Predictors of Nicotine Replacement Therapy Adherence: Mixed-Methods Research With a Convergent Parallel Design.

BACKGROUND: Few studies have examined the effect of baseline attitudes toward nicotine replacement therapy (NRT) on its actual adherence in a smoking cessation intervention. PURPOSE: This study (i) examined the predictability of baseline variables (quantitative data) on NRT adherence and (ii) explored the congruence of participants' statements about NRT products (qualitative data) during counseling sessions with their baseline attitudes. METHODS: This is a mixed-methods research study using a convergent parallel design. Participants included 74 individuals in the treatment group who received behavioral counseling and combination NRT. A Poisson regression analysis was performed to identify baseline variables predicting NRT adherence. Thematic analysis was completed with a subset of participants (n = 38) who varied in NRT attitude scores and adherence. A joint display was created to integrate quantitative and qualitative data and discover convergence. RESULTS: Approximately 59% of the participants (41/74) used NRT continuously for ≥5 weeks. Having negative attitudes toward NRT and depressive symptoms predicted NRT adherence even after controlling for education and anxiety symptoms. Thematic analysis revealed that NRT adherence is a learning process that consists of the following three distinctive but interrelated phases: (i) information needs, (ii) comprehensive readiness, and (iii) experiential learning. Of the 38 participants, 34 (89.5%) showed convergence between baseline attitude scores and statements about NRT made during counseling sessions. CONCLUSIONS: Individuals who have negative attitudes toward NRT are less likely to use the products in a smoking cessation intervention. Counselors should assess attitudes toward NRT at baseline and address them proactively during counseling sessions.

Few research studies have explored how attitudes toward nicotine substitutes (nicotine patches, gum, and lozenges) affect people's adherence to those substitutes (using them consistently as directed). This study examined (i) whether age, gender, education, attitudes toward the substitutes, and depressive and anxiety symptoms would predict peoples' adherence to these nicotine substitutes during a study to help stop smoking and (ii) whether peoples' statements about their experiences with the substitutes would reveal any patterns. The study was conducted with 74 individuals who received behavioral counseling and combination nicotine substitutes. Having negative attitudes toward the substitutes and depressive symptoms predicted adherence. Age, gender, education, positive attitudes, and anxiety symptoms did not. Statements from a subset of participants (n = 38) revealed that adherence to the substitutes is a learning process that consists of the following three phases: (i) needing more information assuring the safety of the substitutes, (ii) being mentally and situationally ready, and (iii) learning while being involved in the process such as "trial and error." Individuals who have negative attitudes toward the substitutes are less likely to use them, and counselors should assess attitudes toward nicotine replacement therapy before suggesting their use and address these attitudes proactively during smoking cessation counseling sessions.

Protocol for a randomized controlled trial of the Enhanced Smoking Cessation Approach to Promote Empowerment (ESCAPE) digitalized intervention to promote lung health in high-risk individuals who smoke.

Low dose computed tomography (LDCT) is an effective screening test to decrease lung cancer deaths. Lung cancer screening may be a teachable moment helping people who smoke to quit, which may result in increased benefit of screening. Innovative strategies are needed to engage high-risk individuals in learning about LDCT screening. More precise methods such as polygenic risk scores quantify genetic predisposition to tobacco use, and optimize lung health interventions. We present the ESCAPE (Enhanced Smoking Cessation Approach to Promote Empowerment) protocol. This study will test a smoking cessation intervention using personal stories and a lung cancer screening decision-aide compared to standard care (brief advice, referral to a quit line, and a lung cancer screening decision-aide), examine the relationship between a polygenic risk score and smoking abstinence, and describe perceptions about integration of genomic information into smoking cessation treatment. A randomized controlled trial followed by a sequential explanatory mixed methods approach will compare the efficacy of the interventions. Interviews will add insight into the use of genomic information and risk perceptions to tailor smoking cessation treatment. Two-hundred and fifty individuals will be recruited from primary care, community-based organizations, mailing lists and through social media. Data will be collected at baseline, 1, 3 and 6-months. The primary outcomes are 7-day point prevalence smoking abstinence and stage of lung cancer screening at 6-months. The results from this study will provide information to refine the ESCAPE intervention and facilitate integration of precision health into future lung health interventions. Clinical trial registration number: NCT0469129T.

