically relevant to the patients individual environment, such as urban versus suburban versus rural communities12. Each of the respective community settings presents the survivor of stroke with unique challenges that may not be identified as attainable and safe if gait speed or endurance measures are exclusively used to determine community mobility status. Assessment of Community Mobility Perry et al10 classified unlimited community ambulation in terms of gait speed measured over a 10-meter distance as .80 m/s or greater and limited community ambulation as .40 m/s to .80 m/s. Although these classifications are useful to observe components of safety and efficiency over the short distance of 10 meters, this small observation does not encompass an adequate duration or distance that is required to complete meaningful and necessary tasks in the community.33 This discrete measure does not adequately take contextual nuances into account, such as the ability to safely cross a street which is categorized as a gait speed of at least 1.0 m/s, thus utilization of a persons 10- meter gait speed alone may not be a sufficient predictor of community mobility. The 10-meter gait speed may represent a minimum gait speed sufficient for typical household activities, yet it may be insufficient for community mobility activities. Community mobility activities that require higher velocity demands such as crossing a commercial street within the allotted signal time9, multitasking such as navigation of uneven terrain and appropriate environmental scanning,12,41,50 and problem solving through unusual Perceptions of Community Mobility 18 occurrences during interactions within community environments,12 may require assessment beyond the 10-meter distance. A systematic review of patients perceptions of community ambulation after stroke by Corrigan and McBurney12, indicated that although a gait speed of greater than .8 m/s in the clinic was perceived to be sufficient for community ambulation, 99% of the individuals assessed could not achieve a gait speed of 1.22 m/s which is necessary to safely negotiate a crosswalk in an appropriate time.28 Investigation of other constructs that impact a survivor of strokes ability to complete community mobility have been identified.10 Van de Port, et al10 identified that in addition to gait speed, balance, endurance, need for assistive device, and motor function were confounding components to the ability to independently complete community mobility tasks.10 Further supporting evidence that the construct of endurance is of vital importance to successful ability to perform community mobility is provided by Altenburger et al.35 Determination of a subjects ability to perform independent community mobility based on a 10-meter gait speed and an endurance measure over a 6-minute duration, may be incomplete if the subjects ability to sustain a selected gait speed is not also assessed and interpreted by the therapist.35 The speed construct of community mobility can both vary and require additional physiological demands that are not evident during shorter distance assessment measures.49,50 Some therapists and insurance carriers view the 150 feet suggested by the Functional Independence Measure (FIM) as a sufficient distance for community ambulation36; however, the distances supported by Brown and colleagues33,49, indicated that minimal distances for essential community mobility are approximately four times the distance of the FIM.33,49 Physical therapists must have a sound appreciation for the range of distances that are required for access to the essential and meaningful locations within a patients community. The findings provided by Perceptions of Community Mobility 19 Brown, Green-Howze and Ray33 indicated that ambulation distances required within the community to essential destinations perceived by older adults as meaningful, range from 10 meters to 1745 meters with a mean minimum distance of 200 meters or 656 feet. 33 A systematic review of distance and speed requirements for community ambulation ranged from 16 m to 677 m and .44 to 1.32 m/s respectively.49 These verified distances are an important considerations for therapist who are preparing their patients for community mobility, given the reported findings of an avoidance rate of 100% for distances greater than 10 blocks by a sample of older adults with mobility impairments.9,41,42 Although the distance of block lengths vary according to community settings, the important concept of distance is conveyed. The meaningful distances to essential destinations supports the concept that prediction of successful return to community mobility after stroke for the adult requires physical therapists to consider and evaluate multiple factors beyond the 10-meter gait speed construct.10, 33,35 Recommended physical performance tests commonly used to predict and assess mobility in both the older adult population and patients who have experienced a stroke include the functional reach, timed up and go, sit to stand timed tests, gait speed over 10 meter distance, distance covered in various timed intervals52 and functional gait assessment.44,50 A mobility assessment measure that specifies performance of multiple environmental dimensions is lacking at the present time.42 Given the understanding that community mobility is a complex task and requires the ability to integrate several dimensions concurrently implies that utilization of assessments that do not encompass the robust constructs required in community mobility to determine the readiness of a person to attempt community mobility may be inadequate for prediction of successful community mobility. Appreciating the reported factors that influence community mobility, the view that safe and feasible independent mobility within the community Perceptions of Community Mobility 20 context is multifactorial and inclusive of the perception of the individual requires the physical therapist utilize an outcome measure that encompasses the robust constructs of community mobility and environments. Physical therapy interventions are often based upon therapist evaluation and assessments. Indication that perhaps the traditional rehabilitation process may be inadequate to appropriately prepare persons who experienced a stroke for community mobility was reported by Latham et al.51 Latham et al51 reported that only 15% of patients who experienced rehabilitation for impairments related to stroke were recipients of interventions that focused on community mobility activities. Community mobility activities only constituted 5% of therapy time and specific description of the various dimensions of community mobility were not qualified or quantified. Lathams reported findings imply that the dimensions of mobility other than speed and distance are poorly attended to during the rehabilitation process. Although this study focused on interventions addressing community mobility, the need to provide intervention may begin with assessment of the patients interest in ability to perform the task. The EAMQ 2.0, which is a self-reported measure containing questions in mirrored pairs regarding the subjects frequency of encounter and avoidance of community constructs that impact community mobility. The EAMQ 2.0 evaluates eight dimensions of the physical environment including distance, temporal, various terrains, ambient features, postural transitions during mobility, attention, and density.41,42 The EAMQ 2.0 has been validated for assessing community mobility levels with older adults and survivors of stroke.8, 9,41,42 The EAMQ 2.0 has reported test-retest reliability with interclass correlations of .98 for comprehensive encounter, and .96 for comprehensive avoidance encounters, and .81-1.0 for individual dimensions. 9,41,42 The EAMQ has also been concurrently validated for self-reported encounters versus observed encounters. (r = .66, P < .001). The EAMQ summary score has been positively correlated with Perceptions of Community Mobility 21 the frequency of participation in the community and inversely related with avoidance of community mobility (r = -0.58, P < .001).41,42 The EAMQ 2.0 has been validated in the older adult population and with patient who have experienced a stroke with the mean age of 68 years.42 Utilizing a validated self-report to establish a baseline appreciation for the dimensions involved in community mobility perceived as barriers may enhance in-depth discussions between physical therapists, other rehabilitation professionals and survivors of stroke. Considering that the EAMQ 2.0 is a robust validated instrument that encompasses multiple dimensions required for community mobility, the information gained from the use of the instrument may significantly augment the interventions used during mobility rehabilitation, providing for adequate preparation for community mobility as suggested by Patla.50 Information gained from the EAMQ 2.0 may facilitate discussions and focus of which dimensions may positively serve as opportunities for development of self-efficacy, confidence, and subsequent enhanced participation in community mobility. Therapist Perceptions of Community Mobility Perceptions, or ones interpretation or impression, about a task or activity is often a driving factor for if, when, or how the individual holding those perceptions will approach the task or activity.27 A physical therapists perception regarding community mobility may enlighten the profession of how therapists approach the task of community mobility with their older adult patients who experience a stroke. It has been reported that therapists justify the need for therapy services by using standardized outcome measures.44 In addition to outcome measures being used to support the need for services, therapists use outcome measure findings to determine discharge from services, recommendation for supportive services, and guidance for participation in Perceptions of Community Mobility 22 community based activities as well as clinical judgement44 Investigation of the perceptions regarding community mobility held by physical therapists may enhance the understanding of the rationale and process used to make decisions and recommendations for the older adult who is status post-stroke. Studies that specifically addressed the views that clinicians held regarding community mobility are limited. Inquiry of the ProQuest, Cinahl, and Medline PubMed, databases elicited only three studies, none of which were based in the US, that have addressed how physical therapists view community mobility. Physical therapists viewed gait speed and over all fitness levels, terrain negotiation, ambient conditions, safety awareness, ability to carry an object, support of person, and the desire to ambulate in the community as factors during decision-making with respect to community ambulation.12, 28, 55 The reported perceptions held by physical therapists do not address all of the dimensions of community mobility found to be valid and necessary by Patla and Shumway-Cook41. Additional dimensions found to be meaningful during community mobility are distance, physical load and density. Survivors of stroke often rely upon their therapists for the development and direction of their plan of care13,14,44. In a study by Moore et al54 it was demonstrated that although patients status post-stroke, who had demonstrated a motor recovery plateau as perceived by their physical therapists could make continued improvements when provided with intensive specific stepping practice.54 The results of this study suggest that therapist perception of a patients performance may actually undermine the patients true capabilities when provided with specific and intensive practice at a task. The findings of this study also support that perhaps the clinical measures used by physical therapists to determine discharge recommendations may not be adequate and support the notion of Patla50 that traditional therapeutic interventions are inadequate to prepare persons with impairment for successful community mobility. A clear understanding of the perceptions held by the physical Perceptions of Community Mobility 23 therapists with respect to various community mobility environments may assist in the development of a comprehensive plan of care that address all the dimensions necessary for independent and safe community mobility following stroke. Patient Perceptions of Community Mobility Interestingly, perceptions regarding community ambulation held by older adults and survivors of stroke have been explored to a greater degree.4,5,8,12,19,27,28,30,31 than the perceptions held by the physical therapist. In the older adult population, maintaining social contact with peers and continuing their roles in the community are described as vital components to maintaining quality of life.28, 31 Survivors of stroke state that gait speed and endurance are necessary skills needed to keep up with their peers31, which not only implies the importance for safety but its direct relationship to meaningful social contexts. Older adults who survived a stroke who indicated the need for assistance with their ADLs also noted the need for physical assistance while negotiating community environments31. The findings of community ambulator classification based on gait speed of .8 m/s as being insufficient for safe community ambulation by Corrigan and McBurney28 further supports the results of other studies8,9 that perception of difficulty and challenging environmental features, relates to lower community mobility participation levels.27, 31 Perceptions held by older adults post-stroke indicate that community accessibility as paramount to being able to negotiate the community environments safely. Determinants of accessibility were described as railings next to ramps and stairs, curb cut-outs, public benches and areas that were not densely populated with pedestrian traffic.27,31 In addition to accessibility constructs, appropriate municipal maintenance of the community environment, such as snow-clearing and sidewalk repair was also cited as an important factor facilitating Perceptions of Community Mobility 24 community mobility.27 Further investigation of the factors that impact participation in community mobility by survivors of stroke and their perceptions of both facilitators and limiters is warranted. Thus, physical therapists, other rehabilitation professionals, and other stakeholders may be enlightened to specific determinants that do not appear within the clinical context, however, are essential for optimal physical participation levels.4 Consideration for Combined Views Review of the literature has revealed that although perceptions of community mobility by both the therapist and the older adult who has experienced a stroke have been previously investigated independently, the independent findings do not necessarily support alignment between each perspective12,13,16,21,22,25,28,30,31,44. The professional standards for the core values held by physical therapists include principles of professionalism, which should include service, collaborative partnership, integrity, respect, advocacy, and empowerment of those served.43 The collaborative partnership between patient and therapist has been associated with clinical benefits.55,56 Patients who collaborated with their therapists to develop plans of care have been found to have decreased anxiety and enhanced confidence.13 One study investigated the degree of agreement between the therapist rating and the older adult patients rating of the degree of change for the Functional Gait Assessment. Investigators discovered poor agreement between the therapist and patient ratings of change.44 Poor agreement between therapist and patient indicate that although both parties were participants in the same activity, differences in perceptions existed. Disagreement in perceptions may stem from therapists and patients using difference reference points. Therapists may be using the limited context of a task being performed in a clinical setting, while the patient is using their everyday Perceptions of Community Mobility 25 life experiences as a reference point of their view.13,44,53 Disagreement between patient and therapist indicates that direct communication between the therapist and patient needs to occur in order to achieve patient-centered care that necessitates consideration of the patients perspective.13 Several studies exploring the level of patient contribution to their plan of care have indicated that patients find benefit from being involved and contributing to their plans of care.13,44,53 The shared decision making process allows for enhanced patient benefits of decreased anxiety, increased confidence, and an overall increased level of understanding of their health status, and health outcomes.13,55,56 A study exploring the degree of implementation of shared decision making by physical therapists elicited poor agreement between therapists and patients, with a majority of the therapists believing that they were responsible to make the decisions on behalf of the patient, although patients wanted to share decisions.13 The findings of the few studies that explored alignment between patients and therapists within the domain of physical therapy indicates that there is a need to further investigate the perceptions of both parties with respect to the desired outcomes of the patients rehabilitation process. Specifically, within the context of community mobility there is a possibility that perceptions held by the therapist concerning priority contextual dimensions of community may become the underlying theme of the plan of care versus the contextual dimensions that are viewed as priority by the patients themselves. Variability of perceptions between the physical therapist and the older adult who has survived a stroke may produce a less than desired outcome. These differences merit discussion and understanding of the respective perceptions in order for optimal patient centered and collaborative care to occur. Perceptions of Community Mobility 26 Based on the findings in the literature that factors such as gait speed, poor endurance, balance, decreased self-efficacy, depression, lack of social support 7-10,15,27,28,31,35,37,40-43 have been linked to decreased participation in community-based activities, comparing and contrasting the perceptions between patient and therapist may elicit sub textual nuances that serve as facilitators or barriers to community mobility. The sub textual nuances may have an influence on the decision-making process of the physical therapist with respect to interventions targeting participation in community mobility. A review of the current body of literature also reveals a broad range of definitions and qualifiers of what constitutes community mobility by both therapists and adults post-stroke with resultant mobility impairments. An investigation of the differences and commonalities of the perceptions held by both the adult post-stroke and their physical therapists may assist in defining meaningful community mobility within the physical therapy profession. Conducting a mixed methods study that explores both perceptions of the adult post-stroke and experienced mobility impairments as a result of stroke and their physical therapists will allow for a greater understanding of the recovery process with potential understanding of the barriers or facilitators that impact optimal meaningful participation at a community level. By triangulating the findings of the qualitative investigation with the EAMQ 2.0, a validated and reliable measure that specifically addresses the dimensions of community mobility a clearer relationship to quantitative information that is used for decision making by physical therapists will allow for salient interventions directed at maximizing community level mobility for adults post-stroke. METHOD Perceptions of Community Mobility 27 Study Design A concurrent triangulation mixed methods research design was employed to gain a full understanding of the perceptions held by adults post-stroke and their discharging physical therapists regarding community mobility. Qualitative and quantitative research methods both have inherent strengths and limitations. It has been suggested that combining qualitative and quantitative methods allows for the limitations of both methods to be counter balanced by the strengths of the other method.59,63 Thus, the qualitative component of the design provides meaning and context to the data that is elicited by the quantitative component of the design which also allows for statistical value and generalizability.63 Utilization of a mixed methods approach allows for a comprehensive analysis that can strengthen the validity of the findings of a study.63 Data were collected using a mixed methods approach using the tenets of phenomenology and concurrent triangulation of data from the EAMQ 2.0 with any emergent themes gathered from separate semi-structured interviews. The primary investigator conducted semistructured interviews with adults post-stroke and their discharging physical therapist.59 Phenomenological research seeks to find meaning in the experiences for a particular group of people through the use of interviews and conversaton.59,63,64 Gaining an understanding of the perceptions that a select group of people have regarding a particular construct, in this case community mobility after stroke, allows for a potentially rich understanding of their experiences. Concurrent triangulation allows for the comparison of multiple data sources, in this case the data elicited from the semistructured interviews and the quantitative EAMQ 2.0 tool.59,65,66 Thus, the utilization of concurrent triangulation allowed for the investigator to gain a deeper understanding of the perceptions of the participants. Use of the EAMQ 2.0 allowed for a quantitative view of Perceptions of Community Mobility 28 encounters and avoidance of the eight dimensions of community mobility. This data were used to confirm, validate, enhance, or contrast the themes that emerged from the semi-structured interviews. Resultant interview themes were compared between individual patients and their therapists and then patient and therapist pairs were compared to one another to gather converging and diverging themes between each group of participants. Data from the self-reported EAMQ 2.0 were analyzed using averages of encounters and avoidances for each adult post-stroke and for each of the environmental dimensions as a whole to augment the findings of the semi-structured interviews. Figure one is a visual representation of the themes of facilitators and detractors as they converge and diverge from community mobility as well in perception consensus between physical therapists and adults post-stroke. Population and Study Sample Population. The targeted participants in this study were adults post-stroke aged 55 years or older and their discharging physical therapists. A sample of convenience was recruited from outpatient clinics in the greater Chicagoland area. Sample size. Six pairs of patients and their physical therapists were interviewed separately.60,61 The small number of participant pairs in this study allowed for an in-depth analysis of the perspectives of both the adult post-stroke and their physical therapists and allowed for exploration of the degree agreement between the parties regarding the perspectives held by the participants.60,61 Inclusion criteria Perceptions of Community Mobility 29 Patients: Adults 55 years of age or older with a confirmed medical history for a first-time stroke of either ischemic or hemorrhagic etiology, and the ability to ambulate at least 0.80 m/s during the 10 meter walk test independently, with or without an assistive device and without physical or verbal assistance of another person, as verified by their outpatient physical therapist. Physical therapists: licensed in the State of Illinois and had participated in the care of one of the patient participants. Exclusion criteria Patients: neurological conditions other than stroke and other health conditions that impeded their ability to walk or complete mobility tasks, visual impairments other than the need for prescription eyeglasses, the inability to verbally communicate at the level required to answer questions from the interview questionnaire, such as aphasia or the need for an interpreter, inability to follow three step commands, and inability to provide informed consent. Participant recruitment The primary investigator (PI) obtained letters of support from six clinics that are known to treat patients with stroke. The PI provided recruitment flyers (see Appendix A) to these clinics that contained the PIs contact information, as well as a description of the topic of investigation, time requirements, and brief description of the interview process and questionnaire. The PI provided information sessions to the clinical staff to familiarize the physical therapists with the inclusion and exclusion criteria of the study and answered any questions. The physical therapists served as the primary screener for the participants with stroke and identified potential patients Perceptions of Community Mobility 30 who met the inclusion/exclusion criteria. Once the potential participant was identified by a therapist, the therapist provided the participant with a study flyer. If the patient with stroke was interested in learning more about the study and verbally agreed to allow the therapist to provide their contact information to the PI, the physical therapist contacted the study PI regarding the eligible patient/PT pair. Data Collection Immediately following the signing of the informed consent document, each participant was interviewed by the PI. Data collection, including the completion of the EAMQ 2.0 and semistructured interview took place within two to three weeks after the participant with stroke was discharged from their outpatient physical therapy episode of care. The interviews with patients and physical therapists took place separately, at a mutually agreed upon place. Basic demographic and stroke characteristic data collected from the participants with stroke included: age, sex, occupation, primary home community name (city, state), if employed occupation community name (city, state), type of stroke (ischemic or hemorrhagic), location of stroke (lobe of brain), date of stroke, length of therapies received, identified concerns or goals, and discharge activity recommendations. Demographic data collected from the physical therapist included length of time in practice, certifications held, and typical outcome measures used to determine community mobility status. Prior to each interview with the participants with stroke, the PI provided each participant with the printed options for the EAMQ 2.0 (never, rarely, sometimes, often, and always) and then asked each question on the EAMQ 2.0 and recorded the participants responses. Analysis of the data gathered using the EAMQ 2.0 occurred after all participants in the study were Perceptions of Community Mobility 31 interviewed to minimize any bias. The EAMQ 2.0 responses represent the quantitative data of the study. Questions based on the EAMQ 2.0 were embedded into the semi-structured interviews for the physical therapists in order to gage their familiarity with the instrument. (A copy of the EAMQ 2.0 can be found in Appendix B). In depth data of the perceptions regarding mobility in the community by the adults with stroke, as well as their physical therapists perceptions about community mobility was gathered via separate semi-structured interviews. The interviews were conducted using open-ended questions to gather informative-rich descriptive data regarding each participants perception of community mobility. In an effort to promote honest responses from the participants, the PI informed and assured the participants that there are not any right, correct, or favorable answers to the interview questions.69 Interviews for all participants included a progressive mode of questions that stemmed from their post-stroke rehabilitation experience which included general descriptions of community mobility. These included but were not limited to destinations, activities requiring community mobility, ambient conditions, distances, timeliness, safety and confidence in negotiating varied terrain, circumstances, factors, level of support and experiences of both successes and challenges unique to their communities and mobility abilities. A complete list of open-ended questions and prompts used may be found in Appendix C. Interviews for physical therapists consisted of a similar progressive line of questioning related to their experience with providing post-stroke rehabilitation, collaborating with patients and decision making regarding various descriptions of community mobility, in addition to the physical therapists preferences for interventions and mode of measurement. A complete list of openended question and prompts used may be found in Appendix D. Prompts to the participants initial answer were used to allow for the participant to provide deeper descriptions of their Perceptions of Community Mobility 32 experiences post-stroke and their experiences relevant to treating individuals post stroke. Use of the prompts allowed for the PI to develop an understanding of each participants perception of community mobility needs, skill set, interventions that may or may not be helpful, and use of various measures of mobility that are perceived to be influential to the process. The components of community mobility and their related impact to quality of life and participation were explored during the interview process. The semi-structured interview process lasted between 45 and 60 minutes allowing the PI to capture the thoughts both groups of participants had regarding the community mobility. The primary investigator took observational field notes during the interviews to appropriately make note of non-verbal communication and any unexpected topics that appeared to be relevant during the interview process. Instruments The quantitative instrument used in this study was the EAMQ 2.0, which is a selfreported outcome measure containing questions in mirrored pairs regarding the participants frequency of encounter and avoidance of community constructs that impact community mobility. The EAMQ 2.0 evaluates eight dimensions of the physical environment including distance, temporal, various terrains, ambient features, postural transitions during mobility, attention, and density. The EAMQ 2.0 uses a five-point Likert scale for response options (never, rarely, sometimes, often, and always). The EAMQ 2.0 has reported test-retest reliability with interclass correlations of .98 for comprehensive encounter, and .96 for comprehensive avoidance encounters, and .81-1.0 for individual dimensions.41 The EAMQ has also been concurrently validated for self-reported encounters versus observed encounters. (r = 0.66, P < .001). The EAMQ summary score has been positively correlated with the frequency of participation in the Perceptions of Community Mobility 33 community and inversely related with avoidance of community mobility (r = -0.58, P < .001).40,41 The EAMQ 2.0 has been validated in the older adult population and with individuals with stroke with the mean age of 68 years.40 Ethical Considerations Prior to each interview, the participant was informed of the procedure, risks and benefits of the study and asked to sign an informed consent document. (Appendix F) The PI answered any questions the participants had prior to beginning the interview. The potential risks to participants were no greater than the normal experiences and or interactions encountered in daily life. Data Management Each participant was assigned a unique numerical identifier known only to the PI and the participant. The PI noted the unique identifier prior to beginning any interview questions on the audio recording. Audio recordings of the semi-structured interviews were made by the PI on a password-protected digital recorder. The interviews were then digitally encrypted using VeraCrypt and sent to Same Day Transcription Service for transcription verbatim. Same Day Transcriptions provided a non-disclosure statement as well as confirmation of HIPPA and CITI training, which was submitted to the IRB for review and approval. The transcribed data were returned to the PI via encrypted password protected email. The PI then forwarded the transcribed interviews to each participant via password protected email with a unique password given to the participant at the time of the interview or via return receipt certified mail or priority mail via the United States Postal Service if the participant so requested. Member checking is a strategy used ensure data accuracy and to provide an opportunity for the participant to add any additional Perceptions of Community Mobility 34 information to the content to ensure that the results truly reflect their reality.62,69 Once the participant approved their transcript and returned the approval form to the PT (Appendix E), data analysis of the transcript was initiated. The PI printed the transcribed interviews out for coding and data analysis; these copies were stored in a locked file cabinet in the PIs locked office. Basic demographic information and the EAMQ 2.0 questionnaires were kept in the designated locked file cabinet in the PIs office. Electronic coding using NVivo was performed on a password protected computer which will be kept for a period of up to 7 years or the year 2024. At which time the data on the computer will be electronically purged and deleted according to the manufacturers guidelines. Data Analysis The PI began qualitative data analysis by reading all interview transcripts in their entirety. The transcripts were then read a second time followed by line-by-line coding using QSR NVivo II (QSR International Ltd., Victoria, Australia) software package. Codes were created by identifying words or phrases related to the research objectives and assigning each a descriptive code. During this coding process, an effort was made to fully explore the participants perceptions of community mobility by identifying concepts or phrases relating to community mobility from either the adult post-stroke or the discharging physical therapist. Specifically, the PI read the transcripts looking for any emphasis on experiences, feelings about, judgments, or concerns regarding the ability or inability to participate in or physically perform a task related to mobility within their identified communities. Initial coding was also performed by a second researcher with experience in neurological physical therapy and qualitative data analysis, but who did not participate in the interview Perceptions of Community Mobility 35 process. The second researcher independently reviewed each member-checked transcript and provided handwritten line-by-line notations and coding, then returned the coded transcripts to the PI for comparison to the original coded transcripts. The PI then reviewed the transcripts once again to determine the extent to which the initial themes identified by both researchers were aligned. In an effort to enhance credibility of the emergent codes and themes, the primary investigator utilized field notes and a journal to conduct a reflexive analysis of the initial themes. Once transcripts were reviewed, the PI prepared for a data analysis meeting with the second researcher by reviewing all field notes and post-interview journal notes to evaluate for any notable bias towards a particular theme (such as the use of a particular outcome measure used by a physical therapist or an experience reported by a participant that trigger a memory of a therapeutic encounter with a former patient). In the data analysis meeting, participant quotes that matched an entry in the PIs field notes were thoroughly discussed with the second researcher to attempt to mitigate researcher bias. For example, the PI focused on the reported outcome measures whereas the second researcher had a more global view of the treatment processes with regard to facilitators and barriers, which allowed for the PI to discuss potential for bias. The PI and the second researcher then reviewed the combined coded transcripts and, through a consensus making process, determined the initial overarching themes. The PI and second researcher met once again after the initial coding process to review and refine the codes and compare those to the data from the EAMQ 2.0 to promote credibility via analyst triangulation. During this meeting, themes were refined and re-categorized in effort to enhance credibility and confirmability through joint analysis and triangulation to the EAMQ 2.0.71 Perceptions of Community Mobility 36 Quantitative data from the EAMQ 2.0 were analyzed by the PI using Microsoft Excel to calculate the mean avoidance and encounter scores for the overall assessment for each participant, as well as the mean avoidance and encounter scores for each dimension by participant. Responses to questions on the EAMQ 2.0 correspond to a 5-point ordinal scale (never, rarely, sometimes, often and always). Scores for encounters and avoidances range from 1 = never, 2 = rarely, 3 = sometimes, 4 = often and 5= always.41 Greater environmental encounters are represented with higher scores on the EAMQ, whereas less avoidance of mobility in the environment is represented by lower scores. Emergent themes regarding community experiences with regard to the encounter and avoidance of the dimensions of community mobility, (distance, temporal, ambient, terrain, physical load, postural transitions, attention, and density) were then triangulated to the EAMQ 2.0 in order to enhance credibility of the thematic findings. Triangulation was performed by comparing the themes identified