Testing a model of health-related quality of life in women living with HIV infection.

PURPOSE: The purpose of this secondary analysis was to test Ferrans et al.'s (J Nurs Scholarsh 37(4):336-342, 2005) revised model of health-related quality of life (HRQoL) (2005) modified from the Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model on women living with HIV. The primary aim was to test this model, examining the relations among the five central components (biological function, symptoms, functional status, general health perceptions, and HRQoL). The secondary aim was to explore the individual (age, children, race, marital status, education) and environmental (HIV-related stigma, social support) characteristics that may impact the main components of the model. METHODS: This study employed a cross-sectional correlational design using baseline data from 178 women living with HIV/AIDS who participated in one of the two independent randomized controlled trials designed to enhance HIV medication adherence. Path analysis using structural equation modeling was used to examine the hypothesized multivariate relations proposed in the revised Wilson and Cleary (J Am Med Assoc 273(1):59-65, 1995) model of HRQoL. RESULTS: While the revised model did not fit, exploratory post hoc modified models with a path from depressive symptoms to overall general health had an adequate model fit. Women with lower depressive symptoms (r = -.457, p < .01), lower HIV-related stigma (r = -.462, p < .01), higher social support (r = .413, p < .01), higher physical functioning (r = .350, p < .01), and higher general health perceptions (r = .537, p < .01) had higher overall HRQoL. CONCLUSIONS: The results of this study have the potential to assist healthcare professionals in improving HRQoL for women living with HIV/AIDS.

Interprofessional collaborative practice incorporating training for alcohol and drug use screening for healthcare providers in rural areas.

Interprofessional collaborative practice expands resources in rural and underserved communities. This article explores the impact of an online education programme on the perceptions of healthcare providers about interprofessional care within alcohol and drug use screening for rural residents. Nurses, behavioural health counsellors, and public health professionals participated in an evidence-based practice (screening, brief intervention, and referral to treatment-SBIRT) model that targets individuals who use alcohol and other drugs in a risky manner. SBIRT is recommended by the United States Preventive Services Task Force as a universal, evidence-based screening tool. Online modules, case simulation practice, and interprofessional dialogues are used to deliver practice-based learning experiences. A quasi-experimental method with pre-tests and post-tests was utilised. Results indicate increased perceptions of professional competence, need for cooperation, actual cooperation, and role values pre-to-post training. Implications suggest that online interprofessional education is useful but the added component of professional dialogues regarding patient cases offers promise in promoting collaborative practice.

Weighing worth against uncertain work: the interplay of exhaustion, ambiguity, hope and disappointment in mothers breastfeeding late preterm infants.

Poor breastfeeding outcomes among late preterm infants (LPIs) have been attributed to inadequate breast milk transfer stemming from physiological immaturities. However, breastfeeding is more than a biological phenomenon, and it is unclear how mothers of LPIs manage other factors that may also impact the breastfeeding course. Using grounded theory methods and incorporating serial post-partum interviews with several novel data collection techniques, we examined breastfeeding establishment over a 6-8-week-period among 10 late preterm mother-infant dyads recruited from a maternity hospital in Pittsburgh, Pennsylvania, USA. We found that breastfeeding in the LPI population was a fluctuating, cascade-like progression of trial and error, influenced by a host of contextual factors and events and culminating with breastfeeding continuation (with or without future caveats for duration or exclusivity of breastfeeding) or cessation. The trajectory was explained by the basic psychosocial process Weighing Worth against Uncertain Work, which encompassed the tension among breastfeeding motivation, the intensity of breastfeeding work and the ambiguity surrounding infant behaviour and feeding cues. Several sub-processes were also identified: Playing the Game, Letting Him Be the Judge vs. Accommodating Both of Us and Questioning Worth vs. Holding out Hope. If valid, our theoretical model indicates a need for earlier, more extensive and more qualified breastfeeding support for mothers of LPIs that emphasizes the connection between prematurity and observed feeding behaviours.

Is difficult childbirth related to postpartum maternal outcomes in the early postpartum period?

