Quality improvement in medicines regulation: a retrospective analysis of the Pharmacy Board of Sierra Leone before and during quality management system implementation.

BACKGROUND: National Medicines Regulatory Authorities like the Pharmacy Board of Sierra Leone are responsible for protecting and promoting public health, implementing regulatory standards, and maintaining a supply chain with an assured supply of medical products that are safe, effective, and of good quality. This retrospective study assesses the identification of substandard and falsified medicines, the changes in the functions and key indicators of assessment, and the quality improvement changes of the Pharmacy Board of Sierra Leone. METHODS: Data was obtained from 2013 to 2021 records using a data collection tool to collate and review all relevant information to address the different objectives. All data were sourced from the Department of Quality Assurance and the Department of Enforcement and Narcotics at the Pharmacy Board of Sierra Leone. The review also included, identified substandard and falsified medicines, the World Health Organisation Global benchmarking self-assessment tool, and internal and external audit records of the quality management system of all twelve departments of the Pharmacy Board of Sierra Leone. RESULTS: The study showed marked changes in identifying substandard and falsified medicines by the Pharmacy Board of Sierra Leone during ISO 9001:2015 implementation (2017- 2020) compared to Pre-ISO 9001:2015 implementation (2013- 2016). Critical functions of the Pharmacy Board of Sierra Leone from the assessment of the WHO GBT ML in 2016 and 2021 showed that several indicators had been addressed during ISO 9001:2015 certification with improvement in the level of maturity for the quality management systems and Pharmacovigilance functions. There was also an improvement in identifying non-conformances and a commitment to continuous improvement of processes during ISO 9001:2015 implementation. CONCLUSIONS: This study revealed that regular checks through standard assessment, internal audits, and standard management review processes that generate follow-up actions, timelines, and a commitment to identifying correction, and corrective actions for non-conformances are essential quality improvement tools for the efficient functioning of an institution (Pharmacy Board of Sierra Leone). Our study revealed that commitment to continuous implementation of proper quality management system could significantly improve institutional efficiency, thereby improving service delivery and customer satisfaction.

Overcoming adversity: a grounded theory of health management among middle-aged and older gay men.

This article presents findings from a grounded theory study in which we explored how self-identifying gay men between 40 and 76 years of age manage their health in the context of homophobia, heteronormativity and discrimination. Data were collected with 25 men over a 6-month period in a large urban setting in Western Canada. A preliminary theory of health management is discussed, consisting of the central phenomenon of overcoming adversity. Three thematic processes are considered that illustrate how adversity and health management are situated within the interrelationships of historical and ongoing discrimination inclusive of and external to the healthcare encounter, the complexity of men's illnesses, and the temporal aspects of HIV epidemics and treatments that occurred throughout their lives. These themes include: advocating for health needs, knowing about health issues and treatments, and engaging in health promoting practices. These findings help to address a gap in knowledge concerning health management among older gay men and support that initiatives aimed at health care with gay men must appreciate the systemic role of discrimination, while supporting men's individual efforts in actively managing their health.

Reformulating the Worker Identity: Men's Experiences After Radical Prostatectomy.

The number of men in the Canadian workforce who have prostate cancer is increasing. The purpose of the study was to explore the processes involved in men's return to work post radical prostatectomy and understand how these events are connected to masculinities. Drawing on data collected through individual interviews with 24 participants, constructivist grounded theory method was used to develop the substantive theory of Reformulating the Worker Identity which comprises two processes, recovering after radical prostatectomy and renegotiating work expectations. Recovering after radical prostatectomy revealed how men overcame side effects at home and evaluated their potential for returning to work. Renegotiating work expectations included participant's strategies for securing graduated return to work accommodations. Study findings revealed that the challenges for fully returning to work post prostatectomy are often underestimated by clinicians and patients. In this context, preempting return to work challenges preoperatively might allay significant anxieties for many men.

A qualitative investigation of mental health promotion among aging gay men.