The Intersectionality of HIV-Related Stigma and Tobacco Smoking Stigma With Depressive and Anxiety Symptoms Among Women Living With HIV in the United States: A Cross-sectional Study.

ABSTRACT: This study examined the intersectionality of HIV-related stigma, tobacco smoking stigma, and mental health among women living with HIV who were daily smokers. This secondary analysis used baseline data from 2 pilot smoking cessation studies. Participants received either an HIV-tailored or an attention-control intervention focused on smoking cessation as an outcome. There were significant positive relationships between HIV-related stigma and depressive and anxiety symptoms. In contrast, tobacco smoking stigma had no significant relationship with either of the symptoms when HIV-related stigma was controlled. However, there was a significant interaction effect (ß = 1.37, p = .02) of tobacco smoking stigma with internalized HIV-related stigma on anxiety symptoms. Tobacco smoking stigma worsened anxiety symptoms for women who had high internalized HIV-related stigma. Health care providers should understand the effect of HIV-related stigma on mental health and address the intersectionality of HIV-related stigma with other socially disapproved behaviors, such as tobacco smoking.

Factors Associated with Treatment Uptake Among Women with Acetic Acid/Lugol's Iodine Positive Lesions of the Cervix in Cameroon.

PURPOSE: Treatment of cervical precancer is the primary aim in secondary prevention of cervical cancer. The purpose of this study was to examine factors associated with treatment uptake among women with acetic acid/Lugol's iodine positive lesions identified by digital cervicography (DC) in a cervical cancer prevention program in Cameroon. PATIENTS AND METHODS: We conducted a cross-sectional survey of medical records from 2013 to 2018 of 755 women in Cameroon who screened positive with acetic acid/Lugol's iodine in 2013. RESULTS: Of the 755 women, 422 (55.9%) had treatment/biopsy on the same day or followed up later, but only 344 (45.6%) received treatment/biopsy and 333 (44.1%) were lost to follow-up. Overall, 180 (52.3%) of the 344 women were treated/biopsied the same day they were screened, and 164 (47.7%) were treated/biopsied after the initial visit. Women aged 30-49 and HIV-positive women were significantly more likely to have received treatment or returned for treatment than women less than 30 and HIV-negative women. Of the 266 women who followed up at a later date, the lesions of 78 (29.3%) women regressed spontaneously without treatment. Women with low-grade lesions, HIV-negative women and women who had follow-up more than a year after the initial exam were significantly more likely to have spontaneous regression with regression rates of 30.6%, 32.1% and 62.2%, respectively (p<0.001). Age was not a significant determinant of spontaneous regression (p=0.149). CONCLUSION: Efforts to increase treatment uptake are needed in this population, including adherence to same day "See and treat" policies.

Prediction of Smoking Abstinence in Women Living With Human Immunodeficiency Virus Infection.

BACKGROUND: This study examined whether baseline negative emotional states (depression and anxiety) would predict craving for cigarettes and other nicotine withdrawal symptoms in early abstinence and whether those emotional states and withdrawal symptoms would predict failure in quitting smoking at 3 months postquit among U.S. women living with the human immunodeficiency virus (HIV). METHOD: The study is a secondary analysis of data from two smoking cessation studies of women living with HIV. Craving for cigarettes and other withdrawal symptoms were assessed weekly with a total of 229 observations during the first 4 weeks following quit day. Descriptive statistics were used to examine baseline characteristics of the participants. A random growth curve model was used to estimate between-person differences in a within-person trend of changes in the withdrawal symptoms. A binary logistic regression analysis was performed to identify predictors of short-term smoking abstinence. RESULTS: Baseline anxiety was a predictor of postquit nicotine withdrawal symptoms but baseline depression was not. Neither baseline anxiety nor depression predicted postquit craving for cigarettes. Participants who received an HIV-tailored smoking cessation intervention showed a greater decline in craving symptom than those who received an attention-controlled intervention. HIV-tailored intervention and less craving predicted smoking abstinence at 3-month follow-up. DISCUSSION: Compared to an attention-controlled intervention, an HIV-tailored intervention effectively decreased craving for cigarette smoking after quitting-which effectively increased the rate of short-term smoking abstinence in women living with HIV.

