Publications

Abstract

Transgender and gender-diverse (TGD) adults experience significant health disparities compared with their cisgender peers. Stigma functions as a fundamental cause of health disparity in TGD communities. Stigma can be tempered by gender-affirming care (GAC), in which TGD adults receive care that validates their gender identity. There is little evidence focusing on outcomes associated with integrated GAC as an approach to care delivery. This integrative review explores the extant evidence on the relationship between integrated GAC and health outcomes in TGD adults in the United States. A comprehensive search of 4 electronic databases was conducted in May 2022. Included studies were peer reviewed, conducted in the United States from 2013 to the present, and described integrated GAC delivery for TGD adults aged 18 and older. After screening 3328 records and reviewing 135 full-text articles, 15 articles were included in this review. Articles were critically appraised, and data extraction and analysis using constant comparison were used to identify themes and relationships across studies. Synthesis suggested that GAC relates to three distinct areas of TGD adult health: physical health, mental health, and health services outcomes. GAC was associated with better overall health and improvements in HIV-related outcomes; significant decreases in mental health symptoms and suicidality; and increases in utilization, engagement, and care retention. There is moderate evidence that GAC delivery is associated with positive health outcomes for TGD adults. This integrative review provides empirical and theoretical support for integrated GAC delivery as an approach to improve health and address stigma-related barriers to care.

Abstract

This integrative review expands on the work of Kramer et al. (2020), by reviewing studies that utilized the Interpersonal Needs Questionnaire (INQ) to examine the interpersonal constructs (thwarted belongingness and perceived burdensomeness) of the Interpersonal Theory of Suicide (ITS) to understand suicidal thoughts and behaviors among service members and Veterans with combat experience. Very few studies (n = 9) in the literature were identified, however important relationships were revealed between combat exposure/experiences, thwarted belongingness, perceived burdensomeness, and suicidal thoughts and behaviors among military samples. Studies also reported risk factors for high levels of thwarted belongingness or perceived burdensomeness in military samples, such as moral injuries, betrayal, and aggression. This review highlights the utility of the INQ to measure ITS constructs among Post-9/11 U.S. Combat Veterans.

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INTRODUCTION: Pregnancy represents a stressful period for both women and their families. Whether the family maintains functioning during pregnancy could have significant implications on maternal and child health. In this study, we explored individual- and family-level factors associated with family functioning in adolescent and young adult mothers.METHODS: This study was a secondary analysis of 295 young mothers, ages between 15 and 21 years. Multivariate logistic regression models were conducted to estimate adjusted odds ratios of exploratory factors on the risk of being in high family functioning group. The parent study was approved by the Institutional Review Boards at Yale University.RESULTS: The mean score of family functioning was 5.14 out of 7. With the inclusion of individual-level factors (Model 1), significant associations were observed between high family functioning and having ever attended religious services (OR = 2.22, 95% CI: 1.20-4.09), low perceived discrimination (OR = 3.04, 95% CI: 1.60-5.75), and high perceived social support (OR = 3.74, 95% CI: 2.01-6.95). After including both individual- and family-level factors (Model 2), results identified significant associations between high family functioning and annual household income>$15,000 (OR = 9.82, 95% CI: 1.67-57.67, p = 0.011) and no experience of violence from any family members (OR = 4.94, 95% CI: 1.50-16.21, p = 0.008).DISCUSSION: The models of care should be structured to support the continuity of maternity care in which health care providers have the opportunity to discover and utilize each family's strengths to provide the optimal caring experience for young mothers and their families as a unit.

Abstract

Introduction: Pregnancy represents a stressful period for both women and their families. Whether the family maintains functioning during pregnancy could have significant implications on maternal and child health. In this study, we explored individual- and family-level factors associated with family functioning in adolescent and young adult mothers. Methods: This study was a secondary analysis of 295 young mothers, ages between 15 and 21 years. Multivariate logistic regression models were conducted to estimate adjusted odds ratios of exploratory factors on the risk of being in high family functioning group. The parent study was approved by the Institutional Review Boards at Yale University. Results: The mean score of family functioning was 5.14 out of 7. With the inclusion of individual-level factors (Model 1), significant associations were observed between high family functioning and having ever attended religious services (OR = 2.22, 95% CI: 1.20-4.09), low perceived discrimination (OR = 3.04, 95% CI: 1.60-5.75), and high perceived social support (OR = 3.74, 95% CI: 2.01-6.95). After including both individual- and family-level factors (Model 2), results identified significant associations between high family functioning and annual household income>$15,000 (OR = 9.82, 95% CI: 1.67-57.67, p = 0.011) and no experience of violence from any family members (OR = 4.94, 95% CI: 1.50-16.21, p = 0.008). Discussion: The models of care should be structured to support the continuity of maternity care in which health care providers have the opportunity to discover and utilize each family's strengths to provide the optimal caring experience for young mothers and their families as a unit.