from the qualitative data with answers on the EAMQ 2.0. Aspects of community mobility that were discussed by participants during interviews were triangulated with scores from the EAMQ 2.0 related to frequency of encounter and avoidance across 24 features of the physical environment. For example, barriers reported by participants with stroke in the qualitative interviews were compared to avoidances in the physical environment as scored on the EAMQ 2.0. The same concept was employed for reported facilitators with respect to scored encounters on the EAMQ 2.0. Themes from the interviews with the physical therapists were then triangulated to the EAMQ 2.0 scores for encounter and/or avoidance reported by patients for the various dimensions to determine if any triangulation could be made. For example, physical therapists reporting intervention priorities such as gait training Perceptions of Community Mobility 37 for distance were evaluated to determine if reported encounters in the distance dimension supported the statements made. Throughout the collaborative data analysis process, the tenet of reflexivity was addressed by discussing the data within the context of each researchers varied backgrounds.71,73 Since each researcher had independent areas of specialty and educational backgrounds each researcher brought a unique perceptive to the codes and interpretation of participant responses. The primary investigators clinical experience is with adults with neurological and orthopedic pathologies while the second researchers experience is primarily with pediatrics and with rehabilitation research methods in general. By discussing these differences in viewpoints, the codes were further refined to be more specific and better informed by the literature and current best practices. Conceptual memo writing was utilized by the PI throughout the data analysis process in order to explore relations between the adults with stroke and their physical therapists as well as the relationship to the EAMQ 2.0. These conceptual memos did not provide the researchers with new information but did help the researchers galvanize their understanding of the text and further refined the codes. In addition to aiding in code refinement, the memo writing aided the PI with EAMQ interpretation by noting if various treatment methods led to encounters or if reported avoidances were related to treatments that were not utilized by physical therapists. Likewise, the same concept was used with the reported experiences of the adults post-stroke when analyzing the reported encounters and avoidances of dimensions on the EAMQ 2.0. These conceptual memos were discussed with the second researcher until all themes were agreed upon. 72 Audit trails consisting of coding changes were maintained by each researcher in order to have confirmability of the resultant themes.71-74 Perceptions of Community Mobility 38 RESULTS Participants Participants included six pairs of adult participants with -stroke and their physical therapists. Participants with stroke were between 58 to 76 years old (see Table 1). All experienced a stroke of ischemic etiology. All participants with stroke reported in their interviews that they were in good health, and that prior to having a stroke they engaged in community mobility daily and did not feel limited by their health. Prior to having a stroke, each participant with stroke reported that they were independently functioning in their activities of daily living. Time since onset of the stroke ranged from between 2.6 months to 24 months. The six physical therapists that participated in this study ranged in age from 26 to 39 years (see Table 2) with an average of 7.16 years of experience treating people with stroke. As revealed during the interviews none of the physical therapists were familiar with the EAMQ 2.0 prior to their participation in this study. Participating physical therapists reported using standardized measures to guide decision making related to community mobility such as the tenmeter walk test, six-minute walk test, Functional Gait Assessment, and Berg Balance Scale. In addition to standardized measures, physical therapists also reported using observational gait assessment and fear avoidance questionnaires to aide in determining a patients needs for mobility within their communities. Interview Themes Perceptions of Community Mobility 39 Inductive analysis of the interview transcripts of adults post-stroke and their physical therapists elicited eight primary themes. Three themes were identified as factors that facilitated community mobility and five themes that detracted from community mobility. Themes facilitating community mobility included: 1) support systems, 2) collaborative goal setting, and 3) meaningful interventions. Themes that detracted from community mobility included: 1) societal perceptions, 2) safety, 3) levels of function, 4) upper extremity function, and 5) third party influences. Although analysis of the interview transcripts indicated a significant degree of agreement between the adults who were post-stroke and their physical therapists regarding the general concepts of the reported themes, the perceptions of the themes differed between the parties. The patients perceptions of the need for continued physical therapy services and what constituted the optimal level of function differed from the perceptions of the physical therapists. Community Mobility Facilitators The overarching theme of factors that contributed to community mobility status was largely agreed upon between the participant with stroke and their treating physical therapists. Themes associated with contributing to the acquisition of community mobility status included: support systems, goal setting, and meaningful physical therapy interventions. Support Systems Both adults post-stroke and the physical therapists identified support systems as a vital component of recovery. Support systems were described as immediate family and friends as well Perceptions of Community Mobility 40 as the therapeutic support received from the physical therapist. The support systems were reported to influence a stroke survivors confidence and self-efficacy. The adult post-stroke perspective indicated that support systems served as advocates for optimal care, sources of motivation and hope, provided a purpose for the recovery, and as a means of expertise to guide recovery. Support systems not only provided motivational encouragement but also supported the acquisition of rehabilitation services by coordinating or advocating on the survivors behalf to ensure that services were received so functional recovery could be initiated. Patient number four perceived that her lack of medical knowledge as barrier, however, her support system was able to intervene and ensure that rehabilitation services were initiated. My sister, whos a practitioner, she made sure there was no stopping. She wanted me in a rehab that was very intense and that had structure, moving about, had a plan in place for what had happened to me. She had talked to the rehab all about me and to make sure that they have a plan in place for someone like me. I only know about education, not medical stuff - So medical I leave up to her. Support systems also provided survivors with hope for recovery despite having functional limitations and doubt of possible recovery. "My next-door neighbor, and then friends at work, and then people from church visited me in the hospital, saying, "You can overcome, you can overcome. I know you're strong." They were giving me encouragement, encouragement that I believed helped me a lot to go over like the darkest side of my life." Patient Five Survivors of stroke and their physical therapists report that supportive relationships, both personal and therapeutic can also serve as a source of motivation and purpose to continue the rehabilitation process. They (family) dont allow me to get lazy or slacking. They push me. I wouldnt say push me; they encourage. They are a safety net if I need it. Patient Two Perceptions of Community Mobility 41 Rehabilitation after stoke needs to include efforts by the PT to build the patients confidence towards activities including balance, strength, mobility and emotions. Therapy efforts should support confidence and serve as a motivation. Physical Therapist Six The rehabilitation experience for survivors of stroke is multi-tiered and carries with it an expectation of progressive functional gains. A collaborative relationship or therapeutic alliance with the treating physical therapist was described as an important facilitator for the recovery process. "They have a game plan when they started my PT, and theyre pretty consistent with the way they do things. And theyre easy. Theyre always watching out for us. If were tired or a fall risk, they see it. And they encourage rest, hard work and rest. Collaboration has been great with them I think. Patient Two "I think helping to point out that the fact that they (the patient) were successful, especially if it's the first time is important" "Were you successful at the task or were you not? - and if they are concerned about quality - then we can focus on the quality aspect later. That's our job as a PT to figure out the quality part too." Physical Therapist Three The treating therapists ability to relate to the patient and be intuitive to the patients needs was also noted as important. Patient six described her therapist as being creative, having a keen ability to problem solve and implement interventions that allowed her to progress in her recovery. Clinical expertise and knowledge of evidence based therapeutic techniques was an expectation of the physical therapist. Both adults post-stroke and physical therapists identified that having the therapist identify progress also served as positive contributor towards community mobility and the rehab process. Personality wise I like him, but hes also seems to know what hes doing. He has lots of different ideas, try this, try that. Hes very encouraging. Yes, you can do this. Hes just very, very positive. He will say - you know, you're doing well, this is improving, look what you couldnt do and that you can do it now. I think a lot of that comes out of his personality. There are people who are very clinically good and not necessarily bad personalities, but just dont relate to you as a patient and that does not help." Patient Six Perceptions of Community Mobility 42 I think as long as they are seeing the reason for treatment as a progression toward their goals, and they are meeting the goals, theyre going to be apt to continue with my suggestions." Physical Therapist Two Conversely, to the aforementioned facets of support systems, the perspective of the physical therapists considered the patients support system as a means to augment therapeutic strategies outside of structured therapy time. Likewise, physical therapists cited that patients have a greater opportunity for progress when they have support outside of therapy that assists with carryover of therapeutic interventions. A support system may serve as a catalyst for building confidence in mobility tasks. Often during recovery from stroke, a person may not be able to drive or may require some light physical assistance to complete tasks that they have not yet mastered, such as ascending and descending stairs without a handrail or safe navigation of uneven terrain. In addition to light physical assistance, the presence of a support person allows for a sense of security when encountering a task that may present as a fall risk. In these instances, the support person serves as safety net should an adverse event should occur. "Man, family support is huge. I think when you talk to patients about their family coming in and helping them through these things; and giving them purpose to kind of do some of these activities and get back to it. People who love their work, kind of including that. Or, getting them, doing activities and therapy that are similar to things they have loved in the past. Physical Therapist Two Physical therapist three reported that while their patient was ready and eager to regain independent functionality, their family was available to support them if needed. This therapist indicated that their patient confidently preformed activities independently while visiting with family. "We set some goals. He not only worked on them here, but worked on them at home. He came back to me after a week and said, "Yeah. We went out of town this weekend. That was at my...." I think it was his wife's parents place. He was helping them outside doing work. They're like, "Okay, sit down." He is like, "No. This is like therapy to me. I want to get Perceptions of Community Mobility 43 better. He was like, "It was great. I was walking over uneven surfaces." He said, "Don't worry. I had someone with me the whole time." But, that I think he took it more upon himself to get right back into the community. Then, you give some patients that sit and wait until they are done with rehab to continue living. He has just continued to live through his rehab, which I think has really brought him even further in a short amount of time." Physical Therapist Three Collaborative Goal Setting Although variations regarding the purpose of goal setting were reported, all participants expressed value in collaborative goal setting. Reported variations related to how the participants viewed of the goals purpose. Adults post-stroke viewed the goals as a means to serve as guide for salient tasks, a means of measuring progress and a mode of motivation. In addition to using goals to measure the degree of recovery, physical therapists established goals as a means of establishing rapport with their patients. Patients conveyed that salient tasks bring forth a personal vestige in the activities that are related to a personally meaningful goal which participants indicated may augment the therapeutic process. "They set goals, for example, something like I would like to probably carry my grandchildren. I want to gain strength on my legs, I want to walk, and with less dependence on the cane. So, they tried to give me all the challenges that I had given them because those are the goals that I set up, so normally they would set the challenge for you, in order for you to, at least, achieve or reach the goal. But being a good therapist, they should be able to detect those things that you need and how to do them." Patient Five Adults post-stroke expressed that the process of regaining functional ability after a stroke can be a daunting experience, likewise physical therapists acknowledged the degree of effort that their patients put towards their recovery. Regular dialogue between therapists that targeted personal goals or patient specific quests was found to be motivational and lead to increased confidence for patients. Perceptions of Community Mobility 44 She said I just gave you the hardest one. (a structured community-based task) You did it in 40 minutes. So, I did improve." "It gave me more confidence even though I wasnt going out a lot during therapy. As time went along, I got more confident because of it." Patient One I am very competitive, so I would say something like, "You can do better than that when I would do something with a score. And it's nice to know how much you have exerted the effort, compared with the past. You have to know, because if it's still an effort for something thats on the average, you want to go a little more above that and do better than before. Patient Six Physical therapists reported that, during their initial evaluations, efforts to establish rapport with the patient were initiated through conversation regarding patient-centered goals. By establishing rapport with the patient and their family members the therapist gained a broad understanding of the patients prior level of function and their motivation to obtain goals based on their interests. Everybody can sit and do whatever exercise you tell them - but it doesn't matter if it is not specific to what they need or want." "Why are we doing balance tasks - is it really what they need or want? PT's need to be specific on why we are doing something and that should relate to the patients desires." Physical Therapist Six "I start on day one and discuss with them what they want to get out of PT, like I want to work on the left side of my body, or I need help to get up and down the stairs, it's good to hear what they have to say." "You have to take into account what the patient wants to do, otherwise you won't have saliency Physical Therapist Four Meaningful Interventions Interventions thought to be helpful in regaining function that promoted community mobility by adults post-stroke, primarily targeted gait, lower extremity function, and balance tasks. The interventions were perceived beneficial when they were administered in a progressive manner. Differing from adults post-stroke, physical therapists viewed meaningful interventions Perceptions of Community Mobility 45 as a mechanism that allowed for the incorporation of principles of neuroplasticity and specificity of relevant environments that were associated with community mobility. Although interventions were activity based, patients indicated that they viewed the activities as a focus on impairments of body structure and function that were involved in the activity, these were valued by adults post-stroke. My first time on the treadmill at rehab. That was really tough and really hard. But I noticed afterward--because we werent really allowed to walk without a therapist around. But I noticed the next day, or later on that day even, it seemed a little easier to walk. And it got better every day. And it was tough at first, but I noticed the next day my leg was moving a lot better. Patient Two I think a lot of the treadmill and the NuStep. They had me in a harness walking down around the track. I think that helped. It kept my balance. And then they had the arm exercises and the hand exercises that helped my hand come back because I couldnt even spread my fingers. I couldnt do nothing. I couldnt open or close it. I can do all of that now on my left hand. When you stay up this here, they have you walking and theyll yank you to check your balance. Or if somebody bumps into me, I can catch myself. Well, I think that they encouraged me every day, you know, just talking to them and them talking to me. And they were pushing me and I was pushing to do better. Patient Four Augmenting the previous theme of support systems where the physical therapist was a component of the patients support system, patients reported an appreciation for structured activities that involved challenging and intensive exertive efforts. I even tease the PT as being, a workhorse, just working us hard. Is this a boot camp or what? But you know, we do that out of love. Theres a group of us that do that. We loved her for making us work and getting us better. Patient Three Likewise, physical therapists reported that direct observation of the patients performance while navigating various locations in the community such as the grocery or department store, were beneficial and allowed for insight of the patients actual capability to complete tasks. The therapists that reported using immersed community mobility interventions were therapists who worked in an interdisciplinary program where community reintegration is a primary focus. Perceptions of Community Mobility 46 Physical therapists working in a sole discipline clinic reported relying on patient report to determine the patients need for community mobility training. "Whenever I ask a patient if they want to go into the community or outside they always seem to view it positively - and thats how I make sure its safe for them." "It's eye opening sometimes you realize they are good in the clinic and on the tile floor, but then you go outside and its a different experience. Physical Therapist Four. Therapeutic interventions reported to be useful incorporated several principles of neuroplasticity including, use it or lose it, intensity, repetition, and salient tasks. "I actually helped out a research lab downtown where that's what they primarily looked at was the step count and how that correlates with community outlook. It's highly correlated in how well they're going to do. So, we need to push, make it intense, and get the step count up. Physical Therapist One Additionally, physical therapists reported their positive experience with group-based training. Therapists utilizing group-based therapeutic interventions reported that patient to patient engagement during group sessions has a positive impact on the patient performance and motivation. Physical Therapist Five reported, "Everyone is working on the same type of task at the same time but individualized to their own ability and needs. The ace in the hole is that when patients are with others they realize that everybody else is trying and so it's not so bad, you have true peer pressure. In traditional outpatient settings, you typically work by yourself and you may not see another person with a stroke working on things. We have a patient who does not to wear her brace, but we asked her to bring it in to try it here, and her standing was so impressive everybody else took notice and the amount of admiration and applause she was getting from her peers that we didn't have to ask her to bring it in next time and she has been wearing it, so that is a positive peer pressure." Physical Therapist Five Community Mobility Detractors Interviews for both groups of participants indicated many positive factors that promoted community mobility post-stroke; however, the in-depth interviews also revealed several factors Perceptions of Community Mobility 47 that detracted from community mobility. Themes that related to factors that impeded from community mobility included: 1) societal perceptions, 2) safety, 3) levels of function, 4) upper extremity function, and 5) third party influences. Societal Perceptions Perceived barriers related to societal perceptions by both groups of participants were revealed. Specifically, expressed frustrations with the recovery process involved several dimensions related to public perception of stroke or disability. Adults post-stroke reported believing that public perception of ones abilities after experiencing a stroke focuses on limitations and dependence instead of functional capability. The idea of these perceptions may prohibit a stroke survivors return to prior activities such as work and foster feelings of pity. For example, patient one indicated that they chose not to divulge their health status to colleagues at work to avoid unhelpful sympathy. According to patient one, I chose not to tell the people at work. I went to the meeting, it was a short meeting, but I attended the meeting. I dont think anybody could tell I had a stroke - Its human nature; to feel sorry for you hope youre okay; whatever I could do for you etc. But that doesnt really help you." Patient One Patient four reported a similar experience to patient one. Patient four indicated that she believed the sympathy people felt undercut their respect for her as a capable individual. She reported that people viewed disability or illness as something that needed to be contained or fixed before interacting with the public. Patient four said, Oh, those kids, theyd love its bad but theyd love seeing me like this, and they dont respect me because they feel sorry for me, you know? You know, they see you with a cane and you got a brace on? Oh my gosh, not as a teacher. And I would tell teachers myself, no, you get yourself together before you get back in here. " Patient Four Perceptions of Community Mobility 48 Patient five also reported interactions with strangers that, while courteous could also be considered infantilizing and condescending. While patient five indicated that he believed these individuals were attempting to be helpful, he also said the courtesy was not necessary. According to patient five, Mostly, a lot of people are very, very courteous. Thats a nice gesture. I think they see me as a guy holding a cane, and they know that it's very hard for me to open using my left hand. So normally, what I do is I put my cane in my hand and then grab the door and tell them you dont have to do that Patient Five Physical therapist six also expressed concern of the general publics perceptions of persons with disability and considered the publics lack of awareness as a barrier. "I think its just our society. There is not a lot of awareness of give someone a little bit of space. If you see them walking with a cane or walking a little bit more slowly. Kind of, I don't know that if community mobility can be limited by only an environmental barrier, but also more of a societal barrier. People just not necessarily being aware of other peoples needs." Physical Therapist Six Physical therapists indicated that they viewed the infrastructure as a societal benefit and should be supported by society as a whole. Therapists conveyed that they perceived that society in general does not hold individuals with disability in high regard, resulting with the priority of accessible and efficient infrastructure to be less likely to be available to those in need. This was indicated by Physical Therapist three, "It's a problem - you may be able to ambulate or walk but you may or may not be able to get to your job. The paratransit system isn't the greatest and it takes a lot of time, so I think it could be a facilitator if it was more efficient, but when you need to get to and from places - so you need transportation and if youre in the suburbs the infrastructure isn't great - so I think having a better infrastructure would be a facilitator versus a barrier." Safety Perceptions of Community Mobility 49 In addition to societal perceptions, the concept of safety was identified by both adults post-stroke and their physical therapists. The general safety of a persons community can present barriers for an older adult recovering from stroke. Decreased mobility, such as a slower walking speed, although capable may leave someone vulnerable to becoming a victim of crime. " I think that their own community is going to be a benefit or barrier. I know one gentleman he was in a not so safe neighborhood so he was reluctant to go into the community because of his safety, since he was slower." Physical Therapist One Functional safety was expressed to be a concern for all parties. An error in safety could be detrimental to the recovery process, lead to additional injury, and even result in irreversible functional status. Appropriate cognitive function is necessary for safe negotiation and interaction in the community. Concern for a patient who may not have insight into their cognitive deficits that may impact their overall safety was expressed. "Speech, I thought I could talk. I could communicate. I knew I was a little slow on my comebacks or whatever. I thought that would get up to speed. I found out I was somewhat slow. The therapy really helped me." " The driving school interestingly, the classroom is about 90 percent of, how do I want to say it, cognitive development. They show you about four or five pictures. Then, they would say, now identify here. You have to, well lets see. It really perplexed me. I found out, they want to see that you can differentiate between sites, pictures and that; more so than just a stop sign. That was interesting. I didnt have insight into my short comings." Patient One Supporting this view, physical therapists worked to optimize physical function, contextual factors such as distracting environments and the need to perform dual tasking were factors impacting safety within the realm of community mobility were reported to be of concern. "As far as the mobility. I mean, if we're strictly talking about physical return, I think each person could have a pretty fair shot regardless of side affected. But differences exist when you consider that community mobility isn't just physical, its also cognitive and mental. It's how you interpret the world. How you can problem solve and be safe? Because if someone has had a stroke that affects the left side. They're having difficulties with language or processing, problem solving. They are unable to speak with someone else without maybe a Perceptions of Community Mobility 50 communication device or something. That can be a major barrier for them. " Physical Therapist Two Due to negative sequela associated with falls, adults post-stroke and their physical therapists identified the potential for falls while performing community mobility as a barrier to community mobility. "So, its like the cycle of falls. So, its either a fear of falling or a history of falling and then its an endless cycle - you know I'm afraid to fall, so I'm not going to risk moving to cause a fall, so I won't be going into the community because I don't want to fall. So, it a fear of falling or fear avoidance. and that decreases motivation. Physical Therapist Four Although patients did not associate falling with the negative sequela that physical therapists did, patients identified an awareness of fall risk and strategies needed to avoid falling. If strategies are unable to be implemented, falls become a higher threat to safety and may be associated with avoidance of community mobility tasks. "The only thing that Ive experienced when Im out is I get tired easy now. And when I get tired a get a little, I dont know--I would say wobbly, but I end up getting a little bit of toe dragging here and there from just being tired, and then I will likely fall if I get distracted. If I sit and rest for a while, Im back at it. I just try to find a place to sit down for a few minutes to prevent the falling." Patient Two Levels of Function Adults post-stroke indicated that returning to their prior level of function was their optimal goal. Pre-stroke level of function served as a measuring stick to which adults post-stroke continuously measured their degree of recovery, including such functions as their driving status. Although the physical therapists viewed the execution of a functional mobility tasks with compensatory strategies as successful and adequate; patients held a different view. Adults poststroke expressed discontent with acceptance of a modified level of function that was attained Perceptions of Community Mobility 51 with the use of assistive devices, use of orthotics, or compensatory strategies. Adults post-stroke disagreed with therapists recommendations for discharge as they expressed belief in their potential for continued progress or goal attainment. Additionally, although adults post-stroke valued the use of their upper extremities for community mobility tasks, physical therapists did not report consideration of upper extremity function in relation to community mobility tasks. Patient three indicated that while she was able to begin recovery with the help of a physical therapist, she did not believe her recovery was complete when her treatment ended. "You know, you (the therapist) get me to the point of moving my leg, matter of fact, I just got my toes start wiggling just last week, so now you're ready to throw me out. I got another phase I have got to get through. So thats what Im saying, that just not right. No, not you taught me a lot, you taught me step by step but that is not how I walked before and that is what I want to do again without the brace. Patient Three Patient four and six indicated that although they were functional and able to demonstrate ability to ambulate, their mechanics of ambulation undermined their confidence with mobility tasks. Its to see myself doing things independent and actually being able to walk down those stairs. Making sure I can walk down the stairs without each step going this way. But, you know, I can be able to do the one, two. step, walk. I dont want to walk around hopping all the time. I just want to feel secure or feel that youve done enough and it just aint gonna happen or its going to happen. But I want to feel like I have a fair chance to get back to normal. Patient Four It is something like--especially if you're walking. When you walk, and you're not walking straight because you're limping et cetera, meaning that something is not working in your body structure. The muscles are not pulling up the right... and they should be able to give you a much better advice, maybe little more activities. " Patient Six The physical therapists focus is to obtain safe function and once the patient obtains that level of function the degree of skill required to support continued interventions becomes questionable and may require discharge to a community program for continued progress. This Perceptions of Community Mobility 52 can be viewed as a form of abandonment by the patient. Physical therapist three expressed her thoughts regarding functional levels of mobility as, "When she's here, she's walking around the clinic on her own, she uses an AFO and a straight cane for the majority of the time. We have done some walking without the cane, and she does pretty well in that. I know, for her, she is an elementary school teacher, and so she is really big on being able to get back into the classroom, and I understand that dealing with the kids may be an issue. I think her ability to do that at this point would be limited, because she does lead them from class to class. I think some of that is from the fact that I don't believe the school district would allow her to go back with some of those limitations. - even though she is functional." Physical Therapist Three For some patients, the label of stroke may lead to self-imposed limitations and thus reduce the possibility of realization of true capabilities. Physical therapist six expressed the importance of gaining the patients confidence through collaboration and education to achieve maximal potential. For her I think she had an internal focus on her stroke - her activities were defined a bit by that, having a little bit more difficulty with balance and walking not even remotely thinking that she could walk quickly, even though she was functional in the community. "Pt. reports that I never thought I would be able to do this much because I had a stroke." Physical Therapist Six. Upper Extremity Function Full and unlimited participation in community activities often requires the use of both hands to carry objects, access destinations by opening and closing doors, and manipulating objects at various height levels. Adults post-stroke expressed concern and described how limited upper extremity function hindered their participation in ADLs, community mobility tasks, and community-based activities. It should be noted that although patients reported on this experience, physical therapists did not mention any issues with upper extremity function throughout all interviews. Perceptions of Community Mobility 53 Yes. I think they have it, but right now I cant hold on tight with this arm. Ive got strength in it. I started getting my strength back, got my hands moving. Im so happy. But theres no strength, no grip. My grip isnt there yet. Like I still cant hold the cane with this hand. But I can hold it with the left hand, but it really is not that successful. I try to avoid it sometime. Its because I dont feel as secure with the left hand. I dont think going to a gym or being in a class is gonna help me because I cant move this hand." Patient Four "Church -that was a little difficult. It was a little difficult. One thing is we do a lot of clapping. I couldnt I cant clap yet. My singing I lost something with the stroke a little bit it kind of affected my vocal cords a little bit. And standing, sitting, standing, sitting, standing that was a little difficult". Patient Five "Well, I cant comb my hair. I cant cook. I cant hold the pots like I want to. Im so afraid with boiling water or trying to make me a cup of tea or something like that. Right now. And its not so much afraid. I just know right now I dont have the strength. " Patient One In addition to upper extremity function being related to community mobility tasks, patients described that due to the requirements of driving, largely based on upper extremity function, lack of the ability to drive also hindered access to their communities. "So right now, my main goal is to drive again. Naturally, my arm is impeding my progress in some things, but I think Ill get there eventually." Patient Three My wife drives me, and I'm her navigator. We go to watch plays. My daughter would buy tickets for my wife and myself, and we'd go to see a play in Chicago, downtown Chicago, so we like going to the movie theaters. But I cant do those things by myself because I cant steer the car with my hand. Patient Five Third Party Influences Patients and physical therapists alike expressed frustration with limited access to comprehensive services that supported full recovery, rather than a focus on achieving minimal functionality. Third party payers were cited as having an objective of supporting rehabilitation services only to the point where the beneficiary of the policy has obtained some function and modified independence with functional mobility within the clinic setting which may not translate to the community. Therapeutic intervention beyond the point of modified independence or as Perceptions of Community Mobility 54 related to community mobility may not be deemed medically necessary, although the patient may have the capability to progress their skills and functional ability with intervention, and have a need to participate in the community. Patient six expressed this by saying, But for people who are not as fortunate, I think the expectation for their recovery should be raised. Its not, as I said, I think, the idea of getting them minimally functional as it is to get