Pilot Randomized Controlled Trial of a Digital Storytelling Intervention for Smoking Cessation in Women Living With HIV.

BACKGROUND: People living with HIV in the USA smoke at a rate nearly three times that of the general population, and Black women are disproportionately affected by HIV infection. PURPOSE: This study was conducted to test the preliminary efficacy of a digital storytelling intervention for smoking cessation in U.S. women living with HIV. METHODS: Participants in the treatment arm viewed a film in which women living with HIV talk about quitting smoking, and those in the control arm viewed an attention-control film in which women talk about living with HIV infection. Participants in both arms received eight weekly video-call counseling sessions focused on smoking cessation and nicotine patches or gum during the same period. Participants were followed on a monthly basis from quit day for 3 months. RESULTS: Of the 53 participants randomized, four withdrew before receiving any intervention, one dropped out during the intervention, and 48 (90.6%) completed the study. No difference was found in the baseline characteristics between the two arms with the exception that the treatment arm had higher nicotine dependence scores [t(1.51) = 2.30, p = .03] than the control arm. Seven day point-prevalence abstinence rates at 3 month follow-up were not found to differ between the two arms. However, the odds of achieving 3 month prolonged abstinence were four times greater (odds ratio = 4.23, 95% confidence interval = 1.10, 16.23) in the treatment arm than the control arm when the analysis was performed with those (n = 49, 92.5%) who received any part of the allotted intervention. CONCLUSIONS: A digital storytelling intervention seems to be a valuable strategy to enhance the effect of conventional tobacco dependence treatment for women living with HIV. However, the underlying mechanism of the effect of digital storytelling necessitates further investigations in a large RCT.Clinical Trials Registration No. NCT03289676.

Barriers and facilitators of follow-up among women with precancerous lesions of the cervix in Cameroon: a qualitative pilot study.

PURPOSE: This pilot study explores the barriers to adherence to follow-up among women with cervical precancer in urban Cameroon. While follow-up of women with a positive screening of cervical precancer is the most important aspect of cervical cancer secondary prevention, women with cervical precancer do not adhere frequently to recommended follow-up schedule in Cameroon. The aim of the study was to explore and describe the barriers and facilitators to follow-up for cervical precancer among women infected and uninfected with HIV in Cameroon. PARTICIPANTS AND METHODS: A qualitative research design was used to answer the research questions. Participants included eight HIV-infected and -uninfected women diagnosed with cervical precancer and 19 nurses. Data were collected by in-depth individual patient interviews and focus groups with nurses. An interview guide with open-ended questions, using the social ecological model as a framework, included questions that addressed the complexities of the lives of individuals and professionals within a relational context. The interviews were audio-taped and transcribed verbatim in English language. Thematic analysis of data was completed with no epistemological or theoretical perspective underpinning the analyses. RESULTS: Four major themes emerged from the study. They were clinic, personal, and social barriers, and strategies to improve follow-up. CONCLUSION: The use of reminder phone calls and fee reduction, coupled with peer counseling and navigation of women who have been diagnosed with cervical precancer, could be effective ways of improving adherence to follow-up. Further research is needed to explore the same phenomenon among women in rural areas, especially those who were initially attended to in mobile clinics.

Revisiting Successful Aging With HIV Through a Revised Biopsychosocial Model: An Update of the Literature.

