Publications

Abstract

Objective: To describe “What Matters” to older adults seeking emergency department (ED) care and to identify patient characteristics associated with meeting desired outcomes. Background: As part of the 4Ms framework, identifying “What Matters” has been captured across healthcare settings, yet limited attention has been directed to older adults in the ED. Methods: We performed a secondary analysis of a multicenter prospective observational study. The study enrolled 1013 patients aged 65 and older during an ED encounter and performed 90-day follow-up interviews. The primary outcome was the quantification of “What Matters” (concerns and desired outcomes) to older adults during emergency care. As secondary outcomes, we assessed concerns at day 90, if desired outcomes were met at follow-up, and patient characteristics associated with outcome achievement by estimating multivariable logistic regression models. Results: Older adults reported specific concerns at the time of the ED visit including: (1) symptom identification and/or persistence (31.4%), (2) ability to take care of oneself (19.4%), and (3) end-of-life (17.8%). Desired outcomes expressed by participants included: (1) getting well and symptom resolution (72.0%), (2) obtaining a diagnosis (25.7%), and (3) functional independence (19.5%). At day 90 follow-up, concerns remained similar to the initial ED visit, and the majority of participants (66.2%) achieved their desired outcome. Frailty (adjusted odds ratio = 0.56, 95% CI: 0.38–0.83, P < 0.01) was associated with older adults not meeting their desired outcomes. Conclusions: Older adults identified a variety of concerns during emergency care, and two-thirds reported that desired outcomes were met at longitudinal day 90 follow-up.

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Purpose: Utilizing a participatory approach, we sought to co-design a 12-week Green Activity Program (GAP) with Hispanic/Latino individuals living with memory challenges and their care partners, local outdoor professionals, and healthcare providers. Methods: Participants were recruited via convenience and snowball sampling in the Bronx, New York with Hispanic/Latino persons living with memory challenges and care partners, outdoor activity professionals, and interdisciplinary healthcare providers/dementia experts. Co-design occurred iteratively with 5 focus groups and 4 individual interviews lasting 30–90 min and focused on program and research design. Sessions were recorded and transcribed. Utilizing directed content analysis data was coded using a priori codes program design and research design. Results: 21 participants completed co-design activities: (n = 8 outdoor activity professionals, n = 6 Hispanic/Latino persons living with memory challenges and care partners, and n = 7 interdisciplinary healthcare providers/dementia experts). Participant preferences for program design were captured by subcodes session duration (30–90 min), frequency (4–8 sessions), and delivery modes (in-person and phone). Participants' preferred nature activities included group exercise and outdoor crafts [crocheting], outcomes of social participation, connectedness to nature, decreased loneliness, and stewardship were identified. Preferred language for recruiting and describing the program were “memory challenges,” “Hispanic/Latino,” and “wellbeing.” Referral pathways were identified including community-based organizations and primary care. Conclusion: Co-design was a successful form of engagement for people living with memory challenges that enabled participants to help design key elements of the GAP and research design. Our processes, findings, and recommendations for tailoring co-design to engage Hispanic/Latino people living with memory challenges can inform the development of other programs for this population.

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Objectives: As symptoms emerge and worsen in people living with dementia, their spouses can benefit from behavioral interventions to support their adjustment as a care partner. The Wish Outcome Obstacle Plan (WOOP) intervention improves the well-being of spouses of people living with dementia early in the disease course, but intervention mechanisms and opportunities for improvement are unclear. The present study gave voice to spouses who participated in a trial of WOOP, describing how WOOP was incorporated into their lives and how it could be improved for future implementation. Method: For this qualitative study, we conducted longitudinal semi-structured interviews among 21 spouses of people living with dementia (three interviews over three months; 63 interviews total). Codebook thematic analysis was performed. Results: Three meta-themes were derived: (1) assessing baseline strengths and limitations of WOOP, (2) learning from experience, and (3) fine-tuning and sustaining WOOP. Participants described how WOOP addressed their interpersonal and emotional stressors, their responses to behaviors of the person living with dementia, and their relationship quality. Considerations for future intervention delivery (e.g., solo vs. in group settings) and instructions (e.g., encouraging writing vs. thinking through the four steps of WOOP) were identified as areas of improvement. Conclusions: WOOP was described as a practical, feasible, and desirable intervention for spouses at the early stages of their partner's dementia. Participants made WOOP easier to incorporate in their everyday lives by adapting the design into a mental exercise that they used as needed. Suggestions from participants specified how to make the everyday use of WOOP more feasible, sustainable, and applicable in a variety of contexts. Trial Registration: ClinicalTrials.gov HIC 2000021852.

