Perspectives on Conducting Research in Indian Country.

BACKGROUND: Certain research principles, framed within an indigenous context, are helpful guideposts to practice ethical, relevant, and sensitive inquiries. It is essential to further adapt research approaches based on the unique geographical, sociopolitical, and cultural attributes of partnering tribal communities. These adaptations are largely shaped by trial and error. OBJECTIVES: The purpose of this article is to offer the prospective novice nurse researcher lessons that we learned when entering Indian country to conduct research for the first time. As indigenous and nonindigenous researchers, we are not seeking to set down a methodology but rather offer a list of processes, environments, timelines, and barriers that we never learned in didactic, seminar, clinical, practicum, or any other academic setting. METHODS: We organized a set of memories and thoughts through a series of semistructured iterative sessions specific to our first encounters as researchers in Indian country. We compiled our written responses and field notes from our dialogue, interpreted these data, and organized them into themes. We have reported what we felt would be the most surprising, frequent, or important information to note. RESULTS: We identified three overarching themes in our collective experience: orientation and negotiation, situating ourselves and our work, and navigating our way. Subthemes included perceiving ourselves as outsiders, negotiating distance and time realities, relying on the goodness of gatekeepers, shaping research questions per community priorities, honing our cross-cultural and intercultural communication skills, discovering the many layers of tribal approval processes, and developing sensibilities and intuition. DISCUSSION: Our previous experiences as novices leading research projects in Indian country have produced unique sensibilities that may serve to guide nurse researchers who seek to partner with tribal communities.

Clinical outcomes of intrauterine device insertions by newly trained providers: The ECHO trial experience.

Objectives: To assess the rates of failed insertion, expulsion, and perforation when intrauterine device (IUD) insertions were done by newly trained clinicians, and to examine factors that may affect these outcomes. Study design: We evaluated skill-based outcomes following IUD insertion at 12 African sites in a secondary analysis of the Evidence for Contraceptive Options and HIV Outcomes (ECHO) randomized trial. Before trial initiation, we provided competency-based IUD training to clinicians and offered ongoing clinical support. We used Cox proportional hazards regression to examine factors associated with expulsion. Results: Among 2582 IUD acceptors who underwent first attempted IUD insertion, 141 experienced insertion failure (5.46%) and seven had uterine perforation (0.27%). Perforation was more common among breastfeeding women within three months postpartum (0.65%) compared with non-breastfeeding women (0.22%). We recorded 493 expulsions (15.5 per 100 person-years, 95% confidence interval [CI] 14.1─16.9): 383 partial and 110 complete. The risk of IUD expulsion was lower among women older than 24 years (aHR 0.63, 95% CI 0.50─0.78) and may be higher among nulliparous women. (aHR 1.65, 95% CI 0.97─2.82). Breastfeeding (aHR 0.94, 95% CI 0.72─1.22) had no significant effect on expulsion. IUD expulsion rate was highest during the first three months of the trial. Conclusions: IUD insertion failure and uterine perforation rates in our study were comparable to those reported in the literature. These results suggest that training, ongoing support, and opportunities to apply new skills were effective in ensuring good clinical outcomes for women receiving IUD insertion by newly trained providers. Implications: Data from this study support recommendations to program managers, policymakers, and clinicians that IUDs can be inserted safely in resource-constrained settings when providers receive appropriate training and support.

Voices of faculty of second-degree baccalaureate nursing students.

The limited research related to accelerated second-degree baccalaureate nursing programs primarily focuses on curricular issues or student experiences. The purpose of this study was to focus on the experiences of faculty teaching these students. Using a hermeneutic phenomenological approach, 14 second-degree faculty from the East Coast region of the United States were interviewed to understand their experiences teaching accelerated second-degree baccalaureate nursing students and how these experiences helped or hindered their teaching and learning practices with these students. The challenges associated with teaching these students were identified in the themes At the Top of My Game and Teaching to Think Like a Nurse. This article describes this study and the implications for teaching accelerated second-degree baccalaureate students.

Disability among older American Indians and Alaska Natives: an analysis of the 2000 Census Public Use Microdata Sample.

PURPOSE: We compared the prevalence of disability among older American Indians and Alaska Natives (AI/ANs) with that among their African American and White peers, then examined sociodemographic characteristics associated with disability among AI/ANs. DESIGN AND METHODS: We analyzed the 5% 2000 Census Public Use Microdata Sample. We assessed disability by functional limitation, mobility disability, and self-care disability for four age groups (55-64, 65-74, 75-84, and 85 years or older). RESULTS: For all age strata, AI/ANs reported the highest rates of functional limitation and African Americans the highest level of mobility disability. In the 55-to-64 age group, AI/ANs experienced the highest prevalence of self-care disability, and among those aged 65 years or older, African Americans reported the highest prevalence. Compared to Whites, the adjusted odds ratios for functional limitation, mobility disability, and self-care disability were significantly elevated in AI/ANs (1.62, 1.33, and 1.56, respectively) and African Americans (1.27, 1.54, and 1.56, respectively). For AI/ANs, being of increased age, being female, having lower educational attainment and household income, not being married or in the labor force, and residing in a metropolitan area were associated with disabilities. IMPLICATIONS: This study contributes to researchers' limited knowledge regarding disability among older AI/ANs. The lack of available empirical data poses obstacles to understanding the antecedents and consequences of disability for AI/ANs. More information on the nature and extent of disabilities among AI/AN elders would enhance the ability of advocates to document their needs and raise public awareness. Likewise, policy makers could enact prevention strategies and make comprehensive rehabilitative and long-term care services available to this population.