The concept of successful aging was recognized only recently by HIV researchers because people living with HIV (PLWH) in the early epidemic were not expected to survive. With the introduction of antiretrovirals that block viral replication, PLWH are now aging with HIV. Given the complex nature of HIV within the social, economic, and political climates in which it occurs, a holistic model of successful aging is needed to guide researchers and clinicians. Several overarching models exist, but must be updated for rapidly advancing HIV and aging research agendas. We provide an updated, adapted, and integrated biopsychosocial model of successful aging with HIV based on the principles of Baltes and Baltes (1998) on 8 essential components of successful aging: (a) length of life, (b) biological health, (c) mental health, (d) cognitive efficiency, (e) social competence, (f) productivity, (g) personal control, and (h) life satisfaction. Clinical practice and research implications are highlighted.

A randomized controlled pilot trial of a smoking cessation intervention for US women living with HIV: telephone-based video call vs voice call.

BACKGROUND: People living with HIV smoke at a rate three times that of the general population. This randomized controlled pilot trial tested the feasibility and acceptability of a video-call smoking cessation intervention in women living with HIV and its preliminary efficacy compared with a voice-call smoking cessation intervention. The study focused on women due to a paucity of studies among this population, and women are less likely than men to quit smoking when provided with conventional treatment. METHODS: Participants in both arms received an HIV-tailored smoking cessation intervention comprising eight 30-minute weekly counseling sessions in conjunction with active nicotine patches for 8 weeks. The only difference between the two arms was the delivery mode of the intervention: via either telephone-based video or voice call. Survival analysis and a Cox proportional hazard regression model were performed to identify factors predicting 6-month prolonged abstinence from smoking. RESULTS: A video-call intervention was almost 30% less feasible than a voice-call intervention because women in their 50s and 60s or poorer women living in some southern states did not have access to video-call equipment. However, those who received the video-call intervention were more likely to complete the study than those who had the voice-call intervention. There was no difference in the acceptability of the two interventions. A survival analysis revealed that those in the video arm were significantly more likely to maintain smoking abstinence over the 6-month follow-up period than those in the voice arm (log rank χ 2=4.02, P<0.05). CONCLUSION: Although a video-call intervention is less feasible than a voice-call intervention, the former seems to outperform the latter in achieving long-term smoking abstinence for women living with HIV, which may offer an advantage over establishing therapeutic alliance and visually monitoring their adherence to nicotine patches. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT02898597.

Covert incivility: Challenges as a challenge in the nursing academic workplace.

PURPOSE: The purpose of this paper is to present a Neuman Systems Model-guided discussion of current knowledge associated with covert incivility in the nursing academic workplace. ORGANIZING STRUCTURE: The Neuman Systems Model provides a multiple discipline, systems perspective of the stressor covert incivility and levels of prevention interventions to counter it. FINDINGS: Covert incivility is defined as a stressor that affects individual, group, community, and social systems' intrapersonal, interpersonal, and extrapersonal levels of function. Two prominent examples of expressing covert incivility in academic settings are identified-pluralistic ignorance and passive aggression. CONCLUSIONS: The Neuman Systems Model can guide development and testing of primary, secondary, and tertiary prevention interventions targeted to covert incivility in the nursing academic workplace, as well as outcomes of the interventions. CLINICAL RELEVANCE: The Neuman Systems Model is a useful multiple discipline conceptual model for identification and testing of the effects of covert incivility in the nursing academic workplace.

The Relevance of Palliative Care in HIV and Aging.

The connection between palliative care and HIV infection has deep and wide roots in the United States that go back to the time when many gay men in the early 1980s were dying from a disease we knew little about, and there was no way to help but to alleviate symptoms in hospice and end of life centers across the United States. More individuals (adults and children), families, and communities attribute the success of antiretroviral therapies and other therapeutic approaches to advancing quality of life and life itself today. The identity of HIV, like many 'life-threatening illness with no cure' has evolved as a 'chronic' condition with a longer time period to address physical, social, and emotional experiences that may concern those living with HIV infection. Chronic conditions create an opportunity for healthcare providers from all types of disciplines to rethink and retool their knowledge and skills, to have conversations with those affected by HIV infection as to what they would ideally want in addressing their care needs; care needs that are now complicated by comorbid conditions of aging and healthcare reimbursement that uniquely intersect with HIV infection. This chapter addresses the current relevance of palliative care in HIV history, both nationally and internationally, and offers ideas for health professionals to use a multidisciplinary integration of knowledge to not just cure but align 'cure and care' toward healing action while being present to others from their perspective and values.