them maximally functional should be the focus. Thats not always possible. I realize that. But I think there probably a lot of people like me, for instance, who could have benefitted from more intervention sooner and not have left us with whatever disabilities we have. Patient Six Like patient six, patient five agreed that there should be greater access to physical therapy in the United States. Patient five believed other countries used more comprehensive models of physical therapy than the United States and individuals needing treatment had better access to services. According to patient five, Speaking about Europe, I had a good friend trained as a physical therapist in Norway back in the 60s even then Europe was a hundred miles ahead of the United States. And it needs to be that way here more. We need to be able access physical therapy more than we do." Patient Five Physical therapists reported that third party payer constraints with respect to therapy services being based solely on medical necessity often limits the possibility of ongoing recovery for older adults. This was discussed by physical therapists six, five and four as described below. "I think we need to be very cautious at what we use to define goals, because people hear it differently. They hear you met your goal and then they think they are done, especially if they are functional. And then if it's insurance they think that is good enough. But maybe the person still has potential to get even better - so really they are not done." Physical Therapist Six I wish the insurance companies would actually pay attention to the research that is out there because the research will tell you that therapy, even if it's maintenance therapy, it is maintaining them at a certain level, so they need less care in the long run. Insurance doesn't understand that if you don't get therapy then they are going to regress and then they need more care in the end." Physical Therapist Five Perceptions of Community Mobility 55 "We are told that we can't set goals to walk over 150 feet, because Medicare doesn't like that - so we can't do a 6-minute walk test, so if they can walk over 150 feet, they can leave the house and therapy won't be covered, and there is chitter chatter between therapists whether its actually true because that really doesn't make sense and it doesn't help the patient to get back to things in the community, which is where they were before." Physical Therapist Four Quantitative Analysis of EAMQ 2.0 Results of EAMQ 2.0 The mean encounter and avoidance scores for each adult post-stroke participant across all dimensions is displayed in Table 3. DISCUSSION The aim of this mixed methods study was to compare and contrast the perceptions of community mobility held by adults post-stroke and their physical therapists. After perceptual themes were identified the secondary aim was to triangulate the reported perceptions with ratings on the EAMQ 2.0 for dimension encounters and avoidances by the adult post-stroke. This chapter will provide a discussion of the study results organized by research question and will offer a triangulation of the qualitative themes to the EAMQ 2.0. Study limitations and areas for further research will also be discussed. Exploration of the participants perspectives of community mobility facilitators revealed the impact meaningful interventions had on dimension encounters. In general, it appeared that targeted interventions supported the higher mean encounter scores on the EAMQ 2.0 within the dimensions of distance, temporal, and terrain when compared to avoidances. Participants poststroke expressed value in the interventions that improved their endurance, balance, and walking Perceptions of Community Mobility 56 abilities which may have contributed to most of the participants reporting greater encounters than avoidances within those dimensions. Utilization of gait speed, distance measures, and balance assessments served as a basis to determine progression of interventions as reported by physical therapists. Reported evidence-based physical therapy interventions focused on gait tempo, distance, balance reactions, and when feasible practice of locomotor skills within the community. This may explain the higher EAMQ 2.0 encounter scores in the dimensions of distance, temporal, and terrain as compared to other dimensions where interventions were lacking. Therapeutic interventions were viewed by both parties as a direct means of recovery of function. Interestingly, adults post-stroke viewed interventions as a means to improve the impairments of the direct body structure and function, while physical therapists viewed the interventions in structured or mechanistic terms such as intensity, repetitions, and impact on outcome measures. For example, participants post-stroke consistently described interventions they participated in and related the outcomes to their recovery of function in their impaired limbs; in contrast physical therapists viewed components of functional activities in terms of principles that drive neuroplasticity. This finding was supported in the recent work of Janssen et. al81 that explored factors surrounding the delivery of intensive inpatient rehabilitation services. The findings by Janessn et al supported that while both patients and therapists may find value in interventions that are intensive, the patient and therapist views may differ in respect to the perceived mechanism of value within the interventions. Patients may focus on tasks directly related to their impairments, while in contrast, physical therapists may relate the delivery of intensive services to the mechanical content of the intervention, such as steps taken, speed, heart rate and other metrics.81 Similarly, the thematic findings of this study supported the finding of variations in intervention perspectives held by adults post-stroke versus their physical therapists. Perceptions of Community Mobility 57 One interesting detractor from community mobility was upper extremity function. The physical therapists interviewed in this study did not indicate that upper extremity function was a consideration for community mobility nor did the physical therapists indicate evaluation of upper extremity function with an outcome measure. In contrast, the participants with stroke reported that lack of sufficient upper extremity function was a significant limiting factor to their community mobility. The dimensions of physical load and postural transitions on the EAMQ 2.0 relate to upper extremity function and capability. In both dimensions, the participants with stroke indicated primarily low encounters, meaning they did not participate in activities that required upper extremity function such as carrying items or opening heavy doors. In accordance, higher degrees of avoidance (1.5 overall, 2.83 for carrying items and reaching above shoulder height, and 2.16 for pushing a heavy door) were found for physical load and postural transition dimension within community mobility tasks. With the exception of multitasking80 upper extremity function is largely neglected as a requirement for community mobility. However, during locomotion, it is reported that arm swing is an essential contributor to the stability of locomotion and is an influencing factor for metabolic cost during locomotion.83 It appears that the when evaluating gait, physical therapists may be under estimating the contribution that upper extremity function has towards community mobility and ultimate participation and performance in community-based tasks. Upper extremity function in relation to the capability of handling a physical load, gait stability, and energy expenditure should be considered as a supplement to clinical measures used to determine prognosis and client performance in the community. In addition to stair navigation trips into the community that involve bimanual tasks, the carrying or manipulation of objects, are reported to present adults post-stroke with difficulties that may require physical assist from another person. Perceptions of Community Mobility 58 Agreement between adults post-stroke and their physical therapists regarding facilitators of community mobility supported previous findings in the literature.12,25,27,28 Both groups reported that support systems were important and served as a means of motivation and physical assistance when needed. The participants with stroke also indicated that support systems were essential in the navigation of the healthcare system and often served as their advocates for services. Collaboration on goals served as a means for both parties to measure progress and communicate priorities. Physical therapists expressed that goal attainment served as a pathway for discharge, while patients although grateful for goal attainment, felt that goals should be progressed to a higher-level and should support the continuation of therapeutic services. Disagreement as to when discharge from therapy services should occur was conveyed by patients. Patients believed they would continue to benefit from the unique specialized services that physical therapists delivered and possibly achieve premorbid functional status. Moore et al.54 determined that perceived plateaus in locomotor function were reversed when intensive and specific locomotor training was provided to individuals post stroke.54 This supportive evidence indicates that collaborative discussions between patients and physical therapists regarding each parties perspectives on the patients level of function and capabilities may serve as a basis for goal progression and continued therapeutic interventions and further skill acquisition. Detractors from community mobility revealed interrelated concepts by both the participants post-stroke and their physical therapists. Both parties viewed residual impairments as a means for society to pass judgment on the individual as unable to complete tasks or potentially as a target for crime. Patients stated that although therapists indicated use of an assistive device or bracing as a viable option for mobility efficiency, the distinction of modified Perceptions of Community Mobility 59 independence or use of an AD was not always acceptable due to the stigma and physical identification it was perceived to carry with it. Some participants post-stroke, expressed that the physical presence of an AD, served as a reminder that they were less than their pre-stroke self, which carries the stigma that post-stroke they do not meet the mark for their familial or societal roles, which may have led to decreased community mobility encounters. One purpose of this study was to explore the perceived barriers to community mobility through the lived experiences of an adult post-stroke, this finding is interesting as it provides a deeper meaning to the reasons adults post-stroke may avoid a dimension of community mobility. Previous literature reports depression and reduced self-efficacy as contributing factor for reduced community mobility encounters, however, the underlying causes of depression and reduced self-efficacy remain unaddressed in the literature.8,9,22,23 Appreciation of the adult post-strokes perspective regarding societal judgment may serve as a basis to build self-efficacy with respect to community mobility. The constraints placed upon the rehabilitation process by third party influences as a whole was perceived as a barrier by both parties. The physical therapists indicated that although they believed that adults post-stroke could continue to make functional gains and community mobility was indeed vital for adults post-stroke to participate in, third party payment systems did not view community mobility as medically necessary. In efforts to advocate for their patients, the physical therapists found themselves creatively circumventing imposed restrictions, by focusing on gait speeds or other measures that did not directly describe community mobility. The physical therapists expressed that they fully realize that even independent ambulation of 150 feet was not indicative of good health, an acceptable functional status, nor a means of achieving the recommended level of physical activity for health maintenance. However, emphasis or documentation of such activities would often result in the third-party payer denying further Perceptions of Community Mobility 60 services. In essence, the concept of being discharge from skilled therapy services at a level of minimal function versus maximal capacity leads to a less than adequate foundation for an adult post-stroke to return to community mobility safely. Limitations This study has several limitations, one being the primary investigators inexperience with qualitative research and interviewing. The PIs inexperience may have negatively impacted her ability to gather further information that could provide elaboration on some concepts. However, lack of experience may also be viewed as a strength as it allows for an unbiased approach to questioning participants. All of the subjects were recruited in the Chicagoland area, thus limiting the transferability of the findings of this study to other geographic areas. It should also be noted that all interviews occurred during the summer months of June to September, thus various ambient conditions such as icy or snowy conditions that pertain to other seasons may be underrepresented in these findings. Selection bias of the participants potentially exists since the participating physical therapists were the primary investigators point of contact, and the paired patient was selected by them. It is possible that the participating physical therapists selected patients that they believed had good alignment with their own views. Due to the nature of the method of using semistructured interviews to gather data, replication of this study may not be possible. Although it is acceptable within qualitative research to have a small number of participants in the study, six participants with stroke, limited the ability to fully utilize the concept of concurrent triangulation with the EAMQ 2.0, thus limiting the utility of the instrument. Perceptions of Community Mobility 61 Future Research The low encounters of the physical load dimension within community mobility tasks was a surprising find in this study. Additional exploration of the impact that decreased upper extremity function has on community mobility tasks appears to merit attention. Bimanual tasks are required in a variety of community mobility tasks, such as accessing non-ADA accommodated structures, attention to upper extremity function within physical therapy interventions should be explored. Additionally, the distinction of community ambulation based upon gait speed appears to have limited application across dimensions. Further investigation as to meaningful clusters of measures that equate to unlimited community mobility may be helpful in identifying, predicting, and addressing mobility disability for adults post-stroke. The EAMQ 2.0 appears to be a useful tool that may augment a physical therapists decision making and development of the plan of care with respect to individuals who are aiming to return to community mobility after experiencing a stroke. The full utility of the EAMQ 2.0 has yet to be explored. Further research to determine its validity and reliability for prediction of mobility associated disability is merited across community settings. Additional research into the perceptions held by both persons with physical impairments and by physical therapists with regard to community mobility tasks may also provide physical therapists with opportunities to advocate for social change. Understanding facilitators and barriers allows for the tailoring of interventions to address the perceived needs of those with resultant impairments after experiencing a stroke. Investigation into the definitions of community mobility as relevant to the clients environment may also enlighten the rehabilitation community Perceptions of Community Mobility 62 to additional barriers, which may be addressed during episodes of care, as well as facilitators which may be strategically utilized to enhance the rehabilitation outcomes for adults post-stroke. As the landscape of healthcare continuously shifts with imposed cuts and limitations from third party payers, there is a clear need for physical therapists to participate and contribute to the development of community-based programs that can adequately and safely address the ongoing health and wellness needs of persons who are post-stroke as well as others who have chronic neurological conditions, investigation of the most effective mode of programming would be beneficial to explore. Contribution to the Profession If the physical therapy profession is to realize its vision statement of transforming society by optimizing movement to improve the human experience, the perceptions of mobility beyond the rehabilitation setting must be explored. Furthermore, in order to fully develop patient centered care that is focused on maximizing meaningful participation in the patients community among peers, it is necessary to determine if alignment between the patient and physical therapist exists and in what aspects alignment or discord lies. While alignment is the aim, aspects of discord could minimize gains in functional recovery during and after rehabilitation services. Collaboration between physical therapists and adults post-stroke appears to serve as a means to establish goals which may augment the therapists selection of therapeutic interventions to address the patients functional impairments and potentially enhance aspects of community mobility post-stroke. Physical therapists who understand their patients perceptions regarding various dimensions of community mobility, may serve as a catalyst to address the environmental and attitudinal challenges that adults post-stroke may face. Once an understanding has been Perceptions of Community Mobility 63 reached, physical therapists may develop therapeutic strategies that empower adults post-stroke to safely navigate environmental challenges and minimize disability. Utilization of a battery of outcome measures, inclusive of the EAMQ 2.0, that addresses the plethora of components relating to community mobility may provide physical therapists with the robust picture necessary to develop a plan of care, determine need for skilled intervention, and appropriate discharge planning. Conclusion Collaboration between physical therapists and adults post-stroke appears to serve as a method of understanding perspectives of community mobility after stroke. Physical therapists who have a sound understanding of their patients perspective of community mobility may be able to develop a robust plan of care that includes interventions that integrate all dimensions of community mobility. Addressing all dimensions of community mobility may lead to increased encounters of within all dimensions of community mobility. Perceptions of Community Mobility 64 Acknowledgements Many sayings come to mind when considering the journey of this project. One relevant saying is that It takes a village. Something about that saying does not quite fit, however, I think a more accurate saying is that It takes a community. True this project focused on community mobility, however, when I consider what community is, it is a common characteristic, not just a place, a common characteristic during this projects journey was that of perseverance. Many people persevered with me to see the completion of this project and for that I am both in awe and eternally grateful. I would like to start by thanking the UIndy community. From my first contact with Perri Herron, I felt I was in the right place. All of the faculty at the University of Indianapoliss Doctor of Health Science Program provided some contribution to this project and deserve recognition. That contribution may be in the form of a thought-provoking discussion board post or an interaction with the patient resource group, where the facultys instruction and feedback served as one of the many building blocks of my professional growth. I am forever grateful and inspired by your examples. Special thanks to the following faculty for their contributions and guidance: Dr. Jennifer Fogo, Dr. Julie Gahimer, Dr. Elizabeth Moore and Dr. Candace Beitman. My committee member, Dr. Lisa Borrero, thank you for inspiring me to take a leap into the world of qualitative research, asking probing questions, and for pulling me back to the focus of the project when I went off the beaten path. Thank you to Dr. Steven Wiley, who always kept the focus on the clinical utility of this project and its value. The ongoing importance of clinical utility grounds us in the why we do what we do as physical therapists. My committee chair, Dr. Stephanie Miller, thank you for being the light at the end of what seemed to be the longest tunnel ever. Thank you for helping me get back up after my many Perceptions of Community Mobility 65 pit falls, by giving me everything from pep talks to tough love, I am better for it. Your tenacity is to be respected and followed. The community of colleagues that I have met through my DHSc journey has been immensely supportive, always offered insightful, constructive, and valuable feedback. These remarkable colleagues include Dr. Danielle Bellows, soon to be Dr. Leslie Buckner, and Mary Lou Stilwell. This project has parts of them infused into it as they have shared perspective and insights that provided me the courage to begin asking the questions that formed this project. My colleagues at Governors State University have been on this journey with me since I was a student physical therapist, their examples of commitment to excellence and inquiry inspired me years ago to continue beyond my physical therapist degree. Dr. Roberta OShea, your wit and humor are a lifeline, phone a friend and a 50/50 answer all rolled into one during my Who wants to be a Doctor show and serve as a survival guide to all challenges. Dr. Rebecca Wojcik, thank you for your unwavering support and encouragement during unconventional times. Dr. David Diers, your level-headed advice always keeps me on track, thank you. Dr. Renee Theiss, your scientific mind is unmatched, may I aspire to be in your league one day. Dr. Amy Bala, your ability to lighten my load and bring me resolve is greatly appreciated, you will never really know just how much you helped. Dr. Jessica Corbus thank you for support and encouragement to see this project to fruition. Dr. Robin Washington, thank you for your insights and sharing your experiences for new perspectives foster growth. A journey is never without its losses. During the journey of this project, two exceptional men passed away, Dr. Scott Fogo and Dr. Dale Schuit. Both men contributed to my educational journey and are dearly missed. Dr. Dale Schuit served as a professional mentor to me for nearly 20 years, without his expertise and guidance, I would not be where I am today. Perceptions of Community Mobility 66 I would like to thank the participants in this study. Their contribution to this study is beyond measure. They graciously offered their time and shared their experiences with me in an honest manner. Their dedication to assisting me in exploring the concepts of this study is an invaluable gift. I would like to finally thank my dear friends and family. To all of my extended friends who in essence are my family thank you for supporting me by letting me talk about a dream and trying to make it real. You truly are my living proof of the beautiful rewards in life especially when you all believe in a promised land. My dear friend Jennifer Brennan, thank you for always having my back and being my person, your willingness to listen and support me leaves me eternally humbled and grateful. My siblings, Coreen and Dwayne, thank you for your belief in my ability to complete this project. Finally, I would like to acknowledge my husband Scott Jones. Thank you for all of the years of unconditional support and love. You believe in me before I believe in myself, the grace you provide me always amazes me. Lastly, I would like to thank the University of Indianapolis and Governors State University with providing the IRB to conduct this study. Perceptions of Community Mobility 67 Budget and Motivation This study is self-funded by the primary investigator. The primary investigator does not have any financial interest in the following providers which have services being utilized by the primary investigator in the course of this study. The following expenses were incurred by the author while conducting the study. Same Day Transcription Service: Based upon a 120 min interview for 16 participants Nominal compensation for participants time: $10 - Gift Card to Panera, Starbucks or Subway ($10 X 16) Total $ 3,200 $160 $3,360 Perceptions of Community Mobility 68 References 1. Centers for Disease Control and Prevention. Stroke facts [Web page]. Centers for Disease Control and Prevention Web site, http://www.cdc.gov/stroke/facts.htm..Accessed March 30, 2015. 2. 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Phys Ther. 2013;94:477-489. 78. Dierckx K, Deveugele M, Roosen P, Devisch I. Implementation of shared decision making in physical therapy: observed level of involvement and patient preference. Phys Ther. 2013;93(10):1321-1330. 79. Hedman LD, Morris DM, Graham CL, et al. Locomotor requirements for bipedal locomotion: a Delphi Survey. Phys Ther. 2014;94:52-67. Perceptions of Community Mobility 74 80. Fulk, GD., Ying H, Pierce B, and Dunning,K. Predicting Home and Community Walking Activity Post stroke. Stroke;a J Cerebral Circ,;201748 (2): 40611. 81. Janssen J, Klassen TD, Connell LA, Eng JJ. Factors Influencing the Delivery of Intensive Rehabilitation in Stroke: Patient Perceptions Versus Rehabilitation Therapist Perceptions. Phys Ther. 2020;100(2):307-316. 82. Sessford JD, Jung M, Brawley LR, Forbes JL. Do older adults beliefs about their community mobility predict walking performance? J Aging Phys Act. 2015;23(2):272-278. 83. Bruijn SM, Meijer OG, Beek PJ, van Dien JH. The effects of arm swing on human gait stability. J Exp Biol. 2010;213(Pt 23):3945-3952. 80. Wesselhoff S, Hanke TA, Evans CC. Community mobility after stroke: a systematic review. Top Stroke Rehabil. 2018;25(3):224-238. Perceptions of Community Mobility 75 Table 1. Demographics of Adults Post-stroke Demographic Subject 1 Subject 2 Subject 3 Subject 4 Subject 5 Subject 6 Mean Information Identifying Sex Male Male Female Male Male Female Age (years) 58 58 61 64 76 73 65 Months since 3.2 2.6 4.75 3.2 13 24 8.45 Left Left Left Right Right Right Yes On On Yes No No Disability Disability Retired after Retired CVA/Engineer after CVA stroke onset Affected Hemisphere Employed/Return to Work Status Railroad Postal Equipment Commercial Grade Specialist Truck School Driver Teacher Worker Registered Nurse Perceptions of Community Mobility 76 Table 2. Demographics of Physical Therapists Demographic PT 1 PT 2 PT 3 PT 4 PT 5 PT 6 Mean 1 5 6 5 13 13 7.16 Information Years of Experience years PT Degree DPT DPT DPT DPT MPT/tDPT DPT Specialty None None NCS None Certification OCS Credentials in Conductive Education Outcome 10 MWT, FGA, Berg, 10 10 MWT, Functional FGA, Measures Used Berg, Berg, 10 MWT, 6 MWT, Assessment, Tinetti, 6 MWT MWT, 6 MWT, Berg, Berg, and Gait 6 MWT, 6 MWT, FGA, FGA, Assessment Fear Clinical Dual Dual Avoidance observation Tasking Tasking Questionnaires Abbreviations: PT Physical Therapy DPT Doctor of Physical Therapy MPT Master of Physical Therapy tDPT Transitional Doctor of Physical Therapy 10 MWT 10-meter walk test, 6 MWT 6-minute walk test, Berg Berg Balance Scale FGA Functional Gait Assessment Tinetti- Tinetti/Performance Oriented Mobility Assessment Perceptions of Community Mobility 77 Table 3. EAMQ 2.0 Mean Responses from Adults Post-stroke EAMQ Dimensions Distance Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Encounter 1 3 3 2 4 4 Avoidance 3 1 1 3 0 0 Encounter 2.5 2.5 1 2.5 1.5 1.5 Avoidance 0 1 3 1 1.5 0 Encounter 2.66 1.33 1 2 1.33 3 Avoidance 0 2.33 2.33 2 1.33 0 Encounter 2.75 2.5 2.25 2 2.25 2.5 Avoidance 0 2.5 0 1.5 1.5 .25 Encounter 1 2 1 2 2 1 Avoidance 1 2 2.5 1 1 1.5 Transition 1.5 1.5 1.5 2 2 3.5 Encounter 0 2.5 1.5 .5 2 0 Encounter 1.75 2 1.5 2 1.75 2.5 Avoidance .5 2 1.33 2.33 2.33 0 Encounter 1 2 2 1 2 2 Avoidance 2 2 1 3 0 0 Encounter 1.77 2.10 1.65 1.94 1.85 2.125 Avoidance 0.81 1.91 1.45 1.66 1.20 .56 Temporal Ambient Terrain Physical Load Postural Avoidance Attention Density Mean Perceptions of Community Mobility Figure 1. Visual Representation of Themes 78 Perceptions of Community Mobility 79 APPENDIX A Recruitment Flyer Perceptions of Community Mobility 80 Perceptions of Community Mobility 81 APPENDIX B Environmental Analysis of Mobility Questionnaire 2.0 Environmental Analysis of Mobility Questionnaire (EMAQ) Revised 2.0 Participant Name: _________________________ Date: __________________ Name of evaluator: ________________________ I am interested in learning more about your walking activities in the community over the past month. In this walking activities questionnaire, I will be asking you to report about trips away from your home. The word trip means when you leave your home and go into the community to perform an activity, such as grocery shopping. I will be asking about questions about how often you go on trips away from your home, where you go, and what time of day you tend to travel, and the kind of obstacles you encounter, such as steps. You are free not to answer any questions you do not wish to answer. Distance Dimension: 1. When you go into the community, how often do you walk long distances (10 or more blocks)? Never Rarely Sometimes Often Always 2. When you go into the community, how often do you avoid walking long distance (10 or more blocks) on trips into the community? Perceptions of Community Mobility Never Rarely 82 Sometimes Often Always Temporal Dimension: 3. When you go into the community, how often do you cross a busy street? Never Rarely Sometimes Often Always 4. When you go into the community, how often do you avoid crossing a busy street? Never Rarely Sometimes Often Always 5. When you go into the community, how often do you cross a street that has a traffic light? Never Rarely Sometimes Often Always 6. When you go into the community, how often do you avoid crossing a street that has a traffic light? Never Ambient Dimension: Rarely Sometimes Often Always Perceptions of Community Mobility 83 7. When you go into the community, how often do you go out when it is dark? Never Rarely Sometimes Often Always 8. When you go into the community, how often do you avoid going out when it is dark? Never Rarely Sometimes Often Always 9. When you go into the community, how often do you go out when it is snowing? Never Rarely Sometimes Often Always 10. When you go into the community, how often do you avoid going out when it is snowing? Never Rarely Sometimes Often Always 11. When you go into the community, how often do you go out when it is raining? Never Rarely Sometimes Often Always 12. When you go into the community, how often do you avoid going out when it is raining? Never Rarely Sometimes Often Always Perceptions of Community Mobility 84 Terrain Dimension: 13. When you go into the community, how often do you walk up or down a single flight of stairs? Never Rarely Sometimes Often Always 14. When you go into the community, how often do you avoid going up or down a single flight of stairs? Never Rarely Sometimes Often Always 15. When you go into the community, how often do you walk up or down two flights of stairs? Never Rarely Sometimes Often Always 16. When you go into the community, how often do you avoid walking up or down two flights of stairs? Never Rarely Sometimes Often Always 17. When you go into the community, how often do you walk up or down a curb? Perceptions of Community Mobility Never Rarely 85 Sometimes Often Always 18. When you go into the community, how often do you avoid walking up or down a curb? Never Rarely Sometimes Often Always 19. When you go into the community, how often do you walk on uneven surfaces? Never Rarely Sometimes Often Always 20. When you go into the community, how often do you avoid walking on uneven surfaces? Never Rarely Sometimes Often Always Physical Load Dimension 21. When you go into the community, how often do you carry two or more heavy items? Never Rarely Sometimes Often Always 22. When you go into the community, how often do you avoid carrying two or more heavy items? Perceptions of Community Mobility Never Rarely 86 Sometimes Often Always 23. When you go into the community, how often do you push open a heavy door? Never Rarely Sometimes Often Always 24. When you go into the community, how often do you avoid pushing open a heavy door? (for example, push the wheelchair button to open a door rather than push it open yourself)? Never Rarely Sometimes Often Always Postural Transition Dimension 25. When you go into the community to shop, how often do you reach above shoulder level? Never Rarely Sometimes Often Always 26. When you go into the community to shop, how often do you avoid reaching above shoulder level? Never Rarely Sometimes Often Always Perceptions of Community Mobility 87 27. When you go into the community to shop, how often do you reach below your knee level ? Never Rarely Sometimes Often Always 28. When you go into the community to shop, how often do you avoid reaching below your knee level? Never Rarely Sometimes Often Always Attention Dimension: 29. When you go into the community, how often do you travel alone? Never Rarely Sometimes Often Always 30. When you go into the community, how often do you travel with 2 or more people? Never Rarely Sometimes Often Always 31. When you go into the community, how often do you avoid travelling alone? Never Rarely Sometimes Often Always Perceptions of Community Mobility 88 32. When you go into the community, how often do you go to noisy or busy places? Never Rarely Sometimes Often Always 33. When you go into the community, how often do you avoid going to noisy or busy places? Never Rarely Sometimes Often Always 34. When you go into the community, how often do you go to unfamiliar places? Never Rarely Sometimes Often Always 35. When you go into the community, how often do you avoid going to unfamiliar places? Never Rarely Sometimes Often Always Density Dimension: 36. When you go into the community, how often do you go to crowded places, where people might bump into you? Never Rarely Sometimes Often Always Perceptions of Community Mobility 89 37. When you go into the community, how often do you avoid going to crowded places, where people might bump not you? Never Rarely Sometimes Often Always Perceptions of Community Mobility 90 APPENDIX C Semi-Structured Interview Questions for Older Adults Post- Stroke Questions: 1) Share with me your experience with the rehabilitation process after your stroke. a. Consider asking about their likes, dislikes, frustrations, what they found meaningful etc. b. What are your thoughts on the therapy you received with respect to your mobility and participation level in the community? c. Describe any tasks or training (interventions) that you found most helpful? d. Describe any tasks/training (interventions) that you did not find helpful? 2) Can you share with me what your experiences have been like? a. Possible prompts for locations or activities involved i. Explore the necessity purpose etc. b. Describe any impact your stroke has had on your participation in these activities. c. Possible prompts for any considerations that you now have to make when performing community mobility? 3) Share with me how you communicated with your PT your thoughts about participating/performing community mobility. a. Were there components you believed to be crucial? b. Did and or How - the mode or degree of collaboration change across the spectrum of care? c. What changes would you make? Perceptions of Community Mobility 91 d. How relevant do you think your participation in your plan of care was to your current level of community participation? Perceptions of Community Mobility 92 APPENDIX D Semi-Structured Interview Questions for Physical Therapists Questions: 1) Share with me your experience treating patient s who have survived a stroke. a. Did treating this patient differ from other experiences you have had treating another patient who have survived a stroke? If so how so? Challenges? 2) Share with me how you collaborate with your patient a. Re: community participation? b. How much influence does the patient have on the plan of care? Do you have any particular strategies or methods to enhance collaboration with the patient? Describe how you know your thoughts are in alignment with your patient? 3) Considering the category of community mobility, how do you describe/define your experience with promoting community mobility with your patient? a. What do you think are barriers or facilitators within the community that your patient is from? b. Considering your patient how would you describe their participation in community mobility tasks? c. Considering the components of community mobility what factors or attributes do you associate with this patient having the potential or capability to participate in community mobility? 