Globalization: Migrant nurses' acculturation and their healthcare encounters as consumers of healthcare.

Globally, one of every eight nurses is a migrant, but few studies have focused on the healthcare experiences of migrant nurses (MNs) as consumers or recipients of healthcare. We address this gap by examining MNs and their acculturation, barriers to healthcare access, and perceptions of healthcare encounters as consumers. For this mixed-methods study, a convenience sample of MNs working in Europe and Israel was recruited. The quantitative component's methods included testing the reliability of scales contained within the questionnaire and using Hayes Process Model #4 to test for mediation. The qualitative component's methods included analyzing interviews with iterative inductive thematic analysis. Quantitative findings on MNs (n = 73) indicated that the association between acculturation and perception of the healthcare encounter, which MNs experienced as healthcare consumers, was mediated by barriers to healthcare access, even after adjusting for age and gender (p = 0.03). Qualitative interviews with MNs (n = 13) provided possible explanations for the quantitative findings. Even after working in the host country's healthcare system for several years, MNs reported difficulties with their healthcare encounters as healthcare consumers, not only due to their limited knowledge about the culture and healthcare resources but also due to the biased responses they received.

A country's efforts toward creating an advanced practice nurse in public health.

AIM: The study goal was to inform the creation of a blueprint for an advanced practice nurse (APN) in public health. BACKGROUND: No internationally accepted standard for an APN in public health exists. Activities of public health nurses (PHN) traditionally have centered on health promotion and disease prevention, but many have added other population-based activities such as chronic and acute disease treatment. INTRODUCTION: An APN in public health is needed to address the global challenges threatening the physical, social, and mental health of populations worldwide. METHODS: This qualitative study was comprised of six focus groups, each containing a different group of stakeholders (n = 40). Study results followed the requirements of the consolidated criteria for reporting qualitative research (COREQ). FINDINGS: Two major themes emerged: the APN role in public health and core expectations. From the APN role theme, four subthemes emerged on APN domains of public health practice and functions. From the core expectations theme, nine subthemes emerged on the APN's qualifications and behaviors. DISCUSSION: Agreement among stakeholders was found in the nine core expectations; however, among the four different visions of an APN in public health, two fit a population-based model rather than the traditional PHN model. CONCLUSIONS: A single APN role in public health is insufficient to address the breadth and complexity of today's global challenges as detailed by the sustainable development goals. Due to the interaction between health and the biopsychosocial environments, we need APNs with different areas of expertise. IMPLICATION FOR NURSING POLICY: Nurses working at universities, in public health services, and as healthcare policymakers are needed to create a multistage strategy that gradually introduces several different types of APNs in public health.

Resilience, optimism and posttraumatic growth in first-time mothers.

This study examines the association between posttraumatic growth (PTG) and two psychological attributes, resilience and optimism, in first-time mothers, after controlling for demographic and motherhood-related characteristics. PTG, the self-examination triggered by life-changing events, contains five factors: (1) relating to others, (2) new possibilities, (3) personal strength, (4) spiritual change, and (5) appreciation of life. Outcomes from studies conflict on whether PTG is associated with the two psychological attributes of resilience (the ability to resume one's life after adversity) and optimism (viewing life in a positive light). This study used a cross-sectional design. A convenience sample of first-time mothers whose infants were between 3 months and 1 year (N = 415) completed questionnaires containing several standardized and reliable instruments including those measuring the independent variables of resilience and optimism, and the dependent variable of PTG. A STROBE checklist guided the reporting of this study. Resilience was associated with overall PTG and four of its five factors. Optimism also was associated with overall PTG but only associated with two of its five factors. PTG profiles and squared semipartial correlations indicated that resilience had the stronger association, compared to optimism, with PTG and most of its factors. Our study's findings on the strong link between resilience and PTG suggest the need for research examining the impact of specific psychosocial nursing activities (e.g., providing emotional support; assisting others to identify their own strengths; encouraging the mobilization of one's internal resources; furnishing needed resources and referrals; and supplying health education and information), as these activities may not only promote resilience but also may contribute to PTG.

