Publications

Abstract

Neurologic complications of the human immunodeficiency virus (HIV) are common in treated individuals, and toxicity of certain antiretroviral therapies (ART) may contribute to cognitive impairment. We investigated exposures to specific ART and cognition among women living with HIV (WLWH). Virologically suppressed (viral load <200 copies/mL during at least two semi-annual visits) WLWH and age/race matched HIV-seronegative controls enrolled in the Women's Interagency HIV Study who completed at least two biennial cognitive assessments were included. Analysis of WLWH was restricted to those with exposure to the drug class of interest and a nucleoside reverse transcriptase inhibitor (NRTI) backbone. Generalized estimating equations were used to evaluate repeated measures of cognition over time in association with ART class exposure. Among 1,242 eligible WLWH, 20% (n = 247) had isolated drug exposure to non-nucleoside reverse transcriptase inhibitors (NNRTI), 18% (n = 219) to protease inhibitors (PIs), and 6% (n = 79) to integrase inhibitors with a NRTI backbone. Cognitive assessments were performed at a median of 3 biennial visits {IQR 2-4 visits}. At the index assessment, 21% of WLWH demonstrated global cognitive impairment versus 29% at their last cognitive assessment. In multivariable analyses adjusted for hypertension, depression, diabetes mellitus, history of AIDS-defining illness, alcohol use, number of medications, and time on ART, WLWH exposed to NNRTIs demonstrated verbal learning improvements (mean T-score change 1.3, p = .020) compared to other treated women. Compared to HIV-seronegative women, WLWH exposed to PIs had worse verbal learning (mean T-score difference -2.62, p = .002) and verbal memory performance (mean T-score difference -1.74, p = .032) at baseline. Compared to HIV-seronegative women, WLWH exposed to PIs had improvements in verbal learning (mean T-score slope difference 0.36, p = .025) and verbal memory (mean T-score slope difference 0.32, p = .042). The index T-score and slope of change in the T-score were similar among other treated groups and the HIV-seronegative group. We noted emerging trends in cognition in WLWH exposed to specific drug classes. Ongoing study of this relatively young group is important to characterize long-term cognitive outcomes and effect of antiretrovirals as treatment guidelines evolve.

Abstract

Purpose: To understand clinicians' views regarding use of clinical criteria, or triggers, for specialist palliative care consultation in the ICU. Materials and methods: Secondary analysis of a qualitative study that explored factors associated with adoption of specialist palliative care in the ICU. Semi-structured interviews with 36 ICU and palliative care clinicians included questions related to triggers for specialist palliative care. We performed a thematic analysis to identify participants' views on use of triggers, including appropriateness of cases for specialists and issues surrounding trigger implementation. Results: We identified five major themes: 1) Appropriate triggers for specialist palliative care, 2) Issues leading to clinician ambivalence for triggers, 3) Prospective buy-in of stakeholders, 4) Workflow considerations in deploying a trigger system, and 5) Role of ICU clinicians in approving specialist palliative care consults. Appropriate triggers included end-of-life care, chronic critical illness, frequent ICU admissions, and patient/family support. Most clinicians had concerns about “trigger overload” and ICU clinicians wanted to be broadly involved in implementation efforts. Conclusions: ICU and palliative care clinicians identified important issues to consider when implementing triggers for specialist palliative care consultation. Future research is needed to longitudinally examine the most appropriate triggers and best practices for trigger implementation.

Abstract

Micrornas (mirnas) may be considered impor- tant regulators of risk for type 2 diabetes (T2d). The aim of the present study was to identify novel sets of mirnas associ- ated with T2d risk, as well as their gene and pathway targets. circulating mirnas (n=59) were measured in plasma from participants in a previously completed clinical trial (n=82). an agnostic statistical approach was applied to identify novel sets of mirnas with optimal co-expression patterns. In silico analyses were used to identify the messenger rna and biolog- ical pathway targets of the mirnas within each factor. a total of three factors of miRNAs were identified, containing 18, seven and two mirnas each. eight biological pathways were revealed to contain genes targeted by the mirnas in all three factors, 38 pathways contained genes targeted by the mirnas in two factors, and 55, 18 and two pathways were targeted by the mirnas in a single factor, respectively (all q<0.05). The pathways containing genes targeted by mirnas in the largest factor shared a common theme of biological processes related to metabolism and inflammation. By contrast, the pathways containing genes targeted by mirnas in the second largest factor were related to endocrine function and hormone activity. The present study focused on the pathways uniquely targeted by each factor of mirnas in order to identify unique mecha- nisms that may be associated with a subset of individuals. Further exploration of the genes and pathways related to these biological themes may provide insights about the subtypes of T2D and lead to the identification of novel therapeutic targets.

