Multilevel Intervention Stepped Wedge Designs (MLI-SWDs).

Multilevel interventions (MLIs) hold promise for reducing health inequities by intervening at multiple types of social determinants of health consistent with the socioecological model of health. In spite of their potential, methodological challenges related to study design compounded by a lack of tools for sample size calculation inhibit their development. We help address this gap by proposing the Multilevel Intervention Stepped Wedge Design (MLI-SWD), a hybrid experimental design which combines cluster-level (CL) randomization using a Stepped Wedge design (SWD) with independent individual-level (IL) randomization. The MLI-SWD is suitable for MLIs where the IL intervention has a low risk of interference between individuals in the same cluster, and it enables estimation of the component IL and CL treatment effects, their interaction, and the combined intervention effect. The MLI-SWD accommodates cross-sectional and cohort designs as well as both incomplete (clusters are not observed in every study period) and complete observation patterns. We adapt recent work using generalized estimating equations for SWD sample size calculation to the multilevel setting and provide an R package for power and sample size calculation. Furthermore, motivated by our experiences with the ongoing NC Works 4 Health study, we consider how to apply the MLI-SWD when individuals join clusters over the course of the study. This situation arises when unemployment MLIs include IL interventions that are delivered while the individual is unemployed. This extension requires carefully considering whether the study interventions will satisfy additional causal assumptions but could permit randomization in new settings.

Addressing diversity, equity, and inclusion: A response of professional nursing organizations to the future of nursing: 2020-2030 recommendations.

One way in which professional nursing organizations have chosen to address the social determinants of health (SDoH) is through policy work focused on diversity, health equity and anti-racism activities. The recent report, Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity (FON 2020-2030), calls on professional nursing organizations and/or nursing coalitions to focus on addressing the SDoH to mitigate health inequities, including a focus on addressing racism and promoting practices to ensure the diversity of the nursing workforce. While these recommendations highlight issues of high importance to nursing and the broader society, they assume that professional nursing organizations or coalitions have not been sufficiently engaged in this work to date. Our goal was to better understand the current and/or ongoing activities of professional nursing organizations around their anti-racism work of diversity, health equity, and inclusion (DEI) activities recommended in the FON 2020-2030 report. To address this goal, we conducted a needs assessment of professional nursing organizations to document their DEI activities and the timing of these activities relevant to the recommendations in the report. The 26 responding organizations indicated they had been engaged in work addressing DEI issues for periods ranging from 4 months to 51 years. Minimal funding was the major barrier to advancing this work. Creating a vigorous shared DEI agenda across the profession, as suggested in the FON 2020-2030 report, will require input from nurses across the profession, as well as identification of resources to support this critical endeavor.

Enumeration of Public Health Nurses in the United States: Limits of Current Standards.

Recent national initiatives in nursing and public health have emphasized the need for a robust public health nursing (PHN) workforce. In this article, we analyze the extent to which recent national enumeration surveys base their counts of this workforce on the definitions, scope, and standards for practice and practice competencies of the PHN nursing specialty. By and large, enumeration surveys continue to rely on practice setting to define the PHN workforce, which is an insufficient approach for meeting the goals of major nursing and public health initiatives. We make recommendations for the development of new standards for PHN enumeration to strengthen the broader public health infrastructure and evaluate PHN contributions to population-level outcomes. (Am J Public Health. 2022;112(S3):S292-S297. https://doi.org/10.2105/AJPH.2022.306782).

Applying Community-Engaged Intervention Mapping to Preparing Nurse Scientists.

BACKGROUND: Preventing and managing chronic illness necessitates multilevel, theory-based interventions targeting behaviors, environmental factors, and personal determinants that increase risk for illness onset, greater burden, and poorer outcomes. OBJECTIVES: The purpose of this article is to provide the basis for multilevel interventions, describe community-engaged intervention mapping as an approach to designing theory-based interventions, and discuss potential benefits of applying community-engaged intervention mapping in preparing nurse scientists to build programs of interdisciplinary research in preventing and managing chronic illness. METHODS: Community-engaged intervention mapping integrates two methodological approaches: intervention mapping and community-engaged research. RESULTS: The six-step intervention mapping approach provides a logical structure for preparing nurse scientists in designing, adapting, and implementing multilevel, theory-based interventions. Community-engaged research approaches offer principles and direction for engaging patients, clinicians, community members, and other stakeholders throughout the research process. Integrating these methods retains the theoretical integrity of interventions; improves the relevance and timely completion of the research and its products; and enhances intended beneficiaries and the community's understanding, trust, and use of the results. DISCUSSION: Potential benefits of preparation in community-engaged intervention mapping to nurse scientists and nursing science include explicit consideration of multilevel factors influencing health. Additional benefits include guidance for linking relevant constructs from behavior- and environment-oriented theories with evidence-based methods for affecting desired changes in care and quality of life outcomes. Moreover, enhancement of the theoretical fidelity of the intervention, explication of the mechanisms influencing change in the primary outcome, and improved relevance and feasibility of interventions for intended beneficiaries and potential adopters are other benefits.

