week 6

Project Summary/Abstract 1

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In the United States, approximately 50,000 children cope with life-limiting illness annually. 3

Children in palliative care often suffer from unnecessary pain due to the underuse of pain 4

medication. Research suggests that misconceptions about pain medication use—for example 5

that they lead to addiction, or that they hasten death--are common. Educational programs aimed 6

at adult patients or their caregivers have been effective in reducing concerns about pain 7

management. However, no program particularly tailored to the needs of children and their 8

caregivers has been previously evaluated. This project has three specific aims: 1) to pilot test 9

and revise an educational program for family caregivers about appropriate palliative care 10

protocols for children; 2) to administer and evaluate the revised program and determine whether 11

it positively affects caregivers’ attitudes, knowledge, and behaviors concerning palliative care for 12

children; and 3) to determine which family caregivers benefit the most and the least from the 13

program. The program itself should enable participants to 1) use provided tools to assess their 14

child’s pain, 2) demonstrate increased knowledge about opioids and their use, 3) describe tools 15

or methods to improve communication with their doctors, and 4) demonstrate changes in their 16

perceptions of opioid use for their child. Researchers will recruit caregivers of a child suffering 17

from an acute life threatening condition or chronic illness which requires ongoing pain 18

management for participation in a 90 minute educational program regarding opioid use for pain 19

management. The following measures will be administered to participants prior to receiving the 20

educational program, directly after participation, and three months after program participation. 21

Participant knowledge will be measured with a brief questionnaire that will include items 22

measuring actual and perceived knowledge of facts from the education program. Attitudes 23

towards opioid use will be measured using modified items from three established measures of 24

concerns about pain medication. Pain management behaviors will be measured using a self-25

report survey administered both before and three months after the implementation of the 26

educational program. Finally, perceptions of healthcare provider communication will also be 27

measured using a standardized self report survey. It is expected that after participation in the 28

program, participant knowledge of opioid use for pain management will significantly increase, 29

participant’s attitudes will be more favorable toward the use of opioids, participant’s use of drug 30

therapy for the child in their care will significantly increase when appropriate as a result of this 31

educational program, and perception of communication with healthcare providers will 32

significantly increase as a result of the educational program. 33

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Project Narrative 35

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Misconceptions about pain medication reliably lead to unnecessary suffering for children in 37

palliative care. This project seeks to create and evaluate an educational program for caregivers 38

of children suffering from an acute life threatening condition or chronic illness which 39

requires ongoing pain management regarding pain medication use and communication with 40

doctors about pain medication. The program should reduce stress for caregivers, and ultimately 41

reduce the unnecessary suffering of children in palliative care. 42

Specific Aims Pediatric patients with life-limiting illnesses often suffer from unnecessary pain at the end of life due to

underuse of pain medication interventions1. We contend that inadequate pain management in child hospice patients is largely a product of a fear of the effects of narcotics on children, a lack of information and education about pain management, and a communication disconnect between family caregivers and medical providers.

Current research on pediatric palliative care underscores the challenges of managing children’s pain at the end of life but offers few specific interventions to educate family caregivers about children’s palliative care options and to improve communication between medical professionals and caregivers. This project seeks to fill both of those gaps. First, we seek to educate family caregivers for children with life-limiting illnesses by designing, implementing, and assessing an educational tool that will allow caregivers to make informed decisions about children’s pain management protocols. Second, we seek to facilitate communication between medical professionals and family caregivers about pain management strategies.

In the research strategy section of this proposal we discuss research literature showing that the majority of studies of education programs for patients and family caregivers about palliative care options have been with adult patients and have not been tested for family caregivers of children with life-limiting illnesses. To our knowledge, none have specifically evaluated an educational program for family caregivers in a pediatric setting. We also review research that underscores the inadequacy of family caregivers’ communication with doctors and other health care providers. Studies have documented children’s family caregivers’ desire for information and clear, direct communication with health care providers about their child’s illness and care options. Research with adult patients has demonstrated that educational programs are beneficial for family caregivers’ knowledge and attitudes about palliative care protocols, but have not specifically tested whether they positively impact communication with health care providers. With appropriate information and education, caregivers’ fears and misconceptions about pain medication interventions may be reduced, resulting in less distress for family caregivers and improved pain management for children.

The overall goal of this project is to design an educational program that provides clear, direct information about specific pain management strategies and increases caregivers’ knowledge about appropriate palliative care for children. Ultimately this will facilitate caregivers’ decisions about children’s pain management and communication with medical staff while also lessening children’s suffering.

Our first specific aim is to pilot test and subsequently revise an educational program for family caregivers providing them with accessible information about appropriate palliative care protocols for children, that is designed to change their attitudes, increase their knowledge, impact their behavior when making palliative care decisions for their children, and enhance their communication with health care providers.

Our second specific aim is to administer and evaluate the educational program and determine whether it positively affects family caregivers’ attitudes, knowledge, and behaviors concerning palliative care for children, and whether it enhances communication with health care providers regarding palliative care measures.

Our third specific aim is to analyze the data and determine which family caregivers benefit the most and the least from the program and evaluate ways in which caregivers’ experiences of the program may be dependent upon their gender, age, race/ethnicity, their relationship to the child (e.g. parent/grandparent/foster parent) and also characteristics of the child including the type and length of illness, prognosis, and age.

The specific aims of this collaborative research study directly address several of the purposes described in the RFA concerning end of life care and the issues and needs of both patients and their caregivers. The outcomes of this study will be caregivers’ improved knowledge of appropriate pediatric palliative care interventions, and specifically a demystification of the most effective palliative measure: opioids. These outcomes are expected to have an important positive impact on pediatric palliative care because the educational program can be easily disseminated to practitioners and employed in real-world health care settings with pediatric patients.

Research Strategy

Significance Pediatric Palliative Care

In the United States, approximately 500,000 children die and 50,000 children cope with life limiting illnesses annually2. The goal of palliative care is to provide the best quality of life for patients and families in the face of acute and life-limiting illnesses3. One of the primary methods of increasing quality of life is by reducing pain and suffering4. Even with significant advances in pain management, pediatric patients with critical illnesses often still suffer from unnecessary pain5. Pediatric palliative care is a pressing issue among healthcare providers because gaps remain in children’s pain management4,6-8. Various studies have identified attitudinal, institutional, regulatory, cultural, and financial barriers to providing high-quality pediatric palliative care2. Managing children’s pain is challenging because pain measures for adults cannot simply be applied to children since children’s needs are contingent upon their developing physiological, psychological, and cognitive statuses1,4. Children’s pain management is also difficult because of their developmentally-dependent communication skills, which often require that medical practitioners work directly with family caregivers to assess pain and develop and implement palliative care protocols1. The centrality of family caregivers to children’s pain management requires that we consider how caregivers’ attitudes and knowledge about appropriate palliative care measures for children affect their decisions.