4) Share with me your decision-making process you may use that help you determine a patients abilities to participate in community mobility tasks. Perceptions of Community Mobility 93 a) Describe your thoughts on why you determined this patient to be a candidate for community mobility and any relevant outcome measures. Perceptions of Community Mobility 94 APPENDIX E Member Checking Transcript Approval Form Sample of member checking approval form, which will be attached to the first page of the transcribed interview SAMPLE Perceptions of Community Mobility by Survivors of Stroke and Their Physical Therapists Participant: #11 SS- AB Interview date: - 11-14-16 Interview Time 5:30 pm I have read the attached transcribed interview which is attached, and edited by me where noted. It is an accurate representation of my view. ______________________________________________________________ __________________________ Participant Initials Date: Perceptions of Community Mobility 95 APPENDIX F INFORMED CONSENT FORM Principal Investigator: Maryleen K. Jones, PT, MPT, CLT, NCS School/Department/Division: Governors State University/College of Health and Human Services/Physical Therapy University of Indianapolis/College of Health Sciences/Physical Therapy Telephone: 708-235-7399 INFORMED CONSENT FOR PARTICIPATION IN RESEARCH ACTIVITIES Perceptions of Community Mobility of Older Adults Who Have Experienced A Stroke and Their Physical Therapists 1. PURPOSE OF THIS RESEARCH STUDY The purpose of this study is to explore how perceptions of community mobility align between older adults recovering from stroke and their physical therapist. Inclusion Criteria Inclusion criteria for the participants with stroke to be included in the study include: A) 55 years of age or older a. have a confirmed medical history for a first-time stroke of either ischemic or hemorrhagic etiology Perceptions of Community Mobility b. 96 Ability to ambulate at least 0.80 m/s during the 10-meter walk test independently with or without an assistive device but without physical or verbal assistance of another person, as verified by their physical therapist. B) For the participants physical therapist to be included in the study a. Must have license to practice physical therapy in the State of Illinois b. Currently practicing physical therapy, and working with patients post- stroke with mobility impairments. c. The physical therapists must agree to participate in the study if they have a patient with stroke who also meets the study criteria. Exclusion Criteria Exclusion criteria of potential participants with stroke include: A) Other neurological conditions other than stroke B) Another health condition that impedes their ability to walk or complete mobility tasks C) visual impairments other than the need for prescription eyeglasses, D) Inability to verbally communicate their perspective, such as aphasia or the need for an interpreter E) Inability to follow three step commands, F) Inability to provide informed consent. G) Physical therapists interviewed will be the definitive discharging therapist to discharge the patient from therapy services; other previous physical therapists would not be included in the interview process. Perceptions of Community Mobility 97 H) Pairs of therapists and patients will be limited to participating one time (i.e. the same therapist may not participate with more than one patient) The purpose of this research study is to explore the perceptions that older adults who have experienced a stroke and their physical therapists have regarding community mobility. I have been asked to participate in this research study because: A: _____________I have experienced a stroke and am able to complete community mobility tasks. B: _____________I am a physical therapist of an older adult who has experienced stroke who is participating in this study. My participation in this study is expected to last between 60 and 120 minutes. I have been informed that I will be one of approximately 12 to 16 persons participating in this study. 2. WHAT WILL BE DONE / PROCEDURES I have been informed that while I am in this study I will be asked various questions pertaining to community mobility. The first I will do is complete a questionnaire and talk with one of the researchers in an office at the Governors State University or at the clinic I received physical therapy this should take between 60 and 120 minutes. I will then go home Perceptions of Community Mobility 98 and live my normal life. I will receive a copy of the interview after it has been typed out word for word. I have the opportunity to verify that my views are accurately reflected. 3. POSSIBLE BENEFITS A) Assist in understanding facilitators and barriers of optimal community mobility for older adults who have experienced a stroke. B) Assist in understanding the physical therapists views of mobility beyond the clinic and the community. C) This information may be used to strategically improve and or develop rehabilitation interventions and focus. 4) POSSIBLE RISKS AND DISCOMFORTS I have been informed that there is a slight risk of fatigue (or possible embarrassment) during my interview or during the completion of the questionnaire. The risks should not be any greater than what I experience in everyday life. 5) CONFIDENTIALITY OF RECORDS I have been informed that any information learned from this study in which I might be identified will remain confidential. All records will be stored in a locked file cabinet in a locked room. All electronic data will be stored on password and/or encryption protected devices. Only the investigator and members of the research team will have access to these records. If information learned from this study is published, I will not be identified by name. Perceptions of Community Mobility 99 By signing this form, however, I allow the research study investigator to make my research records available to the Governors State University and University of Indianapolis Institutional Review Board (IRB) Office and regulatory agencies as required by law. 6) OFFER TO ANSWER QUESTIONS AND RESEARCH INJURY NOTIFICATION Ms. Maryleen K. Jones, PT responsible for this research study, has answered my questions regarding my participation in this research study. I have been informed that if I have any further questions, I can contact Ms. Maryleen K. Jones, PT at (708) 235-7388 (principal investigator's telephone number and extension). I have been informed that I will receive a copy of this informed consent document for my records. I have been informed that a copy of the final research results will be made available to me at the conclusion of the study by contacting Ms. Maryleen K. Jones, PT at 708-235-7388. 7) COST TO THE SUBJECT / PAYMENT TO SUBJECT FOR PARTICIPATION I have been informed that I will receive a ten dollar ($10.00) gift card at the time I complete my review of the typed word for word interview. 8) VOLUNTARY PARTICIPATION WITH RIGHT OF REFUSAL I have been informed that my participation in this research study is voluntary. I am free to withdraw from this study at any time without penalty. If I choose to withdraw, I should contact Ms. Maryleen K. Jones, PT at 708-235-7388. 9) IRB REVIEW AND IMPARTIAL THIRD PARTY Perceptions of Community Mobility 100 I have been informed that this study has been reviewed and approved by the Governors State University and University of Indianapolis Institutional Review Board (IRB). I have been informed that proof of IRB approval appears at the end of this document as the UIndy IRB validation stamp, which includes the dates of approval and expiration of approval. A representative of that Board, from the IRB Office, is available to discuss the review process or my rights as a research subject. The telephone numbers of the University of Indianapolis IRB Office are (317) 781-5774 or (800)-232-8634 ext. 5774. I may also contact Governors State University Institutional Review Board Co-Chair: Rene Theiss, Ph.D. at 708-534-2147 or email at irb@govst.edu. 10) SIGNATURE FOR CONSENT The above-named investigator has informed me of the risks and benefits of participating in this research project. I have seen the IRB validation stamp with proper dates of approval and expiration of approval at the end of this document. I have asked questions and I have received answers that help me better understand the risks and benefits. I have thought about the risks and benefits, and I consent to be a research subject in this study. _______________________ __________________________ ______ Research Participants Name Research Participants Signature Date _________________ ___________________ ______ Investigators Name Investigators Signature Date Perceptions of Community Mobility 101  ...

... HEALTH-PROMOTING BEHAVIORS AMONG RESIDENTS OF THE MISSISSIPPI DELTA AND NORTHWEST REGION Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Veronica H. Johnson, MS, OTR/L, CLT Copyright 2018 By: Veronica H. Johnson, MS, OTR/L, CLT All rights reserved Approved by: Jennifer Fogo, PhD Committee Chair Elizabeth Moore, PhD Committee Member Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program University of Indianapolis Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis Running head: HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI Health-Promoting Behaviors Among Residents of the Mississippi Delta and Northwest Region Veronica H. Johnson University of Indianapolis 1 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 2 Abstract Mississippi is plagued by high rates of chronic disease. Therefore, the purpose of this study was to examine the health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi Region utilizing the Health-Promoting Lifestyle Profile II (HPLP II) to identify specific health-promoting behaviors and the factors that best predict the residents' engagement in health-promoting behaviors. A non-experimental, cross-sectional study was used to assess the health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi Region. A total of 165 individuals completed the survey which revealed that spiritual growth and interpersonal relations were the two behaviors most often practiced by the residents and nutrition and physical activity were the least practiced behaviors. Regression analysis identified general health and education as the two main variables which best predicted the health-promoting behaviors of the participants in this study. General health and education were the significant predictors for the HPLP II total scale and all subscales except physical activity. General health and alcohol were the significant predictors for physical activity. Results from this study could help improve the burden of chronic disease in Mississippi by providing an understanding of the current health-promoting behaviors among residents in rural Mississippi. Understanding their health behaviors could help healthcare professionals develop culturally appropriate community health programs to meaningfully impact their lives. Keywords: chronic diseases, health-promoting behaviors, Health Promotion Model, Health-Promoting Lifestyle Profile II, Mississippi HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 3 Acknowledgements First, I want to acknowledge and thank my Heavenly Father, Jesus Christ, for blessing me throughout my entire doctoral education process. There is no way I could have achieved my goal without his grace, favor, and mercy. Thanks to the best husband in the world, Tarik Johnson, Esq., for your love and infinite support. Our road trips to Indianapolis were always epic and memorable. Thank you being my chauffeur. I love you! Thanks to my family, especially my sweet Nudie, for all the prayers, love, and encouragement. You all mean the world to me. Love you much! I want to thank Dr. Jennifer Fogo and Dr. Elizabeth Moore for their critique, guidance, and support during the completion of my juried project. Finally, I want to thank the men and women of the Mississippi Delta and Northwest Mississippi region for their support and participation in this project. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI Dedication This project is dedicated to: (1) my Heavenly Father, Jesus Christ, who always directs my path; (2) my husband, Tarik Johnson, for your endless love and understanding; and (3) my parents, Earlean Anderson and Gregory Hayes, for your unconditional love, prayers, encouragement, and support throughout my years of academic endeavors. 4 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 5 Table of Contents Page List of Tables .......................................................................................................................8 Introduction ..........................................................................................................................9 Literature Review...............................................................................................................11 Chronic Diseases and the Mississippi Delta ..........................................................11 Occupational Therapy in the Management of Chronic Diseases ...........................14 Defining Health and Health Promotion .................................................................16 Health-Promoting Lifestyle Profile II Framework ................................................17 Health-Promoting Behaviors of African American Women and Men ..................19 Health-Promoting Behaviors and the HPLP II ......................................................22 Health-Promoting Behaviors and Lifestyles ..........................................................24 Socioeconomics and Health Behaviors ..................................................................27 Summary ................................................................................................................29 Method ...............................................................................................................................29 Research Design.....................................................................................................29 Participants .............................................................................................................30 Data Collection ......................................................................................................31 Instrumentation ......................................................................................................31 Procedures ..............................................................................................................32 Data Analysis .........................................................................................................33 Results ................................................................................................................................33 Health-Promoting Behaviors .................................................................................35 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI Health-Promoting Lifestyle Profile II: Total scale ................................................35 Health-Promoting Lifestyle Profile II: Health responsibility ................................36 Health-Promoting Lifestyle Profile II: Physical activity .......................................36 Health-Promoting Lifestyle Profile II: Nutrition ...................................................36 Health-Promoting Lifestyle Profile II: Spiritual growth ........................................37 Health-Promoting Lifestyle Profile II: Interpersonal relationships .......................37 Health-Promoting Lifestyle Profile II: Stress management ...................................37 Summary ................................................................................................................38 Discussion ..........................................................................................................................38 Limitations .............................................................................................................41 Implication for Research ........................................................................................41 Conclusion .............................................................................................................42 References ..........................................................................................................................45 Appendix A ........................................................................................................................63 Appendix B ........................................................................................................................64 Appendix C ........................................................................................................................66 Appendix D ........................................................................................................................68 Appendix E ........................................................................................................................69 6 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 7 List of Tables Page Table 1. Demographic and General Health Characteristics .....................................52 Table 2. Median Household Incomes of Residential Counties ................................54 Table 3. Descriptives for the Health-Promoting Lifestyle Profile II .......................55 Table 4. Regression analysis for the HPLP II Total Scale .......................................56 Table 5. Regression analysis for Health responsibility subscale .............................57 Table 6. Regression analysis for Physical activity subscale ....................................58 Table 7. Regression analysis for Nutrition subscale ................................................59 Table 8. Regression analysis for Spiritual growth subscale.....................................60 Table 9. Regression analysis for Interpersonal relationships subscale ....................61 Table 10. Regression analysis for Stress management subscale................................62 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 8 Health-Promoting Behaviors among Residents of the Mississippi Delta and Northwest Region As the nation's burden of chronic diseases increases, the United States faces a major health crisis (Centers for Disease Control and Prevention [CDC], 2013). According to the Institute of Medicine (IOM; 2012), chronic diseases are long-term health conditions that jeopardize well-being and function in a continuous or progressive way over numerous years. Chronic diseases also lead to considerable levels of impairment and disability (IOM, 2012). According to the CDC (2013), 7 of the 10 leading causes of death in the nation are related to chronic diseases. Similarly, in Mississippi seven of the leading causes of death in 2011 were related to chronic disease (Short, 2014). Heart disease, cancer and diabetes contributed to over half (55%) of all deaths in Mississippi in 2011. In 2010 in Mississippi, there were 155,629 hospital discharges related to chronic conditions and the cost of treating them was over $4 billion. It is predicted that in Mississippi costs related to chronic diseases are expected to increase up to 70% between 2010 and 2020 (Short, 2014). Individuals who live with chronic disease such as cardiovascular disease (CVD), diabetes, hypertension, and cancer often experience limitations in function, health, activity, and work which affect one's quality of life as well as the quality of life of family members (CDC, 2013). In addition, social determinants of health such as income, occupation, and education differ between ethnic/racial groups and may contribute to the burden of chronic diseases (Short, 2014). Mississippi has the highest percentage of non-whites (40%) among all 50 states, and in Mississippi more African Americans live below poverty, have less than a high school education, are unemployed, and lack health care coverage, compared to Caucasians (Short, 2014). In Mississippi, African Americans have the highest prevalence of chronic diseases resulting in the highest mortality rate from those diseases (Short, 2014). HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 9 Consistent with the first goal of the Healthy People 2020 initiative (U.S. Department of Health and Human Services, 2010), occupational therapy practitioners assist in preventing disability and functional limitations related to chronic diseases through prevention. In addition, they are committed to serving individual and population needs in order to improve community health, increase individuals' longevity, and enhance quality of life across the life course (Blanchard, 2012; Reingold & Jordan, 2013). Occupational therapy practitioners address the prevention of chronic conditions such as obesity through holistic and client-centered approaches to lifestyle modifications through engagement in activities that promote health and well-being. Practitioners also utilize interventions that enable individuals to make healthy lifestyle changes, including making informed decisions about eating habits and physical activity, thus improving health outcomes and maintaining long-term wellness (Reingold & Jordan, 2013). Occupational therapy practitioners can help Mississippians form and/or maintain positive health-promoting behaviors by providing health education and meaningful culturally sensitive interventions that encourage ongoing participation. However, the specific health-promoting behaviors of the residents of the Mississippi Delta region remain unknown. Therefore, the purpose of this study was to examine the health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi region to determine factors that best predict these behaviors. To meet the study's purpose, the following objectives were addressed: To determine if residents in the Mississippi Delta and Northwest Mississippi region engage in health-promoting behaviors; To identify the specific health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi region; HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 10 To identify factors that best predict health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi region Results of this study can help occupational therapy practitioners understand the health promoting behaviors of men and women living in rural, underserved communities of the Mississippi Delta plagued by chronic disease. Occupational therapy practitioners can then use the information to develop culturally appropriate interventions which promote healthy behaviors, thereby helping to decrease the prevalence of chronic diseases in the Mississippi Delta and Northwest Mississippi region. Literature Review This review provides an overview of research addressing chronic diseases, occupational therapy in the management of chronic diseases, and concepts of health and health promotion in the Mississippi Delta. This section also presents the conceptual framework for this study, Pender's Health Promotion Model (HPM). In addition, literature related to the Health-Promoting Lifestyle Profile II (HPLP II) is discussed as is the research on health-promoting behaviors/lifestyles. Finally, the relationship between socioeconomic status and health behaviors and other barriers to health behavior change is addressed. Chronic Diseases and the Mississippi Delta The occurrence of chronic disease and related risk factors is typically higher in Mississippi than in other states (Short, 2014). Congestive heart failure, chronic obstructive pulmonary disease (COPD), and diabetes mellitus with complications are the leading causes of hospitalization in Mississippi (Short, 2014). Overall, residents of the United States are healthier and living longer than in previous decades, but the gains in health have not been shown in all individuals (IOM, 2012). Chronic diseases among the elderly, racial, and ethnic minorities are HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 11 markedly disproportionate according to the IOM (2012). Research has shown that racial and ethnic groups are often less healthy than white Americans, and on average, underprivileged ethnic minorities have less formal education, and lower household income which frequently leads to shorter life spans due to higher incidences of chronic diseases and less access to quality health care according to the IOM (2012). For example, individuals in poverty stricken, southern states, like Mississippi, face longstanding disparities in health, often due to lack of insurance and access to needed health services (Artiga, Stephens, Lyons, & Heiman, 2014; Stephens, Artiga, & Paradise, 2014). Mayfield-Johnson, Young, Mohn, and Ebersole (2012) investigated perceptions of health and understanding of health related topics in the Mississippi Delta and found that 400 respondents listed the three top health concerns as diabetes, heart disease, and cancer respectively. A significant percentage of the respondents did not know that diabetes contributed to loss of vision, amputations, kidney failure, stroke, or heart disease. Results of this study revealed that only older and respondents with at least a high school diploma or General Education Diploma (GED) were aware of the importance of monitoring blood pressure; however, these respondents were also less likely to know about the benefits of exercise in reducing the risk of heart disease. As a whole, the residents of the Mississippi Delta were not able to identify the role of exercise in the prevention and management of diabetes and strokes (Mayfield-Johnson et al., 2012). Mayfield-Johnson et al. (2012) sought to address the prevalence of diabetes, hypertension, and cardiovascular disease in the Mississippi Delta by developing a community health education program, ATTACK (Approaches to Take Absolute Control through Knowledge), which focused on educating participants about nutrition and the benefits of physical HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 12 activity. According to the researchers, the ATTACK program was specifically developed to target people in faith-based organizations, churches, and teachers at Head Start Centers throughout the Mississippi Delta. Of the 299 participants in this study, the majority were African American females. Nearly all of the participants had received a high school diploma or GED, and over half of them had acquired an Associate's degree or higher. Most of participants were employed full-time and had group health insurance (Mayfield-Johnson et al., 2012). The ATTACK program provided intensive educational workshops for participants to learn about diabetes, hypertension, and cardiovascular disease. The program also included a culturally adapted "Know Your Numbers " (KYN) campaign, which was adapted from the Mississippi State Plan for Heart Disease and Stroke Prevention and Control (Mayfield-Johnson et al., 2012). As a part of their program, Mayfield-Johnson et al. (2012) developed nutrition education workshops which focused on basic concepts in nutrition, portion control, and label reading, and healthy meal preparations. After implementing the program they assessed the participants' demographics, health status, knowledge, attitudes, and beliefs regarding chronic diseases (i.e., diabetes, hypertension, etc.) and body mass index (BMI) (Mayfield-Johnson et al., 2012). The study revealed an increase in the participants' test scores for knowledge, attitudes, and beliefs regarding chronic disease risk factors and target numbers for blood pressure, blood sugar, and BMI. Participants also demonstrated higher test scores for knowledge about ideal cholesterol numbers. Due to sudden and premature discontinuation of funding for the ATTACK project, the researchers were forced to cancel all outstanding scheduled programs and followups; therefore, complete evaluations for the ATTACK program were not reported in the study (Mayfield-Johnson et al., 2012). HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 13 Occupational Therapy in the Management of Chronic Diseases Occupational therapy practitioners, know how achieving health, well-being, and participation in life through engagement in occupation lead to a positive and satisfying life (American Occupational Therapy Association [AOTA], 2014). Additionally, occupational therapy practitioners understand the significance of habits and routines that promote the adoption and maintenance of healthy behaviors. According to AOTA (2015), understanding the habits and routines of clients allows occupational therapy practitioners to facilitate accomplishment and success by matching the individuals skills to the demands of the activity and offering solutions to challenges associated with changing health status, habits, and routines. Various healthcare professionals are involved in promoting healthy behaviors; however, occupational therapy practitioners use a holistic perspective in their practice to facilitate program success. For example, in a six-week investigation of the efficacy of an occupational therapy led self-management support program, OPTIMAL, for persons with multiple chronic conditions, Garvey, Connolly, Boland, and Smith (2015), found that the occupational therapists' support group was successful in increasing the participants' activity performance and participation which led to reported improvements in self-efficacy, personal goal accomplishment, and health related quality of life. According to Garvey et al. (2015), OPTIMAL also helped improve individuals' participation rate in daily activities such as meal preparation. Participation in the selfmanagement support program for persons with multiple chronic conditions can improve patients' health outcomes by more effectively teaching them to manage their long-term conditions (Garvey et al., 2015). In a scoping review of randomized controlled trials for occupational therapy interventions for chronic diseases, Hand, Law, and McColl (2011) found 16 studies suggesting that HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 14 occupational therapy interventions can improve function in self-care and home management tasks in individuals with chronic conditions like COPD and rheumatoid arthritis. Hand et al. (2011) also noted that evidence suggests occupational therapy interventions may also increase work outcomes for individuals with a diagnosis of depression. According to Reingold and Jordan (2013), through their knowledge of cultural traditions, holistic approaches to practice, and perspectives that influence occupational performance, occupational therapy practitioners are uniquely qualified to assist individuals with development and implementation of personalized approaches to lifestyle changes. Reingold and Jordan (2013) also mentioned that occupational therapy practitioners are uniquely qualified to provide leadership expertise to clients and caregivers, other health professionals, and community-based organizations in the promotion of health and wellness interventions. As part of the American Occupational Therapy Association's commitment to the promotion of health and well-being, occupational therapy practitioners work with community residents to execute primary, secondary, or tertiary prevention strategies for improved health management (Reitz & Scaffa, 2013). In addition, occupational therapy practitioners' role to further facilitate health promotion and prevention include: (a) promoting healthy living; (b) highlighting meaningful activities and roles as important elements of health promotion strategies; and (c) providing interventions to individuals and communities (Reitz & Scaffa, 2013). According to Musavian, Pasha, Rahebi, Roushan, and Ghanbari (2014), health promoting behaviors require positive approaches to living and ways of improving well-being and selfactualization. Using a client-centered approach, occupational therapy practitioners are ideal for empowering Mississippi residents to increase their health literacy, the degree to which people can understand basic health information to make appropriate decisions, to achieve successful HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 15 health outcomes (Alger et al., 2015). Pizur-Barnekow and Darragh (2011), asserted that occupational therapists and occupational therapy assistants promote health by assisting to ensure that all health related information and education provided to clients match the individuals' literacy abilities; cultural sensitivities; and verbal, cognitive, and social skills. Defining Health and Health Promotion Since 1974, health has been defined as a state of total physical, mental, and social wellbeing and not simply the absence of disease and infirmity. This definition of health remains the most popular and comprehensive definition used worldwide (Pender, Murdaugh, & Parsons 2011). Per O'Donnell (2009), health is a means, not an end, for most people because they will be motivated to improve their health if they understand how improving it will help them focus on their personal interests. Health promotion is behavior stimulated by the wish to increase well-being and realize human health potential noted Pender et al. (2011). According to O'Donnell (2009), health promotion is the art and science of helping people realize the accord between their most important enjoyment and best possible health, enhancing their reason to strive for better health, and supporting them in changing their lifestyle to progress toward a state of optimal health. He also explained that optimal health is not a stationary position that one achieves or does not achieve. It is a dynamic balance of emotional, physical, social, spiritual, and intellectual health (O' Donnell, 2009). Health promotion allows individuals, groups, families, and communities to have control over the determinants of their health and to act appropriately. Health promotion is multidimensional (O' Donnell, 2009; Pender et al., 2011), and it focuses on the following six dimensions: individual, family, community, socioeconomic, cultural, and environmental (Pender HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 16 et al., 2011). There is limited research exploring health promotion and health behaviors among rural Mississippians, primarily African American men and women; therefore, the socioeconomic and cultural dimensions explained by Pender et al. (2011), were introduced in the current study to determine if and/or how factors such as education and socioeconomics influence healthpromoting behaviors among residents in rural Mississippi. In the socioeconomic dimension, social conditions (i.e., poverty, limited education, inadequate housing, etc.) in which people live influence their health. In the cultural dimension, culture (i.e., race and ethnicity, socioeconomics, gender, etc.) impacts the effectiveness of health promotion and must be emphasized to achieve individual, family, community, and societal goals (Pender et al., 2011). Health-Promoting Lifestyle Profile II Framework: The Health Promotion Model (Revised) The Health Promotion Model (HPM) was developed as the theoretical framework and basis of the assessment tool used in this study, the Health-Promoting Lifestyle Profile II (HPLP II) (Pender et al., 2011). It is used to assess an individual's motivation for participating in healthpromoting behaviors. The revised HPM has been mainly used as an outline for assessing individuals' health-promoting behaviors (Ballard, 2009) and describes how individuals' characteristics and experiences interact with their behavior to create health-promoting behaviors (Kemppainen et al., 2011). The HPM is a competence-or approach-oriented model, and it does not involve "fear" or "threat" as an explanation for health behavior. It represents the multidimensional character of people interacting with their interpersonal and physical environments in their pursuit of health (Pender et al., 2011). The framework and basis for the HPLP II, consists of three important components that motivate individuals to engage in health-promoting behaviors. The components include: (a) HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 17 individual characteristics and experiences; (b) behavior-specific cognitions and affect; and (c) behavioral outcome (health promoting behavior). The behavioral outcome (health promoting behavior) component is the primary focus of participants for this study (Pender et al., 2011). Individual characteristics and experiences. This first component refers to each individual's personal characteristics and experiences that influence ensuing actions. This component includes personal factors such as biological (age, body mass index, and aerobic capacity), psychological (self-esteem, self-motivation, and perceived health status), and sociocultural (race, ethnicity, acculturation, education, and socioeconomic status). The personal factors which often predict health promoting behaviors are influenced by specific behavior outcomes (Pender et al., 2011). In the current study of residents in the Mississippi Delta and Northwest Mississippi region, individual characteristics and personal factors were assessed as described in Pender's HPM to determine the factors that best predict health-promoting behaviors of the residents. Behavior-specific cognitions and affect. This component has key motivational significance. It includes interpersonal influences related to beliefs, behaviors, or attitudes of one's family, peers, and health care providers. The interpersonal influences, norms, and social support, determine an individual's likelihood to participate in health-promoting behaviors. The interpersonal relations of the participants in this study were also examined to determine if relationships with others influenced their health-promoting behaviors (Pender et al., 2011). Behavioral outcome (health promoting behavior). This component of the model refers to commitment to a plan of action, immediate competing demands and preferences, and healthpromoting behavior (Pender et al., 2011). Commitment to a plan of action implies dedication to carrying out a particular health behavior. Personal strategies are chosen to bolster preferred HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 18 behavioral outcome (Ballard, 2009; Pender et al., 2011). The immediate competing demands and preferences are alternative