Publications

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Background: Health equity is essential for improving the well-being of all individuals and groups, and research remains a critical element for understanding barriers to health equity. While considering how to best support research that acknowledges current health challenges, it is crucial to understand the role of social justice frameworks within health equity research and the contributions of minoritized researchers. Additionally, there should be an increased understanding of the influence of social determinants of health on biological mechanisms. Purpose: Biological health equity research seeks to understand and address health disparities among historically excluded populations. Discussion: While there are examples of studies in this area led by minoritized researchers, some individuals and groups remain understudied due to underfunding. Research within minoritized populations must be prioritized to authentically achieve health equity. Furthermore, there should be increased funding from National Institutes of Health to support minoritized researchers working in this area.

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It is often said that modern-day nursing and midwifery was founded on the spirit of activism. Yet, historically, the link between nursing and activism has been inconsistent. Nursing Now USA was created in response to a global campaign launched in 2020 by the World Health Organization to mark the Year of the Nurse and Midwife. A goal of this initiative is education about how contemporary nurses serve as leaders in healthcare in the United States. This article describes the methods and results of a scoping review that sought to explore the current state of the science, key concepts, and operationalization of activism in nursing. The general consensus in the literature is that the profession of nursing has deep roots in activism, but a lack of a clear definition of activism and operationalization in policy, practice, research, and academic settings likely limits active engagement by many nurses. The current state of nurse activism is more subtle, often unseen, and non-confrontational compared to the participation and contribution of nurses from the 1900s to the 1980s. We identified barriers and facilitators to activism in nursing and our discussion includes implications for nursing practice, education, and leadership.

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Background: In the US, sexual and gender minority (SGM) individuals continue to experience health inequities, and nursing curricula content and nursing faculty with SGM health expertise in the US remain limited. Addressing health disparities begins with the preparation of future nurses—US nursing faculty must be supported to meet these growing needs. Purpose: To describe, appraise, and synthesize research from 2000-2020 on US nursing faculty knowledge, awareness, inclusion, and perceived importance of SGM health content. Methods: Following PRISMA 2020 guidelines, we registered a systematic review and appraisal protocol in PROSPERO, and then executed the protocol and synthesized the literature. Discussion: We found an empirical evidence base surrounding US nursing faculty and SGM health much more limited than expected. Only four cross-sectional, descriptive empirical articles fit the a priori inclusion criteria. The studies were of moderate quality at best and often relied on unvalidated or older measures. In general, the studies focused on examining characteristics of nursing programs, faculty comfort with content, faculty perceptions of content importance, and hours dedicated to content. Conclusion: Since the close of the review, new commentaries and editorials expanding the call for change in the US were published—the time for commentary has passed. It remains unclear whether US nursing faculty are adequately prepared to educate future nurses about SGM health issues—and an unprepared healthcare workforce is yet another barrier to SGM health equity. The evidence base supporting US nursing faculty development desperately needs more studies using rigorous methodologies.

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Background: Maternal mortality in the United States is a public health crisis and national emergency. Missed or delayed recognition of preventable life-threatening symptoms and untimely treatment of preventable high-risk medical conditions have been cited as key contributors to the nation’s worsening mortality rates. Effective strategies are urgently needed to address this maternal health crisis, particularly for Black birthing populations. Morbidity and Mortality Assessment: Lifting Outcomes Via Education (MAMA LOVE) is a web-based platform that focuses on the identification of maternal morbidity and mortality risk factors. Objective: The purpose of this paper is to present the conceptualization, development, heuristics, and utility evaluation of the web-based maternal mortality risk assessment and educational tool MAMA LOVE. Methods: A user-centered design approach was used to gain feedback from clinical experts and potential end users to ensure that the tool would be effective among groups most at risk for maternal morbidity and mortality. A heuristic evaluation was conducted to evaluate usability and need within the current market. Algorithms describing key clinical, mental health, and social conditions were designed using digital canvas software (Miro) and incorporated into the final wireframes of the revised prototype. The completed version of MAMA LOVE was designed in Figma and built with the SurveyJS platform. Results: The creation of the MAMA LOVE tool followed three distinct phases: (1) the content development and creation of an initial prototype; (2) the feedback gathering and usability assessment of the prototype; and (3) the design, development, and testing of the final tool. The tool determines the corresponding course of action using the algorithm developed by the authors. A total of 38 issues were found in the heuristic evaluation of the web tool’s initial prototype. Conclusions: Maternal morbidity and mortality is a public health crisis needing immediate effective interventions. In the current market, there are few digital resources available that focus specifically on the identification of dangerous symptoms and risk factors. MAMA LOVE is a tool that can address that need by increasing knowledge and providing resources and information that can be shared with health care professionals.