Predictors of success for Saudi Arabian students enrolled in an accelerated baccalaureate degree program in nursing in the United States.

In the mid 1980s, a professional nursing education program was initiated between the Kingdom of Saudi Arabia and the United States. Based on a perceived and documented need, a collaborative education and research program was established with George Mason University in Fairfax, Virginia, to begin building a community of new scholars to assist in the advancement of professional nursing in the Kingdom of Saudi Arabia. Four cohorts of Saudi citizens from three institutions (King Faisal Specialist Hospital and Research Center, Saudi Arabia National Guard Hospital, and Ministry of Aviation and Defense Hospital), who held a degree in science or a related field, were enrolled in an accelerated baccalaureate program leading to a bachelor of science in nursing degree. This project was funded by Saudi Arabian sources. A descriptive research study was conducted to identify predictors of success in the program. Results indicated a rate of program completion that was higher than expected. Some of the first graduates went on for a doctor of philosophy degree, but not all enrolled completed the program. Many countries around the world are seeking ways to upgrade and increase the supply of qualified nurses within their own borders. This study identified those factors that were predictors of success for Saudi Arabian students who completed a baccalaureate degree in nursing program in the United States.

An audit of nutritional care in a health board in Scotland.

This article's aim is to describe the processes used and results found when conducting an audit of nutritional care within a health board area in Scotland. Nutritional standards and an audit tool were developed by a multidisciplinary team and all in-patient clinical areas took part. The results demonstrate that there is still a considerable amount of work that needs to be undertaken to ensure that patients are getting the most effective and efficient nutritional care and this article denotes some of the initiatives instilled to address areas of identified challenges.

Preferences between injectable contraceptive methods among South African women.

OBJECTIVE: To examine South African women's preferences between depot medroxyprogesterone acetate (DMPA) and norethisterone enanthate (NET-EN), as well as the reasons for and correlates of these preferences. STUDY DESIGN: A cross-sectional study among women attending 26 primary health care clinics across the Western Cape Province. RESULTS: Of 893 women participating in the survey, 57% (n=511) and 45% (n=399) had ever used DMPA and NET-EN, respectively. Among women who knew of both injectables, 46% stated a preference for DMPA (n=365) and 37% stated a preference for NET-EN (n=297). Most women who preferred DMPA thought that it was more effective in preventing pregnancy, while women who preferred NET-EN stated that it was preferable for women who wanted children in the future. Preferences for NET-EN were independently associated with younger age, higher education and living in an urban area. CONCLUSION: These findings suggest that there are significant misperceptions among women regarding the differences between DMPA and NET-EN, which may have important resource implications for contraceptive services. It is likely that these misperceptions arise from popular discourse and individual user experiences, as well as poor communication with and counseling of women on the part of providers. Interventions aimed at both users and providers are required to dispel the myths and misinformation regarding progestogen-only injectable methods.

Using GIS in a first national mapping of functional disability among older American Indians and Alaska Natives from the 2000 census.

BACKGROUND: Geographical information systems (GIS) have been used mainly in understanding infectious diseases and environmental threats in health research. Here, GIS was used to examine patterns of functional disability as one impact of chronic disease in American Indians and Alaska Natives. The study purpose was to create the first national mapping of functional disability for AIANs using the 2000 U.S. Census. RESULTS: American Indians and Alaska Natives over age 65 reported disability at a rate of 57.6% versus 41.9% for all people over 65 (P < or = 0.0001). Regional differences in levels and type of disability were evident. CONCLUSION: Maps help visualize those who might otherwise be 'lost' from the data. The significance of this study is that gerontologic programs and policies are data-driven, yet there is a lack of reliable national level data from US health systems on functional disability among American Indians and Alaska Natives. One study limitation was that Census questions regarding disability differed from traditional measures of activities of daily living and instrumental activities of daily living. An immediate policy recommendation would be to incorporate standard activities of daily living and instrumental activities of daily living language into future Census for a comprehensive, linked database for the future.

Strengthening American Indian nurse scientist training through tradition: partnering with elders.

American Indian elders have long been the grandparents to not only their own relatives but also other 'grandchildren' in their tribes, clans and extended families. This worldview demands an elder-youth connection and has been integral to the success of the "American Indian MS to PhD Nursing Science Bridge" at the University of Minnesota, School of Nursing. Elders support the program mission to increase the number (from 12) of doctorally prepared Native nurses. They have been participants in formal and informal programming, special advising, and presence from reservations and in urban Minneapolis. Program feedback reveals cultural value in the elders' presence.