Relationship between social support and postpartum depression in migrant and non-migrant first-time mothers.

AIMS AND OBJECTIVES: This study examines the relationship between social status and postpartum depression by migrant generation and determines whether social support moderates the relationship between migrant generations and postpartum depression. BACKGROUND: Postpartum depression (PPD) afflicts more than 1 in 10 childbearing women worldwide; and this mental health problem may be higher among vulnerable populations of women such as migrants, an increasingly prevalent group in many countries. Social support and migrant generation (1st generation-mother and her parents born outside the host country; 2nd generation-mother born in the host country but not her parents; 2.5 generation-mother and one parent born in the host country) may contribute to the conflicting findings on migrant mothers and postpartum depression. DESIGN: This study used a cross-sectional design. METHODS: Sample recruitment of migrant and non-migrant first-time mothers (n=515) was implemented through an online platform. A STROBE checklist guided the reporting of this study. RESULTS: PPD was lower among mothers with social support. While social support was negatively associated with PPD for all mothers, PPD was not associated with migrant generation nor was a moderation effect found. CONCLUSIONS: Social support is negatively associated with PPD for all mothers, but levels of PPD for migrant mothers may be linked to country-specific healthcare resources and immigration policies. Immigrant policies influence migrant mothers' healthcare access; thus, immigration policies may influence PPD among first-time migrant mothers and the manner in which nurses can provide formal support. This study finds that social support, including the formal social support provided by nurses, decreases the likelihood of PPD. Demands on nurses' technical and assessment skills are high, but nurses also need to remember that their skills of providing social support are equally important, and for first-time mothers, may contribute to decreasing PPD.

Levels and sources of adolescents' sexual knowledge in traditional societies: A cross-sectional study.

Gender rules, patriarchy, and cultural taboos on sexual issues in traditional societies may compel adolescents to seek sexual information from informal and inadequate sources. The aim of this cross-sectional study was to determine whether the level and sources of sexual knowledge differed by gender in the traditional community comprising Palestinian-Israeli high school students. Guided by the Human Ecological Systems Model and informed by a community-based participatory research approach, a convenience sample of high school students (n = 558) was recruited. Although findings indicated that both boys and girls had low levels of sexual knowledge, the areas of knowledge deficits varied by gender. The model demonstrated good fit for boys but not for girls. Post hoc analyses indicated that girls obtained sexual knowledge solely from close family members, while boys obtained sexual knowledge from multiple sources. Very few students of either gender obtained sexual knowledge from doctors or nurses, but with community input on cultural issues, nurses can play a pivotal role in creating comprehensive, school-based sex education for adolescents living in traditional societies.

Factors linked to accessing COVID-19 recommendations among working migrants.

OBJECTIVES: Guided by the Health Belief Model (HBM), this study explored factors associated with accessing COVID-19 health information. DESIGN/SAMPLE: A cross-sectional study design was used. SAMPLE: Migrants (n = 259) employed in Israel prior to the onset of the COVID-19 pandemic were recruited. MEASUREMENTS: The on-line questionnaire included: The Satisfaction with Life Scale, the Brief Resilience Coping Scale and Immigrants' Language Ability scale. RESULTS: Migrants obtaining COVID-19 information when issued were more likely to have decreased employment or unemployment after COVID-19 government restrictions (OR = 1.98; CI = 1.03, 3.89; p < .05) and more likely to have a better language ability (OR = 1.20; CI = 1.10, 1.32, p < .0001), but they were less likely to use family and/or friends as their COVID-19 health resource (OR = 0.54, CI = 0.30, 0.96; p < .05). Migrants encountering the most employment difficulties were: female (p < .05), older age (p < .05), unmarried (p < .01), with unstable finances (p < .0001), and in Israel less than 5 years (p < .01). CONCLUSIONS: Migrants with more precarious employment had more societal disadvantage (i.e., women, older age, unmarried, poorer socioeconomic status, and newer migrants) and relied on informal and potentially inaccurate, health sources. Public health officials aiming to decrease COVID-19 infection must improve health information access to all members of society, particularly at-risk groups such as migrants.

