Publications

Abstract

Objective: Examine factors influencing late (> sixth month of gestation) entry into prenatal care by race/ethnicity and insurance payer. Methods: The study population was drawn from singleton live births in California from 2007 to 2012 in the birth cohort file maintained by the California Office of Statewide Health Planning and Development, which includes linked birth certificate and mother and infant hospital discharge records. The sample was restricted to infants delivered between 20 and 44 weeks gestation. Logistic regression was used to calculate relative risks (RR) and 95% confidence intervals (CI) for factors influencing late entry into prenatal care. Maternal age, education, smoking, drug or alcohol abuse/dependence, mental illness, participation in the Women, Infants and Children’s program and rural residence were evaluated for women entering prenatal care > sixth month of gestation compared with women entering < fourth month. Backwards stepwise logistic regression was used to create final multivariable models of risk and protective factors for late prenatal care entry for each race or ethnicity and insurance payer. Results: The sample included 2,963,888 women. The percent of women with late entry into prenatal care was consistently higher among women with public versus private insurance. Less than 1% of white non-Hispanic and Asian women with private insurance entered prenatal care late versus more than 4% of white non-Hispanic and black women with public insurance. After stratifying by race or ethnicity and insurance status, women less than 18 years of age were more likely to enter prenatal care late, with young Asian women with private insurance at the highest risk (15.6%; adjusted RR 7.4, 95%CI 5.3–10.5). Among all women with private insurance, > 12-year education or age >34 years at term reduced the likelihood of late prenatal care entry (adjusted RRs 0.5–0.7). Drugs and alcohol abuse/dependence and residing in a rural county were associated with increased risk of late prenatal care across all subgroups (adjusted RRs 1.3–3.8). Participation in the Women, Infants, and Children’s program was associated with decreased risk of late prenatal care for women with public insurance (adjusted RRs 0.6–0.7), but increased risk for women with private insurance (adjusted RRs 1.4–2.1). Conclusions: The percent of women with late entry into prenatal care was consistently higher among women with public insurance. Younger women, women with <12-year education, those who used drugs or alcohol or resided in rural counties were more likely to enter prenatal care late, with Asian women <18 years at especially high risk. Participation in the Women, Infants, and Children’s program and maternal age >34 years at delivery increased the likelihood of late prenatal care for some subgroups of women and decreased the likelihood for others. These findings can inform institutional factors influencing late prenatal care, especially among lower income women, and may assist efforts aimed at encouraging earlier entry into prenatal care. Rationale: Optimal prenatal care includes initiation before the 14th week of gestation. Beginning care in the first trimester provides an opportunity for sonographic pregnancy dating or confirmation with best accuracy, which can later prove critical for management of preterm labor, maternal or fetal complications, or prolonged pregnancy. In order to improve maternal and infant health by increasing the number of women seeking prenatal care in the first trimester, it is important to examine the drivers for late entry. Here, we examine factors influencing late (> sixth month of gestation) entry into prenatal care by race/ethnicity and insurance payer. We found the percent of women with late entry into prenatal care was consistently higher among women with public insurance. Younger women, women with <12-year education, those who used drugs or alcohol or resided in rural counties were more likely to enter prenatal care late, with Asian women <18 years at especially high risk. These findings can inform institutional factors influencing late prenatal care, especially among lower income women, and may assist efforts aimed at encouraging earlier entry into prenatal care.

