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Adaptation of an Instrument Measuring Perception of Job Flexibility in Chronic Illness Self-Management

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Adaptation of an Instrument Measuring Perception of Job Flexibility in Chronic Illness Self-Management
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GLEASON, ROBYN PANTHER ( Author, Primary )
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2008

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Chronic conditions ( jstor )
Chronic diseases ( jstor )
Diseases ( jstor )
Employment ( jstor )
Factor analysis ( jstor )
Health care industry ( jstor )
Labor ( jstor )
Nursing ( jstor )
Questionnaires ( jstor )
Workplaces ( jstor )

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University of Florida
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University of Florida
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Copyright Robyn Panther Gleason. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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6/30/2007

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ADAPTATIONOFANINSTRUMENTMEASURINGPERCEPTIONOFJOBFLEXIBILITYINCHRONICILLNESSSELF-MANAGEMENTByROBYNPANTHERGLEASONADISSERTATIONPRESENTEDTOTHEGRADUATESCHOOLOFTHEUNIVERSITYOFFLORIDAINPARTIALFULFILLMENTOFTHEREQUIREMENTSFORTHEDEGREEOFDOCTOROFPHILOSOPHYUNIVERSITYOFFLORIDA2006

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Copyright2006byROBYNPANTHERGLEASON

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ACKNOWLEDGMENTSIamverythankfulfortherelatives,friends,andinstructorswhosupported,guided,andencouragedmeduringtheyearsleadingtothecompletionofthisdissertation.IwishtoexpressmygratitudetoDr.ShawnKneipp,mycommitteechair,forpatientlysharingherknowledgeandexperience.Iamalsothankfultopresentandpastcommitteemembers:Drs.BarbaraLutz,RobertFrank,DavidMiller,NancyMenzelandHosseinYarandi(specialthankstohimforhelpwithChapter4–fromDetroit).TheconsistenthelpfulnessoftheCollegeofNursingandCollegeofPublicHealthandHealthProfessionsfacultyandstaffisalsogreatlyappreciated,particularlythatofCecileKiley,KellyReid,JeanAnderson,andRobbieEller.Icouldnothaveattemptedgraduateschoolwithouttheemotionalandfinancialsupportofmyhusband,BillGleason.Hisfaithfulencouragementandmanysacrificesmadeitpossibleformetosucceed.Ithankmychildren,MollyandWes,fortheircontinuedsupport.IamalsogratefulfortheongoingsupportivefriendshipofAndreaGay,TwilaPatten,andPaulaWarrington.Lastly,IthankDr.AlmaDixon,DeanofBethune-CookmanCollegeSchoolofNursing,andthenursingfacultyandstaffwhomademanyallowancesduringthepastyearasIfinishedmydissertation.

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ivTABLEOFCONTENTSpage ACKNOWLEDGMENTS.................................................................................................iiiLISTOFTABLES............................................................................................................viiLISTOFFIGURES...........................................................................................................ixABSTRACT........................................................................................................................xCHAPTER1INTRODUCTION........................................................................................................1ProblemandPurpose....................................................................................................3ResearchQuestions.......................................................................................................3DefinitionofTerms......................................................................................................42BACKGROUNDANDSIGNIFICANCE....................................................................5PresentStateoftheResearchonHealthDisparities.....................................................5ComplicationsofChronicIllness...............................................................................10Self-managementofChronicIllness..........................................................................14JobFlexibility.............................................................................................................17SummaryandConclusion...........................................................................................193METHODOLOGY.....................................................................................................21TheoreticalFramework...............................................................................................21ExistingTheoreticalFrameworks........................................................................21PyramidofSocial-EnvironmentalSupport(PSES).............................................23ResearchDesign.........................................................................................................26SampleandSetting.....................................................................................................26Sample.................................................................................................................26Setting..................................................................................................................28Instrument...................................................................................................................29Gerstal/GallagherJobFlexibilityInstrument......................................................29ChronicIllnessResourceSurvey.........................................................................30AdditionalQuestionsAddedtotheInstrument...................................................32InstrumentFormat...............................................................................................34ProcedureforDataCollection....................................................................................35

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vInformantRecruitment........................................................................................35Inclusion/ExclusionCriteria................................................................................36ProcedureforProtectionofHumanSubjects......................................................37MethodofDataAnalysis............................................................................................38DataEntryProcedures.........................................................................................38DataAnalysisProcedures....................................................................................384RESULTS...................................................................................................................44Step1ExpertReview.................................................................................................44Step2:AdministrationoftheFirstRefinedInstrument.............................................48SampleandSetting..............................................................................................48Correlations.........................................................................................................54FactorAnalysis....................................................................................................57DescriptionofFactors–UnderlyingConcepts...................................................59ItemsRemovedAfterStep2...............................................................................60Step3:AdministrationoftheSecondRefinedInstrument.........................................67SampleandSetting..............................................................................................67Correlations.........................................................................................................70FactorAnalysis....................................................................................................73DescriptionofFactors–UnderlyingConcepts...................................................73RefinementofInstrument....................................................................................75DescriptionofFactors–UnderlyingConcepts...................................................79ItemsRemovedfromInstrumentAfterStep3....................................................80Step4:AdministrationoftheFinalInstrumentandReliabilityTesting....................81SampleandSetting..............................................................................................81ReliabilityAnalysisoftheChronicIllnessSelf-ManagementamongWorkersInstrument........................................................................................................845DISCUSSION.............................................................................................................86OverviewoftheStudy................................................................................................86AnswerstoResearchQuestions..................................................................................87Contentvaliditymeasuredbyexpertreview.......................................................87Constructvaliditymeasuredbyexploratoryfactoranalysis...............................87Internalconsistencymeasuredbycoefficientalpha............................................88Test-retestreliabilitymeasuredbyPearsonproduct-momentcorrelationcoefficient........................................................................................................88InterpretationofResults.............................................................................................88TheoreticalFramework.......................................................................................89ComparisontoGerstal/GallagherandCIRSInstruments...................................90RecruitmentIssues......................................................................................................91EmployerResponse.............................................................................................91TargetPopulationResponse................................................................................95WeaknessesandStrengthsoftheStudy.....................................................................97Limitations...........................................................................................................97UseofSelf-ReportData......................................................................................99

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viImplicationsforFurtherResearch............................................................................100OvercomingNon-ReportofChronicCondition................................................101FurtherUseoftheCISMAWInstrument..........................................................101ImplicationsforNursingandOccupationalHealthPractice....................................103Summary...................................................................................................................104APPENDIXACHRONICILLNESSSELFMANAGEMENTAMONGWORKERSINSTRUMENTSTEP1...........................................................................................106BCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP2...........................................................................................116CCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP3...........................................................................................125DCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP4...........................................................................................131ECHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP4...........................................................................................141LISTOFREFERENCES.................................................................................................151BIOGRAPHICALSKETCH...........................................................................................161

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viiLISTOFTABLESTable page 4-1Step2InstrumentQuestions....................................................................................474-2DemographicsStep2...............................................................................................504-3DifferenceBetweenValidandInvalidCases..........................................................524-4Work-RelatedItemsStep2......................................................................................534-5ChronicHealthConditionStep2.............................................................................544-6CorrelationTableInstrumentStep2........................................................................564-7KMOandBartlett'sTestStep2................................................................................584-8FactorAnalysisStep2..............................................................................................584-9TotalVarianceExplainedStep2..............................................................................594-10InstrumentItemsRemovedAfterStep2..................................................................644-11Step3InstrumentQuestions....................................................................................674-12DemographicsStep3...............................................................................................694-13Work-RelatedItemsStep3......................................................................................704-14ChronicHealthConditionStep3.............................................................................704-15InitialCorrelationsInstrumentStep3......................................................................724-16InitialKMOandBartlett'sTestStep3.....................................................................744-17InitialFactorAnalysisStep3...................................................................................744-18InitialTotalVarianceExplainedStep3...................................................................744-19InstrumentItemsRemovedAfterStep3..................................................................764-20FinalKMOandBartlett'sTestStep3......................................................................784-21FinalFactorAnalysisStep3....................................................................................78

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viii4-22FinalTotalVarianceExplainedStep3....................................................................784-23Step4InstrumentQuestions....................................................................................804-24DemographicsStep4...............................................................................................824-25Work-RelatedItemsStep4......................................................................................834-26ChronicHealthConditionStep4.............................................................................834-27ReliabilityStatisticsStep4......................................................................................84

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ixLISTOFFIGURESFigure page 3-1PyramidofSocial-environmentalSupport...............................................................244-1ScreePlotStep2......................................................................................................594-2PopulationPyramid..................................................................................................624-3InitialScreePlotStep3............................................................................................754-4FinalScreePlotStep3.............................................................................................79

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xAbstractofDissertationPresentedtotheGraduateSchooloftheUniversityofFloridainPartialFulfillmentoftheRequirementsfortheDegreeofDoctorofPhilosophyADAPTATIONOFANINSTRUMENTMEASURINGPERCEPTIONOFJOBFLEXIBILITYINCHRONICILLNESSSELF-MANAGEMENTByRobynPantherGleasonDecember2006Chair:ShawnM.KneippMajorDepartment:NursingDiabetesandchronicrespiratorydiseaseoutcomesanddiseasemanagementtrendsamongthepoorandnearpoorcontinuetofallshortofHealthyPeople2010goals.In2002,over21%ofthepopulationwithdiabetesand/orchronicrespiratorydiseasewerelower-wageworkingadults.Theseworkersareknowntohavepooreroutcomesthanthoseinhigheroccupationalgrades.Employment-relatedbarrierstochronicillnessself-managementmayexplainsomeportionofthedifferenceindiabetesandchronicrespiratorydiseaseoutcomesamongpersonsfromdisparatesocioeconomicgroups.However,littleisknownabouttheeffectofjobflexibilityonsuchoutcomesorwhetheritcontributestohealthdisparitiesbyoccupationalgrade,asnopsychometricallysoundmeasureswereavailabletoconductresearchinthisarea.Thisstudyexaminesthereliabilityandvalidityofaninstrumentdevelopedtomeasurejobflexibilityasitaffectschronicillnessself-managementamongworkers,specificallytargetingdiabetes,asthma,andotherobstructivepulmonarydiseases.The

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xipyramidofsocial-environmentalsupport,anecologicalmodelofhealthbehavior,isthetheoreticalframeworkusedtoguidethisstudyanddeveloptheinstrumentunderexamination.Thestudyconsistedof:a)reviewoftheinstrumentbyexpertsinthefieldofoccupationalhealthandchronicdisease;b)aniterativeprocessofadministrationoftherefinedinstrumenttosamplepopulationsfollowedbyfactoranalysis;andc)reliabilitytestingusingscalereliabilityanalysisandtest-retestreliabilityanalysis.Exploratoryfactoranalysisresultedinanxx-iteminstrumentrevealingfivefactors.Theinstrumentreflectedcontentvalidity,constructvalidity,internalconsistencyreliability(coefficientforthefinalinstrument:.852),andtest-retestreliability(temporalstability)demonstratedbyPearson’srof.862(p=.000).Developmentofavalidandreliableinstrumenttomeasurejobflexibilityasitaffectschronicillnessself-managementamongworkersisanimportantfirststepindeterminingwhethercertainemployment-relatedbarriersaffecttheabilityofpersonswithselectedchronicillnesstoself-managethoseconditions.Thisfieldofresearchcouldultimatelybenefitprioritypopulationssuchaslower-wageminorityworkers,whomaybemorenegativelyaffectedbyoccupationalconstraintsthanthoseinhigher-wageoccupations.

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1CHAPTER1INTRODUCTIONChronicillnessisapartoflifeformorethan90millionAmericans.Thecostofchronicillnesscareexceeds$750billioneachyear,encompassingmorethanthreefourthsofallU.S.medicalcareexpenditures(NationalCenterforChronicDiseasePreventionandHealthPromotion,2004).Complicationsofaselectfewdiseasesaccountforthegreatestcosts,eventhoughpreventionofcomplicationsisknowntobelessexpensivethansecondaryortertiarycare(Hwang,Weller,Ireys,&Anderson,2001).Disparitiesinratesofthesechronicdiseasesareapparentwhencertainnonmedicaldeterminantsofhealthareexamined(Lurie,2002).Untilrecently,mosthealthdisparitiesresearchhasbeennarrowlyfocusedonthreeareas:accesstocare,behavioralandlifestylefactors,andthephysiologicaleffectsofstressonlower-wage/minoritypopulations(Campanelli,2003;Kneipp&Drevdahl,2003).Largelongitudinalstudies,however,haveuncoveredanassociationbetweenemploymentgradeandprevalenceofchronicillness.IntheWhitehallstudies(UnitedKingdom),loweroccupationalgradeworkerswereshowntobeathigherriskofchronicillness(Marmot,Siegrist,Theorell,&Feeney,1999);intheU.S.,non-professionalmaleworkersinallsectorsreportedhighercardiovasculardisease(CVD)ratesthanprofessionalworkers(Muntaner,Sorlie,O'Campo,Johnson,&Backlund,2001).Weknowthatlowerwageworkersexperiencelessrespectfultreatment,lesscontrolovertheirownwork,andhigherratesofexposuretotoxicsubstancesandoccupationalinjuriesthanthoseinmoreskilledorprofessionaloccupations(Adler&Newman,2002;

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2Shellenbarger,1996).Whilethereisabodyofknowledgewhichlinksthechronicstressassociatedwithlowerwageoccupationstothedevelopmentofchronicillness,thepathwaysconnectingdisparitiesindiseaseoutcomeswithlowerwageoccupationsarenotasclearlydefined.ResearchexaminingassociationsbetweenoccupationalstatusandchronicdiseaseismoreeasilycarriedoutincountriessuchasBritain,wherelinkablelongitudinalnationaldatabasesexist,thanintheU.S.,wheremosthealthandoccupationaldataoccupydifferentdatabases,withnonstandardizedmeasures.Althoughmethodshavebeendevelopedtolinkjobcharacteristicsdatatohealthsurveydatausingolderdata(Schwartz,Pieper,&Karasek,1988),U.S.studiesthatattempttoconnectworkingconditionsandhealthtendtofocusonthephysiologicaleffectsofstressrelatingtocardiovasculardisease(Landsbergis,Schnall,Pickering,Warren,&Schwartz,2003;Muntaneretal.,2001;NationalCenterforHealthStatistics,2004).Cardiovasculardisease,diabetes,andrespiratorydisease,consistentlycitedinrecentstudiesasthemostexpensivediseasesintheU.S.,oftendependonintensiveself-managementtopreventdevastatingcomplications(Druss,Marcus,Olfson,&Pincus,2002).Workingconditionsinoccupationsthataffordlesspersonalcontroloveractivitiesintheworkplacemayhaveanegativeimpactondiabetesandasthmaself-management,andthisfactormightinpartexplaindifferencesinoutcomesofthesechronicillnessesbysocioeconomicposition(SEP).Forexample,personswithdiabetesmellitus(DM)requireroutinemonitoringofbloodglucose,someofwhichneedstooccurduringworkinghours.However,studiestodatehavenotexaminedtheabilityofpersonswithchronichealthconditionstoperformglucose-monitoringtasks–asoneexample–duringworkinghours.Instead,moststudiesthatconcentrateonjobflexibilitytendtoreflecttwo

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3dimensionsoftheconstruct:jobdemandsandcontrol,orjobeffectsonfamilylife.Morefocusedstudyisneededonthewayworksitesanddutiesareorganized,andhowthatorganizationaffectsemployeeswithchronicillness,asemploymentenvironmentsmayeithersupportorerodeemployees’abilitytoperformnecessaryself-managementactivitiesattheworksite.ProblemandPurposeAlthoughalife-longassociationbetweenloweroccupationalgradeandpoorhealthisknowntoexist,littlequantitativeresearchhasexaminedoccupationaleffectsonchronicillnessself-management;thatis,theeffectofemploymentgradeonhealthstatusandtheabilityoflowerwageworkerstomanagetheirchronicillnessesintheworkplace(Breezeetal.,2001).Inordertocarryoutthisresearch,reliableandvalidinstrument(s)mustbedevelopedtomeasureconditionsintheworkplacethatmayaffectchronicillnessself-management;specifically,whethercertaintypesofjobflexibilityarecriticalforpersonswhoneedtoperformself-managementactivities.Existingjobflexibilityinstrumentsmaynotmeasurevariablesspecifictochronicillnessself-managementintheworkplace.Therefore,thepurposeofthisstudyistotestthereliabilityandvalidityofaninstrumenttomeasurejobflexibilityasitaffectschronicillnessself-managementintheworkplace.ResearchQuestionsThefollowingresearchquestionswereinvestigatedinthisstudy:1.Doesanadaptedinstrumentmeasuringjobflexibilityasitaffectschronicillnessself-managementintheworkplaceexhibitvalidityasdemonstratedby:a.contentvaliditymeasuredbyexpertreview;b.constructvaliditymeasuredbyexploratoryfactoranalysis?

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42.Doesanadaptedinstrumentmeasuringjobflexibilityasitaffectschronicillnessself-managementintheworkplaceexhibitreliabilityasdemonstratedby:a.internalconsistencymeasuredbycoefficientalpha,andb.test-retestreliabilitymeasuredbyPearsonproduct-momentcorrelationcoefficient?DefinitionofTermsAdaptedinstrument:atoolusedtodeterminethevalueofcertainvariables,thathasbeenmodifiedtobeusedindifferentcircumstancesorpopulations(Merriam-Webster,2004);Chronicillness:“healthproblemsthatrequireongoingmanagementoveraperiodofyearsordecades”(WorldHealthOrganization,2004,np);Jobflexibility:theabilityofemployeestodetermine“when,whereorhowtheygettheirworkdone”(RandstadNorthAmerica,2001,np)andemployerwillingnesstopermittimeofffromjobresponsibilitiesforhealthrelatedactivities;Lower-wageworker:employedadultwhoseannualincome,ifworkingfull-time,wouldbebelow200%oftheFederalPovertyGuideline(FPG);forpurposesofthisstudy,2006figureswillbeutilized(Klein,2003);Occupationalgrade:positionintheU.S.occupationalstructure,asdefinedbytheEqualEmploymentOpportunity(EEO)OccupationalGroupsandTitlesfortheCensus2000SpecialEEOTabulation(U.S.CensusBureau,2004);Self-management:measuresthatpersonswithchronicillnessmustimplementonafrequentbasis,forthetermoftheillness,inordertotreatthesymptomsandpreventthecomplicationsofsaidillness(Barlow,Wright,Sheasby,Turner,&Hainsworth,2002;Hyatt,2002);Workplace:physicallocationorcontextinwhichapersonperformsajob(Thomsson&Menckel,1997)

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5CHAPTER2BACKGROUNDANDSIGNIFICANCEThisliteraturereviewfocusesondisparitiesinchronicillnessoutcomesamongemployeesfromdifferentoccupationalgrades.Gapsintheliteratureareidentifiedrelatedtotheeffectofemploymentconditionsonworkers’abilitytoperformnecessaryself-managementtaskstopreventcostlycomplicationsofchronicdisease.Thefirstsectiondiscusseshowcurrentresearchonhealthdisparitiesislargelyfocusedonpersonalandproviderrelatedvariables.Thesecondsectionexplorestheliteratureonpreventionofchronicillnesscomplications,whichemphasizespersonalbehaviorandproviderinterventionsratherthanotherexternalorinstitutionalfactors.Thethirdsectionexaminestheconceptofjobflexibilityasitimpactschronicdiseaseself-management,andarguestheneedforappropriatemeasurementtoolstoenableitsstudy.PresentStateoftheResearchonHealthDisparitiesAlargebodyofknowledgeexiststhatdemonstratesboththeassociationbetweenloweroccupationalgradeandpoorhealth,andtheeffectofemploymentgradeonhealthstatus(Marmot,Siegrist,Theorell,&Feeney,1999;Muntaner,Sorlie,O'Campo,Johnson,&Backlund,2001).Analysisoflongitudinalsurveysinothercountries,suchastheWhitehallstudies,hasdemonstratedthelifelongeffectsofoccupationalgradeonhealth;however,similarstudieshavenotbeencarriedoutintheU.S.duetounavailabilityofdata.UnliketheUnitedKingdom(U.K.)andothercountrieswithnationalhealthcareprograms,therearenoongoinglongitudinalstudiestyingU.S.

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6occupationaldatatohealthstatusdata.AlthoughtheNationalHealthInterviewSurvey(NHIS)wasrevisedin1997tomoreaccuratelyreflectbothcategoriesofdata,itisacross-sectional,ratherthanlongitudinal,survey(NationalCenterforHealthStatistics,2004).HigherprevalenceofchronicdiseaseamongloweroccupationalgradeworkershasbeendocumentedinthelongitudinalstudiesintheU.K.andScandinaviancountries,andpaststudieshavereplicatedthosehealthdisparityfindingsintheU.S.However,themostrecentU.S.longitudinaldataarefromtheNationalLongitudinalMortalityStudy,whichcoveredtheperiodbetween1979and1989(NationalHeartLungandBloodInstitute,2004;Sorlie,Backlund,&Keller,1995).ThelongitudinaleffectmaybelargerintheU.S.asaresultofpoorerhealthcareaccessforthelowincomeuninsured,whereasintheU.K.allcitizenshaveaccesstobasichealthcareservicesthroughtheirnationalhealthcaresystem.AtpresentintheU.S.,mostresearchonhealthdisparitiesinchronicillnessisnarrowlyfocusedonthreeareas:accesstocare,behavioralandlifestylefactors,andthephysiologicaleffectsofstressonlower-wage/minoritypopulations.Inthefollowingbriefdiscussionofthesethreeareasofresearch,literatureonstressisemphasized,asitisthemostrelevanttothefocusofthisdissertation.AccesstoCareAccesstocarehasbeendescribedasencompassingpatient,providerandhealthcaredeliverysystemlevelvariables(Ibrahim,Thomas,&Fine,2003).Themostfrequentlycitedhealthcaredeliverysystemlevelbarriertoprimaryhealthcareservicesaccessiscost,exacerbatedbyalackofprivateorpublicinsurancecoverage(Strunk&Cunningham,2002).TherehasbeenextensivestudyoftheproblemoftheuninsuredintheU.S.,whichpresentlyincludesover43millionnonelderlyAmericans,twothirdsof

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7whomarefromlow-incomefamilies(KaiserCommissiononMedicaidandtheUninsured,2003).Identifiedprovidervariablesaffectingaccessincludebothstructuralbarriers:communication/languagebarriers,problemsofcapacityinmedicallyunderservedareas/populations;and,ethnic/culturalconstraints:languagedifficulties,culturaldifferences,discrimination(Andrulis,2003).Ibrahim,Thomas,andFine(2003)describethepatientlevelvariablesas“biology,individualdiseasestatus,andpsychosocialcharacteristicssuchasculturalorindividualpreferences”(p.1619)butdonotaddresstheeffectofpsychosocialcharacteristicsoverwhichpatientsmayhavelittlecontrol,suchasoccupationalinequity.BehavioralandLifestyleFactorsBehavioralandlifestylefactorsareoftendescribedaseither“habits”orlackofadherencetohealthpromotionactivitiesorderedbyhealthcareproviders.Thisprevailingviewofchronicillnesses(assolelytheresultofindividualchoice)isdemonstratedbythecurrentresearchandpublicpolicyfocusoftheU.S.DepartmentofHealthandHumanServices(DHHS).TheDHHS“StepstoaHealthierUS”strategyforpreventionofchronicillness(particularlycardiovasculardisease)isthepreventionandcontrolofobesity–estimatedtoaffectover60%ofAmericans.Over$400millionin2004NationalInstitutesofHealth(NIH)fundingissetasideforobesityresearch(U.S.DepartmentofHealthandHumanServices[DHHS],2004).Theprevalenceofobesityisknowntobehigherinlowersocioeconomicgroups;however,resultsofasevenyearcohortstudydemonstratedthatlowerincomewasstronglyassociatedwithearlydeathevenaftercontrollingforhealthbehaviorssuchasoverweight,smoking,andlimitedphysicalactivity(Lantzetal.,1998).Itisalsoknownthatcardiovascularriskpreventionprogramsfindbetterresponseinthosewithhigher

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8SEPduetotheiraccesstomoreresourcesforparticipationinhealthyactivities(Adler&Newman,2002).Poorhealthbehaviorsinadultswerelinkedtolowsocioeconomicpositioninchildhoodina1997study,andtheauthorssuggestedthatchangesineconomicpolicythatbenefitpoorchildrenwill,inthelongrun,helptoreducesocioeconomicinequalitiesinhealth(Lynch,Kaplan,&Shema,1997).Adherencetodietaryandphysicalactivityrequirements,medicationregimensandself-managementactivitiesforcertainchronicillnessesisdependentonbothabilitytoaffordnecessarysuppliesandabilitytoperformnecessaryactions.Conditionsintheworkplacethataffectsuchadherence(e.g.,fearofreprisalforleavingtheworkstationorlackofprivacyduringself-managementactivities)mayactasbarrierstooptimalself-management.StressResponseThestressresponseisthoughttoplayalargepartinthedevelopmentandcourseofchronicillness;althoughphysiologicalresearchinthisareaisintheearlystages,thereisaknownrelationshipbetweenlong-termstressandmanychronicillnesses.Kop(2003)discussesthewaydifferenttypesofstress(acute,episodic,andchronic)havedifferentimpactsoncardiovasculardisease;heexplainsthatthechronicstressassociatedwithlowSEPaffectstheearlystagesofCVDdevelopment.McEwen,whohasbeenwritingaboutallostaticload(thebody’sresponsetorepeatedorchronicstress)since1998,states:“Chronicstresscancauseillness,puttingastrainontheheart,underminingthepoweroftheimmunesystem,andtriggeringresponsesthatmayleadtodiabetesandotherchronicillnesses”(McEwen&Laskey,2002,p.56).Presently,researchersinthephysiologicalsciencesareexaminingsympatheticnervousactivity,thehypothalamic/pituitary/adrenalaxis,andtherenin-angiotensin-aldosteronesystem,andhavealreadyidentifiedvarious

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9biologicalmarkersforstresssuchasbloodpressure,heartrate,high-densitylipoprotein(HDL)cholesterol,insulin,VonWillebrandfactorandfibrinogen(Kop,2003;Pickering,1999).Theeffectofstressesrelatedtolower-wageoccupationshasbeendocumentedintheliteraturesincethe1980s(Karasek,Baker,Ahlbom,Marxer,&Theorell,1981).Loweroccupationalgradeworkersareknowntobeathigherriskofchronicillness,inpartduetothelackofcontroltheyhaveovertheirworkingenvironment,andjobdutiesrequiringgreatereffortthanreward(Marmotetal.,1999;Siegrist&Marmot,2004).Menwhoperformnon-professionalmanufacturingandserviceworkhavehigherratesofCVDthanthosewhoworkingovernmentorfinance,andnon-professionalmaleworkersinallsectorshavehigherCVDratesthanprofessionalworkers(Muntaneretal.,2001).Thelatestresearchexaminescovariationbetweenphysicalandpsychosocialstressorsthatincreasestheeffectofstressonloweroccupationalgradeworkers(MacDonald,Karasek,Punnett,&Scharf,2001).Inadditiontotheaforementionedevidenceoftheeffectsofjobrelatedstressorsonlower-wageworkers,manyoftheseworkershavefamilyincomeswellbelowtheFederalPovertyGuidelines(FPG)andalowincidenceofemployeebenefitcoverage.Differencesinworkingconditionsamongthispopulationarealsodependentonemployercharacteristics,withworkersinsmallerestablishments(54%ofworkersin2001)havingsignificantlylowerearningsandchancestoimprovetheiroccupationalcircumstances(U.S.BureauofLaborStatistics,2003).About12%ofU.S.adultsintheworkforceareverylow-wageworkers,agroupcontainingadisproportionatenumberofminorityworkers(Andersson,Holzer,&Lane,2002).