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This study aims to examine whether adverse childhood experiences (ACEs) are associated with oral health conditions (denture use, difficulty in chewing, and edentulism) among middle-aged and older adults in China and if gender and adulthood education moderate the associations. Data were obtained from the 2014 and 2018 surveys from the China Health and Retirement Longitudinal Study (N = 17,091) and logistic regressions were carried out. Results show that childhood hunger (OR = 1.12), loneliness (OR = 1.10) and family relations (OR = 1.07) were significantly associated with higher odds of denture use and there were significant associations between hunger (OR = 1.16) and difficulty in chewing. For the female subsample, education significantly moderated the adverse effect of childhood hunger on denture use and difficulty in chewing. Findings suggest that ACEs have long-lasting impacts on oral health conditions in later life and adulthood education might offer critical resources for females, helping them buffer the detrimental health impacts of ACEs.

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Objective: To evaluate whether sleep apnea or insomnia among pregnant people is associated with increased risk for adverse infant outcomes. Design: Retrospective cohort study Setting: California Participants: The sample included singleton live births. Sleep apnea and insomnia were defined based on ICD-9 and -10 codes. A referent group was selected using exact propensity score matching on maternal characteristics, obstetric factors, and infant factors among individuals without a sleep disorder. Measurements: Adverse infant outcomes were obtained from birth certificate, hospital discharge, and death records (eg, Apgar scores, neonatal intensive care unit (NICU) stay, infant death, long birth stay, etc.). Logistic regression was used to calculate odds of an adverse infant outcome by sleep disorder type. Results: Propensity-score matched controls were identified for 69.9% of the 3371 sleep apnea cases and 68.8% of the 3213 insomnia cases. Compared to the propensity-matched referent group, individuals with a diagnosis of sleep apnea (n = 2357) had infants who were more likely to have any adverse outcome, low 1-min Apgar scores, NICU stay, and an emergency room visit in the first year of life. Infants born to mothers with a diagnosis of insomnia (n = 2212) were at increased risk of few negative outcomes relative to the propensity matched referent group, with the exception of an emergency room visit. Conclusions: In unadjusted analyses, infants born to individuals with a diagnosis of sleep apnea or insomnia were at increased risk of several adverse outcomes. These were attenuated when using propensity score matching, suggesting these associations were driven by other comorbidities.

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Background: The objectives of this study were to describe trends in the prevalence of postpartum suicidal behaviors in California, 2013-2018, and to estimate associations between adverse perinatal outcomes and suicidal behaviors. Materials and Methods: We used data from a population-based cohort derived from all birth and fetal death certificates. Records were individually linked to maternal hospital discharge records for the years before and after delivery. We estimated the prevalence of postpartum suicidal ideation and attempt by year. Then, we estimated crude and adjusted associations between adverse perinatal outcomes and these suicidal behaviors. The sample included 2,563,288 records. Results: The prevalence of postpartum suicidal ideation and attempt increased from 2013 to 2018. People with postpartum suicidal behavior were younger, had less education, and were more likely to live in rural areas. A greater proportion of those with postpartum suicidal behavior were Black and publicly insured. Severe maternal morbidity, neonatal intensive care unit admission, and fetal death were associated with greater risk of ideation and attempt. Major structural malformation was not associated with either outcome. Conclusions: The burden of postpartum suicidal behavior has increased over time and is unequally distributed across population subgroups. Adverse perinatal outcomes may help identify individuals that could benefit from additional care during the postpartum period.

