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H O F S T R A

HORIZONS SPRING 2018

Making a Difference Through Research • School of Health Professions and Human Services RESEARCH AND SCHOLARSHIP PROMOTING EXCELLENCE IN TEACHING AT HOFSTRA UNIVERSITY


president’s COLUMN

HOFSTRAhorizons Research and Scholarship at Hofstra University

E

ach academic year, Hofstra builds on its tradition of excellence in teaching and scholarship. With our faculty at the forefront, Hofstra’s national and international reputation continues to grow.

I am always proud to introduce an issue of Hofstra Horizons. This issue is dedicated to the innovative research of the faculty of Hofstra’s School of Health Professions and Human Services (HPHS). I’d like to congratulate Dean Holly Seirup and the HPHS faculty on their achievements and thank them for their contributions to the University.

table of contents

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After DOMA: Same-Sex Couples and the Shifting Road to Equality

This year HPHS is celebrating five years as an independent degreegranting school. Today the school is Hofstra’s third largest school and is recognized as a leader in preparing students for rewarding careers as health care professionals. The articles in this issue highlight the research of Dr. Alicia Bosley, who explores the impact on same-sex couples of the 2013 and 2015 Supreme Court rulings on the Defense of Marriage Act (DOMA). Susan DeMetropolis examines the correlation of cognitive and language neurophysiological indices to semantic processing in patients with early-stage Alzheimer’s disease. Dr. Robin Akselrud explores the impact of stress and coping strategies on students enrolled in a master’s level occupational therapy program in the northeastern United States. Dr. Scott Schroeder studies the serious issue of wrong-drug errors, which affects millions of patients each year. Dr. Walter Markowitz offers insight on the Triple Aim model as an approach to achieve a more rational health care policy. Dr. Adam Gonzalez worked with colleagues and students to expand our understanding of muscle physiology, exercise program design, and nutritional supplementation. And finally, Dr. Sharon Phillips conducts an in-depth global study of physical education teacher education programs to determine if social justice is taught as part of the curriculum – and to determine if faculty perceptions of social justice affect and inform that education. All of these articles provide thought-provoking insight on important issues. I applaud the faculty on their impressive scholarly work. Sincerely,

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 ognitive and Language C Neurophysiological Indices for Early-Stage Alzheimer’s Disease

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Identifying Stressors, Coping Strategies, and Utilization of Mental Health Support Services in Occupational Therapy Graduate Students

Stuart Rabinowitz, JD President

Gail M. Simmons, PhD

Provost and Senior Vice President for Academic Affairs

Robert Brinkmann, PhD Vice Provost for Scholarship and Engagement

Stuart Rabinowitz, JD President, Hofstra University

Sofia Kakoulidis, MBA

Associate Provost for Research and Sponsored Programs

Alice Diaz-Bonhomme, BA

Assistant Provost for Research and Sponsored Programs 2

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provost’s COLUMN

H

ofstra University continues to evolve as an internationally renowned university. Our faculty perform advanced research across many different disciplines – research that often has an impact on the lives of members of our global community.

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Health Care Professionals and Wrong Drug Mistakes: Can Language Research Help?

In this issue of Hofstra Horizons, we are proud to showcase the research contributions of faculty in the School of Health Professions and Human Services, which is recognized as a leader in preparing students to meet the growing demands for health care professionals.

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A More Rational Health Policy Approach to Achieve the Triple Aim

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Exercise Science and Sports Nutrition Research

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Exploring Social Justice in Physical Education Teacher Education Programs

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HPHS Faculty Research

HOFSTRA HORIZONS is published annually by the Office for Research and Sponsored Programs, 144 Hofstra University, Hempstead, NY 11549-1440.

Dr. Alicia Bosley explores the impact of the 2013 and 2015 U.S. Supreme Court rulings surrounding the Defense of Marriage Act (DOMA). Her mixed method study provides a clearer understanding of the lives of same-sex couples in our current sociopolitical climate. Susan DeMetropolis’ research provides important information for clinicians and researchers to better assess and design therapy programs for individuals with Alzheimer’s disease. Dr. Robin Akselrud looks at the stressors, priorities, support services, and coping mechanisms of master’s level occupational therapy students, and examines the impact of these factors on student success. And Dr. Scott Schroeder takes an interdisciplinary research approach to probe the problem of drug name errors. His team of language researchers, health care professionals, and computer scientists are studying look-alike sound-alike drug name confusion errors, with the goal of decreasing wrong-drug errors and increasing patient safety. Dr. Walter Markowitz poses questions and presents rational approaches to achieving universal access to high-quality health care, while decreasing costs. And finally, Dr. Adam Gonzalez’s research expands our understanding of muscle physiology and nutritional supplementation for optimizing health and performance, while Dr. Sharon Phillips conducts a comprehensive study of how physical education teacher education programs teach social justice, and how the faculty define the term “social justice.” Congratulations to all the authors, and thank you to Dean Holly Seirup for her support of the HPHS community. I hope you enjoy this issue of Hofstra Horizons.

Each issue describes in lay language some of the many research and creative activities conducted at Hofstra. The conclusions and opinions expressed by the investigators and writers are their own and do not necessarily reflect University policy.

Sincerely,

©2018 by Hofstra University in the United States. All rights reserved. No part of this publication may be reproduced without the consent of Hofstra University. Inquiries and requests for permission to reprint material should be addressed to: Editor, Hofstra Horizons, Office for Research and Sponsored Programs, 144 Hofstra University, Hempstead, NY 11549-1440. Telephone: 516-463-6810.

Gail M. Simmons, PhD Provost and Senior Vice President for Academic Affairs Hofstra University

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Introduction from the Dean of the School of Health Professions and Human Services

HOLLY J. SEIRUP, EdD

As dean of Hofstra’s School of Health Professions and Human Services (HPHS), I am delighted to share the impressive scholarly work of our talented faculty. It is particularly meaningful this year, as we celebrate our five-year anniversary as an independent degree-granting school at Hofstra. During this short period, we have experienced exceptional growth due to our dedicated and distinguished faculty, our passionate and engaged students, and the support of our colleagues on campus and in the community. With this strong foundation, and a consistent focus on our core values of Innovation, Collaboration, Advocacy, Research, and Excellence (I CARE), it is not a surprise that HPHS is now Hofstra’s third-largest school. Most importantly, the School of Health Professions and Human Services is well-positioned for continued growth in academic offerings as well as scholarly contributions – some of which are included in this issue of Hofstra Horizons. The School of Health Professions and Human Services has become a recognized leader in preparing students to meet the growing demand in the workforce for well-trained and highly competent health care professionals. Through interdisciplinary, competency-based instruction, experiential learning, research, and training, our faculty educate students to become effective and compassionate clinicians, evidence-based practitioners, policymakers, managers, and advocates who promote health equity across the lifespan. Through our five undergraduate and 15 graduate programs in the departments of Counseling and Mental Health Professions, SpeechLanguage-Hearing Sciences, and Health Professions, HPHS offers an

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HOFSTRAhorizons

Research and Scholarship at Hofstra University

interprofessional environment where students are educated in the theory and practice of their specialized area of study and benefit from real-world training experience through internships that maximize learning, professional growth, and development. Our commitment to academic excellence is evidenced by 12 programs that are nationally accredited and/or professionally recognized. Our small class sizes encourage an environment that includes meaningful peer interaction and faculty mentoring. Student have the opportunity to collaborate with faculty on research; participate in interprofessional activities; join clubs and professional organizations; and network with alumni, peers, and prominent health care leaders. Our students and faculty share a passion for social justice, and are engaged in and model civic engagement – with the ultimate goal of making an impact on communities both here and abroad. I am proud to share that graduates of the School of Health Professions and Human Services are well-prepared for both advanced graduate studies and rewarding careers in schools, clinics, government and community agencies, hospitals, and other health care facilities. This issue of Hofstra Horizons features only some of the scholarly pursuits of the outstanding HPHS faculty, whose research efforts are wide-ranging and significant. The issue highlights topics such as neurophysiological indices for early-stage Alzheimer’s disease, the Defense of Marriage Act, coping strategies for occupational therapy students, social justice in physical education, wrong-drug pharmaceutical errors, sports nutrition, and health care policy. I hope you enjoy reading about the research initiatives of some of the notable faculty in the School of Health Professions and Human Services. I encourage you to learn more about our academic programs, explore ways we might be able to collaborate, and interact with our impressive faculty, students, and all members of the vibrant HPHS community.

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After DOMA: Same-Sex Couples and the Shifting Road to Equality Alicia Bosley, PhD, Assistant Professor of Counseling and Mental Health Professions, Hofstra University Marriage and Family Therapy Program Abstract Same-sex couples are affected by the social and political climates in which they live, as these create the difference between acceptance and legalization, and discrimination and prohibition, of their relationships. Following the June 26, 2013, ruling that Section Three of the Defense of Marriage Act (DOMA), which defined marriage as between a man and a woman, was unconstitutional, same-sex couples were legally supported and legitimized for the first time. On June 26, 2015, the Supreme Court further ruled that states cannot keep same-sex couples from marrying and must recognize 6

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their unions. Although these rulings represented significant steps in ensuring marriage equality, they were followed by countermovements opposing same-sex marriage. Several states developed bans on same-sex marriage within their state constitutions following the 2013 repeal; others contested the 2015 ruling. Additionally, social and political debates continued, creating a contentious climate and heightened scrutiny of same-sex couples. This paper will present a glimpse into the unique and fleeting time period during which the fight for marriage equality reached its peak and

ultimately its goal, through the words of self-identified LGBTQ+ individuals and members of same-sex relationships. The results of this study may assist professionals working with same-sex couples by increasing comprehension of the impacts of these rulings and sociopolitical contexts. In turn, professionals may work more capably and sensitively with same-sex couples, with a clearer contextual understanding of their lives and relationships in our current sociopolitical climate. Keywords: Defense of Marriage Act, LGBTQ+, marriage equality, samesex marriage


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Introduction On June 26, 2013, the United States Supreme Court ruled that Section Three of the Defense of Marriage Act (DOMA), which defined marriage as between a man and a woman, was unconstitutional (Freedom to Marry, 2013; Human Rights Campaign, 2013; Reilly & Siddiqui, 2013). Under DOMA, married gay and lesbian couples were denied important protections and rights, such as Social Security benefits, family and medical leave, the ability to pool resources without heightened taxation, military family benefits, and hospital visitation rights (Andryszewski, 2008; Freedom to Marry, 2013; GLAAD, 2013; Goldberg, 2009; Mathy & Lehmann, 2004). Thus, the Supreme Court’s decision upheld that all married couples deserve equal treatment and respect under the law, and marked the end of the denial of over 1,100 federal protections and benefits of marriage to same-sex couples (Drescher, 2012; Freedom to Marry, 2013; Human Rights Campaign, 2013; Killian, 2010; Mathy, Kerr, & Lehmann, 2004; Pelts, 2014; Sterngass, 2012). These privileges of legal married status had previously been available to all other married people, and thus the repeal of Section Three of DOMA was a major victory for marriage equality in the United States (Barnes, 2013; Freedom to Marry, 2013; GLAAD, 2013; Human Rights Campaign, 2013; Reilly & Siddiqui, 2013).

variant was used in order to allow the qualitative data to corroborate and elaborate upon the results of the quantitative data, as discussed by Creswell and Plano Clark (2011). Following Institutional Review Board (IRB) approval, participants were recruited online via a social media site (Facebook); ads were placed on the Facebook pages of the Human Rights Campaign and PFLAG chapters, with permission obtained before posting. Interested participants followed a link to a 25-question survey composed of open- and closed-ended questions. Survey methodology was used to obtain responses from people across the country, providing a more representative sample of the larger national LGBTQ+ population than would be feasible via in-person interviewing methods. Twenty-six participants meeting study criteria (over the age of 18; residing in the United States, District of Columbia, or Puerto Rico; and self-identifying as being in a same-sex relationship for at least one year) participated in the survey (see Table 1).

On June 26, 2015, the Supreme Court further ruled that states cannot keep same-sex couples from marrying and must recognize their unions.

... social and political debates continued, creating a contentious climate and heightened scrutiny of same-sex couples.

Method In order to best understand the impacts of the DOMA repeal on same-sex couples, a mixedmethod, convergent parallel design was utilized to attain complementary data on the topic (Morse, 1994). A data validation Hofstra HORIZONS t Spring 2018

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Table 1: Participant Demographics Variables

n

%

Age Range

Variables

n

%

Gender

26-35

11

42.31

Male

18

69.23

36-45

5

19.23

Female

7

26.92

46-55

7

26.92

Transgender

1

3.85

56-65

2

7.69

Total

26

100

66-75

1

3.85

Total

26

100

Sexual Orientation

Ethnicity

Gay

19

73.08

African American

1

3.85

Lesbian

5

19.23

Asian American

1

3.85

Bisexual

1

3.85

Caucasian

20

76.92

Queer

1

3.85

Hispanic or Latino

2

7.69

Total

26

100

Native American

1

3.85

Mixed Race

1

3.85

26

100

Total

Survey responses were analyzed using phenomenological analysis for the qualitative portion and a oneway ANOVA with a Tukey post-hoc test for the quantitative portion. Through the qualitative methodology, participants were asked to describe their experiences related to the repeal to develop an understanding of participants’ lived experiences following the repeal. Through the quantitative paradigm utilized in this study, the relationship between state of residence (and local marriage laws) and perceptions of Section Three’s repeal was sought and assessed. Following data collection, content areas present in both data sets were identified and transferred as needed to facilitate relating the two data types.