Resilience in late adolescence/young adulthood: Rising to the occasion?

The developmental period of late adolescence/young adulthood is characterized by transitioning to an independent individual with a self-identity, established health habits and the components of resilience: (1) confidence in one's abilities (personal competence) and (2) the ability to adapt to changes (acceptance of self and life). This two-wave, prospective study examines the associations among self-identity, health habits and resilience in 18 year olds (n = 149) before military service and six months afterward. The questionnaire included validated scales of resilience and self-identity, as well as instruments measuring health habits, family environment and demographic characteristics. Cross-sectional findings indicated that resilience at baseline was associated with gender-male (p < .05), lower distress (p < .001) and higher identity-affirmation/belonging (p < .05). Longitudinal findings showed that resilience was associated with changes of distress (p < .05) and the resilience component of personal competence (p < .001). Cross-sectional and longitudinal perspectives on 18-year-old military recruits portrayed different pictures. The cross-sectional findings showed that resilience was associated with lower distress and higher feelings of affirmation/belonging (self-identity); however, longitudinal findings showed that resilience was predicted by the ability to adapt to changes under stress. Resilient 18 year olds demonstrated the ability to adapt to stressful situations, but psychological distress may impede the development of self-identity.

The Cultural and Methodological Factors Challenging the Success of the Community-Based Participatory Research Approach When Designing a Study on Adolescents Sexuality in Traditional Society.

Youth growing up in traditional cultures are split between the messages that they receive on sexuality from their families and those they receive via the internet depicting values of Western culture. The Palestinian-Israeli community, a national, ethnic, and linguistic minority, is an example of this situation. The purpose of this community-based participatory research study is to describe the challenges and lessons learned about launching a community advisory board (CAB) in studies on the taboo topic of adolescent sexuality. Using content analysis, we identified two necessary conditions to convene a CAB on adolescent sexuality in a traditional community: (a) an insider academic researcher, fluent in the native language, able to discuss the linguistic difficulties of sexual terminology and (c) the recruitment of motivated, community activists who were knowledgeable on the topic. The mostly traditional society of Palestinian-Israelis shuns discussions on sexuality; but with these two conditions, the study was a success.

Immigrants' Health, Acculturation, and the Work-Retirement Continuum.

Although the link between immigrants' health status and employment is well established, there is little information on the combined impact of three components of acculturation (that is, dual self-identity, language proficiency, and realized expectations) on this link. Immigrants who came to Israel from English-speaking countries (N = 377) were categorized into three groups based on the work-retirement continuum (that is, working, same occupation; working, changed occupation; or retired). Using a cross-sectional design, this study examined whether the link between health and acculturation varied by immigrants' location on the work-retirement continuum. Bivariate analyses revealed group differences for two acculturation components, language proficiency (p < .0001) and dual self-identity (p < .05). Multivariable analyses indicated an interaction effect between the acculturation component of realized expectations and work-retirement continuum group status on health status. As a result, good health was related to higher levels of realized expectations for the retired group; related to lower levels of realized expectations for the "working, changed occupations" group; and unrelated to realized expectations for the "working, same occupation" group. The acculturation component of realized expectations varies depending on the immigrant's location on the work-retirement continuum. Health and social welfare professionals can promote health in working or retired immigrants by providing clear and realistic information to better align with immigrants' expectations.

Occupational strain and job satisfaction: The job demand-resource moderation-mediation model in haemodialysis units.