Abstract

Aims: The purpose of this study was to assess the levels of cardiovascular health (CVH) of Black and Latino adults with type 2 diabetes (T2D) and examine the association of individual and microsystem level factors with their CVH score. Methods: This was a cross-sectional design in 60 Black and Latino Adults aged 18–40 with T2D. Data were collected on sociodemographic, individual (sociodemographic, diabetes self-management, sleep disturbance, depressive symptoms, quality of life, and the inflammatory biomarkers IL-6 and hs-CRP) and microsystem factors (family functioning), and American Heart Association’s Life’s Simple 7 metrics of CVH. Factors significantly associated with the CVH score in the bivariate analyses were entered into a linear regression model. Results: The sample had a mean age 34 ± 5 years and was primarily female (75%) with a mean CVH score was 8.6 ± 2.2 (possible range of 0–14). The sample achieved these CVH factors at ideal levels: body mass index <25 kg/m2 (8%); blood pressure <120/80 (42%); hemoglobin A1c < 7% (57%); total cholesterol <200 mg/dL (83%); healthy diet (18%); never or former smoker > one year (95%); and physical activity (150 moderate-to-vigorous minutes/week; 45%). In the multivariable model, two factors were significantly associated with cardiovascular health: hs-CRP (B = −0.11621, p <.0001) and the general health scale (B = 0.45127, p =.0013). Conclusions: This sample had an intermediate level of CVH, with inflammation and general health associated with overall CVH score.

Abstract

The pandemic exacerbated job stress and burnout among nurses, increasing turnover and intentions to leave, in a workforce struggling with severe shortages. Shortages and turnover are associated with decreased quality of care, poor nurse health, and increased costs. This article reports the findings of a study that sought to identify characteristics of the job, work environment, and psychosocial health outcomes that may predict nurses’ intent to stay at their current nursing position within the next year. Utilizing a cross-sectional design, we electronically surveyed working nurses (n = 629) during the summer of 2020 across 36 states. Demographics, work characteristics, and validated measures of anxiety, insomnia, and depressive symptoms were assessed. Logistic regression models identified factors associated with nurses’ intent to stay at their jobs. Colleague support, organizational support, and organizational pandemic preparedness were associated with increased odds of intent to stay, while both mild and moderate/severe depressive symptoms were associated with decreased odds of intent to stay. Because over a quarter of nurses surveyed reported moderate to severe depressive symptoms, which were strongly associated with turnover intention, organizational leadership should examine mental health resources available to nurses and work characteristics that could be contributing to nurses’ poor psychosocial health. Additionally, further research is needed to assess the meaning of organizational support to nurses in a post-COVID-19 context, as well how to create a work environment in which nurses are able to provide support to their colleagues.

Abstract

Background: Across the globe, family-integrated care (FICare) has become an evidence-based standard in which parents deliver the majority of infant care in the neonatal intensive care unit (NICU). Because of extensive barriers to parent presence, adaptations to FICare may be required for successful implementation. Family management theory may provide structure to the Parent Education of FICare and help nurses guide parents’ skill development as equal care members. Purpose: To identify family management skills employed by NICU parents using the Self- and Family Management Framework (SFMF). Methods: We conducted secondary analyses of qualitative interview data from NICU parents (n = 17) who shared their experiences of using family management skills to care for their infant. We categorized skills according to 3 main self- and family management processes: Focusing on Infant Illness Needs; Activating Resources; and Living With Infant Illness. Results: Parents reported several family management skills currently identified in the SFMF, as well as new skills such as conflict management, power brokerage, and addressing resources related to social determinants of health. Parent activation of resources was critical to sustaining parent focus on the infant’s illness needs. Implications for Practice and Research: By teaching skills that parents reported as helping them manage infant care, neonatal nurses may better facilitate parent integration into the care team. Future researchers can incorporate the skills identified in this study into the design of family management interventions that facilitate FICare implementation in the United States.