Modeling upstream socioeconomic inequities and syndemic conditions among mothers over time.

OBJECTIVES: Mothers in lower social locations are particularly vulnerable to the syndemic conditions of substance abuse, violence, and HIV/AIDS (SAVA), yet few studies have examined the impact of upstream socioeconomic inequities as salient determinants of syndemic conditions in their lives. The purpose of this study was to investigate the influence of Temporary Assistance for Needy Families (TANF) receipt, TANF sanctions, and economic hardship (EH) on SAVA syndemic conditions that included indicators of substance use, HIV risk-taking behaviors, and intimate partner violence among mothers over time. METHODS: Using data from the Fragile Families and Child Wellbeing Study (n = 4,898), we investigated the longitudinal measurement invariance of a proposed measure of syndemic conditions among mothers over five waves and performed path analysis to investigate the relationships between TANF use, TANF sanctions, and EH with syndemic conditions. RESULTS: Analyses revealed the presence of SAVA syndemic conditions and EH predicted increased SAVA in subsequent waves. Relationships between reported race of the mother and the sanctioning of TANF benefits and increased SAVA were also noted. CONCLUSIONS: This study has implications regarding race, welfare policy and sanctioning practices, and the socioeconomic determinants of health that drive syndemic conditions among mothers in the United States.

A Systematic Review of HIV Interventions for Young Women in Sub-Saharan Africa.

Adolescent girls and young women (AGYW) ages (15-24 years old) in Southern and Eastern Africa account for nearly 30% of all new HIV infections. We conducted a systematic review of studies examining the effectiveness of behavioral, structural, and combined (behavioral + structural) interventions on HIV incidence and risky sexual behaviors among AGYW. Following PRISMA guidelines, we searched PubMed, CINAHL, Web of Science, and Global Health. Twenty-two studies met inclusion criteria conducted in Eastern and Southern Africa and comprised behavioral, structural, or combined (behavioral and structural) interventions. All findings are based on 22 studies. HIV incidence was significantly reduced by one structural intervention. All three types of interventions improved condom use among AGYW. Evidence suggests that structural interventions can reduce HIV incidence, while behavioral and combined interventions require further investigation.

Influence of pediatric cancer-related financial burden on parent distress and other stress-related symptoms.

BACKGROUND: Pediatric cancer-induced financial burden is source of stress for parents, particularly mothers, single parents, and parents with lower incomes. This financial burden has been linked to poorer family quality of life (QOL) in terms of new onset material hardships, and could also affect individual QOL in terms of parents' stress-related symptoms. Our purpose was to describe pediatric cancer-induced financial burden among parents of children with that diagnosis, its effects on their stress-related symptoms (distress, anxiety, cognition impairment, sleep impairment), and associations between select risk factors (relationship to the child, marital status, income) and the extent that financial burden affected parents' symptoms. PROCEDURE: We recruited via two parent-led groups and collected data using an online survey. We calculated frequencies of demographic characteristics, financial burden, and symptoms. We used chi-square statistics to examine bivariate associations between the risk factors and extent that cancer-related financial burden affected parents' symptoms. RESULTS: Most (63.6%) respondents reported that pediatric cancer severely affected their finances. The majority (50.23-69.86%) also reported that this burden severely affected their symptoms. Marital status, income, and, for some symptoms, relationship to the child were associated with the extent that financial burden affected the symptoms. Greater proportions of mothers (53-73.5%), divorced/single parents (69.2-90.4%), and parents in the lowest income category (77.3-95.5%) experienced severely affected symptoms compared to fathers (41.7-59.5%), married/partnered parents (41.7-59.5%), and parents in the highest income category (28.6-42.9%). CONCLUSION: Financial burden and symptoms are fitting targets for interventions to improve family and individual QOL in the context of pediatric cancer.