Perceptions of Pediatric Pain Management

Healthcare professionals in palliative care and hospice settings explain that narcotic pain medications, and specifically opioids, are often underutilized and pediatric patients suffer due to misperceptions about narcotic use in children by both healthcare professionals and family caregivers. Among family members and family caregivers, unwarranted fears that children will become addicted to pain medication and that opioids will hasten death discourage use of pain medication even when recommended by the physician9-15. Inadequately treated pain for child patients also affects their family caregivers in multiple ways. Concerns about children’s pain and suffering results in family caregivers’ greater feelings of guilt, anger, distress, sadness, and regret during the child’s illness and, in terminally-ill patients, for years after the child’s death16-19. Furthermore, palliative care for dying children is critically important since memories of children’s unrelieved pain will live on in parents’ and siblings’ memories20. Being able to alleviate family caregivers’ concerns that their children are experiencing pain can prove valuable in providing family members with positive last memories of their children. Thus, the long-term mental health outcomes of family members who have lost a child due to an illness can be significantly altered by changing their perceptions of pain management.

Ultimately, family caregivers’ perceptions and knowledge of pain management protocols influence the kind of interventions children receive21-23. Misinformation continues to affect children’s palliative care options as caregivers are often ambivalent about the appropriate use of pharmacological pain interventions with children. The World Health Organization has recognized that morphine is the opioid of choice for pain management among children with life threatening or life-limiting conditions and this has been validated by various studies1. Various studies address the appropriateness of using opiates with pediatric patients and overwhelmingly conclude that they do not hasten death14. Instead, some demonstrate that the use of opioids may relate to better quality of life for sick children and may even prolong life, since patients who feel better typically live longer20. Nonetheless, the general public have long-feared the use of morphine as an analgesic24. Opioid use in pediatric care is among the most feared interventions even though its analgesic efficacy and cost effectiveness are unparalleled24.

Studies of adult patients and family caregivers find that misperceptions about opioids abounds. For example, evidence from a study of adult cancer patients show that they initially rejected the offer of morphine for managing their pain and enhancing their quality of life because they viewed it only as a comfort measure for people who are dying25, a finding which may also be applicable to family caregivers who may be hesitant to employ opioids for children. Among parents of children undergoing surgery, evidence suggests that while many have misperceptions about pain and the use of analgesics for children, perceptions vary by sociodemographic and personality characteristics of both parents and children26. Other research emphasizes family members’ misperceptions of opioids as appropriate pain management interventions for children suffering from an acute life threatening condition or chronic illness 9-15. Ultimately, the underuse of narcotic pain medications and specifically opioids, results in more suffering for critically ill children.

Communication between Healthcare Providers, Patients, and Family Caregivers

Children’s inadequate pain management is due in part to a lack of communication between healthcare providers, patients, and family caregivers27. Family caregivers often express that they desire more information about children’s pain and palliative care options5,6,9,13,15,18,28 and they want to be involved in decision making29. Yet, medical professionals report that they are significantly untrained in how and when to provide information about palliative care options, especially in pediatric settings, and may be uncomfortable with the topic28,30,31. The economic imperatives of medical practice also discourage doctors from spending adequate time with families and patients explaining pain management options32,33. Deficient communication between caregivers and medical staff often means that caregivers remain under-informed about their options for managing children’s pain34 and staff may be frustrated managing patients’ pain symptoms. In short, family caregivers’ lack of understanding of children’s palliative care options coupled with inadequate communication with providers means that children may not receive palliative measures that would ease their suffering and potentially improve quality of life, even in terminally-ill children.

Clinical research studies show that communication between families and healthcare providers about children’s palliative care options is wanting16,28,32. Furthermore, physicians’ and nurses’ lack adequate training in pediatric palliative care as well as the communication skills to talk with patients and families about pain management and end-of-life care6,30. Amplifying this lack of communication are reimbursement issues and bureaucratic insurance systems that make it cost prohibitive for physicians to spend inordinate amounts of time with patients and their caregivers explaining their treatment options32,33. To address this problem, some research has evaluated the effectiveness of programs intended to empower patients by teaching them how to effectively obtain information from doctors32. In studies of adult oncology patients, interventions have focused on helping to prepare patients for their clinic visits by coaching patients beforehand in order to improve their ability to obtain information from providers35-37. Others have shown that providing audiotapes of visits to the patient or providing feedback to the healthcare provider regarding the patient’s concerns have improved communication38,39.

The evidence is clear that poor communication between healthcare providers, patients, and family caregivers of pediatric patients is a problem for effective pediatric palliative care. However, effective and empathic communication can improve patients’ quality of life, satisfaction with care, and even medical outcomes32. Information and Education about Pain Management

Research about educational programs and interventions for improving pain management has focused on increasing patients’ knowledge of pain management strategies15 but, to our knowledge, none have specifically evaluated programs for increasing knowledge of pain management for family caregivers of pediatric patients suffering from an acute life threatening condition or chronic illness. Instead, research has focused on adult patients and their caregivers or on the use of pediatric post-operative analgesics. Furthermore, we are unaware of any studies that assess the impact of an educational program on family caregivers’ communication with health care providers.

While research has shown that families and patients want more information about treatment options, educational tools and interventions designed specifically for family caregivers of pediatric patients suffering from an acute life threatening condition or chronic illness is nonexistent. Research does demonstrate that family caregivers of these children want information and education. For example, a Canadian study of adolescents with cancer assessed the psychosocial needs of families and found that parents’ highest priority was the receipt of information about various aspects of their child’s disease and treatment40. The study further revealed that although parents preferred face-to-face contact with medical personnel as a means of obtaining information, their next three preferred means were to receive information on paper, via telephone, or via computer CD or website40.