Abstract

Objective: To determine the feasibility of a self-directed training protocol to promote actual arm use in everyday life. The secondary aim was to explore the initial efficacy on upper extremity (UE) outcome measures. Design: Feasibility study using multiple methods. Setting: Home and outpatient research lab. Participants: Fifteen adults (6 women, 9 men, mean age=53.08 years) with chronic stroke living in the community. There was wide range of UE functional levels, ranging from dependent stabilizer (limited function) to functional assist (high function). Intervention: Use My Arm-Remote protocol. Phase 1 consisted of clinician training on motivational interviewing (MI). Phase 2 consisted of MI sessions with participants to determine participant generated goals, training activities, and training schedules. Phase 3 consisted of UE task-oriented training (60 minutes/day, 5 days/week, for 4 weeks). Participants received daily surveys through an app to monitor arm training behavior and weekly virtual check-ins with clinicians to problem-solve challenges and adjust treatment plans. Outcome Measures: Primary outcome measures were feasibility domains after intervention, measured by quantitative study data and qualitative semi-structured interviews. Secondary outcomes included the Canadian Occupational Performance Measure (COPM), Motor Activity Log (MAL), Fugl-Meyer Assessment (FMA), and accelerometry-based duration of use metric measured at baseline, discharge, and 4-week follow-up. Results: The UMA-R was feasible in the following domains: recruitment rate, retention rate, intervention acceptance, intervention delivery, adherence frequency, and safety. Adherence to duration of daily practice did not meet our criteria. Improvements in UE outcomes were achieved at discharge and maintained at follow-up as measured by COPM-Performance subscale (F[1.42, 19.83]=17.72, P<.001) and COPM-Satisfaction subscale (F[2, 28]=14.73, P<.001), MAL (F[1.31, 18.30]=12.05, P<.01) and the FMA (F[2, 28]=16.62, P<.001). Conclusion: The UMA-R was feasible and safe to implement for individuals living in the community with chronic stroke. Adherence duration was identified as area of refinement. Participants demonstrated improvements in standardized UE outcomes to support initial efficacy of the UMA-R. Shared decision-making and behavior change frameworks can support the implementation of UE self-directed rehabilitation. Our results warrant the refinement and further testing of the UMA-R.

Abstract

Background: The prevalence of short sleep duration is rising and is linked to chronic comorbidities, such as metabolic syndrome (MetS). Sleep extension interventions in adults with MetS comorbidities and short sleep duration are limited and vary widely in terms of approach and duration. Objectives: This pilot study aimed to test the feasibility and acceptability of a personalized 12-week systematic sleep time extension intervention on post-intervention sleep outcomes in middle-aged adults at risk forMetSwith actigraphy-estimated short sleep duration. Methods: A single-arm, 12-week, 12-session systematic sleep time extension intervention was delivered weekly via videoconferencing. Feasibility and acceptability were assessed using retention rates and mean sleep diary completions. Sleep was estimated for 14 consecutive days prior to and immediately following the 12-week intervention using wrist actigraphy. Daytime sleepiness was assessed using the Epworth Sleepiness Scale. Paired sample t-tests modeled changes in study outcomes. Results: Study participants (N = 41) had a mean age of 52 years and were mostly female and White; 86% attended >80% of sessions, and mean sleep diary completion was 6.7 diaries/week. Significant improvements in sleep from pre- to post-intervention included increased total sleep time, earlier sleep onsets, more regular sleep onsets, a higher sleep regularity index, and reduced daytime sleepiness. Extending sleep, as well as improving sleep timing and regularity in middle-aged adults with actigraphy-estimated short sleep duration and at risk for MetS, is feasible and acceptable. Discussion: Behavioral sleep characteristics may be modifiable and present a novel behavioral paradigm for mitigating MetS risk. This pilot study provides a proof of concept for the feasibility, acceptability, and preliminary effectiveness of a systematic sleep time extension for middle-aged adults at risk for MetS with actigraphy-estimated short sleep duration.

