Publications

Abstract

Background: Despite Asians being the fastest-growing ethnic group in the US, most studies have focused on Asian Americans as an aggregate racial/ethnic group. The burden of mental health problems is increasing among caregivers due to population aging, yet little is known about the distress experienced by Asian caregivers when examined by disaggregated ethnic groups. Methods: Using 2019–2020 California Health Interview Survey data, we examined disparities in psychological well-beings between non-Hispanic White and Asian American adult caregivers, with an emphasis on understudied Asian ethnic groups. Psychological distress was measured using the Kessler 6 scale, with scores ≥6 indicating mental distress and ≥13 indicating serious mental illness. Multivariable logistic regression adjusted for socio-demographics, physical health, caregiving relationship, intensity of care, and care recipients’ characteristics. Results: The study included 8,722 caregivers (mean age, 58.7 years; 61.3% women; 14.1% Asian [379 Chinese, 260 Filipino, 167 Japanese, 138 South Asian, 105 Korean, 101 Vietnamese, 78 other Asian], 85.9% White). Overall, 26.8% had mental distress, and 8.5% had serious mental illness. Compared to White caregivers, Korean American caregivers had higher odds of mental distress (Odds Ratio [OR], 2.37; 95% CI, 1.47–3.82) and serious mental illness (OR, 2.15; 95% CI, 1.17–3.92), while Chinese (OR, 0.72; 95% CI, 0.55–0.95) and Japanese (OR, 0.67; 95% CI, 0.45–0.99) American caregivers had lower odds of mental distress. Korean American caregivers had the highest prevalence of mental distress (43.1%) and serious mental illness (15.3%), compared with White and other Asian American caregivers. Conclusion: Disaggregating data reveals significant mental health disparities among ethnic subgroups of Asian American caregivers. Tailored resources should address the distinct needs of ethnic subgroups of Asian American caregivers, considering language barriers, acculturation, and cultural norms that may exacerbate psychological distress.

Abstract

AIMS: Compare racial/ethnic disparities in the prevalence of non-obese type 2 diabetes (T2D) and the proportion of non-obese individuals among T2D patients.METHODS: This cross-sectional study used ICD-9/10 codes to ascertain T2D. Participants were classified as non-obese by BMI (<25 kg/m2 for normal weight; <23 kg/m2 for Asian Americans), waist circumference (<102 cm for males, <88 cm for females), and waist-to-hip ratio (<0.9 for males, <0.85 for females). The statistical analysis used marginal standardization of predicted probabilities from multivariable logistic regression to calculate the prevalence.KEY RESULTS: Among 276,736 participants (mean age 51.7, 61.2% female), non-obese T2D prevalence varied: 6.85% (BMI), 4.17% (waist circumference), 3.63% (waist-to-hip ratio). Asian participants had the highest prevalence of normal-weight T2D (2.70% vs. 1.92% in White, OR 1.44, 95% CI: 1.22-1.69) and non-obese T2D by waist circumference (8.04% vs. 3.36%, OR 2.61, 95% CI: 2.35-2.89). Black participants had the highest prevalence using waist-to-hip ratio (5.37% vs. 2.91%, OR 1.91, 95% CI: 1.80-2.03).CONCLUSION: Asian Americans showed higher non-obese T2D prevalence by BMI and waist circumference, while Black adults had higher prevalence by waist-to-hip ratio, suggesting different fat distribution patterns.

Abstract

Background: The recent global pandemic posed extraordinary challenges for healthcare systems. Frontline healthcare workers required focused, immediate, practical, evidence-based instruction on optimal patient care modalities as knowledge evolved around disease management. Objective: This course was designed to provide knowledge to protect healthcare workers; combat disease spread; and improve patient outcomes. Methods: A team of global healthcare workers responded by rapidly creating a competency-based online course. To promote transcultural applicability, the course was developed by an international team of more than 45 educators from over 20 countries. Course delivery included a built-in language translation tool, routine updates, and several innovative course design elements. User feedback was collected to determine efficacy of course content, structure, unique delivery elements, and delivery options. Results: An initial population of online learners (n = 147) living in 23 different countries and representing 22 languages completed the course and participated in post-course surveys. An additional population of learners (n = 505) attended an in-person offering of course materials. Course participants gave positive feedback and several requested additional courses in similar formats. Conclusion: Global open access education courses may provide needed resources to empower healthcare professionals during health crises. Responsive course design can accommodate diverse learner resources and transcultural applicability.