Background: Gay men, particularly middle aged and older men (over 40 years of age) experience a disproportionate burden of mental health issues compared to heterosexual men. Despite ample evidence that chronic exposure to structural and interpersonal discrimination negatively affect their mental health, little is known from gay men's perspectives how they understand mental health or their strategies to address their mental health concerns.Aim: This study's aim was to investigate how middle aged and older gay men experience their mental health and the mitigation strategies used to promote mental health.Method: Semi-structured interviews were conducted with 25 men who self-identified as gay. Data were analyzed using an interpretive descriptive approach.Results: Three overarching themes that best illustrate how men perceived their mental health and manage their mental health concerns were identified: gaining perspective, engaging with health services, and promoting and maintaining mental health.Conclusions: This study provides insight into how gay men come to acknowledge the validity of their mental health concerns, engage with health services, and their participation in other activities deemed essential for mental health promotion. These findings are ideally poised to inform development of health resources to promote and protect the mental health of aging gay men.

Genetic diversity of phytoplasma strains inducing phyllody, flat stem and witches' broom symptoms in Manilkara zapota in India.

During a survey performed in sapota orchards of India, from 2015 to 2018, symptoms of phyllody, little leaf, flat stem and witches' broom were observed in three states: Karnataka, Kerala and Tripura. The association of phytoplasmas was confirmed in all the symptomatic sapota samples by using nested PCR specific primers (P1/P7, R16F2n/R16R2 and 3Far/3Rev) with amplification of fragments of ~ 1.25 kb and ~ 1.3 kb. Association of three phytoplasma groups, aster yellows with flat stem from Tripura (Lembucherra), clover proliferation with phyllody symptoms at Karnataka (Bengaluru) and bermuda grass white leaf with flat stem and little leaf from Kerala (Thiruvananthapuram) and Tripura (Cocotilla) were confirmed by 16S rRNA gene sequence comparison analysis. Virtual RFLP analysis of 16S rRNA gene sequences using pDRAW32 further classified the sapota phytoplasma isolates into 16SrI-B, 16SrVI-D and 16SrXIV-A subgroups. This is the first report on identification of three phytoplasma groups in sapota in world.

The Beneficial Root-Colonizing Fungus Mortierella hyalina Promotes the Aerial Growth of Arabidopsis and Activates Calcium-Dependent Responses That Restrict Alternaria brassicae-Induced Disease Development in Roots.

The endophytic fungus Mortierella hyalina colonizes the roots of Arabidopsis thaliana and stimulates growth and biomass production of the aerial parts but not of roots. An exudate fraction from the fungus induces rapid and transient cytoplasmic Ca2+elevation in the roots. The Ca2+ response does not require the well-characterized (co)receptors BAK1, CERK1, and FLS2 for pathogen-associated molecular patterns, and the Ca2+ channels GLR-2.4, GLR-2.5, and GLR-3.3 or the vacuolar TWO PORE CHANNEL1, which might be involved in cytoplasmic Ca2+ elevation. We isolated an ethyl-methane-sulfonate-induced Arabidopsis mutant that is impaired in this Ca2+ response. The roots of the mutant are impaired in M. hyalina-mediated suppression of immune responses after Alternaria brassicae infection, i.e., jasmonate accumulation, generation of reactive oxygen species, as well as the activation of jasmonate-related defense genes. Furthermore, they are more colonized by M. hyalina than wild-type roots. We propose that the mutant gene product is involved in a Ca2+-dependent signaling pathway activated by M. hyalina to suppress immune responses in Arabidopsis roots.

A Poly(A) Ribonuclease Controls the Cellotriose-Based Interaction between Piriformospora indica and Its Host Arabidopsis.

Piriformospora indica, an endophytic root-colonizing fungus, efficiently promotes plant growth and induces resistance to abiotic stress and biotic diseases. P. indica fungal cell wall extract induces cytoplasmic calcium elevation in host plant roots. Here, we show that cellotriose (CT) is an elicitor-active cell wall moiety released by P. indica into the medium. CT induces a mild defense-like response, including the production of reactive oxygen species, changes in membrane potential, and the expression of genes involved in growth regulation and root development. CT-based cytoplasmic calcium elevation in Arabidopsis (Arabidopsis thaliana) roots does not require the BAK1 coreceptor or the putative Ca2+ channels TPC1, GLR3.3, GLR2.4, and GLR2.5 and operates synergistically with the elicitor chitin. We identified an ethyl methanesulfonate-induced mutant (cytoplasmiccalcium elevation mutant) impaired in the response to CT and various other cellooligomers (n = 2-7), but not to chitooligomers (n = 4-8), in roots. The mutant contains a single nucleotide exchange in the gene encoding a poly(A) ribonuclease (AtPARN; At1g55870) that degrades the poly(A) tails of specific mRNAs. The wild-type PARN cDNA, expressed under the control of a 35S promoter, complements the mutant phenotype. Our identification of cellotriose as a novel chemical mediator casts light on the complex P. indica-plant mutualistic relationship.