State of Residence Arizona

1

3.85

North Carolina

2

7.69

Colorado

6

23.08

Oregon

1

3.85

Connecticut

1

3.85

Texas

2

7.69

Florida

3

11.54

Washington

2

7.69

Michigan

1

3.85

Wisconsin

5

19.23

New York

2

7.69

Total

26

100

Committed Relationship Status*

Same-gender partner

Yes

26

100

Yes

25

96.15

No

0

0

No**

1

3.85

26

100

Total

26

100

Not at all active

4

15.38

Not very active

8

30.77

Somewhat active

11

42.31

Very active

2

7.69

Extremely active

1

3.85

26

100

Total

Level of Involvement in LGBTQ+ Rights Advocacy

Total

*In a committed relationship for at least one year. For the purposes of this study, defined as romantically and emotionally committed to one another. **This participant was in two relationships; one was a male-female relationship and the other was male-male. As the participant was involved in a same-sex relationship, he was included in the survey despite answering “no” to this question.

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In addition to the themes found across all respondents, several themes specific to geographic legal groups emerged. Respondents were divided into three categories: 1) Respondents living in states with constitutional bans (Arizona, North Carolina) 2) Respondents living in states without full legal marriage but some rights (Colorado, Florida, Michigan, Texas, and Wisconsin) 3) Respondents living in states with legal same-sex marriage (Connecticut, New York, Oregon, and Washington) Although most differences were not statistically significant quantitatively, distinct themes within groups and differences between groups were identified and were similar in both the qualitative and quantitative portions of the analysis. See Figures 1-6 for visual representations of state differences.


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Figure 1: Views of DOMA Repeal Group means: States with Legal SSM: 6.50, States in Appeal: 6.18, States with Ban: 6.67

Figure 2: Impacts of Benefits Received Following Repeal* Group means: States with Legal SSM: 0.83*, States in Appeal: 1.92*, States with Ban: 6.33* (Groups with matching symbols are significantly different from one another.)

Results Several experiences regarding the Section Three repeal were discussed by multiple participants. These experiences provide a glimpse into the lived experience of respondents and reveal the essence of this event. Four primary themes emerged from the responses: (1) marry or not?, (2) support or not?, (3) impact or not?, and (4) progress or not? Marry or not? As DOMA and its Section Three both concern the definition of legal marriage in the United States, it is perhaps unsurprising that a central theme arising from participants was that involving marriage and their related decisions, or inability to make decisions. Several people indicated the importance of the repeal in giving them the ability to get married; one respondent stated, “We are [now] legally married in Washington because we were registered domestic partners. Our partnership turned into marriage. We are very happy.” However, this

decision was not as simple for other participants: As one man explained, “For us, getting married might not be a good thing. One of us lives with AIDS, and being married would screw up his needs-based medical care.” Other respondents indicated that they were simply not ready. One man living in Washington explained, “We have only been together for one and a half years – not yet ready to commit to a lifetime together. That said, we are very happy together and both believe marriage and children are possibilities for the future.”

Support or not? Only six of the 26 respondents reported legal support following the repeal, primarily in the form of sharing property and tax benefits. This low percentage could be seen as an indication of the newness of the extension of legal benefits to same-sex couples, the limited number of LGBTQ+ people who actually have access to these benefits, and work still needed to extend benefits to same-sex couples. Those who had received

... the Supreme Court’s decision upheld that all married couples deserve equal treatment and respect under the law ...

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Figure 3: Expected Helpfulness of Repeal in Accessing Benefits Group means: States with Legal SSM: 6.33, States in Appeal: 6.24, States with Ban: 6.0

Figure 4: Impact of Laws on Couple Relationship Group means: States with Legal SSM: 5.83, States in Appeal: 5.00, States with Ban: 6.00

benefits indicated that these were very helpful. A male respondent from Wisconsin expressed, “Being able to share health insurance when we marry is huge. It will give us so much more flexibility and, honestly, a better, fairer quality of life.” Further, reported levels of support from families, friends, and community members varied greatly. Many respondents indicated they had received positive social backing, others reported mixed support, and a few reported continued discrimination and a lack of social support. Responses hinted at the importance of social support; as a woman in Colorado revealed: “My community is very open and accepting and I feel blessed to have moved here.” Conversely, some reported social discrimination following the repeal. A Colorado man reported, “I do feel that the debate has caused some of the community who oppose marriage equality to increase their level of opposition. Only in the past few years have I really felt

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strongly discriminated against ... prior to the current climate of debate about marriage equality they just pretty much left me alone.”

Impact or not? A major issue discussed by respondents was the impact of the repeal and related social responses on their individual and relationship wellbeing and functioning. Generally, participants felt that the repeal had positive effects on themselves and their relationships, but a few spoke of ways that it increased pressure on them. One of the most commonly reported impacts was that of increased legal and social support benefiting respondents’ couple relationships. A Wisconsin man wrote that the responses of family and friends had been “nearly 100% positive and supportive. Their support and love has helped our relationship grow and mature.” Another Wisconsin resident wrote, “I feel we have more of an opportunity for long-term success as a couple by having some federal (and

maybe state) recognition if we get married.” Respondents also spoke of feeling safer following the repeal. A Wisconsin man explained, “I’m happy that opinions are changing; it makes me feel safer, physically and emotionally.” Unfortunately, not all effects were positive. Several respondents reported feeling increased pressure to get married. For example, a Wisconsin man felt that the repeal had “... actually made [our relationship status] a bit more insecure. We do not live together, and it’s caused questions of commitment to come up. Now that we can get married in certain states, will we? If not, what is our relationship all about and where is it leading?” Although many respondents felt their relationships had been impacted by the repeal, others felt unaffected. A Colorado woman explained, “Our relationship is rock solid. Increased legal and/or social recognition is just the icing on the cake. We deserve equality and are glad it is happening but did not expect to see it in my lifetime.”


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Figure 5: Impact of Social and Public Approval on Couple Relationship Group means: States with Legal SSM: 5.17, States in Appeal: 4.88, States with Ban: 5.67

Figure 6: Hopefulness for National Marriage Equality Group means: States with Legal SSM: 6.33, States in Appeal: 6.76, States with Ban: 6.00

Progress or not? In the final category, participants gave their overall opinions of the repeal. Views of the repeal were solidly positive, labeling the repeal as a major event in the movement for LGBTQ+ rights and the morally right decision. Many participants felt that the repeal was an important, even historic, event. One man from New York elaborated, “It is a major domino falling that signifies the beginning of the downfall to marriage inequality throughout the country.” Another man from Colorado went beyond the repeal’s immediate implications: “I feel the repeal has meaning far beyond marriage and deals more with basic human dignity.” Discussion In combining the results of the qualitative and quantitative analysis, several patterns in participants’ responses were elucidated. First, both qualitative and quantitative results revealed that overall, participants across groups viewed the Section Three repeal as a positive and

important event. Furthermore, participants in all states reported beliefs that the repeal would be helpful in providing same-sex couples with access to the privileges and benefits of marriage, as well as supporting the marriage equality movement. Finally, very few participants in any group had received any benefits following the repeal, indicating that more must be done to attain full marriage equality in the United States. In addition, results highlighted important differences between groups. Despite minimal findings of statistical significance between groups, both qualitative and quantitative results indicated that participants in states with bans on same-sex marriage felt that both legal status and social opinion had more impact on their couple relationships than did participants in other states. Further, although few participants in any group reported receiving benefits following the repeal, based on their written commentary to the questions, participants in states

One of the most commonly reported impacts was that of increased legal and social support benefiting respondents’ couple relationships.

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Average Level of Activity by State Group

Figure 7: Level of Activity in LGBTQ+ Rights Advocacy

with bans on same-sex marriage reported the fewest received benefits, and also indicated that these benefits were more helpful to them than did other groups. This finding highlights an important discrepancy between need and actual support provided to participants in states with bans. The narratives of this study indicate that the repeal was an important event for LGBTQ+ rights, with far-reaching implications for marriage and human rights within the United States. However, these narratives also reveal that the fight for marriage equality was not over; there was still much to be done. The subsequent Supreme Court ruling on June 26, 2015, struck down Section Two of DOMA and thus established nationwide marriage equality, regardless of previous state laws (Liptak, 2015). However, many states responded to the 2013 and 2015 repeals by introducing bills allowing religious exemptions for providing service to LGBTQ+ clients, restricting adoption by same-sex couples, and allowing for the refusal to grant marriage licenses (ACLU.org, 2017; Blinder & Perez-Pena, 2015; Harris, 2017; Pizer, 2016). Follow-up research would be helpful in assessing the ongoing state of same-sex couples. This may be especially pertinent considering the rarity of participants in

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Group means: States with Legal SSM: 2.33, States in Appeal: 2.82, States with Ban: 1.33

this study receiving benefits they were purported to get post-repeal. According to phenomenological theory, the truth of history lies in the experiences of those most intimately connected to the event. It is therefore our role as couple and family researchers and therapists to listen and to assist where we are able.

References American Civil Liberties Union. (2017). Past anti-LGBT religious exemption legislation across the country. Retrieved from https://www. aclu.org/other/past-anti-lgbt-religiousexemption-legislation-across-country Andryszewski, T. (2008). Same-sex marriage: Moral wrong or civil right? Minneapolis, MN: Twenty-First Century Books. Aoun, A. R. (2016). The immigration challenges of same-sex binational couples and the impact on relationships, mental health, and wellbeing. Retrieved from ProQuest dissertations and theses. (AAI3663196) Barnes, R. (June 26, 2013). At Supreme Court, victories for gay marriage. Retrieved from http://articles. washingtonpost.com/2013-06-26/ politics/40195683_1_gaycouples-edith --windsor-doma

Blinder, A., & Perez-Pena, R. (2015, September 1). Kentucky clerk denies same-sex marriage licenses, defying court. The New York Times. Retrieved from https://www.nytimes. com/2015/09/02/us/same-sexmarriage-kentucky-kim-davis.html Collins, K. M. T., Onwuegbuzie, A. J., & Jiao, Q. G. (2007). A mixed methods investigation of mixed methods sampling designs in social and health science research. Journal of Mixed Methods Research, 1(3), 267-294. Creswell, J. W. (2013). Qualitative inquiry & research design: Choosing among five approaches (3rd ed.). Los Angeles, CA: SAGE Publications Inc. Creswell, J. W., & Plano Clark, V. L. (2011). Designing and conducting mixed methods research (2nd ed.). Thousand Oaks, CA: SAGE Publications Inc. Dominguez, D. G. (2015). DOMA’s demise: A victory for non-heterosexual binational families. Retrieved from ProQuest dissertations and theses. (AAI3581795) Drescher, J. (2012). The removal of homosexuality from the DSM: Its impact on today’s marriage equality debate. Journal of Gay and Lesbian Mental Health, 16(2), 124-135.


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Freedom to Marry. (2013). The Defense of Marriage Act. Retrieved from http://www.freedomtomarry.org/ states/entry/c/doma Gay and Lesbian Alliance Against Defamation (GLAAD). (July 2013). Frequently asked questions: Defense of Marriage Act (DOMA). Retrieved from http://www.glaad.org/ marriage/doma Goldberg, A. (2009). Lesbian, gay, and bisexual family psychology: A systemic, life cycle perspective. In J. H. Bray & M. Stanton (Eds.), The Wiley-Blackwell handbook of family psychology (576-587). Malden, MA: Blackwell Publishing Ltd. Harris, E. A. (2017, June 20). Samesex parents still face legal complications. The New York Times. Retrieved from https://www.nytimes. com/2017/06/20/us/gay-pride-lgbtqsame-sex-parents.html Human Rights Campaign. (July 30, 2013). Respect for Marriage Act. Retrieved from http://www.hrc.org/ laws-and-legislation/federal-legislation/ respect-for-marriage-act?gclid=COXb opG2qLkCFenm7AodRAMAzw

Killian, M. L. (2010). The political is personal: Relationship recognition policies in the United States and their impact on services for LGBT people. Journal of Gay and Lesbian Social Services, 22(1-2), 9-21. Liptak, A. (2015). Supreme Court ruling makes same-sex marriage a right nationwide. The New York Times. Retrieved from https://www.nytimes. com/2015/06/27/us/supreme-courtsame-sex-marriage.html Mathy, R. M., Kerr, S. K., & Lehmann, B.A. (2004). Mental health implications of same sex marriage: Influences of sexual orientation and relationship status in Canada and the United States. Journal of Psychology and Human Sexuality, 15(2-3), 117-141. Mathy, R. M., & Lehmann, B. A. (2004). Public health consequences of the Defense of Marriage Act for lesbian and bisexual women: Suicidality, behavioral difficulties, and psychiatric treatment. Feminism and Psychology, 14(1), 187-194. Morse, J. M. (1994). Designing funded qualitative research. In N. K. Denzin & Y. S. Lincoln (Eds.), Handbook of qualitative research (220-235). Thousand Oaks, CA: SAGE Publications Inc.

Moustakas, C. (1994). Phenomenological research methods. Thousand Oaks, CA: SAGE Publications Inc. Pelts, M. D. (2014). A look back at the Defense of Marriage Act: Why same-sex marriage is still relevant for social work. Journal of Women and Social Work, 29(2), 237-247. Pizer, J. C. (2016). Lambda Legal condemns passage of anti-LGBT Mississippi bill HB 1523. Retrieved from https://www.lambdalegal.org/ blog/20160405_ms-hb-1523 Reilly, R., & Siddiqui, S. (June 26, 2013). Supreme Court DOMA decision rules federal same-sex marriage ban unconstitutional. Retrieved from http://www. huffingtonpost.com/2013/06/26/ supreme-court-doma decision_n_3454811.html Rimmerman, C. (2008). The lesbian and gay movements: Assimilation or liberation? Boulder, CO: Westview Press. Sterngass, J. (2012). Same-sex marriage. Tarrytown, NY: Marshall Cavendish Corporation.

Alicia Bosley, PhD, assistant professor in the Marriage and Family Therapy Program, earned a PhD in couple and family therapy from Nova Southeastern University. She also holds an MA in couple and family therapy from Antioch University New England, and a BS in human development and family studies from Colorado State University. She has worked clinically with a broad range of clients in residential, hospital, community agency, and private practice settings. Most recently, she worked with a nonprofit organization that provides therapy and other social services for the LGBTQ+ community of South Florida. Her professional and clinical interests include diversity, social justice, sexual orientation and identity, reducing stigma related to mental health problems, and couple therapy.