Unplanned, adverse events during labor or delivery may generate a negative response during the early postpartum period, resulting in disruption of usual functioning and mood. High levels of maternal depressive symptoms are associated with parenting, infant attachment, behavioral problems and cognition (Beck 2002). The purpose of this study was to examine the relationship of adverse events in labor or delivery and depressive symptoms, functional status and infant care at 2-weeks postpartum. The secondary aim was to explore the role of social support as a possible moderator in the relationship between adverse birth events and maternal outcomes. A secondary analysis of data (n = 123) was performed using data collected in a prospective, observational study examining the effects of antidepressant use during pregnancy. Adverse events did not significantly predict depressive symptoms (odds ratio = 1.34, p = .536), functional status (R(2) change = .001, p = .66), or infant care (R(2) change = .004, p = .48) at 2-weeks postpartum when controlling for depression during pregnancy, antidepressant use at delivery, education level, age, and parity. Social support had significant effects on depressive symptoms (p = .02), functional status (p = .014), and infant care (p < .001) but did not moderate the effect of adverse events when predicting depressive symptoms (odds ratio = 1.01, p = .045), functional status (R(2) change = .009, p = .056) and infant care (R(2) change < .001, p = .92). Adverse events did not predict maternal outcomes at 2-weeks postpartum. Social support was related to depressive symptoms, functional status and infant care, but did not moderate the effects of adverse events.

Policy support for expanding the adolescent vaccine school mandate in Pennsylvania to include the human papillomavirus (HPV) vaccine.

Approximately 27,000 men and women are affected by human papillomavirus (HPV)-related cancer every year. The Advisory Committee for Immunization Practices and the Centers for Disease Control and Prevention (CDC) routinely recommend that adolescents receive HPV, tetanus, diphtheria, and acellular pertussis (tetanus-diphtheria-acellular pertussis [Tdap]) and meningococcal (MCV) vaccines at age 11-12 years. Although the CDC and professional organizations such as the American Academy of Pediatrics make national vaccine recommendations, according to the National Vaccine Information Center, it is the responsibility of "state health departments to make and enforce vaccine mandates for school entry." The Pennsylvania Department of Health has only mandated two of the recommended three vaccinations: Tdap and MCV. As of 2016, 92% of adolescents aged 13-17 years in Pennsylvania received the Tdap vaccine and 92.7% received the MCV. However, only 58% of females and 44.4% of males aged 13-17 years received all three doses of the HPV vaccine. A comparison of HPV vaccine rates in states with school mandates was compared with Pennsylvania rates. Human papillomavirus vaccination rates were found to be significantly higher in the District of Columbia and Rhode Island, which have HPV vaccine school-entry requirements, supporting the need for a statewide HPV mandate in Pennsylvania.

Learning and Teaching Together to Advance Evidence-Based Clinical Education: A Faculty Learning Community.

Clinical teaching is a cornerstone of health sciences education; it is also the most challenging aspect. The University of Pittsburgh Schools of Dental Medicine, Nursing, and Pharmacy developed a new evidence-based interprofessional course framed as a faculty learning community (FLC) around the principles of learning in a clinical environment. The aim of this study was to assess the overall effectiveness of this two-semester FLC at four health professions schools in academic year 2014-15. The assessment included anonymous participant surveys in each session and an anonymous end-of-course survey. Thirty-five faculty members from dental, health and rehabilitation sciences, nursing, and pharmacy enrolled in the FLC, with six to 32 enrollees attending each session. All attendees at each session completed the session evaluation surveys, but the attendance rate at each session ranged from 17.1% to 91.4%. Sixteen participants (46%) completed the end-of-course survey. The results showed overall positive responses to the FLC and changes in the participants' self-reported knowledge. Session surveys showed that the participants found the FLC topics helpful and appreciated the opportunity to learn from each other and the interprofessional nature of the FLC. Responses to the end-of-course survey were in alignment with the individual session surveys and cited specific benefits as being the content, teaching materials, and structured discussions. In additional feedback, participants reported interest to continue as a cohort and to extend the peer-support system beyond the FLC. This outcomes assessment of the first round of the FLC confirmed that this cohort-based faculty development in an interprofessional setting was well received by its participants. Their feedback provided valuable insights for changes to future offerings.

A Call to Action to Address Barriers to Breastfeeding and Lactation Faced by Student-Mothers.

Many new mothers returning to school after childbirth face barriers within their academic settings to meeting their goals for exclusive breastfeeding. Potential barriers to breastfeeding faced by student-mothers include lack of legal protection, lack of breastfeeding-friendly university policies, inadequate availability of breastfeeding facilities, and insufficient awareness of the importance of breastfeeding among mothers, health care providers, and university administrators and faculty. Here we advocate for six action steps to help remove barriers to breastfeeding faced by student-mothers.

Do American Colleges and Universities Support the Lactation Needs of Students?