Other research suggests that educational programs are useful for adult patients and caregivers, and that psychosocial interventions for pediatric patients can facilitate pain management. In the last two decades, limited studies have developed psychosocial treatments for child health problems and these interventions have been evaluated and shown to successfully change parents’ attitudes and behavior40. Evidence demonstrates that these psychosocial interventions both reduce symptoms and improve quality of life, yet they are available mainly in small clinics and administered by highly-trained personnel40. Not every pediatric patient has access to individualized highly-trained healthcare professionals. For those who do not, the evidence suggests that some treatments and interventions can be administered just as easily by paraprofessionals who have access

to appropriate information and employ evidence-based tools40,41. In fact, interview data from children (and their parents) with malignant cancer show positive outcomes of better education and more exhaustive information on pain treatment and its side effects (although they did not evaluate a specific educational program). In that study, parents and their children did not refuse opioids for pain management due to fear of addiction42. Thus, clinical evidence suggests that an educational program for family caregivers of children suffering from an acute life threatening condition or chronic illness may be beneficial for children’s pain management.

Educational interventions designed to improve pain management among adults with cancer have shown evidence that educational interventions can successfully influence patients’ perceptions of the use of opioids and that nurses can be trained to effectively administer the educational program43. A recent review of research on patient-based educational interventions for managing cancer pain among adults concluded that evidence from both randomized and non-randomized controlled clinical trials demonstrated that interventions had modest but positive effects on patients’ knowledge and attitudes towards cancer pain protocols and analgesia, and also had a negative effect on pain intensity44. Furthermore, studies of cancer pain among adults have assessed the effectiveness of education programs for both patients and family caregivers. In one experimental and longitudinal study adult cancer patients and their caregivers received a pain management educational program, which was significantly related to reduced concerns or misperceptions about cancer pain management compared with those in the control group45. Results demonstrated that both patients and family caregivers can benefit from an educational program, and provides a basis for designing and evaluating a program for family caregivers of pediatric patients.

In the pediatric arena, a large body of research evaluates the effectiveness of educational programs aimed at healthcare practitioners for improving pediatric palliative care.e.g. 4,46,47 Recent studies of pediatric pain have examined effective and contextually relevant interventions with medical staff and have demonstrated positive changes in knowledge and attitudes48. However, there are no studies that have addressed educational interventions designed for family caregivers to improve pain management among children suffering from an acute life threatening condition or chronic illness. In one study that assessed the effectiveness of using a pain education booklet on parents’ attitudes and management of their children’s postoperative pain from day surgeries, researchers found that parents who received the educational booklet had fewer concerns about using acetaminophen for their children and also administered more doses of the drug to children longer after the surgery than those in control groups21. This finding suggests that children with suffering from an acute life threatening condition or chronic illness may also experience better pain management if their family caregivers are educated about palliative care options.

In short, we know that information and education about pain management for family caregivers of pediatric palliative care patients is limited. However, if what we have learned from adult palliative care patient education and interventions can be applied to pediatric situations, then we can begin to assess the effectiveness of such programs for children. Ultimately, we contend that information and educational programs will be just as useful to family caregivers of children as they are to family caregivers of adults.

Summary

Few, if any, previous studies have addressed the issue of pain education programs for family caregivers of children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. This application proposes to address the challenges in pediatric palliative care by developing and evaluating an educational program that will improve family caregivers’ knowledge of children’s pain management options and increase communication between caregivers and medical personnel. While studies have demonstrated the efficacy of pain education programs for adult patients, they have not examined their utility for family caregivers of children suffering from an acute life threatening condition or chronic illness. Moreover, research has examined interventions to improve patients’ communication with doctors, but has not specifically tested educational programs for family caregivers of pediatric patients and whether they facilitate communication with healthcare personnel. Our goal is to examine whether an educational program for children’s family caregivers improves not only knowledge but also communication between caregivers and healthcare providers. Pediatric patients, family caregivers, and health care providers will benefit from caregivers’ improved knowledge of pain management protocols. Caregivers continually express the desire for more information and this program will specifically address that need. With knowledge of palliative options for children, caregivers will be empowered with information that will facilitate their conversations with healthcare providers. As well, medical staff will have better opportunities for honest communication with family caregivers knowing that caregivers participated in a program that provided clear information about children’s palliative care options. Upon evaluation of this educational program, information can be shared with other health care

providers to improve the experience of pain management for family caregivers of children suffering from an acute life threatening condition or chronic illness. Innovation This study is the first step in establishing and evaluating an educational program that will increase family caregivers’ knowledge of pediatric pain management options and will also facilitate communication between caregivers and health care providers. The study is an opportunity to improve palliative care for children with life-limiting illnesses both before and at the end of life. This project is innovative in five primary ways.

First, this project is a first step to dismantling a critical barrier in the field of pediatric palliative care by directly addressing the problems associated with misinformation and stereotypes about opioid use in children with life-limiting illnesses. Research continues to cite caregivers’ lack of understanding about the appropriate use of opioids for children, and the educational program in this study is designed to directly address this barrier. The results of this study and the educational program itself will have immediate use in the clinical setting and will also provide a foundation for future research examining the utility of educational programs in pediatric palliative care. Ultimately, demystifying opioids through caregiver education will enable medical providers to more effectively manage children’s pain.

Second, the present study moves pediatric palliative care in a new direction by evaluating the effectiveness of an educational program specifically for family caregivers of children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management, which has not been assessed for this population before. Previous research demonstrates that educational programs are an effective way of increasing knowledge about pain management among adult cancer patients and their caregivers16. However these interventions have not been evaluated with family caregivers of specifically pediatric patients. To the extent that educational programs targeting pediatric pain management have been implemented and evaluated, they emphasized parents’ administration of analgesics to children after day surgeries21, and have not studied children suffering from an acute life threatening condition or chronic illness. The present study represents a significant change in studying the effects of education on family caregivers’ attitudes and outcomes for pediatric patients.

Third, the current study fills a gap in the research literature by focusing on the relationship between family caregiver education and communication with health care providers. Information and patient-caregiver- provider communication has been repeatedly shown to be inadequate, yet no research has evaluated the effectiveness of how family caregivers’ increased knowledge ameliorates communication between family caregivers and health care providers for pediatric patients. Fourth, in this study we plan to extend previous research by assessing which groups of family caregivers benefit most from the educational program. Some clinical studies have examined whether family caregivers’ sociodemographic characteristics are predictive of their perceptions of children’s pain and their attitudes about appropriate pain measures for children. We plan to analyze the data to discover the strengths and weaknesses of the educational program for different family caregiver populations. For example, we will analyze ethnoracial or cultural differences across program participants and the relationship to outcomes. In addition, we will compare family caregivers in terms of their relationships to the children: e.g. father, mother, grandparent, foster parent. We also expect to be able to assess the role of the family caregiver’s gender on the effectiveness of the program and specified outcomes.