Abstract

Black and Hispanic adolescents in New York City experience high rates of pregnancy and sexually transmitted infections. A comprehensive understanding of the complexity of adolescent sexual health and family planning decisions and experiences can provide insights into the sustained disparities and inform practice, policy, and future research. The goal of this study was to explore and analyze this complexity, centering Black and Hispanic adolescent mothers as the experts on sexual and reproductive experiences from pre-pregnancy through parenting. As part of formative research for a human-centered design study, we interviewed 16 Black and Hispanic adolescent mothers living in New York City. Using situational analysis, we mapped relationships, discourse, and social structures to explore the various factors that inform adolescent sexual health decisions, in particular choices about contraception. Situational analysis found that, besides interpersonal factors, organizations and non-human elements like social media and physical birth control devices affected adolescent family planning in three social arenas: home, healthcare, and school. Within and across these arenas, adolescents lacked consistent sexual health education and contraceptive counseling and faced gendered expectations of their behaviors. Participants described parents and healthcare providers as most responsible for providing sexual health counseling yet described parents as uncomfortable or overreactive and healthcare workers as paternalistic and biased. A consideration of the many factors that inform sexual health decision-making and recognition of adolescents’ desire for parents and healthcare providers to be a source of education can address health disparities and promote adolescent sexual health and wellbeing.

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Aim(s): Organizational culture has been studied for over four decades among nurses, across countries and contexts. However, wide variation exists in how the concept has been defined and at what level of the organization it is measured. The aim of this study was to use a dimensional analysis to conduct a conceptual synthesis of unit culture from a nursing perspective. Design: Dimensional analysis, rooted in grounded theory methodology, was used to describe unit culture from a nursing perspective. Methods: A literature search was conducted in April 2022. Inclusion criteria were (1) peer review publications, (2) used the term ‘unit culture’ or ‘ward culture’, (3) references nurses' role in unit culture, (4) published in the last 20 years and (5) written in English. One hundred fifteen articles met inclusion criteria, but dimensional saturation was researched after coding 24 articles. Results: Findings were synthesized into four core dimensions and 10 subdimensions. Dimensions of unit culture included customs (practice norms, communication and prioritization), shared beliefs (assumptions, values and attitudes), hierarchy (social and informational) and atmosphere (emotional climate and collaboration). Conditions that shape unit culture include individual nurse characteristics, working conditions, unit policies/procedures and leadership. Unit culture impacts nurse work experiences and decision-making processes, which can affect outcomes including nurse wellbeing, practice behaviours and adherence to unit policies. Conclusions: Identifying the dimensions of unit culture helps to bring clarity to a concept that is not well defined in existing literature. Impact: This model of unit culture can be used to guide development of new instruments to measure unit culture or guide researchers in utilizing existing measures. Developing measures specific to unit culture are warranted to strengthen researchers' ability to assess how changing conditions of a unit (e.g. leadership, workload) changes unit culture and its related outcomes. Patient or Public Contribution: No Patient or Public Contribution.