BACKGROUND: Despite strong evidence for the health benefits of breastfeeding, many mothers cannot continue breastfeeding their infants upon their return to work or school. Students are especially affected by this transition because they do not have legal protection that requires designated lactation space or time to express milk to be provided by places of education. Furthermore, limited research has been completed that specifically addresses the return to school of mothers who are students. MATERIALS AND METHODS: One hundred fifty-seven colleges and universities from across the United States were contacted through telephone and/or e-mail, and their websites were searched to assess the support they offer for lactating students. The presence of a formal policy for lactating students and designated lactation rooms, accessible to students, were the key measures. RESULTS: Information was gathered from 88.53% (n = 139) of the colleges and universities. A mere 3.6% (n = 5) had an official policy for lactating students and/or had the lactation spaces mentioned in the student handbook. However, more than half of the colleges and universities (54.68%; n = 76) had designated lactation spaces accessible to their students. CONCLUSION: The vast majority of the sample did not have a policy for lactating students, and almost half of the schools did not have designated space for milk expression accessible to students. Lactating students will likely encounter challenges in simultaneously sustaining breastfeeding and meeting their educational goals in these contexts. To meet the recommendation of the American Academy of Pediatrics of 6 months of exclusive breastfeeding and continued breastfeeding for 1 year or more, American colleges and universities must establish not only designated spaces for milk expression but also policies to support lactating students.

Characteristics of inner-city pregnant smoking teenagers.

OBJECTIVE: To describe baseline characteristics of inner-city pregnant adolescent smokers and examine these variables as potential predictors of long-term tobacco abstinence. STUDY DESIGN: Descriptive study design of the characteristics of pregnant adolescent smokers, with conceptual underpinnings from the Problem-Behavior Theory. SETTING: Recruitment and data collection were completed in inner-city outpatient clinics and public schools. PARTICIPANTS: The study enrolled 142 pregnant smoking adolescents. MAIN OUTCOME MEASURES: Self-reported smoking behavior (abstinence vs. smoking) assessed at 12 months from study enrollment was the criterion outcome variable. Variables from Problem-Behavior Theory, tobacco use, and demographics variables were selected as predictors of interest. RESULTS: Twelve months following study enrollment, 123 (87%) participants were smoking, with 19 (13%) reporting abstinence. Pregnant adolescents received messages of encouragement from parents and peers to quit smoking but complicated their pregnancies and smoking cessation efforts by concurrently consuming alcohol during the pregnancy. CONCLUSION: Findings from this study support previous research on adolescent smokers and extend our knowledge to the inner-city pregnant adolescent smoker. These pregnant teenagers present many needs and challenges for the nurses responsible for their care.

Implementing evidence-based practice: reducing risk for low birth weight through pregnancy smoking cessation.

In 1989, the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) developed a research utilization program to integrate evidence into practice areas where there were large discrepancies between research evidence and clinical practice. The current program, renamed Research-Based Practice (RBP), uses translational research methods to build from evidence such as that in the Cochrane database and to create protocols for integration of research directly into clinical practice. This article describes the development of the sixth project (RBP6), in which an evidence-based protocol to address smoking in pregnancy was integrated into clinical practice. The protocol includes screening women using descriptive statements and integrates the 5 As (ask, advise, assess, assist, arrange) into prenatal and postpartum care at every visit. By integrating smoking cessation counseling into care, nurses may reduce the risk of low birth weight among pregnant women in both the United States and Canada.

Smoking cessation counseling for pregnant women who smoke: scientific basis for practice for AWHONN's SUCCESS project.

OBJECTIVES: To review the literature addressing smoking cessation in pregnant women. To develop the project protocol for the Association of Women's Health, Obstetric and Neonatal Nurse's (AWHONN) 6th research-based practice project titled "Setting Universal Cessation Counseling, Education and Screening Standards (SUCCESS): Nursing Care of Pregnant Women Who Smoke." To evaluate the potential of systematic integration of this protocol in primary care settings in which women seek care at the preconception, pregnant, or postpartum stages. LITERATURE SOURCES: Computerized searches in MEDLINE and CINAHL, as well as references cited in articles reviewed. Key concepts in the searches included low-birth-weight infants and effects of prenatal smoking on the infant and the effects of preconception and prenatal smoking cessation intervention on premature labor and birth weight. LITERATURE SELECTION: Comprehensive articles, reports, and guidelines relevant to key concepts and published after 1964 with an emphasis on new findings from 1996 through 2002. Ninety-eight citations were identified as useful to this review. LITERATURE SYNTHESIS: Tobacco use among pregnant women and children's exposure to tobacco use (secondhand smoke) are associated with pregnancy complications such as placental dysfunction (including previa or abruption), preterm labor, premature rupture of membranes, spontaneous abortions, and decreased birth weight and infant stature. Neonates and children who are exposed to secondhand smoke are at increased risk for developing otitis media, asthma, other respiratory disorders later in childhood; dying from sudden infant death syndrome; and learning disorders. The "5 A's" intervention and use of descriptive statements for smoking status assessment were synthesized into the SUCCESS project protocol for AWHONN's 6th research-based practice project. CONCLUSIONS: The literature review generated evidence that brief, office-based assessment, client-specific tobacco counseling, skill development, and support programs serve as an effective practice guideline for clinicians. Implementation and evaluation of the guideline is under way at a total of 13 sites in the United States and Canada.