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10Minorityworkersareatincreasedriskforbothchronicillnessandexposuretostress.AfricanAmericansareknowntohaveincreasedratesandpooreroutcomesofhypertension(HTN),DM,CVD,andasthma.Analysisofthemetro-Atlantaheartdiseasestudy(1999–2001)determinedthat“stressfulracist/discriminatoryencountersatworkareassociatedwithincreasedSBPandDBPandincreasedlikelihoodofself-reportedhypertension”(Din-Dzietham,Nembhard,Collins,&Davis,2004,p.458;Burroughs,Maxey,&Levy,2002;Sowers,Ferdinand,Bakris,&Douglas,2002).Currentresearcheffortsareexaminingthepervasivestress-relatedeffectsofdealingwithconsistentdiscrimination;scientificmeasuresofracismandspecificphysiologicresponsestoracism,however,havenotbeenfullyidentified(Betancourt,2002;Harrell,Hall,&Taliaferro,2003;NationalCenterforChronicDiseasePreventionandHealthPromotion,2003;Williams,1999).Althoughweknowthattheprevalenceofchronicdiseaseishigherandtheoutcomesofchronicdiseasearepooreramongloweroccupationalgradeworkers,mechanismsthatdrivethesedisparitiesarenotclearlyidentified.Inparticular,thedifferencesinoutcomesinchronicdiseasearenotfullyexplainedbytheaforementioneddeterminants.Therefore,otherinfluencesequallylikelytoinfluencemanagementofchronicconditionsrequireexamination.ComplicationsofChronicIllnessChronicillnesses,definedas“healthproblemsthatrequireongoingmanagementoveraperiodofyearsordecades”(WorldHealthOrganization,2004,np)areestimatedtoencompass60%oftheworld-widediseaseburdenby2020,comparedtolessthan40%in1990.AlthoughthemostfrequentlyaddressedchronicillnessesarediabetesandCVD,othercomplexconditionssuchaschronicrespiratorydisease,arthritis,HIV/AIDS,and

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11psychiatricillnessesmustalsobeconsidered.Asresearchhasdemonstrated,disablingcomplicationsofthesechronicillnessescanoftenbecontrolledorpreventedbyappropriatediseasemanagement.However,successfuldiseasemanagementislargelydependentontheabilityoftheaffectedpersontoadheretotreatmentplansthatareoftencomplexandtimeconsuming.Socioeconomicdisparitiesintreatmentadherenceareknowntoexist,andarefrequentlyassociatedwitheitherdifferencesinaccesstohealthcareservicesand/ornegativebehaviorsamongthoseinlowersocioeconomicgroups(Goldman&Smith,2002;Reed&Tu,2002,February).Chronicillnessself-managementasitrelatestodiabetesandchronicobstructivepulmonarydiseases(includingasthma)willbeexaminedinthisreviewofliterature.ThesediseasestatesareconsistentlycitedinrecentstudiesofthemostexpensiveconditionsintheU.S.,andintheliteratureonemployment-relatedcosts.Depressivedisorders,musculoskeletaldisorders,andCVDaretheonlyotherchronicconditionscitedasmostcostlyconditionsonaregularbasis.However,onlydiabetesandchronicobstructivepulmonarydiseasesrequirespecificself-managementtasksthataremostlikelytobenecessarytoconductintheworkplace;therefore,examinationofotherconditionsisbeyondthescopeofthisdissertation(Druss,Marcus,Olfson,&Pincus,2002;Goetzel,Hawkins,Ozminkowski,&Wang,2003;Goetzeletal.,2004).CurrentChronicIllnessCareThereisatendencyintheU.S.toviewcertaindiseases(usuallycommunicableconditions)aspublichealthissueswhileaddressingchronicdiseasesasthreatstoindividualsonly,besttreatedwithinaprovider-patientframework.Primaryhealthcareservicesfrequentlyfollowtheacutecaremodel,developedtoprovideaquickresponsetosymptomsusinginstitution-baseddiagnosticandtreatmentservices,withtheillnessin

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12questiontreatedasadiscrete,treatable(curable)condition.Inchronicillnesscarethismodeldoesnotwork;theseillnessesrequireacombinationofprimaryandcommunitycarethatconsidersthecontextinwhichpeopleliveandcommunityresourcesavailabletopreventlong-termcomplicationsratherthanrelieveacutesymptoms(Norris,Glasgow,Engelau,O'Connor,&McCullough,2003;Watt,Browne,&Gafni,1999;WorldHealthOrganization,2004).Intheirongoingworktodevelopanefficientchronicdiseasecaremodel,Norrisetal.havedefinedchronicdiseasemanagementas:anorganized,proactive,multi-component,patient-centeredapproachtohealthcaredeliverythatinvolvesallmembersofadefinedpopulation(e.g.providerpanelorhealthplan)whohaveaspecificchronicdisease,orasubpopulationwithspecificcharacteristics.Careisfocusedonandintegratedacross:(i)theentirespectrumofthediseaseanditscomplications;(ii)thepreventionofcomorbidconditions;and(iii)therelevantaspectsofthehealthcaredeliverysystem.(2003,p.479)Althoughthemodelispatient-centered,itdoesnotaddressmacro-levelaspectsofpatientandcommunitylifethatmayhaveaprofoundeffectonadherencetoatreatmentplan.Likewise,mostotherchronicdiseasemanagementapproachesintheU.S.andU.K.applysimilarclinically-basedinterventions,relyingonpatienteducationandmonitoringtoimproveoutcomes.Alternativeemploymentrelatedexplanationsmightshedlightonbothdisparitiesinratesofadherencetotreatmentanddisparitiesinratesandseverityofdisablingcomplicationsofchronicillness(VonKorff,Glasgow,&Sharpe,2002;Weingartenetal.,2002).JobPerformanceEffectofChronicIllnessOver60millionworkingadults(37%)intheU.S.reporthavingoneormorechronicconditions,costingapproximately$234billiondollarsayearinlostproductivity.Effectiveself-managementofmanychronicillnessescouldgreatlyreduceproductivity

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13losses,inadditiontoreducinglong-termtreatmentcostsforchronicillnessesandtheircomplications(AllianceforHealthReform,2003;Reed&Tu,2002,February).Wang,etal.useddatafromtheWHOHealthandWorkPerformanceQuestionnairetoexaminetheeffectofchronicconditionsonworkperformance.Theauthorsinvestigatedworkperformanceusingthreemeasures:absenteeism,presenteeism(Presenteeismisdefinedas:remainingatworkwhentheeffectsofahealthconditionadverselyaffectsworkperformance),andcriticalincidents.Thetelephonesurveyswereadministeredto2350informantsfromfouroccupationsrepresentingdisparateoccupationalgrades.Results(usinganalysisofcovariance)showedthatpersonswithchronicconditionsreportedmoreabsenteeismthanpresenteeism.However,forthechronicillnessesbeingexaminedintheproposedstudy,presenteeismwashigherthanabsenteeism(diabetes:7.3vs.6.4days/year;respiratorydisease:asthma18.3vs.10.6days/year,pulmonarydisease27.3vs.19.4days/year).Duetosamplesize,effectofcomorbidconditionscouldnotbeanalyzed(Kessleretal.,2003;Lowe,2002,December2;Wangetal.,2003).Similarly,ina1999studyofpersonswithType2diabetes(DM2),participantsreportedworkingwhileexperiencingnumerousdiabetescomplicationsandsymptoms.Usingwellacceptedsamplinganddataanalysismethods,thestudyfoundthatdurationofDM2predictedreductionsinworkperformanceascomparedtothecontrolgroup,buthavingDM2didnotpredictabsencefromwork,supportingtheauthors’contentionthatthereisalengthyperiodofreducedworkperformancebeforepersonswithDM2stopworkingforillness-relatedreasons.Theauthorsstated“employersandhealthplanswouldbewelladvisedtodevelopwaystohelpemployeescontroltheirdiabetes”

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14(Lavigne,Phelps,Mushlin,&Lednar,2000,p.1134)inordertopreventprematureexitfromtheworkforce.Althoughthesestudiesdemonstratethenegativeeffectsofchronicdiseaseonworkperformance,theydonotexaminethedifferencebetweenemployeeswithdifferentlevelsofillnessmanagement;productivitylevelsofpersonswithwellmanagedchronicillnessesmayapproachorequalthoseofemployeeswithouthealthproblems.Thereforeitisimportanttoexaminetheabilityofchronicallyillworkerstoperformthemeasuresthatkeeptheirillnessesingoodcontrol.Self-managementofChronicIllnessChronicillnesstreatmentregimensareoftendependentonpatientself-management–themeasuresthatpersonswithchronicillnessmustimplementonafrequentbasis,forthetermoftheillness,inordertotreatthesymptomsandpreventthecomplicationsofsaidillness.Althoughappropriateself-managementofrespiratoryconditionsandDMisknowntoimprovediseaseoutcomes,adherencetocomplextreatmentregimensrequiringpatientself-managementisknowntobeaslowas20%,andanassociationhasbeenfoundbetweensocioeconomicpositionandlevelofadherence(Barlow,Wright,Sheasby,Turner,&Hainsworth,2002;Goldman&Smith,2002;Hyatt,2002).Currentresearchonpreventionofcomplicationsinchronicillnesstendstofocusoninterventionsbyhealthcareprovidersthatcanimpactpatientself-managementatthepersonalandfamilylevel.Chronicillnessself-managementisknowntobedependentonmultiplefactorsincludingaccesstohealthcare,thequalityofhealthcarereceived,andtheabilitytopayforprescriptions,amongothers(Raphael&Farrell,2002).However,otherelements–whatGlasgow,Strycher,Toobert,andEakin(2000)describeas“moredistalareasofsupport(orbarriers),includingworkplace”(p.561)–mayhavea

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15significantimpactontheabilityofpersonswithchronicdiseasetoperformeffectiveself-management,andmayhelpexplainsocioeconomicdisparitiesinoutcomes.Barlow,etal.(2002)performedameta-analysisofself-managementprogramsusinginterventions;ultimately,145reports(halfofthemrandomizedclinicaltrials)werereviewed.Mostoftheprogramsusedacombinationofpatienteducationandcognitivebehavioral/learningactivitiesprovidedbyhealthcarepractitioners.However,thereviewdidnotmentionanystudiesthataddressedoccupationalconstraintsasfactorsthatimpacttheabilityofpersonswithchronicillnesstoperformself-managementactivities.Infact,thereislittleornoquantitativeliteratureexaminingchronicillnessself-managementintheworkplace;however,qualitativestudiesaddressingotheraspectsofchronicillnessself-managementmayinformourunderstandingofthistopic(Goldman&Smith,2002).Inameta-studyof158journalarticles,usinginterpretivecontentanalysis,ThorneandPaterson(1998)addressthechangesintwodecadesofresearchconcerningclientrolesinchronicillnessfromtheinsider(patient)perspective.Changesovertimeinthefocusandresultsofthesestudiesindicatetheemphasisonclientself-carepredominantinchronicdiseaseresearchprovidesasimplisticviewofillnessmanagement.“Thefindingsofthisresearchpresenttheidealizedchronicallyillpersonasstrong,powerful,andcompetent–misrepresentingthecomplexityofthephenomenon”(p.4).Theauthorsspeculatethatthepresentfocusmaybebasedonthepoliticallycorrectnotionthatweshouldbelookingatchronicillnessasanalternateformofnormality,ratherthanaddressingthenegativeaspectsofchronicconditions(Thorne&Paterson,1998).JoachimandAcorn(2000)wereresearcherson,andusedanalysisfrom,thesamemetastudyreferredtobyThorneandPatterson,combinedwithareviewofquantitative

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16asthmaresearchfromtheoutsider(provider)prospective(1960-1996).Theauthorsdevelopedatheoreticalframeworkthatdescribeshowthevisibilityorinvisibilityofaconditionaffectsaperson’slife.Thisresearchidentifiedstigma,visibilityandinvisibility–factorsthatinfluencedisclosureoftheillnesstoothers.Theabilityofthepersonwithchronicillnesstodisclosetheillnesstoothers(forexample,toco-workersormanagers)affectsmanyaspectsofself-caredecision-making.Thiselementofchronicillnessbehaviorhasnotbeenstudiedextensively,andcouldhaveimmenseimpactoninterventionplanninginchronicillness.Inparticular,itcouldaffecttheabilityofapersonwithchronicillnesstopracticeappropriateself-managementtechniquesintheworkplace(Joachim&Acorn,2000).ChronicillnessintheworkplaceisaddressedinastudybyRose,Kim,Dennison,andHill(2000).Theinvestigatorsusedsemi-structuredinterviewstoexplorethesocioculturalcontextofHTNtreatmentadherenceinthedailylifeof19AfricanAmericanmaleswhowerepurposivelysampledfromtheinterventiongroupofanongoingHTNclinicaltrial.Widelyacceptedqualitativemethodswereusedtoidentifythreethemesinthepatient/providerrelationship:thepersonalcontext(includinghealthbeliefs),thesocialcontext,andtheculturalcontext.Duetothelow-wage,transientnatureoftheiremployment,workoftenaffectedtheinformants’abilitytokeephealthcareappointments,andsomefeltthatemployerswouldnothirethemiftheyknewabouttheirHTN.Intheirconclusionstheauthorsdiscussthewaythatthecomplexityofthelivesofthesemenaffectstheirabilitytoself-managehypertension,andthepositiveeffectsofbothsocialsupportandacaringhealthcareproviderwhounderstandsthatcomplexity.Thisconceptisapplicabletomostclientswithchronicdisease,andisinfrequently

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17addressedinthenursingorotherhealthcareliterature(Rose,Kim,Dennison,&Hill,2000).Interestingly,astudyfromtheothersideoftheworld,usingasamplequitedifferentfromthatofRose,etal.,cametoaverysimilarconclusion.AninterdisciplinaryresearchteaminNewZealandconductedawell-designedphenomenologicstudytoexaminetheexperienceofpeoplewithHTNanditsmanagement.Participants’decisionstoadheretotreatmentwereaffectedbyacomplexintegrationofthemesandsubthemes,leadingtheresearcherstoconcludethatprovidersshouldbeawareofthecontextofclients’livesinordertodevelopanappropriatemanagementplanforHTN(vanWissen,Litchfield,&Maling,1998).Thus,weknowthatwhilecurrentchronicillnessself-managementinterventionsframechronicallyillpersonsaseasilyempoweredandfullycapableofappropriatemanagement,therealityofchronicillnessiscomplicatedbymanyfactorsexternaltoaperson’sabilitiesandcapabilities.Ineffect,thecomplexityofaperson’slifehasmoreimpactontreatmentadherenceandself-caredecision-makingthanthequalityofdiseaseeducationinterventionsprovidedbyhealthcareprofessionals.Employment-relatedconstraintsinparticularmayplayanimportantroleinchronicillnessself-managementandthepreventionofcostlycomplicationsofthoseconditions.JobFlexibilityOneaspectofthelivesofemployedadultsthatmaysignificantlyimpactchronicillnessself-managementisjobflexibility.Forpurposesofthisdissertation,jobflexibilityisdefinedastheabilityofemployeestodetermine“when,whereorhowtheygettheirworkdone”(RandstadNorthAmerica,2001,np)andemployerwillingnesstopermittimeofffromjobresponsibilitiesforhealthrelatedactivities.Intheauthor’smaster’sthesis

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18study,jobflexibilitywasfoundtobeasignificantdeterminantoflower-wageworkersabilitytoaccessprimaryhealthcareservices(Gleason&Kneipp,2004).Similarly,itmayplayanimportantroleinchronicillnessself-managementintheworkplace.PreviousJobFlexibilityStudiesPreviousstudiesonjobflexibilityhavelargelyaddressedworkers’abilitytoworkflexibleschedules,job-share,orworkfromhome,andaregearedtowardpopulationsofmiddleorupperincomeemployees(Appelbaum&Golden,2003).Allcitationsina2001-2004literaturesearch(EBSCOHostAcademicSearchPremier,May22,2004)usingthekeywords“jobflexibility”indicatedthistypeofjobflexibility.Lessthanone-thirdoftheAmericanworkforceparticipatesin“flextime”workingarrangements,andthisgroupisdisproportionatelywhiteandhighlyeducated.Inaddition,flextimepolicies,althougheffectiveformiddleandupperincomeworkers,maynotmeettheneedsoflower-wageworkerswithchronicillnesses,forwhomjobflexibilityismorelikelytobedeterminedbyhoweasyordifficultitistoleaveworkortheworkstationduringregularly-scheduledworkinghours.Nostudieswerefoundtodatethatexaminedtheimpactofemployerwillingnesstopermittimeofffromjobdutiesforhealth-relatedactivitiesinorderforemployeestoperformoraccessneededchronicillnessself-managementactivities.Furtherstudyofthisformofjobflexibilityiswarrantedinordertoanalyzeitsimpactonlower-leveloccupationalworkers’attemptstoself-managechronicillnessesintheworkplace.ExistingJobFlexibilityInstrumentsExistingjobflexibilityinstrumentsmaynotmeasureconstructsspecifictochronicillnessself-managementintheworkplace.Earlyinstrumentsexaminedconceptssuchaslocusofcontrol,whilemanycurrentinstrumentsarefocusedonwork/familyissues.

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19Thesework/familyinstrumentsconcentrateonworkers’abilitytoscheduleworkinghoursaroundfamilyresponsibilities,ratherthanonactivitieswhileatwork,suchasbeingabletostopworkinglongenoughtoperformillnessmanagementactivities(Lyness,Thompson,Francesco,&Judiesch,1999;Spector,1988;Thompson,Beauvais,&Lyness,1999).OneexampleofsuchinstrumentsisafourquestionmeasurementtooldevelopedforanIBMemployeesurvey,withquestionsrelatedtoschedulingflexibilityandflexibilityinmaintainingabalancebetweenworkand“familylifebalance”(Hill,Hawkins,Ferris,&Weitzman,2001,p.52).Duetothefamilyissuefocusofthequestionsonthisandothersimilarinstruments,thesework/familytoolsarenotappropriateformeasurementoftheeffectofjobflexibilityonchronicillnessself-managementintheworkplace.Inordertoexamineworkeffectsonchronicillnessself-management,aninstrumentmustmeasurenotonlytheflexibilityofworkinghours,buttheworkers’abilitytostopworkinglongenoughtoperformnecessaryself-managementactivities(suchasusingmeasureddoseinhalersorpeakflowmetersforasthmamanagementorcheckingbloodglucoselevelsindiabetes).Twoinstrumentsthatdomeasuresuchconstructs,theGerstel/GallagherjobflexibilityscaleandtheChronicIllnessResourceSurveywillbediscussedinChapter3(Gerstel&Gallagher,1994;Glasgow,Strycker,Toobert,&Eakin,2000).SummaryandConclusionHowthenmightloweroccupationalgradeincreasethepossibilitythatalower-wageworkerwithchronicillnesswillencountermoredifficultyinperformingappropriatechronicillnessself-managementtaskswhileonthejob?Insummary,studies

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20havedemonstratedthecontextinwhichpeoplewithchronicillnessliveaffectstheirabilitytoself-managechronicillness.Socioeconomicposition,employment(includingriskofjoblossduetoillnessdisclosure)andculturalissuesarefrequentlycitedasbarrierstoeffectivediseaseself-management,butprovidersoftenfailtoconsiderand/orminimizeimpedimentsassociatedwiththecomplexityoftheirclients’lives.Inparticular,theeffectofemploymentconditionsandconstraintsonchronicillnessself-managementhasnotbeenthoroughlyexamined.However,thisinformationcouldbeofgreatbenefittobetterunderstandwhatfactorsplayaroleinchronicdiseaseoutcomes.Inaddition,itcouldassistnursesandotherprovidersworkingwithchronicallyillclientstodevelopappropriateself-managementplans,andinformoccupationalpolicymakers.Employment-relatedbarrierstochronicillnessself-managementmayexplainsomeportionofthedifferenceindiseaseoutcomesamongpersonsfromdisparatesocioeconomicgroups.Specifically,lower-wageworkersmaybemorenegativelyimpactedbyabsenceofthetypeofjobflexibilitythatenablesself-managementofcertainchronicillnessesintheworkplace.However,thistypeofjobflexibilityhasnotbeenstringentlyexamined,andthereisalackofappropriatetoolstomeasuretheconstruct.Therefore,thefirststeptowardamorecompleteunderstandingofjobflexibilityasitaffectschronicillnessself-managementisthedevelopmentofappropriatemeasurementinstruments.Withtheadditionofquestionsthatfocusontheconstructunderexamination,twoinstruments,theGerstel/GallagherjobflexibilityscaleandtheCIRS,mayformthefoundationforaninstrumentthatvalidlyandreliablymeasuresjobflexibilityasitaffectschronicillnessself-managementintheworkplace.

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21CHAPTER3METHODOLOGYThischaptercontainsanoverviewofthepyramidofsocial-environmentalsupport(PSES),thetheoreticalframeworkusedtoguidethisstudy.The“workandorganization”portionofthePSESwasusedtodevelopthevariablesunderexamination(Glasgow,Strycker,Toobert,&Eakin,2000).Inaddition,theoperationalizationofrelevantvariables,studydesign,settingandsample,datacollectionandanalysisproceduresaredescribedinthissection.TheoreticalFrameworkConceptualmodelstoguidechronicdiseaseself-managementapproachesareimportantforresearch,interventiondevelopment,andprogramimplementation;however,diseasemanagementprogramsbasedonthemostcommonlyusedbehavioral-basedframeworkshavenotshownahighrateofbehaviorchange.Itwasthereforenecessarytolookforamodelthatisresponsivetotheimpactofexternaleventsandstructuresonpersonswithchronicillness.ExistingTheoreticalFrameworksBehavioral/sociallearningtheoriessuchasthehealthbeliefandhealthpromotionmodelshavebeenrigorouslyexaminedinnursing/healthpromotionliterature.Certainvariablesofthosemodels(perceivedbenefit,perceivedbarriers,andself-efficacy)havebeenshowntocorrelatetosomeimproveddiseasemanagementadherence(Janz,Champion,&Strecher,2002;Montano&Kasprzyk,2003).However,currentpatient

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22educationprogramsgenerallyproduceonlysmallimprovementsinoveralladherence,andnewstrategiesareneededtoproducebetteroutcomes(Weingartenetal.,2002).Adaptationtheoriesproposethatpeoplewillchangetheirbehaviortocompensateforobstaclesthatblocktheirdesiredpath.TheRoyAdaptationModelhasbeenextensivelyevaluatedforuseasaframeworkforhealthpromotionanddiseaseself-management–particularlywithinnursing–resultinginanumberofmiddlerangetheoriesandpracticemodelsincludingtheadaptingtodiabetesmellitusmodel.Thismodel,however,isamicrosystems(orintra-individual)model,failingtoaddressanyexternalfactorsthatcouldimpacttheabilityofthepersonwithchronicillnesstoparticipatefullyinself-management.Theassumptionsofthemodelfocusonanindividualizedresponsetostimuli;althoughenvironmentismentioned,sociopoliticalconstructsthatimpacthealthbehaviorarenotconsideredasakeyelementofenvironment(Phillipsetal.,1998;Whittemore&Roy,2002).Initspurestform,empowermenttheoryisabouttheimpactofsocietal/environmentalconstructsonaperson’sabilitytomakeinformedchoices(Gibson,1991).However,liketheadaptationframeworksincurrentuse,empowermentframeworksarepresentlyappliedmainlytonurse/clientinteractionsinchronicillnessself-management,rarelylookingpasttheclient’sinternalbehavioraldecision-makingprocess.Theseframeworksgenerallyfailtoaddressthecomplexityoffactorsthatimpactthemanagementofchronicillness.Complexadaptivesystems(CAS)theorytakesintoaccountallaspectsofthemanycomplexsystemsinteractingtoproducetheoutputofclientchronicdiseaseself-management.Itsassumptionsofnonlinearrelationshipsandinterdependenceamong

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23parts,theelementofsurprise/chaosbeingpresentatalltimes,andtheasymmetryofactionsandreactionsfitwellwiththeunpredictabilityofcomplexchronicdiseases.However,becausetheapplicationofCAStheorytohealthcaredeliveryisanewscienceinthemidstofmodeldevelopment,thereiscurrentlynoestablishedstatisticalproceduretotestthemodel.Therefore,itwasnotanappropriatemodelforthepurposesofthisstudy(Haigh,2002).Empiricalresearchunderlyingthesetheoreticalframeworkshasdemonstratedthatindividualsdonotmakechoicesindependentlyoftheglobalcontextinwhichtheylive,andbehaviorsdonotarisesolelyfrominternalmotivations;theperson’ssociopoliticallifecontexthasamajorimpactontreatmentadherence.Therefore,treatmentsuccessorfailureisnotfullytheresultofclientchoice;theunderlyingfactorsthatpreventadherencemustbeconsidered.Atheoreticalframeworkguidinginterventionstoimprovechronicillnessself-managementshouldberesponsivetotheimpactofexternaleventsandstructuresandthecomplexityofmodernlife,particularlyforlow-incomeworkingadults.Itshouldintegrateboththemicrosystem–thepersonandtheirimmediatesurroundings–andthemacrosystem–thesurroundingcultural/socialclasscontextcomposedofmultiplemicrosystems(Bronfenbrenner,1979).PyramidofSocial-EnvironmentalSupport(PSES)ThePSES,amiddle-rangetheorywithpracticeapplications,wasdevelopedtoaddressthesemicro/macrosysteminfluences.Aresearchteamworkingintheareaofdiabetesself-managementdevelopedthePSES,andapreliminaryversionwaspublishedin1998(Glasgow&Eakin,1998).Thepresentmodelwaspublishedin2000,aspartofaresearchstudybytheRobertWoodJohnsonFoundation(Glasgowetal.,2000).

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24ThePSES,asitsnameimplies,isanecologicalmodelofhealthbehavior.Ecologicalmodels“considertheconnectionsbetweenpeopleandtheirenvironments”(Sallis&Owen,2002,p.462).Thesemodelsassumethatthepersonal,sociologic,cultural,political,andphysicalcontextsinwhichpeoplelivehaveanimpactontheirhealthbehaviors.HealthyPeople2010isanexampleofahealthpromotionstrategybasedonanecologicalmodel(Kickbusch,1996).ThePSEScontainssixpsychosocialandenvironmentalfactors(includingtheworksite)whichinfluencechronicillnessself-management.Themodel(seeFigure3-1below)formsapyramidwithfourlayers:coping(apex),closerelations,context,andculture(base).Formal-InstitutionalInformal-Interpersonal PersonalCopingDiseaseAllManagementOtherCloseRelationsHealthCareFamilyandTeamFriendsContextWorkandNeighborhoodOrganizationPhysicalEnvironmentCultureMediaandCommunityPolicyandRegionPyramidofsocial-environmentalsupportAdaptedfromGlasgow,etal.,2000,p.561 Jobflexibility•controloverworkschedule•abilitytoperformself-managementtasksatworkFormal-InstitutionalInformal-Interpersonal PersonalCopingDiseaseAllManagementOtherCloseRelationsHealthCareFamilyandTeamFriendsContextWorkandNeighborhoodOrganizationPhysicalEnvironmentCultureMediaandCommunityPolicyandRegionPyramidofsocial-environmentalsupportAdaptedfromGlasgow,etal.,2000,p.561 Jobflexibility•controloverworkschedule•abilitytoperformself-managementtasksatworkFigure3-1.PyramidofSocial-environmentalSupportSupportiveandinhibitoryfactorsinfluenceeachlevel.Thebottomthreelayerseachhavetwodimensions:theformal-institutionalandtheinformal-interpersonal.Asthey

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25descend,thelevelsbecomemoredistalfromtheindividualbutexertmoreinfluenceoverhealthbehavior.However,mosthealthpromotioneffortsconcentrateonthetopmosttwolayers:theindividual’scopingbehaviors,interactionswithsignificantothers,andinteractionswiththehealthcareteam(Glasgowetal.,2000).Thenextbroadestlevel,context,containstheconstructofinterestforthisstudy,workandorganization;theotherdimensionofthecontextlevelisneighborhoodandphysicalenvironment.Thebaseofthepyramidisformedbythecultureinwhichthepersonlives,formedbytheformal/institutionalconstructofmediaandpolicy,andtheinformal/interpersonalconstructofcommunityandregion.Forpurposesofthisresearch,therefore,theworkconstructwillbeexamined(Glasgowetal.,2000).Inthecontextofself-managementactivitiesattheworksite,on-sitewellnesspolicies(nosmokingrules,availabilityofnutritiousfoodsandphysicalactivityresources)andflexibleschedulesareconsideredsupportivefactors.Lackofcontrolovertheworkschedule,andinabilitytoperformself-managementactivitiesinprivacyarelistedasinhibitingfactors.Thestigma(embarrassment)ofcertainchronicillnessesmayalsobeaninhibitoryfactor.AsdemonstratedinFigure3-1(above)theinstrumentunderdevelopmentwillchieflyexaminejobflexibility(lackofcontroloverworkschedule,abilitytoperformself-managementtasksatwork);questionsregardingavailabilityofon-sitewellnesspoliciesandstigmawillalsobeincludedinthequestionnaire(Glasgow&Eakin,1998).UseofthePSESallowsresearcherstoexaminespecificconstructsthatinfluencechronicillnessself-management,whileconsideringthebroaderframeworkinwhichpersonswithchronicillnesslive.Forexample,boththepervadingcultureofthe

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26community,andstate/locallawsandpoliciesmayinfluenceworkplacelevelpoliciesthataffectchronicillnessself-management.ThePSESthereforeprovidesafittingframeworkforthedevelopmentofthisjobflexibilitymeasurementtool.ResearchDesignThisstudyusesanexploratory,prospectivedesigntotestthereliabilityandvalidityofaninstrumentdevelopedtomeasurejobflexibilityasitaffectschronicillnessself-managementintheworkplace.Itwasconductedinfoursteps:Step1:initialreviewoftheinstrumentbyexpertsinthefieldofoccupationalhealthandchronicdisease,includingpersonswhoarepartofthetargetpopulation(employedpersonswithchronicillnessesrequiringself-management),followedbyrefinementoftheinstrument;Step2:administrationoftheinstrumenttoasample,followedbyexploratoryreliabilityandfactoranalysiswithfurtherrefinementoftheinstrument;Step3:administrationoftherefinedinstrumenttoasample,followedbyexploratoryreliabilityandfactoranalysiswithfurtherrefinementoftheinstrument;Step4:reliabilityoftheinstrumentwasmeasuredusingtwomethods:scalereliabilityanalysisandtest-retestreliabilityanalysis.Specificsofthemethodsusedaredetailedbelow.SampleandSettingSampleTheconveniencesamplewasdrawnfromemployedadultsinAlachua,Volusia,andFlaglerCountiesinNorthandCentralFlorida.InAlachuaCountyapproximately20,000workingpeoplehaveatleastonechronicillness,whileVolusiaandFlaglerCountieshaveapproximately40,000employedworkerswitheitherdiabetesorchronicrespiratorydisease(NationalCenterforChronicDiseasePreventionandHealthPromotion,2004;U.S.CensusBureau,2000).AlachuaCounty’spopulationhasahighlevelofpersonslivingbelowtheFPG(AlachuaCounty:22.8%;Florida:12.5%;U.S.:12.4%),andalargeAfricanAmericanpopulation(AlachuaCounty:19.3%;Florida:14.3%;U.S.:12.3%);asnotedearlier,AfricanAmericansareknowntohaveincreased

