Honors Thesis Slides Final

Timothy J.R. Little
Mentor: Terry A. Cronan
San Diego State University
The Effects of Comorbidity and Mental Health Status
on the Perceived Likelihood of Hiring a Healthcare
Advocate
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Health Care System
• The United States (U.S.) health care system is complex and difficult to
navigate (Boult, et al. 2008; Seitz, Purandare, & Conn, 2010).
• Health care in the U.S. is tailored more toward patients with acute illness
and injuries than toward those with chronic conditions (Seitz, Purandare, &
Conn, 2010; Steffens, et al., 2000).
• Patients with chronic, comorbid conditions are such frequent health care
users (Robben, et al., 2012) that this can overwhelm the health care system
(Boult, et al. 2008).
 Not equipped to deal with ongoing treatment and management services
(Gruneir, Silver, & Rochon, 2010).

What are the consequences?
• Older adults are at an increased risk for developing multiple chronic
conditions (Anderson and Horvath, 2004).
• As the population lives longer, the health care system will become more
overburdened (Seitz, Purandare, & Conn, 2010).
• This can create a disjointed health care experience (Robben, et al., 2012).
• Barriers may prevent individuals from receiving quality care (Robben, et al.,
2012).

Who are some frequent health care users?
• It is common for patients with mental health conditions to be long-term,
frequent health care users (Seitz, Purandare, & Conn, 2010).
• Therefore, having a mental health condition is a risk factor for
hospitalization and ongoing treatment (Seitz, Purandare, & Conn, 2010).
• One of the most common mental health conditions is dementia (World
Health Organization, 2015).

Dementia
• Dementia is a neurodegenerative disorder affecting memory, thinking,
behavior, and the ability to perform daily tasks (World Health Organization,
2015).
• Patients with dementia have difficulty accessing health care because:
 Dementia is progressive.
 They have impaired decision-making ability.
 They suffer from stigma
(Giebel, Zubair, Jolley, Bhui, & Purandare, 2015).

Who are other frequent health care users?
• 7% of older adults have been diagnosed with depression (Anxiety and
Depression Association of America, 2015).
• Symptoms associated with depression are:
 Reduced quality of life.
 Social deprivation.
 Loneliness.
 Lack of energy/motivation
(Steffens, et al., 2000).
• Patients with depression use more health and home care services than
those without depression (Steffens, et al., 2000).

What about Comorbidity?
• Twenty percent of older Americans are living with multiple chronic
conditions (Vogeli, et al. 2007).
• People with mental health conditions, such as dementia and
depression, often have comorbid physical conditions (Boult, et al.
2008).
• Patients with multiple chronic conditions are more likely to be at
risk of medical errors and conflicting medical prescriptions (Boult,
et al. 2008; Vogeli, et al. 2007).
• These patients may require additional services to navigate the
health care system (Robben, et al., 2012).

Hypertension
• Half of older adults in America are affected by high blood pressure
(hypertension) (AHA, 2007).
• Hypertension is defined as having a blood pressure reading above 140/90.
(World Heart Federation, 2014).
• It is the biggest risk factor for stroke and heart
attacks (World Heart Federation, 2014).

Arthritis
• Arthritis is also among the common chronic diseases for Americans
(Hootman, Helmick, & Brady, 2012), affecting nearly 50% of adults
65 and older (Centers for Disease Control and Prevention, 2009).
• Arthritis affects joints and the tissue that surrounds the joints,
causes pain, stiffness, limited range of motion, and is also a major
contributor to disability (Center for Disease Control and Prevention,
2014).

• 47% of Americans with arthritis have at least one comorbid
condition (2007 National Health Interview Survey).
• Patients with comorbid conditions may benefit from
assistance in navigating the health care system (Boult, et al.
2008; Robben, et al., 2012).

So what can be done?
• Researchers have shown that patients’ involvement in their
health care decisions increases adherence to medical
instructions, improves health, and adds continuity to their
health care experience (Robben, et al., 2012).
• Enhancing collaboration between health care professionals and
patients may help improve the health care experience (Boult, et
al. 2008; Robben, et al., 2012).