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Cognitive and Language Neurophysiological Indices for Early-Stage Alzheimer’s Disease Susan M. DeMetropolis, MA, CCC-SLP, Instructor of Speech-Language-Hearing Sciences, Hofstra University Speech-Language-Hearing Sciences Programs How does the mind represent meaning of words or morphemes, and how does it combine these to represent the meaning of phrases and sentences? How does lexical access change as an individual ages and in neurodegenerative diseases, such as in Alzheimer’s disease? Alzheimer’s disease (AD)

is a degenerative brain disorder defined by neocortical atrophy, neuron and synapse loss and senile plaque, and neurofibrillary tangles in the hippocampus and in the association areas of the frontal, temporal, and parietal lobes (Hyman et al., 1984; Terry et al., 1991). One of the more common symptoms of 14

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AD is the progressive deterioration of cognitive functions, specifically language impairments. The most common clinical manifestation of AD is impairment in episodic memory, which is learning and recalling specific facts from a spatiotemporal context, such as knowing you ate a banana for breakfast. Episodic memory and attentional deficits have been the focus of research with AD. There have been fewer studies on semantic memory, i.e., knowing objects, facts, concepts, words, and meaning (Tulving, 1983). An example of semantic memory would be knowing

that a banana is yellow, that it grows on trees, and that you peel and eat it. As a speech-language pathologist, I know how we assess and treat individuals with different types of dementia, including Alzheimer’s disease. We are not the ones to diagnose the disease, but many times, we assist in making a clinical profile of cognitive and language strengths and weaknesses for these patients. As clinicians, we use paper-pen tests that ask “wh” questions, as well as repetition tasks, confrontation naming, description, following commands, and drawing figures (i.e., clock, bucket, and kite).


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In a study I did for the American Speech-Language-Hearing Association (ASHA) in 2014, I compared lexical access of verbs vs. nouns with healthy older adults and those with early-stage AD. I used a standardized language and cognitive battery used by speechlanguage pathologists called the Arizona Battery for Communication in Dementia (ABCD) (Bayles & Tomoeda, 1993) and the criterion-referenced Northwestern Naming Battery (Thompson & Weintraub, 2014). The results of my study indicated that there was no difference in naming noun pictures (e.g., apple); however, there were differences with naming transitive verbs vs. intransitive verbs, in which it was more challenging for the individuals with AD to name transitive verbs (i.e., an object associated with the action; “stirring” which uses the object of a spoon). I also found differences on a linguistic expression subtest of the ABCD in which healthy individuals were descriptive in their responses with functions-verbs, descriptions-adjectives, and categorical-noun information. The individuals with AD responded with more functions and categorical information, and lacked the descriptive information.

As a clinical researcher, I decided to take these behavioral results further and find out more of what is happening in the semantic system of someone with a neurodegenerative disease such as AD at both the neural and behavioral level. A central question with the semantic system is whether the semantic system is progressively degrading, or is it that individuals cannot easily access their semantic system? This storage vs. access question has been debated from different theoretical perspectives, and further research will inform us on how to best navigate the semantic systems for speech and language/cognition therapy for many of the patients we assess and treat. I designed a dissertation study that uses both behavioral and electrophysiological measures to gain more information on how the semantic system is breaking down in individuals with AD. I am using healthy adults as controls so that we can get more insight on differential diagnoses for typical aging processes and how we can differentiate these pathologies, such as in AD. Word retrieval problems are an indication of how aging affects older adults’ semantic processing. This is a common complaint as healthy elderly age and

for individuals in the early stage of AD and their family members. As the baby boomer generation continues to age, this research is important to advance the specific changes we might observe in the semantic system, and thus, will affect the way we communicate with others. My current research study involves using the cognitive screening MiniMental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975), the ABCD standardized test for overall cognitive and language skills and verification of the stage of AD, and the Pyramids and Palm Tree Test (Howard & Patterson, 1992), which is a standardized test that determines how a person can retrieve semantic information from pictures vs. words. A full hearing test is done in collaboration with the AuD students (consortium with St. John’s, Hofstra, and Adelphi) to rule out any hearing impairments for participation in the EEG part. The EEG portion involves a noninvasive net of 128 electrodes being placed on participants’ scalps. Participants look at a computer screen for a semantic priming task of pictures (black-white line drawings) and hear a consonantvowel-consonant (CVC) word (e.g., hot,

Figure 1: Set-up for EEG with electrodes on scalp and EEG reading on external computer with experiment playing in front of the participant. Retrieved from: http://www. brightbraincentre.co.uk/ electroencephalogram-eeg-brainwaves/ view-of-male-head-showing-electrodeplacement-on-the-scalp-for-an-eegelectroencephalogram/

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Figure 2: Semantic experiment with sentences in which one word is congruent and one word is incongruent. The N400 is a component of time-locked EEG signals known as event-related potentials (ERPs). It is a negativegoing deflection that peaks around 400 milliseconds poststimulus onset, although it can extend from 250 to 500 ms, and is typically maximal over centro-parietal electrode sites. Retrieved from: https://www.researchgate.net/ publication/273063386_Event-related_Potentials_ERPs_ in_Second_Language_Research_A_Brief_Introduction_ to_the_Technique_a_Selected_Review_and_an_ Invitation_to_Reconsider_Critical_Periods_in_L2/ figures?lo=1scalp-for-an-eeg-electroencephalogram/

food, rake) in which the words are divided into 25 congruent descriptions/ adjectives (e.g., picture: whale; word: “big”); 25 incongruent descriptions/ adjectives (e.g., picture: razor; word: “dull”); 25 congruent functions/verbs (e.g., picture: boy swinging bat; word: “hit”); 25 incongruent functions/verbs (e.g., picture: boy throwing snowball; word: “fall”); 25 congruent categories/ nouns (e.g., picture: hamburger; word: “food”), and 25 incongruent categories/ nouns (e.g., picture: pumpkin; word: “job”). In addition to behavioral research, semantic priming has been examined using EEG markers such as event-

related potentials (ERPs). ERPs are a nonintrusive measure of electrical brain activity that provides continuous information about the sequence and timing of brain activity. ERPs are timelocked to the onset of a stimulus or response and are characterized by voltage peaks and troughs that vary in size, timing, or scalp distribution with changes in stimulus, response, and cognitive processing parameters (Schwartz et al., 2003). I am looking at the N400, first described in 1980 (Kutas & Hillyard, 1980). The N400 is a large effect seen in response to words and final words in sentences that are anomalous; it is much

Figure 3: Dissection of the N400 component. Retrieved from: https://www.nrc-cnrc.gc.ca/eng/achievements/ highlights/2005/brain_activity.html

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smaller or not present in congruent sentence completions as a function of their predictability, or how expected the words are within a given context (Kutas & Hillyard, 1984). The N400 is useful in assessing how semantic analysis is affected by typical aging and by neurological disorders, such as AD. In clinical practice, semantic deficits are detected by naming or semantic fluency tasks that require conscious retrieval of semantic information through explicit tasks (Rogers & Friedman, 2008). Marques (2007) suggested that conceptual relations need to be studied through tasks that consider the common features of objects (e.g., visual, auditory, tactile, spatial). This research is designed to give clinicians and researchers semantic information to better design assessment tools and therapy programs that could better assist individuals with AD with their semantic memory skills for communication. The electrophysiological testing provides more neural information on timing and activation location to give us more insight into the sensitivity of behavioral testing in our clinical practice.


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Figure 4: Multiple brain regions are involved in memory encoding. Processing conceptual networks that share few common features is more demanding than processing those with a greater number of features, such as concepts at the superordinate level (e.g., animals). Analysis of the associative network in semantic memory shows that semantic impairment in AD reflects the segregation of concepts (Caputi et al., 2016). Retrieved from: http://slideplayer.com/slide/4395156/14/ images/31/Figure+17.8+Encoding,+Consolidation, +and+Retrieval+of+Declarative+Memories.jpg

References Bayles, K. A., & Tomoeda, C. K. (1993). Arizona battery for communication disorders of dementia. Austin, TX: PRO-ED. Caputi, N., Di Giacomo, D., Aloisio, F., & Passafiume, D. (2016). Deterioration of semantic associative relationships in mild cognitive impairment and Alzheimer disease. Applied Neuropsychology: Adult, 23(3), 186-195. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189-198. Howard, D., & Patterson, K. (1992). Pyramids and palm trees: A test of semantic access from pictures and

words. Bury St. Edmunds: Thames Valley Test Company. Hyman, B. T., Van Hoesen, G. W., Damasio, A. R., & Barnes, C. L. (1984). Alzheimer’s disease: Cell-specific pathology isolates the hippocampal formation. Science, 225, 1168-1170. Katzman, R. (1991). Physical basis of cognitive alterations in Alzheimer’s disease: Synapse loss is the major correlate of cognitive impairment. Annals of Neurology, 30, 572-580. Kutas, M., & Hillyard, S. A. (1980). Reading senseless sentences: Brain potentials reflect semantic incongruity. Science, 207, 203-205. Kutas, M., & Hillyard, S. A. (1984). Brain potentials during reading reflect word expectancy and semantic association. Nature, 307, 161-163.

Marques, J. F. (2007). The general/ specific breakdown of semantic memory and the nature of superordinate knowledge: Insights from superordinate and basic-level feature norms. Cognitive Neuropsychology, 24, 879-903. Rogers, S. L., & Friedman, R. B. (2008). The underlying mechanisms of semantic memory loss in Alzheimer’s disease and semantic dementia. Neuropsychologia, 46, 12-21. Terry, R. D., & Katzman, R. (1983). Senile dementia of the Alzheimer type. Annals of Neurology, 14, 497-506. Terry, R. D., Masliah, E., Salmon, D. P., Butters, N., DeTeresa, R. Hill, R. Hansen, L. A., & Thompson, C., & Weintraub, S. (2014). The Northwestern Battery. Evanston, IL. Tulving, E. (1983). Elements of episodic memory. Oxford: Clarendon.

Susan M. DeMetropolis, MA, CCC-SLP, is an instructor in the Speech-Language-Hearing Sciences Department in the School of Health Professions and Human Services at Hofstra University. She teaches adult neurogenic courses, including motor-speech disorders and aphasia. She is completing a PhD in neurophysiology at Adelphi University on semantic memory processes at the behavioral and electrophysiological levels in healthy adults and those with early-stage Alzheimer disease. She is looking at the N400 component to assess the sensitivity of behavioral measures used by speech-language pathologists and to get more information on the breakdown of the semantic system in Alzheimer disease to assist with related disorders. She is also a speech-language pathologist and works with adult neurogenic individuals after traumatic brain injury, stroke, or degenerative diseases in hospital and rehabilitation settings. Hofstra HORIZONS t Spring 2018

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Identifying Stressors, Coping Strategies, and Utilization of Mental Health Support Services in Occupational Therapy Graduate Students Robin Akselrud, OTD, OTR/L, Assistant Professor of Health Professions and Academic Fieldwork Coordinator, Hofstra University Occupational Therapy Program Abstract The purpose of this qualitative phenomenological study was to explore the impact of stress and coping strategies on students enrolled in a master’s level occupational therapy (OT) program in the northeast region of the United States. The study explored the use of on-campus mental health services and the differences in these factors between one Jewish women’s cohort and a traditional student cohort. Participants completed an information form and a semistructured interview, followed by engagement in a focus group. All interviews were recorded and 18

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transcribed verbatim, and then coded and analyzed for categories and recurring themes. Three overarching themes emerged: (1) coping strategies matter, (2) priorities: school vs. family, and (3) mental health services utilization – suggesting that coping strategies are similar, priorities differ, and mental health services are not utilized among the participants.

Background Graduate students face many forms of stress on a daily basis, which has an impact on their daily function and academic performance. Daily stressors include financial pressures, lack of effective coping skills, and

meeting academic deadlines. Mental health surveys (American College Health Association, 2005) show that a large number of students drop out of college as a result of mental illness. Research studies also show that students’ level of stress affects their academic performance and GPA. Stress in graduate students can be positive or negative and can be attributed to both schoolwork and out-of-school responsibilities (Shields, 2001). Students are expected to juggle the stresses of completing reports and studying for tests, as well as meeting the needs of their significant others, spouses, and children. Aside from the stressors of being a student, students


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are overwhelmed by personal pressures related to finding a job or a spouse (Zivin, Eisenberg, Gollust, & Golberstein, 2009). Some students excel in their studies, despite family responsibilities and lack of social support; however, other students struggle within the same situation, with or without fewer personal responsibilities. A decrease in social engagement often leads to poor selfesteem and disruption of healthy habits, routines, and roles (Misra, 2003).

Stress and Occupational Therapy Students Stress is defined as the lack of ability to cope with a perceived threat to an individual’s mental, physical, emotional, and spiritual well-being, which often results in a series of physiological adaptations and responses (Seaward, 2016). Several studies have been conducted to investigate stress, coping, and social support with students of other disciplines (Walton, 2002), and Everly et al. (1994) surveyed occupational therapy students. These studies concluded that effective coping strategies are extremely important for students and that students have a high level of stress when enrolled in these educational programs. Jewish Orthodox Women as College Students Jewish Orthodox women traditionally have had roles as homemakers, mothers, teachers, and those who assist individuals in need in the community (Ringel, 2007). Nowadays, their roles have changed and expanded and many have chosen to attend college, earn a degree, and then balance a career and a family. Due to this group’s increased interest in obtaining an academic degree, many academic programs in highly populated Jewish Orthodox areas have created customized programs that address the specific needs of these groups of students.

Accommodations include scheduling classes around Jewish holidays, having all-female classes, having a separate refrigerator and microwave that are reserved for kosher food, designating a private room for nursing mothers, and not requiring students to wear pants or T-shirts during lab sections of courses, when hands-on techniques are taught to students. Because these changes in the roles of Jewish Orthodox women are recent, little research exists on this population’s needs and the relationship between religion and stress levels.