Abstract

In 2019, over 3.2 million adolescents in the U.S. reported depressive symptoms—a number that continues to increase annually. Not only can depression negatively impact an adolescent’s academic performance, social development, and cognitive function, but it is also the most common condition associated with suicide. Previous studies have reported prevalence rates and statistical trends by either gender or race. We conducted an in-depth analysis of the current racial and gender trend disparities in adolescent depressive symptoms by examining linear and quadratic trends from the Youth Behavior Risk Survey (N = 158,601) over two decades (1999–2019), stratified by gender and race subgroups, both separately and combined. This novel quantitative method allows for a more nuanced approach when exploring social and cultural influences on adolescent depressive symptoms. We found a significant difference in the prevalence of depressive symptoms between males and females among Black, Hispanic, and multiracial adolescents in each separate year of pooled data. However, an increased prevalence trend over the 20-year period was only seen among the females of these three racial categories. White and Asian female adolescents also exhibited a statistical increase in prevalence of depressive symptoms over time. The only group of males with a significant trend increase over time were White adolescents. Understanding the intersection of gender and race in adolescent depressive symptoms trends enhances evidence for nurses and other healthcare professionals when developing and implementing targeted, effective prevention and intervention measures.

Abstract

Background: A vast literature exists on doctorally-prepared RNs in academia, but little is known about those in practice settings. Purpose: The purpose of this study was to explore demographic, educational, and employment characteristics, as well as practice patterns and professional accomplishments of doctorally-prepared RNs in one practice setting. Methods: Survey of approximately 100 doctorally-prepared RNs in an integrated health system were surveyed. Discussion: Doctors of Nursing Practice (DNPs) outnumber PhDs three to one in the institution. Several statistically significant differences exist between them: DNPs are younger and most likely hold advanced practice nursing positions; PhDs are 10 years older and more likely hold administrative or leadership positions. Little evidence exists that neither nurses nor administrators understand the skills and knowledge that doctorally-prepared RNs bring to the organization. This is particularly true for DNPs who predominantly hold clinical positions also held by master's-prepared RNs. Conclusion: Advocates for continued growth of DNPs in academia and practice should partner more closely to clarify the skills and talents that doctorally-prepared nurses bring to clinical settings.

Abstract

Cardiovascular disease remains the leading cause of death in patients with diabetes. Cardiovascular disease in diabetes is multifactorial, and control of the cardiovascular risk factors leads to substantial reductions in cardiovascular events. The 2015 American Heart Association and American Diabetes Association scientific statement, "Update on Prevention of Cardiovascular Disease in Adults With Type 2 Diabetes Mellitus in Light of Recent Evidence," highlighted the importance of modifying various risk factors responsible for cardiovascular disease in diabetes. At the time, there was limited evidence to suggest that glucose-lowering medications reduce the risk of cardiovascular events. At present, several large randomized controlled trials with newer antihyperglycemic agents have been completed, demonstrating cardiovascular safety and reduction in cardiovascular outcomes, including cardiovascular death, myocardial infarction, stroke, and heart failure. This AHA scientific statement update focuses on (1) the evidence and clinical utility of newer antihyperglycemic agents in improving glycemic control and reducing cardiovascular events in diabetes; (2) the impact of blood pressure control on cardiovascular events in diabetes; and (3) the role of newer lipid-lowering therapies in comprehensive cardiovascular risk management in adults with diabetes. This scientific statement addresses the continued importance of lifestyle interventions, pharmacological therapy, and surgical interventions to curb the epidemic of obesity and metabolic syndrome, important precursors of prediabetes, diabetes, and comorbid cardiovascular disease. Last, this scientific statement explores the critical importance of the social determinants of health and health equity in the continuum of care in diabetes and cardiovascular disease.