Finally, the uniquely interdisciplinary nature of the research team for the present study moves the study of family caregiver education and pediatric palliative care in new directions. The team is comprised of a sociologist, a pharmacologist, nurses, and applied researchers, allowing us to examine the social as well as medical and clinical aspects of improving family caregivers’ knowledge on pediatric palliative caregiving. Thus, we will not only design and evaluate an educational program for family caregivers that will be useful in clinical practice, we will also analyze the data collected during the program to answer research questions about the social, behavioral, and cultural aspects of the program and look for trends in outcomes. Approach This research project will contain two phases; 1) pilot testing and revising a parent educational program focused on the use of drugs in pediatric pain management, and 2) implementation and analysis of the revised educational program. Description of Caregiver Educational Program:

The educational program to be used in this study was developed because research indicates the need for improved communication and the benefits of caregiver education for pain management is well- documented6,9,13,32. In particular, the education program will address common myths regarding the use of opioids including hastening death and addiction6,10,12 and research studies including World Health Organization statements will be provided to overcome these misconceptions. Commonly used clinical tools to assess pain will be provided, and parents will be taught how to use them. As well, tools such as The American Pain Foundation’s “tips to ask your healthcare professional when talking about your pain” and “pain log” will be modified for parents and explained.

The educational program was developed directly in response to the need to overcome misconceptions, increase knowledge about opioids, and improve communication between family caregivers and healthcare professionals. The education program will be administered by a nurse with 20 years of experience, 10 of which were with pediatric patients, and who has spent the last three years developing and building a pediatric hospice program. In addition, the program will be co-administered by the principle investigator, a pharmacist who has substantial experience developing curriculum and instructing on a variety of related topics as well as over three years of experience in the hospice environment. Caregiver Education Program Objectives After the 90 minute program, participants should be able to:

1. Use provided tools to assess their child’s pain 2. Use provided tools (or document ways) to improve their communication with healthcare providers 3. Demonstrate increased knowledge about opioid use 4. Show demonstrable changes in their perceptions of opioid addiction as a risk for their child

Education Program Objectives Description Timing

Introduction 5 minutes

Common Perceptions/Myths 10 minutes

What Is the Truth (dispelling the Myths) 10 minutes

What is Pain and How do you Assess: Common tools will be explained. Numeric scale - an assessment tool for children (6+) with no development delay or cognitive impairment; must understand the use of numbers. Faces scale (also known as Wong-Baker Faces scale). Children as young as 3 years old are able to recognize how they are feeling in the cartoon faces. Descriptive scale: best for children under the age of 3 or nonverbal, cognitively impaired children

15 minutes

Opioids: What is frequently used, what is not? What are side effects? Which side effects are acceptable, unacceptable? Positives outcomes for children's quality of life.

15 minutes

Communicating with your provider Tools to help improve communication between healthcare provider and patient/caregiver such as keeping pain log, diary that may show what is triggering pain, etc.

10 minutes

Question and Answer Period 25 minutes

Total Time 90 minutes

Specific Aim 1: Pilot Testing of Educational Program (September 2011 – February 2012)

Our first specific aim is to pilot and subsequently revise an educational program for family caregivers, providing them with accessible information about appropriate palliative care protocols for children. More specifically, the educational program is designed to change their attitudes, increase their knowledge, impact their behavior when making palliative care decisions for their children, and enhance their communication with health care providers. This will take place in the first six months of the project period. NAH staff will recruit approximately 10 caregivers of children either in palliative care, suffering from an acute life threatening condition or chronic illness which requires ongoing pain management, or have previously lost a child matching these descriptions but has continued to work with NAH. The 10 individuals participating in the pilot program will consist of a convenience sample recruited from NAH. Partner physicians, nurses, and pharmacists will assist in the recruitment of the caregivers by sharing information regarding the pilot with caregivers of pediatric patients. Caregiver recruitment will include both current pediatric patients, and caregivers who have lost a child but have remained in contact with the facility. Hospice staff members are experienced at working with family caregivers of pediatric patients and recruitment will be done tactfully and with sensitivity to the needs of each family.

The pilot testing will take place in a private conference room at NAH. Participants will first be asked to complete a brief demographic questionnaire to determine their personal situation as a caregiver (relationship to the child, length of time treating pain symptoms, pain management methods used) and a brief attitudes questionnaire regarding pain management. Following the completion of the survey instruments, participants will be given the 1.5 hour educational program. Immediately following the program, NICRP staff will facilitate a discussion regarding the following:

o the relevance of the information included in the program o identification of information that needs to be included in the program o perceptions of the sensitivity of the program o perceptions of the program delivery methods o perceptions of pain management of children with serious illnesses and previous interactions

with physicians that could influence the program.

This focus group discussion will be recorded (with the permission of participants) for reference when revising the educational curriculum. Data Analysis Recording from the focus group session will be transcribed by staff from NICRP. NICRP staff will use qualitative analytic techniques to summarize the feedback from the focus group for reference when revising the educational curriculum. More specifically, codes will be developed by an experienced research analyst at NICRP and then discussed with staff from NAH to develop final overall themes in the data. These major themes will be summarized and then be distributed back to the focus group participants for review. Participants will have two weeks to provide any additional feedback with regards to the interpretation of the focus group session. The summary will then be revised to reflect any changes or comments provided by the participants and delivered to the team at NAH for curriculum revisions. Incentives for Participation in Pilot To compensate individuals for their time participating in the pilot test of the educational program, a financial incentive of $20.00 will be provided. The research team believes that by providing each individual with compensation, we will obtain a significantly higher participation rate. Specific Aim 2: Evaluation of the Educational Program (March, 2012 – February, 2013) Our second specific aim is to evaluate the effectiveness of the educational program. This study will test four hypotheses against the following null hypothesis:

HO: There educational program will have no effect on family caregivers’ attitudes, knowledge, or behaviors concerning drug use for pain management of children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management, and the educational program will not enhance communication with health care providers regarding pain management of these children. H1: Participation in the educational program will significantly increase knowledge of drug usage for pain management for children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. H2: Participation in the educational program will significantly change attitudes regarding drugs usage for pain management for children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. H3: Participation in the educational program will significantly change behaviors concerning drugs usage for pain management for children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. H4: Participation in the educational program will significantly enhance communication with health care providers regarding pain management for children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. Expected outcomes:

It is expected that participant knowledge of pain medication treatment for pain management will significantly increase participants’ attitudes such that they will be more favorable toward the use of pain medication, and that participants’ use of pain medication for the child in their care will significantly increase as a result of this educational program.