Significance to Occupational Therapy Occupational therapists promote function and healthy living for people of all ages who have problems that interfere with daily living. Studying the causes of stress and effective and ineffective coping strategies may help educators promote success in occupational therapy students, providing them with stress management and coping strategies that will assist them in achieving their goals. A reduction in stress can improve their performance as students, spouses, parents, co-workers, friends, and community members. When working with the student population, as with all populations, it is important for educators to look at each student with a holistic approach. By identifying factors that affect students’ function, occupational therapy (OT) faculty can assist them with their individual educational needs. Purpose of the Study The purpose of this study is to better understand the perceived stress levels, stressors, role of religion, social supports, and out-of-school responsibilities among two groups of OT graduate students. The students who participated in this study were from two cohorts enrolled in a master’slevel OT program: a traditional group of students and a group of Jewish

Students are expected to juggle the stresses of completing reports and studying for tests, as well as meeting the needs of their significant others, spouses, and children.

Orthodox female students. There is a lack of literature regarding the specific causes of stress in occupational therapy students; the coping methods that they utilize, including mental health services on campus; and whether religion and culture affect their stress, coping, and use of services. The results of this study will provide insight into these critical areas, as well as the extent to which they affect students and OT educators.

Results Three themes emerged from the data obtained during the interviews and focus groups: (1) coping strategies matter, (2) priorities: school vs. family, and (3) mental health services utilization. Coping Strategies Matter Through semi-structured interviews, students in both cohorts discussed the importance of effective coping strategies for successful completion of the OT program. All participants, regardless of their point of study in the program, discussed the fact that they entered the program with ineffective or no coping strategies. The first semester was extremely stressful due to the academic demands of the course work, but also due to their lack of effective coping strategies. As they progressed toward the end of the first semester, all participants had established coping strategies that met their individual needs. Hofstra HORIZONS t Spring 2018

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PARTICIPANT DEMOGRAPHICS Religion

Marital/Relationship Status

Parental Status

Employment Status

F

Jewish Orthodox

Single, but dating

x

x

O. P.

F

Jewish Orthodox

Married

1 child

x

C. D.

F

Jewish Orthodox

Single, but dating

x

x

T. T.

F

Jewish Orthodox

Single

x

yes

E. M.

F

Jewish Orthodox

Married

x

x

J. K.

F

Catholic

In a relationship

x

x

M. D.

F

Catholic

Single

x

x

K. P.

F

Christian

Married

x

x

A. D.

F

Christian

Single

x

yes

N. R.

F

Spiritual

In a relationship

x

x

Name

Gender

D. D.

All students in the Jewish cohort and three students in the traditional cohort discussed the positive impact of religion on their stress levels and coping abilities. Through prayer, the weekly Sabbath, and other rituals, students relayed that their stress levels decreased. All participants relied heavily on the physical and emotional support of their family, spouses, and friends throughout their studies.

Priorities: School vs. Family The Jewish cohort of students all discussed the emphasis in their religion on dating, marriage, and starting a family, while the traditional cohort emphasized academics and performance in the OT program as their top priority, unless there was a family emergency. Mental Health Services Utilization All participants in this study reported not utilizing on-campus mental health services but were aware that these services were available to them. As discussed by the students, they may not have used the services because of their individual effective coping strategies, fear of breach in confidentiality, conflicts with scheduling, and mental health stigma. 20

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Implications for OT Students, Education, and/or Educators The results of this study can aid in educating students on the importance of identifying and establishing individualized coping strategies before entry or upon entry to an OT graduate program. Through early identification, stress can be decreased and there can be improved academic success early in the program. This study also aids in understanding the needs of the Jewish Orthodox culture and the life priorities of this population while enrolled in an OT graduate program. Educators can best accommodate these students by understanding their life roles and responsibilities. The results of this study can also inform potential students about the demands of the program, and the need for social supports. Lastly, this study can educate educators on the need to familiarize students with the benefits and process of accessing on-campus mental health services, so that students will access them, if needed. Limitations of the Study Several limitations to this study should be noted; however, the biggest limitation in this study is the potential bias of the principal investigator, who

identifies as a Jewish Orthodox woman. Other limitations include having a small sample size and having only female participants. As the participants were randomly chosen, it was not possible to determine if this study included a representative sample. The students who participated were at different stages in the program when participating in the interviews; therefore, their feelings and perceptions may have differed due to the stressors and course work they were handling at the time.

Recommendations for Future Research There were several areas related to this study that can direct future research, with the goal of acquiring evidence to guide practice. It would be helpful to explore students’ perceptions in a larger sample and with participants from other OT programs. This would be important, as their perspectives may differ based on their experiences, and may increase the generalizability of this study. It would also be beneficial to have participation by some male students, so that there is diversity in the findings, as gender roles are significantly different in the traditional Jewish Orthodox culture.


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Further, a study with a larger sample size will increase diversity both in gender and in the religion of participants. A study that explores the perceptions of specific groups of students with the same responsibilities but from different religious backgrounds, such as mothers, would give a better explanation of the feelings, perceptions, and specific needs of that group.

Conclusion This study explored the perceived stressors, social supports, and coping strategies utilized by students in a master’s level occupational therapy (OT) program. The study also explored the effects of religion on stress levels, the student’s life priorities, and the utilization of on-campus mental health support services. The study attempted to answer the question of whether students would have more success in completing a master’s level OT program if they had a better understanding of perceived stress, supports required, and priorities with regard to the program. The study also attempted to explore whether religion decreased the students’ stress levels and if mental health services were utilized, if needed. Students reported a high level of stress throughout the program, but especially during the first semester, when their coping strategies were not yet established. All students reported

having a decline in stress once they found coping strategies that were effective for their own needs. Most students reported that religion did in fact decrease their stress levels significantly and assisted them in coping with the demands of the program. All students relied heavily on their families and friends for support, and only two participants were able to keep their jobs while enrolled in the program. While the group of Jewish students described that their priorities while being in the program were to start a family, the traditional group of students reported that academics was always the priority for them, unless there was a family emergency. Mental health services both on and off campus were not utilized by any of the participants for various reasons, even when some participants reported that they were in need of this support.

References American College Health Association. (2005). The American College Health Association National College Health Assessment (ACHA-NCHA), spring 2003 reference group report. Journal of American College Health, 53(5), 199. Everly, J. S., Poff, D. W., Lamport, N., Hamant, C., & Alvey, G. (1994). Perceived stressors and coping strategies of occupational therapy students. American Journal of Occupational Therapy, 48(11), 1022-1028.

Misra, R., & McKean, M. (2000). College students’ academic stress and its relation to their anxiety, time management, and leisure satisfaction. American Journal of Health Studies, 16(1), 41. Misra, R., Crist, M., & Burant, C. J. (2003). Relationships among life stress, social support, academic stressors, and reactions to stressors of international students in the United States. International Journal of Stress Management, 10(2), 137. Ringel, S. (2007). Identity and gender roles of Orthodox Jewish women: Implications for social work practice. Smith College Studies in Social Work, 77(2-3), 25-44. Seaward, B. L. (2016). Essentials of managing stress. Jones & Bartlett Publishers. Shields, N. (2001). Stress, active coping, and academic performance among persisting and nonpersisting college students. Journal of Applied Biobehavioral Research, 6(2), 65-81. Walton, R. L. (2002). A comparison of perceived stress levels and coping styles of junior and senior students in nursing and social work programs (doctoral dissertation, Marshall University, Huntington, WV). Zivin, K., Eisenberg, D., Gollust, S. E., & Golberstein, E. (2009). Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders, 117(3), 180-185.

Robin Akselrud, OTD, OTR/L, is assistant professor and academic fieldwork coordinator in the Department of Health Professions in the School of Health Professions and Human Services at Hofstra University. She brings both her clinical and administrative experiences to the Occupational Therapy program at Hofstra. Dr. Akselrud is a certified early intervention provider and has worked in a variety of treatment settings, including schools, outpatient rehab, and home care for both adult and geriatric clients. She established and owns an OT outpatient facility for both children and adults in Brooklyn, Forward OT PLLC. Dr. Akselrud has served an adjunct professor at LIU Brooklyn, York-CUNY, and Touro College for the past five years. She received her post-professional doctorate from Quinnipiac University in 2017.

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Health Care Professionals and Wrong Drug Mistakes: Can Language Research Help? Scott R. Schroeder, PhD, Assistant Professor of Speech-Language-Hearing Sciences, Hofstra University Speech-Language-Hearing Sciences Programs The next time you go to the pharmacy to pick up a prescription, check to make sure that you have received the right medicine. If you take Hydroxyzine for your allergies, you might have mistakenly been given Hydralazine, a drug that treats high blood pressure. If you take Celebrex® for your arthritis, you might have accidently received Celexa®, which is an antidepressant. These drug names (Celebrex® and Celexa® and Hydroxyzine and Hydralazine) are called look-alike sound-alike drug names, of which there are many, thousands even. (See Table 1.) Fortunately, health care professionals, 22

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such as doctors, nurses, pharmacists, and technicians, are trained to not mistake similarly named drugs, so, most likely, they will not make a mistake on your next prescription. Nevertheless, as the proverb goes, to err is human, and sometimes wrongdrug errors occur. In fact, each year up to 3.9 million of these errors may be made in community pharmacies (Lambert, Lin, & Tan, 2005). When wrong-drug errors occur, they are often quite harmful. For example, a patient once received Durasal® (a wart remover) instead of Durezol® (an eye ointment) and put the wart remover in their eye. Ouch!

(See Figure 1.) Recently, patients taking Brilinta® (a blood thinner) received Brintellix®, an antidepressant that can have many unpleasant side effects, including vomiting, dizziness, and sexual dysfunction. (Note that because of these errors, Brintellix® has been changed to Trintellix®). Errors like Brilinta® Brintellix® are harmful in two ways. One is rather obvious – the patient is taking a drug that they do not need, and taking this drug can lead to highly undesirable consequences (such as vomiting, dizziness, and sexual dysfunction). The second, perhaps less obvious, consequence of the error is that the patient fails to


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receive a drug that they need. For example, a patient who takes the blood thinner Brilinta® might suffer a heart attack if they do not receive the blood thinner. How can this happen? How can welltrained and well-intentioned health care professionals make errors of this magnitude, and do so millions of times each year? Mistakes like these can be made in multiple ways. A doctor might enter in a prescription for Brilinta® by typing in the first three letters (b-r-i), and then the name Brintellix® pops up, and the doctor accidentally selects Brintellix®. Or suppose the doctor calls in a prescription for Brilinta® to the pharmacy, and the pharmacist mishears the name of the drug as Brintellix® because the pharmacy is busy, and there is a lot of noise in the background. Or perhaps the pharmacy technician goes to retrieve Brilinta® from the shelf, becomes preoccupied on the way over there, and then mistakenly picks up Brintellix. Researching why a patient received an antidepressant like Brintellix® instead of a blood thinner like Brilinta® seems odd for someone like me, who teaches in the Speech-Language-Hearing department and does psycholinguistics research. But actually these errors are psycholinguistic errors – in other words, the brain (the “psycho” part of

Table 1: A Short List of Look-Alike Sound-Alike Drug Names Tramadol – Toradol Cymbalta® – Symbyax® Vinblastine – Vincristine Clonidine – Klonopin® Metformin – Metronizadole Prednisone – Prednisolone Zyrtec® – Zantac®

Famotidine – Furosemide the word psycholinguistics) has confused two similar words (the “linguistic” part of psycholinguistics). As psycholinguistics researchers, my colleagues and I have been studying look-alike sound-alike drug name confusion errors for the last few years, with the ultimate goal of decreasing the rates of these errors and increasing patient safety. Before I started researching the problem of drug name errors, a promising solution to the problem had already been put forward. The idea was simple yet very clever, and most importantly, very promising. The idea was (and still is) called Tall Man Lettering, and it entails capitalizing the letters that differ between similarly named drugs. For example, Hydroxyzine and Hydralazine

would appear as hydrOXYzine and hydrALAzine. The difference between the two drug names (in other words, the OXY and ALA) is emphasized, drawing your eyes to the particular letters that crucially distinguish these names. (See Figure 2.) This idea struck many health care professionals as incredibly smart, and so the idea was put into practice across the United States. In fact, the Joint Commission, which is the organization that accredits a very large number of health care organizations and programs in the United States, has strongly encouraged the use of Tall Man Lettering, and many organizations and programs have complied, making Tall Man Lettering highly prevalent. But does Tall Man Lettering actually reduce the number of drug name errors? My colleagues and I argued in an editorial in the British Medical Journal: Quality and Safety that, to date, there is no compelling evidence that Tall Man Lettering truly works (Lambert, Schroeder, & Galanter, 2016). There have been many artificial laboratory experiments that have examined whether people make fewer errors when Tall Man lettering is used. While some of these studies are suggestive of an advantage of Tall Man Lettering over normal lettering, many other studies fail to show a benefit of Tall Man Lettering.

