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.

A VOICE OF THEIR OWN: MUSIC AND SOCIAL COHESION IN TURKISH ALEVI LIFE

This dissertation examines the role that music has played in the expression of identity and revitalization of culture of the Alevis in Turkey, since the start of their sociocultural revival movement in the late 1980s. Music is central to Alevi claims of ethnic and religious difference—singing and playing the bağlama (Turkish folk lute) constitutes an expressive practice in worship and everyday life. Based on research conducted from 2012 to 2014, I investigate and present Alevi music through the lens of discourses on the construction of identity as a social and musical process. Alevi musicians perform a revived repertoire of the ritual music and folk songs of Anatolian bards and dervish-lodge poets that developed over several centuries. Contemporary media and performance contexts have blurred former distinctions between sacred and secular, yet have provided new avenues to build community in an urban setting. I compare music performances in the worship services of urban and small-town areas, and other community events such as devotional meetings, concerts, clubs, and broadcast and social media to illustrate the ways that participation—both performing and listening—reinforces identity and solidarity. I also examine the influence of these different contexts on performers’ musical choices, and the power of music to evoke a range of responses and emotional feelings in the participants. Through my investigation I argue that the Alevi music repertoire is not only a cultural practice but also a symbol of power and collective action in their struggle for human rights and self-determination. As Alevis have faced a redefined Turkish nationalism that incorporates Sunni Muslim piety, this music has gained even greater potency in their resistance to misrecognition as a folkloric, rather than a living, tradition.