Publications

Abstract

Objective: To identify processes affecting agency for safety among perinatal nurses, physicians, and certified nurse-midwives. Design: Grounded theory, as informed by Strauss and Schatzman. Setting: Two academic perinatal units in the western United States. Participants: Purposive sample of 12 registered nurses, 5 physicians, and 2 certified nurse-midwives. Findings: Agency for safety (the willingness to take a stand on an issue of concern) fluctuated for all types of providers depending on situational context and was strongly influenced by interpersonal relationships. While physicians and certified nurse-midwives believed that they valued nurses' contributions to care, their units had deeply embedded hierarchies. Nurses were structurally excluded from important sources of information exchange and from contributing to the plan of care. Nurses'confidence was a key driver for asserting their concerns. Confidence was undermined in novel or ambiguous situations and by poor interpersonal relationships, resulting in a process of redefining the situation as a problem of self. Conclusions: Women and babies should not be dependent on the interpersonal relationships of providers for their safety. Clinicians should be aware of the complex social pressures that can affect clinical decision making. Continued research is needed to fully articulate facilitators and barriers to perinatal safety.

Abstract

The association between socioeconomic status (SES) and current regular alcohol use was examined separately for urban and rural residents of Hubei, China, using the third Chinese National Health Service Survey conducted in 2003. A probability sample of 15,609 respondents, ages 15 through 101 years, was selected from the study base. Alcohol use was a dichotomized variable (current regular users vs. others). Multivariate analyses incorporated four SES indicators: income, education, occupation, and house size. Investigation of status discrepancy indicated that income was positively associated with the likelihood of current regular alcohol use, whereas education was negatively associated. For both urban and rural residents, likelihood of current regular alcohol use was smallest for those in the highest education and lowest income category. Further research, which factors in quantity and frequency, is needed to understand how alcohol use among Chinese urban and rural populations impacts their health.

Abstract

The aims of this replication study were to determine if subgroups of oncology outpatients receiving active treatment could be identified based on their experience with the symptoms of fatigue, sleep disturbance, depression, and pain; whether patients in these subgroups differed on selected demographic, disease, and treatment characteristics; and if patients in these subgroups differed on functional status and quality of life (QOL). A convenience sample of 228 oncology outpatients was recruited from seven outpatient settings in Israel. Patients completed a demographic questionnaire, a Karnofsky Performance Status score, the Multidimensional Quality of Life Scale-Cancer, the Lee Fatigue Scale, the General Sleep Disturbance Scale, the Center for Epidemiological Studies-Depression Scale, and a numeric rating scale of worst pain intensity. Cluster analysis was used to identify the patient subgroups based on their symptom experience. Four relatively distinct patient subgroups were identified based on their experiences with the above symptoms (i.e., low levels of all four symptoms (32.9%), low levels of pain and high levels of fatigue (18.0%), high levels of pain and moderate levels of fatigue (42.5%), and high levels of all four symptoms (6.6%). No differences were found among the four subgroups on any demographic, disease, or treatment characteristics. The subgroup of patients who reported high levels of all four symptoms reported the worst functional status and poorest QOL. In conclusion, differences in the symptom experience of oncology outpatients suggest that patients may harbor different phenotypic characteristics (e.g., environmental or physiologic) or genetic determinants for experiencing symptoms that are independent of demographic, disease, and treatment characteristics.

Abstract

Objective: To explore the practice of midwifery within a busy urban tertiary hospital birth setting and to present findings on the relationships between nurses and midwives in providing maternity care. Design/Method: A focused ethnography on midwifery practice conducted over 2 years (2004-2006) in a teaching hospital serving a primarily Medicaid-eligible population in Northern California. Data were collected through participant observations and in-depth interviews with midwives (N = 11) and nurses (N = 14). Practices and relationships among the midwives and nurses were examined in an ethnographic framework through thematic analysis. Findings: Two themes described the nature of nursing-midwifery relationships: tension and teamwork. Tension existed in philosophic approaches to care, definitions of safe practice, communication, and respect. Teamwork existed when the midwives and nurses worked in partnership with the woman to develop a plan of care. Changes were brought about to improve the midwife-nurse relationship during the conduct of the study. Conclusions: Midwives and nurses experienced day-to-day challenges in providing optimal care for childbearing women. The power of effective teamwork was profound, as was the tension when communication broke down. Failure to include nurses resulted in impaired translation of evidence into practice. All stakeholders in birth practices and policy development must be involved in future research in order to develop effective maternity care models.