Abstract

Background: The Revised Illness Perception Questionnaire (IPQ-R) measures individuals’ unique perceptions of their illness. While psychometric properties of the IPQ-R have been demonstrated in many disease populations, its content validity has not been extensively studied in non-dialysis chronic kidney disease (CKD). Unique features of CKD (e.g., few symptoms in early stages) may impact the measurement of illness perceptions. The purpose of this study was to explore the IPQ-R content validity in a sample of CKD patients. Methods: Thirty-one participants completed the IPQ-R and were interviewed regarding their subscale scores (timeline, consequences, personal control, treatment control, coherence, cyclical, and emotions). Participants’ agreement with their scores was tallied and assessed qualitatively for themes related to the content validity of the measure. Results: Individual participant agreement with their subscale scores averaged 79% (range: 29–100%). Subscale agreement varied: timeline (100%), consequences, coherence, and emotion (83% each), cyclical (75%), personal control (65%), and treatment control (64%). A qualitative exploration of disagreement responses revealed concerns with the relevance and comprehensibility of personal control and treatment control. Conclusions: Some IPQ-R subscales may pose content validity concerns in the non-dialysis CKD population. Item modification for comprehensibility (personal control) and relevance (treatment control) should be considered. Future studies should explore the impact of a patient’s symptom experience on IPQ-R validity, especially in populations like CKD with a higher proportion of asymptomatic patients.

Abstract

Objectives: Behavioral interventions can reduce distress for couples coping with early-stage dementia. However, most interventions are limited in accessibility and fail to address individualized goals. This pilot study examined the dyadic effects on multiple indicators of well-being of the Wish Outcome Obstacle Plan (WOOP) intervention, which guides participants to use Mental Contrasting with Implementation Intentions to achieve attainable goals in their daily lives. Methods: This randomized controlled trial included 45 older persons with early-stage dementia (PWD) and their spousal care partners (CPs: n = 90 individuals). CPs were assigned randomly to WOOP training immediately after baseline (WOOP) or after a 3-month follow-up interview (Control; CON). Both groups received a dementia care education booklet. WOOP CPs were instructed to practice WOOP at least once a day for 2 weeks. All CPs and PWDs completed home surveys (baseline, 2 weeks, and 3 months), measuring perceived stress, depressive symptoms, quality of life, and affect. Results: Mixed-effects models showed significant intervention × time interaction effects with large effect sizes for CPs on three of the five outcomes over 3 months. Compared with CON, WOOP CPs had decreased perceived stress (δ= 1.71) and increased quality of life (δ= 1.55) and positive affect (δ= 2.30). WOOP PWD showed decreased perceived stress (δ= 0.87) and increased quality of life (δ= 1.26), but these effects were not statistically significant. Discussion: WOOP is a promising, brief intervention to improve dementia CPs' well-being that may also positively affect their partners with dementia.

Abstract

There are concerns that the future balance between the supply and demand for nurses will result in major nursing shortages around the world. Some think that nurses are leaving nursing because of the COVID-19 pandemic. In the United States, nurses may be leaving their jobs, but not nursing. Enrollments in nursing programs have increased. Nurse migration to the United States has decreased. This paper, using examples from the United States mainly, aims to explore the issue of supply of nurses and argues that it is not clear that we will have a worldwide nursing shortage going forward.

Abstract

EHRs provide an opportunity to conduct research on underrepresented oncology populations with mental health and substance use disorders. However, a lack of data quality may introduce unintended bias into EHR data. The objective of this article is describe our analysis of data quality within automated comorbidity lists commonly found in EHRs. Investigators conducted a retrospective chart review of 395 oncology patients from a safety-net integrated healthcare system. Statistical analysis included κ coefficients and a condition logistic regression. Subjects were racially and ethnically diverse and predominantly used Medicaid insurance. Weak κ coefficients (κ = 0.2-0.39, P <.01) were noted for drug and alcohol use disorders indicating deficiencies in comorbidity documentation within the automated comorbidity list. Further, conditional logistic regression analyses revealed deficiencies in comorbidity documentation in patients with drug use disorders (odds ratio, 11.03; 95% confidence interval, 2.71-44.9; P =.01) and psychoses (odds ratio, 0.04; confidence interval, 0.02-0.10; P <.01). Findings suggest deficiencies in automatic comorbidity lists as compared with a review of provider narrative notes when identifying comorbidities. As healthcare systems increasingly use EHR data in clinical studies and decision making, the quality of healthcare delivery and clinical research may be affected by discrepancies in the documentation of comorbidities.