Abstract

Background: CareMOBI (mhealth for Organization to Bolster Interconnectedness) is a user-centered mobile application that supports secure communication between adult day health centers, primary care providers, and family caregivers. The aim of this study was to examine the acceptability of CareMOBI in the primary care setting and identify factors contributing to the likelihood of adoption among primary care providers. Methods: We used a mixed-methods concurrent triangulation design. We, first, collected quantitative data using the Technology Acceptance Model questionnaire. Follow-up interview questions allowed participants to elaborate on their experience interacting with CareMOBI. We developed an informational matrix based on major themes within the Technology Acceptance Model (ease of use, value in clinical care, fit within existing workflows, and likelihood of adoption) in which qualitative data were embedded and compared. Results: Our sample included 10 primary care providers. Participants rated CareMOBI high in ease of use (M = 6.71 out of 7), value in clinical care (M = 6.79), and likelihood of adoption (M = 6.71). They found specific functions of CareMOBI helpful, including the summary of health progress and the patient profile. In contrast, participants reported the lowest score for the fit of CareMOBI within existing workflows (M = 5.52). Qualitative feedback attributed this score to concerns over the lack of interoperability between CareMOBI in its current form and electronic health record systems used in the primary care setting. Conclusion: Providers found CareMOBI valuable and easy to use, and there was a high likelihood of eventual adoption. However, apprehensions regarding workflow and electronic health records integration arose, which the team will have to consider as they move forward to the next phase of the application's development.

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Moral distress and moral injury among health workers yield adverse physical, psychological, and labor force outcomes. Research is limited on how psychiatric health care assistants (PHAs) experience these issues. In this multimethod study, we conducted a quantitative survey and qualitative interviews to examine moral distress and injury among PHAs. Almost half screened positive for moral injury. Three qualitative themes emerged: 1) hierarchies prevent contributions to care; 2) trust as a factor in de-escalating patient violence; and 3) navigating psychosocial challenges. Further research is recommended to investigate how to best support and inform practice and policy changes for PHAs.

Abstract

INTRODUCTION: The professional caregiver workforce (nursing assistants and personal care aides) is critical to quality of care and quality of life in nursing home (NH) and assisted living (AL) settings. The work is highly stressful, so improving responses to stress in this workforce could contribute to satisfaction and retention. This research developed a coping measure appropriate for the diverse professional caregiver workforce. METHODS: A multistage process identified and refined existing and new items. Ten racially and ethnically diverse professional caregivers advised on item selection and refinement. Subsequently, using an online QR code-accessed questionnaire, data were collected from 391 professional caregivers from 10 NHs and 3 AL communities in three states, yielding a sample that was 87% female, widely distributed in age and experience, and racially/ethnically diverse (42% Black, non-Hispanic/Latinx; 25% White, non-Hispanic/Latinx; 20% Hispanic/Latinx; 7% Asian, non-Hispanic/Latinx; and 21% born outside the United States). Analyses examined psychometric properties and principal components analysis identified factors within which items and scales aggregated. RESULTS: The final instrument, named the Long-Term Care Cope (LTC Cope), includes 26 items aggregated into six factors, which explained 60% of the variance: avoidance (five items, loadings 0.58–0.76); adaptive psychological strategies (six items, loadings 0.33–0.89); active engagement (five items, 0.47–0.89); maladaptive psychological strategies (three items, loadings 0.90–0.93); actions to minimize emotional impact (four items, loadings 0.28–0.74); and substance use (three items, loadings 0.61–0.88). Respondents often reported using multiple items within multiple factors when responding to stressful situations at work. DISCUSSION: The coping strategies of professional caregivers are highly individual, with caregivers tending to utilize multiple strategies. The LTC Cope instrument and its component subscales are promising for future research to improve understanding of stress-related coping in this diverse workforce and inform and evaluate interventions. Highlights: A new measure was developed to help us better understand how professional caregivers (nursing assistants and personal care aides) deal with work-related stress. Professional caregivers in nursing homes and assisted living tend to use multiple approaches to deal with job stress. Ways professional caregivers cope with stress vary widely—some address problems directly, some try to deal with the emotional toll of the work, and others involve avoiding the problems or their emotional consequences.