AIM: To examine whether job resources moderate the relationship between job demands and occupational strain, and whether occupational strain mediates the relationship between job demands and job satisfaction. BACKGROUND: The job demand-resource model suggests that job demands and job resources are related to occupational strain, and occupational strain is associated with job satisfaction. METHODS: In 2018, a cross-sectional study was conducted with a convenience sample of 85 nurses from six haemodialysis units. Linear regression with moderation-mediation analysis was conducted using SPSS software. RESULTS: Under low workload levels, no association between autonomy and occupational strain existed, but under high workload levels, a negative relationship was found between autonomy and occupational strain. Under low workload levels, a negative relationship was found between social support and occupational strain, but under high workload levels, a positive relationship was found. Finally, there was no association between occupational strain and job satisfaction. CONCLUSION: Job resources are moderators of the relationship between job demands and occupational strain. However, there was no significant association between occupational strain and job satisfaction. IMPLICATIONS FOR NURSING MANAGEMENT: Nurse leaders should strengthen nurses' autonomy, which can reduce occupational strain. Additionally, sources of support are needed to help nurses cope with the workload and occupational strain.

Health indicators and social gradient in adolescent immigrants' health risk and healthcare experiences.

Few studies have assessed healthcare experiences in apparently healthy adolescents, or whether healthcare attitudes are linked to the two leading adolescent health indicators, smoking and obesity. Even fewer have examined these relationships in adolescent immigrant groups or made comparisons to adolescent non-immigrants. Using a cross-sectional study, healthcare experiences were compared among three groups of adolescents (n = 589) including Russian immigrants (n = 154), Ethiopian immigrants (n = 54), and non-immigrants (n = 381). Bootstrap estimates indicated positive healthcare experiences were less common among Russian adolescent immigrants (OR = 0.38, CI = 0.17, 0.86) compared to non-immigrants, unless the Russian adolescent immigrants reported above average socioeconomic status, in which case they were more likely than non-immigrant adolescents to report positive healthcare experiences (OR = 3.22, CI = 1.05, 9.85). Positive healthcare experiences were less likely among adolescents who were smokers (OR = 0.50, CI = 0.27, 0.91), and more likely for adolescents with a normal or low BMI (OR = 3.16, CI = 1.56, 6.40) and for those relying on parents for health information (OR = 1.97, CI = 1.05, 3.70). CONCLUSION: Findings suggest a social gradient in which positive healthcare experiences were more common among adolescence with higher socioeconomic status for some immigrants (Russian adolescents) but not for others. The two leading health indicators were related to healthcare experiences, but as adolescent smokers were less likely to have positive healthcare experiences, proactive efforts are needed to engage this group. What is Known: • Health indicators (such as obesity) and healthcare attitudes are linked to healthcare service use among adolescents sampled from outpatient and inpatient populations. What is New: • A social gradient involving socioeconomic status and being an adolescent immigrant was found regarding risky health indicators (i.e., smoking, use of internet as the primary source of health information). • Problematic health indicators, such as smoking, is linked to less positive healthcare attitudes in apparently healthy adolescents (both immigrants and non-immigrants).

A 5-step framework to promote nursing community inclusivity: The example of nurses with disabilities.

AIMS AND OBJECTIVES: To provide a five-step conceptual framework to promote community inclusivity among nurses and nursing students, using the example of nursing student with a disability. BACKGROUND: The value of cultural diversity, including characteristics such as socioeconomic status, ability/disability, sexual affection and ethnicity and/or race, is integrated into bachelor's nursing programmes. Yet, often the focus centres on patient care rather than to fellow nursing students or registered nurses. DESIGN: Discursive paper describing a five-step health promotion course framework to promote inclusion for students with disabilities into the nursing community. METHODS: Using the health promotion course platform, this framework demonstrates the integration of important issues such as well-being to those of cultural diversity, inclusivity and feeling belonging to a community, which are essential prerequisites towards achieving cultural competence. FINDINGS: Health promotion courses provide an optimal platform to teach students about the social environment, well-being and inclusivity, and gives students the opportunity to reflect on the impact of their attitudes and behaviours on social inclusivity in their student community, and later, on their nursing community. CONCLUSIONS: Using the example of nursing students with disabilities, the five-step framework incorporates the concepts of social well-being, health and community inclusivity. Nursing students belong to a culturally diverse community including individuals with disabilities. A single course on community inclusivity is insufficient; the approach of inclusivity must be woven throughout the nursing curriculum. RELEVANCE TO CLINICAL PRACTICE: As approximately 15% of the world's population has a disability, nurses must possess an understanding of individuals with a disability as an aspect of cultural diversity. It is the responsibility of programmes to instil in nursing students, the ability to appreciate and work with culturally diverse student and registered nurses. Such goals not only reflect nursing goals, but also strengthen the cohesion and inclusivity of the nursing community.