behaviors that can sabotage plans for health-promoting behaviors. Lastly, health-promoting behavior is the behavioral final point in the HPM that is geared toward achieving positive health outcomes. When combined with a healthy lifestyle, health-promoting behaviors result in better health, improved functional ability, and improved quality of life at all stages of development. In the framework of health, lifestyle is viewed as voluntary activities that are part of an individual's daily living routine and considerably influence one's health status. In addition, health-promoting behavior is an expression of the human actualizing tendency that is geared toward optimal well-being, personal fulfillment, and productive living. The HPLP II which was developed to measure health-promoting behavior, the behavioral outcome of Pender's HPM, was used in this study to predict the health-promoting behaviors of men and women in the Mississippi Delta and Northwest Mississippi Region (Pender et al., 2011). Health-Promoting Behaviors of African American Women and Men Using the HPLP II, Brown (2009) investigated the relationships among health status, marital status, income, education, age, BMI, and spirituality on the health-promoting behaviors of 137 African American women. She found that despite African American women having the highest incidence of CVD mortality and morbidity rates, they were not engaging in behaviors which could decrease their risk for CVD. The researcher also found that participants with fewer children reported better health-promoting behaviors, and that participants with more years of formal education had better health-promoting behaviors. Participants who reported having a sense of purpose and meaning to life also reported better health-promoting behaviors. The association between the participants' education and health responsibility was positive and statistically significant, but the correlation between being widowed and health responsibility was HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 19 negative and statistically significant suggesting that participants who had more years of education and who were not widowed had better health-promoting behaviors (Brown, 2009). Participants in this study reported the highest scores for spiritual growth, interpersonal relations, and health responsibility. Lower scores were detected for the stress management and nutrition domains. Physical activity had the lowest score of all the HPLP II domains. Participants' health status, age, and BMI were not statistically related to their health-promoting behaviors although more than half reported being obese and having hypertension as their primary medical condition. Most of the women in the study were at high risk for. Nevertheless, it was concluded that educational attainment, number of children, and having a sense of purpose and meaning in life were all related to better health-promoting behaviors among the African American women in her study (Brown, 2009). In another study investigating the health-promoting behaviors of African- American women, Baker (2011) assessed cultural sway on the health-promoting behaviors of elderly African-American women. Poor health behaviors (i.e., lack of physical activity, poor weight management, high fat diets, etc.) contributed to increased morbidity and mortality rates, especially among older African-American women who found it challenging to overcome poor behaviors due to their rich cultural and traditional values. Using the HPLP II, Modified African American Acculturation Scale Revised (MAAASR), and Demographic Health Survey (DHS) assessment tools, Baker (2011) found that there was a positive correlation for culture and health-promoting behaviors and culture and SES; however, the researcher found no correlations between the participants' age and culture, or educational attainment and culture. There was not a correlation between participants' age and health promoting behaviors (Baker, 2011). HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 20 Baker (2011) noted that older African-American women who acculturated toward the dominant society were more educated, had greater socioeconomic resources, and engaged more in health-promoting behaviors, whereas older African-American women who lived by traditional African-American culture participated in health-promoting behaviors less than those who identified with the culture of the dominant society. It was concluded that cultural influences are important and must be considered in order to promote the health of older African-American women (Baker, 2011). With a majority population of African American men and women in the Mississippi Delta, determining if their culture (i.e., spirituality) influences health-promoting behaviors will be important in creating future programs to address the region's health disparities. Using the HPLP II and the health-related quality of life (HRQOL)-4 Healthy Days Core Module, Calvert, Isaac, and Johnson (2012) sought to identify the health-promoting behaviors in a convenience sample of low income, black men (N=54) and to determine the association between their HRQOL and their health-promoting behaviors. The researchers found significant relationships between HRQOL and engagement in health-promoting behaviors. They noted strong correlations between mentally unhealthy days, spiritual growth, stress management, and nutrition. The men who reported fair or poor health had lower scores for HRQOL and participated in health-promoting behaviors less than those men who reported good or better health and had higher scores for HRQOL. The same was true for men who experienced frequent mental distress, compared to men who reported infrequent mental distress and limited physical activity (Calvert et al., 2012). Much like the findings in the study by Ballard (2009), Calvert et al. (2012) also noted low scores for nutrition and physical activity engagement. From their study, Calvert et al. (2012) concluded that the associations found between measures of the HPLP II and the HRQOL-4 suggest those men experiencing fair or poor health, infrequent mental distress, HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 21 and limited physical activity were less likely to participate in health-promoting behaviors which might ultimately compromise their personal health. In this study, evaluation of the participants' general health will be useful in determining an association with health-promoting behaviors like stress management. Health-Promoting Behavior(s) and the HPLP II Lo, Chair, and Lee (2015) assessed the health-promoting behaviors of 132 adults with metabolic syndrome (MS) or at high risk for metabolic syndrome to determine the association between self-efficacy, the health belief model, and health-promoting behaviors. One-third of the participants reported their highest educational attainment level below secondary school, and nearly half the participants reported a monthly income less than the local median income (Lo et al., 2015). Over half of the participants in this study identified themselves as being obese or being overweight and more than two-thirds had three or more risk factors indicating MS. Persons with MS often exhibit impaired blood glucose, high cholesterol, high blood pressure, and obesity; therefore, individuals with MS are encouraged to make lifestyle modifications, which include undertaking health-promoting behaviors such as an increase in physical activity (Lo et al., 2015). In their research using the HPLP II, Lo et al. (2015), found that despite the high cardiometabolic risk of participants in their mid-life, the individuals showed only moderate levels of health-promoting behavior. Since Mississippians are often plagued by multiple chronic diseases, assessing risk factors such as high cholesterol and obesity and their possible influence on health-promoting behaviors may provide researchers with a clearer understanding of the factors associated with the health-promoting behaviors of the residents in the Delta region. This will allow for the development of more focused health-promoting programs targeting the states' health crisis, particularly in the rural Delta region. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 22 Ballard (2009) examined the relationships between sociodemographic characteristics, health status, health practices and self-efficacy and health promoting behaviors and described the existing health-promoting behaviors of primarily African American, sheltered, homeless women (N=126) in central North Carolina. The instruments were the HPLP II, Self-Rated Abilities for Health Practices Scale (SRAHP), and Personal History Form. The researcher found that the homeless women's overall health-promoting behaviors were positive but not to the level of participating in healthy behaviors routinely. Based on the HPLP II, spiritual growth, interpersonal relations, and stress management were engaged in the most among the women. However, health responsibility, nutrition, and physical activity received the lowest scores for level of engagement (Ballard, 2009). Ballard (2009) found that 10% of the women in the study reported lack of participation in health responsibility or being proactive regarding their own health due to alcohol and drug use, lack of motivation, and lack of money. However, more than half the women in this study reported participation in preventive health services such as Pap test, mammograms, and routine health check-ups. No obstacles to spiritual growth were reported by the women in this study. The women scored highest on this subscale and their mean score was significantly above the midpoint of the HPLP II. Physical activity received the lowest score on all of the subscales of the HPLP II. Some participants reported lack of physical activity due to environmental barriers such as, no gym, lack of safe environment, and lack of money to afford gym membership. In addition, some women reported limited physical activity due health issues such as, asthma, lupus, and high blood pressure. Nutrition scores were the second lowest found in this study, and 7% of the participants reported numerous barriers to healthy eating or nutrition (e.g., lack of food choices, lack of HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 23 knowledge about nutrition, inability to cook own meals, and inability to afford healthy food) (Ballard, 2009). For this study, it will be important to know the personal habits (i.e., alcohol and tobacco use) and lifestyles of Mississippi Delta residents, particularly African American women, and determine how their habits and lifestyles influence health-promoting behaviors. Health-Promoting Behaviors and Lifestyles Health-promoting behaviors are the activities which motivate individuals to protect or promote their health (Brown, 2009). Health-promoting behaviors entail positive ways of enhancing well-being and positive approaches to living. They stop diseases, decrease morbidity, decrease medical costs, and improve quality of life. Chronic diseases are closely related to peoples lifestyle. Eating habits are the most important aspect of health promotion because a healthy diet is vital in the prevention of chronic diseases (Musavian et al., 2014). Some individuals may encounter socioeconomic situations in which they have to make choices about how to spend money for food, paying more for fresh fruits and vegetables or paying less for rice and potatoes (IOM, 2012). In a four year, heart study of 5,301 African Americans in Jackson Mississippi, Liu et al. (2013) identified three dietary habits: the "Southern," the "fast food," and the "prudent." The "Southern" diet consisted of fried fish and chicken, margarine and butter, and pasta and rice. The "fast food" diet consisted of sugary drinks, fast food, and salty snacks. Finally, the "prudent" diet consisted of fruits and vegetables, hot and cold cereals, and nuts and seeds. Participants with higher consumptions of the "Southern" and "fast food" diets exhibited larger waist circumferences, more abdominal adipose tissue, high blood pressure, high cholesterol, and greater possibility of metabolic syndrome. No association was found between the "prudent" diet scores and most cardiometabolic risk factors. The researchers reported that participants were HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 24 more likely to consume the "Southern" diet because it shows their southern roots and African American familial experiences of living in the South (Liu et al., 2013). Like eating habits, physical activity is a vital aspect of health promotion and a predictor of disability and death worldwide. Engaging in regular physical activity, avoiding stress and smoking, and maintaining a healthy body weight characterize a health-promoting lifestyle which helps to prevent numerous chronic diseases (Musavian et al., 2014). Tucker et al. (2014) found that people from low-income and minority groups frequently report lower participation in physical activity and have higher rates of overweight/obesity. Given this finding, Tucker et al. (2014) emphasized the significance of developing and executing health-promoting interventions to modify and prevent obesity, especially among low-income and minority groups. Comparable to the populations in the aforementioned studies, some studies have specifically shown that Mississippians have a long history obesity and an increased morbidity rate, for that reason, knowing their specific dietary and physical activity behaviors of participants in this study can highlight the importance of health-promoting interventions which may help to decrease the high incidence of chronic disease related to poor nutrition and sedentary lifestyles among people in the Mississippi Delta. For people with chronic diseases such as cancer, smoking cessation is an important behavior change goal; however, according to the IOM (2012) many people continue to smoke even if their medical condition is related to smoking. Continued smoking has been shown to exacerbate some chronic conditions such as asthma, diabetes, and cancer. Therefore, persons with chronic illness can benefit from community efforts to encourage tobacco use cessation and reduce exposure to secondhand smoke (IOM, 2012). Mississippi ranks second in the nation for cancer deaths and sixth for smoking prevalence (Short, 2014), so assessing the current smoking HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 25 habits of the participants in this study is important to understand the association between smoking and the participants' health-promoting behaviors. In their study investigating long term changes in health behavior among individuals several years after chronic illness, Newsom et al. (2012) found that the most widespread health behavior change was smoking cessation among people with heart disease. People with lung disease were the least likely to stop smoking after their diagnosis possibly due to established habits. Alcohol consumption also declined following diagnosis of diabetes since people with diabetes are urged to avoid alcohol intake during periods of high blood sugar. The researchers observed that women and younger adults were more likely to decrease both exercise and alcohol use (Newsom et al., 2012). Like smoking, assessing alcohol consumption among this study's participants may offer significant details about their habits which may provide critical information to initiate health-promoting behaviors among Delta residents. Newsom et al. (2012) also found that educational attainment showed the most effect on health behavior changes. Higher educational attainment was associated with greater smoking cessation, decreased alcohol intake, and increased exercise (Newsom et al., 2012). Socioeconomic variables, such as education, often produce underlying health lifestyles that influence exercise, diet, and smoking according to Pampel, Krueger, and Denney (2010). Because there is a gap in research which specifically examines the influence of education on the health-promoting behaviors of men and women in the Mississippi Delta, identifying the educational attainment of the participants in this study will be essential to wholly understand the relationship between education and health-promoting behaviors. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 26 Socioeconomics and Health Behaviors Using 12 focus groups and 66 focus group participants, Hovick, Johnson-Turbes, Freimuth, and Chervin (2011) conducted interviews to assess perceptions of and responses to multiple health risks among individuals living in three southern states with high poverty rates, Alabama, Mississippi, and South Carolina. Their goal was to understand how Southerners perceive multiple health risks and how they manage them with minimal resources. Participants in the focus groups reported they most worry about obesity, diabetes, heart disease, hypertension and high cholesterol and the costs to treat them. Across the groups, participants expressed concern about health care costs due to chronic health conditions, including insurance, co-pays, and medication costs. Study participants reported lack of health insurance, confusing information about ways to protect themselves from health risks, and lack of money as major barriers to health-protective behaviors. They also reported lack of money as a significant barrier for eating healthy meals because healthy food was too expensive to buy (Hovick et al., 2011). Despite the various barriers reported, Hovick et al. (2011) found that study participants reported engaging in some type of health-protective behaviors. In the groups, participants regularly mentioned that eating healthy foods and engaging in physical activity were behaviors that could protect them from chronic health conditions. Some participants reported that they did not use illegal drugs, did not drink alcohol, or drank alcohol only in moderation to protect their health. Others said taking their medication on a regular basis was an important health protective behavior, as was keeping their doctor's appointment. Checking blood pressure and engaging in physical activity were the most frequently reported health-protective behaviors reported during HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 27 the individual interviews. However, physical activity was often described as being part of the participants' job or home life rather than a structured exercise program (Hovick et al., 2011). Findings of this study suggest that low-income individuals are aware of and worried about threats of chronic health conditions which is important since there is more poverty in the southern United States (Hovick et al., 2011). For people in the rural Mississippi Delta, it is essential to know how residing in an impoverished, low-income region influences their health behaviors in order to address the possible health disparities that badly affect indigent populations. Pampel et al. (2010) conducted a review of wide-ranging literatures to explain poor health behaviors among persons of low socioeconomic status (SES). Similar to Newsom et al. (2012), they found that educational attainment had a significant influence on health behavior. High school dropouts had greater chances of smoking and being physically inactive than college graduates. Less educated individuals with jobs that do not provide opportunities for learning exhibited poor nutrition, physical inactivity, and smoking due to limited knowledge about the consequences of unhealthy behaviors. Therefore, these individuals were less motivated to engage in healthy behaviors. The researchers reported that knowledge about the risks of being overweight/obese differed by SES. Individuals with college degrees were more aware about being overweight compared to people with less than a high school diploma. They also reported paying attention to nutritional information compared to people with less than a high school diploma (Pampel et al., 2010). While investigating the association of income with health behavior change and disease monitoring among adults with chronic disease, Campbell et al. (2014) found that despite the frequent recommendations for behavior change among adults with chronic diseases, HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 28 noncompliance is usually high among adults with lower incomes. However, they noted that persons from low SES groups are mostly disadvantaged by structural factors, rather than simply choosing to disregard health advice (Campbell et al., 2014). Fisher et al. (2011) asserted, although obstacles to healthy behavior change such as health literacy and SES, are prominent contributors to health disparities among low income and ethnic minority groups, behavioral practices emphasizing social modeling and coaching on particular approaches to adoption of healthy behaviors are vital for addressing the obstacles. Summary Review of the literature supports the continued need for proper health education and community based health programs to encourage health-promoting behaviors among men and women in the Mississippi Delta to decrease the prevalence of chronic diseases like diabetes and obesity. Although some Mississippians may be aware of the benefits of a healthy lifestyle, the high incidence of chronic diseases suggests that many of the residents may not consistently participate in health-promoting behaviors to prevent such diseases. Socioeconomic, personal, environmental, and cultural barriers to health-promoting behaviors exist among rural, lowincome populations. Fully understanding the Mississippi Delta residents' health-promoting behaviors and the relationships between the behaviors can be critically important in developing health interventions that eliminate noted health disparities. Method Research Design This non-experimental, cross-sectional study examined the health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi region. Participants completed an online survey to identify their health-promoting behaviors. The study was determined to be HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 29 exempt by the Humans Protections Program at the University of Indianapolis prior to participant recruitment. Participants English speaking men and women who resided in the Mississippi Delta and Northwest Mississippi region and who identified themselves as being at least 18 years of age were invited to take the HPLP II survey. Participants were recruited through the use of flyers (see Appendix A) posted at various locations throughout the community such as fitness/wellness centers, office break rooms, and church fellowship halls. Postcards were also distributed door-to-door in multiple neighborhoods, at local walking parks, medical support groups, and shopping centers (see Appendix A). The flyers and postcards were used to direct participants to complete the HPLP II through the online survey data collection software, Qualtrics (Qualtrics, Provo, UT). Snowball sampling technique was used as participants completing the survey electronically were also asked to pass along the Qualtrics link to other individuals in the area. The Qualtrics survey link was also shared through links in social media websites with others in the Mississippi Delta and Northwest Mississippi region. Many residents of the Mississippi Delta live in rural and underserved areas, and they have limited access to the internet. The investigator, therefore, hand delivered hard copies of the HPLP II survey to approximately 19 individuals in a local housing subdivision who did not have computer access. These key individuals were known by the investigator through church, volunteer, or work related activities. The investigator requested that these key individuals pass along additional copies of the survey to other people they knew. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 30 Data Collection Data were collected through both online and paper survey. The survey collected the demographic data and responses to the HPLP II. The demographic data questionnaire (see Appendix C) was adapted from Ballard's (2009) Personal History Form and included questions regarding personal characteristics such as county of residency, age, marital status, educational attainment, race, and gender. A body mass index (BMI) chart (see Appendix D) was also provided as a reference to obtain personal BMI numbers for the related question. Upon receipt, data from the paper surveys were entered into Qualtrics. Once the data were entered, the paper surveys were destroyed. After the survey was closed and all data from the paper surveys were entered, data were downloaded into an Excel spreadsheet. The data were reviewed for errors and cleaned, then exported into a statistical software program for analysis. Instrumentation The Health-Promoting Lifestyle Profile II (HPLP II) (see Appendix E) was used to assess the participants' health-promoting behaviors. The instrument is a 52-item summated rating scale created to measure health-promoting behaviors in six categories: health responsibility, physical activity, nutrition, spiritual growth, interpersonal relations, and stress management (Baker, 2011; Tyszka & Farber, 2010). Participants self-reported the frequency of engaging in healthpromoting behaviors by responding to a four-point Likert-like scale: 1 = never, 2 = sometimes, 3 = often, or 4 = routinely. The total scores range from 52 to 208 with higher ratings signifying more participation in health-promoting behaviors (Baker, 2011; Ballard, 2009). Developers of the HPLP II used mean scoring instead of sums of the scale items to keep the one to four metric of the answers, allowing consistent comparisons of the scores among the subscales (Walker & Hill-Polerecky, 1996). HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 31 The HPLP II was found to be reliable with high internal consistency, Cronbach's alpha of (.94) for the total scale (Walker & Hill-Polerecky, 1996) and Cronbachs alpha for each HPLP II subscale ranging from .79 to .87: Health Responsibility ( = .86), Physical Activity ( = .85), Nutrition ( = .80), Spiritual Growth ( = .86), Interpersonal Relations ( = .87), and Stress Management ( = .79) (Ballard, 2009). It was found to be a stable instrument (r = .89) in a 3week test-retest study (Walker & Hill-Polerecky, 1996). Content validity was established through literature review and content experts' evaluation. The instrument's construct validity was supported by factor analysis that confirmed the six-dimensional makeup of health-promoting lifestyle should be retained in this revised and updated instrument (Ballard, 2009; Walker & HillPolerecky, 1996). Procedures Individuals who agreed to be in the study, after reading the online consent document, completed and submitted the electronic survey. Participants completing a paper survey received written consent information, a cover letter (see Appendix B), a written survey, including BMI chart (see Appendices C-E), and a self-addressed, stamped envelope for return of the survey. The participants were asked to complete the survey and return it in the self-addressed, stamped envelope within 10 days of receipt. Completion and return of the survey served as the participants' consent to participate in this study. The anonymous survey was open to participants for 21 days, and no computer IP addresses were collected. Data Analysis Data were analyzed using IBM SPSS Statistics for Windows, version 23 (IBM Corp., Armonk, NY). Descriptive statistics was conducted on the total sample. The Shapiro-Wilk test was used to determine if the data were normally distributed. Nominal data are reported as HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 32 frequencies and percentages, ordinal data and non-normally distributed interval and ratio data as medians and interquartile ranges, and normally distributed interval and ratio data as means and standard deviations. Comparisons were conducted using the Mann-Whitney U tests and Kruskal-Wallis tests to determine if there were differences in health-promoting behaviors (total score and subscale scores) by respondent characteristics. Any health promoting behavior found to have significant variability (p < .05) between subgroups identified as a possible explanatory variable. .Multiple linear regression analysis was conducted to identify factors predictive of health-promoting behaviors. Explanatory variables were introduced into the regression model simultaneously using the Enter method. Preliminary analyses were performed to confirm assumptions of normality, linearity, multicollinearity, and homoscedasticity. All tests were two-tailed and an alpha level of less than .05 was considered statistically significant. Results A total of 165 individuals completed the HPLP II survey. The majority of the respondents were female (n = 126, 76.3%). Grenada County had the highest number of participants in this study (n = 56, 33.9%), and Yalobusha, Rankin, and Coahoma Counties had the fewest number of participants in this study (n = 1, .6%). The mean age of the participants was 46.49 years (SD = 12.69), and their ages ranged from 19 to 91 years. Detailed demographic results can be found in Table 1. Although more than half of participants reported being nonsmokers, of the 21 participants who reported being a smoker, one participant reported smoking one pack (20 cigarettes) a day. Five was the average number of cigarettes reportedly smoked per day by the participants. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 33 Similar to smoking, the participants were asked about the number of alcoholic drinks they consume in a week and most of the participants (n = 116, 70.3%) reported that they do not consume alcohol. Less than half of the participants reported alcohol consumption. Of the 44 participants who reported alcohol consumption, one participant reported a consumption of 20 alcoholic drinks a week. Ten alcoholic drinks per week was the average number of drinks reportedly consumed by the participants, and 18 of the participants reported having only one alcoholic drink a week. The majority (33.3%) of the survey participants reported having none of the listed chronic medical conditions. However, of the listed chronic medical conditions, high blood pressure was the most frequently (n = 88, 53.5%) reported. Participants were not specifically asked about household income on the survey. Therefore, to try to determine if participants' socioeconomic status had an impact on healthpromoting behaviors, the median household income for the counties represented in the survey according to the United States Census Bureau (2015) were collected. In 2015 the median household income for Mississippi was $39,665. The participants were from 13 counties in Mississippi with the highest percent (n = 56, 33.9%) from Grenada county which had a reported median income of $34,129. A total of 87 (52.7%) participants were from counties with reported median incomes less than $30,000. See Table 2 for a breakdown of median household income by counties represented and the number of participants from each of the counties. Health-Promoting Behaviors Descriptive analyses of the scores resulting from the HPLP II and the HPLP II subscales are represented in Table 3. The highest scores reported represent the health-promoting behaviors most routinely practiced and the lowest scores reported represent the behaviors least frequently practiced by the participants. The highest possible score for the HPLP II total scale the HPLP II HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 34 subscales was 4.0, and the lowest possible score was 1.0. Participants reported that they most often practiced behaviors related to spiritual growth and interpersonal relations and least often engaged in behaviors related to physical activity. Multiple linear regression was conducted on HPLP II total score and each of the subscale scores. Assumptions for the analysis were met based on criteria reported by Field (2013). Linearity was assessed by visual inspection of partial regression plots and a plot of studentized residulals against the predicted values. Multicolinearity was determined using correlations between the independent variables of < .90 and tolerance values > .10. Independence of observations was present, as assessed by the Durbin-Watson statistic of the HPLP II total scale and its subscales with a minimum value of 1.69 and maximum value of 2.09. No residuals were greather than +3 standard deviations, and they were approximately normally distributed as visualized on histograms and P-P plots. Homoscedasticity was confirmed for all models by visual inspection of a plot of studentized residuals versus unstandardized predicted values. Multicolinearity was identified between smoking status and education; therefore, the model was ran with either smoking status or education and variable that accounted for most variation was used for the final model. Health-Promoting Lifestyle Profile II: Total scale. Eight demographic and participant characteristics were identified as being a potential explanatory variable: smoker, diagnosis of heart disease, high blood pressure, or kidney disease, education, employment status, number of chronic conditions, and self-reported general health status. Multiple regression analysis identified two key predictors for the HPLP II total scale, general health and education. Both significantly predicted the score for the total scale and accounted for almost 33% of the overall health- HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 35 promoting behaviors variance R2 = .328, F(2, 149) = 36.41, p < .001. Both variables added significantly to the prediction, p < .05 (Table 4). Health-Promoting Lifestyle Profile II: Health responsibility. Four potential exploratory variables were identified: smoker, kidney disease, education, and general health. Regression analysis identified general health and education as predictors for the subscale. Both significantly predicted the score for health responsibility and accounted for nearly 21% of this health- promoting behavior variance R2 = .207, F(2, 149) = 19.42, p < .001. Both variables added significantly to the prediction, p < .05 (Table 5). Health-Promoting Lifestyle Profile II: Physical activity. Explanatory variables that showed a statistically significant difference for physical activity were smoker, alcohol use, heart disease, high blood pressure, kidney disease, diabetes, education, employment, number of chronic conditions, and general health. Regression analysis identified general health and alcohol use as the significant predictors for physical activity. General health and alcohol significantly predicted the score for physical activity and accounted for 25% of the health- promoting behavior variance R2 = .250, F(2, 151) = 25.20, p < .001 (Table 6). Health-Promoting Lifestyle Profile II: Nutrition. Six potential explanatory variables were identified: smoker, high blood pressure, kidney disease, education, employment, and general health. Regression analysis identified three significant predictors for nutrition: general health, education and diabetes. These three variables significantly predicted the score for nutrition and accounted for 28.9% of the variance R2 = .289, F(3, 148) = 20.08, p < .001. All three variables added significantly to the prediction, p < .05 (Table 7). Health-Promoting Lifestyle Profile II: Spiritual growth. Variables that showed a statistically significant difference for spiritual growth included: smoker, heart diease, high blood HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 36 pressure, high cholesterol, kidney disease, education, employment, number of chronic conditions, and general health. Regression analysis identified general health and education as significant predictors for the subscale. Both significantly predicted the score for spiritual growth and accounted for nearly 25% of this health- promoting behavior variance R2 = .248, F(2, 149) = 24.51, p < .001. Both variables added significantly to the prediction, p < .05 (Table 8). Health-Promoting Lifestyle Profile II: Interpersonal relationships. Seven variables were identified as potential explanatory variables: heart disease, high blood pressure, kidney disease, education, employment, number of chronic conditions, and general health. Regression analysis identified general health, education, and kidney disease as significant predictors for the subscale. All three significantly predicted the score for interpersonal relationships and accounted for nearly 26% of this health- promoting behavior variance R2 = .256, F(3, 148) = 16.96, p < .001. All three variables added significantly to the prediction, p < .05 (Table 9). Health-Promoting Lifestyle Profile II: Stress management. Seven potential explanatory variables were identified: smoker, heart disease, high blood pressure, kidney disease, education, number of chronic conditions, and general health. Regression analysis identified general health and education as significant predictors for the subscale. Both significantly predicted the score for stress management and accounted for approximately 16% of this healthpromoting behavior variance R2 = .159, F(2, 149) = 14.09, p < .001. Both variables added significantly to the prediction, p < .05 (Table 10). Summary Of the 165 respondents of the HPLP II from the Mississippi Delta and Northwest Mississippi region, the majority reported that they were African American, had earned at least a Bachelor's degree, had good general health, and had no chronic medical conditions. Multiple HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 37 regression analysis showed that two significant variables, education and general health predicted the scores for the health-promoting behaviors of residents in the Mississippi Delta and Northwest Mississippi region who participated in this