Abstract

To examine the differences in treatment seeking behaviors, previous suicidal thoughts, previous suicide attempts, and disclosure of suicidal thoughts among female service members (SM)/Veteran suicide decedents who used a firearm and those who used another method. Data was acquired from the National Violent Death Reporting System which is maintained and monitored by the Center for Disease Control and Prevention. Data included in the present study were from suicide deaths that occurred between 2003–2018. Female SM/Veterans who died by firearm suicide had lower proportions of current mental health or substance use treatment, lifetime mental health or substance use treatment, and previous suicide attempts compared to those who used another method. Female SM/Veterans who die by firearm suicide are less likely to encounter mental health services than those who use another method. Conversations on secure firearm storage need to occur outside of the health care setting.

Abstract

Importance: American Indian or Alaska Native and Black adults experience elevated rates of firearm injury and death, but both groups are severely underrepresented in research on firearm exposure and behaviors. Objective: To explore geodemographic differences in firearm behaviors and violence exposure among American Indian or Alaska Native and Black adults in the US. Design, Setting, and Participants: In this survey study, nationally representative samples of American Indian or Alaska Native and/or Black adults recruited from KnowledgePanel were surveyed cross-sectionally. Surveys were administered online between April 12 and May 4, 2023. Main Outcomes and Measures: Firearm access, storage, and carrying behaviors and lifetime firearm violence exposure were the primary outcomes. Demographic factors such as age, geographic location, and political affiliation were considered. Data were weighted to geodemographic distributions from the US Census Bureau's 2022 Current Population Survey. Results: Of 3542 participants, 527 (14.9%) were American Indian or Alaska Native (280 [53.1%] female) and 3015 (85.1%) were Black (1646 [54.6%] female). Both groups exhibited high firearm access rates (American Indian or Alaska Native adults: 238 [45.4%; 95% CI, 39.4%-51.7%]; Black adults: 909 [30.4%; 95% CI, 28.0%-32.9%]), predominantly owning handguns for home protection. The groups demonstrated similar firearm storage patterns, and a substantial proportion endorsed always or almost always carrying firearms outside the home (American Indian or Alaska Native adults: 18.9%; Black adults: 15.2%). Self-protection was a common reason for carrying a firearm (American Indian or Alaska Native adults: 104 [84.9%; 95% CI, 74.1%-91.7%]; Black adults: 350 [88.3%; 95% CI, 82.3%-92.4%]), and a minority of participants cited lack of faith in the police (American Indian or Alaska Native adults: 19 [15.2%; 95% CI, 8.2%-26.7%]; Black adults: 61 [15.4%; 95% CI, 10.3%-21.2%]), indicating potential shifts in public safety dynamics. Conclusions and Relevance: In this survey study of American Indian or Alaska Native and Black US adults, a substantial percentage of both groups reported living in homes with firearms, storing firearms loaded and unlocked, frequently carrying firearms outside the home, and having been exposed directly and indirectly to gun violence. These findings underscore the need for nuanced public health campaigns and policies and highlight challenges for law enforcement in contexts of racial disparities and changing legal frameworks..

Abstract

Aims: This systematic review explores the established causal link between food insecurity and cardiometabolic conditions among adults of African descent. Specifically, this study examined the relationship between food insecurity and the management of type 2 diabetes, highlighting the prevalence of food insecurity among individuals of African descent with type 2 diabetes. Methods: Original English papers were meticulously searched in databases including PubMed, CINAHL, PsycINFO, Medline, Cochrane, Embase and Web of Science. The Cochrane Risk of Bias Tool for quantitative studies and COReQ for qualitative studies were employed to assess biases. Three independent reviewers meticulously evaluated and synthesized results, reaching a consensus. Results: Among the 198 studies identified, 14 met the inclusion criteria for data extraction and analysis, which were conducted independently by three reviewers. The findings indicate that individuals of African descent are more likely to experience food insecurity compared to their White counterparts and are also more prone to diabetes risk factors or the presence of diabetes. Conclusions: This study underscores a higher prevalence of food insecurity and type 2 diabetes among adults of African descent, suggesting that ethnicity and food insecurity play significant roles in diabetes management. Future research should prioritize interventions aimed at reducing these disparities.