Adolescent immigrants, the impact of gender on health status.

Background: : Although studies have described the 'healthy immigrant effect' in adults, far fewer have examined the 'healthy immigrant effect' for adolescents living in immigrant families. Those few studies that did, noted conflicting results, and also differed on whether gender confounds the results. : This cross-sectional study was informed by the community-based participatory research (CBPR) approach in which researchers obtained the expertise and guidance on instrument design and study implementation. Data collection of self-administered surveys was completed between May 2015 and December 2015 on adolescents. Comparisons were made among six groups based on gender and immigrant status. : Of the total sample ( n = 618), more than a third were first or second generation immigrant adolescents ( n = 239). Comparisons among six groups, categorized by gender and immigrant status (i.e. first generation immigrants, second generation immigrants, native born), indicated many differences. However, when the differences were taken into account using logistic regression models, excellent health status was least likely to be reported by second generation immigrant males (versus native born adolescent females) ( P < 0.01), even after adjusting for the independent associations found for psychological symptoms ( P < 0.0001), not smoking ( P < 0.05) and having normal BMI ( P < 0.05). : This study demonstrates the relative disadvantage of second generation immigrant boys, but not first generation boys or first and second generation immigrant girls relative to their native counterparts. Reasons for the gap may be differences in support services and/or parental expectations; however further studies are needed to confirm these possibilities.

Statewide Policy Change in Pediatric Dental Care, and the Impact on Pediatric Dental and Physician Visits.

Introduction In 2007, the California signed legislation mandating a dental visit for all children entering kindergarten or first grade; no such mandate was made for physician visits. This study examines the impact of this policy change on the risk factors associated with obtaining pediatric dental and physician health care visits. Methods Every 2 years, California Health Interview Survey conducts a statewide survey on a representative community sample. This cross-sectional study took advantage of these data to conduct a "natural experiment" assessing the impact of this policy change on both pediatric physician and dental care visits in the past year. Samples included surveys of adults and children (ages 5-11) on years 2005 (n = 5096), 2007 (n = 4324) and 2009 (n = 4100). Results Although few changes in risk factors were noted in pediatric physician visits, a gradual decrease in risk factors was found in pediatric dental visits from 2005 to 2009. Report of no dental visit was less likely for: younger children (OR -0.81, CI 0.75-0.88), insured children (OR 0.34, CI 0.22-0.53), and children who had a physician's visit last year (OR 0.37, CI 0.25-0.53) in 2005. By 2007, absence of insurance was the only risk factor related to having no dental visit (OR 0.34, CI 0.19-0.61). By 2009, no a priori measured risk factors were associated with not having a dental visit for children aged 5-11 years. Conclusions A statewide policy mandating pediatric dental visits appears to have reduced disparities. A policy for medical care may contribute to similar benefits.

Double whammy: Adverse childhood events and pain reflect symptomology and quality of life in women in substance abuse treatment.