Abstract

BACKGROUND: Advanced practice registered nurses (APRNs) are essential to care for the growing number of individuals with advanced illness given the shortage of palliative care clinicians. PROBLEM: Graduate education for specialty practice palliative APRNs lacks consistency in structure, content, and standardization of specialty palliative APRN education. APPROACH: A workgroup of expert palliative APRNs and graduate faculty conducted focused discussions and a literature review to develop consensus recommendations based on national palliative APRN competencies and aligned with the 8 core concepts of the AACN Essentials. OUTCOME: Recommendations include: (a) definition of core concepts; (b) associated skills; (c) andragogical approaches; (d) evaluation methods; and (e) references for curricular development. CONCLUSION: The Recommendations for Specialty Palliative APRN Education is a first step toward the standardization of quality advanced practice specialty palliative nursing education. These recommendations provide the foundation for a comprehensive curriculum for palliative APRNs.

Abstract

Background: Cesarean birth increases risk of maternal morbidity and mortality. Purpose: Examine the relationship between labor and delivery staffing and hospital cesarean and vaginal birth after cesarean (VBAC) rates. Methods: Survey of U.S. labor nurses in 2018 and 2019 on adherence to AWHONN nurse staffing standards with data linked to American Hospital Association Survey data, patient discharge data, and cesarean birth and VBAC rates. Findings: In total, 2,786 nurses from 193 hospitals in 23 states were included. Mean cesarean rate was 27.3% (SD 5.9, range 11.7%–47.2%); median VBAC rate 11.1% (IQR 1.78%–20.2%; range 0%–40.1%). There was relatively high adherence to staffing standards (mean, 3.12 of possible 1–4 score). After adjusting for hospital characteristics, nurse staffing was an independent predictor of hospital-level cesarean and VBAC rates (IRR 0.89, 95% CI 0.84–0.95 and IRR 1.58, 95% CI 1.25–1.99, respectively). Discussion: Better nurse staffing predicted lower cesarean birth rates and higher VBAC rates. Conclusion: Hospitals should be accountable for providing adequate nurse staffing during childbirth.

Abstract

ABSTRACT: This secondary analysis of the National Youth Risk Behavior Survey (years 2015-2019) examines associations between school-based protective factors (i.e., safe school environments and academic achievement) and HIV risk behaviors among sexually experienced adolescent gay and bisexual men ( n = 644), a population with the highest prevalence of undiagnosed HIV infections. Demographics included Hispanics/Latinos (25%, n = 158), Other race/ethnicity (14%, n = 88), and non-Hispanic Blacks/African Americans (13%, n = 81). Adjusted models showed that protective factors reduced odds for early sexual debut, multiple sexual partners, sex under the influence of drugs/alcohol, and condomless sex, with an additive effect demonstrated when two protective factors were present. Hispanics/Latinos had greater odds of reporting multiple sexual partners and HIV testing, indicating opportunities for school-based HIV prevention and further research. Our findings provide support for school-based programs that aim to improve social and structural determinants of health and ultimately reduce adolescent HIV burdens.

Abstract

Objectives: We investigated the association between maternal leukocyte telomere length (LTL) in the immediate postpartum period and moderate to late preterm birth (32– < 37 weeks) among Latinas, a population at high risk for preterm birth. Methods: Maternal LTL was measured using quantitative polymerase chain reaction at delivery in a prospective San Francisco primarily Latina birth cohort. Logistic regression models were used to investigate the association between postpartum maternal LTL and preterm birth. Maternal LTL was analyzed as a continuous predictor. Results: Out of 194 participants, 23 (11.9%) had preterm delivery. Longer postnatal maternal LTL was associated with preterm birth (crude OR 4.68; 95% confidence interval (CI) 1.07, 20.6, p = 0.039; adjusted OR 12.8, 95% CI 1.83, 99.9, p = 0.010). Age-stratified analysis showed that being under 35 years increased the effect size of the association between maternal LTL and preterm birth (adjusted OR 32.5, 95% CI 2.58, 597, p < 0.01). Conclusions for Practice: Latina mothers with moderate to late preterm infants had longer LTL in the immediate postpartum period compared to those with term infants. This association was stronger for mothers under the age of 35 years. LTL may serve as a biomarker to better understand the pathophysiology and risk of preterm birth and could inform targeted interventions for prevention and early detection. Future studies are needed to understand physiological changes in maternal LTL from the prenatal to postnatal period in relation to birth outcomes.