Abstract

PROBLEM IDENTIFICATION: The impact of mental health disorders (MHDs) and substance use disorders (SUDs) on healthcare utilization (HCU) in patients with cancer is an understudied phenomenon. LITERATURE SEARCH: A literature search of studies published prior to January 2018 that examined HCU in patients with preexisting MHDs or SUDs diagnosed with cancer was conducted. DATA EVALUATION: The research team evaluated 22 studies for scientific rigor and examined significant trends in HCU, as well as types of the MHD, SUD, and cancer studied. SYNTHESIS: The heterogeneity of HCU outcome measures, MHD, SUD, sample sizes, and study settings contributed to inconsistent study findings. However, study trends indicated higher rates of HCU by patients with depression and lower rates of HCU by patients with schizophrenia. In addition, the concept of HCU measures is evolving, addressing not only volume of health services, but also quality and efficacy. IMPLICATIONS FOR RESEARCH: Oncology nurses are essential to improving HCU in patients with MHDs and SUDs because of their close connections with patients throughout the stages of cancer care. Additional prospective studies are needed to examine specific MHDs and different types of SUDs beyond alcohol use, improving cancer care and the effectiveness of HCU in this vulnerable population.

Abstract

This chapter examines behaviors which place female sex workers in El Paso and Juarez and their clients, among them migrant farmworkers, at risk for human immunodeficiency virus (HIV) infection. It investigates the differences in drug use and sexual behaviors between two cohorts of female sex workers in El Paso and Ciudad Juarez, and the implications of these behaviors for HIV transmission. The chapter discusses the possible risks of HIV exposure for sojourners and those for migrant workers who come from the interior of Mexico and stay in the border region only for the time necessary to secure safe transportation to other agricultural zones in the interior of the US Given the relationship between drugs, sex and HIV transmission, it also examines the drug using behavior of female sex workers in both cities, and how these behaviors affected the spread of sexually transmitted diseases, including HIV, among a specific segment of the Mexican male population, namely, migrant farmworkers.

Abstract

Objective: To assess postdischarge mortality and morbidity in infants diagnosed with different etiologies and severities of persistent pulmonary hypertension of the newborn (PPHN), and to identify risk factors for these adverse clinical outcomes. Study design: This was a population-based study using an administrative dataset linking birth and death certificates, hospital discharge and readmissions records from 2005 to 2012 in California. Cases were infants ≥34 weeks' gestational age with International Classification of Diseases, 9th edition, codes consistent with PPHN. The primary outcome was defined as postdischarge mortality or hospital readmission during the first year of life. Crude and adjusted risk ratio (aRR) with 95% CIs were calculated to quantify the risk for the primary outcome and to identify risk factors. Results: Infants with PPHN (n = 7847) had an aRR of 3.5 (95% CI, 3.3-3.7) for the primary outcome compared with infants without PPHN (n = 3 974 536), and infants with only mild PPHN (n = 2477) had an aRR of 2.2 (95% CI, 2.0-2.5). Infants with congenital diaphragmatic hernia as etiology for PPHN had an aRR of 8.6 (95% CI, 7.0-10.6) and infants with meconium aspiration syndrome had an aRR of 4.0 (95% CI, 3.6-4.4) compared with infants without PPHN. Hispanic ethnicity, small for gestational age, severe PPHN, and etiology of PPHN were risk factors for the primary outcome. Conclusions: The postdischarge morbidity burden of infants with PPHN is large. These findings extend to infants with mild PPHN and etiologies with pulmonary vascular changes that are thought to be short term and recoverable. These data could inform counseling of parents.

Abstract

Background: Pain can negatively affect the inpatient hospitalization experience; however, in patients with compromised metabolic pathways who are more vulnerable to medication side effects, pain control becomes even more challenging. Aims: This evidence-based practice quality improvement project explored the feasibility of implementing a music therapy intervention for improved pain management (pain intensity, analgesic volume) and patient satisfaction among patients with a diagnosis of cirrhotic end-stage liver disease in the acute care setting. Design: The plan–do–check–act cycle served as the implementation framework. Four nurse champions were trained to implement a 30-minute music intervention. Self-selected musical selections were delivered via unit-based iPads with earbud headphones during 3 consecutive days. Methods: Data collection was performed using unit-based measures for pain and patient satisfaction and an investigator-developed audit tool. Bivariate analyses and descriptive statistics were used to assess the effect of the intervention on the three outcomes of interest. Results: Overall results from data collected with eight participants during a 6-week period indicated a 10% reduction in pain intensity and a 30% improvement in patient satisfaction with pain management care. Conclusions: Findings from this evidence-based practice quality improvement project provide support for the effectiveness of music therapy as an adjunct to traditional pharmacologic modalities for pain management of the end-stage liver disease patient population.