BACKGROUND: This study examined the profiles of symptoms and health-related quality of life (QOL) of women in substance abuse treatment, comparing those with higher versus lower histories of adverse childhood events (ACE), and those with versus without current pain. METHODS: Adult women in outpatient substance abuse treatment (n = 30) completed questionnaires (cross-sectional study) on topics including drug use, adverse childhood events (ACE), QOL, functional ability, current pain, and depression. RESULTS: Women with pain indicated significant differences in emotional (p < 0.05), and functional ability (p < 0.01); but no significant differences were found between women with high versus low levels of ACE. Yet, radar plots of women with both current pain and high levels of ACE, versus those without, portrayed a distinctive profile indicating high levels of anxiety and depression. CONCLUSIONS: Rather than a checklist, visual composites of symptoms experienced by women in substance abuse treatment illustrates areas of concern in the overall status of women in substance abuse treatment.

Work Role Perspectives of Clinical Instructors From Three Countries.

BACKGROUND: Educational institutions partner with health facilities to provide clinical education, but the impact of these partnerships on clinical instructors is rarely examined. METHOD: A cross-sectional study was used to obtain surveys from a convenience sample of clinical instructors (n = 135) working in Israel, Norway, and the United States. The Nursing Clinical Instruction Role Assessment Tool (N-CIRAT) was developed to elicit clinical instructors' perspectives on the importance and nature of their work roles. FINDINGS: The N-CIRAT exhibited good reliability and revealed three different work roles: educator, hospital partner, and patient advocate. The educator work role did not differ by primary employer; it did for the work role of hospital partner (p < .05) and patient advocate (p < .05). Patient advocate work role importance was rated high for all clinical instructors. CONCLUSION: The educator role of clinical nurse educators, including being a role model and encouraging reflection, is universal among clinical instructors.

A qualitative study assessing cardiovascular risk factors: the accumulative stressors influencing societal integration of teenage African immigrants.

BACKGROUND: This study examines the nature of disparities in cardiovascular risk by exploring chronic stressors and other cardiovascular risk factors on youth of African descent who are integrating into an industrialized society. METHODS: Qualitative data on cardiovascular risk and acclimation to the dominant society were collected from three groups of key informants: (1) community leaders; (2) youth; and (3) a community advisory group. RESULTS: Youth of Ethiopian descent engaged in the same western diets, computerized social networking, and habits in smoking and alcohol use as did youth from the dominant society. However, informants of Ethiopian descent encountered and witnessed racism, institutional discrimination and evidence of devaluing Ethiopian culture, influencing youths' ability to integrate into the society. CONCLUSION: Immigrant youth of Ethiopian descent face an accumulation of conflicting social support, psychosocial factors, and stressors, including: living in low-income, high-crime areas; encountering pervasive discrimination; acclimating to a new and industrialized culture; and navigating within an often unhospitable society. Contributing to these factors are changes in health behaviors such as adding processed foods and sugary drinks to the diet, increasing heavy alcohol use and substituting screen use for physical activity. The accumulative impact of these factors contributes to the marginalization of youth of Ethiopian descent in the dominant society and perpetuates a cycle of increasing cardiovascular risk.

The relationship between mentoring on healthy behaviors and well-being among Israeli youth in boarding schools: a mixed-methods study.

BACKGROUND: Although 10% of Israeli youth live in boarding schools, few studies, except for those focusing on mental health, have examined the well-being of this population subgroup. Thus, the aims of this study were to explore: (1) the prevalence rates of five aspects of well-being (i.e., healthy habits, avoidance of risky behaviors, peer relationships, adult relationships, and school environment) in youth residing at Israeli boarding schools; (2) the relationships between youth well-being and youth perception of their mentor; and (3) the different subgroups of youth with higher rates of risky and healthy behaviors. METHODS: This study used a mixed-methods approach including a quantitative survey of youth (n = 158) to examine the association between youth behaviors and perception of their mentor; and a qualitative study consisting of interviews (n = 15) with boarding school staff to better understand the context of these findings. RESULTS: Greater proportions of boarding school youth, who had positive perceptions of their mentor (the significant adult or parent surrogate), believed both that their teachers thought they were good students (p < 0.01), and that they themselves were good students (p < 0.01). This finding is supported by the qualitative interviews with mentors. Youth living in a boarding school had very similar healthy habits compared to other youth living in Israel; however, youth in the general population, compared to those in the boarding schools, were eating more sweets (OR = 1.39, 95% CI = 1.02-1.90) and engaging in higher levels of television use (OR = 2.64, 95% CI = 1.97-3.54). CONCLUSIONS: Mentors, the significant adult for youth living in residential education environments, have a major influence on school performance, the major focus of their work; mentors had no impact on healthy behaviors. Overall, there were many similarities in healthy behaviors between youth at boarding schools and youth in the general population; however, the differences in healthy habits seemed related to policies governing the boarding schools as well as its structural elements.