Abstract

Objectives: A large gap exists in the development of culturally sensitive interventions to reduce stress related to dementia care among Chinese Americans, one of the fastest growing minority populations in the United States. We developed and pilot tested the feasibility and preliminary efficacy of a peer mentoring program for Chinese American dementia caregivers. Method: A pilot randomized controlled trial was conducted among 38 Chinese American caregivers in New York City. Four outcome variables—caregiving competence, loneliness, caregiver burden, and depressive symptoms—were measured at baseline and 3-month and 9-month follow-ups. The study protocol and preliminary results are available at clinicltrial.gov [NCT04346745]. Results: The feasibility of the intervention was high, as indicated by an acceptable retention rate, fidelity, and positive feedback from caregivers and mentors. Compared with the control group, the intervention group had greater reductions in scores for loneliness at 3-month follow-up and for caregiver burden and depressive symptoms at 9-month follow-up. We did not find significant differences in caregiving competence between the two groups. Conclusion: The results indicated the high feasibility and potential efficacy of empowering existing human resources of experienced caregivers in the same ethnic community to improve the mental health of Chinese caregivers. Further research is needed to test the efficacy in a larger sample of this population.

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Electronic health record proficiency is critical for health professionals to deliver and document patient care. There is scarce research on this topic within undergraduate nursing student populations. The purpose of this study is to describe the psychometric evaluation of the Digital Literacy, Usability, and Acceptability of Technology Instrument for Healthcare. A cross-sectional pilot study for psychometric evaluation of the instrument was conducted using data collected through an emailed survey. Exploratory factor analysis, inter-item and adjusted item-total correlations, and Cronbach's α calculated subscale reliability. A total of 297 nursing students completed the survey. A seven-factor structure best fit the data: technology use - engagement, technology use - confidence, technology use - history, electronic health record - ease of use, electronic health record - comparability, and electronic health record - burden. Cronbach's α indicated good to very good internal consistency (α =.68 to.89). The instrument effectively measured digital literacy, acceptance, and usability of an electronic health record and may be implemented with good to very good reliability across varied healthcare simulation and training experiences.

Abstract

Objective: This epigenomics sub-study embedded within a randomized controlled trial examined whether an evidenced-based behavioral intervention model that decreased stimulant use altered leukocyte DNA methylation (DNAm). Methods: Sexual minority men with HIV who use methamphetamine were randomized to a five-session positive affect intervention (n = 32) or an attention-control condition (n = 21), both delivered during three months of contingency management for stimulant abstinence. All participants exhibited sustained HIV virologic control – an HIV viral load less than 40 copies/mL at baseline and six months post-randomization. The Illumina EPIC BeadChip measured leukocyte methylation of cytosine-phosphate-guanosine (CpG) sites mapping onto five a priori candidate genes of interest (i.e., ADRB2, BDNF, FKBP5, NR3C1, OXTR). Functional DNAm pathways and soluble markers of immune dysfunction were secondary outcomes. Results: Compared to the attention-control condition, the positive affect intervention significantly decreased methylation of CpG sites on genes that regulate β2 adrenergic and oxytocin receptors. There was an inconsistent pattern for the direction of the intervention effects on methylation of CpG sites on genes for glucocorticoid receptors and brain-derived neurotrophic factor. Pathway analyses adjusting for the false discovery rate (padj < 0.05) revealed significant intervention-related alterations in DNAm of Reactome pathways corresponding to neural function as well as dopamine, glutamate, and serotonin release. Positive affect intervention effects on DNAm were accompanied by significant reductions in the self-reported frequency of stimulant use. Conclusions: There is an epigenetic signature of an evidence-based behavioral intervention model that reduced stimulant use, which will guide the identification of biomarkers for treatment responses.