What is a Health Care Advocate?
A hired professional who works exclusively for the patient and
his/her family.
 Provides emotional, physical, and logistical support.
 Stays overnight in the hospital, manages complex medical
regimens, medical appointments, and research treatment
options.
Health Care Advocates (HCA) can facilitate the process of
navigating through the fragmented health care system
(Vasserman-Stokes, Cronan, & Sadler, 2012).

Health Care Advocate Defined
• Professional who is trained to have a complete understanding of how the
health care system works.
• Understands symptoms and treatments for both physical and mental
health conditions.
• Informs all treatment providers about changes to the patient’s treatment
plans.
• Maintains the patient’s treatment records and assists with obtaining
services.

What impact can an HCA have?
Health Care Advocates can improve the patient’s health care
experience and reduce the burden on both the patient and
the family as well as the health care system (Van Liew & Cronan,
2012).

What can they do?
• Provide on-call resources for long-term health care service users.
• Provide more tailored medical plans.
• Help alleviate the overburdened health care system and provide patient-
specific support leading to better health outcomes.

What is the purpose of this thesis?
• The purpose of this thesis was to examine the effects of
mental health status and comorbidity on the likelihood of
hiring an HCA.
• It was hypothesized that participants asked to imagine
themselves as being diagnosed with dementia and having
comorbid conditions (arthritis and hypertension) would be
significantly more likely to hire an HCA than those with
depression and no comorbid conditions.

Where?
• Participants were randomly selected from Balboa Park.
 Culturally diverse environment.
• Participants (N = 1200) were primarily middle-aged (M = 47.7 years old),
female (53%), and Caucasian (74.8%).

What did we do?
• Eligible participants were presented with:
 A cover letter explaining the nature of the study;
 Information about their rights as research participants;
 A one-paragraph definition of the role of a healthcare advocate;
 A vignette describing a medical scenario;
 A brief survey to assess the perceived likelihood of hiring an HCA.
• Participants were randomly assigned to read vignettes that varied in
mental health condition and whether there was a comorbid condition.

What did the vignettes describe?
• Mental health condition in the vignette:
 Dementia: Forgot several appointments, forgot to take medications, misplaced
things, and forgot to turn off the oven twice.
 Depression: Feeling low to no motivation, hopeless, low energy, difficulty
concentrating and making decisions.
• Comorbidity in the vignette:
 Treated for high blood pressure and arthritis in the knees and hips
 If no comorbid conditions, described as otherwise healthy.

What variables were examined?
• Independent Variables:
 Mental Health Condition (Dementia or Depression)
 Comorbidity (Arthritis and Hypertension or Otherwise Healthy)
• Dependent Variable:
 Combined mean score of 10 items on the likelihood of hiring an HCA

What analyses were performed?
• A Cronbach’s alpha was performed to measure the internal consistency (α
= .946) of the ten items used to measure the likelihood of hiring an HCA.
• Understanding of an HCA’s role, gender, potential HCA cost and education
were added as covariates because previous findings and preliminary
analyses indicated that they significantly predicted the perceived
likelihood of hiring an HCA.
• A 2 (mental health condition: dementia or depression), by 2 (comorbidity:
hypertension and arthritis or otherwise healthy) between-subjects
analysis of covariance was performed on the mean likelihood of hiring an
HCA.

And what was found in the ANCOVA?
5.6
5.8
6
6.2
6.4
6.6
6.8
7
7.2
7.4
7.6
Dementia Depression
Likelihood of hiring an HCA
F(1, 1087) = 87.19, p < .001.

What does that tell us?
• The findings indicate a greater perceived need of HCA services for
dementia than for depression.
• This may be attributed to the fact that treatments for depression are
available and known to the public, but this is not true for dementia
(National Institute of Mental Health, 2011).
• It also may be attributed to the debilitating effects of dementia. Unlike
depression, dementia is characterized by a progressive deterioration of
cognitive function over time.