Functional decline and satisfaction with nursing care among older hospitalized adults.

Around hospitalization, older adults often experience functional decline which can be a reflection of their need for nursing care. Given a shortage of nurses, determining the relationship between functional change and patients' satisfaction with nursing care can help to gauge the need for care. We assessed this relationship in a mixed prospective-correlational cohort study with 393 patients, 70 years or older. The art, tangible aspects and general satisfaction with nursing care were measured through interviews conducted at discharge. Patients' functional status was assessed at admission and discharge. Decline in functioning during hospitalization was the most powerful predictor of higher satisfaction with art and tangible aspects of nursing care in multivariate regression (ß = 0.17-0.19, P < 0.01). This finding suggests that patients whose functioning deteriorates during hospitalization, have a greater need for and more contact with professional nursing care, and therefore report higher satisfaction with specific aspects of nursing care.

Risks for re-hospitalization of persons with severe mental illness living in rehabilitation care settings.

BACKGROUND: The high rates of psychiatric re-hospitalizations (also termed "revolving door") presents a "wicked problem" which requires a systematic and holistic approach to its resolution. Israel's mental-health rehabilitation law provides a comprehensive set of services intended to support the ability of persons with severe mental illness to rely on community rather than in-patient facilities for their ongoing care needs. Guided by the Health Behavior Model, we examined the relationship between psychiatric re-hospitalizations and the three Health Behavior Model factors (predisposing factor: socio-demographic characteristics and health beliefs; enabling factor: personal and social/vocational relationships facilitated by rehabilitation interventions and services; and need factor: outcomes including symptoms, and mental health and functional status) among persons with severe mental illness receiving rehabilitation services. METHODS: Logistic regression models were used to measure the association between re-hospitalization within a year and variables comprising the three Health Behavior Model factors on the sample of consumers utilizing psychiatric services (n = 7,165). The area under the curve for the model was calculated for each factor separately and for all three factors combined. RESULTS: A total of 846 (11.8%) consumers were hospitalized within a year after the study began. Although multivariable analyses showed significant associations between re-hospitalization and all three Health Behavior Model factors, the magnitude of the model's area under the curve differed: 0.61 (CI = 0.59-0.64), 0.56 (CI = 0.54-0.58), 0.78 (CI = 0.77-0.80) and 0.78 (CI = 0.76-0.80) for predisposing, enabling, need and the full three-factor Health Behavior Model, respectively. CONCLUSION: Findings revealed that among the three Health Behavior Model factors, the need factor best predicted re-hospitalization. The enabling factor, comprised of personal relationships and social/vocational activities facilitated by interventions and services representing many of psychiatric rehabilitation's key goals, had the weakest association with reduced rates of re-hospitalization. Possible explanations may be inaccurate assessments of consumers' personal relationships and social/vocational activities by the mental healthcare professionals, problematic provider-consumer communication on the consumers' involvement in social/vocational activities, or ineffective methods of facilitating consumer participation in these activities. Clearly to reduce the wicked "revolving-door" phenomenon, there is a need for targeted interventions and a review of current psychiatric rehabilitation policies to promote the comprehensive integration of community rehabilitation services by decreasing the fragmentation of care, facilitating continuity of care with other healthcare services, and utilizing effective personal reported outcomes and experiences of consumers with severe mental illness.