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The association between age and mental health symptoms among persons with HIV (PWH) is inconsistent, and little is known about the mediators and moderators of this association. This study aimed to examine the association between age and mental health symptoms, as well as the mediators and moderators of perceived discrimination. Data were from 1,304 PWH who completed a cross-sectional survey in five areas of China. Multiple linear regressions showed that younger age was significantly associated with more severe mental health symptoms and that perceived discrimination moderated this relationship. The Sobel test showed that perceived discrimination also mediated the association between age and mental health symptoms. Our study indicates that perceived discrimination shapes the association between age and mental health symptoms among PWH and highlights the importance of designing age-Tailored mental health intervention strategies for perceived discrimination among young PWH. Interventions addressing discrimination are necessary to help improve mental health, especially for young PWH.

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Background Low socioeconomic status (SES) is robustly associated with increased risks of morbidity and mortality. Affective reactivity to daily stressors has been proposed to be a mediator for this association. However, few longitudinal studies have empirically tested the indirect effect of SES on health through affective reactivity to daily stressors. Purpose This study aimed to test the indirect effect of SES on physical health via affective reactivity to daily stressors over a 10-year period and to explore age and sex differences in such indirect effect. Methods Data were drawn from a subsample of 1,522 middle-aged and older adults (34-83 years of age, 57.2% female, 83.5% White) from the Midlife in the United States study. SES (i.e., education, household income, indicators of financial distress) was assessed in 2004-2006. Affective reactivity to daily stressors was computed using data collected during the 8-day daily stress assessment in 2004-2009. Self-reported physical health conditions were assessed in 2004-2006 and 2013-2014. Results There was a significant indirect effect of lower SES on more physical health conditions via elevated negative affective reactivity to daily stressors among women but not men. The indirect effect of SES on physical health conditions via negative affective reactivity to daily stressors was consistent across the middle and older adulthood. Conclusions Our findings suggest that negative affective reactivity to daily stressors might be a key intermediate process contributing to persistent SES disparities in physical health, particularly among women.

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OBJECTIVE: To explore the age differences in the effects of multi-component periodontal treatments on oral and metabolic indicators among individuals with periodontitis and diabetes.DATA: Trials reporting the effects of multi-component periodontal treatments on oral and metabolic indicators among participants aged 18 and above with periodontitis and diabetes were included.SOURCES: Six databases (PubMed/Medline, Embase, CINHAL, Web of Science, Cochrane Library, and ProQuest) were searched from database inception to August 2022.STUDY SELECTION: Two reviewers selected the included studies independently. We used bivariate and multivariate meta-regression models to examine the association between age and treatment effect size. The primary outcomes were changes in probing depth (PD), clinical attachment level (CAL), and hemoglobin A1c (HbA1c).RESULTS: A total of 18,067 articles were identified in the database search. Of these, 115 trials (119 articles) met inclusion criteria. The mean age of participants was 58 years old, ranging from 35 to 73 years. The pooled evidence demonstrated that multi-component periodontal treatment significantly reduced PD (g=0.929 [0.689-1.169], I2=94.1%), CAL (g=0.879 [0.669-1.089], I2=92.1%), and HbA1c (g=0.603 [0.443-0.763], I2=87.5%). A significant decreasing trend was observed in the effect size for PD (P for trend = 0.020) and CAL (P for trend = 0.028) as age increases. Results from multivariate meta-regression showed that mean age was associated with a smaller effect size for PD (β=-0.123 [0.041], P = 0.004) and CAL (β=-0.159 [0.055], P = 0.006). Compared to their younger counterparts, the effect size for HbA1c was smaller among participants aged 55 and older (β=-0.792 [0.322], P = 0.017).CONCLUSIONS: Multi-component periodontal treatments may be more effective in younger populations in terms of effects on PD, CAL, and HbA1c.CLINICAL SIGNIFICANCE: Our study highlights the importance of early intervention and tailored treatment approaches. Clinicians should take into account the patient's age when developing periodontal treatment plans and may need to employ more aggressive or personalized strategies for older adults to achieve optimal outcomes.