Abstract

Retention in HIV care is a critical precursor to ending the epidemic yet remains suboptimal in the United States. Gaining an understanding of the challenges faced by adolescents and young adults (AYA) living with HIV is essential to improving retention in HIV care. This study explored the barriers and facilitators to retention in care among Black and Hispanic AYA living with HIV. Audio-recorded semi-structured interviews were conducted with 20 AYA living with HIV ages 16–29 years in New York City. Our methods entailed an inductive content analysis to explore key concepts, reconcile codes, and identify a theme, categories, and subcategories. Bronfenbrenner’s socioecological model evolved as an organizing framework around barriers and facilitators to retention in care at the individual, interpersonal, healthcare system, and structural level. Data analysis yielded one overarching theme—the influence of psychosocial factors on retention in HIV care. Psychological struggles, powerlessness, clinic-level characteristics, and socioeconomic struggles were barriers reported by participants. Self-responsibility, social support, patient-friendly healthcare services, and socioeconomic resources emerged as facilitators. Retention in HIV care among AYA living with HIV is a multifaceted and complex phenomenon that involves multiple systems. Strengthening patients, healthcare system, and community partnerships can help address some of the HIV-related health disparities.

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Objective: To qualitatively describe breastfeeding experiences among mothers who used galactagogues to increase their milk supply. Design: One-time, semistructured phone interviews. Setting: US. Participants: Breastfeeding mothers (n = 19) who reported ever consuming foods, beverages, or herbal supplements to increase their milk supply in a cross-sectional online survey were purposefully sampled to participate in this qualitative study. Participants were diverse in terms of race and ethnicity, education, income, infant age (0–18 months), and prior breastfeeding experience (32% first-time breastfeeding). Phenomenon of Interest: Reasons for trying to increase milk supply, sources of information about increasing milk supply, and strategies tried to increase milk supply. Analysis: Interviews were transcribed verbatim and analyzed using reflexive thematic analysis. Results: Participants expressed determination and commitment to breastfeeding but unexpectedly struggled to breastfeed and increase their milk supply. They sought information from multiple sources and used individualized approaches to address milk supply concerns on the basis of recommendations from others, as well as the perceived convenience, cost, palatability, and safety of potential strategies. Conclusions and Implications: Results suggest a need to expand breastfeeding education and support so that lactating parents anticipate common breastfeeding challenges and are aware of evidence-based strategies for increasing their milk supply.

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Psychedelic-assisted therapy (PAT) involves supported experiences with psychedelic medicines in carefully curated environments. Early evidence suggests possible utility of PAT for addressing psychosocial-spiritual-existential concerns, yet gaps remain in understanding findings related to PAT's role in palliative care. This rapid review aims to synthesize current literature on applications of PAT in the context of palliative care. Through a systematic process, we identified 34 articles published between January 2021 and July 2024. Protocols varied yet included common components of participant screening, preparation, dosing, and integration. Psilocybin was the most commonly studied compound. Results support safety and initial efficacy of PAT for psycho-spiritual-existential outcomes among carefully screened and highly homogonous samples of patients with serious illness (predominantly cancer). Current efforts and challenges around integrating PAT into systems of palliative care were highlighted. Additional work is needed to (1) explore PAT's safety and efficacy within more diverse samples and contexts, (2) train palliative care providers on PAT, (3) determine systems of care delivery best suited for translation of PAT into practice, and (4) begin developing policy solutions to support safe and equitable access to PAT. Because many patients lack access to basic psychosocial-spiritual-existential care, careful consideration is needed around integration of PAT.

