Study protocol: home-based telehealth stroke care: a randomized trial for veterans.

BACKGROUND: Stroke is one of the most disabling and costly impairments of adulthood in the United States. Stroke patients clearly benefit from intensive inpatient care, but due to the high cost, there is considerable interest in implementing interventions to reduce hospital lengths of stay. Early discharge rehabilitation programs require coordinated, well-organized home-based rehabilitation, yet lack of sufficient information about the home setting impedes successful rehabilitation. This trial examines a multifaceted telerehabilitation (TR) intervention that uses telehealth technology to simultaneously evaluate the home environment, assess the patient's mobility skills, initiate rehabilitative treatment, prescribe exercises tailored for stroke patients and provide periodic goal oriented reassessment, feedback and encouragement. METHODS: We describe an ongoing Phase II, 2-arm, 3-site randomized controlled trial (RCT) that determines primarily the effect of TR on physical function and secondarily the effect on disability, falls-related self-efficacy, and patient satisfaction. Fifty participants with a diagnosis of ischemic or hemorrhagic stroke will be randomly assigned to one of two groups: (a) TR; or (b) Usual Care. The TR intervention uses a combination of three videotaped visits and five telephone calls, an in-home messaging device, and additional telephonic contact as needed over a 3-month study period, to provide a progressive rehabilitative intervention with a treatment goal of safe functional mobility of the individual within an accessible home environment. Dependent variables will be measured at baseline, 3-, and 6-months and analyzed with a linear mixed-effects model across all time points. DISCUSSION: For patients recovering from stroke, the use of TR to provide home assessments and follow-up training in prescribed equipment has the potential to effectively supplement existing home health services, assist transition to home and increase efficiency. This may be particularly relevant when patients live in remote locations, as is the case for many veterans. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT00384748.

Small-scale Fisheries and the Global Economy: Understanding Common-pool Resource Governance in the Context of Market Pressures, Neoliberal Policies, and Transnational Institutions

The purpose of this dissertation is to contribute to a better understanding of how global seafood trade interacts with the governance of small-scale fisheries (SSFs). As global seafood trade expands, SSFs have the potential to experience significant economic, social, and political benefits from participation in export markets. At the same time, market connections that place increasing pressures on resources pose risks to both the ecological and social integrity of SSFs. This dissertation seeks to explore the factors that mediate between the potential benefits and risks of global seafood markets for SSFs, with the goal of developing hypotheses regarding these relationships.

The empirical investigation consists of a series of case studies from the Yucatan Peninsula, Mexico. This is a particularly rich context in which to study global market connections with SSFs because the SSFs in this region engage in a variety of market-oriented harvests, most notably for octopus, groupers and snappers, lobster, and sea cucumber. Variation in market forms and the institutional diversity of local-level governance arrangements allows the dissertation to explore a number of examples.

The analysis is guided primarily by common-pool resource (CPR) theory because of the insights it provides regarding the conditions that facilitate collective action and the factors that promote long-lasting resource governance arrangements. Theory from institutional economics and political ecology contribute to the elaboration of a multi-faceted conceptualization of markets for CPR theory, with the aim of facilitating the identification of mechanisms through which markets and CPR governance actually interact. This dissertation conceptualizes markets as sets of institutions that structure the exchange of property rights over fisheries resources, affect the material incentives to harvest resources, and transmit ideas and values about fisheries resources and governance.

The case studies explore four different mechanisms through which markets potentially influence resource governance: 1) Markets can contribute to costly resource governance activities by offsetting costs through profits, 2) markets can undermine resource governance by generating incentives for noncompliance and lead to overharvesting resources, 3) markets can increase the costs of resource governance, for example by augmenting monitoring and enforcement burdens, and 4) markets can alter values and norms underpinning resource governance by transmitting ideas between local resource users and a variety of market actors.

Data collected using participant observation, survey, informal and structured interviews contributed to the elaboration of the following hypotheses relevant to interactions between global seafood trade and SSFs governance. 1) Roll-back neoliberalization of fisheries policies has undermined cooperatives’ ability to achieve financial success through engagement with markets and thus their potential role as key actors in resource governance (chapter two). 2) Different relations of production influence whether local governance institutions will erode or strengthen when faced with market pressures. In particular, relations of production in which fishers own their own means of production and share the collective costs of governance are more likely to strengthen resource governance while relations of production in which a single entrepreneur controls capital and access to the fishery are more likely to contribute to the erosion of resource governance institutions in the face of market pressures (chapter three). 3) By serving as a new discursive framework within which to conceive of and talk about fisheries resources, markets can influence norms and values that shape and constitute governance arrangements.

In sum, the dissertation demonstrates that global seafood trade manifests in a diversity of local forms and effects. Whether SSFs moderate risks and take advantage of benefits depends on a variety of factors, and resource users themselves have the potential to influence the outcomes of seafood market connections through local forms of collective action.

The Role of Home Practice Engagement in a Mindfulness-Based Intervention

Over the last three decades, there has been a precipitous rise in curiosity regarding the clinical use of mindfulness meditation for the self-management of a broad range of chronic health conditions. Despite the ever-growing body of evidence supporting the use of mindfulness-based therapies for both medical and psychological concerns, data on the active ingredients of these mind-body interventions are relatively scarce. Regular engagement in formal mindfulness practice is considered by many to be requisite for generating therapeutic change; however, previous investigations of at-home practice in MBIs have produced mixed results. The equivocal nature of these findings has been attributed to significant methodological limitations, including the lack of standardized, systematic practice monitoring tools, and a singular focus on practice time, with little attention paid to the nature and quality of one’s practice. The present study used a prospective, observational design to assess the effects of home-based practice on dispositional mindfulness, self-compassion, and psychological functioning in twenty-eight people enrolled in an MBSR or MBCT program. To address some of the aforementioned limitations, the present study collected detailed weekly accounts of participants’ home-based practice engagement, including information about practice time (i.e., frequency and duration), exercise type, perceived effort and barriers to participation, and practice quality. Hierarchical multiple regression was used to examine the relative contribution of practice time and practice quality on treatment outcomes, and to explore possible predictors of adherence to at-home practice recommendations. As anticipated, practice quality and perceived effort improved with time; however, rather unexpectedly, practice quality was not a significant predictor of treatment-related improvements in psychological health. Home practice engagement, however, was predictive of change in dispositional mindfulness, in the expected direction. Results of our secondary analyses demonstrated that employment status was predictive of home practice engagement, with those who were unemployed completing more at-home practice on average. Mindfulness self-efficacy at baseline and previous experience with meditation or other contemplative practices were independently predictive of mean practice quality. The results of this study suggest that home practice helps generate meaningful change in dispositional mindfulness, which is purportedly a key mechanism of action in mindfulness-based interventions.

The Market for Apples: A Theory of Identity and Consumption

This paper presents an economic model of the effects of identity and social norms on consumption patterns. By incorporating qualitative studies in psychology and sociology, I propose a utility function that features two components – economic (functional) and identity elements. This setup is extended to analyze a market comprising a continuum of consumers, whose identity distribution along a spectrum of binary identities is described by a Beta distribution. I also introduce the notion of salience in the context of identity and consumption decisions. The key result of the model suggests that fundamental economic parameters, such as price elasticity and market demand, can be altered by identity elements. In addition, it predicts that firms in perfectly competitive markets may associate their products with certain types of identities, in order to reduce product substitutability and attain price-setting power.