Predictors of Patient Activation Among Underserved Patients in a Nurse-managed Health Center: A Pilot Study

The concept of patient activation has gained traction as the term referring to patients who understand their role in the care process and have “the knowledge, skills and confidence” necessary to manage their illness over time (Hibbard & Mahoney, 2010). Improving health outcomes for vulnerable and underserved populations who bear a disproportionate burden of health disparities presents unique challenges for nurse practitioners who provide primary care in nurse-managed health centers. Evidence that activation improves patient self-management is prompting the search for theory-based self-management support interventions to activate patients for self-management, improve health outcomes, and sustain long-term gains. Yet, no previous studies investigated the relationship between Self-determination Theory (SDT; Deci & Ryan, 2000) and activation. The major purpose of this study, guided by the Triple Aim (Berwick, Nolan, & Whittington, 2008) and nested in the Chronic Care Model (Wagner et al., 2001), was to examine the degree to which two constructs– Autonomy Support and Autonomous Motivation– independently predicted Patient Activation, controlling for covariates. For this study, 130 nurse-managed health center patients completed an on-line 38-item survey onsite. The two independent measures were the 6-item Modified Health Care Climate Questionnaire (mHCCQ; Williams, McGregor, King, Nelson, & Glasgow, 2005; Cronbach’s alpha =0.89) and the 8-item adapted Treatment Self-Regulation Questionnaire (TSRQ; Williams, Freedman, & Deci, 1998; Cronbach’s alpha = 0.80). The Patient Activation Measure (PAM-13; Hibbard, Mahoney, Stock, & Tusler, 2005; Cronbach’s alpha = 0.89) was the dependent measure. Autonomy Support was the only significant predictor, explaining 19.1% of the variance in patient activation. Five of six autonomy support survey items regressed on activation were significant, illustrating autonomy supportive communication styles contributing to activation. These results suggest theory-based patient, provider, and system level interventions to enhance self-management in primary care and educational and professional development curricula. Future investigations should examine additional sources of autonomy support and different measurements of autonomous motivation to improve the predictive power of the model. Longitudinal analyses should be conducted to further understand the relationship between autonomy support and autonomous motivation with patient activation, based on the premise that patient activation will sustain behavior change.

Developmental Neural Correlates of Social Interaction

Children develop in a sea of reciprocal social interaction, but their brain development is predominately studied in non-interactive contexts (e.g., viewing photographs of faces). This dissertation investigated how the developing brain supports social interaction. Specifically, novel paradigms were used to target two facets of social experience—social communication and social motivation—across three studies in children and adults. In Study 1, adults listened to short vignettes—which contained no social information—that they believed to be either prerecorded or presented over an audio-feed by a live social partner. Simply believing that speech was from a live social partner increased activation in the brain’s mentalizing network—a network involved in thinking about others’ thoughts. Study 2 extended this paradigm to middle childhood, a time of increasing social competence and social network complexity, as well as structural and functional social brain development. Results showed that, as in adults, regions of the mentalizing network were engaged by live speech. Taken together, these findings indicate that the mentalizing network may support the processing of interactive communicative cues across development. Given this established importance of social-interactive context, Study 3 examined children’s social motivation when they believed they were engaged in a computer-based chat with a peer. Children initiated interaction via sharing information about their likes and hobbies and received responses from the peer. Compared to a non-social control, in which children chatted with a computer, peer interaction increased activation in mentalizing regions and reward circuitry. Further, within mentalizing regions, responsivity to the peer increased with age. Thus, across all three studies, social cognitive regions associated with mentalizing supported real-time social interaction. In contrast, the specific social context appeared to influence both reward circuitry involvement and age-related changes in neural activity. Future studies should continue to examine how the brain supports interaction across varied real-world social contexts. In addition to illuminating typical development, understanding the neural bases of interaction will offer insight into social disabilities such as autism, where social difficulties are often most acute in interactive situations. Ultimately, to best capture human experience, social neuroscience ought to be embedded in the social world.