Figure 1: A patient once mistakenly received Durasal®, a wart remover, instead of Durezol®, an eye ointment, resulting in the patient putting the wart remover in their eye. Retrieved from: https://consumerist. com/2011/02/25/man-sues-walgreensfor-giving-him-wart-remover-insteadof-eye-drops/

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Even when a benefit is shown, it is unclear whether results from an artificial laboratory setting translate into real-world clinical practice. Fortunately, a much-needed study recently addressed the real-world effectiveness of Tall Man Lettering, by assessing rates of drug name errors across 42 children’s hospitals from 2004 to 2012 (Zhong, Feinstein, Patel, Dai, & Feudtner, 2016). What did they find? They found that Tall Man Lettering did not reduce the number of drug name errors. Of course, no single research study provides a definitive ruling, and future studies might find that Tall Man Lettering is indeed effective, but at this point, my colleagues and I believe that major skepticism is warranted. If the effectiveness of Tall Man Lettering is questionable, what can we do to reduce drug name errors? My colleagues and I are taking a proactive approach to the problem. In other words, we are trying to prevent confusing drug names from entering the market in the first place (i.e., before they can do any harm). While the U.S. Food and Drug Administration (FDA) has a process for evaluating proposed drug names, confusing names still slip through the cracks and make it onto the market. My colleagues and I have created a battery of tests for proposed 24

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name is mistaken quite frequently on the tests, then Figure 2: To decrease the chances of drug that drug name should not go name mistakes, labels are often printed in on the market. But, of course, Tall Man Lettering. This special type of a claim needs evidence if it is lettering involves capitalizing letters that to be taken seriously. To assess differ between similarly named drugs. For example, Hydroxyzine and Hydralazine are the claim, my colleagues and I similarly named, so the differentiating tested 80 participants (both letters (OXY and ALA) are capitalized, health care professionals and resulting in hydrOXYzine and hydrALAzine. patients) on this battery of tests, and then we analyzed Retrieved from: their error rates on particular https://www.psqh.com/analysis/look-alikedrug-name-errors/ drug name pairs (such as Hydroxyzine-Hydralazine). Specifically, we looked at how drug names that federal regulators the error rates on particular (such as the FDA) can utilize to drug name pairs compared to the error improve their ability to detect bad rates of those same drug names in two names that are prone to confusion and large community pharmacy chains in thus should not be approved. the United States. We found that error rates on our tests could predict the error Our battery of tests consists of simple rates in both community pharmacy video game-style cognitive tests that chains. In other words, if participants assess people’s perception and memory made a lot of Hydroxyzine-Hydralazine of drug names. For example, in a visual errors on our test, then Hydroxyzineperception test, a drug name (such as Hydralazine had a high error rate in Hydroxyzine) is flashed on the real-world pharmacy chains, a result computer screen extremely rapidly (less that we published in the British Medical than a tenth of a second). Then, two Journal: Quality and Safety (Schroeder names pop up on the screen et al., 2017). The important implication (Hydroxyzine and Hydralazine), and the of this result is that when a drug name person has to choose which drug name is proposed and goes up for evaluation they believe they saw. In an auditory by federal regulators, the regulators can version of the perception test, a person insert the proposed drug name into hears a drug name like Hydroxyzine but these cognitive tests and determine at the same time, they hear 20 people whether the drug name is likely to babbling in the background. Then, as in cause real-world errors and thus should the visual perception test, two names not be allowed to enter the market. pop up on the screen (Hydroxyzine and Recently, we conducted a follow-up Hydralazine), and the person has to study with different participants and choose which drug name they believe different drug names, and we replicated they heard. In a memory test, a drug the primary finding: Cognitive tests name is displayed on the screen, and predict real-world drug name errors. then the person solves a math problem These new results, which have yet to be (for example, 2455 + 1392). After submitted for publication, lend further solving the math problem, the person credence to our claim. has to try to remember which drug But what about the drug names that are name they saw. already on the market and are likely to The claim we are making about these continue to be confused, such as cognitive tests is that if a given drug Hydroxyzine and Hydralazine and


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Celebrex® and Celexa®? In addition to our proactive efforts to prevent bad names from entering the market, reactive efforts are also being made to reduce errors involving names that are already on the market. In this vein, my colleagues and I recently conducted a very small pilot study that assessed an unusual approach to reduce drug name errors. The approach is based on the notion that the mind has two distinctive cognitive systems, an idea popularized in the best-selling book Thinking, Fast and Slow by Daniel Kahneman (Kahneman, 2011). System 1 is a fast system that involves automatic processing, whereas System 2 is a slow system that involves effortful processing. My colleagues and I hypothesize that pharmacists are often functioning in System 1 mode when hearing or seeing a drug name. Pharmacists encounter the same drug names over and over, day in and day out, which can lead them to mentally process these names in auto-pilot mode. The problem with operating in automatic mode is that errors are likely to occur. Perhaps, if we can nudge pharmacists from System 1 into the more deliberate System 2, they will make fewer errors. How then can we make the pharmacist’s routine and automatic job of reading drug names from bottles, packages, and computer screens more deliberate?

One possible solution is to put the drug names in harder-to-read fonts, such as Hydroxyzine or Hydroxyzine or Hydroxyzine. By making the drug names harder to read, the pharmacist is forced to slow down and engage System 2. In this more deliberate mind frame, pharmacists may be less likely to make mindless mistakes. In a very small pilot study, our results were promising, but until a full study is conducted and passes through peer review, it is premature to claim that changing fonts is likely to reduce drug name errors. My colleagues and I are continuing our fight against wrong-drug errors. With the belief that difficult problems are often best solved with a diverse group of people, we are taking an interdisciplinary approach. Our team includes language researchers, health communication researchers, medical doctors, pharmacists, computer scientists, and statisticians from several institutions across the United States, including Northwestern University in Illinois, University of Illinois at Chicago, Brigham and Women’s Hospital in Massachusetts, the Institute for Safe Medication Practices in Pennsylvania, and of course, Hofstra University in New York. Together, we are making progress on the problem of wrong-drug errors, but until the problem is solved, please check that you receive the right medication on your next visit to the pharmacy.

References Kahneman, D. (2011). Thinking, fast and slow. Macmillan. Lambert, B. L., Lin, S.-J., & Tan, H. (2005). Designing safe drug names. Drug Safety, 28(6), 495-512. Lambert, B. L., Schroeder, S. R., & Galanter, W. L. (2016). Does Tall Man lettering prevent drug name confusion errors? Incomplete and conflicting evidence suggest need for definitive study. BMJ Qual Saf, 25(4), 213-217. https://doi.org/10.1136/bmjqs-2015004929 Schroeder, S. R., Salomon, M. M., Galanter, W. L., Schiff, G. D., Vaida, A. J., Gaunt, M. J., ... Lambert, B. L. (2017). Cognitive tests predict realworld errors: The relationship between drug name confusion rates in laboratory-based memory and perception tests and corresponding error rates in large pharmacy chains. BMJ Qual Saf, 26(5), 395-407. https:// doi.org/10.1136/bmjqs-2015-005099 Zhong, W., Feinstein, J. A., Patel, N. S., Dai, D., & Feudtner, C. (2016). Tall Man Lettering and potential prescription errors: A time series analysis of 42 children’s hospitals in the USA over 9 years. BMJ Qual Saf, 25(4), 233-240. https://doi.org/10.1136/bmjqs2015-004562

Scott R. Schroeder, PhD, is assistant professor in the Speech-Language-Hearing Sciences Department in the School of Health Professions and Human Services at Hofstra University. He teaches graduate and undergraduate classes in the area of psycholinguistics (the cognitive processes involved in acquiring, producing, and comprehending language). He also directs the Language and Cognition Laboratory and conducts research on bilingualism, communication disorders, and medical errors. Professor Schroeder earned a PhD in the Communication Sciences and Disorders Department at Northwestern University, where he also completed his postdoctoral work. At Northwestern University, he conducted research in the Bilingualism and Psycholinguistics Research Group and the Center for Communication and Health. He completed his undergraduate studies in psychology, linguistics, and speech and hearing sciences at Indiana University.

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A More Rational Health Policy Approach to Achieve the Triple Aim Walter L. Markowitz, EdD, MPA, Assistant Professor of Health Professions, Hofstra University Master of Health Adminstration Program Health care costs in our country are too high. The United States spends more money for health care per capita and as a proportion of gross domestic product than all other industrialized countries. Yet millions in our nation are uninsured or underinsured. Many struggle to pay for recent, sharp increases in their health insurance premiums, co-insurance and deductibles, with the inevitability of continued increases, given congressional and presidential proposals. Increased health insurance costs present a significant financial burden for many families, who must make difficult choices concerning 26

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coverage options, which can force many to accept policies that provide inadequate or minimum benefits. Polices with lower premiums require initial and ongoing higher out-of-pocket health care expenditures for enrollees. Those already struggling to pay higher premiums may feel forced to forgo care, other than for emergent or urgent reasons, rather than pay required, higher deductibles and co-insurance. Those at the lower end of the economic scale, as well as now many in the middle class, have been and will be most likely affected by these trends.

Despite our comparatively huge financial costs for health care, our nation already lags far behind the compendium of Organization for Economic Co-operation and Development (OECD) nations on many health status indicators. The United States compares unfavorably on providing access to care to its citizens; all OECD nations provide some form of universal health coverage, while the U.S. health care system does not. Increased health insurance costs, combined with proposed changes in the Affordable Care Act (ACA) threaten to further diminish the number of insured in the nation. A recent and unexpected


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decline in life expectancy, albeit slight (Rogers, 2016), adds to an unsettling picture of health already existing in our nation, with fears that this negative data may represent an impending trend. Many consider that the goals for our health care system are embodied in the Triple Aim model: universal access, highest quality, and efficiency. If the components of the Triple Aim are to be embraced and achieved, the three should be viewed as interrelated. We must ask ourselves how best to achieve these goals. Which policy options provide the most rational path forward? As a first step, we might consider Willy Horton’s rationale for robbing banks: “That’s where the money is.” We need to ask ourselves where the health care money is. What is driving unsustainably high levels of expenditures and expenditure increases, which consistently outstrip inflation? Can fewer health care dollars be more rationally distributed to provide better care for more people? Currently, the go-to policy approach to high health care costs in the United States is to cut mandates like Medicare and Medicaid. Additional policy options include reducing pay to providers and benefits; limiting choice to providers; increasing co-insurance and deductibles; and limiting or denying access to affordable insurance. The president’s proposed budget for fiscal year 2018 (released May 23, 2017) follows this model. Cuts of $1.25 trillion over the next 10 years are proposed and will limit measures associated with the implementation of the Affordable Care Act. Proposed Medicaid reductions were $610 billion; $5.8 billion would be cut from the CHIP program for children. For 2018, the budget shaved more than $850 million from the Food and Drug Administration, $41.3 billion from

CDC, and $5.8 billion from NIH, with nearly $400 million removed from the Substance Abuse and Mental Health Agency (Jost, 2017). Consider the following: Adjusted for inflation, Medicare reimbursement to hospitals and physicians has been effectively reduced. Hospitals received a 0.95% increase for inpatient stays — a significantly lower increase compared with inflation — in 2017 only if they reported quality data and attested to Electronic Health Record meaningful use requirements (Ellison, 2016). In 2015, federal legislation included Medicare physician payment increases of 0.5% for 2016, 2017, and 2018 (Cherf & Paul, 2017). In contrast, a Medscape survey (Grisham, 2017) indicates that physician compensation over time has risen approximately 5% annually, which can be attributed to competition among potential employers as opposed to rate increases from Medicare, Medicaid, or private insurers. If the Centers for Medicare & Medicaid Services (CMS) is already reducing the number of real dollars paid annually to physicians and hospitals, exploring other parts of the health system is required to provide additional, fruitful, and rational sources for savings. One approach might be to consider a re-direction of some focus in our health care system to prevention and wellness, rather than the current disease treatment focus that dominates how health care dollars are expended. Despite evidence concerning the value and return on investment for public health prevention and wellness efforts, our health care system concentrates on “services delivered only when a patient’s illness becomes symptomatic” (Clarke, 2010,

Increased health insurance costs present a significant financial burden for many families, who must make difficult choices concerning coverage options, which can force many to accept policies that provide inadequate or minimum benefits.

p. S-5). This focus on reactive medicine is consistent with a projected additional decline in public health’s share of total health expenditures from 2.65% in 2014 to 2.40% in 2023 (Himmelstein & Woolhandler, 2016). Clearly, public health and prevention measures have not contributed, and are not anticipated to contribute, to increasing health care costs. However, perhaps a focused re-direction to prevention and wellness can produce longer-term decreases in health care expenditures (Rula, Pope, & Hoffman, 2011; Schwartz et al., 2014). Tellingly, the health insurance sector seems to be gaining wealth at a steady clip. In the second quarter of 2017, the top six health insurers realized $6 Hofstra HORIZONS t Spring 2018

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What rational decisions can provide the best quality of care and improve population health, while increasing access and decreasing costs?

billion in adjusted profit, more than 29% higher than for the same quarter in 2016. The S&P’s health sector’s growth was only 8.5% for the same period (Coombs, 2017). In keeping with these rising profits, the estimated average rise for ACA silver plans next year will be 34% in the more than three dozen states that use the federal exchange. Rate hikes vary by state with Iowans seeing an increase of 69% for the ACA silver plan (Luhby, 2017). Interestingly, a survey of large employers revealed a projected increase of 5% in health plans, consistent with the past several years (Johnson, 2017). The search for a more rational approach to achieving the Triple Aim should consider the imposition of limits on private insurance company premium increases and profits to more closely align with provider reimbursement levels. Another rational approach might be to implement a public option choice, which could compel the private insurance companies to compete on price with government-based insurers. Consider, for example, that administrative costs for Medicare are estimated to be between 1% and 6% and there is obviously no non-direct patient care allowance within Medicare premiums for a company profit (Sullivan, 2013). Medicare Part D premiums, unlike ACA silver plans, are expected to decrease in 2018, to 28

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approximately $33.50 per month on average, down $1.20 from $34.70 in 2017 (CMS, 2017). The pharmaceutical industry is another sector of the U.S. health system in which prices, price increases, and profits appear to lack rationality. U.S. prescription sales in 2016 were $448.2 billion, 5.8% higher versus 2015, following increases of 14.5% and 11.7% in the prior two years (Schumock et al., 2017). “In 2013 the profit margin for pharmaceutical companies ranged from 10% to 42%, with an average of 18%” (Deangelis, 2016, p. 30). Unlike other industrialized countries, the United States permits drug companies to set their own prices to consumers as long as they do not collude on pricing with other companies. Medicare is not permitted to negotiate drug prices, leaving individual health insurers to negotiate individually, and the U.S. population is not permitted to obtain prescription drugs from other countries, which have substantially lower prices for the same drugs that exist in the United States. Drug companies assert that higher prices in the U.S. fund research and development costs; yet profits far outstrip these costs (Yu, Helms, & Bach, 2017). Corporate profit is not the only source of high health care costs that requires some thoughtful attention. Defensive medicine, due to fear of malpractice litigation, should be thoroughly explored as a source of unnecessary resource utilization (Baicker, Wright, & Olsen, 2015). Protection against litigation by practicing evidence-based medicine provides real opportunities for efficiency by ensuring the relationship of resources to positive outcomes. We need to ask ourselves how to achieve the Triple Aim of access, quality, and efficiency. What rational decisions can provide the best quality

of care and improve population health, while increasing access and decreasing costs? The answers may not be universally popular; however, they may lead to a more rational approach to the development and implementation of health policy.