Relationship Between Types of Social Support, Coping Strategies, and Psychological Distress in Individuals Living With Congenital Heart Disease.

BACKGROUND: Many people with congenital heart disease (CHD) experience psychological distress related to medical complications and psychosocial issues related to the disease. Although studies show that social support and coping strategies are closely associated with psychological distress in people struggling with different chronic health challenges, very little is known about whether the same factors hold true for the psychological distress of people living with CHD. OBJECTIVE: The purpose of this study was to examine the relationships between types of social support, coping strategies, and psychological distress for individuals living with CHD. DESIGN: A cross-sectional survey design with self-report questionnaires was used. METHOD: A convenience sample of 272 participants was obtained from the Adult Congenital Heart Disease program at a tertiary care hospital in Western Canada. Structural equation modeling was conducted to examine hypothesized relationships among study variables. RESULTS: Perceived social support was directly related to both anxiety and depression. Received social support influenced anxiety and depression, but its effect was through perceived social support. Wishful-thinking coping strategies mediated the relationships between perceived social support and both anxiety and depression. CONCLUSION: Individuals with CHD who have low perceived and received social support are vulnerable to experiences of psychological distress. Assessments of social support and facilitation of positive coping strategies are integral to nursing care for adults with CHD.

Assessing the impacts and outcomes of youth driven mental health promotion: A mixed-methods assessment of the Social Networking Action for Resilience study.

Mental health challenges are the leading health issue facing youth globally. To better respond to this health challenge, experts advocate for a population health approach inclusive of mental health promotion; yet this area remains underdeveloped. Further, while there is growing emphasis on youth-engaged research and intervention design, evidence of the outcomes and impacts are lacking. The purpose of this paper is to contribute to addressing these gaps, presenting findings from the Social Networking Action for Resilience (SONAR) study, an exploration of youth-driven mental health promotion in a rural community in British Columbia, Canada. Mixed methods including pre- and post-intervention surveys (n = 175) and qualitative interviews (n = 10) captured the outcomes and impacts of the intervention on indicators of mental health, the relationship between level of engagement and benefit, and community perceptions of impact. Findings demonstrate the feasibility and benefits of youth engaged research and intervention at an individual and community-level.

Strengthening population health interventions: developing the CollaboraKTion Framework for Community-Based Knowledge Translation.

BACKGROUND: Much of the research and theorising in the knowledge translation (KT) field has focused on clinical settings, providing little guidance to those working in community settings. In this study, we build on previous research in community-based KT by detailing the theory driven and empirically-informed CollaboraKTion framework. METHODS: A case study design and ethnographic methods were utilised to gain an in-depth understanding of the processes for conducting a community-based KT study as a means to distilling the CollaboraKTion framework. Drawing on extensive field notes describing fieldwork observations and interactions as well as evidence from the participatory research and KT literature, we detail the processes and steps undertaken in this community-based KT study as well as their rationale and the challenges encountered. In an effort to build upon existing knowledge, Kitson and colleagues' co-KT framework, which provides guidance for conducting KT aimed at addressing population-level health, was applied as a coding structure to inform the current analysis. This approach was selected because it (1) supported the application of an existing community-based KT framework to empirical data and (2) provided an opportunity to contribute to the theory and practice gaps in the community-based KT literature through an inductively derived empirical example. RESULTS: Analysis revealed that community-based KT is an iterative process that can be viewed as comprising five overarching processes: (1) contacting and connecting; (2) deepening understandings; (3) adapting and applying the knowledge base; (4) supporting and evaluating continued action; and (5) transitioning and embedding as well as several key elements within each of these processes (e.g. building on existing knowledge, establishing partnerships). These empirically informed theory advancements in KT and participatory research traditions are summarised in the CollaboraKTion framework. We suggest that community-based KT researchers place less emphasis on enhancing uptake of specific interventions and focus on collaboratively identifying and creating changes to the contextual factors that influence health outcomes. CONCLUSIONS: The CollaboraKTion framework can be used to guide the development, implementation and evaluation of contextually relevant, evidence-informed initiatives aimed at improving population health, amid providing a foundation to leverage future research and practice in this emergent KT area.

