Allison P Squires

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BACKGROUND: Obesity affects 36 % of the Veteran population. The Veterans Affairs (VA) Healthcare System offers an intensive weight management program called MOVE!, but only approximately 10 % of eligible patients attend even one session. Since veterans see their PCPs 3.6 times per year, developing primary carebased weight management interventions may improve MOVE! attendance. To inform intervention development, we conducted a single-center qualitative study to explore unique VA patient 1) attitudes, barriers, and facilitators to healthy behavior change; 2) uses and understandings of goal-setting; and 3) weight management-related experiences with health care providers, technology, and MOVE!. METHODS: We sent recruitment letters to overweight and obese patients at the New York Harbor VA. Eligibility criteria included Veterans aged 18-75, having a BMI > 30 or > 25 with at least one co-morbidity, and self-reported ability to read and participate in focus groups. We organized patients into focus groups of 6-11 participants, grouped by gender and MOVE! attendance. The interview guide was informed by the Theory of Planned Behavior (TPB). Sessions were audio-recorded, contextually supplemented with field notes, and transcribed by a professional company. Initial codes were determined based on session recollection and field notes. Using an iterative coding approach, two coders separately reviewed segmented transcripts, modified the codebook as new codes emerged, and met to negotiate codes. We utilized NVivo software to assist with coding and subsequent thematic analysis. RESULTS: We screened 161 patients for eligibility, 77 were scheduled to attend, and 54 attended one of six focus groups (two female and four male). Participants were predominantly male (63 %), African-American (46 %) or White/Caucasian (32 %), college-educated or higher (74 %), and reported having attended MOVE! (61 %). We found that although we attempted to stratify focus groups by MOVE! attendance, the VA electronic health record did not accurately capture this information, and some study participants were confused or unaware of their attendance. Thematic analyses revealed how military service informed participants' attitudes, social norms, and perceived behavioral control with regards to weight management. Participants described how the structured environment and strict standards of the military motivated them to maintain weight control while enlisted, but that lack of autonomy was a barrier to learning how to manage their health when they left service. The military also influenced their perceived need for more personalized and tailored health counseling. Physical activity was largely considered the predominant method to lose weight, and participants felt the MOVE! program lacked a physical activity-related component. While participants acknowledged the potential usefulness of technology to help identify and achieve weight management goals, they expressed the need to have a knowledgeable person (i.e. health coach, PCP, dietician, etc.) provide guidance and support. CONCLUSIONS: This study revealed how military service may influence veterans' intentions to lose weight and their weight management-related experiences. This will guide the development of a computer-assisted intervention to treat obesity within primary care and improve access and quality of weight management services. The implications from this study may be limited as it was conducted at a single site within a specific and a mostly self-selected patient population.

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This review seeks to understand the role of remittances in international nurse migration within the context of three theories of international migration: equilibrium approaches, social networks, and globalization. To analyze the phenomenon, an integrative review of the literature was conducted. Search terms sought articles discussing, either directly or indirectly, remittances and international nurse migration. The initial search returned 369 articles, and further screening decreased the total to 65. Full text screening reduced the final number for the analysis to 48. A directed content analysis structured the analytic approach by examining how authors discussed remittances in the content and context of the paper. The final analysis showed the majority of papers were policy analyses (five); opinion papers, reviews, or editori-als that indirectly discussed remittances (27); or were qualitative and quantitative studies (16), either with primary data collection (14) or secondary data analyses (two). Overall, a nurse's individual motivation for sending remittances home stemmed from familial factors but was never a primary driver of migration. Domestic labor market factors were more likely to drive nurses to migrate. The nurse's country of origin also was a factor in the remittance dynamic. The identity of the author of the paper played a role in how they discussed remittances in the context of international nurse migration. The three theories of migration helped explain vari-ous aspects of the role of remittances in international nursing migration. While the phenom-enon has changed since the 2008 global economic crisis and the passing of the World Health Organization's Global Code of Practice on the International Recruitment of Health Personnel in 2010, future research around the role of remittances needs to consider the confluence of gender, social, political, labor market, and economic dynamics, and not just view the phenomenon from an individual lens.

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Background: Obesity disproportionately affects Latinas living in the United States, and cultural food patterns contribute to this health concern. Objective: The aim of this study was to synthesize the qualitative results of research regarding Latina food patterns in order to (a) identify common patterns across Latino culture and within Latino subcultures and (b) inform future research by determining gaps in the literature. Methods: A systematic search of three databases produced 13 studies (15 manuscripts) that met the inclusion criteria for review. The Critical Appraisal Skills Program tool and the recommendations of Squires for evaluating translation methods in qualitative research were applied to appraise study quality. Authors coded through directed content analysis and an adaptation of the Joanna Briggs Institute Qualitative Assessment and Review Instrument coding template to extract themes. Coding focused on food patterns, obesity, population breakdown, immigration, acculturation, and barriers and facilitators to healthy eating. Other themes and categories emerged from this process to complement this approach. Results: Major findings included the following: (a) Immigration driven changes in scheduling, food choice, socioeconomic status, and family dynamics shape the complex psychology behind healthy food choices for Latina women; (b) in Latina populations, barriers and facilitators to healthy lifestyle choices around food are complex; and (c) there is a clear need to differentiate Latino populations by country of origin in future qualitative studies on eating behavior. Discussion: Healthcare providers need to recognize the complex influences behind eating behaviors among immigrant Latinas in order to design effective behavior change and goal-setting programs to support healthy lifestyles.

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No study has systematically examined how researchers address cross-cultural adaptation of burnout. We conducted an integrative review to examine how researchers had adapted the instruments to the different contexts. We reviewed the Content Validity Indexing scores for the Maslach Burnout Inventory-Human Services Survey from the 12-country comparative nursing workforce study, RN4CAST. In the integrative review, multiple issues related to translation were found in existing studies. In the cross-cultural instrument analysis, 7 out of 22 items on the instrument received an extremely low kappa score. Investigators may need to employ more rigorous cross-cultural adaptation methods when attempting to measure burnout.

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