Abstract

Objectives: We provided an overview of the literature on decision aid interventions for family caregivers of older adults with advanced dementia regarding decision making about tube feeding. We synthesized (1) the use of theory during the development, implementation, and evaluation of decision aids; (2) the development, content, and delivery of decision aid interventions; (3) caregivers’ experience with decision aid interventions; and (4) the effect of decision aid interventions on caregivers’ quality of decision-making about feeding options. Design: Scoping review. Methods: We conducted a scoping review of peer-reviewed studies published January 1, 2000–June 30, 2022, in MEDLINE, EMBASE, The Cochrane Library, CINAHL, and Web of Science databases. The process was guided by Arksey and O'Malley's methodological framework, which includes identifying the research question, choosing related studies, charting the data, and summarizing results. Empirical articles concerning the decision aid interventions about feeding options were selected. Results: Six publications reporting 4 unique decision aid interventions were included. All the interventions targeted caregivers of older adults with advanced dementia. Three decision aids were culturally adapted from existing decision aids. The Ottawa Decision Support Framework and the International Patient Decision Aid Standards Framework were used in these 6 publications. Interventions aimed to improve decision making regarding tube feeding for caregivers through static delivery methods. Caregivers rated these decision aids as helpful and acceptable. Decisional conflict and knowledge of feeding options were the most common outcomes evaluated. Reduction in decisional conflict and increase in knowledge were consistently found among dementia caregivers, but no intervention effects were found on preferences for the use of tube feeding. Conclusions and Implications: Decision aid interventions effectively improve decision-making regarding tube feeding among the target population. Cultural adaptation of an existing decision aid intervention is the main strategy. However, the lack of guidance of a cultural adaptation framework in this process may lead to difficulties explaining caregivers’ behavioral changes. Moreover, merely providing information is not enough to change caregivers’ preferences or behavior of use of tube feeding. A systematic approach to cultural adaptation and interactive intervention is needed in future studies.

Abstract

Preoperative frailty is strongly associated with risks of postoperative delirium. However, gaps exist in targeted recommendations for clinical decision making related to surgical interventions in frail older patients. A case study is presented involving a frail 74-year-old referred to the palliative care team for assistance with clinical decision making and in weighing risks and benefits of a surgical intervention. A literature review on the quantification of postoperative delirium risk and how this information might inform medical decision making in frail surgical patients did not identify clear clinical guidelines. In the absence of practice guidelines, the Patient Priorities Care model is proposed as a framework to help providers working with patients and caregivers facing complex medical decisions to better align interventions with patient values.

Abstract

Background: Approximately one third of adults in adult day services (ADS) centers have Alzheimer's disease (AD) and AD-related dementias (ADRD). Understanding of the impact and effectiveness of ADS on persons living with dementia (PLWD) is limited by a lack of patient and caregiver relevant outcomes (PCRO) data. We identified PCROs collected at ADS sites in states that mandate serial data collection and examined the degree to which these data align with established Dementia Care Practice Recommendations (DCPR) and PCROs used in other areas of long-term care. Methods: We conducted an item analysis of regulatory forms used by ADS. Consistent with the methodology used by the Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory for PCROs collected in other long-term care settings, we created a matrix informed by DCPR. We matched each item in regulatory forms reflecting a PCRO to one of the seven DCPR domains as well as to the 53 PCROs from other long-term care sectors. Results: Ten states routinely collect outcome data in ADS. Among these, 80% assess cognitive function. All 10 states capture PLWD's ability to complete activities of daily living. Presence and frequency of behavioral symptoms were collected by 80% of states. Very few or, in some cases, none of the 10 states, collected PCROs related to care planning and coordination, education, social support, and/or family caregiver burden and support. Discussion: Lack of standardized collection of PCROs hampers researchers’ understanding of ADS. The vast majority of PCROs collected center on participants’ physical health; conversely, data on socialization, social support, and caregiver well-being, which are purportedly the most impactful services offered by ADS centers, are rarely collected. ADS would be well served to focus on these outcome domains as the resulting data could paint a more complete picture of the holistic impact of ADS on PLWD and their caregivers.

Abstract

Background: The National Institutes of Health supports professional development of diverse researchers through diversity supplements. Limited awareness and understanding of the application process have hindered utilization of this funding mechanism. Purpose: We describe perspectives and recommendations of mentee and mentor recipients of diversity supplements. Methods: Our working group, comprised of faculty from an Historically Black College and University and an R1 research university, conducted stakeholder interviews with three mentees and four mentors from various institutions. We used content analysis to derive categories of experiences and recommendations. Discussion: Interviewees reported on advantages of diversity supplements, ensuring institutional support, identifying a good mentee-mentor match, developing grantsmanship specific to diversity supplements, and increasing numbers of these applications. Conclusion: We identify opportunities for stakeholders to increase awareness of diversity supplements. Our data support greater understanding of this mechanism, establishing strong mentoring relationships, and submitting robust applications. Findings can enhance diversity among the scientific community.