study. Education and general health were the significant predictors for the HPLP II total scale and each of its subscales except, physical activity. General health and alcohol use were the two predictors for that subscale. Discussion Results from this study showed that education and general health were significant predictors of health-promoting behaviors among the participants of the study. This finding might be explained by the fact that over half of the participants reported having earned at least a bachelor's degree, and less than half (29.7 %) reported having multiple chronic medical conditions which is contradictory to the findings of Mendy & Vargas (2015) who reported that 21.5 % of Mississippi Delta residents earned less than a high school education and demonstrated significant increases in chronic diseases such as obesity, diabetes, and high cholesterol. The differences in the findings for this study and Mendy & Vargas (2015) may be attributed to the recruitment process for participants of this study. Men and women, at least 18 years of age, were invited to participate in this study through the use of flyers posted at fitness/wellness centers and through postcard distributions at local walking parks and at medical support groups. Targeting these locations may have recruited individuals who had earned at least a high school diploma and were participating in physical exercise and medical support groups to actually improve their overall health. However, consistent with Short's (2014) finding of Mississippians being obese, over half of the sample population reported being overweight/obese. Although more than half of the participants reported a BMI of 25 - 30 and over, the majority of them reported good general HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 38 health and no chronic medical conditions. This finding is somewhat inexplicable given that participants in this study reported low health-promoting scores for nutrition and physical activity yet some participants were recruited through the use of flyers posted at fitness/wellness centers and postcards distributed at local walking parks. Although regression analysis identified general health and education as the two main predictors for the HPLP II total scale and almost all its subscales, general health and alcohol use were the significant predictors for the physical activity subscale. The participants in this study indicated they engaged in health promoting behaviors according to the resulting scores in the HPLP II's six subscales. The highest scores were reported for spiritual growth, interpersonal relations, and health responsibility. Typically, religion and spirituality are very important in African American communities (Reeves, Adams, Dubbert, Hickson, & Wyatt, 2012; Carter-Edwards et al., 2012) which was observed by those who responded in this study. Participants in this study reported that they sometimes engaged in stress management and nutrition health-promoting behaviors but engaged in physical activity even less. Brown (2009) found similar results, reporting that spirituality significantly influenced the healthpromoting behaviors of the participants in her study. However, they did not often engage in stress management, nutrition, nor physical activity as health-promoting behaviors. Also similar to Brown's (2009) findings, neither marital status nor BMI made a significant difference on participants' health-promoting behaviors, even though 60% the participants in this study reported being overweight/obese. In addition, race/ethnicity did not make a significant difference in the health-promoting behaviors of the men and women in this study. However, the finding for educational attainment was consistent with the results for studies by Baker (2011) and Brown (2009) despite all the participants in their studies being African HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 39 American women. The higher the educational attainment, the greater the likelihood of participation in health-promoting behaviors. Although general health and education were the primary predictors for the healthpromoting behaviors of the participants in this study, these variables only accounted for 33% of the variance; therefore, 67% of the health- promoting behaviors variance remains unexplained. This unexplained variance may be due to the high percentage, (95%), of African American participants in this study and their cultural norms related to health-promoting behaviors such as nutrition. For example, Liu et al. (2013) found that African Americans in Mississippi are more likely to consume "fast-food" and "Southern" diets which are characterized by saturated fat, high cholesterol and refined carbohydrates from foods such as grits, corn, butter, and processed meats. Consumption of these type of diets, according to Liu et al., (2013), may be a reflection of African Americans' southern roots and ancestral experience of living in the South. Additionally, the unexplained variance may be due in part to lack of specific information regarding environmental factors and socioeconomic status of the participants. Future research studies should be done to further explore health-promoting behaviors and the factors that best predict those behaviors for the men and women in the Mississippi Delta and Northwest Mississippi Region. Limitations The sample population was comprised of men and women who resided in the Mississippi Delta and Northwest Mississippi region. Consequently due to the small sample size and rural culture of residents in the Delta and Northwest region, study findings cannot be generalized to other men and women throughout the state. Although research has shown socioeconomic factors influence health behaviors, only minimal data was collected regarding health status, education, HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 40 and employment. No substantial data was collected regarding participants' personal income nor living environment. In addition, because the study's survey was primarily electronic, although hard copies were also available, the sample population may not accurately represent the men and women in rural Mississippi without computer access. Moreover, self-reporting of healthpromoting behaviors may have resulted in potential bias. Also, due to minimal published research on the specific health-promoting behaviors among Mississippi Delta residents, inferences about the health-promoting behaviors of this population were limited. Implication for Research There is a paucity of research on the specific health-promoting behaviors of men and women in the Mississippi Delta; therefore, findings from this study can provide an understanding of the current health-promoting behaviors among residents in rural Mississippi. Further research to understand the health-promoting behaviors of Mississippians could help healthcare professionals and public health officials develop community health programs to meaningfully impact their lives. Pender et al. (2011) noted that community based health education programs can increase the dissemination of health information and encourage changes in cultural norms relevant to health behaviors. In addition, because preliminary data have shown that in order to improve the quality of life of Mississippi Delta residents, who are primarily African American, by reducing the prevalence of chronic diseases, more educational efforts should concentrate on culturally adapted health education sessions with opportunities for follow-up measurements, suitable learning modalities, and opportunities to move education into practice (Mayfield-Johnson et al., 2012). Finally, due to the limited amount of data and the significant percentage of variance, 67%, which HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 41 remains unexplained for the health-promoting behaviors of participants in this study, additional research is warranted to help explain the remaining variance. Conclusion Residents of the rural Mississippi Delta are vulnerable to chronic diseases and poor health (Short, 2014). Therefore, understanding the health- promoting behaviors of men and women in Mississippi can be valuable in the development of culturally appropriate, health and wellness programs to help residents of the Mississippi Delta and Northwest Mississippi region gain self-confidence and become proactive in self-management of their health and well-being. The Delta residents might become empowered to take personal responsibility in the initiation or continuation of positive health- promoting behaviors to reduce their personal risk of chronic diseases. Likewise, understanding the health-promoting behaviors of this population may also assist local and state health care and public health professionals create health promotion programs to achieve the national goals of the U.S. Department of Health and Human Services' (USDHHS; 2010) Healthy People 2020 initiative. Individuals' pursuit of health and health behavior is significant to this initiative to extend their years of healthy life (Fisher et al., 2011). According to the USDHHS (2010), the vision of Healthy People 2020 is for a society in which all individuals live long, healthy lives. The USDHHS (2010) established the following goals for its Healthy People 2020 initiative: attain high quality, longer lives free of preventable disease, disability, injury, and premature death; achieve health equity, eliminate disparities, and improve the health of all groups; create social and physical environments that promote good health for all; and promote quality of life, health development, and healthy behaviors across all life stages HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 42 Efforts to increase adoption of healthy behaviors among individuals with chronic diseases should be carried out with sensitivity to barriers often faced by populations living with low socioeconomic status (IOM, 2012). For this reason, understanding the unique cultural backgrounds of Delta residents is a must for providing proper education regarding risk factors and health-promoting behaviors which may increase the ability to triumph over barriers to healthy behaviors, regardless of socioeconomic status. Therefore, policy makers and healthcare professionals should acknowledge specific barriers as they work to develop culturally sensitive and realistic health promotion and wellness programs. Improved health literacy and adequate knowledge of the certain risk factors for chronic diseases may significantly contribute to positive health behaviors in the Delta. Health behavior, according to Fisher et al. (2011), involves improving quality of life, preventing disease, treating chronic diseases, enhancing health, and decreasing mortality. Thus, to decrease the morbidity and mortality rates in Mississippi, more attention and urgency to act are needed in assisting low income, rural residents improve their health behaviors. Because some of the highest scores reported by the participants in this study were related to spiritual growth and interpersonal relations, in addition to health professionals, local churches and community based programs can be integral in motivating and encouraging health-promoting behaviors by developing strategies for social support, as well as spirituality (Brown, 2009). According to Friedman, Hooker, Wilcox, Burroughs, and Rheaume (2012), faith-based organizations have been effective for engaging African Americans in healthy behaviors because spirituality often has an important role in this community. Facilitating health-promoting educational programs to help quell risk factors such as physical inactivity and poor nutrition may be effective in reducing the prevalence of chronic HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 43 diseases throughout Mississippi, but more emphasis on the health-promoting behaviors among Mississippi Delta residents is crucial for the state to meet the goals for the Healthy People 2020 initiative. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 44 References Alger, B., Farr, L., Fink, C., McCarthy, M., Milazzotto, C., Goodman, G., & Demarco, J. (2015). Client education: Using strategies and technologies to improve practice. OT Practice, 20(1), 7-10. American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68 (Suppl.1), S1-S48. doi: 10.5014/ajot.2014.682006 American Occupational Therapy Association. (2015). 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L., Kaplan, R. M.,Ockene, J. K. (2011). Behavior matters. American Journal of Preventive Medicine, 40(5), e15e30. doi:10.1016/j.amepre.2010.12.031 Friedman, D. B., Hooker, S.P., Wilcox, S., Burroughs, E. L., & Rheaume, C. E. (2012). African American men's perspectives on promoting physical activity: "We're not that difficult to figure out!" Journal of Health Communication, 17(10), 1151-1170. doi:10.1080/10810730.2012.665424 Garvey, J., Connolly, D., Boland, F., & Smith, S. M. (2015). OPTIMAL, an occupational therapy led self-management support programme for people with multimorbidity in primary care: A randomized control trial. BMC Family Practice, 16, 1-11. doi: 10.1186/s12875-0150267-0 Hand, C., Law, M., & McColl, M. A. (2011). Occupational therapy interventions for chronic diseases: A scoping review. American Journal of Occupational Therapy, 65, 428-436. doi:10.5014/ajot.2011.002071 Hovick, S. R., Johnson-Turbes, C. A., Freimuth, V. S., & Chervin, D. D. (2011). Assessing perceptions of and responses to multiple health risks among the southern poor. Preventing Chronic Disease, 8(1), 1-7. Retrieved from http://www.cdc.gov/pcd/issues/2011/jan/09_0222.htm. Institute of Medicine. (2012, January). Living well with chronic illness: A call for public health action. Washington, DC: National Academic Press. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 47 Kemppainen, J., Bomar, P. J., Kikuchi, K., Kanematsu, Y., Ambo, H., & Noguchi, K. (2011). Health promotion behaviors of residents with hypertension in Iwate, Japan and North Carolina, USA. Japan Journal of Nursing Science, 8, 20-32. doi:10. 1111/j.1742-7924.2010.00156.x Liu, J., Hickson, D. A., Musani, S. K., Talegawkar, S. A., Carithers, T. C., Tucker, K. L.,... Taylor, H. A. (2013). Dietary patterns, abdominal visceral adipose tissue and cardiometabolic risk factors in African Americans: The Jackson heart study. Obesity, 21(3), 644-651. http://doi.org/10.1038/oby.2012.145 Lo, S.W., Chair, S. Y., & Lee, F. K. (2015). Factors associated with health-promoting behavior of people with or at high risk of metabolic syndrome: Based on the health belief model. Applied Nursing Research, 28, 197-201. Mayfield-Johnson, S., Young, R., Mohn, R.S., & Ebersole, R. (2012). Addressing chronic diseases in the Mississippi Delta through health education prevention. Education: Approaches to take absolute control through knowledge (ATTACK). Delta Journal of Education, 2(1), 1-13. Mendy, V. L., & Vargas, R. (2015). Trends in major risk factors for cardiovascular disease among adults in the Mississippi Delta region, Mississippi behavioral risk factor surveillance system, 20012010. Preventing Chronic Disease, 12(21), 1-8. http://doi.org/10.5888/pcd12.140481 Musavian, A.S., Pasha, A., Rahebi, S. M., Roushan, Z. A., & Ghanbari, A. (2014). Health promoting behaviors among adolescents: A cross-sectional study. Nursing and Midwifery Studies, 3(1), 1-7. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 48 Newsom, J. T., Huguet, N., McCarthy, M. J., Ramage-Morin, P., Kaplan, M. S., Bernier, J.,... Oderkirk, J. (2012). Health behavior change following chronic illness in middle and later life. The Journals of Gerontology, Series B: Psychological Sciences and Social Sciences, 67(3), 279-288. doi: 10.1093/geronb/gbr103 O'Donnell, M. P. (2009) Definition of health promotion 2.0: Embracing passion, enhancing motivation, recognizing dynamic balance, and creating opportunities. American Journal of Health Promotion, 24(1), iv-iv. doi: http://dx.doi.org/10.4278/ajhp.24.1.iv Pampel, F. C., Krueger, P. M., & Denney, J. T. (2010). Socioeconomic disparities in health behaviors. Annual Review of Sociology, 36, 349-370. doi: 10.1146/annurev. soc.012809.102529 Pender, N., Murdaugh, C., & Parson, M. A. (2011). Health promotion in nursing practice (6th ed.). Boston, MA: Pearson. Pizur-Barnekow, K., & Darragh, A. (2011). AOTA's societal statement on health literacy. Retrieved from http://www.aota.org/-/media/Corporate/Files/AboutAOTA/ OfficialDocs/SocietalStmts/Final%20Health%20Literacy%20Statement%2051611.pdf Reeves, R. R., Adams, C. E., Dubbert, P. M., Hickson, D. A., & Wyatt, S. B. (2012). Are religiosity and spirituality associated with obesity among African Americans in the Southeastern United States (the Jackson heart study)? Journal of Religion and Health, 51(1), 3248. http://doi.org/10.1007/s10943-011-9552-y Reingold, F. S., & Jordan, K. (2013). Obesity and occupational therapy. American Journal of Occupational Therapy, 67(6), 39-46. Reitz, S. M., & Scaffa, M.E. (2013). Occupational therapy in the promotion of health and well-being. American Journal of Occupational Therapy, 67(6), 47-59. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 49 Short, V. (2014). Report on the burden of chronic diseases in Mississippi, 2014. Retrieved from http://msdh.ms.gov/msdhsite/_static/resources/4775.pdf Stephens, J., Artiga, S., & Paradise, J. (2014). Health coverage and care in the south in 2014 and beyond. Retrieved from http://kff.org/disparities-policy/issue-brief/health-coverage-andcare-in-the-south-in-2014-and-beyond/ Tucker, C. M., Butler, A., Kaye, L. B., Nolan, S. E. M., Flenar, D. J., Marsiske, M.,Daly, K. (2014). Impact of a culturally sensitive health self-empowerment workshop series on health behaviors/lifestyles, BMI, and blood pressure of culturally diverse overweight/obese adults. American Journal of Lifestyle Medicine, 8(2), 122-132. doi:10.1177/1559827613503117 Tyszka, A.C., & Farber, R. S. (2010). Exploring the relation of health-promoting behaviors to role participation and health-related quality of life in women with multiple sclerosis: A pilot study. American Journal of Occupational Therapy, 64, 650-659. doi: 10.5014/ajot.2010.07121 U. S. Census Bureau (2015). 2011-2015 American Community Survey 5-Year Estimates. Retrieved from http://www.census.gov/search results.html?q=mississippi+ household+income&search.x=0&search.y=0&search=submit&page= 1&stateGeo=none&searchtype=web. U.S. Department of Health and Human Services. (2010). Healthy people 2020. Retrieved from http://www.healthypeople.gov/2020/About-Healthy-People HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 50 Walker, S. N., & Hill-Polerecky, D. M. (1996). Psychometric evaluation of the HealthPromoting Lifestyle Profile II. Unpublished manuscript, University of Nebraska Medical Center. Retrieved from http://www.unmc.edu/nursing/docs/HPLPII_ Abstract_Dimensions.pdf Winham, D. M., & Jones, K. M. (2011). Knowledge of young African American adults about heart disease: A cross-sectional survey. BMC Public Health, 11, 1-11. doi:10.1186/14712458-11-248 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 51 Table 1 Demographic and General Health Characteristics Characteristic Frequency Percentage Single 53 32.1 Married 85 51.5 Separated/Divorced/Widowed 23 13.9 Less than high school 12 7.3 High school diploma/ GED/ Associate's degree 59 35.8 Bachelor's degree or higher 87 52.7 Employed 129 78.2 Unemployed 15 9.1 Retired 16 9.7 African American 128 77.6 Non-African American 31 18.8 Normal/underweight 56 33.9 Overweight/obese 99 60.0 Marital status (N = 161) Education (N = 158) Employment (N = 160) Race/ethnicity (N = 159) Body mass index (N = 155) HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 52 Table 1 (continued) Demographic and General Health Characteristics Characteristic General Health (N = 162) Frequency Percentage Excellent 14 8.5 Very good 49 29.7 Good 75 45.5 Fair 15 9.1 Smoker (N = 162) 21 12.7 Alcohol use (N = 160) 44 26.7 None 55 33.3 1 52 31.5 2-3 49 29.7 4-5 9 5.5 Arthritis (N = 165) 26 15.8 Heart disease (N = 165) 11 6.7 High blood pressure (N = 165) 88 53.3 High cholesterol (N = 165) 34 20.6 Kidney disease (N = 165) 5 3.0 Stroke (N = 165) 4 2.4 Diabetes mellitus, type II (N = 165) 24 14.5 Chronic medical conditions (N = 165) HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 53 Table 2 Median Household Incomes of Participant Counties Order by Highest to Lowest Income County of Residency Mdn N (%) Rankin $57, 380 1 (.6) Shelby $46,250 2 (1.2) Panola $46,250 2 (1.2) Grenada $34,129 56 (33.9) Yalobusha $32,930 1(.6) Carroll $31,039 3 (1.8) Montgomery $30,466 10 (6.0) Bolivar $28,599 3 (1.8) Washington $28,093 14 (8.5) Sunflower $26,619 30 (18.2) Coahoma $26,407 1 (.6) Leflore $24,480 33 (20.0) Humphreys $23,600 6 (3.6) HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 54 Table 3 Descriptive statistics for the Health-Promoting Lifestyle Profile II (N = 157) Median IQR .59 Maximum Score 3.79 Minimum Score 1.17 2.51 Health responsibility 2.44 .78 4.00 1.00 Physical activity 2.00 1.00 3.88 1.00 Nutrition 2.33 .67 3.56 1.22 Spiritual growth 3.11 .78 4.00 1.33 Interpersonal relations 3.00 .78 4.00 1.33 Stress Management 2.37 .63 4.00 1.13 HPLP II (total) HPLP II (subscales) Note. IQR = interquartile range HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 55 Table 4 Regression analysis for the significant predictors of the HPLP II total scale 95% CI HPLP II total scale p (Constant) B SEB LL UL 2.54 .18 2.20 2.90 General health < .001 -.22 .04 -.29 -.15 Education < .001 .24 .05 .14 .34 Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 56 Table 5 Regression analysis for the significant predictors of health responsibility 95% CI Health responsibility p B SEB LL UL 2.50 .23 2.01 2.93 < .001 -.21 .05 -.30 -.12 .001 .23 .07 .09 .36 (Constant) General health Education Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 57 Table 6 Regression analysis for the significant predictors of physical activity 95% CI Physical activity p B SEB LL UL 2.86 .17 2.53 3.19 < .001 -.33 .06 -.44 -.22 .001 .40 .12 .20 .63 (Constant) General health Alcohol Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 58 Table 7 Regression analysis for the significant predictors of nutrition 95% CI Nutrition p (Constant) B SEB LL UL 2.40 .19 2.03 2.80 General health < .001 -.23 .04 -.30 -.15 Education < .001 .21 .06 .10 .32 Diabetes .016 .25 .10 .05 .44 Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 59 Table 8 Regression analysis for the significant predictors of spiritual growth 95% CI Spiritual growth p (Constant) B SEB LL UL 2.86 .24 2.39 3.34 General health < .001 -.22 .04 -.31 -.13 Education < .001 .30 .07 .16 .44 Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 60 Table 9 Regression analysis for the significant predictors of interpersonal relationships 95% CI Interpersonal relationships p B SEB LL UL 2.60 .24 2.11 3.05 .002 -.14 .05 -.23 -.05 < .001 .30 .07 .15 .44 .015 -.63 .30 -1.14 -.12 (Constant) General health Education Kidney disease Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 61 Table 10 Regression analysis for the significant predictors of stress management 95% CI Stress management p B SEB LL UL 2.60 .24 2.10 3.04 < .001 -.20 .05 -.30 -.11 .031 .16 .07 .02 .30 (Constant) General health Education Note: B = unstandardized regression coefficient; SEB = standard error of the coefficient; CI = confidence interval; LL = lower limit; UL = upper limit HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 62 Appendix A Research Volunteers Needed Research volunteers wanted for a research study examining the health-promoting behaviors among residents of the Mississippi Delta and Northwest Mississippi region. You may be eligible to participate if you are: at least 18 years of age an English-speaking resident of the Mississippi Delta and Northwest Mississippi region Benefits of participation: Participants may acquire an increased understanding of health-promoting behaviors. Results of the survey may help healthcare and public health professionals develop appropriate community health programs to reduce Mississippi's health disparities Participants will complete the 10-15 minutes survey online at: https://uindy.co1.qualtrics.com/jfe/preview/SV_e4luHqQFJQK7bGl All information will be kept confidential and will remain anonymous. Participants are free to withdraw from the study at any time without consequences. For more information, contact Veronica Johnson, at johnsonvh@uindy.edu or (662) 229-7673. This research study is being supervised by Jennifer Fogo, PhD, OTR, Associate Professor and Director, College of Health Sciences Postprofessional Programs University of Indianapolis. Please feel free to pass this important information along to others. Thank you in advance! HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 63 Appendix B August 27, 2015 Dear Sir/Madam: I am a graduate student seeking a Doctor of Health Science degree at the University of Indianapolis. As a component of my academic program, I am conducting a research project under the supervision of my faculty advisor, Jennifer Fogo, PhD, OTR. The purpose of this project is to assess the health-promoting behaviors among residents of the Mississippi Delta/Northwest Mississippi region. The results will provide information that can be used to enhance and/or develop health programs to facilitate healthy lifestyles. You are being asked to volunteer for this project because you are an English-speaking man or woman, at least18 years of age, and currently reside in the Mississippi Delta/Northwest Mississippi region. If you agree to participate in this project, please complete the enclosed survey and return it in the self-addressed, stamped envelope within 10 days. The survey should take no more than 10-15 minutes to complete. Completion and submission of the survey will be considered your consent to participate in this research project; however, you are free to withdraw from the project for any reason and at any time without consequences. You are not required to answer any question(s) which make you feel uncomfortable. You may simply move on to the next question. Please do not include your name on the survey. All survey and resulting information will therefore be anonymous, and data will remain confidential. The University of Indianapolis' Institutional Review Board (IRB) has reviewed this project for approval. You may discuss your rights as a participant with Dr. Greg Manship, coordinator of the University of Indianapolis' Institutional Review Board, 1400 East Hanna Avenue, Indianapolis, Indiana 46227; phone (317) 781-5774. If you have any questions or concerns please contact my faculty advisor, Dr. Jennifer Fogo at (317) 788-3513 or email at jfogo@uindy.edu. To request a copy of the research results, please contact me at johnsonvh@uindy.edu or (662) 229-7673. If you have questions or concerns about this study or your participation, you may contact Veronica Johnson using the contact information above. HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI Thank you in advance for your time and assistance in helping me to complete my research project. Sincerely, Veronica H. Johnson Veronica H. Johnson, MS, OTR/L, CLT 64 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 65 Appendix C ID #____________ Health-Promoting Behaviors Demographics Information Demographics (Please mark the appropriate boxes.) 1. Residency: County of ______________________________ 2. Age (in years): ________________ 3. Marital status: Single Married Separated Divorced Widowed Less than high school diploma or GED High school diploma 4. Education: or GED Associate's degree Bachelor's degree Graduate degree 5. Employment: Full-time 6. Race/ethnicity: African American/Black Caucasian/White Part-time Unemployed Retired Asian/Pacific Islander Hispanic/Latino American Indian/Alaskan Natives 7. Gender: Male Female 8. General health: Excellent Very good 9. Body Mass Index (BMI) (see attached chart): Underweight Obese 10. Smoker: Yes Good Normal weight Fair Poor Overweight Extremely Obese No (skip to alcohol consumption) On average, how many cigarettes do you smoke in a day? ______ HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 11. Alcohol consumption: 66 Yes No (skip to Has a doctor ever diagnosed you with...). On average, how many alcoholic drinks do you have in a week? ______ 12. Has a doctor ever diagnosed you with any of the following medical conditions ? (Check all that apply.) Arthritis (rheumatoid arthritis, osteoarthritis), gout, lupus, fibromyalgia Heart disease High blood pressure High cholesterol Kidney disease Stroke Type 2 diabetes (high blood glucose/sugar) None of the above Other: _____________________________________________________________ HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI Appendix D Mississippi State Department of Health's Body Mass Index (BMI) Chart BMI: 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Height Weight (pounds) 4'10" (58") 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 4'11" (59") 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 5' (60") 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 5'1" (61") 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185 5'2" (62") 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 5'3" (63") 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 5'4" (64") 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 5'5" (65") 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210 5'6" (66") 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 5'7" (67") 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 5'8" (68") 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230 5'9" (69") 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 5'10" (70") 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 5'11" (71") 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 6' (72") 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258 6'1" (73") 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 6'2' (74") 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 6'3' (75") 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279 BMI Weight Status < 19 Underweight 19 - 24 Normal weight 25 - 29 Overweight 30 + Obese 40 + Extremely Obese 67 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI Appendix E 68 HEALTH BEHAVIORS OF RESIDENTS OF MISSISSIPPI 69  ...

... EMERGENCY SKILLS IN ATHLETIC TRAINING: PERCEIVED KNOWLEDGE AND CONTINUING EDUCATION Submitted to the Faculty of the College of Health Sciences University of Indianapolis In partial fulfillment of the requirements for the degree Doctor of Health Science By: Brian Gerlach, MS, ATC, CSCS Copyright June 25, 2020 By: Brian Gerlach, MS, ATC, CSCS All rights reserved Approved by: Paul Salamh, Ph.D. Committee Chair __________________________________________ Jessica Jochum, Ph.D. Committee Member __________________________________________ Elizabeth S. Moore, Ph.D. Committee Member __________________________________________ Accepted by: Laura Santurri, PhD, MPH, CPH Director, DHSc Program Chair, Interprofessional Health & Aging Studies University of Indianapolis __________________________________________ Stephanie Kelly, PT, PhD Dean, College of Health Sciences University of Indianapolis __________________________________________ Running Head: EMERGENCY SKILLS IN ATHLETIC TRAINING Emergency Skills in Athletic Training: Perceived Knowledge and Continuing Education Brian Gerlach University of Indianapolis 1 2 Abstract Continuing education (CE) in healthcare, particularly in athletic training, often fails to meet the needs of its participants. Rapid increases in available information make it necessary for CE to be delivered as efficiently as possible. The purpose of this study was to explore whether an interactive teaching strategy and various characteristics of athletic trainers affected the perceived knowledge of emergency skills among certified athletic trainers. The quasi-experimental study used a single group pretest-posttest design. Participants were recruited and data was collected from certified athletic trainers (N = 81) at the Great Lakes Athletic Trainers Association Annual Meeting and Symposium. Participants completed a pre-intervention perceived knowledge questionnaire (PKQ) which included background information questions. They then participated in an emergency skills practice session for anaphylaxis, opioid overdose, diabetes, and asthma and completed a posttest PKQ. A statistically significant difference (p < .001) in PKQ scores from pretest to posttest was found with pretest scores being lower than posttest scores (89.59, 103.02) respectively. Age and years of experience had a weak correlation with PKQ pretest scores (rs = .32 and rs = .33, respectively). Participant characteristics including additional certification (p = .012), anaphylaxis experience (p = .036), opioid overdose experience (p < .001), diabetes experience (p = .025) and combined emergency experience (p = .029) had significantly different pretest PKQ scores. The use of an interactive teaching strategy in CE and certain athletic trainer characteristics significantly affected athletic trainers perceived knowledge of emergency skills. Keywords: Athletic training, continuing education, emergency skills, perceived knowledge 3 Acknowledgements The UIndy Doctor of Health Science program has had a tremendous impact on my life and the way I view many of the world events happening around us in these unprecedented and difficult times. It is impossible for me to appropriately express my gratitude for all of the faculty and staff who have provided support to my classmates and me over the past three years. To my wife Kyleigh, and my children Beckett and Kaylin. Thank you for your constant love, encouragement and patience. Completing this program would not have been possible without your unwavering support. To my classmates and group project partners Jenny Wiley, Molly Jennings, and especially my research assistant, Taylor Arman. The past three years of coursework challenged us in ways we could not have anticipated. Your work ethic, knowledge and integrity has inspired me throughout our coursework together. I appreciate your support and dedication throughout the program, but I am even more grateful for your friendships. To my committee members, Dr. Elizabeth Moore, Dr. Jessica Jochum, and Dr. Paul Salamh. I appreciate your reassurance through the development process, and your detailed, honest and encouraging feedback. I cannot thank you all enough for the time and energy that you put into this project. I have the utmost respect for each of you, and I hope I made you proud. 4 Table of Contents Introduction ..................................................................................................................................... 6 Significance................................................................................................................................. 7 Literature Review ........................................................................................................................... 8 Continuing Education Models .................................................................................................... 8 Adult Learning Theory and Continuing Education .................................................................. 10 Perceived and Actual Knowledge ............................................................................................. 11 Competency-Based Education .................................................................................................. 12 Athletic Trainer Preferences and Characteristics ...................................................................... 14 Method .......................................................................................................................................... 15 Study Design ............................................................................................................................. 15 Participants ................................................................................................................................ 15 Data ........................................................................................................................................... 16 Instrument ................................................................................................................................. 17 Perceived Knowledge Questionnaire. ................................................................................... 17 Procedures ................................................................................................................................. 18 Recruitment. .............................................................................................................................. 18 Informed consent. ................................................................................................................. 19 Incentives. ............................................................................................................................. 19 Data collection. ......................................................................Error! Bookmark not defined. Intervention. .......................................................................................................................... 20 Data management.................................................................................................................. 20 Data Analysis ............................................................................................................................ 21 Results ........................................................................................................................................... 