Connectedness of pregnant adolescents who smoke.

PURPOSE: To examine the relationship of the constructs from the family and school environments and protective individual characteristics to health risk behaviors among pregnant adolescents who smoke. METHODS: Inner-city adolescents (N = 53), aged 14-19 years, who were participating in a smoking cessation intervention program, completed self-report demographic, social, and behavioral questionnaires. FINDINGS: Independent variables included family connectedness, school connectedness, and individual characteristics of religiosity, self-esteem, and grade-point average. Three areas of health risk behavior were dependent variables: delinquent behavior, substance, and precocious sexual behavior. CONCLUSIONS: Positive self-esteem served as a protectivefactorfor alcohol use. In contrast to past studies, school connectedness was a risk, not a protective, factor for substance abuse. Neither school nor family connectedness were protective against delinquent or precocious sexual behavior.

A randomized controlled trial of a smoking cessation intervention for pregnant adolescents.

BACKGROUND: The smoking prevalence rate among pregnant adolescents has been estimated at 59-62%, and 60-80% of these adolescents continue to smoke throughout their pregnancies. OBJECTIVES: The aim of this study was to evaluate the short- and long-term effects of smoking cessation strategies tailored to the pregnant adolescent to attain and maintain abstinence. The specific aim was to examine differences in short- and long-term smoking behaviors among three groups: Teen FreshStart (TFS), Teen FreshStart Plus Buddy (TFS-B), and Usual Care (UC) control. METHODS: In this randomized controlled intervention study, a 3-group (TFS, TFS-B, and UC) by 3-occasion (baseline, 8 weeks postrandomization, and 1-year following study entry) design was used. The study included 142 pregnant adolescents who were aged 14 to 19 years. Both self-reported smoking status collected on the Smoking History Questionnaire and saliva cotinine levels were used to identify smoking behaviors. RESULTS: There were no significant differences among the three treatment groups at baseline in terms of the racial distribution, age, gestational age, age of menses initiation, number in family household, number of family members who smoked, or tobacco use. A significant difference between the UC group and the TFS-B group (p = .010) was seen in smoking behaviors measured 8 weeks following treatment initiation. At 1 year following study entry, however, there were no differences between the groups in smoking behaviors. DISCUSSION: The TFS-B intervention was more effective in attaining short-term smoking cessation in the pregnant adolescent than TFS or UC. Findings suggest that the peer-enhanced programming had a limited effect but could not sustain the participant beyond postpartum (1 year following study entry). Future studies should include relapse prevention to sustain smoking abstinence into the postpartum period.

Predictors of condom use among adolescent Thai vocational students.

PURPOSE: To describe the prevalence of premarital sexual behavior and condom use, and to identify predictors of condom use using the expanded health belief model (EHBM) among vocational students in Bangkok, Thailand. METHODS: A cross-sectional correlational design was used with a cluster-based sample of 425 students aged 18 to 22 years from eight randomly selected private vocational schools in Bangkok. Anonymous self-report questionnaires were used to collect the data. Stepwise multiple regression was conducted to identify predictors of condom use. RESULTS: Overall, 49.9% of participants were sexually active, 64.8% of men and 32% of women. Of the sexually active participants, only 6.3% reported using condoms every time when having sex in the beginning of the relationship, and 10.2% during the last few times. Twenty-four percent of sexually active participants had unplanned pregnancies, and 7% had sexually transmitted diseases (STDs). The predictive model of condom use consisted of perceived benefits from using condoms; interactions between intention to use condoms and gender: knowledge of STDs, HIV, AIDS, pregnancy and peer norms; and alcohol use and age. Adjusting for modifying factors, the predictor set explained 27% of the variance in condom use. CONCLUSIONS: Most of this sample of sexually active Thai vocational students practiced unsafe sex, and many had unplanned pregnancies and STDs. The EHBM provided a modest predictive model of condom use.