Abstract

Problem: Bacterial vaginosis (BV) disproportionally impacts Black and Hispanic women, placing them at risk for HIV, sexually transmitted infections and preterm birth. It is unknown whether there are differences by genetic ancestry in BV risk or whether polymorphisms associated with BV risk differ by ancestry. Methods: Women's Interagency HIV Study (WIHS) participants with longitudinal Nugent scores were dichotomized as having (n = 319, Nugent 7–10) or not having BV (n = 367, Nugent 0–3). Genetic ancestry was defined by clustering of principal components from ancestry informative markers and further stratified by BV status. 627 single nucleotide polymorphisms (SNPs) across 41 genes important in mucosal defense were identified in the WIHS GWAS. A logistic regression analysis was adjusted for nongenetic predictors of BV and self-reported race/ethnicity to assess associations between genetic ancestry and genotype. Results: Self-reported race and genetic ancestry were associated with BV risk after adjustment for behavioral factors. Polymorphisms in mucosal defense genes including syndecans, cytokines and toll-like receptors (TLRs) were associated with BV in all ancestral groups. Conclusions: The common association of syndecan, cytokine and TLR genes and the importance of immune function and inflammatory pathways in BV, suggests these should be targeted for further research on BV pathogenesis and therapeutics.

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The human brain remains one of the greatest challenges for modern medicine, yet it is one of the most integral and sometimes overlooked aspects of medicine. The human brain consists of roughly 100 billion neurons, 100 trillion neuronal connections and consumes about 20–25% of the body’s energy. Emerging evidence highlights that insufficient or inadequate nutrition is linked to an increased risk of brain health, mental health, and psychological functioning compromise. A core component of this relationship includes the intricate dynamics of the brain-gut-microbiota (BGM) system, which is a progressively recognized factor in the sphere of mental/brain health. The bidirectional relationship between the brain, gut, and gut microbiota along the BGM system not only affects nutrient absorption and utilization, but also it exerts substantial influence on cognitive processes, mood regulation, neuroplasticity, and other indices of mental/brain health. Neuroplasticity is the brain’s capacity for adaptation and neural regeneration in response to stimuli. Understanding neuroplasticity and considering interventions that enhance the remarkable ability of the brain to change through experience constitutes a burgeoning area of research that has substantial potential for improving well-being, resilience, and overall brain health through optimal nutrition and lifestyle interventions. The nexus of lifestyle interventions and both academic and clinical perspectives of nutritional neuroscience emerges as a potent tool to enhance patient outcomes, proactively mitigate mental/brain health challenges, and improve the management and treatment of existing mental/brain health conditions by championing health-promoting dietary patterns, rectifying nutritional deficiencies, and seamlessly integrating nutrition-centered strategies into clinical care.

Abstract

Due to a sex ratio imbalance and marriage squeeze in China, many males of marriageable ages cannot find wives. To meet their sexual needs, those bachelors tend to use the internet to find sexual partners in recent years. However, studies on the psychosocial mechanisms underlying having sex with partners met online are scarce. This study examined the relationship between attitude, subjective norms, perceived behavior control, and having sex with online partners based on the Theory of Planned Behavior (TPB). The data were obtained from a cross-sectional survey of bachelors (with rural household registration, at least 28 years old and never married) (N = 735) in several regions of China. Logistic regression models show that attitudes and subjective norms were significantly associated with having sex with online partners. The mediation analysis further indicated that the intention of seeking sex partners online partially mediated the relationships across attitudes, subjective norms, and having sex with partners online. This study provides a better understanding of factors associated with having sex with partners met online. It also extends research concerning a population that is understudied. Additionally, it shows the applicability of the TBP model in explaining the factors associated with having sex with partners.

Abstract

Objectives: Sleep plays an essential role in well-being. Although U.S. immigrants are considerably growing, few studies have examined sleep in this diverse population, particularly those from Asian backgrounds. It is also unclear how sleep differs by the length of residence across immigrant groups. In this study, we examined the relationships among race/ethnicity, length of residence, and sleep using a nationally representative cohort of U.S. immigrants. Methods: We analyzed data from the 2013-2018 National Health Interview Survey. The sample (N = 27,761; 14% ≥65 years old) included foreign-born adults from the following racial/ethnic backgrounds: non-Hispanic White, non-Hispanic Black, Asian (Chinese, Filipino, Asian Indian), and Hispanic/Latino. Length of residence was categorized as <5, 5-9, 10-14, and ≥15 years. Sleep was assessed with self-reported sleep duration (normal, short, and long) and poor sleep quality (trouble falling asleep, trouble staying asleep, and waking up unrested). Results: Filipino and Hispanic/Latino immigrants reported the highest prevalence of short (41.8%) and long (7.0%) sleep, respectively. Non-Hispanic White immigrants had the highest prevalence rate across all three poor sleep quality measures (range 17.7-41.5%). Length of residence ≥15 years was significantly associated with worse sleep, and it moderated White-Asian differences in sleep quality. Immigrants from different racial/ethnic groups showed variations in sleep patterns as they resided longer in the US. Conclusions: Immigrants exhibited substantial heterogeneities in sleep. Future research should investigate the contributing factors to the variations in their sleep patterns, both between groups and within the same group of immigrants, in order to inform tailored interventions.

