Publications

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.

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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

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.

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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.

Abstract

Background: Heightened exposure to racial/ethnic discrimination is associated with poorer sleep health among non-pregnant adults. This relationship has received limited research attention among pregnant women, despite the importance of prenatal sleep quality for optimal maternal and child health outcomes. Methods: We utilized perinatal data from a sample of Black American women (n = 600) participating in a cohort study who reported their lifetime experiences of racial/ethnic discrimination and gendered racial stress during early pregnancy and reported on their sleep quality and depressive symptoms during early and mid-pregnancy. Hierarchical multiple linear regression models were fit to examine associations between lifetime experiences of racial/ethnic discrimination or gendered racial stress and sleep quality during early and mid-pregnancy. We also adjusted for women's concurrent depressive symptoms and tested whether the discrimination/sleep quality association varied by socioeconomic status. Results: Greater exposure to racial/ethnic discrimination was associated with poorer sleep quality during early (ΔR2 = 0.04, ΔF = 26.08, p < 0.001) and mid-pregnancy (ΔR2 = 0.02, ΔF = 9.88, p = 0.002). Similarly, greater gendered racial stress was associated with poorer sleep quality during early (ΔR2 = 0.10, ΔF = 65.72, p < 0.001) and mid-pregnancy (ΔR2 = 0.06, ΔF = 40.43, p < 0.001. These findings largely held after adjustment for concurrent prenatal depressive symptoms. Socioeconomic status did not modify the observed relationships. Conclusions: Efforts to decrease institutional and interpersonal experiences of racial/ethnic discrimination and gendered racism would benefit the sleep quality of pregnant Black American women, particularly during early pregnancy.

Abstract

Objectives: This article aims to examine the disparities in dental service utilization among 3 age groups: younger adults (20–49 y), middle-aged adults (50–64 y), and older adults (65+ y), among Whites, Hispanics, Blacks, Asians, American Indians or Alaska Natives (AIAN), and Native Hawaiian or other Pacific Islanders (NHOPI). Methods: Weighted logistic regression models were conducted to analyze 9 waves of cross-sectional survey data (2002–2018) from the Behavioral Risk Factor Surveillance System. We estimated age group- and race/ethnic–specific prevalences of dental service utilization adjusting sociodemographics and self-rated health for each wave and compared with crude analysis. Next, we performed linear regression analysis of the trend of adjusted prevalences over time and the average level by race/ethnicity and age groups. Results: Racial/ethnic disparities increased with age, even though the adjusted prevalences of dental service utilization were less apparent than the crude analysis. The all-wave average prevalence was 71%. Black older adults had the lowest level of dental service utilization (65%) as compared with the 2 highest groups: White older adults (79%) and Asian older adults (76%). The general younger adult populations had low prevalences, with the lowest among Asian younger adults (65%). AIAN and NHOPI individuals from all age groups tended to have average or below average prevalences. In addition, a decreasing trend of dental service utilization was observed among White individuals of all age groups (0.2%–0.3% lower per year, P < 0.01) and AIAN younger adults (0.5% lower per year, P < 0.01). Conclusion: Health policy, federal funding, and community-based programs should address the needs of dental service utilization for racial/ethnic minorities including Blacks, AIANs, and NHOPIs. Knowledge Transfer Statement: Our study offers insights into our understanding of disparities in dental service utilization among minority racial/ethnic groups. As health policy, federal funding, and community-based programs seek to improve oral health, there is a need to address access to and utilization of dental service for Blacks, American Indians or Alaska Natives, and Native Hawaiian or other Pacific Islanders.