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27ratesandpooreroutcomesofthechronicillnessesunderconsideration(Betancourt,2002;U.S.CensusBureau,2000).Sincethedatacollectedfromthissamplewasanalyzedusingfactoranalysis,apoweranalysistodeterminesamplesizewasnotappropriate(therebeingnonullhypothesis).Thereisnoabsolutedeterminationofsamplesizeforthistypeofanalysisintheliterature.Variousmethodologicalstudies(andopinions)setappropriaterangesfrom2-20itemsperfactor,andfrom20-300minimuminformants(Sapnas&Zeller,2002;Yarandi,2003).Inaddition,inductivelyderivedquestionnairessuchasthatinthepresentstudymayhavelessmeasurementerror,astheyarebasedoninformants’experiencesratherthanonquestionnairesderivedfromresearchersdistaltophenomenonofinterest,andmaythereforerequireasmallersample(Sapnas&Zeller,2002).ArecentstudyusingMonteCarlocomputersimulationstodetermineinadequate,adequate,andexcessivesamplesizeforinstrumentdevelopmentinsocialsciencesrecommendsusing50-100cases.SapnasandZeller(2002)foundthata“samplesizeof50isbarelyadequate,asamplesizeof100isfullyadequate,andsamplesizeof250ormoreisexcessive”(p153).Thetest-retestportionofthisstudywillbeanalyzedusingCronbach’salpha,forwhichsamplesizehaslittleeffectexceptinsamplessmallerthan25(Sapnas&Zeller,2002).Initially,samplesof120informantsforeachadministrationoftheinstrument(Steps2and3)wereplanned.ThissizemetbothSapnasandZeller’s(2002)requirementsandthemoretraditionallyacceptedfiveinformantsperfactorrequirement(Harman,1976;Yarandi,2003).However,recruitmentofemploymentsitesforadministrationofthequestionnaireduringStep2metunexpectedobstacles,andresponse

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28rateatrecruitedsiteswaslowerthanexpected(furtherdiscussionoftheneedforachangeinmethodologycanbefoundinChapter5).TherationaleforreducingsamplesizeisbasedonthefindingsofSapnasandZeller(2002–seeabove),andMacCallum,Widaman,Zhang,andHong(1999),whostate:Ourtheoreticalframeworkandresultsshowclearlythatcommonrulesofthumbregardingsamplesizeinfactoranalysisarenotvalidoruseful....mostimportantly,levelofcommunalityplaysacriticalrole.Whencommunalitiesareconsistentlyhigh,probablyallgreaterthan6,thenthataspectofsamplingthathasadetrimentaleffectonmodelfitandprecisionofparameterestimatesreceivesalowweight...thusgreatlyreducingtheimpactofsamplesizeandotheraspectsofdesign....Goodrecoveryofpopulationfactorscanbeachievedwithsamplesthatwouldtraditionallybeconsideredtoosmallforfactoranalyticstudies,evenwhenNiswellbelow100.(p.96)Forthetest-retestportion(Step4),thequestionnairewasadministeredtwiceto16informantsatatwo-weekinterval.Theretestcontainedaqualitativequestiontoindicatewhetheranychangeshadoccurredintheworkenvironmentsincetheinitialtest.Informantsreportingchangesintheworkenvironmentthatmightresultinresponsedifferenceswereexcludedfromthetest-retestsample.SettingThisstudywasconductedatvariousworksites(inAlachua,Volusia,andFlaglerCountiesinNorthandCentralFlorida)thatemployworkersfromthefollowingoccupationalgroups:professional;technicalandrelated;executive,administrative,andmanagerial;administrativesupport;sales;skilledtrades,machineoperators,assemblers,andinspectors;andserviceoccupations.Sitesincludedmanufacturingfacilities,callcenters,professionaloffices,skillednursingfacilities,hospitals,banks,fastfood

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29restaurants,constructioncompanies,medicaloffices,andeducationalfacilities.Inaddition,variouspubliclocationsinCentralFloridaincludingwaitingroomsofhealthcareprovidersandhealthfairswereutilizedasrecruitmentsites.InstrumentExistingjobflexibilityinstrumentsmaynotmeasurevariablesspecifictochronicillnessself-managementintheworkplace.Earlyinstrumentsexaminedconceptssuchaslocusofcontrol,whilemanycurrentinstrumentsarefocusedonmanagingorbalancingwork/familyissues(Lyness,Thompson,Francesco,&Judiesch,1999;Spector,1988;Thompson,Beauvais,&Lyness,1999).OnesuchinstrumentisafourquestionmeasurementtooldevelopedforanIBMemployeesurvey,withquestionsrelatedtoschedulingflexibilityandflexibilityinmaintainingabalancebetweenworkand“familylifebalance”(Hill,Hawkins,Ferris,&Weitzman,2001,p.52).Duetothefamilyissuefocusofthequestionsonthisinstrument,andperhapsbecauseofitsdevelopmentforuseinaspecificcompanyenvironment,itwasnotappropriateforuseasameasureoftheeffectofjobflexibilityonchronicillnessself-managementintheworkplace.Gerstal/GallagherJobFlexibilityInstrumentThemeasureofjobflexibilityinstrumentadaptedbyGerstel&Gallagher(1994)assessescertaincharacteristicsofemploymentthatmaybeusefulwhenmeasuringemploymenteffectsonself-management.Thisinstrumentinvokeslessrespondentburdenthanothermeasuresofemploymentandcapturestheconceptualaspectsofemploymentrelevantfortheaimsofthisresearch.Validityandreliabilityofthejobflexibilityinstrumentwasdemonstratedinapreviouspilotstudy(Kneipp,Castleman,&Gailor,2004),atwhichtimethetest-retestreliabilitycoefficientfortheinstrumentinasmallsampleoflow-incomewomenindicateditisverystable,withr=.966(p=<0.000,n=18).

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30Itemsintheinstrumentalsodemonstratedanacceptabledegreeofinternalconsistency,withaCronbach’salphaof0.72inalargersampleofwomen(n=32).Thesixitemquestionnaire,conductedusingaLikertresponsescalerangingfrom0to2(“notatall”to“verymuchso”),containedthefollowingitems:1.ThetimeIstartworkisflexible.2.IfIneedapersonaldayoff,itiseasytotake.3.ThehourIleaveworkisflexible.4.Iamgivenalotoffreedomtodecidehowtodomywork.5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone.6.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat(reversecoded).ChronicIllnessResourceSurveyTheChronicIllnessResourceSurvey(CIRS)wasdevelopedtomeasuredifferenttypesofresourcesavailabletopersonswithchronicillness,includingthoseintheworkplace.ThetheoreticalframeworkofthisinstrumentisthePyramidofSocial-EnvironmentalSupportmodel(PSES).AlthoughtheCIRSwasdevelopedspecificallytomeasureworkplaceresources,itdoesnotcaptureallaspectsoftheworkplacethataffectchronicillnessself-management(Glasgowetal.,2000).TheprospectivevalidationstudyoftheCIRSincluded123studyparticipantswhoeachhadatleastonechronicillness,recruitedusingconvenience-samplingtechniques(samplesizedeterminedbyanaprioricalculation).Thesurveyswereadministeredatgroupsessions,withfollow-upadministrationatfourmonths.Retestsweregiventoasubsetofparticipants.The“Work”segmentofthe64-iteminstrumentcontains8questionsregardingdiseasemanagementissuesintheworkplace(Glasgowetal.,2000).

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31ConvergentvaliditywastestedbycomparingtheCIRStopreviouslyvalidatedself-efficacy,socialsupport,medicalsatisfaction,community,andcompany/co-workersupportscales.Dietarybehavior,physicalactivity,illnessintrusiveness,mental/physicalfunctioning,illnessmanagement,socialsupportRTeating/activity,interpersonalsupport,andsocialnetworkinstrumentswerecomparedtotheCIRStoestablishcriterionvalidity.TheBalancedInventoryofDesirableRespondingwasadministeredtoeachparticipanttocontrolforresponsebiasbymeasuringinformants’inclinationtogivemisleadingdesirableself-reports.Cronbach’salphaandtest–retestPearsonproduct–momentcorrelationcoefficientswerecomputedforallCIRSsubscales.Correlationsbetweendocumentedsupportandperceivedsupport,constructvalidityvariabilityandtemporalstabilityoftheCIRSscaleandthesubscaleswereexaminedusingdescriptiveandcorrelationanalysestoguidedevelopmentofabriefversionoftheCIRS(Glasgowetal.,2000).IntheCIRS”Work”scale,sevenofthequestionsusefivepointhorizontalLikertscaleanswers(numbered1-5with1:“notatall”;3:“amoderateamount”;5:“agreatdeal”)whiletheremainingquestionisanopenendedqualitativequestionaboutassessingsupportmechanisms.The“Work”scalecontainedthefollowingeightitems–onlyitemswithanasterisk(*)areincludedintheBriefCIRS,whichcontainedtheentiretextofasmallernumberofitems:1.Overthepast3months,towhatextent:a.*Haveyouhadaflexibleworkschedulethatyoucouldadjusttomeetyourneeds?b.Hasyourworkofferedwellnessprogramsorfitnessfacilities?

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32c.*Hasyourworkplacehadrulesorpoliciesthatmadeiteasierforyoutomanageyourillness(suchasnosmokingrulesortimeoffworktoexercise)?d.Haveyourcoworkerscoveredforyouwhenyouneededtodosomethingtomanageyourillnessorwerenotfeelingwell?e.*Haveyouhadcontroloveryourjobintermsofmakingdecisionsandsettingpriorities?f.Hasyouremployerprovidedpaidtimeoffworkforhealthcareorfitnessactivities?2.*Howimportantareworksitesupportandresourcestoyouinmanagingyourillness?3.Pleaselistotherthingsthathappenedorotherresourcesyouusedoverthepast3monthsthathelpedyoutomanageyourillness:(open-ended).BoththeGerstel/GallagherscalequestionsandtheCIRSscalequestionswillbeincludedintheevaluationofanewjobflexibilityinstrumentthatisthesubjectofthisdissertation.AdditionalQuestionsAddedtotheInstrumentTheobjectiveoftheadaptedinstrumentistoaccuratelyreflectthedegreetowhichworkplaceaffectschronicillnessself-management.Therefore,additionalquestionswereadded.Thesequestionswereidentifiedusingpriorknowledgeoftheresearcherandheradvisorrelatedtochronicillnessself-managementandlower-wageworkingconditionsthatwerebasedinyearsofclinicalexperienceworkingwiththispopulation.Asmallqualitativestudyofmembersofthetargetedpopulationwascarriedoutbytheresearchertoidentifyadditionalconceptsthatmayimpactchronicdiseaseself-managementintheworkplace.Asaresult,thefollowingquestionswereaddedtothejobflexibilityportionoftheinstrument:1.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat.

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332.Areyouallowedtostopworkinglongenoughandoftenenoughtodowhatyouneedtodototakecareofyourillness?Forinstance,areyouallowedtoleaveyourworkstationwhenyoufeelyouneedtotake5minutestoperformanecessarytasktohelpmanageyourcondition?3.Doesyourworkplacehaverulesorpoliciesthatmakeiteasierforyoutotakecareofyourillness?Forinstance,areyouallowedtoleaveyourworkstationwhenyoufeelyouneedtodoacheckonyourillnessortreatyoursymptoms?4.Howeasyisitforyoutoleaveyourjobdutiesforroutine(“non-sick”)healthvisitstomanageyourchronicdisease?5.Howeasyisitforyoutoleaveyourjobdutiesfor“sickvisit”care(officeorhealthcareappointments)whenyouhaveaspecifichealthproblem?6.Howeasyisitforyoutoleaveyourjobdutiesforpersonalneeds(forexample,leavingtotakecareofbankingneeds)?7.Howeasyisitforyoutoleaveyourjobdutiesforfamilyneeds(forexample,leavingtoattendkids’schoolactivities)?8.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotake5minutestoperformanecessarytasktohelpmanageyourcondition?9.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments?Demographicquestionsaddressedgender,age,racial/ethnic/culturalgroup,lengthoftimeatpresentjob,descriptionandnameofjob,type(s)anddurationofchronicillness,householdincomelevel.Inaddition,informationalquestionswereaddedbasedontheresultsofanearlier,related,qualitativepilotstudythatexaminedhowfull-timeemploymentimpactsillnessself-managementinworkerswithchronicdisease.Findingsledtotheinclusionoffouradditionaljob-relatedquestionsinthequestionnairepresentlyunderstudy:1.Doyouknowsomeoneatyourjobsitewiththesameillness?Ifyouansweredyes,isthatpersonyoursupervisor?2.Doesyouremployerknowaboutyourillness?Ifyouansweredno,pleasetelluswhyyoudidnottellyouremployer.

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343.Whodecideswhetherornotyoucanleaveyourworkstation?(Ido,mymanagerdoes,[nameofpositiontitle]does)4.Howoftendoyouthinkaboutyourillnesswhileyouareatwork?InstrumentFormatTheinitialquestionnaire(priortoStep1)contained37items(bothclosed-andopen-endedquestions),andcouldbecompletedin5-15minutes,dependingonthetypeofworksiteandseverityoftheinformant’sillness.TheFleschReadabilityoftheinstrumentwas75.6%,itsFlesch-KincaidGradelevelwas6.4.Thus,theinstrumentwasappropriateforthosewhoreadatlowerproficiencylevels.Although36%ofAlachuaCountyresidentsreadatthe2lowestproficiencylevels(outof5),adultswhoareemployedfull-timeareknowntohavehigherreadingproficiency(ComprehensiveAdultStudentAssessmentSystem,2003;NationalCenterforEducationStatistics,2003;Sum,2002).Inadditionto8work-siterelated,5demographic,and2diseaserelatedquestions,theinitialChronicIllnessSelf-ManagementAmongWorkersinstrumentconsistedof22(5point)Likert-scaledquestions.ThefivepointscalingformatwaschosenbasedonitsusebybothGlasgowetal.(2000)intheCIRS,andLikertinhisoriginalscale,andaspriorresearchhasshownthatincreasesinthenumberofcategoriesinaLikert-typescaleimprovesreliability.Useofqualifiers/anchorsmorecloselyapproximatesintervallevelmeasurement.Therefore,theCIRSscalewasadaptedtoincludequalifiersforchoicestwoandfourinordertoimprovecontinuityoftheinstrument(Gerstel&Gallagher,1994;Glasgowetal.,2000;Masters,1974;Pett,Lackey,&Sullivan,2003;Weng,2004).

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35ProcedureforDataCollectionInformantRecruitmentVariousmethodsofinformantrecruitmentwereusedinthisstudy.Sincetheinstrumentneededtobetestedonemployedpersonswithselectchronicillnesses,theprincipalinvestigatorworkedwithhumanresourcesmanagers,supervisorsandownersatthepreviouslydescribedworksitestodistributequestionnairestotheentireworkforce,askingonlythosewithdiabetesorasthma/otherobstructivepulmonarydisease(hereafterreferredtoas“respiratorycondition”)tofilloutandreturnthequestionnaire.Asecureinternetsitewithanonlineversionofthequestionnairewasmadeavailabletocounteracttheaforementionedrecruitmentproblems(seeChapter5,Discussion).Emailnotificationofthequestionnairewithalinktotheinternetsitewasdistributedtoemployeesthroughhumanresourcesmanagers,supervisorsandownersatthepreviouslydescribedworksites.Recruitmentflyers,questionnaires,andinformationabouttheinternetsitewereplacedinplaceswhereworkerscongregatedatjobsiteswhereitwasnotpossibletomass-distributethequestionnaires.Recruitmentflyers,questionnaires,andinformationabouttheinternetsitewerealsoplacedinvariouspubliclocationsinCentralFlorida.Recruitmentcontinueduntildesiredsamplesizewasreached,withongoingrecruitmentofnewsitesasnecessary.Forthetest-retestsample,questionnairesweredistributedbyanemailmessagewithalinktotheinternetquestionnairetofacultyandstaffmembersinvariouscollegesattheUniversityofFlorida(UF)HealthScienceCenter.Thispopulationwasexpectedtohaveslightlyhighersocioeconomiccharacteristicstothepriorsamplewhilecontainingasufficientpercentageoflower-wageworkers.Thepurposeoftemporalstabilitytestingistodeterminereliabilityoftheinstrumentwhenadministeredtothesamegroupof

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36individualsoveraspecifictimeinterval,ratherthancomparisonofthissample’sscoreswithearliersamples.Therefore,thisdifferenceinsamplecharacteristicwasnotdeemedalimitation–themaininclusioncriteria(havingeitherdiabetesorchronicrespiratorydisease)providedadequatesimilarityofsamplecharacteristics.Inclusion/ExclusionCriteriaInformantseligibletoparticipateineachsegmentofthisstudywere:betweentheagesof18-70;employedfull-time(32hoursperweekormore);andhadbeendiagnosedwithandondailymedicationforeitherdiabetesmellitusorarespiratorycondition.Thecoversheetclearlyexplainedeligibilityrequirementsanddirectedthosewhowerenoteligibletoparticipateinthestudytoeither:1)callthePIforclarification,or2)returnordisposeoftheunopenedquestionnaire.Personswhoparticipatedinthefirstadministrationoftheinstrumentwereexcludedfromthesecondadministrationsampleandthetest-retestsample,asrecruitmentduringeachstepofthestudytookplaceatdifferentemploymentsites–thefirstandsecondadministrationstookplaceatdifferentlocationstopreventsampleoverlap;thecoversheetclearlydescribedthisexclusiontopreventrepeatadministrationtoemployeeswhohadmovedfromoneworksitetoanother.PersonswithDMwhocontroltheirdiseasebydietandexerciseratherthandailymedicationwereexcludedfromthestudyastherearenocurrentrecommendations/standardsforselfmonitoringofbloodglucosebypersonswithstablediet-controlledDM(AmericanDiabetesAssociation,2004),andthemonitoringofbloodglucoseinthisgroupinpracticetendstobefarlessintensivethanwhentakingmedication(e.g.,monitoringonceortwiceperweekfordiet-controlledasopposedtooneormoretimesdailyforthoseonmedication).

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37ProcedureforProtectionofHumanSubjectsQuestionnairepacketsandtheinternetquestionnairecontainedacoversheetwithallnecessaryelementsofinformedconsentanddirectionsregardinginclusionandexclusioncriteria.Attheendofthequestionnaire,Step2informantsusingthepaperquestionnairewereinstructedtosealthequestionnaireinsidetheattachedenvelopeandmailit(postpaid)tothePI.Thesecureonlineversionofthequestionnairedidnotrecordrespondent’sIPaddresses.Questionnairesfortheonlinetest-retestsamplegroupaskedforrespondent’semailaddressforthetwo-weekretest.Oncethetwo-weekretestwassenttotherespondent,allidentifyinginformationwasdeleted.ThisstudywassubmittedtoandapprovedbyInstitutionalReviewBoard02attheUniversityofFlorida(UFIRB02)asanexpeditedstudywithawaiverofdocumentationofinformedconsent.RevisionsforuseoftheonlinequestionnairewereapprovedbyUFIRB02.Thewaiverofdocumentationwasjustified,astheuseordisclosureofpersonalhealthinformation(PHI):(a)involvednomorethanaminimalrisktotheprivacyofsubjectsas,althoughsubjectsself-reportedachronicdiseasediagnosis,noidentifiablePHIwasmaintainedincollecteddata;(b)thewaiverofwritteninformedconsentdid“notadverselyaffecttherightsandwelfareofthesubjects”(UniversityofFloridaHealthScienceCenterInstitutionalReviewBoard01,2003p.4);(c)theresearchcouldnotbepracticallyconductedifwritteninformedconsentwererequiredduetothenecessityofdistributingthequestionnairestolargegroupsofemployeesatvariousjobsites-ifinformedconsentwasdocumented,subjectsmightperceivetheexistenceofapapertrailthatcouldmatchthemwithdisclosuresregardingnegativeworkingconditions,causinglossofpotentialsubjectstothestudy;and(d)allelementsofinformedconsent

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38wereexplainedonthequestionnairecoversheet(UniversityofFloridaHealthScienceCenterInstitutionalReviewBoard01,2003).MethodofDataAnalysisDataEntryProceduresDatawasenteredintoStatisticalProgramfortheSocialSciences(SPSS)statisticalsoftwareprogrambytheprincipalinvestigator.Datafromarandomsampleof20%oftheenteredcaseswascheckedagainstquestionnairesforerrors.InStep2,greaterthan10%ofrandomlysampledcaseswerefoundtocontainerrors,thereforealldatawasreviewedfordataentryerrorsandcorrectionsweremadeto11datapoints.InSteps3and4,fewerthan10%ofrandomlysampledcaseswerefoundtocontainerrors,thereforealldatadidnotneedtobereviewedfordataentryerrors.DataAnalysisProceduresRationale.Datawasanalyzedusing:descriptivestatisticalanalysisofdichotomousandnon-Likertscaledvariables,andexploratoryfactoranalysisandreliabilityanalysisoftheinstrumentitself(includingvariablesfromthefirst23Likert-scaledquestionsintheinstrumentforStep2,17questionsinStep3).Factoranalysisdefinesaclassofmultivariateanalysistechniquescommonlyusedtoreduceandsummarizedata.Exploratoryfactoranalysisisemployedtoexplaininterrelationshipsamongvariablesandidentifycommonanduniquefactorsunderlyingthosevariableswhentheorganizationofthosevariableshasnotbeenpreviouslyestablished.Thismethodistypicallyusedininstrumentdevelopment.Confirmatoryfactoranalysis(CFA)isthepreferredmethodwhenpriorresearchoranunderlyingtheoreticalbasishasalreadyestablishedsomeorderororganizationforthedata,e.g.,whendataiscollectedtoconfirmatheoryormodel.InCFA,theresearcherpre-specifiesthenumberoffactorsandwhichitemsshouldloadon

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39eachfactor,requiringtheuseofstructuralequationmodeling.Therefore,exploratoryfactoranalysisistheappropriatemethodforeachsegmentofthisstudy(Pett,Lackey,andSullivan,2003)Infactoranalysis,thevariablesareexaminedtodeterminetheirinterrelationshipsandtoidentifyunderlyingfactorsthatexplainthoseinterrelationships.Sincethemajordataassumptionforfactoranalysisistheexistenceofoneormoreofthesecommonfactors,adegreeofmulticollinearityamongthevariablesshouldexist.AlthoughfactoranalysisbeginswithPearsonproductmomentcorrelations,thecontinuousdatarequirementforthatanalysistechniquemaybeviolated,anddichotomousorscaleleveldatamaybeusedinexploratoryanalyses.Because“thecriticalassumptionsunderlyingfactoranalysisaremoreconceptualthanstatisticaldeparturesfromnormality,homoscedasticity,andlinearityapplyonlytotheextentthattheydiminishtheobservedcorrelations”(Hair,Anderson,Tatham,&Black,1998,p.99).ThereforetheBartletttestofsphericity(whichteststomakesurethecorrelationmatrixisnotanidentitymatrixwithzerocoefficientsforallvaluesnotinthediagonal)wasusedtodeterminethatthecorrelationmatrixwasappropriateforfactoranalysis(Pett,Lackey,andSullivan,2003;Yarandi,2003).Procedures.Descriptivestatisticswereperformedonalldichotomousandnon-Likertscaledvariables.Exploratoryfactoranalysisandreliabilityanalysisoftheinstrumentitself(variablesfromLikert-scaledquestions)involvedfoursteps(aspreviouslydelineated,andfurtherdefinedbelow).Step1.Priortodatacollectionandanalysistheinstrumentwasreviewedbyeightexpertsinthefieldofoccupationalhealthandchronicdisease,includingfivepersons

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40whoarepartofthetargetpopulation(employedpersonswithchronicillnessesrequiringself-management)todeterminecontentvalidity.Theseexpertsusedascoringsystemdevelopedbytheresearcher(seeAppendixA).Basedonthisreview,theChronicIllnessSelf-ManagementAmongWorkersinstrumentconsistedof23(5point)Likert-scaleditems,resultinginaquestionnairecontaining12work-siterelated,7demographic,and2diseaserelatedquestions.Therefinedinstrumentwasthenanalyzedforreliabilityandvalidityasfollows.Step2.Afteradministrationoftheinstrumenttothefirstsamplegroupandpriortofactoranalysis,datawasexaminedusingunivariatestatisticalmethodstoassessformissingdata.Forthe23instrumentitems,missingvalueswerereplacedbysubstitutingthevariable’smeanvaluecomputedfromavailablecases,asfactoranalysisrequiresthatallcasescontainallvariables.ThismethodisrecommendedbyPolit(1996)andothers,andwasdiscussedwithcommitteemembers.ExploratoryfactoranalysiswasthencarriedoutusingSPSS.Initially,theprincipalcomponents(PC)methodoffactoranalysiswasused,followedbytheprincipalaxisfactoring(PAF)method(aformofcommonfactoranalysis)asrecommendedbyPett(2003).Sinceeachvariablewasmeasuredusingafive-pointLikertscale,therequirementofstandardizationforPCanalysiswasmet.Promax(oblique)factorrotationwasemployedinthePCandPAFanalyses.Factorrotation“improve[s]themeaningfulnessandinterpretationofthegeneratedfactors”(Pett,Lackey,andSullivan,2003,p.131).Oblique(asopposedtoorthogonal)rotationmethodsareappropriatewhenfactorsareassumedtobecorrelated,astheyareinthisstudy.

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41ThePCmethodoffactoranalysisconsidersallthreetypesofvariance(common,specific,error)to“summarizetheinterrelationshipsamong[the]setoforiginalvariablesintermsofasmallersetofuncorrelated(orthogonal)principalcomponentsfactorsthatarelinearcombinationsoftheoriginalvariables”(Pett,Lackey,andSullivan,2003;Yarandi,2003).Factorextractionwasaccomplishedusingthecorrelationmatrixratherthanthecovariancematrix;thismethodisrecommendedinexploratoryfactoranalysis.2testissignificant,theassumptionthatthecorrelationmatrixisnotanidentitymatrixismet)andtheKaiser-Meyer-OlkinMeasureofSamplingAdequacy(KMO)–ascoregreaterthan.50indicatestheassumptionofsamplingadequacyismet(Pett,Lackey,andSullivan,2003;UniversityofNewCastleuponTyne,2002).InPCanalysis,thecommunality(amountofvarianceexplainedbyextractedfactors)ofeachitemisfirstestimatedbyincludingallsourcesofvariancewhenidentifyingthePCs(alsocalledfactors).Thisprocessreliesontheassumptionthatthereisnomulticollinearityamongthesefactors,andthat“theyarelinearcombinationsoftheitemsincludedintheanalysis”(Pett,2003,p.89);therefore,thevarianceofeachitemis1.0(withameanof0).TheamountoftotalvarianceexplainedbyeachPCisdemonstratedbyaneigenvalue.Eigenvaluesmustbegreaterthanzeroinfactoranalysis,andnogreaterthanthetotalamountofvarianceinthecorrelationmatrix,whichequalsthetotalnumberofvariables(asthevarianceofeachequals1.0).ThedefaultforfactorselectioninSPSSrequiresthateigenvaluesbegreaterthan1.0.Thisvalueisconsideredappropriatewhen:(a)thediagonalconsistsof1.0s,asinPCanalysis,(b)variablesnumberlessthan40,(c)thesamplesizeisreasonable,and(d)n/3–n/5factorsare

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42expected.Therefore,thismethodwasappropriateforthepresentstudy.However,ascreeplotwasalsogeneratedandexaminedforcomparisonbyidentifyingbreakinslopeofthefactorvariancestoverifythenumberoffactorsthatshouldbekept.Maximumiterationsforconvergencewasleftatthedefault(25)whichadherestocurrentresearchstandards(Pett,Lackey,andSullivan,2003).Onceasolutionwasreached,resultsofthePCanalysiswerecomparedtoPAFusingthesamematrix;inPAF,R2foreachvariableisusedinthecorrelationdiagonal,andaniterativeprocessiscarriedoutpriortofactorextraction.Pett’s(2003)suggestionthattheresearchershouldthen“picktheonethatisthebestfitandmakesthemostintuitivesense”(p.115)wasthenfollowed,resultinginuseofthePCanalysismethod.Step3.FurtherrefinementoftheinstrumentbasedonStep2resultedina17-itemChronicIllnessSelf-ManagementAmongWorkersinstrumentinaquestionnairecontaining6work-siterelated,5demographic,and2diseaserelatedquestions.Therevisedquestionnairewasthenadministeredtothesecondsamplegroup;exploratoryfactoranalysiswasagaincarriedoutusingthesameprocedures.Step4.FurtherrefinementoftheinstrumentbasedonStep3resultedina12-itemChronicIllnessSelf-ManagementAmongWorkersinstrumentinaquestionnairecontaining6work-siterelated,5demographic,and2diseaserelatedquestions.Reliabilityoftheinstrumentwasthenmeasuredusingtwomethods.Scalereliabilityanalysis(internalconsistencymeasuredbycoefficientalpha)wasperformedinSPSS.Acoefficientalphagreaterthan.60wasconsidered“legitimateevidenceofinternalconsistencyreliabilityinanewinstrument”(H.Yarandi,personalcommunication,July20,2006).Inaddition,therefinedinstrumentwasadministeredtwicetoasubsampleat

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43timepointstwoweeksapartfollowedbytest-retestreliability(temporalstability)analysis,usingPearsonproduct-momentcorrelationcoefficient(Pearson’sr)inSPSS.AlthoughaPearson’srof0.70-1.0isconsideredevidenceoftest-retestreliability,forthisstudyaresultgreaterthan0.80wasconsideredsatisfactory,asidenticalinstrumentsfromidenticalinformantswerebeingcompared(Allen&Yen,1979;Pett,Lackey,andSullivan,2003;Polit&Hungler,1995).