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As the life expectancy and growth of the aging population increase globally, efforts to promote healthy longevity become more important. Holistic policy guidelines and actions have been designed to advocate and fortify healthy aging at multiple levels. Oral health, a fundamental contributor of overall health and well-being, forms a core part of the noncommunicable disease agenda within the sustainable development goals set by the World Health Organization. Aging significantly heightens the risk of myriad oral disorders and other noncommunicable diseases. As of 2019, oral disorders accounted for 8.9 million disability-adjusted life-years in individuals older than 60 y. In addition to the development of multidisciplinary aging-friendly policies to promote healthy aging, basic biology and translational research has been encouraged that focuses on deciphering the underlying mechanisms involved in age-related physical and cognitive decline or dysregulation of oral tissues. Given the relevance of oral health aging as a critical component of the One Health Initiative, this special issue encompasses a collection of articles dedicated to recent advances in the behavioral and social implications of age-related oral diseases and tooth loss on several aspects of the quality of life of adults as they age. Furthermore, it includes articles detailing molecular mechanisms associated with cellular aging and their implications for oral tissue health, periodontal disease severity, and the regenerative potential of stem cells.

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The COVID-19 pandemic has required close examination of workforce-related stressors that over decades have contributed to widespread burnout, negative health outcomes, including mental health outcomes, and the loss of the well-educated professionals who are the future of the nursing profession. In the United States and globally, evidence points to factors known to diminish well-being, including inequities, issues of minority status, persistent discrimination, and demanding work environments. The American Academy of Nursing (AAN), dedicated to organizational excellence, nursing leadership and evidence-based policy, develops statements reflecting its mission and those of its nursing affiliates and corporate member, The American Nurses Association. Within nursing, despite the efforts of its members toward advancement, professional fulfillment is often constrained by the systems in which nurses practice and workplace factors over which they have little control. Action by key organizations to initiate changes at systems levels in workplace safety, to increase professional mobility, and propel policies that increase access to health care resources could improve nurse well-being. This paper proposes recommendations from the AAN Expert Panels on Building Health Care System Excellence, Psychiatric Mental Health and Substance Use, and Global Health Expert Panels for the American Academy of Nursing to leverage related policy in the arenas of government and professional/healthcare organizations. Transforming health care work environments and advancing nurse well-being and equity can be accomplished through key, innovative policy changes. These will be achieved through collaboration among associations, organizations, nonprofit groups, and with the public and the media.

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Changing practice is complex and multifaceted. I discuss an evidence-based change management model that can be applied to guide clinical practice improvement projects. I use NICHE as a case example. The overall success of any change initiatives relies on creating and following an action plan to address the “what of change” and the “how of change”. The “what of change” focuses on developing tailored interventions aligned with each nursing unit or service line strengths and opportunities to improve nursing care for older adults by implementing the four components of the NICHE practice model. The “how of change” focuses on the activities to prepare the environment to implement the NICHE practice model. Activities to manage the change process include how to effectively communicate a vision for change; mobilize managers, clinical leaders, and front-line staff to support the change in nursing practice; and tracking progress towards meeting clinical improvement goals over time.

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Chinese Americans comprise the largest Asian subgroup in the U.S. Yet, little research has focused on the well-being of this population. This study aimed to (1) examine psycho-physiological health (psychological stress and fatigue) and lifestyle behaviors (sleep and physical activity) between Chinese Americans and whites, and (2) investigate whether race and lifestyle behaviors were independent predictors of psycho-physiological health. This study included 87 middle-aged healthy adults (41 Chinese Americans, 46 whites). Each participant underwent a two-night actigraphy-based sleep assessment. Chinese Americans reported higher psychological stress and fatigue, had poorer objective sleep outcomes (shorter sleep duration, lower sleep efficiency, and longer sleep onset), and engaged in lower physical activity levels than whites. Race and poor perceived sleep quality were independently associated with high psychological stress and fatigue. The findings warrant further exploration of social and cultural determinants of health in this minority group to reduce health disparities.

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Background: Negative beliefs can be a barrier to provide quality nursing care for persons living with mental health conditions. This international SP simulation study explored nursing students’ beliefs toward persons with mental health conditions in the United States (US) and Turkey before and after participating in a mental health standardized patient simulation. Methods: A quasi-experimental study design was used in two settings in two countries. Measures included a socio- demographic survey and the Beliefs toward Mental Illness scale. Results were analyzed using paired sample t-test, independent t-test, and chi-square tests. Results: Students in the US had significantly lessened negative attitudes toward persons with mental health conditions when compared to the Turkey group. Conclusion: SP simulation may offer opportunities to improve nursing students’ beliefs toward persons with mental health conditions.