References Baicker, K., Wright, B., & Olson, N. (2015). Reevaluating reports of defensive medicine. Journal of Health Politics, Policy and Law, 40(6), 11571177. doi: 10.1215/03616878-3424462. Centers for Medicare and Medicaid Services. (August 2, 2017). CMS announces 2018 Medicare Part D premiums. Reported in Medical Benefits. Retrieved from https://eds-aebscohost-com.ezproxy.hofstra.edu/ eds/pdfviewer/pdfviewer?vid=3&sid= 2f11d811-26ca-4a6e-b046852a0ab984af%40sessionmgr4010 Cherf, J., & Paul, A. (October 2017). Unsustainable physician reimbursement rates. American Association of Orthopedic Surgeons Now. Retrieved from https://www. aaos.org/AAOSNow/ 2017/Oct/Cover/ cover01/?ssopc=1 Clarke, J. (2010). Preventive medicine: A ready solution for a health care system in crisis. Population Health Management, 13(Supplement 2), S3-S11. doi: 10.1089/pop2010.1382 Coombs, B. (August 5, 2017). As Obamacare twists in political winds, top insurers made $6 billion (not that there is anything wrong with that). Retrieved from https://www.cnbc. com/2017/08/05/top-health-insurersprofit-surge-29-percent-to-6-billiondollars.html Deangelis, C. (2016). Big pharma profits and the public loses. The Milbank Quarterly, 94(1), 30-33. Ellison, A. (August 3, 2016). CMS final IPPS rule for 2017: 9 points to know. Retrieved from https://www. beckershospitalreview.com/finance/


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cms-final-ipps-rule-for-2017-9-pointsto-know.html?tmpl=component&print =1&layout=default&page= Grisham, S. (April 5, 2017). Medscape physician compensation report 2017. Retrieved from https://www.medscape. com/slideshow/compensation-2017overview-6008547#1 Himmelstein, D., & Woolhandler, S. (2016). Public health’s falling share of U.S. health spending. American Journal of Public Health, 106(1), 56-57. doi: 10.2105/AJPH.2015.302908 Johnson, C. (August 8, 2017). Large employers say health plans will cost more than $14,000 for an employee in 2018. The Washington Post. Retrieved from ezproxy.hofstra.edu/login?url= http://go.galegroup.com/ps/i.do?p= STND&sw=w&u=nysl_li_hofs&v=2.1 &id=GALE%7CA500091892&it=r&asi d=058582516f07c4677297cb0b510c7fd6. Jost, T. (May 23, 2017). Trump budget proposes big health cuts. Health Affairs Blog. Retrieved from http:// www.healthaffairs.org/do/10.1377/ hblog20170523.060239/full/

Luhby, T. (October 26, 2017). Here’s what you’ll pay for Obamacare in 2018. Retrieved from http://money.cnn. com/2017/10/26/news/economy/ obamacare-premiums-openenrollment/index.html Rogers, K. (December 8, 2016). Life expectancy in U.S. declines slightly, and researchers are puzzled. New York Times. Retrieved from https://www.nytimes.com/2016/12/08/ health/life-expectancy-us-declines. html?_r=0 Rula, E., Pope, J., & Hoffman, J. (2011). Potential Medicare savings through prevention and risk reduction. Population Health Management, 14 (Supplement 1), s35-s44. Schumock, G., Li, E., Wiest, M., Suda, K., Stubbings, J., Matusiak, L., Hunkler, R., & Vermeulen, L (2017). National trends in prescription drug expenditures and projections for 2017. American Journal of HealthSystem Pharmacy. 74(15), 1158-1173. doi:10.2146/ajhp170164

Schwartz, S., Mason, S., Wang, C., Pomana, L., Hyde-Nolan, M., & Carter, E (2014). Sustained economic value of a wellness and disease prevention program: An 8-year longitudinal evaluation. Population Health Management, 17(2), 90-99. doi: 10.1089/pop.2013.0042 Sullivan, K. (2013). How to think clearly about Medicare administrative costs: Data sources and measurement. Journal of Health Politics, Policy and Law, 38(3), 479-504. doi: 10.1215/03616878-2079523 Yu, N., Helms, Z., & Bach, P. (March 7, 2017). R&D costs for pharmaceutical companies do not explain elevated U.S. drug prices. Health Affairs. doi: 10.1377/ hblog20170307.059036. Retrieved from http://www.healthaffairs.org/ do/10.1377/hblog20170307.059036/full/

Walter Markowitz, EdD, MPA, is assistant professor in the Department of Health Professions at Hofstra’s School of Health Professions and Human Services since September 1, 2017. He holds an EdD from Dowling College and an MPA from BaruchCUNY/Mt. Sinai. For more than 30 years, Dr. Markowitz held administrative, planning, and research positions for Northwell Health or its predecessor-component hospitals. He spent the last 15 years of his career in health care as director of strategic planning for Northwell. While director of strategic planning, Dr. Markowitz worked with the Northwell Center for Learning and Innovation, regularly teaching workshops in health care management, strategic planning, and grant-writing. He was successful in securing grant funding for multiple service delivery programs and other projects. Since the 1980s, Dr. Markowitz has held adjunct faculty positions in health administration programs at various colleges and universities on Long Island, including the past five years as an adjunct faculty member at Hofstra. For more than a decade, he served as a member of the Suffolk and the Oyster Bay Consortium Workforce Investment (Development) Boards and was a member of New York State WIB for three years. Since his retirement from Northwell, in addition to adjunct faculty work, he has worked with Dr. Kathleen Gallo – dean of the Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies – responding to three HRSA grant proposals for the school and successfully securing $1.6 million in grant funds to support a project titled “Creating a Nurse Practitioner Student Transition-to-Primary Care Practice Model.”

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Exercise Science and Sports Nutrition Research Adam M. Gonzalez, PhD, NSCA-CSCS, CISSN, Assistant Professor of Health Professions, Hofstra University Exercise Science Progam Exercise science and sports nutrition research strives to advance the field of exercise physiology, and the community at large, by bridging the gap between science and application. Exercise scientists seek to improve the knowledge base of strength and conditioning practitioners by conducting studies on topics such as sets and reps for optimizing resistance training programs, the physiological responses to training, and the effectiveness of dietary strategies. As an exercise physiologist and educator, I strive to conduct research in the areas of sport science, exercise physiology, and nutritional supplementation. My primary research interests include exercise and nutritional strategies to optimize body composition, maximize health and performance, and enhance 30

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adaptations to resistance exercise. With the assistance of my colleagues and students, we have had the opportunity to publish several research studies to further expand our understanding of muscle physiology, exercise program design, and nutritional supplementation.

Enhancing adaptations to resistance exercise Maintaining skeletal muscle mass and function is critical for disease prevention, mobility, quality of life, and whole-body metabolism. Resistance exercise is known to be a primary regulator for promoting gains in muscle size and strength; however, the resistance exercise parameters for maximizing muscular adaptations remain unclear. We have recently set out to compare common resistance training programs and variables to provide science-based

recommendations for strength and conditioning professionals.

Hypertrophy vs. Strength Resistance Training Protocols Resistance training paradigms are often divided into protocols designed to promote an increase in either hypertrophy or strength. Hypertrophy-style protocols typically involve greater volume (3-6 sets; 8-12 repetitions), moderate intensities (<85% 1 repetition maximum [1RM]), and short rest intervals (30-90 seconds), whereas strengthstyle protocols typically involve higher intensities (>85% 1RM), low volumes (2-6 sets; <6 repetitions), and longer rest intervals (3-5 minutes). My colleagues and I have recently published a series of papers comparing hypertrophy- and strengthstyle resistance training. We have investigated hormonal, immune, and


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metabolic responses; intramuscular anabolic signaling; muscle growth, strength, and power; and muscle activation during these two common styles of weight training. Most recently, our work published in Muscle & Nerve 1 investigated the electromyographical (EMG) activation of the muscle during resistance exercise at 70% vs. 90% 1RM. Our findings indicated that across a set to repetition failure, 90% 1RM produced greater muscle activation during the leg press exercise; however, similar peak EMG was observed during the final common repetitions of each set. These findings provide support to our acute and chronic studies, which have shown that emphasis on either training volume or intensity may be effective for maximizing muscular hypertrophy when utilizing relatively heavy loads. In our acute studies published in European Journal of Applied Physiology 2 and Physiological Reports,3 we showed that both hypertrophy- and strength-style resistance exercise protocols elicit similar intramuscular anabolic signaling, despite significant differences in markers of muscle damage and the hormonal response. Subsequently, in our 8-week training study published in Physiological Reports,4 we compared a hypertrophy-style training program (70% 1RM; 4 x 10-12 repetitions; 1-minute rest intervals) and a strengthstyle training program (90% 1RM; 4 x 3-5 repetitions; 3-minute rest intervals) in resistance-trained men. Pre- and post-training assessments included lean body mass via dual energy X-ray absorptiometry; muscle crosssectional area and thickness of the vastus lateralis, rectus femoris, pectoralis major, and triceps brachii muscles via ultrasonography; and strength in the back squat and bench press exercises. After 8 weeks of training, the strength-style routine stimulated significantly greater gains in lean arm mass and bench press strength compared with the hypertrophy-style routine. However, no other differences

between protocols were noted for measures of lean body mass, muscle size, or strength. The greater gains in some measures of muscle size and strength observed after the strengthstyle routine indicate that using a greater intensity load might provide a superior stimulus for muscle hypertrophy and strength in trained men. Thus, these results provide evidence that strength development among well-trained individuals may be realized with greater intensity loads. Ultimately, the research supports the notion that maximal strength benefits are obtained from the use of heavy loads, while muscle hypertrophy can be equally achieved across a spectrum of loading ranges.5

Optimal Rest Intervals for Resistance Exercise Performance and Muscular Adaptation Among several other resistance training parameters, including intensity, volume, and frequency, interset rest interval length is an important consideration. How long should you rest in between sets when performing resistance exercise? In search of the answer, I recently conducted an extensive literature search and published a brief review in Strength and Conditioning Journal 6 to discuss the effect of interset rest interval length on resistance exercise performance, the acute hormonal and metabolic response, and training-induced muscular adaptation. Common dogma

has recommended restricting rest interval (<1.5 minute) to promote muscle growth solely based on the transient elevation in hormones and metabolic responses observed in the post-workout period. However, the majority of literature does not support the hypothesis that training for muscular hypertrophy requires shorter rest intervals than training for strength development. In fact, our review paper published in Sport Medicine 7 concluded that transient increases in the hormonal milieu after resistance exercise was not related to exercise-induced muscle hypertrophy. Several studies have shown that the number of repetitions performed during a resistance-training bout may be compromised with shorter rest intervals. During compound exercises, such as bench press or back squat, a 3- to 5-minute rest interval has been shown to produce less performance decrements when compared to a rest interval that is less than 2 minutes. Since training intensity and volume seem to be reduced proportionally as rest interval length is reduced during multi-joint resistance exercise, it appears that at least 2-3 minutes of rest between sets would provide sufficient recovery so as not to compromise total workout volume and subsequent hypertrophy and strength outcomes. For assistance or single-joint exercises, a shorter rest interval of 1-2 minutes may suffice.

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Nutritional supplementation is a multibillion-dollar industry, with more than 70% of young adults reporting the use of at least one supplement.

All things considered, rest interval recommendations depend on several factors, including training intensity, complexity of the given exercise, type of muscle contraction, activated musculature, exercise order, training status, and strength level. Therefore, it is difficult to precisely define an optimal rest interval, and it could be argued that on a global basis, it may not exist. Ultimately, several rest intervals can be implemented within a periodized training model to achieve the desired physiological adaptations. Manipulation of training variables, including rest interval, is always dependent on the specific training goals of the individual.

Nutritional Supplementation Nutritional supplementation is a multibillion-dollar industry, with more than 70% of young adults reporting the use of at least one supplement. Energy drinks and multivitamins, along with muscle building and weight loss supplements, are among the most popular supplements on the market. However, because products marketed as dietary supplements do not require preapproval from the Food and Drug Administration, there seems to be a pill, powder, or bar that claims just about every health benefit out there. It is important for consumers to understand the benefits and risks associated with dietary supplementation, and the only way to truly understand if a nutritional 32

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supplement is useful is through vigorous randomized, double-blind, placebo-controlled research. We recently tested the efficacy of several popular supplements and multiingredient products. Below are descriptions of our research and results.

Phosphatidic Acid Supplementation Phosphatidic acid has shown to be a key player in stimulating muscle protein synthesis following exercise by serving as an intracellular lipid second messenger, which mediates protein signaling activity. Therefore, researchers have questioned if dietary supplementation of phosphatidic acid can further increase muscle gains. Given that the preliminary research on this ingredient has yielded inconclusive evidence, we set out to determine the effects of phosphatidic acid supplementation on muscle thickness and strength in resistancetrained men. The purpose of this study 8 was to investigate the effects of phosphatidic acid supplementation on muscle thickness and strength following an 8-week, supervised resistancetraining program. Fifteen resistancetrained men followed an 8-week, supervised resistance-training program and were randomly assigned to a group that consumed either 750 mg of phosphatidic acid or a placebo. Pre- and post-testing included muscle thickness of the rectus femoris, vastus lateralis, biceps brachii, and triceps brachii muscles via ultrasonography, along with strength assessment of the squat, deadlift, and bench press exercises. All participants experienced significant improvements in each measure of muscle thickness and strength; however, the phosphatidic acid supplementation did not further enhance traininginduced muscular adaptations. In conclusion, supplementation of 750 mg phosphatidic for 8 weeks in conjunction with a supervised resistance-training program did not have a differential effect compared to a placebo on changes in muscle thickness or strength.