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44CHAPTER4RESULTSThischapterdetailstheresultsofdatacollectionandanalysistestingofthereliabilityandvalidityofaninstrumentmeasuringjobflexibilityasitaffectschronicillnessself-managementintheworkplace.Thisresearchwascarriedoutinfoursteps:Step1:initialreviewoftheinstrumentbyexpertsinthefieldofoccupationalhealthandchronicdisease,includingpersonswhoarepartofthetargetpopulation(employedpersonswithchronicillnessesrequiringself-management),followedbyrefinementoftheinstrument;Step2:administrationoftheinstrumenttoasample,followedbyexploratoryreliabilityandfactoranalysiswithfurtherrefinementoftheinstrument;Step3:administrationoftherefinedinstrumenttoasample,followedbyexploratoryreliabilityandfactoranalysiswithfurtherrefinementoftheinstrument;Step4:reliabilityoftheinstrumentmeasuredusingtwomethods:scalereliabilityanalysisandtest-retestreliabilityanalysis.Specificsofthemethodsusedaredetailedbelow.Step1ExpertReviewPriortodatacollectionandanalysis,ninepeoplewereaskedtoreviewtheoriginal22iteminstrument(with15additionaldemographic,work-,anddisease-relatedquestions)forcontentvalidityusingascoringsystemdevelopedbytheresearcher(seeAppendixA).Eightreturnedthereviewingmaterialsorsentanarrativereview:ADMeducatorspecializinginself-managementtechniqueswhohasType1DM.ACareCoordinatorforanadvancedillness/palliativecareproject;sheisaNursePractitionerwhohasasthmaandnewlydiagnosedDM.Achronicdiseaseresearcher,author,andeducatorwhoisanAssistantProfessorinaCollegeofNursing,specializingincommunityhealthnursing.Herqualitativeresearchfocusesonchronicdisease.

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45Anoccupationalhealthspecialist,consultant,author,andeducatorwhoisanAssistantProfessorinaCollegeofNursing.Sheisafederallyfundedresearcherspecializinginpreventionofchronicbackinjuriesamongworkingnurses.AnAssistantProfessorinaCollegeofNursingwhoseresearchinterestsconcerninterventionsforagingruralobesewomenwithDM.Acommunitymemberwhoparticipatedintheprevioussmallqualitativestudyofmembersofthetargetedpopulation,whichwasusedtoidentifyadditionalconceptsthatmayimpactchronicdiseaseself-managementintheworkplace.ShehasType2DMandasthma.AnAssistantProfessorinaCollegeofNursingwhoseresearchfocusesoncaregiversofpersonswithchronicdisease.Shealsohasasthma.AClinicalAssistantProfessorinaCollegeofNursingwhohasasthma.Herresearchcentersondevelopingstrategiestoimproveadherencetoasthmapreventivemedicationinadults.ThreereviewersratedtheinstrumentusingtheLikert-scaledratingsystem(-3Notatall–+3Completely)resultinginthefollowinganswerstothequestions“Overall,howwelldoesthisinstrumentmeasuretheinformant’sperceptionof”:Jobcontrol/flexibility:+2(n=1),+3(n=2)Jobcontrol/flexibilityasitrelatestochronicillnessself-management:+2(n=2),+3(n=1)Availabilityofworkplacechronicillnessself-managementresources:+2(n=2),+3(n=1)Availabilityofworkplacewellnessresources:+2(n=2),+3(n=1)Importance/valueofchronicillnessself-management:+1(n=1)+2(n=1),+3(n=1).Mostofthereviewerschoseinsteadtoprovidenarrativereviews,whichstatedtheinstrumentseemedtocovertheconceptswellbutrequiredadditionalitemsorrewordingincertainitems(seebelow)andonthecoversheet(informedconsent).Basedontheexpertreview,thefollowingadditions/changesweremadetothequestionnaire:Bulletingofinformedconsentinclusioncriteria.Useoftheterm“healthcondition”ratherthan“illness”.

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46AdditionofARNP/RNtotheinvestigators’names.Boldingof“month”ininstructionsandtableforincomequestion.Additionalinformationalquestionsadded:“Donothavediabetes”and“Donothaveasthma”categorieswereaddedtothequestionregardinglengthofchronichealthcondition.Howareyoupaid?(hourlyorsalary)Doesyourworkplacehaverulesorpoliciesthatmakeitdifficultforyoutotakecareofyourhealthcondition?Forinstance,isthereapolicythatsaysyouareneverallowedtoleaveyourworkstation?Areyouworriedthatyouwillbecriticizedifyouneedtoleaveyourworkstationtemporarilytocheckonyourillnessortreatyoursymptoms?Haveyoueverbeencriticizedforneedingtoleaveyourworkstationtemporarilytotakecareofyourcondition?Areyousingleormarried/livingwithapartner?Additionalitemsaddedtotheinstrument:Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition?Changestoinstrumentquestions:CIRSitems(andothers)wererewordedtoreflectthesameformatastheGerstal/Gallagherinstrument(presenttensedeclarativestatementsratherthan“towhatextenthas”questions).Thephrase“take5minutestoperformanecessarytask”wasreplacedwith“takesometimetoperformanecessarytask”–onereviewerpointedoutthatresolutionofhypoglycemicepisodesinDMmaytake30minutesormore.TheCIRSquestion“Towhatextenthaveyourcoworkerscoveredforyouwhenyouneededtodosomethingtomanageyourillnessorwerenotfeelingwell?”wasregardedastoovague;itcouldbeinterpretedas“Docoworkershelptocoverupyourabsencefromtheworksite?”.Itwasretained,aswerealltheGerstal/GallagherandCIRSitems.Reviewerssuggestedaddingquestionsregardingotherhealthrelatedactivities

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47allowedintheworkplace(suchastobaccobreaks),anduse/overuseofsickdays.However,thisinformationwasnotdeemedappropriatetotheconceptunderstudy.Expertreviewresultedina44-itemquestionnairecontaining12work-siterelated,7demographic,and2diseaserelateddescriptivequestions.TherevisedChronicIllnessSelf-ManagementAmongWorkersinstrumentconsistedof23(5point)Likert-scaleditems(seeTable4-1below).Table4-1.Step2InstrumentQuestions 1.ThetimeIstartworkisflexible.2.IfIneedapersonaldayoff,itiseasytotake.3.ThehourIleaveworkisflexible.4.Iamgivenalotoffreedomtodecidehowtodomywork.5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone.6.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat.7.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds.8.Myworkplaceofferswellnessprogramsand/orfitnessactivities.9.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise10.MycoworkerscoverformewhenIneedtodosomethingtomanagemyillnessordonotfeelwell.11.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities.12.Myemployerprovidedpaidtimeoffworkforhealthcareorfitnessactivities.13.Worksitesupportandresourcesareimportanttomeinmanagingmyillness.14.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat.15.IamallowedtostopworkinglongenoughandoftenenoughtodowhatIneedtodototakecareofmyhealthcondition(forexample,leavingmyworkstationwhenIfeelIneedtotakesometimetoperformanecessarytasktohelpmanagemycondition).16.Itisdifficultformetoleavemyjobdutiesforroutine("non-sick")healthvisitstomanagemycondition.17.Itiseasyformetoleavemyjobdutiesfor"sickvisit"care(officeorhealthcareappointments)whenIhaveaspecifichealthproblem.18.Itisdifficultformetoleavemyjobdutiesforpersonalneeds(forexample,leavingtotakecareofbankingneeds).19.Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids'schoolactivities).

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48Table4-1.Step2InstrumentQuestionscontinued 20.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition?21.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtoleaveworkwhenyouneedtoattendhealthcareappointments?22.Howoftendoyouthinkaboutyourhealthconditionwhileyouareatwork?23.Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition? Step2:AdministrationoftheFirstRefinedInstrumentSampleandSettingPaperquestionnairesandinvitationstothewebsiteweredistributedtoemployeesatnumerousworksitesinNorthandCentralFlorida:arestaurant,abank,ahealthdepartment,variousmanufacturers(boats,utilitypoles,windows,watertanks,pneumaticcomponents,mechanicalautomobilecomponents,skincareproducts),municipalities,privatecolleges,substanceabusetreatmentfacilities,andsecondaryandelementaryschools.Inaddition,questionnairesweremadeavailableinwaitingroomsofthreeprimarycarepractices,andtwoprimarycareproviderswereaskedtogivethequestionnairetopotentialparticipants.Over2200paperquestionnairesandemailinvitationsweredistributedbetweenSeptember2005andApril2006,with104mailandinternetresponses.Basedonatargetpopulationof20%ofthedistributionpopulationexpectedtohaveeitherDMorrespiratorycondition,thisdemonstratesa27%responserate.However,astheinclusioncriteriaincludeddailymedicationforDMorchronicrespiratorycondition,thetargetpopulationmayhavebeenmuchsmallerthan440;notallpersonswithDMorCRCtakedailymedication,andcompliancewithprescribeddailymedicationregimensisknowntobesuboptimal(Boccuzzietal.,2001;Bousheyetal.,

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492005).Thereforeresponseratemayhavebeenmuchhigher;forinstance,ifonly10%ofthetargetpopulationmetinclusioncriteria,theresponserateiscloseto50%.Of48questionnairesreturnedbymail,29metinclusioncriteria.Of56completedinternetquestionnaires,27metinclusioncriteria.ThemostfrequentexclusioncriteriawasmissingdataforthequestionconfirmingtherespondentmetthecriteriaofhavingDMorasthma/otherchronicrespiratorycondition(18mailresponses,22internetresponses);interestingly,manyoftheserespondentsfilledoutthequestionnaireandreportedneedingtoleavetheworksitetoattendtoahealthcondition.Morethanhalfofthenon-responders(29/41)didnotanswer“donothavediabetes(orrespiratorycondition)”;however,whenasked“Whatchronichealthcondition(s)doyouhave?”theydidnotcheckeitherdiseasecategory.Astherewasnowaytodeterminethattheydidmeetinclusioncriteria,thesecaseswereexcluded.Fourrespondentswereexcludedduetoreportofbeingunemployed.Twointernetresponsesandonemailresponsewereduplicates.Demographics(seeTable4-2,below).Morefemalesthanmalesansweredthequestionnaire(60%,n=33vs.40%,n=22).Onerespondentchosenottoreportgender.Thelargestgroupofrespondents(69%,n=38)wasbetween46and64yearsofage,roughlycorrespondingtothe“babyboom”agegroup.Nopersonsyoungerthan26(andonly4peopleolderthan65)respondedduringStep2.Onepersondidnotreportage.Theagereportedmostfrequentlywas60(n=8).Medianageofthesamplewas55,approximatingcensusfiguresfortheNorthandCentralFloridaworkforce.Respondentstendedtobemarriedorlivingwithapartner(69.6%,n=39)ratherthansingle(U.S.CensusBureau,2001a,2001b).

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50Whitescomprised78%(n=44),Black/AfricanAmericans18%(n=10)ofthesamplegroup.OnlyonerespondentreportedHispanic/Latinoethnicity,andonlyonereportedrace/ethnicityas“Other”.MostofthesurveyedworksiteswerelocatedingeographicalareaswithlowerthanusualHispanic/LatinopopulationsandhigherthanusualBlack/AfricanAmericanpopulationscomparedtoFloridaingeneral(U.S.CensusBureau,2001c)Allrespondentswerehighschoolgraduatesandalmosthalfheldatleastabachelor’sdegree.Thehighnumberholdinggraduatedegrees(26.8%)correspondstothenumberofhightechnologycompaniesandeducationalinstitutionssurveyed.Table4-2.DemographicsStep2 n% MajorOccupationalGroup MOGAProfessionalTechnical1731.5 MOGBExecutiveAdministrativeManagerial47 MOGDAdministrativeSupportClerical1731.5 MOGEPrecisionProductionCraftRepair36 MOGFMachineOperatorsAssemblersInspectors59 MOGKServiceOccupations815 Total54100.0 Age 26-451324 46-643869 65+47 Total55100.0 Gender Male2240 Female3360 Total55100.0 Maritalstatus Single1730 Marriedorlivingwithapartner3970 Total56100.0 Race/ethnicity White4478 Black/AfricanAmerican1018 HispanicorLatino12 Someotherrace12 Total56100.0

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51Table4-2:DemographicsStep2continued n% Educationstatus Highschooldiploma1119.6 Somecollege1933.9 Bachelor'sdegree610.7 Somegraduateschool58.9 Graduatedegree1526.8 Total56100.0 HouseholdIncome < 250%FPG1532.6 >250-< 400%FPG1532.6 >400%FPG1634.8 Total46100.0 Employment(seeTable4-2,above).Thetwolargestoccupationgroupswereprofessional/technicalandadministrativesupport(each31.5%,n=17)Fourrespondents(7%)reportedexecutive/administrative/managerialpositions.Productionworkerscomprised15%ofthesample(skilledn=3,unskilledn=5),while8respondentsreportedworkinginserviceoccupations(13%).Samplepercentagesdonotcorrespondto2005figuresfortheDeltona/Daytona/OrmondBeachMSA,aspercentagesofprofessional/technicalandadministrativesupportrespondentsweresignificantlyhigherthaninthepopulation.Thismaybedueinparttouseofaweb-basedquestionnairewhichwasmoreaccessibletowhitecollarworkersthanthoseinlowerleveloccupations.Asexpectedbasedoneducationandoccupation,35%ofthesamplereportedfamilyincomegreaterthan400%FPG,andnorespondentsreportedincomeslowerthan100%FPG.However33%couldbeconsidered“nearpoor”or“lowincome”,withfamilyincomeoflessthan250%FPG(Wobus&Olin,2005).Thesampleincluded30workerspaidonanhourlybasis(54%),and26salariedworkers(46%).Amajorityofrespondents(60%,n=30)workedfortheirpresentemployerformorethan5years,reflectingnationalstatisticsforbabyboomerageworkers(U.S.BureauofLaborStatistics,2004).

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52Ofthe41casesexcludedduetonotdisclosingeitherDMorasthma/otherCRC,29didnotsaydecisivelythattheydidnothaveeitherdisease.These29respondentsreportedsimilardemographic,employment,andwork-relatedfrequenciestothesample,withtheexceptionofageandanswerstothreework-relatedquestions.Thelowerages(61.5%were19-45yearsofage)mayberelatedtothedifferencesindecision-makingpower.DifferencesinwhethertherespondentsknowsomeonewiththesamehealthconditionorhavedisclosedtheirconditiontotheemployermayrelatetonotreportingDMorrespiratorycondition–oranychroniccondition(seeTable4-3,below). Table4-3.DifferenceBetweenValidandInvalidCases Valid cases% Nodisease marked% n=41 “Donot have”% n=12 Age 18-45 24 63.2 75.0 46-64 69 33.2 16.7 65+ 7 2.6 8.3 Ido 74.5 51.4 41.7 mymanagerdoes 21.6 25.7 33.3 Ifyouareallowedtoleaveyour workstation,whodecideswhen andifyoucanleave? someoneotherthan mymanagerdoes 3.9 22.9 25.0 yes 58 29.7 33.3 Doyouknowsomeoneatyourjobsitewhohas thesamehealthconditionasyouhave? no 42 70 66.7 yes 82 37.9 18.2 Doesyouremployerknowaboutyourhealth condition? no 18 62.1 81.8 Workingconditions.Manyrespondents(55%)reportedworkplaceswithrulesorpoliciesthatmakeiteasiertotakecareoftheirhealthcondition;only9%reportedrulesorpoliciesthatmakeitmoredifficult.Mostworkershadcontroloverleavingtheworkstation(68%,n=38).However27%(n=15)reportedbeingworriedtheywillbecriticizediftheyleavetheworkstationtoself-managetheirhealthcondition(27%,n=15).Interestingly,only9respondents(16%)reportedbeingcriticizedinthosecircumstances.Morethanhalf(56%,n=26)knewanotheremployeewiththesamehealthcondition;17%saiditwastheirsupervisor(seeTable4-4,below).

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53Disease-relatedquestions.Nearlytwo-thirdsofrespondents(62.5%,n=56)reportedhavingDM,while41%(n=23)hadasthmaoranotherCRC(2respondentshadbothdiseases).ThelargestgroupofpeoplewithDM(57%)hadthediseasefrom1-10years,whilethelargestgroupofpeoplewithasthma/otherCRChadthediseaseformorethan10years(seeTable4-5,below).Participantsinthisstudyweremuchmorelikely(82%,n=41)totelltheiremployerabouttheirchronicconditionthansamplesinpreviousstudies(Munir,Leka,&Griffiths,2005).Oftheeightrespondentswhoexplainedtheirreasonsfornondisclosure,onlytwofeltitwouldnegativelyaffectworkingconditions.Thismayreflectatypeofresponsebias,inthatperhapsrespondentstothequestionnaireweremorelikelytohaveacomfortableworkingrelationshipwithimmediatesupervisorsthanthenorm. Table4-4.Work-RelatedItemsStep2 n % yes 30 54.5 no 25 45.5 Doesyourworkplacehaverulesorpoliciesthatmakeiteasierforyouto takecareofyourhealthcondition?Forinstance,isthereapolicythat saysyouareallowedtoleaveyourworkstationwhenfeelyouneedtodo acheckonyourconditionortreatsymptoms? Total 55 100.0 yes 5 9.1 no 50 90.9 Doesyourworkplacehaverulesorpoliciesthatmakeitdifficultforyou totakecareofyourhealthcondition?Forinstance,isthereapolicythat saysyouareneverallowedtoleaveworkstation? Total 55 100.0 Ido 38 74.5 mymanagerdoes 11 21.6 someoneotherthanmy managerdoes 2 3.9 Ifyouareallowedtoleaveyourworkstation,who decideswhenandifyoucanleave? Total 51 100.0 yes 15 26.8 no 41 73.2 Areyouworriedthatyouwillbecriticizedifyouneedtoleaveyour workstationtemporarilytocheckonyourhealthconditionormanage yoursymptoms? Total 56 100.0 yes 9 16.1 no 47 83.9 Haveyoueverbeencriticizedforneedingtoleaveyourworkstation temporarilytocheckonyourhealthconditionortreatyoursymptoms? Total 56 100.0 manager 3 coworker 3 Ifyes,positionofpersonwhocriticizedyou: Total 4 -

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54 Table4-4.Work-RelatedItemsStep2continued yes 29 58.0 no 22 42.0 Doyouknowsomeoneatyourjobsitewhohasthesamehealthcondition asyouhave? Total 50 100.0 yes 5 17.2 no 24 82.8 Ifyes,isthatpersonyoursupervisor? Total 29 100.0 lessthan6months 4 8.0 6monthstolessthan1year 1 2.0 1yearormorebutlessthan 5years 15 30.0 5yearsormorebutlessthan 10years 11 22.0 10yearsormorebutless than20years 13 26.0 20yearsormore 6 12.0 Howlonghaveyoubeenworkingatyourpresent job? Total 50 100.0 hourly 30 53.6 salary 26 46.4 Howareyoupaid? Total 56 100.0 Table4-5.ChronicHealthConditionStep2 ChronicCondition<1year1-10years>10years n%n%n%n% Diabetes3562.57202057823 AsthmaorotherCRC2341293131878 Both(2)(3.5)-----56100-----YesNo n%n% Doesyouremployerknowaboutyourhealthcondition?4182918 CorrelationsSevensignificantcorrelationsamonginstrumentitemsweregreaterthan.600(seeTable4-6below):Items1and3,“ThetimeIstartworkisflexible.”and“ThehourIleaveworkisflexible.”(r=.675,p.01);Item4“Iamgivenalotoffreedomtodecidehowtodomywork.”wasstronglycorrelatedwithtwoitems:Item5“Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone.”(r=.735,p.01),and

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55Item11“Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities.”(r=.721,p.01).Item5wasalsostronglycorrelatedwithItem11(r=.740,p.01).Item6:IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat”wasstronglycorrelatedwithtwoitems:Item14“IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat.”(r=.800,p.01),andItem16“Itisdifficultformetoleavemyjobdutiesforroutine("non-sick")healthvisitstomanagemycondition.”(r=.668,p.01).Item14wasalsostronglycorrelatedwithItem16(r=.709,p.01).Item20“Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition?”andItem21“Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtoleaveworkwhenyouneedtoattendhealthcareappointments?”(r=.733,p.01).Items1,3,20and21had1strongcorrelation,Items4,5,6and14had2strongcorrelations,andItem16had3strongcorrelations;thus,thestrengthoftherelationshipbetweentheseitemsisofahighmagnitude.Sincethecorrelationmatrixisusedinfactoranalysis,“thereshouldbeanumberofsizeablecorrelationsbetweenthevariablesonthematrix”(Polit,1996,p.349).Therewere57correlationsrangingfrom.300-.800amongthe253itemsonthecorrelationmatrix(seeTable4-6below).

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56 5 6Table4-6.CorrelationTableInstrumentStep212345678910111213141516171819202122231 1 2 .351** 1 3 .675** .317* 1 4 .350** .296* .410** 1 5 .275* .154 .153 .735** 1 6 .228 .464** .368** .360** .175 1 7 .512** .198 .458** .464** .436** .296* 1 8.145 .003 .045 .077 .119 .162 .326* 1 9 .192 .056 .274* .187 .071 .090 .025 .331* 1 10. 334* .441** .539** .345** .027 .455** .184 .106 .117 1 11 .315* .248 .260 .721** .740** .418** .378** .235 .251 .229 1 12.032 .157 .084 .135 .044 .094 .069 .350** .383** .094 .112 1 13 .043 .036 .178 .068 .204 .052 .019 .173 .277* .096 .013 .190 1 14.302* .557** .386** .294* .077 .800** .224 .007 .197 .415** .305* .155 .023 1 15 .260 .344** .227 .251 .106 .276* .179 .098 .181 .334* .188 .303* .047 .257 1 16.260 .407** .408** .298* .066 .668** .235 .064 .230 .615** .431** .269 .150 .709** .378** 1 17 .052 .015 .040 .162 .108 .030 .063 .082 .044 .087 .124 .045 .036 .035 .129 .120 1 18.292* .388** .334* .315* .122 .47 0** .296* .133 .125 .341* .287* .112 .196 .592** .203 .407** .099 1 19 .241 .380** .185 .172 .159 .211 .075 .095 .073 .261 .228 .099 .110 .186 .068 .237 .273* .094 1 20 .063 .218 .066 .020 .082 .054 .001 .039 .312* .087 .009 -. 167 .016 .166 .051 .097 .089 .136 .207 1 21 .125 .240 .161 .046 .043 .068 .077 .080 .197 .025 .123 .020 .102 .223 .085 .080 .118 .217 .127 .733** 1 22.020 .001 .135 .055 .216 .119 .113 .088 .025 .142 .201 .017 .283* .057 -.09 0 .285* .110 .136 .067 .025 .025 1 23r.082 .228 .187 .067 .025 .474** .034 .029 .132 .293* .216 .070 .029 .371** .042 .421** .249 .179 .214 .061 .077 .319* 1 Pearson’sr,n=56;**Significantatthe.01level;*Significantatthe.05level;Significantcorrellations>.300shaded

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57FactorAnalysisPrincipalcomponentsanalysisusingPromaxrotationandprincipalaxisfactoranalysiswereobtainedforthe23-iteminstrument.Of1272responsestotheinstrumentitems,16datapointsweremissingatrandom.Meanswereimputedformissingdata,asdiscussedinChapter3.Bartlett'sTestofSphericityconfirmedthatthecorrelationmatrixisnotanidentitymatrix(p<.001)andtheKaiser-Meyer-Olkintest>.5(Table4-7,below)indicatedtheassumptionofsamplingadequacyismet(Pett,Lackey,&Sullivan,2003;UniversityofNewCastleuponTyne,2002).Onlytwoitemshadcommunalitiesbelow.6(seecommentsinfollowingsection),anotherindicationofsamplingadequacy.Eightfactorswereidentified(Table4-8);allexceptFactor8containedatleasttwoitems.Fiveitemsloadedonmorethanonefactorwithloadingswithin.200ofthehigherloading;thiswasexpectedastheitemswereassumedtobecorrelated(thereasonforusingPromax,anobliquerotation).AlthoughFactors1-8hadeigenvaluesover1.0(onemethodusedtodeterminewhichfactorstoextract),onlyFactors1-7metthe5%requirementoftotalvarianceexplained(seeTable4-9below)–acommonlyacceptednormforinclusion–foracumulativevarianceof70.622%.Thescreeplot(seeFigure4-1,below)couldbeinterpretedasdisplaying7factors–screelayinginasomewhatstraightlineafterFactor7(Pett,Lackey,andSullivan,2003;UCLAAcademicTechnologyServices,2006).Principalaxisfactoring(PAF)wasnotused,asonlyfiveoftheeightfactorsextractedmettherequirementofthateachfactorcontainatleast5%ofthetotalvarianceexplained.ThefactorsextractedinPAFdidnotmakeasmuchintuitiveortheoreticalsenseasthoseextractedinPCanalysis–theseresultsdemonstratethatPAFisnot

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58appropriateforthisdataset,aspreviouslydiscussedinChapter3(Pett,Lackey,andSullivan,2003).Table4-7.KMOandBartlett'sTestStep2Kaiser-Meyer-OlkinMeasureofSamplingAdequacy.613Approx.Chi-Square557.924df253Bartlett'sTestofSphericitySig..000Table4-8.FactorAnalysisStep2StructureMatrixFactorItem#Comm12345678.73214.811.873-.206-.340-.161-.112-.042-.114-.1766.788.870-.315-.293.023.050.068-.168-.16116.818.830-.213-.364.173-.224.289-.055-.2912.545-.643.259.383.281-.047.126.253.08118.647.642-.266-.353-.175.033-.376.060-.19510.546-.640.118.523-.040.037-.172.217.263123.713.588-.053-.042.231-.104.362-.487.279.8935.917.032.950.061.047-.057-.044.033.03024.803-.390.839.444-.034.082.072-.038.21611.831-.443.836.291-.105.214-.119.041.061.7823.791-.466.206.869.066.115-.127.063.2131.764-.322.310.844.078-.050.065.123.19637.691-.260.513.635-.003-.347-.010-.101.224.83621.856-.084-.066.143.907-.092.089.051.116420.855-.081.081.026.899-.171.043.133-.125.6198.763.044.106-.191-.004.777-.163-.082-.1379.734-.193-.024.345-.327.730-.039.033.218512.696-.129.016.018-.102.642-.054.021.558-.77722.808.158-.151-.046.069-.023.851-.150.025613.750.052-.286.285.092.454-.617-.264.171.42917.711-.005-.179.005.038-.039-.132.769.096719.621-.312.236.195.145.020.048.718-.0448n/a15.812-.319.142.315-.001.038-.025.064.863ExtractionMethod:PrincipalComponentAnalysis.RotationMethod:VarimaxwithKaiserNormalization.Rotationconvergedin7iterations.Bold:CommunalitiesItalic:Sharedloadings>.400with>.200difference

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59 Table4-9.TotalVarianceExplainedStep2 Component InitialEigenvalues ExtractionSumsofSquaredLoadings Total %of Variance Cumulative % Total %of Variance Cumulative % 1 5.694 24.755 24.755 5.694 24.755 24.755 2 2.413 10.490 35.245 2.413 10.490 35.245 3 2.216 9.633 44.878 2.216 9.633 44.878 4 1.639 7.125 52.003 1.639 7.125 52.003 5 1.535 6.673 58.676 1.535 6.673 58.676 6 1.484 6.454 65.130 1.484 6.454 65.130 7 1.263 5.492 70.622 1.263 5.492 70.622 8 1.028 4.471 75.093 1.028 4.471 75.093 ExtractionMethod:PrincipalComponentAnalysis. 2322212019181716151413121110987654321 ComponentNumber 6543210 E i g e n v a l u e ScreePlotFigure4-1.ScreePlotStep2DescriptionofFactors–UnderlyingConceptsThefollowingconceptswereidentifiedforthesevenrelevantfactors:1.Jobflexibilityrelatedtoself-managementofchronicillnessa.Abilitytoleaveworkstationwhennecessarytoperformon-siteoroff-sitechronicillnessself-managementactivities;

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602.Jobcontrola.Abilitytoautonomouslymakedecisionsandsetprioritiesrelatedtojobduties;3.Jobflexibilityrelatedtoworkhoursa.Abilitytoautonomouslyadjustworkhours;4.Employee’sneedforjobflexibilityrelatedtoself-managementofchronicillnessa.Importanceofbeingabletostopworkactivitiesorleavetheworksiteforchronicillnessself-managementactivities;5.Worksiteresourcesrelatedtoself-managementofchronicillnessa.Employerregulatedbenefitsthataffectchronicillnessself-managementactivities;6.Self-managementofchronicillnessa.Activitiesutilizedbytheemployeetocheckstatusortreatsymptomsofchroniccondition.7.Jobflexibilityrelatedtoabilitytoleaveworksitea.Abilitytoautonomouslydecidetoleaveworkforreasonsincludingbutnotlimitedtochronicillnessself-managementactivities;ThetwoitemsthatloadedonFactor8weremostcloselyrelatedtoFactor5,worksiteresourcesrelatedtoself-managementofchronicillness.ItemsRemovedAfterStep2Certaindemographicandwork-relatedquestionsusedinStep2wereremovedpriortoStep3.Duetorecruitmentconstraints(detailedinChapter5),itwasnecessarytoshortentheentirequestionnaireinadditiontousingfactoranalysistoperformdatareductionoftheinstrument.DemographicandWork-Related.Eightnon-instrumentquestionswereremovedfromthequestionnaireforStep3,basedontheoreticalandstatisticalconsiderations.Demographicquestionsremoved:1.Areyousingleormarried/livingwithapartner?