Fathers' psychological responses to pediatric cancer-induced financial distress.

BACKGROUND: To describe how pediatric cancer-induced financial distress and perceptions of their social role affected fathers' psychological responses to this distress, and quality of life (QOL) for them and their families. PROCEDURE: We analyzed father-only responses from a larger cross-sectional survey study about the impact of pediatric cancer-induced financial distress on parents. Our analytic sample was n = 87 fathers who participated in the larger study. We analyzed their data using descriptive statistics and directed content analysis. RESULTS: Conflicting role responsibilities (be there for child; work to maintain income and insurance coverage) seemed to generate responses resembling characteristic posttraumatic stress symptoms in reaction to acute declines in family finances and/or the chronic stress of insufficient finances to meet financial demands, that is, financial trauma. Fathers' personal sense of not being able to adequately provide for their child with cancer and also meet their family's basic needs produced embarrassment and humiliation, which led to discomfort talking about finances; fear, persistent thoughts and anxiety about money; reduced joy; beliefs that they did not deserve to express their needs; and feeling vulnerable to repeated financial stressors. CONCLUSIONS: Pediatric cancer-induced financial burden contributed to fathers' symptom severity and burden, and QOL declines. Clinicians should develop sensitivity to the multiple ways that pediatric cancer affects individuals and families. Future research should examine the effects of pediatric cancer-induced financial burden on mothers, and develop ways to sensitively and systematically assess financial burden, associated psychological responses and declines in QOL, and intervene as indicated.

Learning migraine self-management: the role of mothers and socioeconomic status.

One in five U.S. women have migraine. Most do not seek migraine-specific treatment, relying heavily on social networks for knowledge. Self-management is fundamental, but little is known about how women learn to self-manage during and in-between headaches. We present findings here from an exploratory qualitative study. We interviewed 6 women on how and from whom they learned to self-manage migraine. Results indicate migraine self-management strategies reflect the migraine self-management behaviors observed in trusted migraineurs - who were predominantly mothers and grandmothers. Strategies and what was learned from trusted migrainuers varied between women with higher and lower socioeconomic status. How social learning affects current self-management among women with migraine needs additional research to guide providers in understanding, and optimizing, migraine self-management counseling with their patients.

Participation of lower-to-middle wage workers in a study of Chronic Disease Self-Management Program (CDSMP) effectiveness: Implications for reducing chronic disease burden among racial and ethnic minority populations.

BACKGROUND: Although the Chronic Disease Self-Management Program (CDSMP) improves chronic disease outcomes, little is known about CDSMP participation in populations less than 65 years of age. We explore study and CDSMP participation rates by demographic characteristics with younger (40-64 years old), lower-to-middle wage workers with chronic disease in a randomized clinical trial (RCT) conducted in North Carolina. METHODS: Descriptive statistics and regression models were used to examine associations between demographic, chronic disease burden, and employment variables, and time-dependent study enrollment and intervention participation outcomes that ranged from initiating consent (n = 1,067) to CDSMP completion (n = 41). RESULTS: Overall, participation among non-Whites was disproportionately higher (43%-59%) than that of Whites (42%-57%) relative to the age-matched racial composition of North Carolina (31% non-White and 69% White). Among participants randomized to the CDSMP, racial and ethnic minorities had the highest rates of participation. There were no significant demographic, chronic disease burden, or employment predictors among the participation outcomes examined, although this may have been due to the limited number of CDSMP workshop participation observations. CONCLUSIONS: Extending the CDSMP to lower-to-middle wage workers may be particularly effective in reaching racial and ethnic minority populations, who complete the program to a greater extent than their White, non-Hispanic counterparts.

A Qualitative, Systems Thinking Approach to Study Self-Management in Women With Migraine.