HMB Supplementation Recovery from high-intensity exercise is vital for overcoming fatigue and building muscle. Ă&#x;-Hydroxy-Ă&#x;methylbutyrate (HMB) supplementation has shown to improve recovery by increasing muscle protein synthesis and decreasing muscle protein breakdown. HMB is a metabolite of the amino acid leucine, meaning that when we eat protein, a small percentage gets converted to HMB. To get an effective dose of HMB (~3 grams) from your diet, you would need to eat 60 grams of leucine, which would be about 600 grams of high-quality protein. Thus, supplementation is the more practical option. Calcium-HMB has been the most popular form, but recently, HMBfree acid has been shown to have a greater absorption rate and bioavailability, which has been suggested to provide a superior stimulus for exercise recovery. In collaboration with colleagues in Brazil, I published a systematic review in Nutrition Research9 examining the effect of HMB-free acid supplementation on recovery and muscle adaptations after resistance training. When combined with resistance training, HMB-free acid supplementation may attenuate markers of muscle damage, augment acute immune and endocrine responses, and enhance training-induced muscle mass and strength. HMB-free acid supplementation may also improve markers of aerobic fitness when combined with high-intensity interval training. Nevertheless, more studies are needed to determine the overall efficacy of HMB-free acid supplementation as a nutritional supplement. Citrulline Malate Supplementation Pre-workout nutritional supplementation has become increasingly popular among recreational and competitive athletic populations as a means of boosting exercise performance. Recently, citrulline malate has garnered much attention for its potential to increase


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nitric oxide (NO) production, which may enhance resistance exercise performance. The potential beneficial effects of citrulline malate may be attributed to the synergistic combination of both L-citrulline and malate at the cellular metabolic level. L-citrulline is a nonessential amino acid that functions as a precursor to L-arginine, which synthesizes NO when catalyzed by the enzyme nitric oxide synthase. Malate is an intermediate of the tricarboxylic acid cycle, and supplementation may augment energy production and increase the rate of adenosine triphosphate (ATP) production. My colleagues and I recently published a study in the Journal of Strength and Conditioning Research10 investigating the effect of citrulline malate supplementation on upper-body resistance exercise performance. Twelve recreationally resistance-trained men underwent two testing sessions administered in a randomized, doubleblind fashion. During each visit, participants were provided with either 8 grams of citrulline malate or a placebo 40 minutes prior to initiating a barbell bench press resistance exercise protocol consisting of 5 sets of 15 repetitions at 75% 1RM with 2-minute rest intervals. The results showed that supplementation with 8 grams of citrulline malate did not increase exercise performance, augment the muscle swelling response to training, or alter subjective measures of focus, energy, and fatigue in recreationally resistance-trained men. Although preliminary studies have reported small, but significant, increases in resistance

exercise performance following citrulline malate supplementation, our study did not support this notion. Future research is necessary to further evaluate the acute and chronic effects of citrulline malate supplementation on resistance training outcomes.

Endnotes: 1 Gonzalez,

A. M. (2016). Acute anabolic response and muscular adaptation after hypertrophy-style and strength-style resistance exercise. The Journal of Strength & Conditioning Research, 30, 2959-2964. 2 Gonzalez, A. M. (2016). Effect of interset rest interval length on resistance exercise performance and muscular adaptation. Strength & Conditioning Journal, 38, 65-68. 3  Gonzalez, A. M., Ghigiarelli, J. J., Sell, K. M., Shone, E. W., Kelly, C. F., & Mangine, G. T. (2017). Muscle activation during resistance exercise at 70% and 90% 1-repetition maximum in resistance trained men. Muscle & Nerve, 56, 505-509. 4  Gonzalez, A. M., Hoffman, J. R., Stout, J. R., Fukuda, D. H., & Willoughby, D. S. (2015). Intramuscular anabolic signaling and endocrine response following resistance exercise: Implications for muscle hypertrophy. Sports Medicine, 46: 671-685. 5  Gonzalez, A. M., Hoffman, J. R., Townsend, J. R., Jajtner, A. R., Boone, C. H., Beyer, K. S., Baker, K. M., Wells, A. J., Mangine, G. T., & Robinson, E. H. (2015). Intramuscular anabolic signaling and endocrine response following high volume and high intensity resistance exercise protocols in trained men. Physiological Reports, 3, e12466.

6  Gonzalez,

A. M., Hoffman, J. R., Townsend, J. R., Jajtner, A. R., Boone, C. H., Beyer, K. S., Baker, K. M., Wells, A.J., Mangine, G. T., & Robinson, E. H. (2016). Intramuscular MAPK signaling following high volume and high intensity resistance exercise protocols in trained men. European Journal of Applied Physiology, 116, 1663-1670. 7  Gonzalez, A. M., Sell, K. M., Ghigiarelli, J. J., Kelly, C. F., Shone, E. W., Accetta, M. R., Baum, J. B., & Mangine, G. T. (2017). Effects of phosphatidic acid supplementation on muscle thickness and strength in resistance-trained men. Applied Physiology, Nutrition, and Metabolism, 42, 443-448. 8  Gonzalez, A. M., Spitz, R. W., Ghigiarelli, J. J., Sell, K. M., & Mangine, G. T. (2017, e-published ahead of print). Acute effect of citrulline malate supplementation on upper-body resistance exercise performance in recreationally resistance-trained men. Journal of Strength and Conditioning Research. 9  Mangine, G. T., Hoffman, J. R., Gonzalez, A. M., Townsend, J. R., Wells, A. J., Jajtner, A. R., Beyer, K. S., Boone, C. H., Miramonti, A. A., & Wang, R. (2015). The effect of training volume and intensity on improvements in muscular strength and size in resistance trained men. Physiological Reports, 3, e12472. 10 Silva, V. R., Belozo, F. L., Micheletti, T. O., Conrado, M., Stout, J. R., Pimentel, G.D., & Gonzalez, A. M. (2017). ß-Hydroxy-ß-methylbutyrate free acid supplementation may improve recovery and muscle adaptations after resistance training: A systematic review. Nutrition Research, 45, 1-9.

Adam M. Gonzalez, PhD, NSCA-CSCS, CISSN, is an assistant professor in the Department of Health Professions in the School of Health Professions and Human Services at Hofstra University. He holds a PhD in exercise physiology from the University of Central Florida, where he spent years working in a human performance laboratory researching sports science, exercise physiology, and nutritional supplementation. He earned a bachelor’s degree in health and exercise science and master’s in health science education at The College of New Jersey. Dr. Gonzalez has authored or co-authored over 65 scientific articles in some of the top-tiered journals of applied physiology and sports nutrition. His primary research interests include exercise and nutritional strategies to optimize body composition, maximize health and performance, and enhance adaptations to resistance exercise.

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Exploring Social Justice in Physical Education Teacher Education Programs Sharon Phillips, PhD, Assistant Professor of Health Professions, Hofstra University Community Health and Health Science Programs Introduction Changes in politics, culture, and economics are roaring ahead in our present day. These changes have a significant influence on our education system, both here on Long Island and around the world. These shifts present new challenges to issues of social justice. Teacher educators and/or researchers have started to bring attention to the intensification of diversity that is now occurring both in and out of our schools. Unfortunately, education systems tend to grant privileges to a few students while marginalizing many others because of their social class, race, disability, and gender/sex. Magnifying that marginalization are powerful pedagogical outlets like popular culture and social media. Physical Education Teacher Education (PETE) programs, both in 34

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the United States of America (US) and abroad, have responded and are working to prepare pre-service teachers (PSTs) to encounter diverse students in the gymnasium. Oftentimes PETE programs focus on sociocultural issues in some form. It could materialize as a field experience or “stand-alone” course, or as part of their overall mission statement. This is likely to be, partly, in response to professional standards and the need to meet accreditation requirements. There is a set of literature that pushes for PETE students to develop a critical consciousness, appreciate multiple perspectives, and engage in actions to enhance social justice (Hill et al., in press; Tinning, 2016). Researchers have followed suit and looked at the effectiveness of teaching sociocultural issues to PSTs,

and the findings are quite mixed. Some researchers have suggested that PSTs are unaffected by courses addressing issues such as cultural diversity (Curtner-Smith, 2007; Devís-Devís & Sparkes, 1999; Evans & Penney, 2008; Mordal-Moen & Green, 2012), while other education experts have noted that a more individual approach to these issues – approaches that examine personal histories in relation to beliefs – results in change toward a higher level of acceptance (Cochran-Smith, 1995). Whatever way teacher educators in PETE programs have addressed these issues, as I have experienced, addressing sociocultural issues with PSTs can be challenging.

Purpose of the Research My colleagues and I embarked upon an in-depth exploration of PETE programs to see if social justice is


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being taught at universities and colleges around the world. How do faculty explicitly teach PSTs about social justice within their program and classes, if they do indeed teach about these issues. Additionally, we wanted to investigate faculty perceptions of social justice. How do faculty define the term “social justice,” and what are their beliefs about social justice. While there is consensus on the importance of teaching social justice (Bialystok, 2014), the variation in definition is a potential issue (Randall & Robinson, 2016). Our goal was to help shed light on what is or is not happening in PETE programs globally regarding social justice.

A Team Effort Before going any further, it is imperative to give credit where credit is due. This study was a team effort with several folks from around the globe. Dr. Jennifer Walton-Fissette from Kent State University started work on this topic and pulled together an extraordinary team. Also representing America was Dr. Sue Sutherland of The Ohio State University and Dr. Sara Flory from the University of South Florida. From New Zealand (NZ)/ Aotearoa (the Miori, the indigenous people of NZ, refer to the country as Aotearoa) were Drs. Rod Philpot and Alan Ovens from the University of Auckland, and from across the pond in the United Kingdom (UK) were Drs. Joanne Hill and Michelle Flemons from the University of Bedfordshire. It has been an incredible experience to work internationally on this project, and I am thankful for the opportunity. As all of us want to better inform the field of PETE, we eagerly set out to collect data. The first step was to create our methodology, which included conducting a pilot study of our semistructured interview process. Once the pilot study, which included 10 participants, concluded, our study

began. Over 70 PETE professors from seven countries around the world participated in the interview process and submitted accompanying documents such as syllabi and plans of study. We analyzed the data and learned we had an incredibly rich database of information. Seeking out opportunities for the dissemination of our research, we first organized the data into potential papers. While the research can lead us in endless directions, the first avenue we took brought us to writing papers that will be included in a special edition of the Journal of Physical Education and Sport Pedagogy, which is based in the UK. From there we wanted to make connections with teacher educators at the local, state, national, and international levels. There have been a number of presentations given globally at all levels, and we look forward to two symposia coming up in 2018 at the SHAPE America National Convention and the International Association for Higher Education in Physical Education. The remainder of this article will discuss the findings of one of our papers, which looked at conceptualizing social justice in physical education pedagogy.

The Hidden Curriculum An important concept that guides this research is the idea of a hidden curriculum (Bain, 1990). The hidden curriculum has existed in schools throughout the world in all areas, including physical education. The term “hidden curriculum” came to fruition in the early 1970s and can be seen often in educational research and literature. The hidden curriculum describes “what is taught to students by the institutional regularities, by the routines and rituals of teacher/student lives” (Weis, 1982, p. 3). In working toward uncovering the hidden curriculum, part of the goal of our study was to begin to unpack faculty perceptions. These perceptions

In working toward uncovering the hidden curriculum, part of the goal of our study was to begin to unpack faculty perceptions.

guide social justice opinions, experiences, and behaviors. If PETE faculty are unaware of their own embodied identities, or if they struggle to deconstruct socially constructed messages that influence their social identities, it makes it far more challenging to educate PETE students about issues of social justice. It becomes impossible to revitalize the physical education social justice agenda and to create physical education teachers who can then act at the agents of social change in our schools (Hill et al., in press). One example of our participants’ awareness of their own embodied identities and what that means for their role in society was Jeff, from the UK. He shared his view of himself and his place in society. Jeff discussed how his Hofstra HORIZONS t Spring 2018

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experiences are a result of the combination of his social identities. He defines himself as a white, cisgender, straight, middle-class male. He mentioned that this has provided him with privileges and that his perspective may affect and inform his social justice teaching (Hill et al., in press).