Ageism, Aging and HIV: Community Responses to Prevention, Treatment, Care and Support.

Ageism, in the form of prejudice, stereotyping, and discrimination targeting older adults, represents a barrier to addressing the graying of the HIV epidemic. There is widespread misperception on the part of older adults themselves, as well as service providers and society in general that HIV risk is low as one ages. In addition, internalized ageism may play a role in poorer physical and mental health outcomes, as the negative stereotypes associated with aging become a self-fulfilling prophecy. A number of steps can be taken to address HIV and aging in the context of ageism with regard to: prevention, education, and outreach; treatment guidelines for older adults with HIV; funding to address the aging of the epidemic; engagement of communities, health and social service organizations, and other providers around mental health and social support, and addressing the needs of special populations. Caring for an aging population with HIV represents a challenge, which is exacerbated in low and/or middle-income countries that typically lack the infrastructure of high resource settings. How we address the aging-related issues of the HIV epidemic across regions and settings could serve as a model in dealing with aging in our society in general regardless of HIV status.

HIV Prevention, Stigma, and Care in Ho Chi Minh City and Da Lat Vietnam.

PURPOSE: A four-week interdisciplinary student/faculty research project in Vietnam served as a focused experience in understanding Vietnamese healthcare structures, functions, outcomes. DESIGN: Testing the validity and feasibility of a successful US HIV intervention program called Women's Voices Women's Lives© using group and individual interviews. FINDINGS: Healthcare inequities and poverty were found to paralyze individual, family, and community mobilization in HIV testing while stigma is a key barrier to both testing and care seeking. IMPLICATIONS: Vietnam has become a place where living with HIV infection challenges communities in a distinct socio-cultural context while incidence and prevalence rates continue to rise.

The concept of "silencing the self" in low-income, aging, HIV-infected African American women: a 10-year community-based participatory program of research with results.

Despite a resilient spirit, the challenges that face low-income, aging Black women living with HIV infection are immense. This article describes a 10-year iterative history of using the Theory of Silencing the Self (TSTS) as an explanatory model that was found to be gender sensitive, culturally relevant, and helpful in guiding a community-based participatory research group of low-income, HIV-infected Black women living in Boston, Massachusetts. The group, called Sistah Powah, used the TSTS to design and implement a structured writing intervention in a women's drop-in center targeting low-income, aging Black women living with HIV infection as a way to give them and others a voice.

Delivering palliative care to patients and caregivers in inner-city communities: challenges and opportunities.

OBJECTIVE: Social and economic barriers can hinder access to quality palliative and end-of-life care for patients living in inner-city communities. Using a community-based participatory research (CBPR) approach, we investigated the stresses associated with living with a chronic disease and barriers to access and utilization of palliative care resources experienced by low-income patients and caregivers in five inner-city communities. METHODS: Four focus groups (N = 33) were conducted with community stakeholders, including healthcare professionals (social workers and nurses), persons living with chronic illnesses (e.g., HIV/AIDS, cardiovascular disease, and cancer), and caregivers. Focus group responses were analyzed using thematic analyses. RESULTS: Patients' and caregivers' stresses centered around five themes: lack of family support, communication barriers with healthcare professionals, minority stress, caregiver burden, and lack of spiritual support. The community stakeholders identified resources and services to improve access to care and the quality of life of underserved, low-income populations living with chronic illnesses. SIGNIFICANCE OF RESULTS: A CBPR approach enabled us to develop an interdisciplinary and culturally sensitive intervention to begin addressing the palliative and end-of-life needs of the patients and caregivers of the inner-city community.

The Sistah Powah structured writing intervention: a feasibility study for aging, low-income, HIV-positive Black women.