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Background and Objectives: Despite the importance of provider continuity across healthcare settings, continuity among home care workers who provide hands-on long-term care is understudied. This project describes home care worker continuity, identifies factors associated with increased continuity, and examines associations between continuity and client outcomes. Research Design and Methods: We conducted a retrospective cohort study of clients receiving Medicaid-funded home-based long-term care (n = 3,864) using insurance plan and home care agency data from a large nonprofit organization. We estimated home care worker continuity for clients between 6-month clinical assessments using Bice-Boxerman scores. We then used generalized estimating equations to model associations between home care worker continuity and (1) client characteristics (e.g., cognitive impairment), and (2) client functional, health, and psychosocial outcomes. Results: While home care worker continuity was lowest for clients receiving the most weekly care hours, a range of continuity existed across all levels of care need. Those who were male, older, Asian/Pacific Islander/Native American, cognitively impaired, and functionally impaired had lower continuity. Higher home care worker continuity was significantly associated (p <. 05) with fewer falls, a higher likelihood of functional improvement/stabilization, and fewer depressive symptoms. Discussion and Implications: The finding that home care worker continuity is associated with the health and well-being of home-based long-term care clients underscores the importance of building high-quality relationships in long-term care. Continued efforts are necessary to understand and advance home care worker continuity and to identify other aspects of the home care experience that benefit those receiving long-term care at home.

Abstract

Background: Home health care is a core benefit of Medicare and Medicaid insurance programs and includes services to improve health, maintain health, or slow health decline. Objective: To examine the relationship between home health care use during the last three years of life and hospice use in the last six months of life among Medicare beneficiaries with and without dementia. Design: Nationally representative retrospective cohort study. Setting/Subjects: Medicare beneficiaries with at least three years of continuous enrollment who died in 2019 in the United States (n = 2,169,422). Measurements: The primary outcome was hospice use, and the secondary outcome was hospice duration. The independent variable was a composite of the presence and timing of home health care initiation during the last three years of life. Results: Home health care was used by 46.4% of Medicare beneficiaries and hospice care was used by 53.1% of beneficiaries, with 28.3% using both. Compared with beneficiaries who did not use home health care, those who started home health care before the last year of life (odds ratio [OR] = 1.57, 95% confidence interval [CI] = 1.56-1.58) or during the last year of life (OR = 1.75, 95% CI = 1.74-1.77) were more likely to use hospice. The effects were stronger in those without a diagnosis of dementia (OR = 1.92, 95% CI = 1.90-1.94) compared with those without a dementia diagnosis (OR = 1.34, 95% CI = 1.32-1.35) who started home health in the final year of life. Conclusions: Receiving home health care in the final years of life is associated with increased hospice use at the end-of-life in Medicare beneficiaries with and without a dementia diagnosis.

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Objective: Despite being the fastest growing minority group in the USA, Asian Americans are among the least studied ones, particularly in the home and community-based services settings. This study aimed to review and synthesize extant evidence on Asian American’s access, utilization, and outcomes of home health care. Methods: This is a systematic review study. A comprehensive literature search was conducted in PubMed and CINAHL as well as hand search. Each study was screened, reviewed, and evaluated for quality by at least two reviewers independently. Results: Twelve articles were determined eligible and included for review. Asian Americans were less likely to be discharged to home health care following hospitalization. At admission to home health care, Asian Americans had a high rate of inappropriate medication issues (28%) and they also had poorer functional status compared to White Americans. Asian Americans were also reported with less improvement in functional status at the end of home health care; however, there were some inconsistencies in the evidence on Asian Americans’ utilization of formal/skilled home health care. Quality evaluation indicated that findings from some studies were limited by small sample size, single site/home health agency, analytic approaches, and other methodologic limitations. Conclusions: Asian Americans often experience inequities in home health care access, utilization, and outcomes. Multilevel factors may contribute to such inequities, including structural racism. Robust research using population-based data and advanced methodology is needed to better understand home health care to Asian Americans.