It is also expected that this increase in knowledge as a result of the program will improve family caregivers’ communication with the health care providers regarding palliative care pain protocols. Procedures

In keeping with the current research methods in field of palliative care, the current study will utilize a quazi-experimental design. The research team decided against the use of a control group for this evaluation due to the time sensitive conditions of the population that will be sampled. Implementation of the final educational program for family caregivers of pediatric patients will commence directly after revisions of the curriculum. This educational program will be delivered to at least 100 caregivers of children suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. Participants will include parents/caregivers of children who currently have a child suffering from an acute life threatening condition or chronic illness which requires ongoing pain management. Although multiple caregivers for a single child can attend the program, the recruitment of 100 individual caregivers included in data analysis will only include one caregiver for each child. That caregiver will be identified as the primary person who will make the final decision on treatment for the child. It is recognized that this decision may be, in reality, the result of consultations and negotiations among multiple caregivers. However, this selection strategy will allow the team to track the pain management behaviors for each child.

Participants will be recruited from the Nathan Adelson Hospice in Las Vegas, NV as well as the Children’s Specialty Center of Nevada and the Children’s Critical Care Network in Las Vegas, NV. Eligible participants will be recruited using flyers in the care center, letters sent to past patients from the care center, and verbal recruitment from health care providers at the care centers. Given this is a sensitive topic and a vulnerable population; recruitment will be handled discreetly and with respect for the families’ difficult situations. The educational program will be conducted in a private conference room at the hospice center.

Prior to the educational program, participants will be asked to complete the following: 1) a brief questionnaire which will include questions about participants’ demographic characteristics as well as their current pain management practices for their child and their perception of the quality of communication with their healthcare professional, and 2) a survey on attitudes toward pain management in children in palliative care or suffering from an acute life threatening condition or chronic illness. Immediately following the educational program, participants will be asked to complete the same survey on attitudes toward pain management as well as a program satisfaction survey. Approximately three months after the program,

participants will be contacted to complete a brief follow-up interview. The interview will determine current attitudes toward pain management and assess current pain management practices. Interviews will be conducted by staff at NICRP. If a caregiver’s child has passed away by the three month follow-up, that caregiver will not be contacted for an interview out of respect for the caregiver. Incentives for Participation

To compensate individuals for their time participating in the educational program, either breakfast or lunch will be provided during the program. In addition, a financial incentive of $20.00 will be provided to each participant upon completion of the three month follow-up questionnaires. The research team believes that by providing each participant with the incentive of compensation, we will obtain a significantly higher participation rate. Measures Demographic Measures

Basic demographic information to be collected from participants includes, but is not limited to: age, gender, ethnicity, education, current medical facility of participant’s child, and type of illness of pediatric patient. Attitude Measures

The researchers know of no single, established measure that captures parental attitudes about palliative drug therapy for children in palliative care or suffering from an acute life threatening condition or chronic illness. Therefore, the researchers will combine and gently modify items from three established measures: The Barriers Questionnaire-II, The Medication Attitude Questionnaire, and The Pain Medication Attitude Questionnaire. Below is a description of each measure as well as plans for modification.

The Barriers Questionnaire-II (BQ-II)49 is a measure of patient-related barriers to pain management, and particularly patient concerns about reporting pain and using pain medication. The BQ-II consists of 27 items on a six-point scale (0 = “Do not agree at all” and 5 = “Agree very much”). Respondents are asked to indicate levels of agreement with statements about the use of pain medication (e.g. “If you take pain medicine when you have some pain, then it might not work as well if the pain becomes worse”). Specific items of interest to the proposed study include items that reference specific side effects (e.g. “Pain medicine makes you say or do embarrassing things”) as well as items that concern a patient’s potential desire to not complain about their pain (e.g. “It is important to be strong by not talking about pain”). All items are written about pain medication in a general sense and do not reference a particular patient. Therefore, the researchers will modify some items to specifically reference child patients. For example, the item “Drowsiness from pain medicine is difficult to control” will be changed to “Drowsiness from pain medicine is difficult to control in children.” The content validity of the original items was supported by a review by an expert panel. The measure is divided into four subscales: physiological effects, fatalism, communication, and harmful effects. The measure had an internal consistency of 0.89, while the subscales had internal consistencies ranging from 0.75 to 0.8549.

The Medication Attitude Questionnaire (MAQ)11 is a 16-item measure of parents’ attitudes about using pain medication to treat children’s pain. Respondents indicate on seven-point scales the degree to which they agree with statements about children’s use of pain medications (e.g. “Children should be given pain medication as little as possible because of side effects”), where 1 = “strongly disagree” and 7 = “strongly agree.” All items are written from the perspective of a parent about pain medication use in children, and therefore do not need to be modified for the present study. Internal consistency (Cronbach’s alpha) has been reported as 0.5826, 0.6811 and 0.7821. Scores on the MAQ have been associated with the number of doses of medication parents give their children for pain11.

The Pain Medication Attitude Questionnaire50 is a 47-item measure of beliefs and concerns about pain medication. Respondents indicate on a six-point scale (0 = “never true,” and 5 = “always true”) agreement with various statements about their own attitudes towards medication use as well as their actual behaviors regarding use of pain medication (e.g. “I worry about how other people view my use of pain medication/s”). The items are written from the perspective of a pain medication user him or herself. Therefore, researchers will modify the items to reflect the perspective of a parent thinking about his or her child’s pain medication use. For example, the item “I trust my doctor to give me the correct dose,” will be changed to “I trust the doctor to give my child the correct dose.” The measure includes seven subscales: Addiction, Need, Scrutiny, Side Effects, Tolerance, Mistrust, and Withdrawal. Unique to this measure and of particular interest to the proposed study are items from the Scrutiny subscale, which concern the opinion of others as it relates to pain medication use,

and the Mistrust subscale, which concern participant trust of doctors’ advice as it relates to pain medication use. Internal consistencies for all seven subscales were reported between 0.77 and 0.8550. Knowledge Measures