Abstract

Preceptors are essential in the clinical education of prelicensure registered nursing and advanced practice registered nursing students. However, there is a growing scarcity of preceptors available to provide clinical education. Additionally, preceptors have not uniformly received professional development in the practice of teaching that is essential in delivering high quality clinical education, and clinical education in nursing is an unfunded mandate. This article reviews the current state of preceptors, the importance and challenges of preceptors in clinical education, the lack of funding for clinical education by preceptors, and proposed solutions.

Abstract

This paper is an examination of the relationship between continuity of care with home health physical therapists following hospitalization and the likelihood of readmission. We conducted a retrospective cohort study. Using rehospitalization as the dependent variable, a continuity of care indicator variable was analyzed with a multivariable logistic regression. The indicator variable was created using the Bice-Boxerman Index to measure physical therapist continuity of care. The mean of the index (0.81) was used to separate between high continuity (0.81 or greater) of care and low continuity of care (lower than 0.81). The sample included 90,220 patients, with data coming from the linking of the Outcome Assessment and Information Set (OASIS) and an administrative dataset. All subjects lived in the NYC metro area. Inclusion criteria was a patient’s admission to their first home health care site following discharge occurring between 2010 and 2015, and individuals who identified as Male or Female. In comparison to low continuity of physical therapy, high continuity of physical therapy significantly decreased hospital readmissions (OR = 0.74, 95% CI 0.71-0.76, p ≤.001, AME = −4.28%). Interpersonal continuity of physical therapy care has been identified as a key factor in decreasing readmissions from the home care setting. The research suggests an increased emphasis in preserving physical therapist continuity following hospitalization should be explored, with the potential to reduce hospital readmissions.

Abstract

This paper is an examination of the relationship between continuity of care with home health physical therapists following hospitalization and the likelihood of readmission. We conducted a retrospective cohort study. Using rehospitalization as the dependent variable, a continuity of care indicator variable was analyzed with a multivariable logistic regression. The indicator variable was created using the Bice-Boxerman Index to measure physical therapist continuity of care. The mean of the index (0.81) was used to separate between high continuity (0.81 or greater) of care and low continuity of care (lower than 0.81). The sample included 90,220 patients, with data coming from the linking of the Outcome Assessment and Information Set (OASIS) and an administrative dataset. All subjects lived in the NYC metro area. Inclusion criteria was a patient’s admission to their first home health care site following discharge occurring between 2010 and 2015, and individuals who identified as Male or Female. In comparison to low continuity of physical therapy, high continuity of physical therapy significantly decreased hospital readmissions (OR = 0.74, 95% CI 0.71-0.76, p ≤.001, AME = −4.28%). Interpersonal continuity of physical therapy care has been identified as a key factor in decreasing readmissions from the home care setting. The research suggests an increased emphasis in preserving physical therapist continuity following hospitalization should be explored, with the potential to reduce hospital readmissions.

Abstract

Introduction: Although prostate magnetic resonance imaging (MRI) is commonly used in the diagnosis, staging and active surveillance of prostate cancer, little is known about patient perspectives on MRI. Methods: We performed a qualitative study consisting of in-depth, semi-structured interviews of patients with low- and intermediate-risk prostate cancer managed with active surveillance. Interviews focused on experiences with and knowledge of prostate MRI and MRI-ultrasound fusion biopsy during active surveillance. We purposively sampled patients who received prostate MRI as part of their clinical care, conducted interviews until reaching thematic saturation and performed conventional content analysis to analyse data. Results: Twenty patients aged 51–79 years (mean = 68 years) participated in the study. At diagnosis, 17 (85%) had a Gleason grade group 1, and three (15%) had a grade group 2 tumour. Overall, participants viewed prostate MRI as a valuable tool that accurately localizes and monitors prostate cancer over time, and they considered prostate MRI central to active surveillance monitoring. We identified five thematic categories related to MRI use: (1) the experiential aspects of undergoing an MRI scan; (2) the experience of visualizing one's own prostate and prostate cancer; (3) adequacy of provider explanations of MRI results; (4) confidence in prostate MRI in decision-making; and (5) the role of prostate MRI in longitudinal follow-up, including an interest in using MRI to modify the timing of, or replace, prostate biopsy. Conclusion: Patients value prostate MRI as a tool that enhances their confidence in the initial diagnosis and monitoring of prostate cancer. This work can inform future studies to optimize patient experience, education and counselling during active surveillance for prostate cancer.