Migration and young people's mental health in Canada: A scoping review.

BACKGROUND: Young people's mental health is a public health priority. Given the influences of migration and resettlement on mental health, synthesis of current research with young people from migrant backgrounds can help inform mental health promotion initiatives that account for and are responsive to their needs. AIMS: This article distils the results of a review of published literature on the mental health of adolescent immigrants (ages 10-19) living in Canada. METHOD: Scoping review methods were used to define inclusion and exclusion criteria; inform the search strategies; and extract and synthesize key findings. RESULTS: Fourteen articles met criteria for inclusion. Analysis of the studies indicate diversity in mental health indicators, e.g., mental distress, emotional problems and behavioral problems, as well as a wide range of influences on mental health from age at migration and length of stay to place of residence, income and discrimination. CONCLUSIONS: Findings support the need to account for the array of influences on young people's mental health in relation to migration and to augment initiatives beyond the level of individual intervention.

An Arabidopsis mutant impaired in intracellular calcium elevation is sensitive to biotic and abiotic stress.

BACKGROUND: Ca2+, a versatile intracellular second messenger in various signaling pathways, initiates many responses involved in growth, defense and tolerance to biotic and abiotic stress. Endogenous and exogenous signals induce cytoplasmic Ca2+ ([Ca2+]cyt) elevation, which are responsible for the appropriate downstream responses. RESULTS: Here we report on an ethyl-methane sulfonate-mediated Arabidopsis mutant that fails to induce [Ca2+]cyt elevation in response to exudate preparations from the pathogenic mibrobes Alternaria brassicae, Rhizoctonia solani, Phytophthora parasitica var. nicotianae and Agrobacterium tumefaciens. The cytoplasmic Ca2+elevation mutant1 (cycam1) is susceptible to infections by A. brassicae, its toxin preparation and sensitive to abiotic stress such as drought and salt. It accumulates high levels of reactive oxygen species and contains elevated salicylic acid, abscisic acid and bioactive jasmonic acid iso-leucine levels. Reactive oxygen species- and phytohormone-related genes are higher in A. brassicae-treated wild-type and mutant seedlings. Depending on the analysed response, the elevated levels of defense-related compounds are either caused by the cycam mutation and are promoted by the pathogen, or they are mainly due to the pathogen infection or application of pathogen-associated molecular patterns. Furthermore, cycam1 shows altered responses to abscisic acid treatments: the hormone inhibits germination and growth of the mutant. CONCLUSIONS: We isolated an Arabidopsis mutant which fails to induce [Ca2+]cyt elevation in response to exudate preparations from various microbes. The higher susceptibility of the mutant to pathogen infections correlates with the higher accumulation of defense-related compounds, such as phytohormones, reactive oxygen-species, defense-related mRNA levels and secondary metabolites. Therefore, CYCAM1 couples [Ca2+]cyt elevation to biotic, abiotic and oxidative stress responses.

Towards the development of a gender-sensitive measure of women's mental health.

AIMS AND OBJECTIVES: To develop a gender-sensitive measure of women's mental health and to evaluate the measure's psychometric properties. BACKGROUND: Mental health problems are a leading global burden of disease, and gender differences in the prevalence of these problems are well documented. Improving mental health is as important as resolving mental health problems. Although many mental health scales have been developed, few measure women's positive mental health from a gender perspective. DESIGN: Instrument development and psychometric evaluation were used. METHODS: First, a new mental health scale (Women's Mental Health Scale) grounded in women's subjective experiences was formulated from the narratives of four female focus groups (n = 23). The new scale was evaluated using principal component analysis and internal consistency reliability in a sample of female participants (n = 106). Next, the Women's Mental Health Scale, the Chinese version of Beck Depression Inventory-II and Social Adjustment Scale Self-Report were used in a survey of female undergraduate students (n = 163) for examining the concurrent criterion-related validity. Finally, gender differences were examined by assessing the discriminated validity of the Women's Mental Health Scale in a sample of male and female undergraduate students (n = 357). All participants were recruited from communities and universities in middle and south Taiwan. RESULTS: A 50-item Women's Mental Health Scale with four concepts of self, interpersonal, family and social domains was developed. It revealed that the Women's Mental Health Scale had acceptable psychometric properties. There was a significant negative correlation between scores of the Women's Mental Health Scale and the Chinese version of Beck Depression Inventory-II and a significant positive correlation between scores of the Women's Mental Health Scale and Social Adjustment Scale Self-Report. There were significant gender differences in the family domain and social domain. Women reported greater mental health in the family domain and social domain than men. CONCLUSIONS: The Women's Mental Health Scale is a promising gender-sensitive tool to measure women's mental health. RELEVANCE TO CLINICAL PRACTICE: The Women's Mental Health Scale appears to be a gender-sensitive measure to assess the positive mental health potentials among women population.