Participants will be given a brief questionnaire that will include items measuring the participant’s actual and perceived knowledge of facts concerning opioid use in children in palliative care or suffering from an acute life threatening condition or chronic illness which requires ongoing pain, the side effects of opioids, the assessment of pain in children, and how to communicate with healthcare providers about opioid use. Questions will be constructed from the information in the provided educational materials for the courses. Behavior Measures

Real world palliative care behaviors will be measured using a self-report survey administered both before and three months after the implementation of the educational program. The measure will ask the participant to indicate what pain management treatments they used with their child in the previous three months and whether their doctor recommended opioid use. If the participant did not use opioids as a treatment for their child, they will be asked to indicate why not. If they did use opioids as a treatment for their child, they will be asked to indicate the perceived effects of the treatment. Healthcare Provider Communication

Curtis et al.51 developed a measure of doctor-patient communication based on focus groups with patients in end-of-life care. Four concerns were identified from these focus groups: (1) the clinician can anticipate treatment preferences of the patients; (2) the clinician is attentive to patient opinions; (3) the clinician is attentive to the patient in general; and (4) the patient perceives that the clinician cares about the patient. The measure includes one question to address each concern. Respondents can indicate either “No” “Yes” or “Definitely Yes.” The measure also includes a simple satisfaction question about their communication with doctors, ranging from “Poor” to “Excellent.” These questions are all written from the perspective of the receiver of palliative care, and therefore will be modified for the proposed study. For example, “When you are talking with your doctor about the kinds of treatment you want if you get very sick, do you feel that your doctor cares about you as a person?” will be changed to read “When you are talking with your doctor about the kinds of treatment you want for your child, do you feel that your doctor cares about your child as a person?” The measure had high internal reliability (alpha 0.81) and has a significant positive correlation with overall medical care satisfaction (r = 0.76, p < 0.0001)51. Program Satisfaction Measures

Participants will complete a questionnaire to indicate their satisfaction with elements of the educational program, the educational materials, the trainers, and the outcomes of the program. Response options will range from “Excellent” to “Needs Improvement.” Participants will also be given the opportunity to leave their own comments at the end of the survey. Data Security

Researchers from UNLV all have previous training in data collection and have gone through the training required by UNLV’s Office for the Protection of Research Subjects (CITI Course completion required). In addition, all members of the research team will be required to sign an internal confidentiality agreement in order to work on the project. All data collected at each event will be immediately brought back to the NICRP office and locked in a designated filing cabinet located inside a locked office. Only the Lead Principle Investigator and NICRP staff will have access to raw data and all information will be immediately de-identified as the consent forms will not be kept with the completed questionnaire packets. Data will be entered into an SPSS database and kept on a flash drive which will be secured in the same locked file cabinet in order to secure the data. Hard copies of the data will be kept in the file cabinet for three years and then destroyed in accordance with UNLV policy. Data Analysis

The data will be analyzed using the PASW Statistic (formally SPSS) version 18.0 (SPSS, 2009). Demographic characteristic statistics such as average age, gender, ethnicity, education level, pediatric patient’s illness type, and participant’s location (medical facility) will be created. A multivariate analysis of variance (MANOVA) and chi square analysis on all demographic data will be computed to determine if

demographic variables significantly differed based on recruitment location. Significant differences found among location will be included as covariates in the following analysis.

The effect of the educational program on the dependent variables (knowledge, attitude change, behavior change, communication, and satisfaction) will be examined via a repeated measures multivariate analysis of covariance (MANCOVA). An omnibus F-test will be used to compare the levels of each hypothesis. In cases where the independent variable has more than two levels, subsequent pair wise comparisons (tests of simple effects) will be performed for all significant F-values.

Because the accuracy of MANCOVA results relies on several assumptions, the data will be tested for violations of these assumptions. Prior to conducting the analysis, the data will be screened for multivariate outliers and tested to see if the assumption of sphericity has been violated using Bartlett’s test of sphericity. If the assumption of sphericity has been violated, the subsequent analyses will be univariate in nature. If the assumption of sphericity has not been violated, analysis will be conducted. In addition, the data will be tested to determine if the assumption of homoscedasticity has been violated using the generalized Breusch-Pagan test. If the assumption of homoscedasticity has been violated, the subsequent analyses will be univariate in nature. If the assumption has not been violated, the analysis will be conducted as planned. Specific Aim 3: Advanced Data Analysis (March, 2013 – August, 2013)

Our third specific aim is to conduct additional analyses of the data to determine which family caregivers benefit the most and the least from the program. More specifically the program will be evaluated to determine how the success of the program may be dependent upon their gender, age, race/ethnicity, their relationship to the child (e.g. parent/grandparent/foster parent) and also characteristics of the child including the type and length of illness, prognosis, and age.

The data will be analyzed using the PASW Statistic (formally SPSS) version 18.0 (SPSS, 2009). The effect of the independent variables (caregiver age, gender, ethnicity, education, and child age, illness type, length of illness, and prognosis) on the dependent variables (knowledge of pain medication use for child, attitude change of use of pain medication with child, behavior change in the use of pain medication with child, communication between caregiver and healthcare provider, and program satisfaction) will be examined via a repeated measures multiple analysis of variance (MANOVA). An omnibus F-test will be used to compare the levels of each hypothesis. In cases where the independent variable has more than two levels, subsequent pair wise comparisons (tests of simple effects) will be performed for all significant F-values. Because the accuracy of MANOVA results relies on a few assumptions, the data will be tested for violations of these assumptions as described above for the MANCOVA.

If the results of the MANOVA are statistically significant we will take the additional step of estimating multivariate regression equations predicting each of the dependent variables while controlling for the independent variables. Since each of the dependent variables are comprised of multiple-item scales, we will use OLS regression techniques to predict the relationships between family caregivers’ characteristics and each of the dependent variables. Prior to analysis, we plan to assess the data to ensure that we do not violate any of the assumptions of OLS regression.

Limitations

This study will make significant contributions to the research literature on family caregivers’ education about palliative care for children and will also provide a model for clinical practitioners working with critically-ill children and their family caregivers. Notwithstanding these contributions, the study is also potentially limited in two primary ways.

First, in the proposed methodology the sample of family caregivers will be a convenience sample and may therefore have limited generalizability to the population of family caregivers for pediatric patients. Furthermore, since it will not be a probability sample, some groups may be overrepresented which may limit our ability to compare across different types of family caregivers in the analysis. While this is a potential limitation, it is also a reminder to the researchers to use caution in interpreting our findings about variation in the effectiveness of the educational program across different types of family caregivers.