BACKGROUND: A dearth of effective and affordable treatment options has rendered nonpharmacological self-management a crucial part of living with migraine-a debilitating neurobiological condition without cure that disproportionately disables vulnerable women. OBJECTIVE: The aim of the study was to describe the development and use of a systems thinking, problem-structuring data collection approach that was applied to the study of migraine self-management with women in diverse social locations. METHODS: Two systems mapping activities were developed for use in focus groups: one to unpack a migraine episode (system support map) and the other (connection circle [CC]) to construct a mental model of self-management. Later in the process, a strengths-based problem-solving tool was developed to replace the CC. RESULTS: The CCs-often enlightening for affluent participants-left marginalized women feeling overwhelmed and defeated, as a solution to one challenge became the cause of another. Through constant comparison analysis, we recalibrated the approach using a theory, clinical experience, and participant feedback and replaced the CC with a strengths-based problem-solving activity highlighting relationships and trade-offs in a more agential, actionable way. DISCUSSION: Bringing a critical lens and strengths-based approaches to work with vulnerable populations can replace traditional deficit thinking in healthcare, developing options for leveraging resources and understanding complex health behaviors without losing sight of systemic, distributional justice issues. These systems thinking tools can provide a way to extrapolate the complexities of actual self-management behaviors and challenges faced by vulnerable women with migraine versus what they may be instructed to do by a medical model that does not always account for the social and structural determinants of equity and health.

Trends in Health Disparities, Health Inequity, and Social Determinants of Health Research: A 17-Year Analysis of NINR, NCI, NHLBI, and NIMHD Funding.

BACKGROUND: The theoretical landscape of health disparities research now emphasizes health inequities and the role that social determinants of health (SDOH) play in creating and perpetuating them. Whether National Institutes of Health (NIH) funding patterns reflect this theoretical shift is unknown. OBJECTIVES: The aim of this study was to examine the National Institute of Nursing Research's (NINR) funding for research focused on health disparities, health inequities, and SDOH, relative to other key NIH institutes. METHODS: Data on 32,968 projects funded by NINR, the National Cancer Institute, the National Heart, Lung, and Blood Institute, and the National Institute of Minority Health and Health Disparities (NIMHD) during the years 2000 through 2016 were downloaded from NIH RePORTER; those with health disparities, health inequity, or SDOH terms used in the abstract were identified. Descriptive statistics and a general linear model approach were used to assess differences in cumulative project counts and funding proportions, and funding trends over time. RESULTS: Overall, funding for health disparities projects was 14-19 times greater than for health inequity and SDOH projects and was more concentrated in centers and institutional training than in individual research projects. NINR's proportion of funding for disparities projects was consistently greater than that of the National Cancer Institute and the National Heart, Lung, and Blood Institute, but not for inequities and SDOH projects. NIMHD's proportion of funding for disparities, and inequities and SDOH projects (combined) was 2-30 times greater than that of other institutes. Over the 16-year period, funding for disparities, inequity, and SDOH projects each increased (all ps < .05); however, growth in inequities and SDOH funding was not evident in more recent years. DISCUSSION: Funding for projects focused on health equities and the SDOH lag behind theoretical shifts in the broader health disparities research arena. With the exception of NIMHD, there is a disconnect between funding for projects with a disparities orientation in institutional training and center projects relative to individual research projects. These trends have implications for nurse scientists seeking NIH funding to support health equity-oriented research.

Chronic disease self-management education courses: utilization by low-income, middle-aged participants.

BACKGROUND: Individuals living in lower-income areas face an increased prevalence of chronic disease and, oftentimes, greater barriers to optimal self-management. Disparities in disease management are seen across the lifespan, but are particularly notable among middle-aged adults. Although evidence-based Chronic Disease Self-management Education courses are available to enhance self-management among members of this at-risk population, little information is available to determine the extent to which these courses are reaching those at greatest risk. The purpose of this study is to compare the extent to which middle-aged adults from lower- and higher-income areas have engaged in CDSME courses, and to identify the sociodemographic characteristics of lower-income, middle aged participants. METHODS: The results of this study were produced through analysis of secondary data collected during the Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative. During this initiative, data was collected from 100,000 CDSME participants across 45 states within the United States, the District of Columbia, and Puerto Rico. RESULTS: Of the entire sample included in this analysis (19,365 participants), 55 people lived in the most impoverished counties. While these 55 participants represented just 0.3% of the total study sample, researchers found this group completed courses more frequently than participants from less impoverished counties once enrolled. CONCLUSION: These results signal a need to enhance participation of middle-aged adults from lower-income areas in CDSME courses. The results also provide evidence that can be used to inform future program delivery choices, including decisions regarding recruitment materials, program leaders, and program delivery sites, to better engage this population.

Strategies for recruiting populations to participate in the chronic disease self-management program (CDSMP): A systematic review.