Abstract

OBJECTIVES: To characterize the needs and preferences for pain self-management support (SMS) among patients with cancer during the transition of cancer care from the hospital to the home setting. SAMPLE & SETTING: 38 participants with cancer pain at a research-intensive cancer center in New England. METHODS & VARIABLES: A descriptive, crosssectional survey study was conducted to investigate relationships among preferred and received support, extent and management of transitional change, and pain outcomes. Pain intensity and interference were measured using the Brief Pain Inventory-Short Form, transitional change was measured using the Measurement of Transitions in Cancer Scale, and SMS was measured using dichotomous questions. RESULTS: About half of participants reported concordance between preferred and received cancer pain SMS in the hospital and at home. The extent of transitional change in cancer care was found to be a significant predictor of average pain intensity in the hospital and pain interference at home. Satisfaction with cancer pain SMS was a significant predictor of pain intensity at home. IMPLICATIONS FOR NURSING: The extent of change during care transitions should be considered when fulfilling patient needs and preferences for cancer pain SMS to optimize outcomes.

Abstract

Background: Pregnant women with gestational diabetes mellitus (GDM) have a higher risk of developing elevated depressive symptoms than women without GDM. The aim of this study was to investigate the sociodemographic (eg, location), clinical (eg, health care–seeking behaviors), and psychological (eg, active coping skills) factors associated with elevated depressive symptoms in Chinese women with GDM. Methods: This was a secondary data analysis of a cross-sectional study among Chinese women with GDM. Data (n = 323) were collected in 2018 from two hospitals in Hunan Province in China. The Center for Epidemiological Survey Depression Scale was used, with a criterion score ≥20 indicative of clinically elevated depressive symptoms. Descriptive, bivariate, and multiple logistic regression analyses were completed. Findings: The women had a mean age of 32.71 (SD = 5.17), and the majority were married (84.2%), college-educated (65.6%), and with Han ethnicity (89.8%). About 68% of women had elevated depressive symptoms. Women with higher active coping scores were less likely (OR = 0.19, 95% CI: 0.10-0.38) to have elevated depressive symptoms. Women from one geographical location (Changde) who had more emergency room visits had higher odds (OR = 3.10, 95% CI: 1.88-5.10) of elevated depressive symptoms. Discussion: There was a high co-occurrence of GDM and elevated depressive symptoms among pregnant women in our sample. Assessment for depressive symptoms in women with GDM is warranted. More research about increasing active coping skills may improve health outcomes in women with GDM.

Abstract

Purpose: The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form. Description: In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality. Assessment: Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs. Conclusion: The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Abstract

Background: Acute postpartum care utilization and readmissions are increasing in the United States and contribute significantly to maternal morbidity, mortality, and healthcare costs. Currently, there are limited data on the prediction of patients who will require acute postpartum care utilization. Objective: To develop and validate a risk prediction model for acute postpartum care utilization. Study design: A retrospective cohort study of delivery hospitalizations with a linked birth certificate and discharge records in California from 2011 to 2015 was divided into a training and testing set for analysis and validation. Predictive models for acute postpartum care utilization using demographic, comorbidity, obstetrical complication, and other factors were developed using a backward stepwise logistic regression on training data. A risk score for acute postpartum care utilization was developed using beta coefficients from the factors remaining in the final multivariable model. Risk scores were validated using the testing dataset. Results: The final sample included 2,045,988 delivery hospitalizations with an acute postpartum care utilization rate of 7.6% in both training and testing cohorts. Twenty-two risk factors were identified for the final multivariable model, including several that were associated with two or more increased odds of acute care utilization (public insurance, postpartum hemorrhage, extremes of maternal age). The mean risk score was 2.45, conferring a 15 times higher risk of acute postpartum care utilization compared to those with a risk score <1 (RR 15.4, 95% CI: 11.0, 21.7). Demographics and test performance characteristics were comparably similar in predictive capability in both models (0.67 in both the training and testing cohorts). Conclusion: Risk factors that are identifiable before discharge can be used to create a cumulative risk score to stratify patients at the lowest and highest risk of acute postpartum care utilization with satisfactory accuracy. External validation and the addition of other granular clinical variables are necessary to validate the feasibility of use.