Abstract

Fatigue is the most common and distressing symptom reported by patients undergoing radiation therapy (RT). However, limited information is available on the trajectories of fatigue, as well as on the predictors of interindividual variability in fatigue. This study evaluated a sample of patients who underwent RT for prostate cancer to examine how ratings of evening and morning fatigue changed from the time of simulation to four months after the completion of RT and to investigate whether specific patient, disease, and symptom characteristics predicted the initial levels of fatigue and/or characteristics of the trajectories of evening and morning fatigue. Using hierarchical linear modeling, a large amount of interindividual variability was demonstrated in the trajectories of evening and morning fatigue. Findings from this study suggest that younger men with a higher level of fatigue at the time of the simulation visit were at increased risk for higher levels of evening and morning fatigue over the course of RT. In addition, the level of morning fatigue over the course of RT appears to depend on the patient's level of depression at the time of the simulation visit. In future studies, the use of hierarchical linear modeling as an analytic tool will assist in the identification of patients who are most at risk for prolonged fatigue trajectories. This type of analysis may lead to the identification of subgroups of patients who are at higher risk for negative outcomes and who require different types of interventions for the fatigue associated with RT.

Abstract

This item contains this abstract: Moving patients from one care setting to another.

Abstract

Background: Heart failure (HF) self-care is extremely challenging and few people master it. Self-care was defined as an active, cognitive process in which persons engage for the purpose of maintaining their health (maintenance) and managing symptoms (management). Aim: To examine the contribution of attitudes, self-efficacy, and cognition to HF self-care management. Methods: In this mixed methods study, 41 individuals (63.4% male, 68.3% Caucasian, mean age 49.17 (10.51) years, 58.5% NYHA III, median ejection fraction 30%) were interviewed and completed instruments on HF self-care, cognition, and physical functioning. Content analysis of narrative data revealed themes of self-care management practices, attitudes and self-efficacy towards self-care. Non-parametric tests assessed differences based on the types identified in the content analysis. Results: A self-care typology was constructed from the data: experts, novices and inconsistent. There were statistically significant differences (p = 0.001) in self-care practices among types and variance in attitudes, self-efficacy, and cognition. Experts had experience and skill in self-care, which novices lacked, and positive attitudes and self-efficacy that aligned with their behaviors. Most patients (71%) were classified as inconsistent, a self-care type associated with impaired cognition, poor physical functioning, negative attitudes, and poor self-efficacy. Conclusions: This typology provides insight into how expertise in self-care develops and the reasons why it is not always sustained.

Abstract

Colecta-PALM is a Web-based application delivered on PDAs that provides behavioral messaging based on risk assessment responses for HIV patients. Usability testing was undertaken with 15 people living with HIV.AIDS (PWLHA) in two clinics in Lima. Sixty percent (9/15) were somewhat/very satisfied with Colecta-PALM, with usefulness rated 3.7/5. Users found the tool innovative, interesting, easy to use, educational, trustworthy, private, and non-judgmental. Colecta-PALM was well-received and easily usable by most.

Abstract

Congenital heart defects (CHDs) are the most common of all birth defects. For many newborns with a CHD, prenatal versus postnatal detection is associated with substantially decreased morbidity and mortality risks. Although technological advances in fetal echocardiography have led to an increased capacity to detect CHDs prenatally, pregnancies without an identified risk factor are not routinely screened. With the aim of identifying pregnancies at increased risk for CHDs, this study examined the relationship between CHDs and typically collected second trimester biomarker data collected on a large population-based sample of singleton pregnancies with one or more second trimester screen positive result for Down syndrome, trisomy 18 (T-18), Smith-Lemli-Opitz syndrome (SLOS), or a neural tube defect (NTD). Where possible, logistic models for cases and controls were built and potential referral models were tested among study subsamples with information on the presence or absence of CHDs reported pre- and perinatally. When considered in combination, screen positive for T-18, screen positive for SLOS, nuchal fold measurement ≥ 5 mm, and/or having an adjusted hCG multiple of the median ≥ the 95th centile detected 42.7% of all pregnancies with a CHD in the combined subsample (where co-occurrence with chromosomal defects was not considered) and detected 29.7% of all pregnancies with a CHD in the no-chromosomal defect subsample. A nuchal fold measurement ≥ 5 mm detected 18.2% of those with a CHD in the Down syndrome subsample and an adjusted hCG multiple of the median (MoM) ≤ 5th centile detected 92.9% of those with a CHD in the T-18 subsample.

Abstract

Violence against women is a major public health concern. This paper describes an educational strategy to increase nursing students' understanding of the experience of violence and to foster recognition and intervention with victims of violence. Students in an elective course were asked to critically reflect on the personal stories of victims/survivors of violence. The assignment provided four learning opportunities that include examination of societal myths on sexual victimization, understanding the lived experience of the victim, exploration of personal beliefs and values, and the relationship of the individual's experience to theoretical content of the course. Students gave permission for the use of quotes from papers to illustrate the learning opportunities.