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61a.Thisquestionwasincludedbasedonexpertreview,howeveritdidnotseemtohaveanyrelationshiptotheinstrumentitems.Sumsofthe23instrumentitems(recodedtoreflectreverse-codedvalues)weresimilarforbothcategories–apopulationpyramidreflectedsimilarshapes(seeFigure4-2,below).2.Whatracial/ethnic/culturalgroupdootherpeopleusuallythinkyoubelongto?a.Thisquestionwasoriginallyincludedtoexaminedifferencesinjobflexibilityscoreswhenemployersassumedapersonbelongedtoarace/ethnicitydifferentfromtheiractualrace/ethnicity.However,onlyfourresponsesdifferedfromanswersto“Whatisyourracial/ethnic/culturalgroup?”.Thereforethisquestionwasremoved.Work-Relatedquestionsremoved:1.Doesyourworkplacehaverulesorpoliciesthatmakeitdifficultforyoutotakecareofyourhealthcondition?Forinstance,isthereapolicythatsaysyouareneverallowedtoleaveyourworkstation?a.Thisquestionwasinsertedasacomparisontoanotherquestion(“Doesyourworkplacehaverulesorpoliciesthatmakeiteasierforyoutotakecareofyourhealthcondition?Forinstance,isthereapolicythatsaysyouareallowedtoleaveyourworkstationwhenyoufeelyouneedtodoacheckonyourconditionortreatyoursymptoms?).b.While91%answered“no”tothisquestion,almosthalfoftherespondentsanswered“yes”tothesimilarquestion,whichwasleftinthequestionnaireasitseemedtobeabettermeasureoftheconcept.2.Pleaselistotherthingsthathavehappenedatworkorotherresourcesyouhaveusedatworkthathelpedyoutomanageyourcondition:a.NoqualitativequestionswereaskedinStep3.b.Therewere18responsestothisquestionincluding4relatedtoselfmanagementactivities,5relatedtobreaksduringtheworkday,5relatedtosickleave/coverage,3relatedtohealthresources,andonerelatedtomanagementsupport.3.Haveyoueverbeencriticizedforneedingtoleaveyourworkstationtemporarilytotakecareofyourcondition?Ifyouansweredyestothisquestion,putacheckbythepositionofthepersonwhocriticizedyouheldatthattime(orfillintheblank).a.Therelatedquestion“Areyouworriedthatyouwillbecriticized”seemedtobettercapturethisconcept,asitaddressedtherespondentsperceptionofthesituation,ratherthanwhethercriticismhadactuallyhappened..

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62 4.Doyouknowsomeoneatyourjobsitewhohasthesamehealthconditionasyouhave?a.Sumsofthe23instrumentitems(recodedtoreflectreverse-codedvalues)weresimilarforbothcategories–thepopulationpyramidreflectedsimilarshapes(seeFigure4-2,below)..Therewasnodiscernabledifferenceinthehistogramsofscoresforyesornoanswers.b.Thisquestionwasaddedbasedonanearlierpilotstudy.However,over90%ofrespondentsanswered“no”.Doesyouremployerknowaboutyourhealthcondition?1.Sumsofthe23instrumentitems(recodedtoreflectreverse-codedvalues)weresimilarforbothcategories–histogramsandpopulationpyramidsreflectedsimilarshapes(seeFigure4-2,below).Therewasnodiscernabledifferenceinthehistogramsofscoresforyesornoanswers.Instrument.Twomethodswereusedtodeterminewhichitemstoremovefromtheinstrument.Inmostcases,itemswithlowerfactorloadingswereremovedifthatremovalimprovedCronbach’sfortheitemsremaininginthefactor.However,incertaincases,theoreticalandintuitivereasonsresultedinremovalofitemswithhigherloadingsthanthoseretained(seeTable4-10,below).Figure4-2.PopulationPyramid

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63Thefollowingsixitemswereremoved:1.Gerstal/GallagherJobFlexibilityInstrumentquestions:a.IfIneedapersonaldayoff,itiseasytotakeb.Iamgivenalotoffreedomtodecidehowtodomywork2.ChronicIllnessResourceSurvey(CIRS)questions:a.MycoworkerscoverformewhenIneedtodosomethingtomanagemyillnessordonotfeelwellb.Myworkplaceofferswellnessprogramsand/orfitnessactivities3.QuestionsthatwereaddedtotheinstrumentafterStep1(expertreview):a.Itisdifficultformetoleavemyjobdutiesforpersonalneeds(forexample,leavingtotakecareofbankingneeds)b.IamallowedtostopworkinglongenoughandoftenenoughtodowhatIneedtodototakecareofmyhealthcondition(forexample,leavingmyworkstationwhenIfeelIneedtotakesometimetoperformanecessarytasktohelpmanagemycondition).ThedetailedrefinementoftheinstrumentresultedinarevisedChronicIllnessSelf-ManagementAmongWorkersinstrumentconsistingof17(5point)Likert-scaledquestions.Thequestionnairealsocontained6work-siterelated,5demographic,and2diseaserelatedquestions.Thisrevisedquestionnaire(seeTable4-11,below)wasthenadministeredtothesecondsamplegroup;exploratoryfactoranalysiswasagaincarriedoutontheinstrumentusingthesameprocedures.

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64Table4-10.InstrumentItemsRemovedAfterStep2 FactorItemsConceptafteritemsremovedComments 1IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothatg/gIfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothatItisdifficultformetoleavemyjobdutiesforroutine("non-sick")healthvisitstomanagemyconditionItisdifficultformeto leavemyjobdutiesfor personalneeds(for example,leavingtotake careofbankingneeds) g/gIfIneedapersonal dayoff,itiseasytotake HowoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourconditionCIRSMycoworkers coverformewhenIneed todosomethingto managemyillnessordo notfeelwell Jobflexibilityrelatedtoself-management.732.842Communalitycloseto.6(.647)andnotrelatedtochronicillnessLowcommun-ality.545AlsoloadedonFactor7JobflexibilityRTabilitytoleaveworksiteLowcommunality.546,alsoloadedonFactor3,JFRTworkhours 2g/gItismyownresponsibilitytodecidehowmyjobgetsdoneg/gIamgivenalotof freedomtodecidehowto domywork CIRSIhavecontrolovermyjobintermsofmakingdecisionsandsettingprioritiesJobcontrol.893.850Littlechangeinreliabilityifitemremoved,otherquestionsseemedtocaptureconceptmoreclearly

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65Table4-10.InstrumentItemsRemovedAfterStep2continued FactorItemsConceptafteritemsremovedComments 3ThehourIleaveworkisflexible.ThetimeIstartworkisflexible.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds.Jobflexibilityrelatedtoworkhours.783N/A 4HowimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtoleaveworkwhenyouneedtoattendhealthcareappointmentsHowimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourconditionNeedforjobflexibilityrelatedtoself-managementofchronicillness.836N/A 5CIRSMyworkplaceoffers wellnessprogramsand/or fitnessactivities CIRSMyworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise)CIRSMyemployerprovidedpaidtimeoffworkforhealthcareorfitnessactivitiesWorksiteresourcesrelatedtoself-managementofchronicillness,.619.550Similartothirdquestion,whichwascloselyrelatedtoself-managementofchronicillnessLoadedat.642onthisfactorand.558onfactor8(Factor8wasremovedasitdidnotmeetthe5%oftotalvariancerequirement)

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66Table4-10.InstrumentItemsRemovedAfterStep2continued FactorItemsConceptafteritemsremovedComments 6HowoftendoyouthinkaboutyourhealthconditionwhileyouareatworkCIRSWorksitesupportandresourcesareimportanttomeinmanagingmyillnessSelf-managementofchronicillness-.777N/AAlsoloadsonFactor5(.454,thisfactor.617),WorksiteresourcesRTSMofCI 7Itiseasyformetoleavemyjobdutiesfor"sickvisit"care(officeorhealthcareappointments)whenIhaveaspecifichealthproblemItiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids'schoolactivities)Jobflexibilityrelatedtoabilitytoleaveworksite.429N/A 8Iamallowedtostop workinglongenoughand oftenenoughtodowhatI needtodototakecareof myhealthcondition(for example,leavingmy workstati onwhenIfeelI needtotakesometimeto performanecessarytaskto helpmanagemycondition) N/AN/AThisfactorloadedonlyoneitemseparatelyfromotherfactors,anddidnotmeetthe5%oftotalvariancerequirement. g/g:Gerstal/GallagherJobFlexibilityScaleCIRS:ChronicIllnessResourceSurvey

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67Table4-11.Step3InstrumentQuestions 1.ThetimeIstartworkisflexible.2.ThehourIleaveworkisflexible.3.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone.4.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat.5.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds.6.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise7.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities.8.Myemployerprovidedpaidtimeoffworkforhealthcareorfitnessactivities.9.Worksitesupportandresourcesareimportanttomeinmanagingmyillness.10.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat.11.Itisdifficultformetoleavemyjobdutiesforroutine("non-sick")healthvisitstomanagemycondition.12.Itiseasyformetoleavemyjobdutiesfor"sickvisit"care(officeorhealthcareappointments)whenIhaveaspecifichealthproblem.13.Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids'schoolactivities).14.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition?15.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtoleaveworkwhenyouneedtoattendhealthcareappointments?16.Howoftendoyouthinkaboutyourhealthconditionwhileyouareatwork?17.Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition? Step3:AdministrationoftheSecondRefinedInstrumentSampleandSettingInvitationstothewebsiteweredistributedtoemployeesatnumerousworksitesinNorthandCentralFlorida:anadministrativeandtechnicalcompanywithacallcenter,aprivatecollege,andalargecountyschoolsystem–apotentialdistributiontoover11,000workers.Inaddition,invitationstothewebsiteweredistributedbyproviderstopatientsatalargeprimarycarepracticeinVolusiaCountyandbyword-of-mouthandsnowballeffect.Of74internetresponses,64metinclusioncriteria.Onceagain,themostfrequentexclusioncriteriawasabsence(ornon-report)ofDMorasthma/otherchronicrespiratorycondition.

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68Demographics(seeTable4-12,below).Morefemalesthanmalesansweredthequestionnaire(55.6%,n=35vs.44.4%,n=28).Fewerthanhalfoftherespondents(39.7%,n=25)werebetween46and64yearsofage,while58.7%(n=37)were19-45yearsofage.Nopersonsyoungerthan19andonly1personolderthan65respondedduringStep3.Theagesreportedmostfrequentlywere38,40,43,44,and46(3each).Medianageofthesamplewas43.ThereforetheStep3samplewasmorerepresentativeofGenerationXandY(postbabyboomers),whiletheStep2samplewasmorerepresentativeoftheBabyBoomergeneration.Whitescomprised84.4%(n=54),Black/AfricanAmericans6.3%(n=4)ofthesamplegroup.ThreerespondentsreportedHispanic/Latinoethnicity,1reportedAsianrace/ethnicity,and1reportedrace/ethnicityas“Other”.Allbut3respondentswereatleasthighschoolgraduatesand35heldatleastabachelor’sdegree.Thirteenrespondentsheldgraduatedegrees(20.3%),slightlyfewerthaninStep2.Employment(seeTables4-12and4-13,below)..Thelargestoccupationgroupwasprofessional/technical(34.4%,n=22);10respondents(16.1%)reportedexecutive/administrative/managerialpositions.Thirteenrespondents(21.0)workedinadministrativesupportpositionsand5respondents(8.1%)workedinsales.Productionworkerscomprised14.5%ofthesample((skilledn=6,unskilledn=3),while3respondentsreportedworkinginserviceoccupations(4.8%).Asexpectedbasedoneducationandoccupation,34.0%ofthesamplereportedfamilyincomegreaterthan400%FPG,andonly1respondentreportedincomelowerthan100%FPG.Thesampleincluded32workerspaidonanhourlybasis(51.6%),and30salariedworkers(48.4%).Amajorityofrespondents(51.6%,n=33)workedfortheirpresentemployerformorethan5

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69years.Mostrespondentshadcontroloverleavingtheworkstation(63.5%,n=40).Table4-12.DemographicsStep3 N% MajorOccupationalGroup MOGAProfessionalTechnical2235.5 MOGBExecutiveAdministrativeManagerial1016.1 MOGCSales58.1 MOGDAdministrativeSupportClerical1321.0 MOGEPrecisionProductionCraftRepair46.5 MOGFMachineOperatorsAssemblersInspectors23.2 MOGHHandlersEquipmentCleanersLaborers34.8 MOGKServiceOccupations34.8 Total62100.0 Age 19-453758.7 46-642539.7 65+11.6 Total63100.0 Gender Male2844.4 Female3555.6 Total63100.0 Race/ethnicity White5485.7 Black/AfricanAmerican46.3 HispanicorLatino34.8 Asian11.6 Someotherrace11.6 Total63100.0 Educationstatus Lessthanhighschooldiploma34.7 Highschooldiploma1015.6 Somecollege1625.0 Bachelor'sdegree1218.8 Somegraduateschool1015.6 Graduatedegree1320.3 Total64100.0 HouseholdIncome < FPG12.0 <250%FPG1632.0 >250-<400%FPG1632.0 >400%FPG1734.0 Total50100.0

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70Disease-relatedquestions.Overtwothirdsofrespondents(n=40)reportedhavingDMwhile45.3%(n=29)hadasthmaoranotherCRC(5respondentshadbothdiseases).ThelargestgroupofpeoplewithDM(55%)hadthediseasefrom1-10years,whilethelargestgroupofpeoplewithasthma/otherCRC(72%)hadthediseaseformorethan10years(seeTable4-14,below). Table4-13.Work-RelatedItemsStep3 n % Ido 40 63.5 mymanagerdoes 23 36.5 Ifyouareallowedtoleaveyourworkstation,who decideswhenandifyoucanleave? Total 63 100.0 yes 24 38.1 no 39 61.9 Areyouworriedthatyouwillbecriticizedforneedingtoleaveyour workstationtemporarilytocheckonyourhealthconditionortreatyour symptoms? n 63 100.0 lessthan6months 4 6.3 6monthstolessthan1year 6 9.4 1yearormorebutless than5years 21 32.8 5yearsormorebutless than10years 11 17.2 10yearsormorebutless than20years 19 29.7 20yearsormore 3 4.7 Howlonghaveyoubeenworkingatyourpresent job? N 64 100.0 Hourly 32 51.6 Salary 30 48.4 Howareyoupaid? N 62 100.0 Table4-14.ChronicHealthConditionStep3 ChronicCondition<1year1-10years>10years n%n%n%n% Diabetes4062.5615.02255.01230.0 AsthmaorotherCRC2945.328.0520.01872.0 Both(5)(7.8)-----64100-----CorrelationsPearson’sr(r)wasperformedforbivariatecorrelationsbetweeninterval-orratio-leveldata.Sixsignificantcorrelationsamonginstrumentitemsweregreaterthan.600(seeTable4-15below):

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71Items1and2,“ThetimeIstartworkisflexible.”and“ThehourIleaveworkisflexible.”(r=.792,p.01);Item4“Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone.”wasstronglycorrelatedwithtwoitems:Item10“Worksitesupportandresourcesareimportanttomeinmanagingmyillness.”(r=.623,p.01),andItem11“IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat.”(r=.604,p.01).Item10wasalsostronglycorrelatedwithItem11(r=.702,p.01).Item12:“Itisdifficultformetoleavemyjobdutiesforroutine("non-sick")healthvisitstomanagemycondition.”wasstronglycorrelatedwithItem13“Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids'schoolactivities).”(r=.656,p.01).Item14“Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids’schoolactivities).”wasstronglycorrelatedwithItem15“Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition?”(r=.733,p.01),andItems1,2,12,13,14and15had1strongcorrelation;and,Items4,10,and11had2strongcorrelations;thus,thestrengthoftherelationshipbetweentheseitemsisofahighmagnitude.Therewere19correlationsrangingfrom.300-.800amongtheitemsonthecorrelationmatrix(seeTable4-15below).

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72 Table4-15.InitialCorrelationsInstrumentStep3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 1 1 2 .792** 1 3 .236 .198 1 4 -.151 -.205 .187 1 5 .519** .489** .260* -.118 1 6 .293* .237 .005 -.253* .243 1 7 .271* .181 .541** -.003 .309* .152 1 8 .035 .102 .286* -.021 .065 .532** .292* 1 9 -.078 -.017 -.048 -.014 .013 .283* -.051 .273* 1 10 -.223 -.314* -.035 .623** -.264* -.267* -.294* -.108 -.014 1 11 -.213 -.349** .122 .604** -.286* -.304* -.074 -.211 .074 .702** 1 12 .017 .129 -.081 -.152 .035 .024 -.105 .096 .007 -.304* -.318* 1 13 .084 -.013 .140 .034 .113 -.063 .144 .120 .029 -.159 -.122 .656** 1 14 -.019 -.010 .247 -.005 -.027 .042 .081 .233 .366** -.016 .006 .009 .010 1 15 -.073 -.037 .088 -.138 .014 .027 .138 .146 .284* -.290* -.177 .074 -.021 .733** 1 16 .099 .057 .231 .047 .088 -.104 .034 .030 .178 .027 .237 -.158 -.010 .406** .279* 1 17 r .068 .069 .056 .098 -.181 .004 -.053 .119 .117 .136 .237 -.162 -.220 .180 .029 .443** 1 Pearson’sr,n=56;**Significantatthe.01level;*Significantatthe.05level;Significantcorrellations>.300shaded 7 2

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73FactorAnalysisPrincipalcomponentsanalysisusingPromaxrotationandprincipalaxisfactoranalysiswereobtainedforthe17-iteminstrument.Principalaxisfactoring(PAF)wasnotused,asthefactorloadingsdidnotmakeasmuchintuitivesenseasthoseintheprincipalcomponentanalysis.Of1088possibleresponsestotheinstrumentitems,6datapointsweremissingatrandom.Meanswereimputedformissingdata,asdiscussedinChapter3.Bartlett'sTestofSphericityconfirmedthatthecorrelationmatrixisnotanidentitymatrix(p<.001)andtheKMO>.5(seeTable4-16below)indicatedtheassumptionofsamplingadequacyismet.Threeitemshadcommunalitiesbelow.6,andnonewerebelow.538,anotherindicationofsamplingadequacy.Sixfactorswereidentified;allcontainingatleasttwoitems.Allsixfactorsmetthe5%requirementoftotalvarianceexplained,foracumulativevarianceof73.560%(Tables4-17and4-18).DescriptionofFactors–UnderlyingConceptsTheitemsloadedonthesamefactorsasinStep2,withoneexception:factor3“Employee’sneedforjobflexibilityrelatedtoself-managementofchronicillness”containedthetwoitemsthatloadedonthesamefactorinStep2,aswellasoneitemfrom“Self-managementofchronicillness”(“Howoftendoyouthinkaboutyourhealthconditionwhileyouareatwork?”)andoneitemfrom“Jobflexibilityrelatedtoself-managementofchronicillness”(Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition?”).

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74Table4-16.InitialKMOandBartlett'sTestStep3 Kaiser-Meyer-OlkinMeasureofSamplingAdequacy.578 Approx.Chi-Square420.732 df136 Bartlett'sTestofSphericitySig..000 Table4-17.InitialFactorAnalysisStep3 StructureMatrix Factor Item# Comm 1 2 3 4 5 6 11 .791 .873 -.192 .142 -.098 -.232 -.251 10 .764 .844 -.216 -.038 -.241 -.160 -.246 1 .843 4 .702 .781 -.145 .008 .108 -.129 -.011 1 .822-.161 .895 -.026 .222 .120 .021 2 .798 -.268 .869 -.006 .139 .158 .046 2 .820 5 .538 -.270 .624 -.058 .413 .109 .100 14 .777 -.032-.101 .847 .159 .239 .044 15 .795 -.322 -.195 .742 .190 .146 .065 16 .669 .277 .262 .728 -.015 -.039 -.124 3 .651 17 .542 .392 .263 .472 -.303 .147 -.306 7 .749 -.159 .200 .040 .848 .170 .037 4 .700 3 .744 .161 .253 .229 .773 .079 .076 6 .796. -.320 .279 -.065.067 .828 -.063 8 .762 -.101 .039 .156 .316 .823 .135 5 .636 9 .555 .043 -.058 .456 -.175 .594 .044 13 .852 -.091 .000 -.044 .241 .012 .908 6 .789 12 .849 -.323 .001 -.060 -.053 .067 .883 ExtractionMethod:PrincipalComponentAnalysis.RotationMethod:PromaxwithKaiserNormalization.Rotationconvergedin7iterations.Bold:CommunalitiesItalic:Sharedloadings>.400with>.200difference Table4-18.InitialTotalVarianceExplainedStep3 Component InitialEigenvalues ExtractionSumsofSquared Loadings Total %of Variance Cumulative % Total %of Variance Cumulative % 1 3.554 20.907 20.9073.554 20.90720.907 2 2.543 14.956 35.8632.543 14.95635.863 3 2.086 12.269 48.1332.086 12.26948.133 4 1.661 9.768 57.9001.661 9.76857.900 5 1.417 8.334 66.2351.417 8.33466.235 6 1.245 7.326 73.5601.245 7.326 73.560 ExtractionMethod:PrincipalComponentAnalysis. Thescreeplot(seeFigure4-3,below)couldbeinterpretedasdisplaying6factors–screelayinginasomewhatstraightlineafterFactor6.

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75 1716151413121110987654321 ComponentNumber 43210 E i g e n v a l u e ScreePlotFigure4-3.InitialScreePlotStep3RefinementofInstrumentFiveitemswereremovedfromtheinstrument(seeTable4-19,below):1.Item9:Worksitesupportandresourcesareimportanttomeinmanagingmyillness;2.Item12:Itiseasyformetoleavemyjobdutiesfor"sickvisit"care(officeorhealthcareappointments)whenIhaveaspecifichealthproblem;3.Item13:Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids'schoolactivities);4.Item16:Howoftendoyouthinkaboutyourhealthconditionwhileyouareatwork;5.Item17:Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition.Item9hadacommunalityoflessthan.600,andloadedhigherthan.400onmorethanonefactor.Inaddition,itsloadingonFactor3wasmorethan.200lessthantheotherFactor3items.

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76Factor6,“Jobflexibilityrelatedtoabilitytoleaveworksite”istheoreticallydifferentfromtheconceptofjobflexibilityasitaffectsself-managementofchronicillness.Thetwoitems(12and13)containedinthisfactor–easeofleavingworkforfamilyneedsorwhensick–relatetoallworkers,notjustthosewithchronicillness.Thetwoitemswereaddedtothequestionnaireinordertomeasureanyassociationbetweenjobflexibilitythataffectsallworkersandtheconceptbeingexamined;however,theironlystrongcorrelationwaswitheachother.Factor6alsocomprisesonly7.3%ofvariance.Thetwoadditional“howoften”itemsloadingonFactor3(16and17)measureintensityofneedtoleavetheworkstationforself-managementactivities,ratherthanperceivedimportanceofself-managementjobflexibility.Item17loadedmorethan.200lowerthantheitemaboveitonFactor3,hadloadingsof.300orgreateronthreeadditionalfactors(1,4,and6),andhadacommunalitybelow.600.LeavingItem16whileremovingItem17didnotmaketheoreticalsense.Table4-19.InstrumentItemsRemovedAfterStep3 FactorItem(s)ConceptafteritemsremovedComments 3Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition?Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtoleaveworkwhenyouneedtoattendhealthcareappointments?Howoftendoyouthinkaboutyour healthconditionwhileyouareatwork; Howoftendoyourequireabreakfrom yourjobduti estoperformanecessary tasktohelpmanageyourcondition? Employee’sneedforjobflexibilityrelatedtoself-managementofchronicillness.651.832 Theoretically differentfrom remaining items. Loadedon multiple factors.

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77Table4-19.InstrumentItemsRemovedAfterStep3continued FactorItem(s)ConceptafteritemsremovedComments 5Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexerciseMyemployerprovidedpaidtimeoffworkforhealthcareorfitnessactivities.Worksitesupportandresourcesare importanttomeinmanagingmy illness. Worksiteresourcesrelatedtoself-managementofchronicillness.636.694Communality<.600;Loadingson2factors.Loading>.200lessthanitemabove 6Itiseasyformetoleavemyjob dutiesfor"sickvisit"care(officeor healthcareappointments)whenIhave aspecifichealthproblem. Itiseasyformetoleavemyjob dutiesforfamilyneeds(forexample , leavingtoattendkids'school activities). JobflexibilityrelatedtoabilitytoleaveworksiteN/A–factorre-movedtheoretic-callydifferentfromtheconcept g/g:Gerstal/GallagherJobFlexibilityScaleCIRS:ChronicIllnessResourceSurvey Instrumentcorrelationsoftherefinedinstrument.Fivestrongcorrelationsremainedbetweentheitemsretained,5greaterthan.600(seecorrelationsforretaineditemsonTable4-16,above).Factoranalysisoftherefinedinstrument.PrincipalcomponentsfactoranalysisusingPromaxrotationresultedinfivefactorswithsimilarloadingstotheinitialanalysis(seeTables4-20,4-21,and4-22,below).Allbutoneloadingonfactorswasgreaterthan.800.Nosharedloadingsweregreaterthan.400.Of768possibleresponsestotheinstrumentitems,3datapointsweremissingatrandom.Meanswereimputedformissingdata,asdiscussedinChapter3.Bartlett'sTestofSphericity

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78confirmedthatthecorrelationmatrixisnotanidentitymatrix(p<.001)andtheKaiser-Meyer-Olkintest>.6indicatedtheassumptionofsamplingadequacyismet(Pett,Lackey,&Sullivan,2003;UniversityofNewCastleuponTyne,2002).Onlyoneitemhadacommunalitybelow.600,anotherindicationofsamplingadequacy.PAFwasnotused,asthefactorloadingsdidnotmakeasmuchintuitivesenseasthoseintheprincipalcomponentanalysis.Table4-20.FinalKMOandBartlett'sTestStep3 Kaiser-Meyer-OlkinMeasureofSamplingAdequacy.624 Approx.Chi-Square309.938 df66 Bartlett'sTestofSphericitySig..000 Table4-21.FinalFactorAnalysisStep3 StructureMatrix Factor Item# Comm 1 2 3 4 5 10.851 .895-.290-.135-.225-.182 11.772 .867-.322-.069.019-.304 1 .843 4.727 .838-.183-.051.142-.144 1.856-.205 .923-.057.229.187 2.826-.310 .905-.022.166.197 2 .820 5.570-.271 .724-.030.366.153 14.904.031-.022 .940.179.161 3 .832 15.877-.245-.065 .916.160.074 7.812-.167.247.100 .882.232 4 .700 3.768.162.258.220 .848.147 8.844-.100.047.221.346 .879 5 .694 6.812-.322.326.006.039 .867 RotationMethod:PromaxwithKaiserNormalization.Rotationconvergedin6iterations;Bold:Communalities Table4-22.FinalTotalVarianceExplainedStep3 Component InitialEigenvalues ExtractionSumsofSquared Loadings Total %of Variance Cumulative % Total %of Variance Cumulative % 1 3.443 28.694 28.6943.443 28.69428.694 2 1.992 16.601 45.2951.992 16.60145.295 3 1.917 15.974 61.2691.917 15.97461.269 4 1.255 10.461 71.7301.255 10.46171.730 5 1.012 8.437 80.1671.012 8.437 80.167 ExtractionMethod:PrincipalComponentAnalysis.