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This panel paper is the second installment in a six-part Nursing Outlook special edition based on the 2022 Emory Business Case for Nursing Summit. The 2022 summit convened national nursing, health care, and business leaders to explore possible solutions to nursing workforce crises, including the nursing shortage. Each of the summit's four panels authored a paper in the special edition on their respective topic(s), and this panel paper focuses on the topic of nursing workforce growth. It discusses priority areas for academia to help ameliorate nursing shortages, including through changes to nursing curricula and/or programming, greater attention to nursing financial needs (including nursing student loans), and regulatory reforms.

Abstract

Objectives: This study examined whether older Chinese adults with different types of hukou status (government household registration system) exhibited different cognitive outcomes and whether receiving support from friends, an under-appreciated resource, helped mitigate the negative impacts of agricultural hukou status on cognitive health disparities. Methods: Using nationally representative data from the China Longitudinal Aging Social Survey, this study tested these relationships with well-validated measures. Results: Our results showed that older Chinese adults with agricultural hukou were more likely to have worse cognitive function than those with non-agricultural hukou. Further, friend support characteristics moderated the association between hukou status and cognitive function, whereby having better friend support was related to a weaker negative effect of agricultural hukou status on cognitive function. Discussion: The findings suggested that agricultural hukou status reflects the effects of accumulated disadvantage across the life course with negative consequences for late-life cognition. The cognitive health disparities between agricultural and non-agricultural residents may be reduced in the context of a higher level of friend support, supporting a stress buffering hypothesis.

Abstract

Background: The US still has a high burden of preterm birth (PTB), with important disparities by race/ethnicity and poverty status. There is a large body of literature looking at the impact of pre-pregnancy obesity on PTB, but fewer studies have explored the association between underweight status on PTB, especially with a lens toward health disparities. Furthermore, little is known about how weight, specifically pre-pregnancy underweight status, and socio-economic-demographic factors such as race/ethnicity and insurance status, interact with each other to contribute to risks of PTB. Objectives: The objective of this study was to measure the association between pre-pregnancy underweight and PTB and small for gestational age (SGA) among a large sample of births in the US. Our secondary objective was to see if underweight status and two markers of health disparities–race/ethnicity and insurance status (public vs. other)–on PTB. Study design: We used data from all births in California from 2011 to 2017, which resulted in 3,070,241 singleton births with linked hospital discharge records. We ran regression models to estimate the relative risk of PTB by underweight status, by race/ethnicity, and by poverty (Medi-cal status). We then looked at the interaction between underweight status and race/ethnicity and underweight and poverty on PTB. Results: Black and Asian women were more likely to be underweight (aRR = 1.0, 95% CI: 1.01, 1.1 and aRR = 1.4, 95% CI: 1.4, 1.5, respectively), and Latina women were less likely to be underweight (aRR = 0.7, 95% CI: 0.7, 0.7). Being underweight was associated with increased odds of PTB (aRR = 1.3, 95% CI 1.3–1.3) and, after controlling for underweight, all nonwhite race/ethnic groups had increased odds of PTB compared to white women. In interaction models, the combined effect of being both underweight and Black, Indigenous and People of Color (BIPOC) statistically significantly reduced the relative risk of PTB (aRR = 0.9, 95% CI: 0.8, 0.9) and SGA (aRR = 1.0, 95% CI: 0.9, 1.0). The combined effect of being both underweight and on public insurance increased the relative risk of PTB (aRR = 1.1, 95% CI: 1.1, 1.2) but there was no additional effect of being both underweight and on public insurance on SGA (aRR = 1.0, 95% CI: 1.0, 1.0). Conclusions: We confirm and build upon previous findings that being underweight preconception is associated with increased risk of PTB and SGA–a fact often overlooked in the focus on overweight and adverse birth outcomes. Additionally, our findings suggest that the effect of being underweight on PTB and SGA differs by race/ethnicity and by insurance status, emphasizing that other factors related to inequities in access to health care and poverty are contributing to disparities in PTB.