The cow and the coronary: epidemiology, biochemistry and immunology.

BACKGROUND: Certified death rates from coronary heart disease (CHD) are positively correlated country-by-country with milk consumption, particularly with that of the non-fat portion of milk. CHD death is also associated with circulating antibodies against milk fat-globule membrane (MFGM), raising the possibility that milk intake might be a specific risk factor for CHD. We studied the epidemiology and immunology of milk to see if the association is causal. METHODS: We plotted the intake of various foods country-by-country against CHD death rates to see if they were correlated in space and/or in time. We prepared fluorescein-tagged human antibodies against bovine MFGM to see if they showed any auto-reactivity against human tissue. RESULTS: Milk showed a positive correlation with CHD death rates in both space and time (r>0.9 in some cases). Beef was not correlated and cheese was negatively correlated, though not strongly. Wine was strongly negatively correlated. Human anti-bovine MFGM antibodies bind to human large granular lymphocytes and also to human platelets, causing aggregation. CONCLUSIONS: We suggest that non-fat aspects of milk, particularly the Ca/Mg ratio, lactose and MFGM antigens, have specific coronary atherogenic effects, both biochemical and immunological, and the simultaneous attack from these three directions may explain why this foodstuff has such a strong effect. Wine appears to be an antidote for the harmful effects of milk.

GIS(c): a scientific framework and methodological tool for nursing research.

The purpose of this article was to bring to nursing science a theoretical framework and technology that can transport with it new ways of knowing by exploiting microperspectives and macroperspectives, both from "within the map" and globally. Nursing continues to find its voice, but it also must lend its voice to the forming of Geographic Information Systems and Science in a pan-disciplinary partnership with geography, cartography, sociology, public health, and information technology. It is proposed that nursing take advantage of the latest databases that hold "person" information and layer these over geographical maps holding "environment" and "health" information as a new way of seeing and applying the metaparadigms of nursing. By using Geographic Information Systems for understanding spatial, numeric, health, and population relationships as they relate to nursing practice, research, and teaching, nursing science will continue to evolve at a speed needed to be effective in the new millennia.

Survey of knowledge, attitudes and practices surrounding the intrauterine device in South Africa.

BACKGROUND: The Copper T intrauterine device (IUD) is a safe, effective, reversible contraceptive that is used widely worldwide but little in South Africa. This study assesses the knowledge, attitudes and practices of potential IUD users and health care providers to inform strategies for expanding IUD use in South Africa. STUDY DESIGN: A descriptive, cross-sectional survey was conducted among 205 clients and 32 health care providers at 12 public sector clinics in two provinces. RESULTS: Twenty-six percent of clients had heard of the IUD; of those, 9% had misconceptions or incorrect information that negatively influenced their opinion of the method. After being given a description of the Copper T IUD, 74% said they would consider using it. Provider knowledge about Copper T IUDs was inaccurate and inadequate. Providers held incorrect beliefs about IUD candidate selection and risks. Almost all providers said that they needed more training and information about the IUD. CONCLUSION: If IUD use is to be expanded in South Africa, potential users will need education about the method and providers will need training on counseling and provision.

TOLERATED ILLNESS concept and theory for chronically ill and elderly patients as exemplified in American Indians.

BACKGROUND: The TOLERATED ILLNESS phenomenon refers to a noted discordance between subjective and objective health measures in the chronically ill patient. The TOLERATED ILLNESS theory of care helps explain why some patients will report good to excellent health in spite of their having low functional ability. METHODS: TI facilitates provider recognition of this largely unrecognized phenomenon and is instructive as to the why's for the patient tolerating illness. RESULTS: The goal of presenting this theory is to provide a way to identify, assess, and assist those previously silent with unmet needs to bring about optimum patient outcomes. CONCLUSIONS: Importantly, patient and provider goals may diverge.

Functional disability and associated factors among older Zuni Indians.

Few studies have focused on American Indian elderly and functional disability, and none have explored potential moderating or mediating factors that may lend themselves to subsequent intervention. The purpose of this study was to describe the extent of functional disability in elders and to determine which factors were associated with a higher number of Activities of Daily Living (ADL) limitations. The study was a secondary data analysis of an existing survey of American Indian elders in one southwest tribe. Functional disability was defined as limitations in ADLs and was measured by the percent of respondents reporting specific limitations and by the mean total ADL limitations. Multiple linear regression analyses were used to determine the demographic, socioeconomic and health factors associated with ADL limitations. In the 90 elders surveyed, 40 percent of respondents reported a limitation with bathing, 31 percent with walking, and 22 percent with dressing. Only 6 percent of the elders surveyed, however, reported their health status as "poor" on a 5-point scale. Factors associated with more ADL limitations included poorer health status, less frequent exercise, and more elder care services used. Rates of functional disability in this tribe were higher than those found in the U.S. for all races. Further studies are needed to understand functional disability in American Indian elders and their need for long-term care services.