• There was no main effect for comorbidity or an interaction.
• Participants were relatively young and may not have understood the
additional impact that comorbid conditions could have on health status.
• Additionally, the fictitious individual in the vignette was described as
having the comorbid conditions treated for 10 years. This may have
reduced the perceived need for hiring an HCA for the comorbid condition.
• These findings are inconsistent with previous research indicating that
mental health, together with comorbid physical conditions, creates
additional burden for individuals and their caregivers (Boult, et al. 2008).
• Additional research is needed to examine whether different combinations
of physical and mental health conditions increase the perceived likelihood
of hiring an HCA.

Conclusions
• It is expected that by 2030, one in five people in the United States will be
65 and older (US Department of Health and Human Services, 2015).
• Thus, it is important to determine the conditions under which additional
health care services are needed (Robben, et al., 2012).
• More research is needed to understand people’s perceptions of the
burden of various combinations of mental and physical conditions.
• This will allow health care providers to plan more effectively for the needs
of older people in the U.S.

Acknowledgements
Terry A.
Cronan Ph.D
April MayMaya D'Eon
Bianca Ayscue
Heather Synder
Mathew Mansoor
Lauren McKinley
Breanna Holloway
Symone McKinnon
Cliff Ridenour
Nancy Cronan

References
• American Heart Association. (2007). “Test Your High Blood Pressue IQ”, retrieved on June 19,
2014, from: http://www.americanheart.org/presenter.jhtml?identifier=3021399
• Anderson, G. & Horvath, J. (2004). The growing burden of chronic disease in America. Public
Health Reports, 119(3), 263-270.
• Beekman, A., Copeland, J., & Prince, M. (1999). Review of community prevalence of
depression in later life. The British Journal of Psychiatry, 174(4).
• Boult, C., Reider, L., Frey, K., Leff, B., Boyd, C., Wolf, J., Wegener, S., & Marsteller, J. (2008).
Early effects of "guided care" on the quality of health care for multimorbid older persons: A
cluster-randomized controlled trail. Journal of Gerontology, 63(3), 321-327.
• Brooks, V., & Osborn, J. (2012). High-Fat Food, Sympathetic Nerve Activity, and Hypertension
Danger Soon After the First Bite? Hypertension: Journal of American Heart Association, 1498-
1502.
• Seitz, D., Purandare, N., & Conn, D. (2010). Prevalence of psychiatric disorders among older
adults in long- term care homes: A systematic review. International Psychogeriatrics, 22(7),
• Steffens, D., Skoog, I., Norton, M., Hart, A., Tschanz, J., Plassman, B., Bonita, W., Welsh-
Bohmer, K., & Breitner, J. (2000). Prevalence of Depression and Its Treatment in an Elderly
Population: The Cache County Study. Arch Gen

• Robben, S., Huisjes, M., Achterberg, T., Zuidema, S., Rikkert, M., Schers, H., Heinen, M.,
&Melis, R. (2012). Filling the gaps in a fragmented health care system: Development of the
health and welfare information portal (zwip). JMIR Research Protocols, 1(2), 1-13.
• Giebel, C. , Zubair, M. , Jolley, D. , Bhui, K. , Purandare, N., (2015). South Asian older adults
with memory impairment: Improving assessment and access to dementia care. International
Journal of Geriatric Psychiatry,
• Gruneir, A., Silver, M. J., & Rochon, P. A. (2010). Emergency department use by older adults: a
literature review on trends, appropriateness, and consequences of unmet health care
needs. Medical Care Research and Review.
• Vogeli, C., Shields, A. E., Lee, T. A., Gibson, T. B., Marder, W. D., Weiss, K. B., & Blumenthal, D.
(2007). Multiple chronic conditions: Prevalence, health consequences, and implications for
quality, care management, and costs. Journal of General Internal Medicine, 22(3), 391-395.
• World Health Organization Dementia Fact Sheet. (2015, March 1). Retrieved March 1, 2015,
from http://www.who.int/mediacentre/factsheets/fs362/en/
• World Heart Federation (2014). “Cardiovascular disease risk factors: hypertension”:

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