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Objectives: To describe the implementation of a mentored staff-delivered sleep program in nursing facilities. Design: Modified stepped-wedge unit-level intervention. Setting and Participants: This program was implemented in 2 New York City nursing facilities, with partial implementation (due to COVID-19) in a third facility. Methods: Expert mentors provided staff webinars, in-person workshops, and weekly sleep pearls via text messaging. We used the integrated Promoting Action on Research Implementation in Health Services (i-PARiHS) framework as a post hoc approach to describe key elements of the SLUMBER implementation. We measured staff participation in unit-level procedures and noted their commentary during unit workshops. Results: We completed SLUMBER within 5 units across 2 facilities and held 15 leadership meetings before and during program implementation. Sessions on each unit included 3 virtual webinar presentations and 4 in-person workshops for each nursing shift, held over a period of 3 to 4 months. Staff attendance averaged >3 sessions per individual staff member. Approximately 65% of staff present on each unit participated in any given session. Text messaging was useful for engagement, educational reinforcement, and encouraging attendance. We elevated staff as experts in the care of their residents as a strategy for staff engagement and behavior change and solicited challenging cases from staff during workshops to provide strategies to address resident behavior and encourage adoption when successful. Conclusions and Implications: Engaging staff, leadership, residents, and family of nursing facilities in implementing a multicomponent sleep quality improvement program is feasible for improving nursing facilities’ sleep environment. The program required gaining trust at multiple levels through presence and empathy, and reinforcement mechanisms (primarily text messages). To improve scalability, SLUMBER could evolve from an interdisciplinary investigator-based approach to internal coaches in a train-the-trainer model to effectively and sustainably implement this program to improve sleep quality for facility residents.

Abstract

Background Currently, only about half of U.S. adults achieve current physical activity guidelines. Routine physical activity is not regularly assessed, nor are patients routinely counseled by their healthcare provider on achieving recommended levels. The three-question physical activity vital sign (PAVS) was developed to assess physical activity duration and intensity and identify adults not meeting physical activity guidelines. Clinical decision support provided via a best practice advisory in an electronic health record (EHR) system can be triggered as a prompt, reminding healthcare providers to implement the best practice intervention when appropriate. Remote patient monitoring of physical activity can provide objective data in the EHR. Objectives This study aimed to evaluate the feasibility and clinical utility of embedding the PAVS and a triggered best practice advisor into the EHR in an ambulatory preventive cardiology practice setting to alert providers to patients reporting low physical activity and prompt healthcare providers to counsel these patients as needed. Methods Three components based in the EHR were integrated for the purpose of this study: Patients completed the PAVS through their electronic patient portal prior to an office visit, a best practice advisory was created to prompt providers to counsel patients who reported low levels of physical activity, and remote patient monitoring via Fitbit synced to the EHR provided objective physical activity data. The intervention was pilot-Tested in the Epic EHR for 1 year (July 1, 2021 to June 30, 2022). Qualitative feedback on the intervention from both providers and patients was obtained at the completion of the study. Results Monthly assessments of the use of the PAVS and best practice advisory and remote patient monitoring were completed. Patients' completion of the PAVS varied from 35% to 48% per month. The best practice advisory was signed by providers between 2% and 65% and was acknowledged by 2%-22% per month. The majority (58%) of patients were able to sync a Fitbit device to their EHR for remote monitoring. Discussion Although uptake of each component needs improvement, this pilot demonstrated the feasibility of incorporating a physical activity promotion intervention into the EHR. Qualitative feedback provided guidance for future implementation.

Abstract

A team comprising nursing, medical staff, and administrative leaders at an urban academic orthopedic hospital in the northeastern United States sought to revise a preoperative laboratory testing protocol based on evidence and practice guidelines. The goal was to decrease unnecessary tests by 20% without negatively affecting patient outcomes. After adding the revised protocol to the electronic health record, audits revealed that the target goal was not met and additional strategies were implemented, including educational webinars for surgeon office personnel who ordered tests, additional webinars for advanced practice professionals, and the creation of scorecards to track surgeons’ progress. Overall, a downward trend in the ordering of unnecessary laboratory tests for patients without identified risks was observed, but a 20% reduction was not achieved. Surgical complications during the project were not associated with laboratory tests. Clinicians continue to use the revised preoperative laboratory testing protocol at the facility.