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There is a clear and growing need to be able record and track the contributions of individual registered nurses (RNs) to patient care and patient care outcomes in the US and also understand the state of the nursing workforce. The National Academies of Sciences, Engineering, and Medicine report, The Future of Nursing 2020–2030: Charting a Path to Achieve Health Equity (2021), identified the need to track nurses’ collective and individual contributions to patient care outcomes. This capability depends upon the adoption of a unique nurse identifier and its implementation within electronic health records. Additionally, there is a need to understand the nature and characteristics of the overall nursing workforce including supply and demand, turnover, attrition, credentialing, and geographic areas of practice. This need for data to support workforce studies and planning is dependent upon comprehensive databases describing the nursing workforce, with unique nurse identification to support linkage across data sources. There are two existing national nurse identifiers– the National Provider Identifier and the National Council of State Boards of Nursing Identifier. This article provides an overview of these two national nurse identifiers; reviews three databases that are not nurse specific to understand lessons learned in the development of those databases; and discusses the ethical, legal, social, diversity, equity, and inclusion implications of a unique nurse identifier.

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Objective: To characterize the biochemical and demographic profiles of pregnant people with maternal immune activation (MIA) and identify the prenatal characteristics associated with neurologic morbidity in offspring. Study design: This was a retrospective cohort study of 602 mother-infant dyads with births between 2009 and 2010 in California. Multivariable logistic regression was used to build a MIA vulnerability profile including mid-pregnancy biochemical markers and maternal demographic characteristics, and its relationship with infant neurologic morbidity was examined. Results: Of the 602 mother-infant dyads, 80 mothers and 61 infants had diagnoses suggestive of MIA and neurologic morbidity, respectively. Our model, including two demographic and seven biochemical characteristics, identified mothers with MIA with good performance (AUC:0.814; 95% CI:0.7–0.8). Three demographic and five inflammatory markers together identified 80% of infants with neurological morbidity (AUC:0.802, 95% CI:0.7–0.8). Conclusion: Inflammatory environment in mothers with pre-existing risk factors like obesity, poverty, and prematurity renders offspring more susceptible to neurologic morbidities.

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Importance: Secure firearm storage may help reduce firearm injury and death. Broad implementation requires more granular assessments of firearm storage practices and greater clarity on circumstances that may prevent or promote the use of locking devices. Objective: To develop a more thorough understanding of firearm storage practices, obstacles to using locking devices, and circumstances in which firearm owners would consider locking unsecured firearms. Design, Setting, and Participants: A cross-sectional, nationally representative survey of adults residing in 5 US states who owned firearms was administered online between July 28 and August 8, 2022. Participants were recruited via probability-based sampling. Main Outcomes and Measures: Firearm storage practices were assessed via a matrix provided to participants in which firearm-locking devices were described both via text and images. Locking mechanisms (key/personal identification number [PIN]/dial vs biometric) were specified for each type of device. Obstacles to the use of locking devices and circumstances in which firearm owners would consider locking unsecured firearms were assessed via self-report items developed by the study team. Results: The final weighted sample included 2152 adult (aged ≥18 years), English-speaking firearm owners residing in the US; the sample was predominantly male (66.7%). Among the 2152 firearm owners, 58.3% (95% CI, 55.9%-60.6%) reported storing at least 1 firearm unlocked and hidden, with 17.9% (95% CI, 16.2%-19.8%) reporting storing at least 1 firearm unlocked and unhidden. Gun safes were the most frequently used device both among participants who use keyed/PIN/dial locking mechanisms (32.4%; 95% CI, 30.2%-34.7%) and those who use biometric locking mechanisms (15.6%; 95% CI, 13.9%-17.5%). Those who do not store firearms locked most frequently noted a belief that locks are unnecessary (49.3%; 95% CI, 45.5%-53.1%) and a fear that locks would prevent quick access in an emergency (44.8%; 95% CI, 41.1%-48.7%) as obstacles to lock usage. Preventing access by children was the most often reported circumstance in which firearm owners would consider locking unsecured firearms (48.5%; 95% CI, 45.6%-51.4%). Conclusions and Relevance: In this survey study of 2152 firearm owners, consistent with prior research, unsecure firearm storage was common. Firearm owners appeared to prefer gun safes relative to cable locks and trigger locks, indicating that locking device distribution programs may not match firearm owners' preferences. Broad implementation of secure firearm storage may require addressing disproportionate fears of home intruders and increasing awareness of the risks associated with household firearm access. Furthermore, implementation efforts may hinge on broader awareness of the risks of ready firearm access beyond unauthorized access by children..