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79Thescreeplotwasdefinitiveoffivefactors,withscreeinanobviousstraightlineafterFactor5(seeFigure4-4,below). 121110987654321 ComponentNumber 43210 E i g e n v a l u e ScreePlotFigure4-4.FinalScreePlotStep3DescriptionofFactors–UnderlyingConceptsThefollowingconceptswereidentifiedforthefiverelevantfactors:1.Jobflexibilityrelatedtoself-managementofchronicillnessa.Abilitytoleaveworkstationwhennecessarytoperformon-siteoroff-sitechronicillnessself-managementactivities;2.Jobflexibilityrelatedtoworkhours(same3items)a.Abilitytoautonomouslyadjustworkhours;3.Needforjobflexibilityrelatedtoself-managementofchronicillnessa.Importanceofbeingabletostopworkactivitiesorleavetheworksiteforchronicillnessself-managementactivities;

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804.Jobcontrola.Abilitytoautonomouslymakedecisionsandsetprioritiesrelatedtojobduties;5.Worksiteresourcesrelatedtoself-managementofchronicillness(same3items)a.Employerregulatedbenefitsthataffectchronicillnessself-managementactivities;ItemsRemovedfromInstrumentAfterStep3TherevisedChronicIllnessSelf-ManagementAmongWorkersinstrumentconsistedof12(5point)Likert-scaledquestions.Thequestionnairealsocontained6work-siterelated,5demographic,and2diseaserelatedquestions.Therevisedquestionnairewasthenadministeredtothethirdsamplegroupforvalidityandreliabilityanalysis.Table4-23.Step4InstrumentQuestions 1.ThetimeIstartworkisflexible.2.ThehourIleaveworkisflexible.3.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone.4.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat.5.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds.6.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise7.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities.8.Myemployerprovidedpaidtimeoffworkforhealthcareorfitnessactivities.9.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat.10.Itisdifficultformetoleavemyjobdutiesforroutine("non-sick")healthvisitstomanagemycondition.11.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition?12.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtoleaveworkwhenyouneedtoattendhealthcareappointments?

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81Step4:AdministrationoftheFinalInstrumentandReliabilityTestingSampleandSettingInvitationstothewebsiteweredistributedtofacultyandstaffatfiveUniversityofFloridaColleges:Nursing,PublicHealthandHealthProfessions,Pharmacy,Medicine,andDentistry.All22internetresponsesmetinclusioncriteria.Demographics(seeTable24,below).Morefemalesthanmalesansweredthequestionnaire(91%,n=20vs.9%,n=2).Thelargestgroupofrespondents(71%,n=15)wasbetween46and64yearsofage.Nopersonsyoungerthan25orolderthan65respondedduringStep4.Theagesreportedmostfrequentlywere51and57(n=3each,13.6%).Medianageofthesamplewas49.Whitescomprised82%(n=18),Black/AfricanAmericans14%(n=3)ofthesamplegroup.NorespondentsreportedHispanic/Latinoethnicity,andonereportedrace/ethnicityasNativeAmerican/AlaskanNative.Allrespondentswerehighschoolgraduatesand16heldatleastabachelor’sdegree.Employment(seeTables4-24and4-25).Thetwolargestoccupationgroupswereprofessional/technical(54%,n=12)andadministrativesupport(27%,n=6).Onerespondent(x%)reportedanexecutive/administrative/managerialposition.Tworespondentsreportedworkinginsales,andonerespondentreportedworkinginaserviceoccupation.Althoughoverhalf(54%)oftherespondentsheldagraduatedegree,only27%ofthesamplereportedfamilyincomegreaterthan400%FPG(n=6).Norespondentsreportedincomeslowerthan100%FPG.Overhalf(54%)reportedbetween250-400%FPG.Thesampleincluded7workerspaidonanhourlybasis(32%),and15salariedworkers(68%).Halfoftherespondentsofrespondents(n=11)

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82hadworkedfortheirpresentemployerforlongerthan5years.Themajorityofworkershadcontroloverleavingtheworkstation(59%,n=13).Table4-24.DemographicsStep4 n% MajorOccupationalGroup MOGAProfessionalTechnical1254.5 MOGBExecutiveAdministrativeManagerial14.5 MOGCSales29.1 MOGDAdministrativeSupportClerical627.3 MOGEPrecisionProductionCraftRepair00.0 MOGFMachineOperatorsAssemblersInspectors00.0 MOGKServiceOccupations14.5 Total22100.0 Age 25-45628.6 46-641571.4 65+00 Total2121 Gender Male29.1 Female2090.9 Total22100.0 Race/ethnicity White1881.8 Black/AfricanAmerican313.6 HispanicorLatino00.0 NativeAmerican/AlaskanNative14.5 Total100.0 Educationstatus Highschooldiploma313.6 Somecollege313.6 Bachelor'sdegree29.1 Somegraduateschool29.1 Graduatedegree1254.5 Total22100.0 HouseholdIncome <250%FPG14.5 >250-<400%FPG1254.5 >400%FPG627.3 Total19100.0

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83 Table4-25.Work-RelatedItemsStep4 n % Ido 13 59.1 mymanagerdoes 7 31.8 someoneotherthanmy managerdoes 1 4.5 Ifyouareallowedtoleaveyourworkstation,who decideswhenandifyoucanleave? Total 21 100.0 yes 5 22.7 no 17 77.3 Areyouworriedyouwillbecriticizedforneedingtoleaveyour workstationtemporarilytocheckonyourhealthconditionortreatyour symptoms? n 22 100.0 lessthan6months 0 0.0 6monthstolessthan1year 1 4.5 1yearormorebutlessthan 5years 10 45.5 5yearsormorebutlessthan 10years 4 18.2 10yearsormorebutless than20years 4 18.2 20yearsormore 3 13.6 Howlonghaveyoubeenworkingatyour presentjob? n 22 100.0 hourly 7 31.8 salary 15 68.2 Howareyoupaid? n 22 100.0 Disease-relatedquestions.Forty-onepercentofrespondents(n=10)reportedhavingDMwhile54.5%(n=13)hadasthmaoranotherCRC(1respondenthadbothdiseases).Mostrespondents(80%)withDMreportedhavingthediseaseformorethanoneyear,whilethelargestgroupofpeoplewithasthma/otherCRChadthediseaseformorethan10years(seeTable4-26,below).Table4-26.ChronicHealthConditionStep4ChronicCondition<1year1-10years>10yearsn%n%n%n%Diabetes1040.9220440440AsthmaorotherCRC1354.500330770Both(1)4.5------22100.0------

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84ReliabilityAnalysisoftheChronicIllnessSelf-ManagementamongWorkersInstrumentReliabilityoftheinstrumentwasthenmeasuredusingtwomethods,scalereliability(internalconsistencymeasuredbycoefficient)analysisandtest-retestreliability(temporalstability)analysis.ScalereliabilityanalysiswasperformedinSPSS.Coefficientfortheentireinstrumentwas.852.Reliabilityanalysisforeachfactorwasalsoperformed,andrangedfrom.649to.764(seeTable4-27,below).Coefficientgreaterthan.60isconsideredtobeacceptableforanewinstrument(H.Yarandi,personalcommunication,July20,2006).Table4-27.ReliabilityStatisticsStep4n(cases)CISMAW.85221Factor1.76422Factor2.75621Factor3.64922Factor4.72922Factor5.75822CISMAWtest-retest Test(n=22)Retest(n=17Test-retestMeanSDMeanSDrSig.CISMAW26.349.1925.3210.37.862.000Factor17.363.146.653.67.789.000Factor23.842.554.183.43.880.000Factor36.002.205.652.26.605.010Factor45.731.785.532.29.810.000Factor53.412.423.322.49.723.001Therefinedinstrumentwasadministeredtwoweekslatertoasub-sampleof17respondents,followedbytest-retestreliability(temporalstability)analysis.All12itemsweresummedforeachcase.SumsforthetwotestswerecomparedusingPearsonproduct-momentcorrelationcoefficient(Pearson’sr).Pearson’srforthetest-retestwas.862(p<.000),demonstratingevidenceoftest-retestreliability(seeTable4-27,above).Inaddition,itemsoneachsubscaleweresummedforeachcase,and

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85correlationswererunonthetestandretestsums.Subscalecorrelationsrangedfrom.605to.880.Allwerestatisticallysignificant.

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86CHAPTER5DISCUSSIONThischapterpresentsaninterpretationofreportedresultsoftheChronicIllnessSelf-ManagementAmongWorkers(CISMAW)instrumentstudyaswellastherelationshipofthoseresultstopreviousresearch.Connectionsbetweenthefinalversionoftheinstrumentandthetheoreticalframeworkforthestudyarediscussed,asaresignificantsamplingissuesencounteredduringdatacollection.Implicationsforfurtherresearchanduseofthisinstrumentinresearchandpracticearediscussed,asarelimitationsofthestudy.OverviewoftheStudyMostadultsspendthemajorportionoftheirdayintheworkplace.Althoughinternationalhealthservicesresearchhasdemonstratedthatworkingconditionsaffectlongtermhealthstatus,fewstudiesfocusontheeffectofworkingconditionsonoutcomesofchronicdiseasesrequiringself-managementactivities(Marmot,Siegrist,Theorell,&Feeney,1999;Muntaner,Sorlie,O'Campo,Johnson,&Backlund,2001).Employment-relatedbarrierstochronicillnessself-managementmayexplainsomeportionofthedifferenceindiabetesandchronicrespiratorydiseaseoutcomesamongpersonsfromdisparatesocioeconomicgroups.Inparticular,pooreroutcomesmaybeassociatedwithlackofcontroloverworkschedules,resultinginlessenedabilitytobothleaveworktoaccessprimaryhealthcareservicesandperformcertainself-managementtasksatwork.However,littleisknownabouttheeffectofjobflexibilityonsuchoutcomesorwhetheritcontributestohealthdisparitiesbyoccupationalgrade.

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87Examinationofemployment-relatedbarriers–inparticular,jobflexibilityasitaffectschronicillnessself-management–mayshedlightonadynamicofchronicillnessself-managementthatpartiallyexplainsdifferencesindiseaseoutcomesamongpersonsfromdifferentsocioeconomicgroups.Therefore,thepurposeofthisstudywastoexaminethereliabilityandvalidityofaninstrumentdevelopedtomeasurejobflexibilityasitaffectschronicillnessself-managementamongworkers,specificallytargetingdiabetesandrespiratoryconditions.Twoexistinginstrumentsandquestionsdevelopedfrompilotstudieswereusedtoconstructtheinstrument.Thepyramidofsocial-environmentalsupportmodel,anecologicalmodelofhealthbehavior,wasthetheoreticalframeworkusedtoguidethisstudyanddeveloptheinstrumentunderexamination.Thisstudyconsistedof:reviewoftheinstrumentbyexpertsinthefieldofoccupationalhealthandchronicdisease,includingemployedpersonswithchronicillnessesrequiringself-management;aniterativeprocessofadministrationoftherefinedinstrumenttosamplepopulationsfollowedbyfactoranalysis;andreliabilitytestingusingscalereliabilityanalysisandtest-retestreliabilityanalysis.AnswerstoResearchQuestionsContentvaliditymeasuredbyexpertreviewEightreviewersagreedthattheinstrumentexhibitedcontentvaliditywiththeadditionorrewordingofcertainquestions.ConstructvaliditymeasuredbyexploratoryfactoranalysisForexploratoryfactoranalysis,validityisdefinedas“supportedtotheextentthatthederivedfactorsmakeconceptualsenseinrelationtotheconstructthatisthefocusofmeasurementanditsconceptualframework”(Strickland,2003,p.204).Factoranalysis

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88oftheCISMAWresultedin125-pointLikert-scaleditemsthatcaptured5factors/concepts:1.Jobflexibilityrelatedtoself-managementofchronicillnessa.Abilitytoleaveworkstationwhennecessarytoperformon-siteoroff-sitechronicillnessself-managementactivities;2.Jobflexibilityrelatedtoworkhoursa.Abilitytoautonomouslyadjustworkhours;3.Needforjobflexibilityrelatedtoself-managementofchronicillnessa.Importanceofbeingabletostopworkactivitiesorleavetheworksiteforchronicillnessself-managementactivities;4.Jobcontrola.Abilitytoautonomouslymakedecisionsandsetprioritiesrelatedtojobduties;5.Worksiteresourcesrelatedtoself-managementofchronicillnessa.Employerregulatedbenefitsthataffectchronicillnessself-managementactivities.InternalconsistencymeasuredbycoefficientalphaCoefficientfortheoverallfinalinstrumentwas.852.Coefficientforeachfactorrangedfrom.649-.764.Coefficientof.60orgreaterisconsideredevidenceofinternalconsistencyreliabilityforanewinstrument.Test-retestreliabilitymeasuredbyPearsonproduct-momentcorrelationcoefficientTest-retestreliability(temporalstability)wasdemonstratedbyPearson’srof.862(p<.000).InterpretationofResultsBasedonstatisticalanalysisofresponses,theCISMAWinstrumentappearstovalidlyandreliablymeasurejobflexibilityasitaffectschronicillnessself-managementintheworkplace,aconceptthatmayplayanimportantroleinworkers’attemptsto

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89achieveoptimalcontrolofchronicillnesses.Previousstudieshavedemonstratedtheconnectionbetweenthecomplexityofpeoples’livesandtheirabilitytoself-managechronicillness;althoughsocioeconomicfactorsareknowntobebarrierstoeffectivediseaseself-management,researchersandprovidersmayfailtoconsiderlackofjobflexibilityasitaffectschronicillnessself-managementamongworkersasanimpediment.Infact,employment-relatedbarrierstochronicillnessself-managementmayexplainsomeportionofthedifferenceindiseaseoutcomesamongpersonsfromdisparatesocioeconomicgroups,particularlylower-wageworkers.Therefore,thisstudyreflectsthedevelopmentofanappropriateinstrumenttomeasurejobflexibilityasitaffectschronicillnessself-management–thefirststeptowardamorecompleteunderstandingofthisconcept.TheoreticalFrameworkTheidentifiedfactorsarecloselyrelatedtothetheoreticalframeworkforthisstudy,thePyramidofSocial-EcologicalSupport(PSES).ThePSESisasocio-ecologicalmodelconsistingoffourlayers–coping(apex),closerelations,context,andculture(base)–eachwithinfluentialsupportiveandinhibitoryfactors.Eachofthebottomthreelayerscontainstwodimensions:theformal-institutionalandtheinformal-interpersonal.Thedecendinglevelsbecomemoredistalfromtheindividualbutexertmoreinfluenceoverhealthbehavior.Theformal/institutionalconstructofcontext,onthesecondlevelfromthebase,containstheconstructofinterestforthisstudy,workandorganization(Glasgow,Strycker,Toobert,&Eakin,2000).Factor1(jobflexibilityrelatedtoself-managementofchronicillness),Factor2(jobflexibilityrelatedtoworkhours),Factor3(needforjobflexibilityrelatedtoself-managementofchronicillness),andFactor4(jobcontrol)capturethesupportive

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90constructofjobflexibility(controloverworkschedule,abilitytoperformself-managementtasksatwork)whichwasaddedtothePSESmodel.Factor5(worksiteresourcesrelatedtoself-managementofchronicillness),relatestothesupportiveconstructofavailabilityofon-sitewellnesspoliciesintheoriginalPSES.Stigmarelatedtodisclosureofchronicillness,apossibleinhibitoryfactor,wasnotreflectedinthefactoranalysis.Inthework-siterelatedquestions(notpartoftheinstrumentitself)onlytworespondentsreportedthatdisclosuremightnegativelyaffectworkingconditions(Glasgow&Eakin,1998).ComparisontoGerstal/GallagherandCIRSInstrumentsThesixitemscontainedinthemeasureofjobflexibilityinstrumentadaptedbyGerstel&Gallagher(1994)wereincludedinStep1and2oftheCISMAWinstrument,duetotheirpossibleusefulnessinmeasuringemploymenteffectsonself-management.FouroftheseitemsremaininthefinalCISMAW.TwoquestionwereremovedafterfactoranalysisinStep2showedthemtobepoorpredictorsofjobflexibilityrelatedtoself-managementofchronicillness(“IfIneedapersonaldayoff,itiseasytotake.”–verylowloadingandcommunality;and“Iamgivenalotoffreedomtodecidehowtodomywork”.–lowestloadingonfactor,littlechangeinreliabilitywhenitemremoved,otheritemsseemedtocaptureconceptmoreclearly).FourofthesevenLikert-scaleditemsfromtheCIRSremainedonthefinaltest-retestinstrumentinStep4.Oneresourcesitem(“Myworkplaceofferswellnessprogramsand/orfitnessfacilities”.)wasremovedafterStep2asitwasthelowestloadingofthreerelatedquestions.OneCIRSitemseemedambiguoustotheexpertreviewersandwasremovedafterStep2duetolowloadingandcommunalities(“MycoworkerscoverformewhenIneedtodosomethingtomanagemyillnessordonotfeelwell.”).Thethird

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91removedCIRSitem(“Worksitesupportandresourcesareimportanttomeinmanagingmyillness”–communalitylessthan.600,lowestloadingonthefactor,andmultipleloadings)didnotseemtocapturethefactor’sconceptofperceivedneedforjobflexibilityrelatedtoself-managementofchronicillness.CertainquestionsontheGerstal/GallagherandCIRSinstrumentswerethusshowntobegoodmeasuresofjobcontrol,worksiteresourcesrelatedtoself-managementofchronicillness,andjobflexibilityrelatedtoworkhours.Theseconstructsareimportantwhenmeasuringthetypeofjobflexibilitynecessaryforoptimalself-managementofchronicillness,butdonotexploreallaspectsoftheconcept.TheCISMAWinstrumentthereforeincludesquestionsexaminingotherworkingconditionsthataffectchronicillnessself-management.RecruitmentIssuesSignificantdifficultiesoccurredduringrecruitmentforthisstudy.Initially,recruitmentofworksiteswasexpectedtobefairlysimple;theresearcherhadmanypreexistingcontactswithemployersandwasrecruitingfromageographicalareasurroundingamajoruniversityknownforitsresearch.However,resistancetoparticipationwasapparentearlyintherecruitmentphaseofStep2.EmployerResponseKeydecision-makerswerecontactedinperson,byphone,andbyemailrequestingameetingwiththeresearcher.Whengatekeeperspreventeddirectcontact,apacketcontainingarequestletterandcopyoftheinstrumentwereleftforthedecision-maker,followedbyphonecallsand/oremails(seeAppendixE,RecruitmentTools).Thepurpose,method,andpotentialfutureuseinresearchandpracticewereexplainedtoemployers,and(inStep2)methodofdistributionofthepapersurveyswasdiscussed.

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92SomeemployerswantedtolimitdistributiontoemployeeswithDMorrespiratorycondition–ratesofandreasonsforemployeenon-disclosureofdiseasetoemployerswasthenexplained.Whenface-to-faceorphonecontactoccurred,HumanResources(HR)personnelwerefrequentlyconsulted–oftenresultingina“no”decision.ThemostcommonreasongivenbyHRpersonnelforemployernonparticipationwasconcernthatdistributionofthequestionnairewouldinvalidateacompanyno-solicitation/distributionrule(commonlyinplacetopreventsolicitationbylaborunions).Eventheuniversity’sownPhysicalPlantDepartmentdeclinedparticipationforthisreason,althoughotheruniversitydepartmentsdidnotdecline.Inmanycases,aHumanResourcesgatekeepermadethisdecisionwithnoinputfromcompanyofficersorotherdepartments.Thismaybebasedonanoverlyrigidinterpretationoftherule;generallytheemployerruledoesnotapplytosurveysthatcouldnotbeinterpretedasadvancingorinhibitingunionactivity(forexample,whenemployershaveusedindependentresearchgroupstogatheremployeesatisfactioninformationinordertochangepolicyandtherebycircumventunionorganizingactivity)(NationalLaborRelationsBoard,2006).DuringStep2,only5of20contactedemployersinAlachuaCountyagreedtoparticipate(25%).Thesetendedtobesmallemployersrangingfrom15-135employees.WhenthesettingwasenlargedtoincludeotherpartsofNorthCentralandCentralFlorida,employerresponserateimprovedtoover50%(12/22employers).Thesewerelargeremployers,5withlessthan100employees,4with100-400employees,and3withmorethan400employees.AttheendofStep2,twolargeemployersagreedtoparticipateusingonlyemailinvitationstotheweb-basedquestionnaireratherthandistributionof

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93paperquestionnaires.OneoftheseemployerswasalargeprivatecollegewithitsownIRB–aninformalIRBreviewwasperformedandthestudywasdeemedexemptfromneedforformalIRBreview.TheseemployerswereutilizedatthebeginningofStep3.Twootherverylargeemployersagreedtoparticipatebutdidnotdistributetheemailinvitationtoemployees.EighteenemployerswhohadbeencontactedbutdidnotrespondorparticipateinStep2and3weresentblindemailsrequestingparticipation,resultinginincreasedresponses(asemployerswerenotidentified,itwasnotpossibletotracktheemployeroforigin).Onelargehealthcareproviderwithover6500employeesagreedtoparticipateinStep3,butdidnotdistributequestionnaires.ThisemployerhaddeclinedparticipationinStep2,stating“Ouremployeeshaveparticipatedintoomanyinternalsurveys”,andalsorefusedtoallowdistributionofpaperquestionnairesinwaitingroomsofitsmanyprimaryandspecialtyclinics.ReviewoftheliteratureshowsthatintheU.S.,samplesforpreviousstudiesofemployedpersonswithchronicillnesshavebeendrawnfromavarietyofsources:worksite-basedtreatmentprograms,inpatients,outpatients,diseasesupportgroups,HMOrecords,andblanketadvertisingforcommunityvolunteers.Insomecases,secondaryanalysiswasperformedondatafromnationalandstate-levelpopulation-basedstudies.Thereare,however,noavailablestudiesonchronicillnessintheworkplacewithrecruitmenttechniquessimilartothisstudy.Thisisunfortunate,asitisdifficulttocompareproblemsencounteredintherecruitmentphaseofthisstudytoexperiencesofotherresearchers.

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94However,thereisonepublishedstudywhereresearchersencounteredsimilarproblems.Inthelate1980s,researchersfromtheUniversityofMinnesotaSchoolofPublicHealthapproachedemployersintheMinneapolis/St.Paulareatoconductastudyutilizingaweightloss/smokingcessationprogram.Of115eligibleemployers,only32(28%)agreedtoparticipate.Inthewordsoftheauthors:Attheoutset,webelievedthatthisprojectwouldbeattractivetoemployers,sinceitoffereda50-50chanceofreceivingfreeweightlossandsmokingcessationprogramsinexchangeforthemodestcostofcompletingtwoemployeesurveys.Nevertheless,amajorityofsitesthatwereeligibletoparticipatedeclined(72%).Theseresultssuggestthattheoverallreceptivenessofemployerstowork-sitehealthpromotionmaybemoremodestthansomeadvocateshavesuggested.(Jefferyetal.,1993,p.399)Theresearchersfoundlargeremployersandthoseinthepublicsectormorewillingtoparticipate.Reasonsfornonparticipationincludedinconvenienceandinterferencewithbusinessactivities.EmployerhesitancytowardsparticipationintheCISMAWstudywasperplexingtothisresearcher,inthatdistributionofquestionnairesrequiredlittleeffortontheemployers’part,particularlywhenitinvolvedonlyemailinvitationstoemployeesvialistserv.Manyemployersseemedtounderstandandagreewiththeneedforthestudy,yetwereunwillingtoallowdistributiontoemployees.Humanresourcesprofessionals,inparticular,hadmanyconcernsaboutprivacyandHIPAAviolations,althoughthestudyhadIRBapprovalandresponsescouldnotbetracedtotheemployeeorjobsite.Onlyone(non-participating)employerstatedhisconcernthatthestudycoulduncoverworkingconditionsnotcommensuratewithcompanypolicies;however,thismayhavebeenanunderlyingfactorinthelowemployerresponserate.Althoughworksiteswerenotidentifiedbysurveyrespondents,someemployeridentitiescouldbeinferredbasedontypeofworkandnameofposition.Basedonthoseinferences,the

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95employerwascorrect–lowerlevelemployeesofentitieswithseeminglyrobustpoliciesofaccommodationfrequentlyreportedlittleaccommodationforself-managementactivities.Thisreflectsfindingsofcurrentstudiesshowingmanagers’lackofunderstandingofneedsforaccommodationandinabilitytoimplementaccommodationswhentheneedforsameisidentified(Unger&Kregel,2003).TheremayalsobeaconnectionbetweenthecurrenteconomicsituationandthatoftheerawhentheUniversityofMinnesotastudytookplace.Asenseofeconomicinsecuritycurrentlyexistsatmanylevelsofthejobmarketinatimeofeconomicexpansionandoutsourcingtoothercountries;althoughtheeconomicnewsisgoodforemployers,workersmayfeeluncertainabouttheiroccupationalfutureinthefaceofderegulationandprivatizationofindustry,marketglobalization,anddecreasedsocialservicespending.Additionally,recentlyreleasedstatisticsfrom2004showthatthemajorityofpersonalU.S.economicgainhasbeenamongthetop1%ofthepopulation,whileactualmedianincomehasfallen–anothersourceofeconomicuncertaintyamongmiddleclassworkers(Aron-Dine&Shapiro,2006;Coburn,2000;U.S.CongressionalBudgetOffice,2005).TargetPopulationResponseEvenwhenemployerswerewillingtodistributethequestionnaires,responseratesfromthetargetpopulationwerelowerthanexpected.Oneprobableexplanationforthisisaninflatedestimateofworkerswiththetargetedchronicillnesses,expectedtobe20%ofworkingadultsbasedonnationaldata(NationalCenterforChronicDiseasePreventionandHealthPromotion,2004;U.S.CensusBureau,2000).Also,alowerpercentagethanexpectedmaybeondailymedication(aninclusionrequirement),ormaynotbe

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96compliantwithprescribedmedicationregimens–thisphenomenoniswidelyreportedinrecenthealthservicesresearchstudies(Boccuzzietal.,2001;Bousheyetal.,2005).Exclusionrate.DuetothedifficultiesinemployerrecruitmentinStep2,atotalof365paperquestionnairesweredistributedbetweenAugustandDecember2005,resultingin3questionnairesreturnedwithaGainesvilleareapostmark–a4%responseratefromthetargetpopulationofapproximately73people.Inall,over2260paperandemail-invitedquestionnairesweredistributedoutsideAlachuaCountybetweenJanuaryandApril2006,resultingin109paperandweb-basedresponses–a24%responseratefromtheestimatedtargetpopulationof455people.InStep3(websiteonly)76responseswerereceivedafterdistributiontoapossible6000employees(targetpopulation:approximately600–estimating10%).ThisresponseratewaslowerthaninStep2,howeveritisdifficulttoestimatethedistribution,astheresearcherdidnothaveanywayofknowingthenumberofemployeeswhohadaccesstoemail.Itmayalsoreflectworkers’concernsaboutfillingoutasurveyregardingworkingconditionsthatreachedthemthroughcompanyemail.Asmentionedearlier,employershavebeenknowntouseindependentresearchgroupstogatherinformationintimesofknownworkerdissatisfactionwithmanagement.Failuretoanswerdiseasequestion.Ofthetotalof200responses,only142mettheinclusioncriteria,almostallexclusionswereduetoabsence(ornon-report)ofdiabetesorasthma/otherchronicrespiratorycondition.Onthepaperquestionnaires,29/41nonrespondersreportednothavingeitherofthesediseases;somewroteinadescriptionoftheirnon-includedchroniccondition(e.g.,chronicbackpain,degenerativediskdisease).Therefore,acertainportionofrespondentswereapparentlyinterestedin

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97describinghowworkingconditionsaffecttheirabilitytoself-managechronicillnessesotherthandiabetesorasthma/otherchronicrespiratorycondition,despiteknowingtheirresponseswouldbeexcludedfromthestudy.InStep3,thisexclusionwasclearlyspelledout(“NOTE:ifyoudonothaveoneoftheseconditionsand/ordonotcircleone,wecannotincludetherestofyourresponsesinthestudy.”wasincludedafterthequestion),yetsevenrespondentsstillfilledoutthequestionnaire.Astheresearchertookpainstoassureanonymityofrespondentsandtheirworksites,thereisnowaytoexaminethereason(s)whyrespondentswhodidnotanswerthequestionorsaytheydidnothaveeitherdiseasestillfilledoutthequestionnaire(14/104inStep2,7/74inStep3).Munir,Leka,andGriffiths(2005)reportedanumberofreasonswhyemployeeschoosenottodiscloseillnesstoemployers;however,therewasnoriskofthiskindofdisclosureinthisstudy–buttheinterpretationof“norisk”bytherespondentsthemselvesisunknown(andagoodreasontodofutureexploratory/descriptiveresearchinthisarea).Aswiththoseemployerswhochosenottodistributethequestionnaires,fearofresponsesreachingcompanyprincipalsorownersmaybelinkedtoeconomicuncertaintyamongworkers,particularlythoseinlowerwagejobs.However,reasonsforlackofresponsecanonlybesurmised.WeaknessesandStrengthsoftheStudyLimitationsGeneralizability.Resultsofthisstudymayhavelimitedgeneralizabilitytoallpersonswithchronicillnessrequiringself-management,duetoitsapplicationonlytopersonswithDMorrespiratoryconditions–otherconditionssuchasarthritis,chronicintractablepain,cancer,HIV/AIDS,andmentalillnessmayalsorequireintensiveself-managementactivities.However,furtherresearchmaydeterminethatquestions

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98containedintheinstrumenteasilytranslatetootherconditions.Althoughmanytypesofworksiteandoccupationwererepresentedinthesample,itmaynotberepresentativeofthegeographicalareaoroftheU.S.asawhole.Self-selectionbias.Theremaybesomeself-selectionbiasduetothequestionnairetopicandrelianceonself-report.Employeeswhohavedifficultyself-managingtheirchronicillnessesintheworkplacemaybemoreapttorespondthanthosewhodonotperceiveanybarrierstoself-management.Infutureapplicationoftheinstrument,responsestothequestionsregardingfrequencyofbreaksnecessarytomanagetheconditionandthinkingabouthealthconditionatworkcouldbeusedtocontrolforthisbias.Lackofcongruentvaliditymeasurement.Thisinstrumentmeasuresconceptsthatarenotexaminedinanypreviouslyavailableinstrument;thereforecomparisonsdemonstratingcriterion-relatedvalidity(congruentvalidity)werenotpossible.Numberofitemsininitialinstrument.Ideally,thenumberofitemsintheinitialinstrumentshouldbefiveormoretimesgreaterthanthenumberoffactorsobtained.Factoranalysisoftheinitial23itemCISMAWresultedin8factors,oneofwhichhadonlyoneitemloading.AccordingtoMacCallum,Widaman,Zhang,andHong(1999)“This[5ormoreitems/factor]isnotanecessaryconditionforasuccessfulfactoranalysis...butratherisanaspectofdesignthatisdesirabletoachievebothclearsimplestructureandhighlyoverdeterminedfactors”(p.90).Thelownumberofinitialitemscomparedtoextractedfactorsmayhaveresultedindeletionofitemsthatexplorefurtheraspectsoftheconceptathand.Certaindeleteditems,particularlythosethataddressseverityofillness

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99and/orneedforself-managementjobflexibilityrequireadditionalresearchtodetermineimportanceofconstructsnotaddressedinthecurrentinstrument.UseofSelf-ReportDataAlthoughtheuseofself-reportdataisfrequentlyreferredtoasalimitation,inthisstudyitcouldbeconsideredastrength.Self-managementofchronicillnessamongworkersisanewareaofstudyrequiringreliableandvalidmeasurementinstruments.Whenexaminingbehavioraloutcomesofchronicdiseasemanagement,thesubject’sperceptionofrealityismoreimportantthanrealityitself.Inaddition,theimportanceofperceivedcontrolinself-managementofdiseasehasbeendemonstratedinmanystudies.Inareviewof57studiesexaminingthetheoryofplannedbehavior,researchersfoundthatperceivedbehavioralcontrolwasasignificantpredictorofintentiontoperformhealthbehaviors(Godin&Kok,1996).Perceivedbehavioralcontrolreferstoaperson’sbeliefthattherearebarriersorsupportingfactorsaffectingtheirabilitytoperformdesiredbehaviors.Self-reporthasbeenshowntobeas/morevalidthanobjectivedatainmanyareasofoccupationalhealthresearch,particularly:healthstatus,employmentrelated-data,exposures,workimpairment,andproductivityinallergy/asthmaAdministrativedataonself-managementofchronicillnessamongworkersmaybemissingimportantinformation,sincepolicyadherenceisdependentonactionsofspecificmanagers.Impliedconsequencesofaskingfortimeawayfromtheworkstationmayincludefearofappearingnonproductiveorfearofthestigmaofchronicillness.Inaddition,althoughemployersbelievetheyknowwhichemployeeshavechronicillnesses,atleast20%oftheseemployeesdonotdisclosesuchillnessestoemployers;thus,employerrecordsmaybeincomplete(Munir,Leka,&Griffiths,2005).