22 Two-By-Two Mixed ANOVA .................................................................................................. 23 Additional certification. ........................................................................................................ 23 Anaphylaxis experience. ....................................................................................................... 24 Diabetes experience. ............................................................................................................. 25 Asthma experience. ............................................................................................................... 25 Overall emergency experience. ............................................................................................. 26 Opioid Overdose. .................................................................................................................. 26 Job Settings. .......................................................................................................................... 27 5 Discussion ..................................................................................................................................... 28 Clinical Skills Practice and PKQ .............................................................................................. 29 Adult learning theory. ........................................................................................................... 30 Participant Characteristics and PKQ......................................................................................... 31 Age and Years of experience. ............................................................................................... 31 Professional certifications. .................................................................................................... 32 Emergency experiences. ....................................................................................................... 33 Limitations ................................................................................................................................ 36 Implications for Future Research and Continuing Education ................................................... 37 Conclusion ................................................................................................................................ 38 References ..................................................................................................................................... 39 Table 1 .......................................................................................................................................... 44 Table 2 .......................................................................................................................................... 46 Appendix A ................................................................................................................................... 47 Appendix B ................................................................................................................................... 49 Appendix C ................................................................................................................................... 50 Appendix D ................................................................................................................................... 51 6 Emergency Skills in Athletic Training: Perceived Knowledge and Continuing Education Continuing education (CE) is required by credentialing agencies for health care professionals such as physical therapists, nurses, physicians, and athletic trainers in order to maintain skills, knowledge, and certifications (Doherty-Restrepo, Hughes, Del, & Pitney, 2009; Forsetlund et al., 2009; Neil, Eberman, Games, & Kahanov, 2018). In order to stay current in their profession and to maintain certification athletic trainers must participate in 50 hours of CE activities every two years (Board of Certification [BOC], 2018). However, it can be difficult for athletic trainers to maintain their knowledge and skills when the amount of materials available to them nearly doubles every 18 months (BOC, 2018). The exponential growth of information available to athletic trainers creates a need for CE to be delivered in an efficient and effective manner (BOC, 2018; Institute of Medicine, 2010). Despite the requirement for athletic trainers to maintain their knowledge and skills in order to remain certified, many CE opportunities offered fail to meet the needs of attendees in several aspects such as perceived benefits, implementation into clinical practice (Edler & Eberman, 2019), and overall efficacy and feasibility of the activity (Armstrong & Weidner, 2011). Currently, CE opportunities in athletic training use teaching strategies that are considered to be either passive or interactive (Armstrong & Weidner, 2010). Athletic trainers report gaining greater knowledge through passive teaching strategies such as lecture-based programs, while experiencing greater skill development and implementation to clinical practice through interactive activities (Armstrong & Weidner, 2010). Athletic trainers over-perception and under-perception regarding their knowledge of emergency skills can cause lack of competency in performing a skill, and or an unwillingness to utilize a specific skill in a critical situation (Edler & Eberman, 2015). A knowledge gap is 7 demonstrated by a difference in the athletic trainers perception of his or her knowledge compared to their actual knowledge of the same content or skills (Eberman & Tripp, 2011) and athletic trainers have been shown to display significant knowledge gaps, particularly with emergency skills (Edler, Eberman, Kahanov, Roman & Mata, 2015; Neil et al., 2018). Multiple studies have indicated that athletic trainers often overestimate their competence with emergency management skills (Edler et al., 2015; Neil et al., 2018) making it important to understand how CE effects athletic trainers perceived knowledge of emergency skills. The primary purpose of this study was to explore the effect an interactive teaching strategy used in a CE activity may have on perceived knowledge of emergency skills among certified athletic trainers. A secondary aim of the study was to see if there was a relationship between athletic trainer characteristics and perceived knowledge of emergency skills among certified athletic trainers. The study will address the following objectives: 1. To determine if there is a statistically significant difference in perceived knowledge of certified athletic trainers emergency skills after participating in an interactive, hands-on CE activity. 2. To determine if certified athletic trainers perceived knowledge of emergency skills is related to their demographic characteristics. Significance This study adds to available research by providing unique insights through investigating perceived knowledge before and after an interactive CE activity. This research design investigating perceived knowledge has not been used in the current literature with a CE activity as the intervention. The study provides information for CE programmers to guide the development of future CE activities, as well as provide insight to the athletic trainers comfort 8 level with implementing the skills completed during the CE activity into clinical practice. This study also provides information for potential marketing strategies for CE programmers to identify individuals who may have varying levels of perceived knowledge and not feel the need for CE in emergency management. Literature Review The Institute of Medicine (2010) stated that healthcare CE as a whole does not provide consistent and adequate support to healthcare professionals. In athletic training specifically, available research on CE is limited. Researchers have investigated the effectiveness of various CE models (Armstrong & Weidner, 2011; Doherty-Restrepo et al., 2009; Frank et al., 2020; Pitney, 1997), athletic trainers preferences for CE activities (Armstrong & Weidner, 2010; Armstrong & Weidner, 2011; Edler & Eberman, 2019), effect of perceived knowledge on performance (Neil et al., 2018), gaps between perceived and actual knowledge (Eberman & Tripp, 2011; Edler et al., 2015;), and implementation of adult learning theory in CE activities (Doherty-Restrepo et al., 2009; Frank et al., 2020; Pitney, 1997). While this is a broad range of topics discussed in the literature, the quantity of studies on each specific topic is limited. Therefore, it is valuable to consider the landscape of CE research of other allied health professionals, such as physical therapists, occupational therapists, nurses, and physicians. It is also important to discuss how athletic training educational competencies influence the athletic training knowledge base, the need for effective CE (National Athletic Trainers Association [NATA], 2011) and how the implementation of adult learning theory, or lack thereof, impacts CE development and effectiveness (Doherty-Restrepo et al., 2009; Pitney, 1997; Samdperil, 2012). Continuing Education Models 9 Various models of CE are used throughout athletic training and other allied health professions such as physical therapists, occupational therapists, nurses, and physicians. (Forsetlund et al., 2009). Existing studies have separated athletic training CE into various categories: formal and informal activities (Armstrong & Weidner, 2010, 2011), continuing professional education (Doherty-Restrepo, Hughes, Del Rossi & Pitney, 2009), and continuing professional development (Samdperil, 2012). Continuing professional education and continuing professional development are forms of CE discussed in literature which more commonly place an emphasis on adult learning theory as their foundation, and are more often comprised of informal CE activities (Armstrong & Weidner, 2010; Doherty-Restrepo et al., 2009; Samdperil, 2012). In athletic training, Armstrong and Weidner (2010) described formal CE activities as those approved for BOC credit and include small group activities and lectures which were instructor-centered and largely passive for the participants. Informal CE activities, not approved for CE credit for athletic trainers, include reading journal articles, serving as a clinical instructor for athletic training students, and mentoring (Armstrong & Weidner, 2010). Traditional, formal CE activities in healthcare are often teacher-centered lecture presentations (McLeod, 2004). Several researchers have investigated effects of formal and informal CE activities in athletic training and other healthcare professions. Armstrong and Weidner (2010) found that both formal and informal CE positively impacted athletic trainers practice. Athletic trainers perceived formal CE as having the greatest impact on knowledge, while informal CE was thought to have the greatest impact on clinical skills (Armstrong & Weidner, 2010). Most recently, Frank et al. (2020) demonstrated a significant increase in knowledge and skill development before and after two separate types of interactive CE activities. The study found that an in-person, interactive CE activity improved heart sound auscultation skills greater than the computer-based activity and 10 that these interactive opportunities achieved greater results than a formal, lecture-based CE course (Frank et al., 2020). Research among healthcare professionals other than athletic training, such as physical therapists, nurses (Bahn, 2007; Forsetlund et al., 2009), occupational therapists (Andersen, 2001), and physicians (Forsetlund et al., 2009) have demonstrated similar findings. Occupational therapists reported that informal CE activities had a greater impact on clinical skills than formal CE (Andersen, 2001), while Bahn (2007) found that athletic trainers and nurses perceived informal CE as having improved patient care more than formal CE. A systematic review of nursing, physical therapy and physician CE by Forsetlund et al. (2009) found that a combination of didactic and interactive activities improved effectiveness of CE. Adult Learning Theory and Continuing Education Adult learning theory suggests that recognizing a knowledge deficit, or gap, prior to a learning activity can increase participants effort (Knowles, 2011). Conversely, not understanding or recognizing that a gap exists, especially with respect to emergency skills, can put patients at risk (Edler et al., 2015). The gap between athletic trainers perceived and actual knowledge of rarely used skills, particularly emergency skills, highlights a need for improved CE techniques. A variety of studies indicate that the incorporation of adult learning theory can have a positive effect on CE by including activities that are a self-directed, learner-centered, interactive experience, rather than passive and instructor-centered activities (Pitney, 1997; Sampdperil, 2012). The concepts of adult learning theory are often not incorporated into formal CE, which typically consists of lecture activities with little to no interaction by participants (Armstong & Weidner, 2010; McLeod, 2004). Davis et al. (1999) suggested that interactive techniques better align with adult learning theory, and should be incorporated into the CE 11 activities. This was further supported by study results presented by Forsetlund et al. (2009) that found adding an interactive component to CE activity increased effectiveness in nursing, physical therapy, and medicine. Previously, Davis (1998) also found that a combination of interactive and lecture in CE delivery for physicians significantly improved clinical performance. Doherty-Restrepo (2009) suggested that athletic training CE activities that do not incorporate adult learning theory may inhibit participants from effectively incorporating topics into clinical practice. Perceived and Actual Knowledge Despite efforts through various models of CE programming to keep healthcare providers up-to-date on skills and knowledge, gaps exist in providers perceived knowledge and actual knowledge (Edler et al. 2015; Neil et al., 2018). Regardless of whether a study is investigating perceived knowledge, actual knowledge, or both, it is important to discuss the existing research regarding actual knowledge and knowledge gaps as well as the relationship between these two concepts (Eberman & Tripp, 2011; Edler et al., 2015; Neil et al., 2018). Edler et al. (2015) found a weak relationship between perceived and actual knowledge in athletic trainers emergency skills, suggesting overconfidence among athletic trainers may likely lead to improper administration of emergency skills. The lack of awareness of the presence of a knowledge gap may create a barrier to athletic trainers seeking out CE opportunities (Edler et al., 2015). In addition, it may increase the potential for clinician incompetence, which can have dangerous implications in emergency situations (Edler et al., 2015). These findings are consistent with Neil et al. (2018) who found clinicians were unable to accurately depict their actual knowledge. Eberman and Tripp (2011) also found that actual knowledge and perceived knowledge were poorly correlated and noted that the gap between them was strongly correlated to posttest 12 perceived knowledge and knowledge gap among athletic trainers. In a qualitative study, Edler and Eberman (2019) found that athletic trainers were confident about their knowledge following a CE session and had varying degrees of confidence in performing skills based on level of previous knowledge. Reported within the existing literature is a consistent finding that athletic trainers have low awareness of their lack of knowledge with certain rarely used skills, such as the use of airway adjuncts and managing a spine-injured athlete (Edler et al., 2015, Neil et al., 2018). Frank et al (2020) did not assess perceived knowledge, but found that athletic trainers actual knowledge of heart sound auscultation and ability to complete a comprehensive cardiovascular assessment was poor, noting the infrequent use of these skills as one potential explanation. It is important that researchers continue to explore the most effective means of educating professional athletic trainers on skills which are rarely employed but vital to patient welfare, specifically emergency care skills, (Edler et al., 2015, Neil et al., 2018). Competency-Based Education Athletic training education is based on specific competencies set forth by the NATA which were updated in 2011 to include skills such as emergency management, specifically the treatment of at-risk athletes with conditions such as diabetes and asthma (NATA, 2011). Maehle et al. (2017) indicated that professions whose initial level of education has expanded to cover a wider range of topics are at greater risk of skill decay. Frank et al. (2020) noted that a factor in athletic trainers particularly low pretest scores of heart sound auscultation was participants never having learned the skills during their professional education. The implementation of other athletic training skills also face this dilemma. Athletic trainers who completed previous versions of competency-based education did not learn emergency skills, such as asthma and diabetes that 13 they currently need while athletic trainers who were educated under the most recent competencies have been educated on needed emergency skills (NATA, 2011). Therefore, it could be suggested that athletic trainers who have completed educational competencies more recently, would be more confident and knowledgeable about these emergency skills than athletic trainers who did not receive this formal education. Expanded educational competencies (NATA, 2011) and CE initiatives for athletic trainers are aimed at reducing knowledge gaps, specifically with regards to emergency skills (Edler et al., 2015). Athletic trainers should have the knowledge to manage various scenarios, but the frequency of actual use of these skills is low (Neil et al., 2018). This study focused on the perceived knowledge of four specific emergency skills: management of anaphylaxis, management of a diabetic emergency, management of an asthmatic emergency, and management of an opioid overdose scenario. Several researches studied athletic trainers role in emergency management of diabetes and asthma (Casa et al., 2012; Conley et al., 2012; Jiminez, 1997; Jiminez et al., 2007; MacKnight et al., 2009; Miller et al., 2005). In addition to addressing specific conditions, these studies include NATA position statements on general prevention of sudden death (Casa et al., 2012) and recognition of disqualifying conditions for athletes (Conley et al., 2014). To date, no studies have connected athletic training and emergency situations involving opioid overdose or anaphylaxis. There are numerous factors that influence preference for CE in athletic training. Athletic trainers prefer CE opportunities that are grounded in adult learning theory principles, have the opportunity to impact clinical abilities, and are interactive in nature (Armstrong & Weidner, 2010). The literature also indicates that athletic trainers overestimate their knowledge in certain areas. Currently, no researchers have investigated the effect of an interactive CE opportunity on 14 perceived knowledge, and little is known about whether athletic trainers characteristics effect their perceived knowledge of emergency skills. This study sought to contribute to the current literature by investigating a variety of factors within athletic training CE. It investigated perceived knowledge after an interactive CE activity, and examine how athletic trainers age, years of experience, job setting, additional certifications, and actual emergency experience with each of the four skills discussed, shaped their perceived knowledge. The study will provide information for CE programmers to guide the development of future CE activities, as well as provide insight into athletic trainers comfort level with implementing skills completed during the CE activity into clinical practice. Athletic Trainer Preferences and Characteristics Athletic trainers prefer to attend and participate in activities which are practical in nature, consequently aligning with adult learning theory principles (Armstrong & Weidner, 2010; Doherty-Restrepo, 2009). Armstrong and Weidner (2010, 2011) found that athletic trainers participated in informal CE activities more often than formal CE, but preferred formal activities due to the ability to receive credit. Within the category of formal CE, hands-on workshops were preferred but less commonly offered, and were perceived as having the greatest benefit to clinical skills (Armstrong & Weidner, 2010, 2011). Doherty-Restrepo et al. (2009) discussed the need for more athletic training CE opportunities that incorporate workshops and interactive programs, suggesting that athletic trainers perceived these activities as having the greatest practical applications. These findings are consistent in physical therapy and nursing indicating that hands-on CE activities were preferred by professionals and more effective than traditional seminar and lecture formats (Chau et al., 2012; Draganov et al., 2013). 15 Existing studies on perceived knowledge of emergency skills have not reported the presence of a relationship between reported perceived knowledge and health professional characteristics. Neil et al. (2018) reported the frequency of performing emergency skills experience for athletic trainers, emergency medical technicians, and dual credentialed providers, but they did not discuss the effects of characteristics on perceived knowledge. Armstrong and Weidner (2010) found that demographic data had no significant effect on the perceived effectiveness of formal or informal CE activities. Edler et al. (2015) found no significant difference between years of experience and actual knowledge of adjunct airway administration. These findings suggest that there is a gap in the existing literature regarding the influence of years of experience, job setting, and emergency experience on perceived knowledge of emergency skills. Method Study Design This was a quasi-experimental study using a single group pretest-posttest design. The study, conducted in March 2020, evaluated athletic trainers perceived knowledge of emergency management skills after participating in an interactive CE activity. Prior to the start of participant recruitment, the study was approved by the University of Indianapolis Human Research Protections Program (Minimal risk study # 01218; approved March 2, 2020). Participants A convenience sample of certified athletic trainers was recruited at the Great Lakes Athletic Trainers Association (GLATA) Annual Meeting and Symposium in Wheeling, IL. This event was a networking and CE opportunity for certified athletic trainers and athletic training students (GLATA, 2019). During the GLATA symposium, there was an interactive lab during 16 which athletic trainers were given the opportunity to learn and practice emergency skills. To be included in the study an individual had to be an athletic trainer with up-to-date certification (selfreported), an attendee at the GLATA Annual Meeting and Symposium, and a participant in the skills lab offered during the GLATA Annual Meeting and Symposium. The following individuals were excluded from the study: athletic training students, certified athletic trainers attending the conference as vendors or marketers, athletic trainers who were retired or not practicing, and members of the GLATA Education Committee. To estimate the minimum sample size required to sufficiently power the study, G*Power 3.1 (Faul et al., 2009), was used. Based on conducting a paired t test to compare pretest Perceived Knowledge Questionnaire (PKQ) scores to posttest PKQ scores with an alpha of .05, effect size of .40, and power of .80, a minimum sample size of 52 total participants was required. To account for possible attrition, the minimum sample size was increased by 20% for a final minimum total sample size of 62. The effect size used for this study was based on previous studies utilizing a pretest and posttest PKQ scores. Eberman and Tripp (2011) reported an effect size of .45, based on a sample of 103 and Neil et al. (2018) reported an effect size of .64 based on a sample size of 726. For this study, a lower effect size of .40 was selected to be more conservative due to the smaller possible sample size. Data Collection Prior to data collection, participants were provided information about the study through an informed consent question in the survey (Appendix A). Participants were then given the option of giving consent, or opting out of the study. Demographic information, participant characteristics, and perceived knowledge were collected in Qualtrics via computer, tablet, or smartphone. Participants who completed the surveys on their personal devices accessed the 17 survey page by scanning a quick response (QR) code or entering the website link. Researchers also had tablets with the surveys pre-loaded and available for participants who chose not to complete the surveys on their own device. After participants completed the pretest survey, they attended the skills lab at their scheduled time, or on a walk-in basis. As participants exited the emergency skills lab, they had the opportunity to complete the posttest survey on a tablet or their own smartphone. Two hours following the end of the skills lab, participants were reminded via email to complete the posttest if they failed to complete it immediately at the conclusion of the intervention. Pretest and posttest surveys were linked by participant email addresses. The link to the posttest remained active for 12 hours following the clinical lab skills practice session. Demographic and participant characteristics collected included age, years of experience, job setting, additional professional certifications, and self-reported actual clinical emergency experience with each of the four emergency skills: anaphylaxis, opioid overdose, diabetes and asthma (collected as four separate yes or no answers). Perceived knowledge was operationalized as the total score received on the PKQ. Participant email addresses, demographics, participant characteristics, and the pretest PKQ were collected at the same time, prior to the skills lab at the time of recruitment. At the end of the emergency skills lab, the posttest PKQ was collected. Demographic information, participant characteristics, and both pretest and posttest PKQ were collected using Qualtrics software (Qualtrics, Provo, UT), an online survey platform. Instrument Perceived Knowledge Questionnaire. The PKQ used in this study (Appendix B) was a 20-item self-reported measure in which the items are scored on a seven-point Likert-like scale. The instrument is a variation of the subjective knowledge assessment tool which is designed to 18 be interchangeable between constructs and disciplines (Flynn & Goldsmith, 1999). Flynn and Goldsmith (1999) completed five studies in their development of the subjective knowledge assessment tool, demonstrating internal consistency (Cronbachs alpha = .88 - .92), test retest reliability (r = .79), criterion validity (r = .25), and construct reliability (r = .87-.93). The five studies that yielded these psychometric properties included several different constructs and content, expanding the generalizability of the instrument (Flynn & Goldsmith, 1999). These unique properties allowed the researchers of this study to insert the four emergency conditions as the content to be evaluated by the PKQ. In athletic training, Flynn and Goldsmiths (1999) subjective knowledge assessment tool had been adapted by three previous studies to fit their content. Neil et al. (2018) used the instrument to demonstrate perceived knowledge of managing the spine injured athlete. Edler et al. (2015) implemented the tool to assess athletic trainers knowledge of airway adjuncts; and Eberman and Tripp (2011) adapted the instrument to assess perceived knowledge of recognition, treatment, and management of exertional muscle cramping. Procedures Recruitment. Recruitment of participants began four days prior to the GLATA Annual meeting and the start of the emergency skills lab on the morning of March 12, 2020. Attendees of the meeting were asked to participate in the study if they intended to participate in the skills lab. 1) Individuals who signed up for the skills lab prior to the GLATA meeting were contacted via email (Appendix C) informing them of the intentions of the study and giving them the opportunity to begin their participation immediately via a link to the Qualtrics pretest survey. Emails were sent to potential participants on Sunday, March 8 and Tuesday, 19 March 10. The list of registrants and their email addresses were provided by the GLATA Education Committee. 2) The primary researcher (B. G.) and a research assistant recruited participants upon registration/check-in at the GLATA annual meeting on Wednesday, March 11. An easel displaying the survey flier (Appendix D), along with the survey QR code and website link, along with information about the study, was set-up adjacent to the registration area, where participants will be informed about the study and asked if they are interested in participating. Researchers also had tablets available with consent and surveys preloaded. 3) Prior to the start of the emergency skills lab activity, there was a one-hour lecture, entitled Clinical Skills Primer, which prepared registrants for the interactive session. The researcher and research assistant verbally recruited participants for the study before and after the Clinical Skills Primer, and throughout the day at the entrance to the skills lab activity. An additional easel with the study flier was situated at the entrance/exit of the skills lab, so that participants could easily scan the QR code with their personal devices if they chose not to use the provided tablets. Informed consent. Conference attendees who indicated interest in participating in the study, were provided a link to the online survey. The first page of the survey was the informed consent form (Appendix D). To complete the survey, potential participants read the informed consent and indicated their consent. Failure to provide consent did not allow participants to continue with the survey. Incentives. Participation in the study was incentivized by offering participants the option to be entered in a drawing to win one of four $25 Amazon gift cards. Attendees willing to participate in the study had the option following the posttest survey to indicate whether they 20 wanted to be included in the drawing. The drawing took place at the completion of the study, and winners were notified via email. Gift cards were emailed directly to the winners following email correspondence. Intervention. The GLATA Emergency Skills Lab was developed and administered by the GLATA Education Committee. The researchers of this study were not involved in the development or administration of the skills lab. The lab was conducted from approximately 10:00 a.m. to 5:00 p.m. on March 12, 2020, and each participant spent approximately 45 minutes participating in four emergency skills stations: asthma, anaphylaxis, opioid overdose and diabetes. Each station was overseen by an expert in the field of the specific emergency skill management. Participants received an overview and review of the skill, and were provided with the opportunity to practice the skill under supervision. They repeated this process for each of the four skill stations. The asthma station focused on signs and symptoms of an asthmatic emergency and the use of a peak flow meter, or how to use a toilet paper roll or similar item to substitute for a peak flow meter. The anaphylaxis station focused on the use of an Epi-Pen. The diabetes station allowed participants to practice using a glucometer. The opioid overdose station focused on the use of intramuscular and intranasal Naloxone, or Narcan, administration to treat victims of an opioid overdose. Upon completion of the skills lab the posttest PKQ was completed. Data management. Data were housed in the cloud-based University of Indianapolis (UIndy) Google shared drive on a secured server. Access to the UIndy Google suite is only available to UIndy employees and students, and only researchers for this study had access to the secured data. Data are securely stored and will be retained for a period of 3 years (Lin, 2009), at 21 which point it will be permanently deleted. Data were housed on a UIndy owned laptop with a secure login required to access data. Data Analysis Data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY). Descriptive statistics were used to describe the sample and PKQ results. All comparisons were two-tailed and an alpha level less than .05 was considered to be statistically significant. Nominal data (job setting, and additional certifications, emergency experience) were presented as frequencies and percentages while normally distributed interval data (pretest and posttest PKQ scores) were reported as means and standard deviations and non-normally distributed ratio data (age, years of experience) were reported as medians and interquartile ranges. The Shapiro-Wilk test was used to determine normality of the data and the Levenes test was used to determine if there is equality of variance between groups for normally distributed interval and ratio data. To determine if there was a statistically significant difference in PKQ scores from pretest to posttest, a paired t test was conducted. To determine if there were differences or correlations with pretest PKQ scores by participant demographics and characteristics, independent t-tests, Mann-Whitney U tests, one-way ANOVA, and Spearman rho correlation tests were conducted, as appropriate. The interpretation of correlation coefficients was r = 0 - .25 - little or no relationship; r = .25 - .50 - fair relationship; r = .50 - .75 - moderate-to-good relationship; and r > .75 - good-to-excellent relationship (Portney & Watkins, 2015). In addition, a two-by-two mixed design ANOVA was used to determine if there was an interaction between change in PKQ scores over time (pretest to posttest) and additional certifications, and between job setting and emergency experience groups. As needed, pairwise post hoc tests were used with the Bonferroni 22 multiple comparison adjustment. Effect sizes were calculated and interpreted based on recommendations of Cohen (1992). Due to low responses in the categories of two variables, professional certifications other than athletic training and job setting, some of the categories were collapsed. Responses to whether a participant held professional certifications other than athletic training were collapsed into yes or no categories. Job setting responses were collapsed into three groups: athletics (consisting of responses college athletics and secondary school), academia (consisting of responses college academics and college dual appointment), clinical and outpatient (consisting of responses public safety, administrative/rehab, occupational health, and physician practice). To determine if there was a difference in pretest PKQ scores between those who had any actual emergency experience and those who had none, a new variable emergency experience (yes/no) was created. Individuals who responded yes to at least one of the four emergency skills were categorized as having emergency experience while those who responded no to all four of the emergency skills were categorized as not having any emergency skills. Results Eighty-two individuals completed the study. One participant answered strongly agree for all responses whether positively and negatively worded; therefore, data from that participant were removed from analysis. Based on 81 participants, the median age (interquartile range) was 33.00 (15.00) years and median years of experience was 10.00 (14.00) years. Pretest PKQ scores had a mean of 89.59 (17.84) and posttest PKQ scores had a mean of 103.02 (16.08). Frequencies and percentages for job setting, each of the four emergency experiences, and overall emergency experience are displayed in Table 1. 