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Introduction: The aim of the study was to assess factors associated with the perceived risk of developing Alzheimer's disease and related dementias (ADRD) and how the perceived risk of ADRD was related to cognitive function. Methods: We conducted a retrospective cohort study using 5 waves of data from the Health and Retirement Study (2012–2022) that included adults aged 65 years or older with no previous diagnosis of ADRD at baseline. Cognitive function was measured at baseline and over time using a summary score that included immediate/delayed word recall, serial 7′s test, objective naming test, backwards counting, recall of the current date, and naming the president/vice-president (range = 0–35). Perceived risk of developing ADRD was categorized at baseline as “definitely not” (0% probability), “unlikely” (1–49%), “uncertain” (50%), and “more than likely” (>50–100%). Additional baseline measures included participants’ sociodemographic background, psychosocial resources, health behaviors, physiological status, and healthcare utilization. Results: Of 1457 respondents (median age 74 [IQR = 69–80] and 59.8% women), individuals who perceived that they were “more than likely” to develop ADRD had more depressive symptoms and were more likely to be hospitalized in the past two years than individuals who indicated that it was “unlikely” they would develop ADRD. Alternatively, respondnets who perceived that they would "definitely not" develop ADRD were more likely to be non-Hispanic Black, less educated, and have lower income than individuals who indicated it was “unlikely” they would develop ADRD. Respondents who reported their risks of developing ADRD as “more than likely” (β = −2.10, P < 0.001) and “definitely not” (β = −1.50, P < 0.001) had the lowest levels of cognitive function; and the associations were explained in part by their socioeconomic, psychosocial, and health status. Conclusions: Perceived risk of developing ADRD is associated with cognitive function. The (dis)concordance between individuals’ perceived risk of ADRD and their cognitive function has important implications for increasing public awareness and developing interventions to prevent ADRD.

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Background: This study aimed to examine the association between tooth loss and frailty among Chinese older adults and the mediating role of dietary diversity in this association. Methods: Data from five waves of the Chinese Longitudinal Healthy Longevity Survey conducted between 2005 and 2018 were used. Path analyses were employed to assess both concurrent and cross-lagged relationships between tooth loss and frailty index while accounting for intrapersonal correlation. Furthermore, the mediation effect of dietary diversity was also examined. Results: In concurrent models, severe tooth loss was associated with frailty after adjusting for demographic characteristics (odds ratio [OR] = 1.82, p < 0.001). The OR of frailty for severe tooth loss was only slightly decreased to 1.74 (p < 0.001) when dietary diversity was added to the model and to 1.64 (p < 0.001) when socioeconomic status, family support, and healthy lifestyles were further adjusted. In the cross-lag or longitudinal models, the ORs were mildly or moderately reduced to 1.29, 1.27, and 1.23, respectively, yet remained statistically significant (p < 0.001 or p < 0.01). The mediation analyses showed that dietary diversity had some small yet significant effects on the relationship between tooth loss and frailty in both concurrent and longitudinal settings. Conclusions: This study improves current knowledge regarding the impact of tooth loss on frailty among Chinese older adults. Future intervention strategies designed to improve healthy diets may have preventive effects against the risk of frailty among Chinese older adults with severe tooth loss.