Conceptualizing Social Justice We felt it was important to conceptualize what faculty perceive social justice to encompass. When asked to define sociocultural issues, PETE professors described them as the issues that create a need for social justice. These findings were organized into themes: (1) neoliberalist notion of individual responsibility; (2) humanist awareness of diversity; (3) critical or “post” perspectives, examining and challenging injustice, and taking action for justice; and (4) connections to social movements and national contexts. The most popular definitions of sociocultural issues included ethnicity/race/racism, gender, sexual orientation, class/ socioeconomic status, and the body (disability and/or obesity). A few professors discussed home life, religion, political participation, education access, and bigotry in general as also being sociocultural issues (Hill et al., in press). Regarding the neoliberalist notion of individual responsibility, there were 36

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participants who felt that while it was important to cover sociocultural issues, it was not paramount. These participants felt that society is fairly equal. Cliff from the United States even went as far as to say that some people are “way too sensitive.” While many did feel that it is important to “cover” sociocultural issues, they felt no need to challenge the status quo and would not feel comfortable doing so, nor did they think it would help. Yet others, in alliance with the humanist awareness of diversity, shared the thought that social justice requires the acceptance of diversity and difference, and a greater understanding of equality (Hill et al., in press). In looking at critical perspectives, we found that some participants conceptualized social justice as an analysis of structural power, taking action for democracy and equity and critical self-reflection. Each of the following quotes are from Hill et al. (in press). Russ from the United States elaborates: Understanding the different world views of different groups, for example, understanding history and current social context from the perspective of men and women, from people of different sexualities, races, ethnicities, nationalities ... social justice also has to have a big component of equity and understanding historical forms of oppression and the ways in which power has leverage by certain groups over other groups. Sarah, from New Zealand, suggested: There are power relationships everywhere ... who is advantaged, who is disadvantaged, who has a vested interest in maintaining power, who has a vested interest in trying to create change or who is marginalised. As we continued to dig deeper, we found that, for a few participants, taking

action was an explicit part of their understanding of social justice. Connor, an American living in NZ/Aotearoa, said that to him, social justice is action against injustices. He stated: I don’t know if you could technically have one definition of [social justice] but I think that working to eradicate inequality for specific areas, such as gender, race, sexuality, colonialism and things like that ... social justice education is actually trying to eradicate social inequalities. Lastly, others related to social justice by connecting to social movements and national contexts. Interestingly, some issues were manifested in specific examples of activism or rights-based movements. For example, “race lenses from different countries were mentioned as informing positions on sociocultural issues: Black Lives Matter, institutional racism and civil rights in the US; antiIslamophobia, immigrant rights and Brexit issues in the UK; and tackling socioeconomic disparities and attacks on cultural expressions for Máori and Pasifika students in NZ and for indigenous Australians” (Hill et al., in press). The conclusions from our research continue on from the conceptualization of social justice, as discussed here. The topics range, for example, from looking at how standards affect the teaching of social justice in PETE to how PETE matters in the social justice education.

Conclusion For the reader, this issue of Hofstra Horizons is dedicated to the School of Health Professions and Human Services, and I am a professor teaching in the Health Science and Community Health programs. How, then, does studying issues of social justice in PETE relate to health? The Theory of Reasoned Action suggests that if a person thinks (cognition) that something is important


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and feels (affect) that something is enjoyable, they will have a more positive attitude and are more likely to participate (behavior) (Ajzen & Fishbein, 1980). For instance, if a person feels that eating vegetables is important and enjoys doing so, they are more likely to have a positive attitude toward vegetables and to eat them. Research strongly suggests that a person’s attitude toward, and experience in, physical education class directly affects their physical activity levels outside of school; the more positive the experience in the gymnasium, the higher the likelihood of participation in physical activity outside of school (Phillips & Silverman, 2015; Solmon & Lee, 1996). These habits outside of school have been linked to activity habits into adulthood (Kohl & Hobbs, 1998; Phillips & Silverman, 2015). Therefore, students having a positive experience in physical education class – and not feeling marginalized by physical education teachers who not only embody teaching social justice but create safe spaces in class for students to flourish – creates the opportunity for the development of positive attitudes toward physical education. This positive attitude cycles into the system of having healthy physical activity habits outside of school, which then has a direct impact on personal health habits throughout life. Moreover, in looking at the larger picture of social justice, as it states in the mission statement for the Hofstra School of Health Professions and Human Services, two of the goals

are for our students to become compassionate clinicians and to advocate for underserved populations. Hopefully, our research will help create space for our students to do just that.

References

Hill, J., Philpot, R., Walton-Fisette, J. L., Sutherland, S., Flemons, M., Ovens, A., Phillips, S. R., & Flory, S. (in press). Conceptualising social justice and sociocultural issues within physical education teacher education: International perspectives. Physical Education and Sport Pedagogy.

Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall.

Kohl, H. W., & Hobbs, K. E. (1998). Development of physical activity behaviors among children and adolescents. American Academy of Pediatrics, 101, 549-554.

Bain, L. (1990). A critical analysis of the hidden curriculum. In D. Kirk & R. Tinning (Eds.), Physical education, curriculum and culture: Critical issues in the contemporary crisis (23-42). London: The Falmer Press.

Mordal-Moen , K., & Green, K. (2012). Neither shaking nor stirring: A case study of reflexivity in Norwegian physical education teacher education. Sport, Education and Society, 19(4): 415-434.

Bialystok, L. (2014). Politics without “brainwashing”: A philosophical defence of social justice education. Curriculum Inquiry, 44(3), 413-440.

Phillips, S. R. & Silverman, S. (2015). Upper elementary school student attitudes toward physical education. Journal of Teaching in Physical Education, 34, 461-473.

Cochran-Smith, M. (1995). Color blindness and basket making are not the answers: Confronting the dilemmas of race, culture and the language diversity in teacher education. American Educational Research Journal, 32, 493–522.

Randall, L., & Robinson, D. B. (2016). An introduction. In D. B. Robinson & L. Randall (Eds.). Social justice in physical education: Critical reflections and pedagogies for change (1-14). Toronto: Canadian Scholars’ Press.

Curtner-Smith, M. D. (2007). The impact of a critically oriented physical education teacher education course on preservice classroom teachers. Journal of Teaching in Physical Education, 26(1): 35-56.

Solmon, M. A., & Lee, A. M. (1996). Research on social issues in elementary school physical education. The Elementary School Journal, 103, 229-239.

Devís-Devís, J., & Sparkes, A. C. (1999). Burning the book: A biographical study of a pedagogically inspired identity crisis in physical education. European Physical Education Review, 5(2): 135-152. Evans, J., & Penney, D. (2008). Levels on the playing field: The social construction of physical “ability” in the physical education curriculum. Physical Education and Sport Pedagogy, 13(1): 31-47.

Tinning, R. (2016). Transformative pedagogies and physical education. In C. Ennis (Ed.), The Routledge handbook of physical education pedagogies (281-294). New York: Routledge. Weis, L. (1982). Schooling and the reproduction of aspects of structure. Issues in education: Schooling and the reproduction of class and gender inequalities. Occasional Paper #10, SUNY at Buffalo, 1-16.

Sharon R. Phillips, PhD, is assistant professor in the School of Health Professions and Human Services (HPHS) and teaches in the Community Health and Health Science programs. She earned a PhD and MPhil in kinesiology from Columbia University, an MA in educational administration and supervision from Kean University, and a BA in health and physical education from Rowan University. Dr. Phillips is new to HPHS, having been on the faculty at Hofstra’s School of Education for the past five years. Prior to coming to Long Island, she taught in the Sport and Leisure Studies Department at the University of Waikato in New Zealand. Her research interests focus on the experiences of children in physical activity. Outside of Hofstra, she is proud to be the founder of the Christopher and Susan Phillips Foundation and resides in New Jersey with her husband and daughter. Hofstra HORIZONS t Spring 2018

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HPHS FACULTY RESEARCH The faculty in the School of Health Professions and Human Services are actively engaged in research in many diverse. We hope you enjoyed reading this issue of Hofstra Horizons, which highlights the research of some of our newest faculty. Below are the research initiatives of other distinguished faculty in our school.

COUNSELING AND MENTAL HEALTH PROFESSIONS Joan Atwood Couple and family therapy; infidelity; military families; relationship communication issues Joan Bloomgarden Creativity in everyday activities and with all populations; play therapy; imagery and imagery scripts Deborah Elkis-Abuhoff Creative arts impact on Parkinsonâ&#x20AC;&#x2122;s disease Laurie Johnson Counseling; conflict resolution Jamie Mitus Workplace socialization regarding employees with disabilities; psychological issues of individuals with traumatic brain injury Andrea Nerlich Vocational evaluation; transition services for students with disabilities Sage Rose Positive psychology; survey design; factor analysis; motivation Dan Sciarra Racial identity; multicultural issues; white privilege; Latinos; school counseling; intensity of the high school curriculum Holly Seirup Impact of hope on academic success; transition from high school to college; mental health issues on the college campus; college persistence Genevieve Weber LGBTQ+ inclusion; substance abuse/heroin addiction

HEALTH PROFESSIONS James Battaglia Hand and upper extremity rehabilitation; orthotic fabrication; clinical reasoning; developing emotional competence in treatment Gioia Ciani Palliative care; neurorehabilitation Edward Coffield Health economics; cost-benefit analyses Jayne Ellinger Athletic training curriculum development and assessment; student success support initiatives Jamie Ghigiarelli Biomechanics; strength/conditioning for human performance; sports nutrition Martine Hackett Public health and health inequities, particularly in the American suburbs and minority communities; maternal child health; infant mortality Jessica Holzer Obesity; physical activity; ethics; community engagement in research; health disparities, maternal health Yu-Pin Hsu Low vision rehabilitation; neuro vision rehabilitation; performing arts medicine Corinne Kyriacou Health policy; integrating medical and social services for chronically ill; time banking Robert Lazow Drugs and alcohol, organizational behavior and analysis in health care Kristin LoNigro Athletic training; anatomy; clinical experience; CPR/AED/First Aid instructor Khalid Moidu Health informatics; health information systems; expert systems; analytics; HIPAA Sharon Phillips Research methods; physical education pedagogy; student attitudes and perceptions toward physical activity and physical education; social justice in PE pedagogy Maria Sanmartin Health economics; health policy; behavioral health and long-term care Anthony Santella HIV/STI/sexual health; LGBTQ+ health; oral health; correctional health Israel Schwartz Adolescent sexuality Katie Sell Exercise physiology; fitness assessment; wildland firefighter fitness assessment; student-athlete fitness

SPEECH-LANGUAGE-HEARING SCIENCES Jason Davidow Stuttering Aniruddha Deshpande Tinnitus; hyperacusis; amplification; hearing conservation Doron Milstein Diagnostic, geriatric, and rehabilitation audiology Jenny Roberts Language/literacy development; language/literacy disorders; language assessment tools; community literacy; international adoption Kathleen Scott Child language and literacy disorders, language development of children adopted internationally, assessment and evaluation of communication disorders 38

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Hofstra at a Glance LOCATION Hempstead, Long Island, 25 miles east of New York City. Telephone: 516-463-6600

Trustees of Hofstra University

CHARACTER A private, nonsectarian, coeducational university.

OFFICERS Alan J. Bernon,* Chair David S. Mack,* Vice Chair Michael Roberge,* Vice Chair Robert D. Rosenthal,* Vice Chair Martha S. Pope, Secretary Stuart Rabinowitz, President

PRESIDENT Stuart Rabinowitz, JD COLLEGES AND SCHOOLS Academic Health Sciences Center (Donald and Barbara Zucker School of Medicine at Hofstra/Northwell; Hofstra Northwell School of Graduate Nursing and Physician Assistant Studies at Hofstra University; School of Health Professions and Human Services); Frank G. Zarb School of Business; Fred DeMatteis School of Engineering and Applied Science; Hofstra College of Liberal Arts and Sciences (Peter S. Kalikow School of Government, Public Policy and International Affairs; School of Education; School of Humanities, Fine and Performing Arts; School of Natural Sciences and Mathematics); Honors College; Lawrence Herbert School of Communication; Maurice A. Deane School of Law; Hofstra University Continuing Education FACULTY There are 1,236 faculty members, of whom 493 are full-time. Ninety-one percent of full-time faculty hold the highest degree in their fields. STUDENT BODY Undergraduate enrollment of 6,861. Total University enrollment, including graduate, School of Law, and School of Medicine, is about 11,131. Undergraduate male-female ratio is 47-to-53. PROGRAM OPTIONS Bachelorâ&#x20AC;&#x2122;s degrees are offered in about 160 program options. Graduate degrees, including PhD, EdD, PsyD, AuD, JD, and MD, advanced certificates and professional diplomas, are offered in about 165 program options. THE HOFSTRA CAMPUS With 116 buildings and 244 acres, Hofstra is a member of the American Public Gardens Association. LIBRARIES The Hofstra libraries contain 1 million+ volumes and provide 24/7 online access to more than 100,000 full-text journals and 200,000 electronic books. ACCESSIBILITY Hofstra is 100 percent program accessible to persons with disabilities. JANUARY AND SUMMER SESSIONS Hofstra offers a January session and three summer sessions between May and August. Hofstra University is committed to extending equal opportunity to all qualified individuals without regard to race, color, religion, sex, sexual orientation, gender identity or expression, age, national or ethnic origin, physical or mental disability, marital or veteran status in employment and in the conduct and operation of Hofstra Universityâ&#x20AC;&#x2122;s educational programs and activities, including admissions, scholarship and loan programs, and athletic and other school-administered programs. For more information, visit hofstra.edu/eoe.

As of May 2018

MEMBERS Kenneth Brodlieb Susan Catalano Steven J. Freiberg* Arno H. Fried Martin B. Greenberg* Leo A. Guthart Peter S. Kalikow* Arthur J. Kremer Diana E. Lake* Randy Levine* Elizabeth McCaul Janis M. Meyer* John D. Miller* Marilyn B. Monter* Julio A. Portalatin* Debra A. Sandler* Thomas J. Sanzone* Donald M. Schaeffer Peter G. Schiff Michael Seiman* Leonard H. Shapiro Joseph Sparacio* George J. Tsunis Steven C. Witkoff* Frank G. Zarb*

DELEGATES Stuart L. Bass,* Speaker of the Faculty George A. Giuliani, Chair, University Senate Executive Committee William Caniano, Chair, University Senate Planning and Budget Committee Kathleen Stanley,* President, Alumni Organization Rita Cinquemani, President, Student Government Association Abby Normandin, Vice President, Student Government Association

Wilbur Breslin, Trustee Emeritus Emil V. Cianciulli,* Chair Emeritus John J. Conefry, Jr., Chair Emeritus Maurice A. Deane,* Chair Emeritus George G. Dempster,* Chair Emeritus Joseph L. Dionne,* Trustee Emeritus Lawrence Herbert,* Trustee Emeritus Florence Kaufman, Trustee Emerita Walter B. Kissinger, Trustee Emeritus Ann M. Mallouk,* Chair Emerita Norman R. Tengstrom,* Trustee Emeritus *Hofstra alumni

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