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100Therefore,employeeperceptionsprovideamorevaliddatabasethanemployerpoliciesorintentions.Ifresultsbetweendatasourcesdiffer,itmayreflectdifferencesinperceptionofpolicyorhowpolicyiscarriedoutatdifferentlevelsofbureaucracy,ratherthaninvalidityofthedata(Fisher,2003;Turpinetal.,2004).Whenexaminingthisconstruct,self-reportmaybethemostaccurate,unbiasedresponseformat,asresearchbasedonlyondatacollectedfromemployersandotherobjectivesourcesmayresultindevelopmentofconclusionsthatdonotreflectemployeeperception.ImplicationsforFurtherResearchRecruitmentdifficultiesencounteredduringthisstudyilluminatetheneedforchangestosamplingstrategy.Beforethisstudycanbereplicated,researchersmustengagelargepublicandprivateemployersinstudydesigntoensurecompletionofanyfuturestudy.Onewaytoaccomplishthismaybepursuitofstateornationallevelfundingforastudyutilizinggovernmentemployees.Evenonthemunicipallevel,governingentitiesmaintainworkforcestouchingmostoccupationalgroupswiththepossibleexceptionofsales-relatedandhealthoccupations.However,fundingatthestateornationallevelmaygrantaccesstogovernmentcontractorsthatemployasalesforce,andwouldincludestate-levelhealthcareworkers.UseoflargeindependentsamplesisrequiredinordertoexamineusefulnessoftheCISMAWinstrumentinspecificchronicconditionssuchasdiabetes,respiratoryconditions,arthritis,intractablepain,mentalillness,HIVAIDS,andotherchronicillnesses.InadditiontheinstrumentshouldbeadministeredtomorediversepopulationscontainingmoreLatinosandotherraces.

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101OvercomingNon-ReportofChronicConditionAsalmost25%ofrespondentswereunwillingtoreportwhatchronicdiseasetheyhad,apilotstudyexaminingthisresponseproblemisnecessarypriortouseofthisself-reportinstrument.Focusgroupsorotherqualitativeinvestigationmethodsamongemployedpersonswithchronicdiseasemightuncovertheunderlyingreasonsfornondisclosure;however,therewouldonceagainbesomedegreeofself-selectionbiasinthatpeoplewhodidnotwanttodisclosetheirillnesswouldnotrespondtorecruitment.Recruitmentfromsettingsusedinotherstudies,ratherthanemploymentsites(e.g.,outpatients,diseasesupportgroups,HMOrecords,andblanketadvertisingforcommunityvolunteers)mayyieldasufficientpurposivesampleforsuchresearch.Largermetropolitanareasmayyieldrespondentsforfocusgroupswhenpeopleperceivelowerriskofbeingplacedinagroupcontainingpastorpresentcoworkersormanagers.FurtherUseoftheCISMAWInstrumentTheCISMAWinstrumentcouldbeusedtostudyandcomparetheeffectofbeinginspecificoccupationalgroups,industries,socio-economicorracial/ethnicgroupsonabilitytoself-managechronicillnessintheworkplace.Inparticular,theeffectoforganizationalstructureandtheresultingconcentrationsofhierarchy,power,anddominationamongdifferentoccupationalgradesmayinfluenceworkers’perceptionofjobflexibilityasitaffectschronicillnessself-management.Forinstance,dolower-levelmanagerswhosejobperformanceismeasuredbytheoutputoftheemployeestheysupervisesubvertwrittencompanyaccommodationspolicyandactionsofmiddlemanagers?Duringthecurrentstudy,itwasfrequentlypossibletoidentifyworksitesbasedonrespondents’descriptionsoftheirtypeofwork;manager’s

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102reportsofaccommodationpolicystatedduringinitialrecruitmenteffortsoftendifferedmarkedlyfromlaterresponsesofworkersinlowerleveljobs.AsnotedinChapter2,chronicdiseasemayhaveanegativeeffectonworkperformance;however,improvementinself-managementofchronicillnessmaysignificantlyreducethateffect.FuturestudyusingtheCISMAQinstrumentwouldbeenhancedbyconcurrentexaminationofemployers’accommodationpolicies(andtheirimplementation),aswellasobjectiveexaminationofchronicallyillworkers’productivity.Classicalsociologicaltheory(Turner,Beeghley,andPowers,2002)states:thegreaterthelevelofinequality,thegreatertheconflictofinterestbetweendominantandsubordinatesegments(Marx);thosewithpowerlimitaccesstoresources(Marx);and,thosewhoholdpowerseektolegitimizetheirpoweras“authority”intheeyesofthosewhoaresubordinate(Weber).Currenttheoryexaminingdifferenttypesofpowerandtheeffectofincomeinequalityreflectsimilarthemes.Whenanemphasisonproductivitysupercedesalongerviewvaluingindividualemployees,“theincreasingemphasisonhierarchicalrelationsofdominanceandsubordination”(Wilkinson,2000,p.412)invadestheworkworld,withhierarchydefinedas:individualaccesstoanduseofpower,coercion,andaccesstoresourceswithnoregardfortheneedsofotherpeople.Areviewofsociologicalstudiesin2002foundthatthesehierarchicalpatternsworkagainstwomenandminoritiesintheworkplace,asthoseinauthoritytendto“reproducethemselvesthroughbothexclusionaryandinclusionaryprocesses”(Smith,2002,p.510),leadingtoongoingpatternsofdominanceandabuseofpower.Thistendencytowarddisrespectfultreatmentof

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103low-wageworkersiselucidatedinarecentbestseller,TheBetrayalofWork:HowLowWageJobsFail30MillionAmericans(Shulman,2004).Thus,thereisaneedforfurtherexaminationoftheeffectofworksite-baseddominationandresultingsubordinationonoutcomesofchronicillnessrequiringself-management,particularlyamonglowerwageworkers.Ultimatelythisinstrumentcouldhelpresearchersexaminethewayinwhichoutcomesofchronicillnessareaffectedbythesebarrierstonecessaryhealthrelatedactivitiesbylinkingworkingconditionswithdiseaseoutcomesinlongitudinalstudies.ImplicationsforNursingandOccupationalHealthPracticeInadditiontoitsuseforresearchpurposes,theCISMAWinstrumentisintendedforexamineusefulnessofCISMAWinspecificchronicconditions.Furtherresearchisnecessarytodetermineanappropriatescoringsystemfortheinstrument(e.g.,totalscoredeterminestheclienteitherneedshelpwithaccommodations,mayneedhelpwithaccommodations,orhassufficientjobflexibility).Thisscoringsystemmaynecessitateweightingoftheinstrumentbasedonintensityofneedtoperformself-managementactivities.ThiswouldrequireadditionalresearchonitemsremovedfromtheCISMAWinstrumentduringfactoranalysis(e.g.,“howoftendoyourequireabreakfromyourjobduties”question).Theinstrumentcouldthenbeusedbyprimaryandspecialtycareclinicianswithbothnewlydiagnosedclientsandlong-termdiagnosedclientswhoarenotachievingoptimalself-management.Clinicianscouldassistclientswhorequireworkaccommodationstoenhanceself-managementinachievingthoseaccommodations.TheCISMAWinstrumentcouldalsobeusedbyemployerstodetermineifaccommodationpoliciesimplementedonthecompanylevelareactuallybeingcarriedout

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104andtakenupatthelowerlevelsofthecompany.Aremanagersfollowingcompanypolicyoraretheymakingtheirownpolicy?Docertainfactorssuchasoccupationalgroup,race,orgenderaffectthewaythataccommodationsarecarriedoutbymanagersortakenupbyemployees?However,smalleremployersmaynothavetheexpertiseorstafftocarryoutthistypeofproject.Onepossiblesolutionisanursepractitionermanagedemployerassistanceprogramprovidingworkplaceeducationaboutandstrategiestoimproveemployeechronicillnessself-managementatworkforsmallemployers.Thesemethodscouldhelptopreventpresenteeism/absenteeismduetochronicillnesses,andassistemployerstomeetAmericanswithDisabilitiesActaccommodationrequirements.Inaddition,consultantscouldassistemployeesoftheseclientstoimprovetheirchronicillnessself-managementintheworkplace,andinaccessingprimarycareandcasemanagementservicesinthecommunity.SummaryThisstudyoftheCISMAWinstrumentfoundittobeareliableandvalidmeasureofjobflexibilityasitaffectschronicillnessself-managementamongworkers,specificallytargetingdiabetesandrespiratoryconditions.Thetheoreticalframeworkforthestudywasanecologicalmodelofhealthbehavior.Theinstrumentexhibitedcontentvalidity,constructvalidity,internalconsistencyreliability,andtest-retestreliability(temporalstability).Factoranalysisledtoidentificationoffivefactors/conceptsunderlyingtheinstrument:(1)jobflexibilityrelatedtoself-managementofchronicillness;(2)jobflexibilityrelatedtoworkhours;(3)needforjobflexibilityrelatedtoself-managementofchronicillness;(4)jobcontrol;and,(5)worksiteresourcesrelatedtoself-managementofchronicillness.

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105Significantrecruitmentdifficultieswereencounteredduringdatacollection,contributingtolimitationsofgeneralizabilityandself-selectionbias.Useofself-reportdataisconsideredastrengthofthisstudy,asemployeeperceptionofbarrierstoperformanceofself-managementactivitiesmayhavemoreeffectonhealthbehaviorsthanactualworkingconditions.Furtherstudyisneededwithdesignadaptationandlarger,morediversesamplestoovercomelimitations.Afterfurtherresearch,theCISMAWcouldbeusedinbothresearchandpractice,providingavalidandreliableinstrumentmeasuringjobflexibilityasitaffectschronicillnessself-managementamongworkers.Thisnewareaofresearchseekstoexploreunderlyingcausesofhealthdisparitiesamongoccupationalgroups,particularlytheeffectoflowerwageoccupationsonoutcomesofchronicillnessesrequiringself-management.Mosthealthpromotioneffortsforthesediseasesconcentrateonindividualcopingbehaviors,interactionswithsignificantothers,andinteractionswiththehealthcareteam;however,eventsattheworksitemayinfluenceoutcomesmorestronglythanpreviouslysuspected(Glasgowetal.,2000).Continuingstudyofthisareaofjobflexibilityisnecessarytoimprovediseaseoutcomeswhenillnessesrequireself-managementactivitiesduringworkinghours.

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106APPENDIXACHRONICILLNESSSELFMANAGEMENTAMONGWORKERSINSTRUMENTSTEP1

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ExpertReview(ContentValidity)InstrumentName:__________________________________________________________Date:___________________Pleasedescribeyourbackgroundinthefieldofchronicillnessand/oroccupationalhealth:______________________________________________________________________________________________________________________________________________________________________________________________________Overall,howwelldoesthisinstrumentmeasuretheinformant’sperceptionof:NotatallCompletely1.Jobcontrol/flexibility2.Jobcontrol/flexibilityasitrelatestochronicillnessself-management3.Availabilityofworkplacechronicillnessself-managementresources4.Availabilityofworkplacewellnessresources5.Importance/valueofchronicillnessself-management6.Ifyouthinkanyconcepts/constructsof“jobcontrol/flexibilityasitrelatestochronicillnessself-management”aremissingfromthisinstrument,pleasedescribethem:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 1 0 7

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108Didyouidentifyanyquestion(s)needingrewordingoromission?Ifsopleaseidentifyandexplain:Question#Explanation_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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109ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep1Pleaseanswerthefollowingquestionsbycheckingtheanswerthatbestdescribesyourworksituation.1.ThetimeIstartworkisflexible. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso2.IfIneedapersonaldayoff,itiseasytotake. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso3.ThehourIleaveworkisflexible. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso4.Iamgivenalotoffreedomtodecidehowtodomywork. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso6.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso

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1107.Towhatextentdoyouhaveaflexibleworkschedulethatyoucanadjusttomeetyourneeds? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal8.Towhatextenthasyourworkofferedwellnessprogramsorfitnessfacilities? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal9.Towhatextenthasyourworkplacehadrulesorpoliciesthatmadeiteasierforyoutomanageyourillness(suchasnosmokingrulesortimeoffworktoexercise)? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal10.Towhatextenthaveyourcoworkerscoveredforyouwhenyouneededtodosomethingtomanageyourillnessorwerenotfeelingwell? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal11.Towhatextenthaveyouhadcontroloveryourjobintermsofmakingdecisionsandsettingpriorities? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal

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11112.Towhatextenthasyouremployerprovidedpaidtimeoffworkforhealthcareorfitnessactivities? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal13.Howimportantareworksitesupportandresourcestoyouinmanagingyourillness? Notsoatall Alittlebitso Amoderateamount Quiteabit Agreatdeal14.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso15.Areyouallowedtostopworkinglongenoughandoftenenoughtodowhatyouneedtodototakecareofyourillness?Forinstance,areyouallowedtoleaveyourworkstationwhenyoufeelyouneedtotake5minutestoperformanecessarytasktohelpmanageyourcondition? Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso16.Howdifficultisitforyoutoleaveyourjobdutiesforroutine(“non-sick”)healthvisitstomanageyourchronicdisease? Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso

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11217.Howeasyisitforyoutoleaveyourjobdutiesfor“sickvisit”care(officeorhealthcareappointments)whenyouhaveaspecifichealthproblem? Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso18.Howdifficultisitforyoutoleaveyourjobdutiesforpersonalneeds(forexample,leavingtotakecareofbankingneeds)? Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso19.Howeasyisitforyoutoleaveyourjobdutiesforfamilyneeds(forexample,leavingtoattendkids’schoolactivities)? Notsoatall Alittlebitso Sometimesso Usuallyso Verymuchso20.Howoftendoyouthinkaboutyourillnesswhileyouareatwork? Never Afewtimesaweek Everyday Severaltimeseveryday Allthetime21.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotake5minutestoperformanecessarytasktohelpmanageyourcondition? Notimportantatall Alittlebitimportant Somewhatimportant Fairlyimportant Veryimportant

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11322.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notimportantatall Alittlebitimportant Somewhatimportant Fairlyimportant VeryimportantPleaseanswerthefollowingquestionsbycirclingthecorrectanswerorfillingintheblank:23.Whodecideswhetherornotyoucanleaveyourworkstation? Ido_____ Mymanagerdoes______________________________________does(usethenameoftheperson’sjob,nottheirname)24.Doesyourworkplacehaverulesorpoliciesthatmakeiteasierforyoutotakecareofyourillness?Forinstance,areyouallowedtoleaveyourworkstationwhenyoufeelyouneedtodoacheckonyourillnessortreatyoursymptoms? Yes No25.Pleaselistotherthingsthathavehappenedorotherresourcesyouhaveusedthathelpedyoutomanageyourillness:___________________________________________________________________________________________________26.Doyouknowsomeoneatyourjobsitewiththesameillness? Yes.Isthatpersonyoursupervisor? Yes No No27.Doesyouremployerknowaboutyourillness? Yes No.Whydidn’tyoutellyouremployer?_______________________________________________________________________________28.Areyou: Female Male29.Howoldareyou? ______

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11430.Whatisyourracial/ethnic/culturalgroup?Putacheckinfrontofeachdescriptionthatyouthinkappliestoyou: White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative31.Whatracial/ethnic/culturalgroupdootherpeopleusuallythinkyoubelongto? White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative32.Howlonghaveyoubeenworkingatyourpresentjob? Years Monthsor Weeks33.Whatkindofworkdoyoudo?_______________________________________34.Whatisyourjobcalled?____________________________________________ 35.Whatchronicillness(es)doyouhave(checkallthatyouhave)? Diabetes Asthmaorotherchronicrespiratorydisease36.Howlongagohaveyouhad:Diabetes: 1yearorless 1-10years MorethantenyearsAsthmaorotherchronicrespiratorydisease: 1yearorless 1-10years Morethantenyears

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11537.Circlethenumberofpeoplewholiveinyourhouse.Thenfindtheplaceonthatsamelinethatisclosesttotheamountofmoneythatcomesintoyourhouseeverymonth.Forexample,ifthereare6peoplelivinginyourhouseandeveryonewhoworksbringsinatotalofabout$3000,youwouldcircle“6”andthen“$$2,157-5,390”.Howmanypeopleliveinyourhouse?Abouthowmuchmoneycomesintoyourhouseeverymonth? 1$0-798$799-1,994$1,995-3,190$3,191ormore 2$0-1,069$1,070-2,673$2,674-4,277$4,278ormore 3$0-1,341$1,342-3,352$3,353-5,363$5,364ormore 4$0-1,613$1,614-4,031$4,032-6,450$6,451ormore 5$0-1,884$1,885-4,710$4,711-7,537$7,538ormore 6$0-2,156$2,157-5,390$5,391-8,263$8,264ormore 7$0-2,428$2,429-6,069$6,070-9,710$9,711ormore 8ormore$0-2,699$2,700-6,748$6,749-10,797$10,798ormore

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APPENDIXBCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP2

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117ChronicIllnessSelf-ManagementAmongWorkersStudyInformedConsentStatementSteps2and3Pleaseconsidertakingthetimetofillouttheattachedstudyquestionnaireifyou:areondailymedicationforeitherdiabetesorasthma(oranotherobstructivepulmonarydisease)areemployedfull-time(32hoursperweekormore),andarebetweentheagesof18and70.Ifyoudonotmeettheserequirements,orifyouhavecompletedandreturnedthisquestionnaireatanotherworksite,pleaseeithercallthePIforclarificationorthrowthispacketaway.Thepurposeofthisresearchstudyistomeasurehowyourjobaffectsyourabilitytomanageyourhealthcondition.Inordertodothis,weneedinformationfrompeopleworkinginallkindsofjobs,withallkindsofincomelevels.Itwilltakeabout15minutestocompletethisquestionnaire.Althoughtherearenodirectrisksorbenefitsofparticipatinginthisstudy,thisquestionnairecouldbeusedinthefuturetocollectinformationleadingtoabetterunderstandingofhowworkingaffectschronicillnessself-management.Youridentitywillremainanonymous.Althoughyouwillrevealthatyouhaveeitherdiabetesmellitusorasthma/otherobstructivepulmonarydisease,youwillnotputyournameanywhereonthequestionnaire.Thiswillensurethatyourhealthinformationremainsconfidential.Byfillingoutthequestionnaire,youareagreeingthatyouunderstandthisinformationandgiveyourconsentforouruseofyourinformation.However,youmaychoosenottoansweranyorallofthequestions.Yourparticipationiscompletelyvoluntary.Youdonothavetoansweranyquestionyoudonotwishtoanswerandyoumaywithdrawyourconsenttoparticipateatanytimewithoutpenalty.ApprovedByUniversityofFloridaInstitutionalReviewBoard02Protocol#2005-U-0448ForUseThrough06/15/2007Shouldyouhavequestionsaboutyourrightsasaresearchparticipant,pleasecontacttheUFIRBatP.O.Box112250,Gainesville,FL32611or352-392-0433.Pleasekeepthiscoversheetoracopyincaseyouneedtocontacttheprincipalinvestigatorforthisstudyand/orhercommitteechairperson:RobynPantherGleason,ARNP,PhDCandidate,PrincipalInvestigatorUniversityofFloridaCollegeofNursing(352)284-2123rgleason@nursing.ufl.eduShawnKneipp,ARNP,PhD,CommitteeChairpersonUniversityofFloridaCollegeofNursing(352)273-6417skneipp@nursing.ufl.edu

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118ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep2Pleaseanswerthefollowingquestionsbycheckingtheanswerthatbestdescribesyourworksituation.1.ThetimeIstartworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso2.IfIneedapersonaldayoff,itiseasytotake. Notatall Alittlebit Sometimes Usually Verymuchso3.ThehourIleaveworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso4.Iamgivenalotoffreedomtodecidehowtodomywork. Notatall Alittlebit Sometimes Usually Verymuchso5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notatall Alittlebit Sometimes Usually Verymuchso6.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso

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119Thefollowingquestionsmayseemlikequestionsyouhavealreadyanswered.Pleaseanswerthemwithoutlookingbacktoseehowyouansweredtheearlierquestions.7.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds. Notatall Alittlebit Sometimes Usually Verymuchso8.Myworkplaceofferswellnessprogramsorfitnessfacilities. Notatall Alittlebit Sometimes Usually Verymuchso9.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise). Notatall Alittlebit Sometimes Usually Verymuchso10.MycoworkerscoverformewhenIneedtodosomethingtomanagemyillnessordonotfeelwell. Notatall Alittlebit Sometimes Usually Verymuchso11.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities. Notatall Alittlebit Sometimes Usually Verymuchso12.Myemployerprovidespaidtimeoffworkforhealthcareorfitnessactivities. Notatall Alittlebit Sometimes Usually Verymuchso

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12013.Worksitesupportandresourcesareimportanttomeinmanagingmyillness. Notatall Alittlebit Sometimes Usually Verymuchso14.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso15.IamallowedtostopworkinglongenoughandoftenenoughtodowhatIneedtodototakecareofmyhealthcondition(forexample,leavingmyworkstationwhenIfeelIneedtotakesometimetoperformanecessarytasktohelpmanagemycondition.) Notatall Alittlebit Sometimes Usually Verymuchso16.Itisdifficultformetoleavemyjobdutiesforroutine(“non-sick”)healthvisitstomanagemyhealthcondition. Notatall Alittlebit Sometimes Usually Verymuchso17.Itiseasyformetoleavemyjobdutiesfor“sickvisit”care(officeorhealthcareappointments)whenIhaveaspecifichealthproblem. Notatall Alittlebit Sometimes Usually Verymuchso

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12118.Itisdifficultformetoleavemyjobdutiesforpersonalneeds(forexample,leavingtotakecareofbankingneeds). Notatall Alittlebit Sometimes Usually Verymuchso19.Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids’schoolactivities). Notatall Alittlebit Sometimes Usually Verymuchso20.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition? Notatall Alittlebit Sometimes Usually Verymuchso21.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notatall Alittlebit Sometimes Usually Verymuchso22.Howoftendoyouthinkaboutyourhealthconditionwhileyouareatwork? Never Afewtimesaweek Onceaday Severaltimesaday Allthetime

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12223.Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition? Never Afewtimesamonth Afewtimesaweek Onceaday SeveraltimesadayPleaseanswerthefollowingquestionsbycheckingthecorrectanswerorfillingintheblank:24.Doesyourworkplacehaverulesorpoliciesthatmakeiteasierforyoutotakecareofyourhealthcondition?Forinstance,isthereapolicythatsaysyouareallowedtoleaveyourworkstationwhenyoufeelyouneedtodoacheckonyourconditionortreatyoursymptoms? Yes No25.Doesyourworkplacehaverulesorpoliciesthatmakeitdifficultforyoutotakecareofyourhealthcondition?Forinstance,isthereapolicythatsaysyouarenotallowedtoleaveyourworkstation? Yes No26.Ifyouareallowedtoleaveyourworkstation,whodecideswhenandifyoucanleave? Ido_____ Mymanagerdoes_____ Someoneotherthanmymanagerdoes.Pleasewriteinthenameofthatperson’sjob_____________________________________________27.Areyouworriedthatyouwillbecriticizedifyouneedtoleaveyourworkstationtemporarilytocheckonyourhealthconditionortreatyoursymptoms? Yes No28.Haveyoueverbeencriticizedforneedingtoleaveyourworkstationtemporarilytotakecareofyourcondition? Yes.Ifyes,putacheckbythepositionthatpersonheldatthattime(orfillintheblank): Manager Coworker Other:______________________________________ No

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12329.Pleaselistotherthingsthathavehappenedatworkorotherresourcesyouhaveusedatworkthathelpedyoutomanageyourillness:_______________________________________________________________________________________________30.Doyouknowsomeoneatyourjobsitewiththesamehealthcondition? Yes.Isthatpersonyoursupervisor? Yes No No31.Doesyouremployerknowaboutyourhealthcondition? Yes No.Whydidn’tyoutellyouremployer?_________________________________________________________________________________________________32.Howlonghaveyoubeenworkingatyourpresentjob? Years Monthsor Weeks33.Whatkindofworkdoyoudo?_________________________________________34.Whatisyourjobcalled?_____________________________________________ 35.Howareyoupaid: Pernumberofhoursworked Salary(paidacertainamountperweek,month,oryear–notbasedonhoursworked)36.Areyou:(NOTE:onlinesurveyresponseis“male”followedby“female”) Female Male37.Howoldareyou?_____38.Areyou: Single Marriedorlivingwithapartner39.Whatisyourracial/ethnic/culturalgroup?Putacheckinfrontofeachdescriptionthatyouthinkappliestoyou: White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative Someotherrace

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12440.Whatracial/ethnic/culturalgroupdootherpeopleusuallythinkyoubelongto? White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative Someotherrace41.Howmuchschoolingdoyouhave? Lessthanhighschooldiploma Highschooldiploma Somecollege Bachelor’sdegree Somegraduateschool Graduatedegree42.Whatchronichealthcondition(s)doyouhave(checkallthatyouhave)? Diabetes Asthmaorotherchronicrespiratorydisease43.Howlongagohaveyouhad:Diabetes: 1yearorless 1-10years Morethantenyears DonothaveAsthmaorotherchronicrespiratorydisease: 1yearorless 1-10years Morethantenyears Donothave44.Circlethenumberofpeoplewholiveinyourhouse.Thenfindtheplaceonthatsamelinethatisclosesttotheamountofmoneythatcomesintoyourhouseeverymonth,andcirclethenumber.Forexample,ifthereare6peoplelivinginyourhouseandeveryonewhoworksbringsinatotalofabout$3000permonth,youwouldcircle“6”andthen“$2,157-5,390”.Howmanypeopleliveinyourhouse?AbouthowmuchmoneycomesintoyourhouseeveryMONTH? 1$0-798$799-1,994$1,995-3,190$3,191ormore 2$0-1,069$1,070-2,673$2,674-4,277$4,278ormore 3$0-1,341$1,342-3,352$3,353-5,363$5,364ormore 4$0-1,613$1,614-4,031$4,032-6,450$6,451ormore 5$0-1,884$1,885-4,710$4,711-7,537$7,538ormore 6$0-2,156$2,157-5,390$5,391-8,263$8,264ormore 7$0-2,428$2,429-6,069$6,070-9,710$9,711ormore 8ormore$0-2,699$2,700-6,748$6,749-10,797$10,798ormore Pleasechecktomakesureyouhavecompletedall44questionsonthequestionnaire(unlesstherearequestionsyouchoosenottoanswer).Thankyoufortakingthetimetoparticipateinthisresearchstudy.