Abstract

People interpret virginity in a variety of ways with different implications for sexual identity and behaviour. In Arab societies, heterosexuality and compulsory virginity before marriage are traditionally understood as ideals for a ‘good’ Arab girl, a ‘good’ Arab family and, consequently, a ‘good’ Arab society. In this study, our goal was to gain an in-depth understanding of the enactment of sexual agency and decision-making around virginity from the perspectives of Arab women living in the USA. We conducted a qualitative phenomenological study involving interviews with ten women whose accounts could be grouped into three distinct types: ‘For me, it’s the person you marry that you will be doing these things with’; ‘I want to wait until marriage but I know there might be a possibility where I’m not’; and ‘I started dating this guy, and I did lose my virginity to him’. The life stories of the women illustrate different ways of enacting sexual agency that are strongly influenced by socio-cultural norms and contexts. Our findings have important implications for future research to better understand decisions and behaviours about virginity and how Arab women in the USA enact their sexuality.

Abstract

Background and ObjectivesA growing body of literature indicates that neighborhood social cohesion is generally associated with lower levels of psychological distress and higher levels of life satisfaction (LS). However, very few studies have examined these relationships among Chinese older adults, the fastest growing aging population across all racial/ethnic groups in the U.S. Focusing on this population, the current study aims to examine the associations of neighborhood cohesion with psychological distress and LS as well as the mediating role of resilience and the moderating role of birth place in the associations.Research Design and MethodsOrdinary least squares regressions were applied to analyze data collected among 430 Chinese older adults aged 55 and older residing in Honolulu, Hawai’i.ResultsResults show that neighborhood social cohesion was positively associated with lower levels of psychological distress and higher levels of LS for the whole sample. The association between social cohesion and psychological distress was moderated by birth place such that the protecting effects of neighborhood cohesion on distress were only salient for the U.S.-born but not for the foreign-born. Moreover, the mediating role of resilience was identified: It contributed to more than 60% of the association between social cohesion and psychological distress, and more than 22% of the association between social cohesion and LS.Discussion and ImplicationsOur findings indicate the importance of a cohesive social environment and resilience in shaping psychological well-being and quality of life for older Chinese adults, the U.S.-born in particular, living in Honolulu, Hawai’i.

Abstract

ObjectivesThis study aims to investigate which neighborhood‐based social capital components are associated with a higher level of cognitive function in LMICs.MethodsThis international population‐based study used cross‐sectional survey data from the World Health Organization's Study on global AGEing and adult health (SAGE), a study of adults aged 50 years or older in China, Ghana, India, the Russian Federation, and South Africa from 2007 through 2010 (N=29,528). Associations between neighborhood‐based social capital indicators (trust in neighbors, perceived neighborhood safety, and community participation) and cognitive function were examined using ordinary least squares regressions and random‐effects meta‐analyses.ResultsResults of the meta‐analyses of within‐country effects indicated that trust in neighbors were positively associated with cognitive function across India, Russia, and Ghana, but negatively associated in South Africa (β = ‐0.041, SE = .013, p < .01) and no effect in China (p >.05). The significant effect of perceived neighborhood safety was only found in South Africa (β = 0.051, SE = .007, p < .001) and China (β = 0.030, SE = .005, p < .001). Community participation approached a null effect in South Africa (p > .05).DiscussionDifferent indicators of neighborhood‐based social capital, which are well‐established protective resources for cognitive function, may have varied relationships with cognitive function cross‐nationally. This finding provides a better understanding of the mechanisms by which neighborhood social capital may contribute to better cognitive function in LMICs than high‐income countries, potentially due to differences in neighborhood environments, health systems, and availability of public resources.