The purpose of this review was to better understand how to market the Chronic Disease Self-Management Program to new audiences. Eight databases were searched for peer-reviewed studies of the CDSMP. A total of 39 articles were analyzed to describe the theoretical basis of recruitment strategies and their effectiveness while engaging diverse populations. Findings included that female, Caucasian, and elderly groups are overrepresented in CDSMP literature and recruitment efforts have not been explicitly grounded in theory. This review provides insight into trends in CDSMP recruitment and identifies the need for further research regarding the application of marketing theory to future enrollment efforts.

Social Factors Related to Smoking among Rural, Low-Income Women: Findings from a Systematic Review.

OBJECTIVE: This systematic review of the literature assesses congruency of findings from descriptive, qualitative, and association studies focusing on factors influencing smoking and smoking cessation with findings from smoking cessation interventions that included low-income rural women. DESIGN AND SAMPLE: Six databases relevant to the health and social sciences were searched in this systematic review using combinations of select keyword terms, specific inclusion criteria, and studies between 1997 and 2012. RESULTS: Descriptive studies on this population of smokers provide economic, environmental, and social factors related to smoking patterns. Qualitative studies found social support received from an individual's social network was viewed as most beneficial when considering or maintaining smoking cessation while randomized controlled trials included in this review implemented social support through peripheral resources or resources with little personal connection to the sample and failed to produce significant results. CONCLUSIONS: Few studies have focused on the specific needs and difficulties of smoking cessation among rural low-income women and interventions have not targeted the complex social network of this population. Incongruence in study findings supports the need for smoking assessment and cessation interventions that incorporates the unique social and cultural meanings of smoking in rural low-income women.

The Effects of Collateral Consequences of Criminal Involvement on Employment, Use of Temporary Assistance for Needy Families, and Health.

Criminal convictions are often associated with collateral consequences that limit access to the forms of employment and social services on which disadvantaged women most frequently rely--regardless of the severity of the offense. These consequences may play an important role in perpetuating health disparities by socioeconomic status and gender. We examined the extent to which research studies to date have assessed whether a criminal conviction might influence women's health by limiting access to Temporary Assistance for Needy Families (TANF) and employment, as a secondary, or "collateral" criminal conviction-related consequence. We reviewed 434 peer-reviewed journal articles retrieved from three electronic article databases and 197 research reports from three research organizations. Two reviewers independently extracted data from each eligible article or report using a standardized coding scheme. Of the sixteen eligible studies included in the review, most were descriptive. None explored whether receiving TANF modified health outcomes, despite its potential to do so. Researchers to date have not fully examined the causal pathways that could link employment, receiving TANF, and health, especially for disadvantaged women. Future research is needed to address this gap and to understand better the potential consequences of the criminal justice system involvement on the health of this vulnerable population.

A Public Health Nursing Model Assists Women Receiving Temporary Assistance for Needy Families Benefits to Identify a Usual Source of Primary Care.

Women enrolled in Florida's Temporary Assistance for Needy Families (TANF) program experience high rates of chronic health problems and often lack a usual source of care. Thus, in this study, we aimed to identify variables related to being in a usual source of care at time of study enrollment and determine whether a public health nursing case management intervention affected the obtainment of a usual source of care. To achieve these aims, we conducted a secondary analysis of a randomized controlled trial of a public health nursing case management intervention, which included women with chronic health conditions enrolled in TANF (n = 432). Results indicated 35% of the women did not identify a usual source of care at time of study enrollment, and the public health nursing intervention was effective in helping women obtain a usual source of care (OR = 2.5, 95% CI 1.004-6.491). Thus, a public health nursing case management intervention is an effective way to connect TANF participants to a usual source of care, which may lead to improved health outcomes in this vulnerable population of women.

Nurse scientists overcoming challenges to lead transdisciplinary research teams.

Increasingly, scientific funding agencies are requiring that researchers move toward an integrated, transdisciplinary team science paradigm. Although the barriers to and rewards of conducting this type of research have been discussed in the literature, examples of how nurse investigators have led these teams to reconcile the differences in theoretical, methodological, and/or analytic perspectives that inevitably exist are lacking. In this article, we describe these developmental trajectory challenges through a case study of one transdisciplinary team, focusing on team member characteristics and the leadership tasks associated with successful transdisciplinary science teams in the literature. Specifically, we describe how overcoming these challenges has been essential to examining the complex and potentially cumulative effects that key intersections between legal, social welfare, and labor market systems may have on the health of disadvantaged women. Finally, we discuss this difficult but rewarding work within the context of lessons learned and transdisciplinary team research in relation to the future of nursing science.