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Purpose: The purpose of this study is to systematically review interventions that address food insecurity for persons with prediabetes or type 2 diabetes using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Methods: Six databases (OVIDMEDLINE, OVIDEMBASE, OVID APA PsycINFO, Web of Science, Cochrane Central Registry of Controlled Trials, and EBSCO CINAHL Complete) were searched through January 2023. Research team members independently performed screening of abstracts and full texts, data abstraction, and risk assessment. Results: In all, 3,139 unique citations were identified, and 20 studies met inclusion criteria. Interventions included medically tailored meals/groceries (n = 10) or produce prescriptions/vouchers (n = 10). Reach and effectiveness were the highest reported RE-AIM elements. Interventions reached a high-risk population via food banks, community-based outreach, and federally qualified health centers. A majority of participants identified as female, Black, or Hispanic/Latinx and were living below the federal poverty level. Most studies reported at least 1 diabetes outcome (ie, A1C, hypoglycemia, diabetes distress, diabetes self-management). Seventeen studies reported impact on A1C, with the majority reporting a decrease in A1C and 53% (9/17) of studies demonstrating a decrease over time. Self-management improved in 50% (3/6) of studies that evaluated this outcome. Self-efficacy improved in 40% (2/5) of studies, and improvements were seen in depressive symptoms/diabetes distress (4/7 studies) and quality of life (5/5 studies). Seven studies reported statistically significant improvements in food insecurity. Conclusion: Food insecurity has been associated with higher risks and adverse clinical outcomes in adults with diabetes. Implementing interventions that address food insecurity among adults with or at risk for diabetes can enhance food security and clinically important diabetes-related outcomes. Additional research dedicated to the sustainability of interventions is needed.

Abstract

Background: In China, Internet-Based Sharing Nursing Service (IBSNS) is a new mode of nursing service delivery that has been in practice for over five years, which enables nurses to provide care at clients’ home. However, the acceptance and associated factors of IBSNS among caregivers of elderly with chronic diseases who are the major clients of the service were unclear. Aim: To explore the acceptance of IBSNS and its associated factors among Chinese caregivers of elderly patient with chronic diseases based on the modified Technology Acceptance Model (mTAM). Methods: A cross-sectional study was conducted from February 2023 to March 2023. Caregivers of hospitalized elderly with chronic diseases were recruited using convenience sampling method from three hospitals in Beijing, China. Data were obtained from self-reports of participants. Structural equation modeling was used to analyze data. Results: A total of 65.1% of the caregivers had neutral to weakly positive behavioral intention of IBSNS use. The mTAM model was supported with good model fit. Perceived ease of use was positively associated with perceived usefulness. Both perceived usefulness and perceived security were positively associated with attitude, consequently, attitude was associated with behavioral intention. Conclusions: Improving the ease of use, security, and usefulness may be helpful to increase the positive attitude towards IBSNS and behavioral intention of using IBSNS, which provides valuable insights that can help healthcare providers improve the integration of technology in patient care, ultimately leading to better health outcomes and more efficient healthcare systems.

Abstract

School connectedness is the degree to which students experience acceptance, inclusion, and care by school personnel and peers. A sense of belonging incorporates an emotional connection to the community. School connectedness and belonging are protective factors that promote student engagement, accomplishment, and community performance. Despite the rise in students from immigrant families in the United States, belonging and connectedness for youth from diverse cultural and linguistic experiences are understudied. School-based nurses, our term, is inclusive of advanced practice pediatric, family, and psychiatric nurse practitioners, are well-positioned to support school connectedness for youth who may encounter hurdles to health care because of cultural and linguistic differences. We present practice suggestions for language, culture, and inclusion using three health conditions experienced by youth: anxiety, asthma, and obesity. School-based nurses and other school personnel who provide linguistic and culturally appropriate care can support students in feeling connected and included in their school communities.

Abstract

Loneliness and social isolation affect more than 1 in 4 community-dwelling older adults in the United States, who may also require long-term care support. Despite being seen as a solution to the long-term care crisis, most older adults prefer to age in place rather than using skilled nursing facilities. However, in-home care is unsustainable due to a shortage of direct care workers and may exacerbate social isolation by confining older adults to their homes. Adult Day Services (ADS) addresses both issues. ADS provides care to adults with physical, functional, and or cognitive limitations in non-residential, congregate, community-based settings. ADS also provides daily cognitive and physical stimulation, often with medical support, in a social and supported environment, centered around the needs and preferences of participants. Before the COVID-19 pandemic, nearly 5,000 ADS centers were widely available. However, with limited public support, the ADS industry has struggled as demand by the growing number of older adults and families need health and social support. The ADS industry must be recognized for its unique ability to buffer social isolation and loneliness in chronically ill older adults while serving as an effective platform for chronic disease management. This perspective piece highlights the critical role of ADS centers in reducing loneliness and social isolation and promoting healthy equity. We also explore the benefits of ADS, the financial, policy, and societal barriers to utilizing ADS, and the potential solutions to ensure its sustainability and growth.