Abstract

The complexities of managing heart failure among employees have not been studied. In this mixed methods study, the authors explored how cognition, physical functioning, attitudes, and self-efficacy influence self-care among employees with heart failure. Forty-one adults (White, 68.3%; male, 63.4%; median age, 51 years; employed, 48.8%) completed in-depth interviews and standardized instruments. Content analysis was used to derive themes from narrative accounts of self-care practices, attitudes, and self-efficacy within the context of employment. Descriptive and nonparametric statistics were used to describe the sample and generate hypotheses about relationships among the variables. Most of the employed participants (N = 13) worked full-time (65%), primarily in sedentary jobs. Cognition and physical functioning were better in those who were employed (p = .02), but self-care practices were lower (p = .03). Those who successfully managed heart failure and work described strategies to incorporate self-care into their workdays, self-efficacy in managing symptoms while at work, and favorable attitudes toward employment.

Abstract

Low serum HDL-cholesterol (HDL-C) is a major risk factor for coronary artery disease. We performed targeted genotyping of a 12.4 Mb linked region on 16q to test for association with low HDL-C by using a regional-tag SNP strategy. We identified one SNP, rs2548861, in the WW-domain-containing oxidoreductase (WWOX) gene with region-wide significance for low HDL-C in dyslipidemic families of Mexican and European descent and in low-HDL-C cases and controls of European descent (p = 6.9 × 10-7). We extended our investigation to the population level by using two independent unascertained population-based Finnish cohorts, the cross-sectional METSIM cohort of 4,463 males and the prospective Young Finns cohort of 2,265 subjects. The combined analysis provided p = 4 × 10-4 to 2 × 10-5. Importantly, in the prospective cohort, we observed a significant longitudinal association of rs2548861 with HDL-C levels obtained at four different time points over 21 years (p = 0.003), and the T risk allele explained 1.5% of the variance in HDL-C levels. The rs2548861 resides in a highly conserved region in intron 8 of WWOX. Results from our in vitro reporter assay and electrophoretic mobility-shift assay demonstrate that this region functions as a cis-regulatory element whose associated rs2548861 SNP has a specific allelic effect and that the region forms an allele-specific DNA-nuclear-factor complex. In conclusion, analyses of 9,798 subjects show significant association between HDL-C and a WWOX variant with an allele-specific cis-regulatory function.

Abstract

Objectives. We examined the mechanisms by which living in a disadvantaged minority community influences smoking and illegal cigarette sale and purchasing behaviors after a large cigarette tax increase. Methods. Data were collected from 14 focus groups (n=104) that were conducted during the spring of 2003 among Blacks aged 18 years and older living in New York City. Results. A large tax increase led to what focus group participants described as a pervasive illegal cigarette market in a low-income minority community. Perceived pro-smoking community norms, a stressful social and economic environment, and the availability of illegal cigarettes worked together to reinforce smoking and undermine cessation. Conclusions. Although interest in quitting was high, bootleggers created an environment in which reduced-price cigarettes were easier to access than cessation services. This activity continues to undermine the public health goals of the tax increase.

Abstract

Background. Internet tools, cell phones, and other information and communication technologies are being used by HIV-positive people on their own initiative. Little is known about the perceptions of HIV-positive people towards these technologies in Peru. The purpose of this paper is to report on perceptions towards use of information and communication technologies as a means to support antiretroviral medication adherence and HIV transmission risk reduction. Methods. We conducted a qualitative study (in-depth interviews) among adult people living with HIV in two community-based clinics in Peru. Results. 31 HIV-positive individuals in Lima were interviewed (n = 28 men, 3 women). People living with HIV in Peru are using tools such as cell phones, and the Internet (via E-mail, chat, list-serves) to support their HIV care and to make social and sexual connections. In general, they have positive perceptions about using the Internet, cell phones and PDAs for HIV health promotion interventions. Conclusion. Health promotion interventions using information and communication technology tools among people living with HIV in resource-constrained settings may be acceptable and feasible, and can build on existing patterns of use.

Abstract

This study examines age distribution and risk factors for the onset of severe disability among community-dwelling older adults with functional limitations. Data were obtained from the initial community-dwelling sample (n = 6,088) of the National Long-Term Care Survey in 1982 and the follow-up interviews in 1984, 1989, 1994, and 1999. Multiple proportional hazard regression was conducted using age at onset of severe disability as the dependent variable. Explanatory variables included chronic diseases and sociodemographic and personal characteristics. Of the 3,485 elders who were not severely disabled initially, 1,364 were identified as developing severe disability over time. The onset age ranged from 66 to 109 years with the peak occurring at 82 to 83 years. The predictors for earlier onset of severe disability were paralysis, arthritis, obesity, hypertension, and middle education level (Grades 9-12). These findings provide practical implications for identifying at-risk individuals and developing health behavior interventions to delay onset of severe disability.