Health care professionals implementing a smoke-free policy at inpatient psychiatric units.

Smoke-free grounds policies (SFGPs) were introduced to inpatient psychiatric hospital settings to improve health among patients, staff, and visitors. We conducted an ethnographic study in Northern British Columbia, Canada, to describe how the implementation of SFGPs is affected by institutional cultures. Data reported here included participant observation, document review, informal discussions (n = 11), and interviews with health care professionals (HCPs; n = 19) and staff (n = 2) at two hospitals. We used iterative and inductive processes to derive thematic findings. Findings related to HCPs illustrate how local contexts and cultural factors affect SFGP implementation. These factors included individual beliefs and attitudes, the influence of group norms, leadership and consensus building, and locale-specific norms. Strong, consultative leadership, in which leaders solicited input from and long-term support of people most directly responsible for policy implementation, was key to success.

The Influences of Health Beliefs and Identity on Adolescent Marijuana and Tobacco Co-Use.

Among youth, the co-use of marijuana and tobacco is highly prevalent, yet a considerable gap remains in the drug-prevention literature pertaining to such co-use. In particular, the prevention field lacks research exploring how adolescents understand the health implications of smoking these two substances in combination. In this article, we draw on qualitative interviews with adolescents from three communities in British Columbia, Canada, and describe the health beliefs and social identities that they associated with smoking marijuana and tobacco. We argue that smoking prevention and cessation initiatives targeting adolescents must address both marijuana and tobacco. Such initiatives must also be designed to identify and address how adolescents frame the potential health harms associated with smoking these substances.

Piriformospora indica suppresses the symptoms produced by Banana bract mosaic virus by inhibiting its replication and manipulating chlorophyll and carotenoid biosynthesis and degradation in banana.

Banana bract mosaic virus (BBrMV) infection results in characteristic reddish streaks on pseudostem and chlorotic spindle lesions on leaves leading to traveler's palm appearance and complete crop loss depending on the stage of infection in banana plants. Here, we discuss the influence of P. indica colonization (a beneficial fungal root endophyte) on BBrMV infection, specific viral component genes responsible for symptom development, chlorophyll and carotenoid biosynthesis, and degradation in BBrMV-infected banana plants. P. indica colonization significantly and substantially reduced the severity of Banana bract mosaic disease (BBrMD) in addition to increased growth, development and yield of banana plants. The percent disease incidence (PDI) of BBrMV ranges from 50 to 70 per cent in plants raised from suckers and from 58 to 92 per cent in TC plants under artificial inoculation. P. indica-colonized plants inoculated with BBrMV resulted in an enhanced plant height, root length, leaf width, and leaf length of 72, 88, 90, and 60 per cent, respectively, compared to BBrMV alone-infected banana plants along with the reduced disease severity. BBrMV infection showed a drastic decrease of chlorophyll a, chlorophyll b, and total chlorophyll contents by down-regulating chlorophyll biosynthesis (Chlorophyll synthase-CHLG) and upregulating chlorophyll degradation (Chlorophyllase-CLH1 and CLH2 and Pheophytin pheophorbide hydrolase-PPH) genes; and by up-regulating carotenoids biosynthesis (Phytoene synthases-PSY1 and PSY2) and down-regulating its degradation (Phytoene desaturase-PDS) genes compared to P. indica-colonized banana plants challenge inoculated with BBrMV. P. indica also inhibited the expression of the viral genes (P3 and HC-Pro) involved in symptom development. P. indica-colonized banana plants reduced the BBrMV symptoms severity by enhancing chlorophyll biosynthesis; and decreasing chlorophyll degradation and carotenoid biosynthesis and degradation; and inhibiting the viral genes responsible for symptom development in addition to enhanced growth and yield of banana plants. Supplementary Information: The online version contains supplementary material available at 10.1007/s13205-024-03983-y.