Abstract

Foreign-born (first-generation) South Asians face a growing diet-related chronic disease burden. Little is known about whether the adult US-born (second-generation) children of South Asian immigrants can provide unique insights as changemakers in their parents’ dietary behaviors. This study aims to assess how second-generation South Asians describe and influence the dietary behaviors of their parents. Between October and November 2020, 32 second-generation South Asians [mean age 22.4 (SD 2.9), 53% female] participated in online interviews centered around factors involved in their (and their parents) eating behaviors. Thematic analysis revealed three types of parental dietary drivers (socioecological factors that impact the dietary choices of parents): goal-oriented (i.e., parents’ dietary intentionality), capacity-related (e.g., environmental barriers) and sociocultural (cultural familiarity, religion and traditions). Participants described three major mechanisms of influence: recommending new foods, cooking for parents, and bringing new foods home. These influences primarily occurred in the household and often involved participants leveraging their own nutritional knowledge and preferences to expand dietary diversity and healthier behaviors among their parents. Evidence suggests that second-generation South Asians may act as powerful agents of dietary change within their households and can provide novel insights to help address and overcome sociocultural, linguistic, and other structural barriers to better understanding and intervening in the health of the South Asian community.

Abstract

Context: Despite efforts to enhance equity, disparities in early palliative care (PC) access for historically minoritized patients with advanced breast cancer (ABC) persist. Insight into patient and clinician perspectives are needed to inform future models aimed at improving equity in PC access and outcomes. Objectives: To explore qualitative barriers and facilitators to early PC access in an urban setting with Black and Latina women with ABC. Methods: In this qualitative descriptive study, we conducted one-on-one interviews with Black and Latina women with ABC (N = 20) and interdisciplinary clinicians (N = 20) between February 2022 and February 2023. Participants were recruited from urban academic and community cancer clinics. Transcripts were analyzed using an inductive coding and thematic analysis approach. Results: Barriers identified by both patients and clinicians included lack of communication between oncology, PC, and primary care teams, limited understanding of PC among patients and non-PC clinicians, language and health literacy-related communication challenges, and racism and marginalization, including implicit bias and lack of diverse racial/ethnic representation in the supportive care workforce. Facilitators identified by both patients and clinicians included patient-to-patient referrals, support groups breaking cultural stigma on topics including self-advocacy and PC, referrals from trusted providers, and community organizations’ abilities to overcome challenges related to social determinants of health, most specifically logistical and financial support. Conclusions: Patients and clinicians reported similar barriers and facilitators to PC access, most commonly through the lens of care coordination and communication. These findings will inform future adaptation of a culturally and linguistically care model to improve access to early PC services for Black and Latina women with ABC.

Abstract

Objectives: This qualitative study explored experiences of 15 women in New York City who suffered physical, emotional, and socioeconomic consequences of severe maternal morbidity (SMM). This study aimed to increase our understanding of additional burdens these mothers faced during the postpartum period. Methods: Qualitative analysis of in-depth interviews (n = 15) with women who had given birth in NYC hospitals and experienced SMM. We focused on how experiences of SMM impacted postpartum recoveries. Grounded theory methodology informed analysis of participants’ one-on-one interviews. To understand the comprehensive experience of postpartum recovery after SMM, we drew on theories about social stigma, reproductive equity, and quality of care to shape constant-comparative analysis and data interpretation. Findings: Three themes were generated from data analysis: ‘Caring for my body’ defined by challenges during physical recuperation, ‘caring for my emotions’ which highlighted navigation of mental health recovery, and ‘caring for others’ defined by care work of infants and other children. Most participants identified as Black, Latinx and/or people of color, and reported the immense impacts of SMM across aspects of their lives while receiving limited access to resources and insufficient support from family and/or healthcare providers in addressing postpartum challenges. Conclusions for Practice: Findings confirm the importance of developing a comprehensive trauma-informed approaches to postpartum care as a means of addressing SMM consequences.