Abstract

Background: Previous findings related to the association of adverse pregnancy outcomes with anorexia nervosa are mixed. Objective: This study aimed to investigate the association of adverse live-born pregnancy outcomes with anorexia nervosa using adjustment modeling accounting for confounding factors, and a mediation analysis addressing the contribution of underweight prepregnancy body mass index and gestational weight gain to those outcomes. Study Design: The sample included California live-born singletons with births between 2007 and 2021. The administrative data set contained birth certificates linked to hospital discharge records. Anorexia nervosa diagnosis during pregnancy was obtained from International Classification of Diseases codes on hospital discharge records. Adverse pregnancy outcomes examined included gestational diabetes, gestational hypertension, preeclampsia, anemia, antepartum hemorrhage, premature rupture of membranes, premature labor, cesarean delivery, oligohydramnios, placenta previa, chorioamnionitis, placental abruption, severe maternal morbidity, small for gestational age, large for gestational age, low birthweight, and preterm birth (by timing and indication). Risk of each adverse outcome was calculated using Poisson regression models. Unadjusted risk of each adverse outcome was calculated, and then the risks were adjusted for demographic factors. The final adjusted model included demographic factors, anxiety, depression, substance use, and smoking. A mediation analysis was performed to estimate the excess risk of adverse outcomes mediated by underweight prepregnancy body mass index and gestational weight gain below the American College of Obstetricians and Gynecologists recommendation. Results: The sample included 241 pregnant people with a diagnosis of anorexia nervosa and 6,418,236 pregnant people without an eating disorder diagnosis. An anorexia nervosa diagnosis during pregnancy was associated with many adverse pregnancy outcomes in unadjusted models (relative risks ranged from 1.65 [preeclampsia] to 3.56 [antepartum hemorrhage]) in comparison with people without an eating disorder diagnosis. In the final adjusted models, birthing people with an anorexia nervosa diagnosis were more likely to have anemia, preterm labor, oligohydramnios, severe maternal morbidity, a small for gestational age or low-birthweight infant, and preterm birth between 32 and 36 weeks with spontaneous preterm labor (adjusted relative risks ranged from 1.43 to 2.55). Underweight prepregnancy body mass index mediated 7.78% of the excess in preterm births and 18.00% of the excess in small for gestational age infants. Gestational weight gain below the recommendation mediated 38.89% of the excess in preterm births and 40.44% of the excess in low-birthweight infants. Conclusion: Anorexia nervosa diagnosis during pregnancy was associated with a number of clinically important adverse pregnancy outcomes in comparison with people without an eating disorder diagnosis. Adjusting for anxiety, depression, substance use, and smoking during pregnancy decreased this risk. A substantial percentage of the excess risk of adverse outcomes was mediated by an underweight prepregnancy body mass index, and an even larger proportion of excess risk was mediated by gestational weight gain below the recommendation. This information is important for clinicians to consider when caring for patients with anorexia nervosa. Considering and treating anorexia nervosa and comorbid conditions and counseling patients about mediating factors such as preconception weight and gestational weight gain may improve live-born pregnancy outcomes among people with anorexia nervosa.