Second, although the proposed study will be readily able to measure changes in attitudes, knowledge, and perceptions of communication with health care providers, it may be more difficult for us to capture changes in family caregivers’ actual behaviors regarding palliative care options for their children. Specifically, since the follow-up with family caregivers will be three months after they participate in the educational program, it is possible that this three month window may not be long enough to acquire a large enough group of family caregivers who actually did have to make decisions about their children’s palliative care protocols. Indeed, we

may not have enough family caregivers who, by the three month follow-up, had to make a decision about whether or not to administer opioids to their child. If this is the case, it will limit our ability to draw conclusions about the effectiveness of the educational program for changing family caregivers’ actual behaviors regarding palliative care options for their children. Preliminary Studies

Although, the primary investigators have no preliminary studies that directly stem from this topic, Dr. Keene’s related research experience and experience studying caregiver populations combined with Dr. Kullgren’s experience in pediatric palliative care pain medication both provide the expertise necessary to conduct the proposed study.

Dr. Keene co-authored book, Death and Dying in America (Polity Press, 2009), which was a large survey of the empirical research literature on death and dying in the American context. The book covered a wide variety of issues, many of which are pertinent to the current project, including hospice care, palliative care measures, issues surrounding euthanasia, and children’s experiences with death. This book is the basis for much of her expertise in social thanatology. She has also published various peer-reviewed papers on family caregiving, multigenerational co-residence, and the work-family balancing act for workers trying to manage their family caregiving responsibilities (for children and/or for aging parents) with the demands of their employment. These studies draw on secondary datasets and use advanced statistical analyses to address their specific research questions.

• Jennifer Reid Keene and Anastasia H. Prokos. 2007. “The Sandwiched Generation: Multiple Caregiving Responsibilities and the Mismatch between Actual and Preferred Work Hours.” Sociological Spectrum 27, 4: 365-387.

• Jennifer Reid Keene and John R. Reynolds. 2005. “The Job Costs of Family Demands: Gender Differences in Negative Family-to-Work Spillover.” Journal of Family Issues 26, 3: 275-299.

• Jennifer Reid Keene. 2004. “Balancing Work and Caregiving.” Pp. 123-131 in Thriving on an Aging Workforce: Strategies for Organizational and Systemic Change. Paulette T. Beatty and Roemer M. S. Visser Eds. Melbourne, FL: Krieger Publishing Co.

• Jennifer Reid Keene and Jill S. Quadagno. 2004. “Predictors of Perceived Work-Family Balance: Gender Difference or Gender Similarity?” Sociological Perspectives 47, 1: 1-24.

• Jennifer Reid and Melissa Hardy. 1999. “Multiple Roles and Well-Being among Midlife Women: Testing Role Strain and Role Enhancement Theories.” Journals of Gerontology: Social Sciences 54B, 6: S1-S10.

The Nathan Adelson Hospice (NAH) is a nationally recognized as a model for superior hospice care having

cared for over 44,000 people since its inception. NAH is proud to be accredited by the Joint Commission on Accreditation of Health Care Organizations. NAH has experience providing training for staff and to medical professionals across the country. NAH brings applied experience from the field of pediatric palliative care and is looking to partner with researchers from the university to expand their abilities to offer the most effective programs both locally and nationally. For the purpose of this proposal, we have identified several initiatives that indicate our expertise in education and hospice and palliative care.

Nathan Adelson Hospice Learning Academy The Nathan Adelson Hospice Learning Academy provides no cost continuing education trainings for all staff and volunteers. Nurses, social workers, and certified nursing assistants are able to receive valuable continuing education credits toward their certifications through this program. In service trainings are regularly provided and in 2009, 248 training sessions took place. Through the Nathan Adelson Hospice Learning Academy, we are contracted with University of Nevada Las Vegas, College of Southern Nevada, Touro University Nevada and Nevada State College to provide rotations for students in pharmacy, social work, and nursing. Dr. Wheeler is the preceptor for medical students or residents. Justin Kullgren is the preceptor for pharmacy students.

Nathan Adelson Hospice’s Elaine Wynn Palliative Care Program Nathan Adelson Hospice is the first organization in Southern Nevada to have a dedicated Palliative Medicine Program. In 2009, Nathan Adelson Hospice formalized a palliative care partnership with Sunrise Hospital.

Pediatric Program In 2010, due to a significant increase in pediatric patients, Nathan Adelson Hospice created the first and only comprehensive Pediatric Program in the state of Nevada led by Angela Berg, RN. This program meets the unique needs of this patient population in our community. A dedicated team of pediatric health care professionals including board certified hospice and palliative care pediatrician, nurses, social workers and bereavement team. This team is comprised of seasoned professionals in the special needs of this fragile population whose needs were not previously being met.

In addition, the use of staff at the Nevada Institute for Children’s Research and Policy adds another

level of expertise. The Nevada Institute for Children's Research and Policy (NICRP) that conducts academic and community-based research that will guide the development of policies, programs and services which will enhance the health and well-being of Nevada's children. Both Tara Phebus and Amanda Haboush (as referenced in their respective biosketches) design and conduct program evaluation research and have expertise in methods, statistics and the production of final written reports for community partners and federal agencies (NIH and CDC through subcontracts with other state agencies and academic partnerships at UNLV).

BIOGRAPHICAL SKETCH Provide the following information for the Senior/key personnel and other significant contributors.

Follow this format for each person. DO NOT EXCEED FOUR PAGES.

NAME Amanda Haboush

POSITION TITLE Research Analyst

eRA COMMONS USER NAME (credential, e.g., agency login) EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, include postdoctoral training and residency training if applicable.)