Abstract

Our objective was to assess the relationship between hyperbilirubinemia with and without kernicterus and metabolic profile at newborn screening. Included were 1,693,658 infants divided into a training or testing subset in a ratio of 3:1. Forty-two metabolites were analyzed using logistic regression (odds ratios (ORs), area under the receiver operating characteristic curve (AUC), 95% confidence intervals (CIs)). Several metabolite patterns remained consistent across gestational age groups for hyperbilirubinemia without kernicterus. Thyroid stimulating hormone (TSH) and C-18:2 were decreased, whereas tyrosine and C-3 were increased in infants across groupings. Increased C-3 was also observed for kernicterus (OR: 3.17; 95% CI: 1.18–8.53). Thirty-one metabolites were associated with hyperbilirubinemia without kernicterus in the training set. Phenylalanine (OR: 1.91; 95% CI: 1.85–1.97), ornithine (OR: 0.76; 95% 0.74–0.77), and isoleucine + leucine (OR: 0.63; 95% CI: 0.61–0.65) were the most strongly associated. This study showed that newborn metabolic function is associated with hyperbilirubinemia with and without kernicterus.

Abstract

The United Nations 2030 Agenda for Sustainable Development was implemented on January 1, 2016 and is composed of 17 Sustainable Development Goals (SDGs) and further delineated by 169 targets. This article offers background information on the 2030 Agenda as it relates to nursing and midwifery, professional organizational initiatives currently advancing the SDGs, the ethos of global citizenship, the urgency to respond to dwindling planetary health, the salience of nursing and midwifery advocacy in SDG attainment, and the myriad opportunities for nurses to lead and collaborate toward realizing these Global Goals. A US-based perspective is employed to underscore the Agenda's relevance to the US nursing workforce and healthcare system. The SDGs, with their holistic bio-psycho-social-environmental approach to health, present enormous opportunities for nurses and midwives. The SDG framework is naturally aligned with the foundational philosophy and purpose of our professions.

Abstract

The public image of nursing is important because it can facilitate or create barriers to achieving an adequate supply of nursing human resources. This study sought to gain a better understanding of nursing’s professional image within the Republic of Georgia. The Nursing Human Resources Systems model was used to guide the study’s exploratory, qualitative approach. Data collection occurred over a 2-week period in the Republic of Georgia, and thirty-three participants formed the final study sample. Participants included healthcare professionals, key informants from nonprofit and research institutions, and patients. Data analysis occurred using directed content analysis techniques, and three themes emerged: (a) gender dimension; (b) the nursing service recipient experience; and (c) historical legacies. Themes revealed the complexities of nursing’s image in the country. Findings from this study serve as baseline data for understanding nursing’s image in the Republic of Georgia which could assist with improving pre-entry nursing production issues.

Abstract

Hepatitis C virus (HCV) infection is a significant public health concern worldwide. Georgia is among the countries with a high burden of HCV infection. People who inject drugs (PWID) have the highest burden of infection in Georgia. In 2015, the Government of Georgia, with partners’ support, initiated one of the world’s first Hepatitis C Elimination Programs. Despite notable progress, challenges to achieving targets persist. This qualitative study is aimed to better understand some of the barriers and facilitators to HCV testing and treatment services for PWID to inform HCV treatment policies and practices. The study instrument examined social, structural, and individual factors influencing HCV testing and treatment practices. We started with key informant interviews to guide the study instrument development and compare the study findings against health care planners’ and health care providers’ views. Forty PWID with various HCV testing and treatment experiences were recruited through the snowball method. The study found that along with structural factors such as political commitment, co-financing of diagnostic and monitoring tests, and friendly clinic environments, knowledge about HCV infection and elimination program benefits, and support from family and peers also play facilitating roles in accessing testing and treatment services. On the other hand, inability to co-pay for diagnostic tests, fear of side effects associated with treatment, poor knowledge about HCV infection, and lack of social support hampered testing and treatment practices among PWID. Findings from this study are important for increasing the effectiveness of this unique program that targets a population at high risk of HCV infection.