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BACKGROUND: Family support is important in assisting with diabetes self-management for individuals with cognitive impairment, but what types of family support are most effective remain unknown.OBJECTIVES: We aimed to examine the association between the types of family support in diabetes self-management with glycemic control in middle-aged and older adults with cognitive impairment.METHODS: A total of 267 individuals were included with diabetes and cognitive impairment (27-point Telephone Interview for Cognitive Status score <12), using the data of 2003 Health and Retirement Study (HRS) Diabetes Study and 2004 wave of the HRS.RESULTS: Most respondents were White (68.9%), followed by Black (25.8%). The mean age was 73.4±8.4 years. Adults with strong family support (as indicated by a "strongly agree" response) in testing sugar and in handling feelings about diabetes had significantly lower A1C compared with those with less family support (mean ± standard deviation: 7.08±1.39 vs. 7.51±1.42, P=.03; 6.79±0.87 vs. 7.57±1.53; P=.007 respectively).CONCLUSIONS: Our findings indicate that family members of individuals with cognitive impairment provide critical support to patients with diabetes and cognitive impairment, and may need additional intervention to assist with diabetes self-management tasks that require unique knowledge and skills.

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Objective: To examine the association between types of loneliness (transient, incident, and chronic) and the risk of functional disability. Methods: Data were from the Health and Retirement Study 2006/2008-2016/2018. A total of 7,148 adults aged ≥50 was included. Functional status was measured by activities of daily living (ADL) and instrumental activities of daily living (IADL). Loneliness was assessed using the 3-item UCLA Loneliness Scale. We defined loneliness as no/transient/incident/chronic loneliness based on the pattern and duration of loneliness across 2006/2008 and 2010/2012. We applied multivariate Cox proportional hazard models with the new-onset ADL/IADL disability as outcome. Results: Overall, 69.3% respondents showed no loneliness; while 10.3%, 8.9%, and 11.5% showed transient, incident, and chronic loneliness, respectively. A total of 1,298 (18.16%) and 1,260 (17.63%) functionally normal respondents developed ADL and IADL disability during 36,294 person-years of follow-up, respectively. After adjusting for socio-demographic, behavioral, and health factors, chronic loneliness was associated with higher risks of ADL (hazard ratio [HR] = 1.37, 95% confidence interval [CI] = 1.16–1.63, p <0.001, χ2 = 3.60, degree of freedom [df] = 1) and IADL disability (HR = 1.25, 95% CI = 1.09–1.44, p = 0.002, χ2 = 3.17, df = 1) compared to no loneliness. By contrast, no significant associations between transient loneliness and ADL (HR = 1.17, 95% CI = 0.88–1.57, p = 0.273, χ2 = 1.10, df = 1) or IADL disability (HR = 1.16, 95% CI = 0.97–1.39, p = 0.112, χ2 = 1.59, df = 1) were found. Chronic loneliness was not associated with the risk of IADL disability in men (HR = 1.13, 95% CI = 0.91–1.40, p = 0.263, χ2 = 1.12, df = 1). Conclusion: Chronic loneliness, rather than transient loneliness, is an independent risk factor for functional disability in middle-aged and older adults, especially for women.

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Importance: Hypertension self-management is recommended for optimal blood pressure (BP) control, but self-identified residential contextual factors that hinder hypertension self-care are understudied. Objective: To quantify perceived neighborhood health and hypertension self-care and assess interactions with the area deprivation index (ADI) and healthy food availability at home. Design, Setting, and Participants: A cross-sectional study was conducted in Baltimore, Maryland, including primary care adults enrolled in the Achieving Blood Pressure Control Together trial between September 1, 2013, and June 30, 2014. Participants were Black and had at least 2 BP readings greater than or equal to 140/90 mm Hg in the 6 months before enrollment. Analyses were conducted from August 5, 2021, to January 28, 2022. Exposures: Participants' perceived neighborhood health, defined as the mean standardized score across 4 subdomains of aesthetic quality, walkability, safety, and violence, with a higher score signifying better neighborhood health. Main Outcomes and Measures: Hypertension self-care behavior and self-efficacy. Multivariable generalized linear models were fit regressing each outcome on perceived neighborhood health (higher scores on each domain signify better perceived neighborhood health), adjusted for confounders, and interaction terms between neighborhood health and potential modifiers (ADI [higher percentiles correspond to more deprivation] and healthy food availability [higher scores indicate greater availability]) of the primary association were included. Results: Among 159 participants (median [IQR] age, 57 [49-64] years; mean [SD] age, 57 (11) years; 117 women [74%]), median (IQR) hypertension self-care behavior was 50 (45-56) and self-efficacy was 64 (57-72). Better perceived neighborhood health was associated with greater hypertension self-care behavior (β, 2.48; 95% CI, 0.63-4.33) and self-efficacy (β, 4.42; 95% CI, 2.25-6.59); these associations persisted for all neighborhood health subdomains except aesthetic quality. There were no statistically significant interactions between perceived neighborhood health or its subdomains with ADI on self-care behavior (P =.74 for interaction) or self-efficacy (P =.85 for interaction). However, better perceived neighborhood aesthetic quality had associations with greater self-care behavior specifically at higher healthy food availability at home scores: β at -1 SD, -0.29; 95% CI, -2.89 to 2.30 vs β at 1 SD, 2.97; 95% CI, 0.46-5.47; P =.09 for interaction). Likewise, associations of perceived worse neighborhood violence with lower self-care behavior were attenuated at higher healthy food availability at home scores (β for -1 SD, 3.69; 95% CI, 1.31-6.08 vs β for 1 SD, 0.01; 95% CI, -2.53 to 2.54; P =.04 for interaction). Conclusions and Relevance: In this cross-sectional study, better perceived neighborhood health was associated with greater hypertension self-care among Black individuals with hypertension, particularly among those with greater in-home food availability. Thus, optimizing hypertension self-management may require multifaceted interventions targeting both the patients' perceived contextual neighborhood barriers to self-care and availability of healthy food resources in the home.