PURPOSE: The purpose of this study was to test the feasibility and assess outcomes of health care adherence based on whether participants engage in particular risky behaviors relevant to general health or living with human immunodeficiency virus (HIV) infection and the frequency of these adherent behaviors. Health adherent behaviors include both self-advocacy and decreased stigma as underlying key components. DESIGN: A randomized control trial comparing peer-led attention control support and intervention groups. SETTING: Community-based women's drop-in center in an urban, black neighborhood of Boston, Massachusetts. SUBJECTS: Aging, low-income, black women living with HIV infection. INTERVENTION: Peer-led, small-group, structured writing using film clips from Women's Voices Women's Lives as a writing prompt. MEASURES: Demographic and outcome data that included adherence, self-advocacy, and stigma; collected at baseline, 6 weeks, and 6 months. ANALYSIS: Repeated-measures analysis of variance scores were examined between groups and waves. Paired-sample t-tests were used to examine mean differences across time. RESULTS: Sample included 110 women (intervention, n = 56; comparison, n = 54). Retention was 85.5%. Repeated-measures analysis indicated intervention group condom use (n = 69, F = 8.02, df = 1, p < .01) and safe sex (n = 71, F = 13.02, df = 1, p < .01) was higher than that of comparison group. A time effect was also found in the Silencing the Self Scale (n = 91, Pillai's trace = 7.21, df = 2, p < .01). CONCLUSION: This study demonstrates the feasibility of a tailored, peer-led, and culturally relevant interventions and tentative efficacy in populations affected by health disparities. Key limitations include no comparison intervention format with women who can't write and the need to test generalizability.

Making things right: nurses' experiences with workplace bullying-a grounded theory.

While bullying in the healthcare workplace has been recognized internationally, there is still a culture of silence in many institutions in the United States, perpetuating underreporting and insufficient and unproven interventions. The deliberate, repetitive, and aggressive behaviors of bullying can cause psychological and/or physical harm among professionals, disrupt nursing care, and threaten patient safety and quality outcomes. Much of the literature focuses on categories of bullying behaviors and nurse responses. This qualitative study reports on the experiences of nurses confronting workplace bullying. We collected data from the narratives of 99 nurses who completed an open-ended question embedded in an online survey in 2007. A constructivist grounded theory approach was used to analyze the data and shape a theory of how nurses make things right when confronted with bullying. In a four-step process, nurses place bullying in context, assess the situation, take action, and judge the outcomes of their actions. While many nurses do engage in a number of effective yet untested strategies, two additional concerns remain: inadequate support among nursing colleagues and silence and inaction by nurse administrators. Qualitative inquiry has the potential to guide researchers to a greater understanding of the complexities of bullying in the workplace.

Recommendations and reality: perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions.

In 2006, the Centers for Diseases Control and Prevention (CDC) released recommendations calling for routine HIV testing to be offered to those ages 13 to 64 as a standard of general health care. This recommendation included a plan to conduct HIV testing as part of a general consent. The reasoning and evidence for this recommendation is supported by experts, patients, and sponsored screenings by the CDC. The rationale behind this approach includes that knowledge of one's HIV status helps (1) infected individuals adopt risk-reduction behaviors and access to life-prolonging treatment and (2) uninfected individuals maintain behaviors that reduce their risk of becoming infected. This article discusses the perceived patient, provider, and policy barriers to implementing routine HIV screening and proposed solutions that can be part of a nurse-led contribution to develop and adopt innovative, patient-centered care models that can address the need for screening.

A new, four-item instrument to measure workplace bullying.

Studies on workplace bullying either in the U.S. or internationally rarely include nurses. We tested the concurrent validity of the Negative Acts Questionnaire-Revised (22 items) with a sample of nurses. Five hundred eleven registered nurses (RNs) responded to a mailed survey. Factor, reliability, and regression analyses tested dimensionality, reliability, and construct and criterion validity. Workplace bullying is best seen as a one-dimensional construct. A subset of four items was found to be both valid and reliable in measuring bullying in this sample. Findings support the use of a one-dimensional, four-item questionnaire to measure perceived bullying in nursing populations. Using a four-item questionnaire decreases participant and researcher burden and makes available an outcome measure for future descriptive and predictive interventional research.