Abstract

Background While Type 2 Diabetes Mellitus (T2DM) prevalence is increasing among younger individuals, few studies have examined how age at T2DM diagnosis relates to dementia risk in diabetic populations. We aimed to investigate the association between age at T2DM diagnosis and subsequent dementia risk, and to determine whether obesity moderates this relationship. Methods We conducted a prospective cohort study using data from the Health and Retirement Study (2002–2016) matched with its 2003 Diabetes Mail-Out Survey. The study included 1,213 dementia-free adults aged ≥50 with diagnosed T2DM. Primary exposures were age at T2DM diagnosis (categorized as <50, 50–59, 60–69, and ≥70 years) and obesity status (BMI ≥30 kg/m2). The outcome was incident dementia, assessed using the Telephone Interview for Cognitive Status. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for sociodemographic factors, health behaviors, health status, and diabetes medication use. Results Over a median follow-up of 10 (interquartile range, 6–14) years, 216 (17.8%) participants developed dementia. Compared to participants diagnosed with T2DM at age ≥70 years, those diagnosed at younger ages had increased dementia risk: HR 1.70 (95% CI, 1.03–2.80) for 60–69 years, 1.72 (95% CI, 1.06–2.79) for 50–59 years, and 1.90 (95% CI, 1.14–3.18) for <50 years. Obesity significantly moderated this relationship, with obese individuals diagnosed with T2DM before age 50 showing the highest dementia risk (HR 3.05; 95% CI 1.23–7.56) compared to non-obese individuals diagnosed at ≥50 years. Conclusions Younger age at diagnosis of T2DM was significantly associated with a higher risk of dementia, particularly among individuals with obesity. Interventions specifically targeting obesity may be more effective in preventing dementia for adults with a younger onset of T2DM.

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This report highlights the 2023-2028 American Association of Nurse Practitioners Research Agenda (AANP-RA), which focuses on the research goals of AANP as an organization and is based on its mission and strategic plan. The purpose of the AANP Research Agenda is to outline research priorities that advance the AANP Strategic Plan and concurrently address gaps in nursing science. American Association of Nurse Practitioners supports research studies that are rigorously designed and conducted using quantitative, qualitative, and mixed-methods approaches, as well as implementation science with the potential to positively impact both NP practice and patient health outcomes. The AANP-RA strategy is guided by the PEARL acronym: examining NP Practice, Education, policy Advocacy, Research, and Leadership. A discussion of each area is presented along with suggested topics.

Abstract

INTRODUCTION: Certified nursing assistants (CNAs) constitute the largest segment of the nursing home workforce, with over 50% of the dementia care workforce comprised of racial and ethnic minoritized individuals. Despite their critical role in dementia care, CNAs face significant inequities in terms of salary, treatment, and working conditions. To enhance equity and improve working conditions, valid and reliable measures are essential for nursing homes to assess their current environment, track progress, and refine strategies. This paper synthesizes existing measures and tools that assess equity-related constructs among CNAs. METHODS: We conducted an environmental scan to identify existing measures, tools, and instruments assessing equity-related constructs among CNAs in nursing homes. Our search focused on nine key equity-related constructs: training, job satisfaction, compensation, staffing/workload, burnout, working conditions/environment, role, leadership, and turnover. RESULTS: Our environmental scan resulted in 15 measures, tools, or instruments relevant to CNA equity. These instruments focused on job satisfaction, retention and turnover, job commitment, leadership experiences, and work environment. Sixty percent of these tools lacked reported validity or reliability data. While the remaining 40% demonstrated strong psychometric properties, overall, the methodological rigor of available measures is inconsistent. A critical gap in the existing literature is the absence of tools measuring burnout or workload, among CNAs. DISCUSSION: The identified measures/tools offer potential for evaluating the effectiveness of interventions addressing CNA equity. However, it is imperative to establish the validity and reliability of these instruments across diverse populations, particularly among racial and ethnic minoritized groups, and develop or adapt tools that measure burnout and workload for CNAs. Furthermore, a deeper understanding of the underlying mechanisms driving these inequities through qualitative data is crucial for developing targeted and impactful interventions. Highlights: Measuring equity among CNAs is important to evaluate strategies intended to improve equity. The identified tools enable assessment of how CNAs feel about important constructs that are related to equity. We found no tools that comprehensively measured workload or burnout experienced by CNAs.