Abstract

Objective: To describe “What Matters” to older adults seeking emergency department (ED) care and to identify patient characteristics associated with meeting desired outcomes. Background: As part of the 4Ms framework, identifying “What Matters” has been captured across healthcare settings, yet limited attention has been directed to older adults in the ED. Methods: We performed a secondary analysis of a multicenter prospective observational study. The study enrolled 1013 patients aged 65 and older during an ED encounter and performed 90-day follow-up interviews. The primary outcome was the quantification of “What Matters” (concerns and desired outcomes) to older adults during emergency care. As secondary outcomes, we assessed concerns at day 90, if desired outcomes were met at follow-up, and patient characteristics associated with outcome achievement by estimating multivariable logistic regression models. Results: Older adults reported specific concerns at the time of the ED visit including: (1) symptom identification and/or persistence (31.4%), (2) ability to take care of oneself (19.4%), and (3) end-of-life (17.8%). Desired outcomes expressed by participants included: (1) getting well and symptom resolution (72.0%), (2) obtaining a diagnosis (25.7%), and (3) functional independence (19.5%). At day 90 follow-up, concerns remained similar to the initial ED visit, and the majority of participants (66.2%) achieved their desired outcome. Frailty (adjusted odds ratio = 0.56, 95% CI: 0.38–0.83, P < 0.01) was associated with older adults not meeting their desired outcomes. Conclusions: Older adults identified a variety of concerns during emergency care, and two-thirds reported that desired outcomes were met at longitudinal day 90 follow-up.

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Purpose: Utilizing a participatory approach, we sought to co-design a 12-week Green Activity Program (GAP) with Hispanic/Latino individuals living with memory challenges and their care partners, local outdoor professionals, and healthcare providers. Methods: Participants were recruited via convenience and snowball sampling in the Bronx, New York with Hispanic/Latino persons living with memory challenges and care partners, outdoor activity professionals, and interdisciplinary healthcare providers/dementia experts. Co-design occurred iteratively with 5 focus groups and 4 individual interviews lasting 30–90 min and focused on program and research design. Sessions were recorded and transcribed. Utilizing directed content analysis data was coded using a priori codes program design and research design. Results: 21 participants completed co-design activities: (n = 8 outdoor activity professionals, n = 6 Hispanic/Latino persons living with memory challenges and care partners, and n = 7 interdisciplinary healthcare providers/dementia experts). Participant preferences for program design were captured by subcodes session duration (30–90 min), frequency (4–8 sessions), and delivery modes (in-person and phone). Participants' preferred nature activities included group exercise and outdoor crafts [crocheting], outcomes of social participation, connectedness to nature, decreased loneliness, and stewardship were identified. Preferred language for recruiting and describing the program were “memory challenges,” “Hispanic/Latino,” and “wellbeing.” Referral pathways were identified including community-based organizations and primary care. Conclusion: Co-design was a successful form of engagement for people living with memory challenges that enabled participants to help design key elements of the GAP and research design. Our processes, findings, and recommendations for tailoring co-design to engage Hispanic/Latino people living with memory challenges can inform the development of other programs for this population.

Abstract

Objectives: As symptoms emerge and worsen in people living with dementia, their spouses can benefit from behavioral interventions to support their adjustment as a care partner. The Wish Outcome Obstacle Plan (WOOP) intervention improves the well-being of spouses of people living with dementia early in the disease course, but intervention mechanisms and opportunities for improvement are unclear. The present study gave voice to spouses who participated in a trial of WOOP, describing how WOOP was incorporated into their lives and how it could be improved for future implementation. Method: For this qualitative study, we conducted longitudinal semi-structured interviews among 21 spouses of people living with dementia (three interviews over three months; 63 interviews total). Codebook thematic analysis was performed. Results: Three meta-themes were derived: (1) assessing baseline strengths and limitations of WOOP, (2) learning from experience, and (3) fine-tuning and sustaining WOOP. Participants described how WOOP addressed their interpersonal and emotional stressors, their responses to behaviors of the person living with dementia, and their relationship quality. Considerations for future intervention delivery (e.g., solo vs. in group settings) and instructions (e.g., encouraging writing vs. thinking through the four steps of WOOP) were identified as areas of improvement. Conclusions: WOOP was described as a practical, feasible, and desirable intervention for spouses at the early stages of their partner's dementia. Participants made WOOP easier to incorporate in their everyday lives by adapting the design into a mental exercise that they used as needed. Suggestions from participants specified how to make the everyday use of WOOP more feasible, sustainable, and applicable in a variety of contexts. Trial Registration: ClinicalTrials.gov HIC 2000021852.