Abstract

Importance: Staffing shortages in nursing homes (NHs) threaten the quality of resident care, and the COVID-19 pandemic magnified critical staffing shortages within NHs. During the pandemic, the US Congress enacted the Paycheck Protection Program (PPP), a forgivable loan program that required eligible recipients to appropriate 60% to 75% of the loan toward staffing to qualify for loan forgiveness. Objective: To evaluate characteristics of PPP loan recipient NHs vs nonloan recipient NHs and whether there were changes in staffing hours at NHs that received a loan compared with those that did not. Design, Setting, and Participants: This economic evaluation used national data on US nursing homes that were aggregated from the Small Business Administration, Nursing Home Compare, LTCFocus, the Centers for Medicare & Medicaid Services Payroll Based Journal, the Minimum Data Set, the Area Deprivation Index, the Healthcare Cost Report Information System, and the US Department of Agriculture Rural-Urban Continuum Codes from January 1 to December 23, 2020. Exposure: Paycheck Protection Program loan receipt status. Main Outcome and Measures: Staffing variables included registered nurse, licensed practical nurse (LPN), and certified nursing assistant (CNA) total hours per week. Staffing hours were examined on a weekly basis before and after loan receipt during the study period. An event-study approach was used to estimate the staffing total weekly hours at NHs that received PPP loans compared with NHs that did not receive a PPP loan. Results: Among 6008 US NHs, 1807 (30.1%) received a PPP loan and 4201 (69.9%) did not. The median loan amount was $664349 (IQR, $407000-$1058300). Loan recipients were less likely to be part of a chain (733 [40.6%] vs 2592 [61.7%]) and more likely to be for profit (1342 [74.3%] vs 2877 [68.5%]), be located in nonurban settings (159 [8.8%] vs 183 [4.4%]), have a greater proportion of Medicaid-funded residents (mean [SD], 60.92% [21.58%] vs 56.78% [25.57%]), and have lower staffing quality ratings (mean [SD], 2.88 [1.20] vs 3.03 [1.22]) and overall quality star ratings (mean [SD], 3.08 [1.44] vs 3.22 [1.44]) (P <.001 for all). Twelve weeks after PPP loan receipt, NHs that received a PPP loan experienced a mean difference of 26.19 more CNA hours per week (95% CI, 14.50-37.87 hours per week) and a mean difference of 6.67 more LPN hours per week (95% CI, 1.21-12.12 hours per week) compared with nursing homes that did not receive a PPP loan. No associations were found between PPP loan receipt and weekly RN staffing hours (12 weeks: mean difference, 1.99 hours per week; 95% CI, -2.38 to 6.36 hours per week). Conclusions and Relevance: In this economic evaluation, a forgivable loan program that required funding to be appropriated toward staffing was associated with a significant increase in CNA and LPN staffing hours among NH PPP loan recipients. Because the PPP loans are temporary, federal and state entities may need to institute sufficient and sustainable support to mitigate NH staffing shortages..