Abstract

BACKGROUND/OBJECTIVESLimited research is available on the relationship between oral health symptoms and cognitive function among community‐dwelling US Chinese older adults. The purpose of this study was to examine the associations between tooth/gum symptoms and changes in cognitive function.DESIGNTwo‐wave epidemiological study.SETTINGPopulation Study of Chinese Elderly in Chicago (PINE).PARTICIPANTSUS Chinese older adults (N = 2713; mean age = 72.6 y; 58.4% women).MEASUREMENTSWe selected self‐reported oral (tooth and gum) symptoms as independent variables. To examine changes in cognitive function (wave 2: Baseline), we chose the following three domains: episodic memory (East Boston Memory Test); executive function (Symbol Digit Modalities Test); and working memory (Digit Span Backwards). In addition, we assessed global cognitive function by constructing a composite measure.RESULTSAt baseline, 1297 participants (47.8%) reported having teeth symptoms, and 513 participants (18.9%) reported having gum symptoms. Adjusting for sociodemographic and health‐related characteristics, participants who reported having teeth symptoms at baseline experienced their global cognition decrease by 0.07 units (estimate = −0.07; p = .003) and their episodic memory decrease by 0.07 units (estimate = −0.07; p = .026). Participants who reported having teeth symptoms at baseline experienced a faster rate of decline in global cognition for every additional year (estimate = 0.02; p = .047). However, this effect disappeared once we adjusted for all covariates (estimate = 0.02; p = .069). We found no significant relationship between baseline gum symptoms and change of cognitive function.CONCLUSIONHaving teeth symptoms was associated with a decline in cognitive function among US Chinese older adults. Developing policy measures aimed at ameliorating health and improving cognition in this high‐risk fast‐growing population in the United States would need to include oral health preventive and dental care services. J Am Geriatr Soc 67:S532–S537, 2019.

Abstract

Background: Assisted reproductive technologies (ARTs) have been associated with the development of endothelial dysfunction. Objective: To determine potential differences in outcomes associated with pulmonary vascular disease in infants born to mothers receiving any infertility treatment including ART and non-IVF fertility treatments (NIFTs). Design/Methods: The sample was derived from an administrative database containing detailed information on infant and maternal characteristics for live-born infants in California (2007-2012) with gestational age (GA) 22 to 44 weeks. Cases were defined as infants with ICD-9 code for pulmonary vascular disease (PVD) and records for ART/NIFT. Controls were randomly selected at a 1:4 ratio. The primary outcome was 1-year mortality. Crude and adjusted odds ratio (OR) with 95% confidence interval (CI) were calculated. Results: We identified 159 cases and 636 controls. Mothers that utilized ART/NIFT were older, to be of the Caucasian race, to have pre-eclampsia, private insurance, and education >12 years (P <.001). Cases compared to controls were more premature, had lower birth weights, and were more often the product of a multiple gestation pregnancy (P <.001). Cases had a higher 1-year mortality (18.2% vs 9.1%; OR: 2.2; 95% CI: 1.4, 3.6), more severe PVD (86.2% vs 72.3%; OR: 2.4; 95% CI: 1.5, 3.9), and a longer hospital stay (66.7 ± 73.0 vs 32.5 ± 47.2 days; P <.001) than controls. However, when adjusting for GA these differences become statistically insignificant. Conclusion: Children born following ART/NIFT with PVD had increased mortality compared to infants with PVD but without ART/NIFT. The primary driver of this relationship is prematurity.

Abstract

Unexpected cognitive lucidity and communication in patients with severe dementias, especially around the time of death, have been observed and reported anecdotally. Here, we review what is known about this phenomenon, related phenomena that provide insight into potential mechanisms, ethical implications, and methodologic considerations for systematic investigation. We conclude that paradoxical lucidity, if systematically confirmed, challenges current assumptions and highlights the possibility of network-level return of cognitive function in cases of severe dementias, which can provide insight into both underlying neurobiology and future therapeutic possibilities.