Abstract

There is a growing need to better capture comprehensive, nuanced, and multi-faceted qualitative data while also better engaging with participants in data collection, especially in virtual environments. This study describes the development of a novel 3-step approach to virtual mind-mapping that involves (1) ranked free-listing, (2) respondent-driven mind-mapping, and (3) interviewing to enhance both data collection and analysis of complex health behaviors. The method was employed in 32 virtual interviews as part of a study on eating behaviors among second-generation South Asian Americans. Participants noted the mind-mapping experience to be (1) helpful for visual learners, (2) helpful in elucidating new ideas and to structure thoughts, as well as (3) novel and interesting. They also noted some suggestions that included improving interpretability of visual data and avoiding repetition of certain discussion points. Data collection revealed the adaptability of the method, and the power of mind-maps to guide targeted, comprehensive discussions with participants.

Abstract

Certain dietary patterns are associated with an increased risk of obesity and its comorbidities. However, these associations vary across populations. The prevalence of obesity has been rising amid a drastic nutrition transition in China during the country’s rapid economic growth. This systematic review and meta-analysis were conducted to summarize how dietary patterns are associated with obesity in the Chinese population. We searched for articles from 1 January 2000 to 1 February 2022 in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus that assessed the relationship between dietary patterns and obesity outcomes. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using a random effects model. From the 2556 articles identified from the search, 23 articles were included in the analysis. We found that the traditional Chinese dietary pattern was associated with a lower risk of overweight/obesity (OR = 0.69, 95% CI: 0.57, 0.84, p < 0.001), whereas the Western dietary pattern was associated with a higher OR of overweight/obesity, but not reaching statistical significance (OR = 1.34, 95% CI: 0.98, 1.84, p = 0.07). There were inconsistent results for other dietary patterns, such as meat/animal protein and plant/vegetarian patterns. In conclusion, the traditional Chinese diet characterized by vegetables, rice, and meat was associated with a lower risk of obesity. The heterogeneity in characterizing dietary patterns contributes to the inconsistency of how dietary patterns are associated with obesity in the Chinese population.

Abstract

Objective: To conduct a dimensional analysis to identify conceptual gaps around shared decision making (SDM) in reproductive health care and to refine the conceptual definition of SDM as related to contraceptive counseling. Data Sources: We identified source data through systematic searches of the CINAHL and PubMed databases. Study Selection: We included peer-reviewed research and nonresearch articles that addressed contraceptive counseling for pregnancy prevention in the United States. We did not consider date of publication as an inclusion criterion. We included 35 articles in the final review. Data Extraction: Using dimensional analysis, we extracted data to clarify the definition of SDM as a socially constructed concept that varies by perspective and context. Data Synthesis: Data synthesis enabled us to compare SDM from patient and provider perspectives and to identify four primary dimensions of SDM that varied by context: Patient Preferences, Relationship, Provider Bias, and Clinical Suitability. Conclusion: The four dimensions we identified illustrate the complexity and depth of SDM in contraceptive counseling encounters and broaden the definition of SDM to more than an encounter in which decision making incorporates clinician expertise and patient participation. We identified several assumptions that indicate the need for improved understanding that SDM is not a universal concept across perspectives and contexts. Most researchers in the included articles addressed the Patient Preferences dimension. Fewer considered the patient–provider relationship, the effect of provider bias, and the effect of specific clinical circumstances on SDM. We propose a conceptual map and model that can be used to refine the concepts that inform SDM and guide providers and researchers. Future research is needed to address the remaining gaps.

Abstract

BACKGROUND: Midwives are a vital component of addressing maternal mortality crisis in the United States (US); however, there is scant understanding of the elements of midwifery practice that affect patient outcomes and the stability of the midwifery workforce in the country. This study investigates US midwives’ perceptions of factors influencing their practice and willingness to stay in the profession. METHODS: We applied a pragmatic qualitative design using summative content analysis techniques to code 1,035 comments from a national sample of 2,887 certified nurse-midwives and certified midwives. Two coders identified categories and themes of midwives’ perceptions of their practice environments, which were confirmed by an independent auditor. RESULTS: Eight themes emerged from the data: I love midwifery but…; feeling valued and respected…or not; workload; time and its consequences; the multilevel geography of midwifery practice; changes at odds with quality midwifery care; midwives withdrawing from practice to cope; and the ambiguity of “I just want to practice like a midwife.” CONCLUSION: Midwives readily identified aspects of their practice environment that negatively impact quality of care and stability of the midwifery workforce, including not valuing midwives, high workload, regulatory restrictions, and moral distress; however, respondents expressed strong commitment to the profession of midwifery. The findings also demonstrated the lack of a universally accepted definition of midwifery care within respondents’ professional communities and among respondents. Initiatives to increase integration of midwifery into the US perinatal health system will benefit from taking these findings into consideration.