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APPENDIXCCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP3

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126ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep3Pleaseanswerthefollowingquestionsbycirclingtheanswerthatbestdescribesyoursituation.Ifanyseemlikequestionsyouhavealreadyanswered,pleaseanswerthemwithoutlookingbacktocheckyouranswers.1.Whatchronichealthcondition(s)doyouhave? Diabetes AsthmaorotherchronicrespiratorydiseaseNOTE:ifyoudonothaveoneoftheseconditionsand/ordonotcircleone,wecannotincludetherestofyourresponsesinthestudy.2.ThetimeIstartworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso3.ThehourIleaveworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso4.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notatall Alittlebit Sometimes Usually Verymuchso5.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso6.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds. Notatall Alittlebit Sometimes Usually Verymuchso

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1277.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise). Notatall Alittlebit Sometimes Usually Verymuchso8.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities. Notatall Alittlebit Sometimes Usually Verymuchso9.Myemployerprovidespaidtimeoffworkforhealthcareorfitnessactivities. Notatall Alittlebit Sometimes Usually Verymuchso10.Worksitesupportandresourcesareimportanttomeinmanagingmyillness. Notatall Alittlebit Sometimes Usually Verymuchso11.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso12.Itisdifficultformetoleavemyjobdutiesforroutine(“non-sick”)healthvisitstomanagemyhealthcondition. Notatall Alittlebit Sometimes Usually Verymuchso

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12813.Itiseasyformetoleavemyjobdutiesfor“sickvisit”care(officeorhealthcareappointments)whenIhaveaspecifichealthproblem. Notatall Alittlebit Sometimes Usually Verymuchso14.Itiseasyformetoleavemyjobdutiesforfamilyneeds(forexample,leavingtoattendkids’schoolactivities). Notatall Alittlebit Sometimes Usually Verymuchso15.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition? Notatall Alittlebit Sometimes Usually Verymuchso16.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notatall Alittlebit Sometimes Usually Verymuchso17.Howoftendoyouthinkaboutyourhealthconditionwhileyouareatwork? Never Afewtimesaweek Onceaday Severaltimesaday Allthetime

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12918.Howoftendoyourequireabreakfromyourjobdutiestoperformanecessarytasktohelpmanageyourcondition? Never Afewtimesamonth Afewtimesaweek Onceaday SeveraltimesadayPleaseanswertherestofthequestionsbycheckingthecorrectanswer(s)orfillingintheblank(s):19.Ifyouareallowedtoleaveyourworkstation,whodecideswhenandifyoucanleave? Ido Mymanagerdoes Someoneotherthanmymanagerdoes.20.Areyouworriedthatyouwillbecriticizedifyouneedtoleaveyourworkstationtemporarilytocheckonyourhealthconditionortreatyoursymptoms? Yes No21.Howlonghaveyoubeenworkingatyourpresentjob? Yearsor Monthsor Weeks22.Whatkindofworkdoyoudo?__________________________________________23.Whatisyourjobcalled?________________________________________________24.Howareyoupaid: Pernumberofhoursworked Salary(paidacertainamountperweek,monthoryear,regardlessofhoursworked)25.Areyou: Male Female26.Howoldareyou?_____27.Whatisyourracial/ethnic/culturalgroup?Putacheckinfrontofeachdescriptionthatyouthinkappliestoyou: White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative Someotherrace

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13028.Howmuchschoolingdoyouhave? Lessthanhighschooldiploma Highschooldiploma Somecollege Bachelor’sdegree Somegraduateschool Graduatedegree29.Monthlyfamilyincome:Howmanypeopleliveinyourhouse?____________Whatisyourfamily’sMONTHLYincome?Inotherwords,abouthowmuchmoneycomesintoyourhouseeveryMONTH?_____________30.Howlonghaveyouhad:Diabetes:_____________Asthmaorotherchronicrespiratorydisease:_____________Pleasechecktomakesureyouhavecompletedall30questionsonthequestionnaire(unlesstherearequestionsyouchoosenottoanswer).Thankyoufortakingthetimetoparticipateinthisresearchstudy.

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APPENDIXDCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP4

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132ChronicIllnessSelf-ManagementAmongWorkersStudyInformedConsentStatementFirstdistributionPleaseconsidertakingthetimetofillouttheattachedstudyquestionnaireifyou:areondailymedicationforeitherdiabetesorasthma(oranotherobstructivepulmonarydisease)areemployedfull-time(32hoursperweekormore),andarebetweentheagesof18and70.Ifyoudonotmeettheserequirements,orifyouhavecompletedandreturnedthisquestionnaireatanotherworksite,pleaseeithercallthePIforclarificationordonotcompletethequestionnaire.Theaimofthisresearchstudyistodevelopaquestionnairetomeasurejobflexibilityasitaffectschronicillnessself-managementamongworkers.Inordertodothis,weneedinformationfrompeopleworkinginallkindsofjobs,withallkindsofincomelevels.Itwilltakeabout5-10minutestocompletethisquestionnaire.Althoughtherearenodirectrisksorbenefitsofparticipatinginthisstudy,thisquestionnairecouldbeusedinthefuturetocollectinformationleadingtoabetterunderstandingofhowworkingaffectschronicillnessself-management.Thispartofthestudyrequiresfillingoutthequestionnairetwotimes,attwo-weekintervals.Therefore,pleaseputyouremailaddressinthespaceprovidedonthequestionnairesothatasecondinvitationcanbeissuedtoyouintwoweeks..Youridentitywillremainanonymous.Althoughyouwillrevealthatyouhaveeitherdiabetesmellitusorasthma/otherobstructivepulmonarydisease,andplaceyouremailaddressonthequestionnaire,yournamewillnotberecordedanywhereandtheemailaddresswillonlybeusedtodeliverthequestionnaireforthetwo-weekretestandwillthenbedeleted.Thiswillensurethatyourhealthinformationremainsconfidential.Byfillingoutthequestionnaire,youareagreeingthatyouunderstandthisinformationandgiveyourconsentforouruseofyourinformation.However,youmaychoosenottoansweranyorallofthequestions.Yourparticipationiscompletelyvoluntary.Youdonothavetoansweranyquestionyoudonotwishtoanswerandyoumaywithdrawyourconsenttoparticipateatanytimewithoutpenalty.Whenyouarefinishedfillingoutthequestionnaire,pleasesubmittheonlinesurvey.ApprovedByUniversityofFloridaInstitutionalReviewBoard02Protocol#2005-U-0448ForUseThrough06/15/2007Shouldyouhavequestionsaboutyourrightsasaresearchparticipant,pleasecontacttheUFIRBatP.O.Box112250,Gainesville,FL32611or352-392-0433.Pleasekeepthiscoversheetoracopyincaseyouneedtocontacttheprincipalinvestigatorforthisstudyand/orhercommitteechairperson:RobynPantherGleason,ARNP,PhDCandidate,PrincipalInvestigatorUniversityofFloridaCollegeofNursing(352)284-2123rgleason@nursing.ufl.eduShawnKneipp,ARNP,PhD,CommitteeChairpersonUniversityofFloridaCollegeofNursing(352)273-6417skneipp@nursing.ufl.edu

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133ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep4a1.Pleaseenteryouremailaddresssoanemailinvitationcanbesenttoyouintwoweeks:_____________________________________________________________Pleaseanswerthefollowingquestionsbycheckingtheanswerthatbestappliestoyoursituation:2.Whatchronichealthcondition(s)doyouhave? Diabetes Asthmaorotherchronicrespiratorydisease BothdiabetesandasthmaorotherchronicrespiratorydiseaseNOTE:ifyoudonothaveoneoftheseconditionsand/ordonotcircleone,wecannotincludetherestofyourresponsesinthestudy.3.ThetimeIstartworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso4.ThehourIleaveworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notatall Alittlebit Sometimes Usually Verymuchso

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1346.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso7.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds. Notatall Alittlebit Sometimes Usually Verymuchso8.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise). Notatall Alittlebit Sometimes Usually Verymuchso9.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities. Notatall Alittlebit Sometimes Usually Verymuchso10.Myemployerprovidespaidtimeoffworkforhealthcareorfitnessactivities. Notatall Alittlebit Sometimes Usually Verymuchso11.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso

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13512.Itisdifficultformetoleavemyjobdutiesforroutine(“non-sick”)healthvisitstomanagemyhealthcondition. Notatall Alittlebit Sometimes Usually Verymuchso13.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition? Notatall Alittlebit Sometimes Usually Verymuchso14.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notatall Alittlebit Sometimes Usually VerymuchsoPleaseanswertherestofthequestionsbycheckingthecorrectanswer(s)orfillingintheblank(s):15.Ifyouareallowedtoleaveyourworkstation,whodecideswhenandifyoucanleave? Ido Mymanagerdoes Someoneotherthanmymanagerdoes.16.Areyouworriedthatyouwillbecriticizedifyouneedtoleaveyourworkstationtemporarilytocheckonyourhealthconditionortreatyoursymptoms? Yes No17.Howlonghaveyoubeenworkingatyourpresentjob? Yearsor Monthsor Weeks18.Whatkindofworkdoyoudo?__________________________________________

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13619.Whatisyourjobcalled?________________________________________________20.Howareyoupaid: Pernumberofhoursworked Salary(paidacertainamountperweek,monthoryear,regardlessofhoursworked)21.Areyou: Male Female22.Howoldareyou?_____23.Whatisyourracial/ethnic/culturalgroup?Putacheckinfrontofeachdescriptionthatyouthinkappliestoyou: White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative Someotherrace24.Howmuchschoolingdoyouhave? Lessthanhighschooldiploma Highschooldiploma Somecollege Bachelor’sdegree Somegraduateschool Graduatedegree25.Monthlyfamilyincome:a.Howmanypeopleliveinyourhouse?____________b.Whatisyourfamily’sMONTHLYincome?Inotherwords,abouthowmuchmoneycomesintoyourhouseeveryMONTH?_____________26.Howlonghaveyouhad:a.Diabetes:_____________b.Asthmaorotherchronicrespiratorydisease:_____________Pleasechecktomakesureyouhavecompletedall26questionsonthequestionnaire(unlesstherearequestionsyouchoosenottoanswer).Anemailinvitationtofilloutthequestionnairewillbesenttoyouintwoweeks-yoursecondsubmissionwillhelpto validatethequestionnaire.Thankyoufortakingthetime toparticipateinthisresearchstudy.

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137ChronicIllnessSelf-ManagementAmongWorkersStudyInformedConsentStatementSecond(Retest)DistributionBeforeyoumoveontothesurveyquestions,pleasereadthefollowinginformedconsentinformation:Theinvitationtotakethissurveyhasbeensenttoyouasafollowuptothequestionnaireyoucompletedtwoweeksago.Whenyouarefinishedfillingoutthisquestionnaire,pleasesubmittheonlinesurvey.Itwilltakeabout5minutestocompletethisquestionnaire.Ifyourworkenvironmenthaschangedsinceyoufirstfilledoutthequestionnaire,pleasewriteadescriptionofthechanges(seeQuestion2).Youridentitywillremainanonymous.Althoughyouhaverevealedthatyouhaveeitherdiabetesmellitusorasthma/otherobstructivepulmonarydisease,andhaveprovidedyouremailaddressonthequestionnaire,yournamewillnotberecordedanywhereandtheemailaddresswillbedeletedassoonasyourresponsesarerecorded.Thiswillensurethatyourhealthinformationremainsconfidential.Yourparticipationiscompletelyvoluntary.Youdonothavetoansweranyquestionyoudonotwishtoanswerandyoumaywithdrawyourconsenttoparticipateatanytimewithoutpenalty.Byfillingoutthequestionnaire,youareagreeingthatyouunderstandthisinformationandgiveyourconsentforouruseofyourinformation.ApprovedByUniversityofFloridaInstitutionalReviewBoard02Protocol#2005-U-0448ForUseThrough06/15/2007Shouldyouhavequestionsaboutyourrightsasaresearchparticipant,pleasecontacttheUFIRBatP.O.Box112250,Gainesville,FL32611or352-392-0433.Pleasekeepthiscoversheetoracopyincaseyouneedtocontacttheprincipalinvestigatorforthisstudyand/orhercommitteechairperson:RobynPantherGleason,ARNP,PhDCandidate,PrincipalInvestigatorUniversityofFloridaCollegeofNursing(352)284-2123rgleason@nursing.ufl.eduShawnKneipp,ARNP,PhD,CommitteeChairpersonUniversityofFloridaCollegeofNursing(352)273-6417skneipp@nursing.ufl.edu

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138ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep4b1.Pleaseenteryouremailaddresssoyourresponsecanbematchedtoyourfirstsurvey:________________________________________________________2.Ifyourworkenvironmenthaschangedsinceyoufirstfilledoutthequestionnaire,pleasewriteadescriptionofthechanges:___________________________________________________________________________________________Pleaseanswerthefollowingquestionsbycheckingtheanswerthatbestappliestoyoursituation:3.ThetimeIstartworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso4.ThehourIleaveworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notatall Alittlebit Sometimes Usually Verymuchso6.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso7.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds. Notatall Alittlebit Sometimes Usually Verymuchso

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1398.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise). Notatall Alittlebit Sometimes Usually Verymuchso9.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities. Notatall Alittlebit Sometimes Usually Verymuchso10.Myemployerprovidespaidtimeoffworkforhealthcareorfitnessactivities. Notatall Alittlebit Sometimes Usually Verymuchso11.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso12.Itisdifficultformetoleavemyjobdutiesforroutine(“non-sick”)healthvisitstomanagemyhealthcondition. Notatall Alittlebit Sometimes Usually Verymuchso

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14013.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition? Notatall Alittlebit Sometimes Usually Verymuchso14.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notatall Alittlebit Sometimes Usually VerymuchsoPleasechecktomakesureyouhavecompletedall14questionsonthequestionnaire(unlesstherearequestionsyouchoosenottoanswer).Youremailaddresswillbedeletedassoonastheseresponsesarerecorded.Thankyouagainfortakingthetimetoparticipateinthisresearchstudy.

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APPENDIXDCHRONICILLNESSSELF-MANAGEMENTAMONGWORKERSINSTRUMENTSTEP4

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142ChronicIllnessSelf-ManagementAmongWorkersStudyInformedConsentStatementFirstdistributionPleaseconsidertakingthetimetofillouttheattachedstudyquestionnaireifyou:areondailymedicationforeitherdiabetesorasthma(oranotherobstructivepulmonarydisease)areemployedfull-time(32hoursperweekormore),andarebetweentheagesof18and70.Ifyoudonotmeettheserequirements,orifyouhavecompletedandreturnedthisquestionnaireatanotherworksite,pleaseeithercallthePIforclarificationordonotcompletethequestionnaire.Theaimofthisresearchstudyistodevelopaquestionnairetomeasurejobflexibilityasitaffectschronicillnessself-managementamongworkers.Inordertodothis,weneedinformationfrompeopleworkinginallkindsofjobs,withallkindsofincomelevels.Itwilltakeabout5-10minutestocompletethisquestionnaire.Althoughtherearenodirectrisksorbenefitsofparticipatinginthisstudy,thisquestionnairecouldbeusedinthefuturetocollectinformationleadingtoabetterunderstandingofhowworkingaffectschronicillnessself-management.Thispartofthestudyrequiresfillingoutthequestionnairetwotimes,attwo-weekintervals.Therefore,pleaseputyouremailaddressinthespaceprovidedonthequestionnairesothatasecondinvitationcanbeissuedtoyouintwoweeks..Youridentitywillremainanonymous.Althoughyouwillrevealthatyouhaveeitherdiabetesmellitusorasthma/otherobstructivepulmonarydisease,andplaceyouremailaddressonthequestionnaire,yournamewillnotberecordedanywhereandtheemailaddresswillonlybeusedtodeliverthequestionnaireforthetwo-weekretestandwillthenbedeleted.Thiswillensurethatyourhealthinformationremainsconfidential.Byfillingoutthequestionnaire,youareagreeingthatyouunderstandthisinformationandgiveyourconsentforouruseofyourinformation.However,youmaychoosenottoansweranyorallofthequestions.Yourparticipationiscompletelyvoluntary.Youdonothavetoansweranyquestionyoudonotwishtoanswerandyoumaywithdrawyourconsenttoparticipateatanytimewithoutpenalty.Whenyouarefinishedfillingoutthequestionnaire,pleasesubmittheonlinesurvey.ApprovedByUniversityofFloridaInstitutionalReviewBoard02Protocol#2005-U-0448ForUseThrough06/15/2007Shouldyouhavequestionsaboutyourrightsasaresearchparticipant,pleasecontacttheUFIRBatP.O.Box112250,Gainesville,FL32611or352-392-0433.Pleasekeepthiscoversheetoracopyincaseyouneedtocontacttheprincipalinvestigatorforthisstudyand/orhercommitteechairperson:RobynPantherGleason,ARNP,PhDCandidate,PrincipalInvestigatorUniversityofFloridaCollegeofNursing(352)284-2123rgleason@nursing.ufl.eduShawnKneipp,ARNP,PhD,CommitteeChairpersonUniversityofFloridaCollegeofNursing(352)273-6417skneipp@nursing.ufl.edu

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143ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep4a1.Pleaseenteryouremailaddresssoanemailinvitationcanbesenttoyouintwoweeks:_____________________________________________________________Pleaseanswerthefollowingquestionsbycheckingtheanswerthatbestappliestoyoursituation:2.Whatchronichealthcondition(s)doyouhave? Diabetes Asthmaorotherchronicrespiratorydisease BothdiabetesandasthmaorotherchronicrespiratorydiseaseNOTE:ifyoudonothaveoneoftheseconditionsand/ordonotcircleone,wecannotincludetherestofyourresponsesinthestudy.3.ThetimeIstartworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso4.ThehourIleaveworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notatall Alittlebit Sometimes Usually Verymuchso

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1446.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso7.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds. Notatall Alittlebit Sometimes Usually Verymuchso8.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise). Notatall Alittlebit Sometimes Usually Verymuchso9.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities. Notatall Alittlebit Sometimes Usually Verymuchso10.Myemployerprovidespaidtimeoffworkforhealthcareorfitnessactivities. Notatall Alittlebit Sometimes Usually Verymuchso11.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso

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14512.Itisdifficultformetoleavemyjobdutiesforroutine(“non-sick”)healthvisitstomanagemyhealthcondition. Notatall Alittlebit Sometimes Usually Verymuchso13.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition? Notatall Alittlebit Sometimes Usually Verymuchso14.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notatall Alittlebit Sometimes Usually VerymuchsoPleaseanswertherestofthequestionsbycheckingthecorrectanswer(s)orfillingintheblank(s):15.Ifyouareallowedtoleaveyourworkstation,whodecideswhenandifyoucanleave? Ido Mymanagerdoes Someoneotherthanmymanagerdoes.16.Areyouworriedthatyouwillbecriticizedifyouneedtoleaveyourworkstationtemporarilytocheckonyourhealthconditionortreatyoursymptoms? Yes No17.Howlonghaveyoubeenworkingatyourpresentjob? Yearsor Monthsor Weeks18.Whatkindofworkdoyoudo?__________________________________________

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14619.Whatisyourjobcalled?________________________________________________20.Howareyoupaid: Pernumberofhoursworked Salary(paidacertainamountperweek,monthoryear,regardlessofhoursworked)21.Areyou: Male Female22.Howoldareyou?_____23.Whatisyourracial/ethnic/culturalgroup?Putacheckinfrontofeachdescriptionthatyouthinkappliestoyou: White BlackorAfricanAmerican HispanicorLatino Asian NativeHawaiianorotherPacificIslander NativeAmericanorAlaskanNative Someotherrace24.Howmuchschoolingdoyouhave? Lessthanhighschooldiploma Highschooldiploma Somecollege Bachelor’sdegree Somegraduateschool Graduatedegree25.Monthlyfamilyincome:a.Howmanypeopleliveinyourhouse?____________b.Whatisyourfamily’sMONTHLYincome?Inotherwords,abouthowmuchmoneycomesintoyourhouseeveryMONTH?_____________26.Howlonghaveyouhad:a.Diabetes:_____________b.Asthmaorotherchronicrespiratorydisease:_____________Pleasechecktomakesureyouhavecompletedall26questionsonthequestionnaire(unlesstherearequestionsyouchoosenottoanswer).Anemailinvitationtofilloutthequestionnairewillbesenttoyouintwoweeks-yoursecondsubmissionwillhelptovalidatethequestionnaire.Thankyoufortakingthetimetoparticipateinthisresearchstudy.

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147ChronicIllnessSelf-ManagementAmongWorkersStudyInformedConsentStatementSecond(Retest)DistributionBeforeyoumoveontothesurveyquestions,pleasereadthefollowinginformedconsentinformation:Theinvitationtotakethissurveyhasbeensenttoyouasafollowuptothequestionnaireyoucompletedtwoweeksago.Whenyouarefinishedfillingoutthisquestionnaire,pleasesubmittheonlinesurvey.Itwilltakeabout5minutestocompletethisquestionnaire.Ifyourworkenvironmenthaschangedsinceyoufirstfilledoutthequestionnaire,pleasewriteadescriptionofthechanges(seeQuestion2).Youridentitywillremainanonymous.Althoughyouhaverevealedthatyouhaveeitherdiabetesmellitusorasthma/otherobstructivepulmonarydisease,andhaveprovidedyouremailaddressonthequestionnaire,yournamewillnotberecordedanywhereandtheemailaddresswillbedeletedassoonasyourresponsesarerecorded.Thiswillensurethatyourhealthinformationremainsconfidential.Yourparticipationiscompletelyvoluntary.Youdonothavetoansweranyquestionyoudonotwishtoanswerandyoumaywithdrawyourconsenttoparticipateatanytimewithoutpenalty.Byfillingoutthequestionnaire,youareagreeingthatyouunderstandthisinformationandgiveyourconsentforouruseofyourinformation.ApprovedByUniversityofFloridaInstitutionalReviewBoard02Protocol#2005-U-0448ForUseThrough06/15/2007Shouldyouhavequestionsaboutyourrightsasaresearchparticipant,pleasecontacttheUFIRBatP.O.Box112250,Gainesville,FL32611or352-392-0433.Pleasekeepthiscoversheetoracopyincaseyouneedtocontacttheprincipalinvestigatorforthisstudyand/orhercommitteechairperson:RobynPantherGleason,ARNP,PhDCandidate,PrincipalInvestigatorUniversityofFloridaCollegeofNursing(352)284-2123rgleason@nursing.ufl.eduShawnKneipp,ARNP,PhD,CommitteeChairpersonUniversityofFloridaCollegeofNursing(352)273-6417skneipp@nursing.ufl.edu

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148ChronicIllnessSelf-ManagementAmongWorkersInstrumentStep4b1.Pleaseenteryouremailaddresssoyourresponsecanbematchedtoyourfirstsurvey:________________________________________________________2.Ifyourworkenvironmenthaschangedsinceyoufirstfilledoutthequestionnaire,pleasewriteadescriptionofthechanges:___________________________________________________________________________________________Pleaseanswerthefollowingquestionsbycheckingtheanswerthatbestappliestoyoursituation:3.ThetimeIstartworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso4.ThehourIleaveworkisflexible. Notatall Alittlebit Sometimes Usually Verymuchso5.Itisbasicallymyownresponsibilitytodecidehowmyjobgetsdone. Notatall Alittlebit Sometimes Usually Verymuchso6.IfIneededtoleaveworkinthemiddleoftheday,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso7.IhaveaflexibleworkschedulethatIcanadjusttomeetmyneeds. Notatall Alittlebit Sometimes Usually Verymuchso

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1498.Myworkplacehasrulesorpoliciesthatmakeiteasierformetomanagemyillness(suchasnosmokingrulesortimeoffworktoexercise). Notatall Alittlebit Sometimes Usually Verymuchso9.Ihavecontrolovermyjobintermsofmakingdecisionsandsettingpriorities. Notatall Alittlebit Sometimes Usually Verymuchso10.Myemployerprovidespaidtimeoffworkforhealthcareorfitnessactivities. Notatall Alittlebit Sometimes Usually Verymuchso11.IfIneededtoleaveworkinthemiddleofmyshift,itwouldbeveryhardtodothat. Notatall Alittlebit Sometimes Usually Verymuchso12.Itisdifficultformetoleavemyjobdutiesforroutine(“non-sick”)healthvisitstomanagemyhealthcondition. Notatall Alittlebit Sometimes Usually Verymuchso

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15013.Howimportantisitforyoutohaveajobwhereyouareabletostopworkinglongenoughoroftenenoughtotakesometimetoperformanecessarytasktohelpmanageyourcondition? Notatall Alittlebit Sometimes Usually Verymuchso14.Howimportantisitforyoutohaveajobwhereyouareabletoleaveworkwhenyouneedtoattendhealthcareappointments? Notatall Alittlebit Sometimes Usually VerymuchsoPleasechecktomakesureyouhavecompletedall14questionsonthequestionnaire(unlesstherearequestionsyouchoosenottoanswer).Youremailaddresswillbedeletedassoonastheseresponsesarerecorded.Thankyouagainfortakingthetimetoparticipateinthisresearchstudy.

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151LISTOFREFERENCESAdler,N.E.,&Newman,K.(2002).Socioeconomicdisparitiesinhealth:Pathwaysandpolicies.Inequalityineducation,income,andoccupationexacerbatesthegapsbetweenhealth"haves"and"havenots".HealthAffairs,21(2),60-76.Allen,M.J.,&Yen,W.M.(1979).Introductiontomeasurementtheory.ProspectHeights,IL:Waveland.AllianceforHealthReform.(2003).Coveringhealthissues:2003,chroniccare.RetrievedMay20,2004,fromhttp://www.allhealth.org/sourcebook2002/ch15_tc.htmlAmericanDiabetesAssociation.(2004).Standardsofmedicalcareindiabetes.DiabetesCare,27(S1),S15-S35.Andersson,F.,Holzer,H.J.,&Lane,J.I.(2002).Theinteractionsofworkersandfirmsinthelow-wagejobmarket.Washington,DC:UrbanInstitute.Andrulis,D.P.(2003).Reducingracialandethnicdisparitiesindiseasemanagementtoimprovehealthoutcomes.DiseaseManagementandHealthOutcomes,11(12),789-800.Appelbaum,E.,&Golden,L.(2003).Whogetstoridethehighroad?ThedistributionofflexibleschedulesintheU.S.Paperpresentedatthe'From9-to-5to24/7:HowWorkplaceChangesImpactFamilies,Work,andCommunities'Conference,Orlando,FL.Aron-Dine,A.,&Shapiro,I.(2006).Newdatashowextraordinaryjumpinincomeconcentrationin2004.RetrievedJuly12,2006,fromCenterOnBudgetandPolicyPriorities:http://www.cbpp.org/7-10-06inc.pdfBarlow,J.,Wright,C.,Sheasby,J.,Turner,A.,&Hainsworth,J.(2002).Self-managementapproachesforpeoplewithchronicconditions:Areview.PatientEducationandCounseling,48,177-187.Betancourt,J.(2002)."UnequalTreatment":TheInstituteofMedicine'sfindingsandrecommendationsonhealthcaredisparities.HarvardHealthPolicyReview,3(2),1-3.Boccuzzi,S.J.,Wogen,J.,Fox,J.,Sung,J.C.Y.,Shah,A.B.,&Kim,J.(2001).Utilizationoforalhypoglycemicagentsinadrug-insuredU.S.population.DiabetesCare,24(8),1411-1415.

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161BIOGRAPHICALSKETCHRobynPantherGleasonisaboard-certifiedFamilyNursePractitionerwithaMasterofScienceinNursingandMasterinPublicHealthfromtheUniversityofFlorida,andaBachelorofScienceinNursingfromFloridaSouthernCollege.Hergraduatestudiesandresearchhavefocusedonchronicdiseaseoutcomesanddiseasemanagementtrendsamongthepoorandnearpoor;interestinthistopicdevelopedovermanyyearswhilepracticingpublichealthandacutecarenursingattheLPN,ADN,BSNandNursePractitionerlevels.Shegainedexperienceteachinginavarietyofnursingandpublichealthcoursesduringhergraduatestudies,includingbachelor’sandmaster’slevelnursingcoursesandpublichealthcoursesatthemaster’slevel.SheiscurrentlyanAssistantProfessoratBethune-CookmanCollegeSchoolofNursing,andProjectDirector/PrincipalInvestigatoroftheCentralCityFrontPorchClosingtheGapAdultImmunizationProject.