Weeding out the information: an ethnographic approach to exploring how young people make sense of the evidence on cannabis.

BACKGROUND: Contradictory evidence on cannabis adds to the climate of confusion regarding the health harms related to use. This is particularly true for young people as they encounter and make sense of opposing information on cannabis. Knowledge translation (KT) is in part focused on ensuring that knowledge users have access to and understand best evidence; yet, little attention has focused on the processes youth use to weigh scientific evidence. There is growing interest in how KT efforts can involve knowledge users in shaping the delivery of youth-focused public health messages. To date, the youth voice has been largely absent from the creation of public health messages on cannabis. METHODS: This ethnographic study describes a knowledge translation project that focused on engaging young people in a review of evidence on cannabis that concluded with the creation of public health messages generated by youth participants. We facilitated two groups with a total of 18 youth participants. Data included transcribed segments of weekly sessions, researcher field notes, participant research logs, and transcribed follow-up interviews. Qualitative, thematic analysis was conducted. RESULTS: Group dynamics were influential in terms of how participants made sense of the evidence. The processes by which participants came to understand the current evidence on cannabis are described, followed by the manner in which they engaged with the literature for the purpose of creating an individual public health message to share with the group. At project end, youth created collaborative public health messages based on their understanding of the evidence illustrating their capacity to "weed out" the information. The content of these messages reflect a youth-informed harm reduction approach to cannabis use. CONCLUSIONS: This study demonstrates the feasibility of involving young people in knowledge translation initiatives that target peers. Youth participants demonstrated that they were capable of reading scientific literature and had the capacity to engage in the creation of evidence-informed public health messages on cannabis that resonate with young people. Rather than simply being the target of KT messages, they embraced the opportunity to engage in dialogue focused on cannabis.

The process of safer crack use among women in Vancouver's Downtown Eastside.

In this article we discuss the findings from a grounded theory study in which we explored how women residing in Vancouver's Downtown Eastside (DTES) minimized some of the physical, psychological, and interpersonal harms associated with crack cocaine use, and identify the social, economic, and political factors that influence safer use. Data were collected over a 3-month period and involved group interviews with 27 women at an agency run by drug users in the DTES. A preliminary theory of safer crack use is discussed, consisting of the central phenomenon of caring for self and others. In addition, four thematic processes are described: (a) establishing a safe physical space, (b) building trusting relationships, (c) learning about safer crack use, and (d) accessing safer equipment. Implications of the findings are discussed in relation to supporting women's efforts and improving health outcomes.

Reconciling parenting and smoking in the context of child development.

In this article we explore the micro-social context of parental tobacco use in the first years of a child's life and early childhood. We conducted individual interviews with 28 mothers and fathers during the 4 years following the birth of their child. Using grounded theory methods, we identified the predominant explanatory concept in parents' accounts as the need to reconcile being a parent and smoking. Desires to become smoke-free coexisted with five types of parent-child interactions: (a) protecting the defenseless child, (b) concealing smoking and cigarettes from the mimicking child, (c) reinforcing smoking as bad with the communicative child, (d) making guilt-driven promises to the fearful child, and (e) relinquishing personal responsibility to the autonomous child. We examine the agency of the child in influencing parents' smoking practices, the importance of children's observational learning in the early years, and the reciprocal nature of parent-child interactions related to parents' smoking behavior.

Maternal-infant health outcomes and nursing practice in a remote First Nations community in northern Canada.

This article reports those findings related to maternal-infant health outcomes of an ethnographic study that explored nursing practice, continuity of care, and health outcomes in one remote First Nations community in northern Canada. Use of multiple data sources within an ethnographic design ensured that quantitative health outcomes data were interpreted within a contextualized understanding of the remote First Nations community.The sample comprised the charts of 65 mothers and 63 infants randomly selected for retrospective chart review. The findings suggest suboptimal maternal-infant health outcomes on several of the health indicator criteria identified for the purposes of this study. The authors discuss long-term sequelae of prenatal and infant health in terms of diabetes and other chronic health conditions in First Nations populations.They explore the implications of these findings in relation to nurses' preparation to offer prenatal and infant primary care in remote First Nations communities.