Abstract

Introduction: The time from symptom debut to assessment of cognitive impairment (TSA) is usually substantial, and many factors can influence the length of this interval. Our objective was to discern whether elevated alcohol consumption is associated with TSA. Methods: Alcohol consumption was measured among 3,236 older Norwegians assessed for cognitive impairment. Elevated consumption was defined as drinking 4-7 times a week. TSA was defined as the number of months between symptom debut and assessment. The association between alcohol consumption and TSA was examined with a multiple regression analysis controlled for sociodemographic and clinical covariates. Results: Mean (SD) and median TSA were 34.8 (35.8) and 24.0 months, respectively. Elevated alcohol consumption was not associated with TSA. Longer TSA was associated with being male, having a high education level, being retired or unemployed, being single, having low scores on the Mini-Mental State Examination (MMSE) or Personal Activities of Daily Living (PADL), having high subsyndrome scores of depression or agitation on The Neuropsychiatric Inventory - Questionnaire (NPI-Q), or having a spouse/cohabitant as the designated next of kin. Conclusion: This study indicates that elevated alcohol consumption does not influence TSA. Possible explanations are discussed, but further research is needed to determine the effect of alcohol definitively. We did identify other novel characteristics associated with TSA which may be important in minimizing the risk of delayed cognitive assessments and should be kept in mind when considering assessment.

Abstract

The effect of the COVID-19 related stressors on the mental health of both infected patients and the general public has been well established. However, knowledge is limited on how psychosocial support buffers the association. This study aimed to examine this buffering role in the context of China. We utilized cross-sectional data collected online in mid-March 2020, involving 585 respondents. Mental health status was determined through depression symptoms and loneliness. COVID-19 related stressors include three aspects: perceived severity, perceived threat to life and health, and perceived risk of COVID-19 infection. Psychosocial support included family and social supports. Analyses include ordinary linear regression. The finding showed that psychosocial support buffered the negative effect of loneliness in the context of perceived severity of COVID-19, but appeared to intensify the negative effect of depression symptoms in the context of perceived threat to life and health. However, there was no significant buffering effect on depression or loneliness in the context of the perceived risk of infection. The buffering effect of psychosocial support on COVID-19 related stressors is of mixed patterns. This study contributes to the emerging body of literature trying to understand how the COVID-19 impacts the mental health of individuals.

Abstract

Background: The ability to rate delirium severity is key to providing optimal care for persons with Alzheimer's Disease and Related Dementias (ADRD). Such ratings would allow clinicians to assess response to treatment, recovery time and prognosis, nursing burden and staffing needs, and to provide nuanced, appropriate patient-centered care. Given the lack of existing tools, we defined content domains for a new delirium severity instrument for use in individuals with mild to moderate ADRD, the DEL-S-AD. Methods: We built upon our previous study in which we created a content domain framework to inform development of a general delirium severity instrument, the DEL-S. We engaged a new expert panel to discuss issues of measurement in delirium and dementia and to determine which content domains from the prior framework were useful in characterizing delirium severity in ADRD. We also asked panelists to identify new domains. Our panel included eight interdisciplinary members with expertise in delirium and dementia. Panelists participated in two rounds of review followed by two surveys over 2 months. Results: Panelists endorsed the same content domains as for general delirium severity, including Cognitive, Level of Consciousness, Inattention, Psychiatric-Behavioral, Emotional Dysregulation, Psychomotor Features, and Functional; however, they excluded six of the original subdomains which they considered unhelpful in the context of ADRD: cognitive impairment; anxiety; fear/sense of unease; depression; gait/walking; and incontinence. Debated measurement challenges included assessment at one point in time versus over time, accounting for differences in clinical settings, and accurate assessment of symptoms related to delirium versus dementia. Conclusions: By capturing a range of characteristics of delirium severity potentially present in patients with ADRD, a population that may already have attention, functional, and emotional changes at baseline, the DEL-S-AD provides a novel rating tool that will be useful for clinical and research purposes to improve patient care.