23 To address the first objective of the study, pretest PKQ total scores were compared to posttest PKQ total scores. The difference between mean pretest scores, 89.59 (17.84), and mean posttest scores, 103.02 (16.08), were statistically significant t(80) = -8.62, p < .001,) with a moderate correlation (r =.66). The statistically significant mean difference of 13.43 and a large effect size (d = 0.91) indicate that participants PKQ scores were significantly higher following the clinical skills practice session. To address the secondary study objective, pretest PKQ total scores were compared to each of the demographic and professional characteristics that were collected. There was a fair relationship between age and pretest PKQ scores (rs =.32; p =.004) and between years of experience and pretest PKQ scores (rs =.33; p = .003). Independent t-test results for participant background information and each of the four emergency experiences are displayed in Table 2. A one-way ANOVA indicated that whether an athletic trainer was employed in an athletic, clinical, or academic job setting, there was not a statistically significant difference in pretest PKQ scores, F(2, 77) = 2.27, p = .110. Two-By-Two Mixed ANOVA For the following two-by-two mixed ANOVA results, tests of assumptions were met. There were no outliers, as assessed by a boxplot. Data were normally distributed as assessed by a Shapiro-Wilk test (p > .05). There was homogeneity of variances (p > .05) and covariances (p > .05) as assessed by Levenes test of homogeneity and variances and Boxs M test. Additional certification. There was no statistically significant interaction between additional certification and PKQ scores from pretest to posttest, F(1, 79) = 2.28, p = .135, partial 2= 0.03. The main effect of time showed a statistically significant difference in mean PKQ scores at pretest and posttest, F(1 79) = 53.56, p < .001, partial 2 = 0.40. The mean (standard 24 error) posttest PKQ score of 104.49 indicated that study participants had significantly higher PKQ scores after the CE activity compared to the mean pretest PKQ score of 92.09. The partial eta squared showed a large effect size. The main effect of group showed there was a statistically significant difference in mean PKQ scores between participants with and without additional professional certifications F(1, 79) = 7.23, p < .001, partial 2= 0.08. Participants with additional certifications, with a mean PKQ score of 13.17, had higher PKQ scores compared to the mean PKQ score of 93.42 for participants without additional certifications. Results indicate that study participants who had additional certifications had significantly higher perceived knowledge of emergency skills compared to study participants without additional certifications. However, both groups had significant improvement in PKQ scores from pretest to posttest. The partial eta squared showed a small effect size. Anaphylaxis experience. There was no statistically significant interaction between additional certification and PKQ scores from pretest to posttest, F(1, 79) = 0.08, p = .785, partial 2= .001. The main effect of time showed a statistically significant difference in mean PKQ scores at pretest and posttest, F(1 79) = 42.05, p < .001, partial 2= 0.35. The mean posttest PKQ score of 106.03 indicated that study participants had higher PKQ scores after the CE activity compared to the mean pretest PKQ score of 92.94. The partial eta squared showed a large effect size main effect of time. The main effect of group showed there was a statistically significant difference in mean PKQ scores between participants with and without actual anaphylaxis experience F(1, 79) = 5.50, p = .022, partial 2= 0.07. Participants with actual anaphylaxis experience, with a mean PKQ score of 104.53, had higher PKQ scores compared to the mean PKQ score of 94.44 for participants without actual anaphylaxis experience. Results indicate that study participants with actual anaphylaxis experience had significantly higher PKQ scores 25 compared to participants without actual anaphylaxis experience. However, both groups showed significant improvement in PKQ scores from pretest to posttest. The partial eta squared showed a small effect size for main effect of group. Diabetes experience. There was no statistically significant interaction between additional certification and PKQ scores from pretest to posttest, F(1, 79) = 0.15, p = .703, partial 2 = .002. The main effect of time showed a statistically significant difference in mean PKQ scores at pretest and posttest, F(1 79) = 70.95 p < .001, partial 2 = 0.47. The mean posttest PKQ score of 104.23 indicated that study participants had higher PKQ scores following the CE activity compared to the mean pretest PKQ score of 90.66. Partial eta squared showed a large effect size for main effect of time. The main effect of group showed there was a statistically significant difference in mean PKQ scores between participants with and without actual diabetes experience F(1, 79) = 8.18, p = .005, partial 2 = 0.09. Participants with diabetes experience, with a mean PKQ score of 102.29, had higher PKQ scores compared to the mean PKQ score of 92.60 for participants without actual diabetes experience. Results indicate that study participants with actual diabetes experience had significantly higher PKQ scores compared to those without actual diabetes experience. However, both groups had significant improvement in their PKQ scores from pretest to posttest. Partial eta squared showed a small effect size for main effect of group. Asthma experience. There was no statistically significant interaction between asthma experience and PKQ scores from pretest to posttest, F(1, 79) = 0.04, p = .843 , partial 2 = 0.04. The main effect of time showed a statistically significant difference in mean PKQ scores at pretest and posttest, F(1 79) = 73.32, p < .001, partial 2 = 0.48. The mean posttest PKQ score of 103.24 indicated that study participants had higher PKQ scores following the CE activity compared to the mean pretest PKQ score of 89.79. Partial eta squared showed a large effect size 26 for main effect of time. The main effect of group showed there was not a statistically significant difference in mean PKQ scores between participants with and without actual asthma experience F(1, 79) =3.90, p = .052, partial 2= 0.05. Participants with actual anaphylaxis experience, with a mean PKQ score of 99.86, had higher PKQ scores, compared to the mean PKQ score of 93.17 for participants who did not have actual asthma experience, but this did not yield a statistically significant difference. Overall emergency experience. There was no statistically significant interaction between additional certification and PKQ scores from pretest to posttest, F(1, 79) = 0.13, p = .721, partial 2 = .002. The main effect of time showed a statistically significant difference in mean PKQ scores at pretest and posttest, F(1 79) = 67.00, p < .001, partial 2 = 0.46. The mean posttest PKQ score of 101.70 indicated that study participants had higher PKQ scores following the CE activity compared to the mean pretest PKQ score of 88.42. Partial eta squared showed a small effect size for main effect of time. The main effect of group showed there was a statistically significant difference in mean PKQ scores between participants who had and did not have overall emergency experience F(1, 79) = 7.94, p = .006, partial 2 = 0.09. Participants with actual overall experience, with a mean PKQ score of 99.87, had higher PKQ scores compared to the mean PKQ score of 90.25 for participants without actual overall experience. Results indicate that study participants who had overall emergency experience had significantly PKQ scores compared to study participants without actual overall emergency experience. However, both groups had significant improvement in their PKQ scores from pretest to posttest. Partial eta squared showed a small effect size for main effect of the overall experience group. Opioid Overdose. There was a significant interaction effect for opioid overdose experience F(1,79) = 5.37, p = .023, 2 = 0.64. The mean difference in pretest PKQ scores 27 between individuals with and without opioid experience was statistically significant 28.31 (p = .001) indicating that participants with opioid overdose experience scored significantly higher on the PKQ than those without opioid overdose experience. The mean difference in posttest PKQ scores of 12.60 between the groups was not statistically significant (p = .127) which indicates that while the posttest scores of participants with opioid overdose experience remained higher than participants without experience, the difference was not statistically significant. Participants without opioid overdose experience had lower mean pretest PKQ score (88.17) compared to their mean score at posttest (102.40). The mean difference of 14.23 was statistically significant (p < .001). The mean difference of 2.00 between PKQ pretest and posttest for those with opioid overdose experience was not statistically significant (p = .770). Interaction results show that before participating in the CE activity, those with opioid overdose experience perceived their knowledge of opioid overdose skills greater than participants without experience. Those without opioid experience increased their PKQ scores from pretest to posttest, but those with opioid experience PKQ scores remained relatively the same from pretest to posttest. The partial eta squared showed a large effect size. Job Settings. There was a significant interaction effect for job settings F(1,79) = 5.10, p = .008, 2 = 0.12. The mean difference between athletics and academics at pretest was 12.54, for athletics and clinical the mean difference was 0.18, and the mean difference between academics and clinical was 12.72. Bonferroni post hoc test results showed none of the comparisons were statistically significantly difference (p = .136, p = 1.000, p = .157, respectively). The mean difference between athletics and academics was at posttest was 1.30, for athletics and clinical it was 9.01, and the mean difference between academics and clinical was 10.31. Bonferroni post hoc test results showed none of the comparisons were statistically significantly difference (p = 28 1.000, p = .055, p = .217, respectively. The partial eta squared indicates a nearly medium effect size. Participants working in athletics (mean difference 18.05, p < .001) and clinics (mean difference 9.21, p < .001) significantly increased their posttest PKQ scores after participating in an emergency skills practice session. However, those working in academia did not significantly improve their PKQ scores (mean difference 6.80, p = .113). Discussion This study sought to address two specific research objectives with respect to athletic training CE and emergency skills: (a) to determine if a hands-on CE activity had an effect on athletic trainers perceived knowledge of emergency skills, and (b) to determine if specific athletic trainer characteristics had an effect on their perceived knowledge of emergency skills. Limited research has been done on CE in athletic training, and this study is the first of its kind to explore how the implementation of adult learning principles in an interactive CE activity effect perceived knowledge. It is important to discuss how implementing these principles can influence the effectiveness of CE activities. Understanding how certain athletic trainer characteristics effect their perception of knowledge of these skills has the potential to assist CE programmers and educators for future CE development and marketing strategies. This study also sought to explore the frequency of athletic trainers use of these emergency skills in real world situations. This understanding can help educators decide which skills are most frequently used and whether frequency impacts decisions as to which skills may be most beneficial to teach athletic trainers, or if athletic trainers see more value in attending CE activities for skills which are more rarely versus more commonly used in practice. 29 In addition to selecting the most prevalent and relevant CE topics, it is vital that CE is delivered as efficiently as possible. Previous research indicates that athletic trainers face numerous barriers when seeking CE such as costs and travel distance (Armstrong & Weidner, 2011), as well as time constraints and ability to implement skills learned (Edler & Eberman, 2019). Because of these challenges, it is important for all CE activities to not only be feasible for athletic trainers, but also to be delivered in ways that make it possible for athletic trainers to easily implement new skills and knowledge into clinical practice (Edler & Eberman, 2019). Clinical Skills Practice and PKQ The first study objective was to determine if there was a significant difference in pretest and posttest PKQ scores after athletic trainers participated in an emergency skills lab. Results of the comparison indicate that study participants perceived knowledge of the four emergency conditions (anaphylaxis, opioid overdose, diabetes, and asthma) increased significantly after having the opportunity to practice the skills associated with managing these conditions. In addition to a statistically significant finding, the results were also clinically relevant, with a large effect size, indicating that athletic trainers are likely to experience improved perceived knowledge following this type of intervention. This study is unique as it is the only existing athletic training CE study to assess perceived knowledge with a pretest posttest design with an interactive intervention. One recent study is the only study with a similar design, with the main difference being the collection of participants actual knowledge, rather than perceived knowledge, of heart sound auscultation before and after two CE activities with interactive techniques (Frank et al., 2020). Other previous studies investigated the effect of an actual knowledge assessment on perceived knowledge of specific topics in athletic training, including the use of airway adjuncts (Edler et al., 2015), knowledge, prevention, and management of 30 exercise induced muscle cramps (Eberman & Tripp, 2011), and management of spine-injured athletes (Neil et al., 2018). Results of this study differ from a study by Neil et al. (2018) who found a decrease in PKQ scores following an actual knowledge assessment and Edler et al. (2015) who found no difference between pre and posttest PKQ scores following an actual knowledge assessment. These findings suggest that the use of an interactive learning activity is effective at increasing participants perceived knowledge of those skills, while the use of an actual knowledge assessment as an intervention has the potential to decrease or have no effect on specific athletic training related skills (Eberman & Tripp, 2011; Edler et al., 2015; Neil et al., 2018). Frank et al. (2020) found a significant increase in actual knowledge scores among participants in both in-person interactive and computer-based interactive intervention groups. However, the group which was given the opportunity to interact and have hands-on practice with the skills increased significantly more than the computer-based group (Frank et al., 2020). These findings are consistent with the existing literature regarding adult learning theory concepts and efficacy of continuing education (Davis, 1998; Forsetlund, 2009; Pitney, 2002). Adult learning theory. The effectiveness of incorporating adult learning theory foundations into CE has been documented among other healthcare professionals such as nurses, physicians, and physical therapists (Davis, 1998; Forsetlund, 2009), but it had not been studied specifically in athletic training until a recent study by Frank et al (2020). Pitney (2002) theorized that athletic training CE should incorporate adult learning theory to maximize effectiveness. The intervention in this study utilized interactive activities and self-directed learning, implementing the principles of adult learning theory, and was considered a formal activity because it was approved for athletic training CE credit (Armstrong & Weidner, 2010). The statistically 31 significant increases in PKQ score following the self-directed, learner centered CE activity in this study are consistent with these suggestions and previous findings. It is also important to consider the previous studies that suggests athletic trainers and other health care professionals such as physical therapists and nurses prefer hands-on CE activities (Chau et al., 2012; Draganov et al., 2013). These interactive activities have been discussed in the literature as traditionally being associated with non-formal CE, or those not approved for CE credit (Armstrong & Weidner, 2010; McLeod & McLeod, 2004). The significant PKQ change from pretest to posttest adds to the existing literature which advocates for the implementation of these types of CE activities. Participant Characteristics and PKQ To address the second study objective, several participant characteristics including age, years of experience, job setting, additional professional certifications, and experience with each of the four emergency skills, were collected and their relationship to pretest PKQ scores were analyzed. Among these variables, results were mixed. Several participant characteristics showed significant differences in PKQ scores, while others displayed non-significant changes. While available research is largely limited, a few athletic training studies have incorporated participant characteristics into their research of perceived knowledge of emergency skills. Age and years of experience. Participants age and years of experienced displayed a significant but weak relationship to pretest PKQ scores (rs = .32 and rs = .33, respectively). Very little research has been done in this area, however there is one study (Edler et al., 2015) that discussed certain participant characteristics and their relationship to the use of airway adjuncts. Edler et al. (2015) found no difference in years of experience and the relationship to perceived knowledge of the use of airway adjuncts (N = 150, p = .98). The authors of this study expected 32 that younger athletic trainers, with less years of experience, would have had higher PKQ scores, as a result of more recent education and addition of diabetes and asthma as athletic training educational competencies in 2011 (BOC, 2011). To the contrary, there was not a strong relationship, possibly suggesting that more experienced athletic trainers have greater perceived knowledge as a result of increased experience. However, previous researchers (Edler et al., 2015; Neil et al., 2018) have demonstrated that this perception of adequate knowledge can be an overestimation, and that the actual skills and knowledge associated with that perception do not align. Professional certifications. A number of participants (N = 23, 28.7%) reported the possession of professional certifications in addition to their athletic training certification. These individuals scored significantly higher on the pretest PKQ than those without additional certifications, although both groups saw a statistically significant increase in PKQ scores from pretest to posttest. There was a medium effect size for those with additional certifications versus those without, indicating that these individuals may possess greater perception of knowledge. The results also suggest that these individuals with additional certifications may be more likely to have pursued continuing education on these topics previously, which would increase their perceived knowledge in those specific areas. While there is no existing evidence in athletic training on additional certifications and its effect on perceived knowledge of emergency skills, Neil et al. (2018) reported that dual-credential individuals scored higher on an actual knowledge assessment than other groups. Despite the lack of existing research in this area, literature in interprofessional education suggests that including individuals from a variety of healthcare disciplines has a positive effect on patient outcomes (Reeves, Zwarenstein, & Goldman, 2013). This finding suggests that this subset of participants has more experience with other professions, 33 which may contribute to their initially higher perceived knowledge of these emergency skills and subsequently higher scores at posttest. Emergency experiences. Study participants experiences related to each of the four emergency conditions addressed in the intervention had varying effects on pretest and posttest PKQ scores. In addition to the pretest and posttest PKQ scores, the frequency of athletic trainers with experience managing the emergency conditions in this study is important to help determine the relevance of selected continuing education activities and topics. In this study, the frequency of experience was lowest among opioid overdose experience, followed by anaphylaxis, diabetes and asthma. This finding should be noted and considered by continuing education programmers in deciding which skills are most prevalent among this sample of athletic trainers to guide development of future activities. Anaphylaxis and diabetes experience. Participants with experience managing anaphylaxis and diabetes demonstrated significantly higher PKQ scores at pretest with medium effect sizes, suggesting that these two groups either have more knowledge, or an inflated perception of their knowledge with emergency skills. Both groups participants, with and without respective experience, demonstrated a significant increase in PKQ scores from pretest to posttest, suggesting that the participants did not have an over perception of knowledge. These findings are similar to previous studies in which perceived and actual knowledge were compared with previous use of emergency skills. Edler et al. (2015) found that athletic trainers who employed life-saving skills more often had higher actual knowledge scores than those who had not employed life-saving skills. Opioid overdose experience. Participants with experience managing opioid overdose had significantly higher pretest PKQ scores compared to those without opioid overdose 34 experience, and a large effect size. This suggests that these individuals had greater confidence in their abilities with the selected emergency conditions. However, the group with opioid overdose experience did not have a significantly significant increase in PKQ scores at posttest, while the group without opioid overdose experience demonstrated a significant increase in PKQ scores. This suggests that individuals with opioid overdose experience had an over perception of knowledge, and as such, did not gain the perceived benefits as those with no prior opioid overdose experience. This finding suggests that individuals with no prior opioid experience have the potential to get more benefit from an interactive CE activity for emergency skills. Asthma experience. Participants with experience managing asthma had no significant difference in pretest PKQ scores as compared to those without asthma experience. However, participants with asthma experience demonstrated a statistically significant change in PKQ scores from pretest to posttest. The lack of difference in pretest PKQ scores could be attributed to the fact that asthma can be managed by athletic trainers in both emergent and non-emergent scenarios, thus making it part of an athletic trainers normal skillset, rather than a specialized and rarely used emergency skill. However, diabetes is a similar condition that yielded more significant results, making this finding difficult to explain. Lack of research on asthma management and continuing education makes it difficult to suggest the reason for these results. The authors suggest that further research is needed to determine an explanation. The small effect size suggests that these results have little clinical relevance. Overall emergency experience. Participants with experience managing any of the four emergency conditions had significantly higher pretest PKQ scores. Participants with and without experience in any of the four conditions had significant increases in PKQ scores from pretest to posttest. Similar to diabetes and anaphylaxis alone, previous research supports these findings, as 35 athletic trainers with more experience in emergency situations had higher knowledge than those who did not (Edler et al., 2015). Job settings. Participants current professional job settings were recorded and they consisted of three groups: athletics, academics, and clinical outpatient. The athletics and clinical groups significantly increased their PKQ scores from pretest to posttest, while participants in academia did not demonstrate a significant increase. This finding suggests that participants in academia did perceive a significant benefit from the CE activity as compared to individuals in athletics and clinical settings. The effect size was nearly medium, indicating clinical relevance that the emergency skills session was less beneficial for individuals working in academia. These individuals, according to these findings, should be the target of those developing CE activities in the future, as they have the potential to get the greatest benefit from the activity. There was no significant difference between the three groups at pretest. The authors anticipated that individuals in certain settings would have higher perceived knowledge of emergency skills due to their exposure to certain conditions and, for educators, the knowledge to be able to educate students on these emergency conditions. However, the data collected did not produce the expected results with respect to pretest PKQ scores. This is consistent with Edler et al. (2015) who found no significant difference in actual knowledge among after stratifying sample by gender and employment setting. In contrast, Neil et al. (2018) found that dual credentialed individuals, athletic trainers combined with either paramedic or emergency medical technician (EMT) credentials, had a higher knowledge with management of spine-injured athletes. This significant finding is likely due to the studys larger sample size with both single and dual credentialed individuals in the relevant fields: athletic trainer/EMT or athletic trainer/paramedic (N = 29) (Neil et al., 2018). 36 The current study utilized a small sample size (N = 81) and only had two individuals who worked in public safety, limiting the ability for statistical analysis. Limitations One of the limitations of the study is that the convenience sample was not randomly selected, plus participants were a relatively homogenous group of certified athletic trainers attending a CE conference. Although these participants had differences in years of experience, age, job setting, and other characteristics, they all displayed a desire to seek out CE activities by attending the conference, and by participating in the clinical skills lab. The bias in sampling had the potential to affect the study results. The size of the sample added to the limitations of the study. A larger sample, and a greater stratification of job settings would have allowed the authors to conduct additional statistical analyses similar to Neil et al. (2018). Another study limitation was the time between pretest and posttest PKQ and the potential for a recall effect. A majority of participants completed both the pre and posttest on the same day, many being completed directly before and after the intervention, a span of approximately 45 minutes. This timing was the most feasible from a logistical standpoint, but it was not ideal considering the original development of the PKQ instrument was shown to be reliable using a 4week test re-test reliability (Flynn & Goldsmith, 1999). The decision to utilize an immediate test retest method was based on previous athletic training studies (Eberman & Tripp, 2011; Edler et al., 2015; Neil et al., 2018) who utilized a pretest, actual knowledge assessment intervention, and immediate posttest design and yielded significant findings. Another study limitation was the lack of an actual knowledge assessment and skill assessment. Previous athletic training studies (Eberman & Tripp, 2011; Edler et al., 2015; Neil et al., 2018), compared an actual knowledge assessment to perceived knowledge scores, but the 37 relationship between perceived knowledge and actual knowledge was inconsistent. These previous findings combined with logistical challenges of collecting data from conference participants led to the decision to exclude the actual knowledge assessment from the study. Also, the addition of a skills assessment would allow researchers to determine if the intervention had a significant effect on the participants skills for each of the four conditions. These limitations allow for numerous opportunities for future research. Implications for Future Research and Continuing Education This study provides a foundation of evidence with respect to perceived knowledge, interactive CE, athletic trainer characteristics and emergency experiences. In a field with little existing research, future studies can use evidence provided to develop studies incorporating actual knowledge assessments for specific topic areas. While this study did not assess actual knowledge, previous studies have reported that an increase in perceived knowledge can be accompanied by an increase in actual knowledge. It is important to understand the previously established correlation between perceived and actual knowledge, to help guide future research directions. Previously, Eberman and Tripp (2011), Edler et al. (2015), and Neil et al. (2018) incorporated the use of an actual knowledge assessment as an intervention, but also to analyze and discuss the knowledge gap between perceived and actual knowledge. Edler et al. (2015) found a poor positive relationship between perceived and actual knowledge. Consistently, Eberman and Tripp (2011) found a poor significant correlation while Neil et al. (2018) found a poor and insignificant relationship between perceived and actual knowledge. Additionally, Eberman and Tripp (2011) found that pretest knowledge gap (difference between perceived and actual knowledge) was a significant predictor of posttest knowledge gap. 38 Results from this study also provides a foundation of evidence describing a set of emergency conditions that are often seen in clinical practice. This has the potential to guide CE programmers decisions on which conditions to highlight at seminars, symposiums, and other CE events. Conclusion The interactive CE activity, which utilized adult learning theory principles, had a significant effect on PKQ scores. This demonstrated that the implementation of adult learning theory concepts can have a positive impact on perceived knowledge of the management of specific emergency conditions. This study also provided evidence that several different athletic trainer characteristics such as additional certifications, certain emergency condition experiences, years of experience, and age have an effect on perceived knowledge of relevant emergency conditions. This study has demonstrated that an interactive method of instruction should be considered for CE of emergency skills, and that relevance and frequency should be discussed when selecting topics for athletic training CE activities. 39 References Andersen, L. (2001). Occupational therapy practitioners' perceptions of the impact of continuing education activities on continuing competency. The American Journal of Occupational Therapy, 55(4), 449-454. Armstrong, K. J., & Weidner, T. G. (2010). 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Resuscitation, 83(9), 1055-60. https://doi:10.1016/j.resuscitation.2012.02.027 44 Table 1 Participant Background Information and Emergency Experience (N = 81) Characteristic N (%) Job Settings Athletics 41 (51.3%) Academics 10 (12.5%) Clinical 29 (36.3%) Additional Certifications Yes 23 (28.7%) No 57 (71.3%) Anaphylaxis Experience Yes 15 (18.5%) No 66 (81.5%) Yes 4 (4.9%) No 77 (95.1%) Yes 31 (38.2%) No 50 (61.8%) Yes 38 (46.9%) No 43 (53.1%) Opioid Experience Diabetes Experience Asthma Experience 45 Overall Experience Yes 51 (63.0%) No 43 (37.0%) 46 Table 2 Comparison of Pretest PKQ Scores by Participant Background Information (N = 81) Characteristic N (SD) Additional Certifications Yes 98.43 (20.29) No 85.95 (15.72) Anaphylaxis Experience Yes No 98.27 (19.80) Yes 117.00 (15.98) No 88.17 (16.84) Diabetes Experience Yes 95.19 (18.48) No 86.12 (16.69) Asthma Experience Yes No p (Cohens d) .012* 0.68 .036* 0.58 < .001* 1.76 .025* 0.52 .109 0.36 87.62 (16.92) Opioid Experience *p < .05 Effect Size Pretest PKQ Score 92.97 (19.19) 86.60 (16.21) 47 Appendix A Informed Consent University of Indianapolis Doctor of Health Sciences Program KEY INFORMATION FOR POTENTIAL RESEARCH PARTICIPANTS We know that athletic training and health care continuing education often fails to meet the needs of its participants. This study will investigate the effects of a hands-on continuing education activity for emergency skills on athletic trainers perceived knowledge. There are 20 pre-test and 20 post-test survey questions, along with 4 demographic and characteristic questions. Combined, both tests should take approximately 10 minutes to complete. There are no direct benefits for your participation, but your participation will help with this research. In appreciation, you will have the option enter a drawing for one of four $25 gift cards. The study is completely voluntary, and you are not expected to participate if you feel uncomfortable doing so. If you would like to volunteer for the study, please read the information below prior to beginning the questionnaire. CONSENT TO PARTICIPATE IN RESEARCH STUDY STUDY TITLE: Emergency Skills in Athletic Training: Perceived Knowledge and Continuing Education PRINCIPAL INVESTIGATOR: Paul Salamh, Ph.D. CONTACT DETAILS: Tel: 1 (317) 788-3379 Email: salamhp@uindy.edu STUDENT INVESTIGATOR: Brian Gerlach, ATC CONTACT DETAILS: Email: gerlachb@uindy.edu PURPOSE AND DURATION: This study involves research on perceived knowledge of athletic trainers. The purpose of this study is to see if there is a difference in athletic trainers perceived knowledge after the clinical skills practice session, and to see if athletic trainer characteristics affect perceived knowledge. We hope that this study will provide information to guide future continuing education programming. We expect that the pre-test and post-test questionnaires will take approximately 10 minutes of your time. PROCEDURES: You will be responding to 4 questions about your demographics and professional characteristics, along with a 20 question Perceived Knowledge Questionnaire before and after the Clinical Skills Practice Session. RISKS AND DISCOMFORT: There are no foreseeable risks or discomfort associated with this study. 48 BENEFITS: There are no direct benefits to you, but your participation will help us with our research and is greatly appreciated. COMPENSATION: You will not receive any compensation for participating in this study, but in appreciation, you will be given the option to enter a drawing for one of four $25 gift cards. CONFIDENTIALITY: Any information that is obtained in connection with this study that can identify you will remain confidential. The results of this study will be used for presentation of my doctoral research project. However, your name and other identifiers will not be used. FUTURE RESEARCH: It is possible that de-identified data from this study could be used for future research or shared with other researchers for use in studies, without additional informed consent. De-identified means that any codes and personal information that could identify you will be removed before the data is shared. WITHDRAWAL OF PARTICIPATION: Your participation is voluntary. Should you decide at any time during the study that you no longer wish to participate, you may withdraw your consent and discontinue your participation. REQUEST FOR MORE INFORMATION: You may ask more questions about the study at any time. Please e-mail the principal investigator at psalamh@uindy.edu or call either 1 (317) 788-3379 with any questions or concerns. In addition, if you have questions about your rights as a participant or any other pertinent questions, you may contact the Human Research Protections office by either emailing hrpp@uindy.edu or calling 1 (317) 781-5774 or 1 (800) 232-8634 ext. 5774. CONSENT: Below you will be prompted to select, Yes, I voluntarily consent to participation and wish to proceed or No, I do not consent to participation and am exiting the questionnaire. 49 Appendix B Perceived Knowledge Questionnaire (PKQ) 1) I know pretty much about anaphylaxis 2) I do not feel very knowledgeable about anaphylaxis* 3) Among my colleagues, I am one of the experts on anaphylaxis 4) Compared to most other ATs, I know less about anaphylaxis* 5) When it comes to , I dont know a lot anaphylaxis* 6) I know pretty much about opioid overdose 7) I do not feel very knowledgeable about opioid overdose* 8) Among my colleagues, I am one of the experts on opioid overdose 9) Compared to most other ATs, I know less about opioid overdose* 10) When it comes to , I dont know a lot opioid overdose* 11) I know pretty much about diabetes 12) I do not feel very knowledgeable about diabetes* 13) Among my colleagues, I am one of the experts on diabetes 14) Compared to most other ATs, I know less about diabetes* 15) When it comes to , I dont know a lot diabetes* 16) I know pretty much about asthma 17) I do not feel very knowledgeable about asthma* 18) Among my colleagues, I am one of the experts on asthma 19) Compared to most other ATs, I know less about asthma* 20) When it comes to , I dont know a lot asthma* Items scored on a 7-point Likert-scale, 1 = Strongly Disagree, 7 = Strongly Agree *Item was reverse scored 50 Appendix C Recruitment Email Hello and thank you for Registering for the GLATA 2020 Clinical Skills Practice Session. My name is Brian Gerlach, and I am a doctoral student at the University of Indianapolis. I am writing to invite you to participate in my doctoral research project entitled Emergency Skills in Athletic Training: Perceived Knowledge and Continuing Education. Participation in the study should take a total of 5-10 minutes, including pre and post-tests. Data collection will consist of a perceived knowledge pre-test with demographic and professional characteristics survey, and a perceived knowledge post-test. Participation in this study is completely voluntary. The study will investigate the effects of the hands on continuing education as well as the effect of demographic and professional characteristics on perceived knowledge of emergency skills. By participating in the study, you will be eligible to enter a drawing to win one of four $25 Amazon gift cards!!! To participate, please click the link below and you will be taken to the demographic survey and pre-test. Pre-Test Link https://uindy.co1.qualtrics.com/jfe/form/SV_7W1M3VQ2RKlLVM9 or https://tinyurl.com/re65xtt Post-Test Link https://uindy.co1.qualtrics.com/jfe/form/SV_8zSJkgq5cALYn65 or https://tinyurl.com/tftnzl7 If you have any questions about the study, please contact Brian Gerlach, gerlachb@uindy.edu. Thank you! Brian Gerlach Doctoral Student University of Indianapolis 51 Appendix D Recruitment Flier  ...