Abstract

Introduction: This study explored factors influencing patient access to medications for opioid use disorder (OUD), particularly for individuals eligible but historically suboptimal follow-up with in-house referrals to office-based opioid treatment (OBOT). Objectives: In-depth qualitative interviews among a mostly underserved sample of adults with OUD elicited: 1) knowledge and experiences across the OUD treatment cascade; and 2) more nuanced elements of patient-centered care, including shared decision making with providers, experiences in OBOT versus specialty addiction treatment, transitioning from methadone to buprenorphine or extended-release naltrexone (XR-NTX), and voluntary discontinuation of medications for OUD. Methods: We conducted semi-structured qualitative interviews between January and February of 2018 among adult inpatient detoxification program patients with OUD (n = 23). Preliminary analysis of interviews yielded key themes and ideas that were coded from a grounded theory approach. Results: Willingness to engage with OBOT was influenced by a complex array of practical considerations, including access to patient-centered care in OBOT settings, positive experiences with illicitly obtained buprenorphine, and differential experiences pertaining to OBOT versus specialty addiction treatment. Responses were generally favorable towards OBOT with buprenorphine, yet knowledge regarding extended-release naltrexone was limited. Respondents were often frustrated by clinicians when requesting to transition from methadone to buprenorphine or XR-NTX. Lastly, participants elucidated limited access to OBOT programs in underserved neighborhoods and suburban settings. Conclusion: Limited access to patient-centered care in OBOT with buprenorphine and extended-release naltrexone may exacerbate challenges to retention and/or reengagement with OUD care.

Abstract

Objectives: To understand how patients make decisions regarding a left ventricular assist device (LVAD). Design: A qualitative multiple case study design was used to explore the context and influence of individuals regarding patients’ decision-making processes through: 1) detailed, in-depth interviews of those mostly involved in the patient's decision and 2) pertinent data including observations, medical records, educational information and physical artifacts. Data clusters and patterns of co-occurring codes were examined using thematic analysis. Main outcome measures: Themes were extrapolated from individual case summaries to provide an in-depth analysis of each case and a cross-case analysis across the multiple cases. The predominant theme, consistent with other studies, was the salience of survival. Findings: This case study approach revealed new themes beyond those of prior studies. Patients considered: 1) self-care management for patients without a caregiver, 2) acceptability and future expectations of the LVAD and 3) the role of nurses in eliciting patients’ fears, values and preferences. Conclusion: The patients’ decision-making processes regarding an LVAD involve a cost-benefit analysis of the anticipated needs and consequences of the LVAD. Acceptability of the device is relevant to clinical practice and public policy. Nurses have a unique role in seeking patients’ concerns, an essential component of shared decision-making.

Abstract

Objective †To describe the characteristics and risk factors for preterm birth in Hawaiian and Pacific Islander women. Study Design †Retrospective cohort study of 10,470 women of Hawaiian or Pacific Islander descent drawn from a population-based birth cohort dataset in California. Variables were examined across preterm birth subtype (spontaneous, provider initiated) and by gestational age grouping (early preterm birth and late preterm birth) and all preterm births. Results †Hawaiian/Pacific Islander women were at higher risk for preterm birth when they had fewer than three prenatal visits; were underweight, reported tobacco, alcohol, or illicit drugs use in pregnancy; had a diagnosis of anemia, gestational diabetes, preexisting diabetes, or hypertension with or without pre-eclampsia; or had a history of previous preterm birth. Obesity was found to be protective for preterm birth. Conclusion †Women of Hawaiian and Pacific Islander descent demonstrate a similar yet unique constellation of risk and protective factors for preterm birth as compared with other groups at high risk for preterm birth. Interventions aimed to prevent preterm birth need to support the specific needs of this population.