INSTITUTION AND LOCATION DEGREE (if applicable) MM/YY FIELD OF STUDY

University of Nevada Las Vegas; Las Vegas, NV B. A. 05/02 Psychology University of Nevada Las Vegas; Las Vegas, NV M. A. 05/06 Clinical Psychology

University of Nevada Las Vegas; Las Vegas, NV Ph. D. 05/2011 (anticipated) Experimental Psychology

A. Personal Statement The main purpose of this research is to determine if there are culturally differences in parent perceptions in the use of pain medication for children with life limiting illnesses and based on these results create a culturally sensitive measure of parent perceptions as well as a culturally sensitive educational tool kit for health care providers. I have been conducting original research and evaluation of community-based programs at UNLV for the past ten years and at NICRP for the past four years. As a research analyst at NICRP I have designed research and evaluation strategies for multiple projects, which include both qualitative, quantitative, and mix methods techniques, as well as been involved in every aspect of said project (interviews, focus groups, data analysis, report writing, publications). I am currently working on several papers for publications on cross cultural validation of measures of acculturation, acculturative stress as a predictor for suicidal ideation in youth, and a qualitative review of case notes of social workers in child protective services. As a doctoral candidate in the experimental psychology program, my studies have focused on statistics and research methods with an overall goal of conducting rigorous research in cultural diverse populations with a emphasis in culturally appropriate measure development/adjustment. I have completed all required graduate level coursework and is currently preparing her dissertation research entitled, Qualitative Research to Assess the Conceptual Equivalence of Measures of Emotion Regulation in Diverse Populations. Prior to entering the doctoral program in experimental psychology, I was a doctoral candidate in the Clinical Psychology program and completed all graduate coursework for the program as well as 2.5 years of clinical experience. The current application builds on my previous work in culturally appropriate research methodology and both my research and clinical experience afford me the skills necessary to carry out all project related activities especially the qualitative interviews and analyses.

B. Positions and Honors

Positions and Employment 2002 Substance Abuse Prevention Specialist, Counseling and Psychological Services,

University of Nevada, Las Vegas (UNLV) 2002-2003 Research Assist, Dr. Floyd, Psychology Department, UNLV 2003-2006 Research Assistant, University of Nevada, Las Vegas Center on Aging 2004-2005 Intern, Center for Individual, Couple and Family Counseling, UNLV 2005-2006 Intern, Neurological Testing Center, Las Vegas, NV 2005- Present Part Time Professor, University of Nevada, Las Vegas Departments of Psychology,

Social Work, Physical Education 2006-Present Research Analyst, Nevada Children’s Institute for Research and Policy, UNLV

Other Experience and Professional Memberships 2003-2006 American Psychological Association, Student Member 2006 Legislative Committee Member, Nevada State Psychological Association 2008-2009 Nevada Evaluation Association, Southern Chair 2009 Participant, CDC/Harvard Evaluation Training 2009 Participant, American Psychological Association Advanced Training Institute on

Research Methods with Diverse Groups

Honors 2009 Integral Diversity Research Award

C. Selected Peer-reviewed Publications (Selected from 3 peer-reviewed publications)

Most relevant to the current application

1) Haboush, A., Phebus, T., Tanata Ashby, D., Zaikina-Montgomery, H., & Kindig, K. (Under

Review). Still Unhealthy 2009: Building Community Research to Identify Risk Factors and Health Outcomes in Childhood Obesity. Journal of Community Health, 36(1), 111-120, DOI 10.1007/s10900- 010-9288-8

2) Haboush, A., Floyd, M. Caron, J., LaSota, M., & Alvarez, K. (2006). Ballroom Dance Lessons for Geriatric Depression: A Pilot Study. The Arts in Psychotherapy, 33(2), 89-97.

3) Benuto, L., Forrester, S., & Haboush, A. (2007). Compensatory Efforts for Body Dissatisfaction: Some Gender and Ethnic Differences. The New School Psychology Bulletin, 5, 19-25.

Additional recent publications of importance to the field (in chronological order)

1.

D. Research Support

Ongoing Research Support Lead Evaluator: Childhood Lead Poisoning Prevention Project This project examines all aspects of lead poisoning (prevention, treatment, policy, etc.) in adolescents in Clark County. Main responsibilities in this grant include creating an evaluation plan for all workgroups, data management and analysis, and assisting in final written product. Field Director: Every Child Matters in Nevada This initiative which aims to bring children’s issues to the forefront of the presidential campaign. Responsibilities include organization volunteers for state candidate events, educational outreach regarding issues and caucus process, attendance at candidate events and other community events, supervision of two student workers, coordinate with national office state emails and hosting local events.

Co –Evaluator: Evaluation of the One and Only Campaign This project is an evaluation of the One & Only Campaign educational information designed to help provide education and promote awareness about safe injection practices by health care providers. My role in this project include project coordination of activities, development of assessment tools and focus group questions, holding statewide focus groups, supervising graduate assistants, conducting qualitative and quantative analyses, and contributing to all final reports and publications.

Lead Evaluator: DA PAID Project This project is a process and outcome evaluation for the Research, Development, and Demonstration Project in support of the Project to Avoid Increasing Delinquencies (PAID). My role in this project includes a professional review of all materials, conducting focus groups to review project materials, and conduct on-line and in-person interviews with clients and staff regarding the success of the implementation of the project.

Completed Research Support

Lead Evaluator: Garret Lee Smith Suicide Prevention Program Main responsibilities in this grant include creating an evaluation plan for local initiatives for suicide prevention, data management and analysis, and production of final written products.

Lead Evaluator: Smaller Learning Communities Contract with the Clark County School District to provide an evaluation of the Smaller Learning Communities federal grant program in eight Clark County high schools. Main responsibilities in this grant include creating an evaluation plan for local initiatives, data management and analysis, and assisting in final written product. Analyst/Trainer. Contract with the Nevada State Department of Health to create a Social Marketing Evaluation Tool and Desk Reference Guide. Interviewer and Data Analyst. Legislative Counsel Bureau, Legislative Audit Division to conduct a Performance Audit of Nevada’s Child Welfare Agencies Conducted interviews, case reviews, and final written report which provided recommendations for improvements to policy and practice at the state and local level. Co- Evaluator. Nevada Communities in Schools Provide evaluation and technical assistance in data collection and analysis for this intiative which connects service providers with schools across the state of Nevada. Primary Investigator: Anti-Aging Media, Acculturation and Attitudes Towards Older People The study explored whether an individual’s involvement in utilizing anti-aging methods (i.e. anti wrinkle lotion) impacts their attitudes toward older adults or the aging process. This study also examined the differences in attitudes as a function of acculturation.

Co-Primary Investigator: Examining Cultural Links Between Media Influence and Externalizing Behaviors Related to Body Image This study attempts to determine whether or not individuals who hold on strongly to their ethnic heritage will be less willing to conform to Western standards of body image and examine if they are more satisfied with their body. Co-developed study to examine effects of acculturation and media influencing on body perception and behaviors related to those perceptions. Created, conducted, and presented study at American Psychological Association National Convention.