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Background: Nurse practitioner (NP) education was originally reserved for experienced nurses, but it has gradually opened to nurses with little to no clinical experience at the registered nurse (RN) level as well as to non-nurses. The existence of multiple paths to NP training and practice raises questions about the role of generalist RN experience in learning clinical decision-making and other aspects of the NP role. Purpose: To describe educators’ perceptions of the role of prior nursing experience in the development of clinical judgment during NP graduate education. Methods: In this qualitative descriptive study, 27 NP faculty from four universities participated in individual interviews. Transcripts were analyzed using a thematic approach. Results: According to participants, previous nursing experience—or any relevant experience—can either be helpful or detrimental in the development of NP students’ clinical judgment. Three themes were generated: variations in students’ baseline knowledge and skills, different frames of reference to grasp new content and skills, and challenges related to professional identity. In addition, participants described factors that they believe can affect the impact of different types of experience. Conclusion: Students with and without prior nursing experience face distinct challenges in learning NP-level clinical decision-making and judgment, but they reach similar end-of-program competence. Educators are confronted with contradictions between generally held wisdom, their professional socialization, and first-hand observations regarding the role of experience (inside and outside nursing) in preparing students to become NPs.

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Introduction: Strategies are needed to increase implementation of evidence-based tobacco dependence treatment (TDT) in health care systems in low-and middle-income countries (LMICs). Aims and Methods: We conducted a two-arm cluster randomized controlled trial to compare the effectiveness of two strategies for implementing TDT guidelines in community health centers (n = 26) in Vietnam. Arm 1 included training and a tool kit (eg, reminder system) to promote and support delivery of the 4As (Ask about tobacco use, Advise to quit, Assess readiness, Assist with brief counseling) (Arm 1). Arm 2 included Arm 1 components plus a system to refer smokers to a community health worker (CHW) for more intensive counseling (4As + R). Provider surveys were conducted at baseline, 6 months, and 12 months to assess the hypothesized effect of the strategies on provider and organizational-level factors. The primary outcome was provider adoption of the 4As. Results: Adoption of the 4As increased significantly across both study arms (all p <. 001). Perceived organizational priority for TDT, compatibility with current workflow, and provider attitudes, norms, and self-efficacy related to TDT also improved significantly across both arms. In Arm 2 sites, 41% of smokers were referred to a CHW for additional counseling. Conclusions: The study demonstrated the effectiveness of a multicomponent and multilevel strategy (ie, provider and system) for implementing evidence-based TDT in the Vietnam public health system. Combining provider-delivered brief counseling with opportunities for more in-depth counseling offered by a trained CHW may optimize outcomes and offers a potentially scalable model for increasing access to TDT in health care systems like Vietnam. Implications: Improving implementation of evidence-based TDT guidelines is a necessary step toward reducing the growing burden of noncommunicable diseases and premature death in LMICs. The findings provide new evidence on the effectiveness of multilevel strategies for adapting and implementing TDT into routine care in Vietnam and offer a potentially scalable model for meeting Framework Convention on Tobacco Control Article 14 goals in other LMICs with comparable public health systems. The study also demonstrates that combining provider-delivered brief counseling with referral to a CHW for more in-depth counseling and support can optimize access to evidence-based treatment for tobacco use.

Abstract

Background: There has been a rich body of literature on informal caregivers of persons with dementia (PWD). However, little has been discussed on how to facilitate person-centered dementia care in home settings with spouses as primary caregivers. We tend to take it for granted that spouses provide person-centered care for PWD. However, being spouses of PWD and living with them for several decades does not necessarily mean that it is easier for them to provide person-centered dementia care and maintain valued and healthy relationships. Objective: The current study aimed to explore dyadic experiences of PWD and their spousal caregivers and develop a culturally and contextually-sensitive understanding of person-centered dementia care in home-based settings. Methods: A total of 20 dyads of PWD and their care partners were selected for this study. A trained qualitative interviewer conducted a one-on-one interview with each participant with dementia and their care partners separately. We adopted both conventional and directed content analyses. Results: Our findings provide examples of care partners provide person-centered care, resulting in a profound positive impact on their wellbeing. Adaptive leadership and collaborative work emerged as a key finding in facilitating person-centered dementia care. Cultural relevancy of person-centered dementia care was also interpreted from the data. The study findings provide implications for the evolving of person-centered dementia care model in home-based settings. Conclusion: Findings from this study highlight the significance of facilitating person-centered dementia care in home-based settings between PWD and their primary family caregivers.