Abstract

Barriers to following dietary recommendations have been described; however, they remain poorly understood. The purpose of this qualitative study was to explore perceived barriers to adherence to dietary recommendations in a diverse hemodialysis patient population. Participants were eligible to participate in a semi-structured qualitative telephone interview prior to randomization for an ongoing clinical trial to evaluate the efficacy of an intervention designed to reduce dietary sodium intake. Interviews were digitally recorded, transcribed verbatim and coded using an iterative qualitative process. In total, 30 (37% females, 53% Caucasians) participants, 63.2 ± 13.3 years, were interviewed. Time, convenience, and financial constraints hindered dietary adherence. Dietary counseling efforts were rated positively but require individualization. Ability to follow recommended guidelines was challenging. Suggestions for addressing barriers include technology-based interventions that allow patients to improve food choices and real-time decision-making, and permit tailoring to individual barriers and preferences.

Abstract

Middle-aged and older adults with HIV experience double discrimination and cognitive impairment due to both their HIV status and their age. However, the relationship between perceived discrimination and self-reported cognitive ability in middle-aged and older people living with HIV (PLWH) is less clear. We measured self-reported perceived discrimination and cognitive ability using the Expanded Everyday Discrimination Scale and the subscale of the AIDS Health Assessment Questionnaire (AIDS-HAQ). The study sample included 324 middle-aged and older PLWH (over 45 years old) from five designated HIV hospitals in three regions (east coast, middle, and southwest regions) of China. The descriptive analysis showed that 45.37% of the participants reported perceiving discrimination at least once in the past twelve months, and 47.22% reported having at least one type of cognitive impairment. Multiple linear regression results showed that higher levels of perceived discrimination (β = −0.121, P = 0.036) were significantly associated with lower levels of self-reported cognitive ability after controlling for several covariates, including sociodemographic variables, mental health status, health behaviors, and social support. A longer duration of HIV was also related to a lower level of self-reported cognitive ability. Our findings indicate that perceived discrimination is related to self-reported cognitive ability and suggest that counseling services and support systems should be developed to reduce age- and disease-associated discrimination. A reduction in perceived discrimination would improve not only overall wellbeing but also cognitive ability in later life.

Abstract

Background: Patient populations with low socioeconomic status (SES) experience psychological stress because of social determinants of health. Social determinants of health contribute to self-care - especially among patients with heart failure (HF). Objective: We sought to describe the influence of stress and social determinants of health on self-care in patients with HF who have low SES. Methods: In this mixed-methods, concurrent embedded study, participants (N = 35) were recruited from 2 urban hospitals in Chicago if they had low SES and were readmitted within 120 days of an exacerbation of HF. We conducted semistructured interviews to collect qualitative data about stressors associated with patients' living circumstances, strategies patients used to foster self-care, family dynamics, and coping strategies patients used to decrease stress. We measured psychological stress (Perceived Stress Scale [PSS-10]), and self-care (Self-care of Heart Failure Index). Content analysis was used to analyze the qualitative data, and descriptive statistics were used to describe the sample. In the final analytic phase, the qualitative and quantitative data were integrated. Results: Self-care was poor: 91.5% of participants had Self-care of Heart Failure Index subscale scores lower than 70. Perceived stress was high: 34% of participants had PSS-10 scores of 20 or higher. Several social determinants of health emerged as affecting self-care: financial stress, family personal health, past impactful deaths, and a recent stressful event (eg, child's death). Participants lived in areas with high crime and violence, and participants described many stressful events. However, among participants whose PSS-10 scores were lower than 20 (indicating lower stress), there was discordance among the description of factors impacting self-care and their PSS-10 score. Conclusions: Social determinants of health negatively impact the ability of low-SES patients to manage their HF symptoms and adhere to a medication and dietary regimen. It is important that healthcare providers assess patients' stressors so appropriate referral to services can occur.