Leading Stressors and Coping Strategies Associated With Maternal Physical and Mental Health During the Extended Postpartum Period.

INTRODUCTION: A critical gap exists in understanding stressors and coping that affect women's health beyond 6 weeks postpartum. Using new stressor and coping scales tailored to postpartum women, we examined the relationship of postpartum-specific stressors and coping to women's physical and mental health between 2 to 22 months after childbirth. METHODS: A total of 361 women of diverse race, ethnicity, and functional abilities recruited through clinical and online methods completed online surveys that included Sources of Stress-Revised subscales, such as overload, changes after pregnancy, and low support resources; Postpartum Coping Scale subscales, such as self-regulation, self-care, and health promotion; Patient-Reported Outcomes Measurement Information System Global Health, covering physical and mental health dimensions; and social demographic items. Analyses included hierarchical linear regression models adjusted for social factors. RESULTS: Education and employment were the only social factors associated with physical and mental health, respectively. After adjusting for social factors, overload (P < .001) and coping through health promotion (P = .020) were the only additional variables associated with physical health. After adjusting for social factors, overload (P < .001) and low support resources (P = .002) and coping through self-care (P = .036) were the only additional variables associated with mental health. Thus, being overloaded was the key stressor associated with decreases in physical and mental health. Health promotion was associated with increases in physical health, and self-care was associated with increases in mental health. DISCUSSION: These findings point to directions for health care and community interventions to promote health for postpartum women under stress. Strengths of our study include application of stress and coping scales tailored to postpartum women, whereas a limitation is use of a cross-sectional design.

Improving Data Integrity and Quality From Online Health Surveys of Women With Infant Children.

BACKGROUND: Online surveys have proven to be an efficient method to gather health information in studies of various populations, but these are accompanied by threats to data integrity and quality. We draw on our experience with a nefarious intrusion into an online survey and our efforts to protect data integrity and quality in a subsequent online survey. OBJECTIVES: We aim to share lessons learned regarding detecting and preventing threats to online survey data integrity and quality. METHODS: We examined data from two online surveys we conducted, as well as findings of others reported in the literature, to delineate threats to and prevention strategies for online health surveys. RESULTS: Our first survey was launched inadvertently without available security features engaged in Qualtrics, resulting in a number of threats to data integrity and quality. These threats included multiple submissions, often within seconds of each other, from the same internet protocol (IP) address; use of proxy servers or virtual private networks, often with suspicious or abusive IP address ratings and geolocations outside the United States; and incoherent text data or otherwise suspicious responses. After excluding fraudulent, suspicious, or ineligible cases, as well as cases that terminated before submitting data, 102 of 224 (45.5%) eligible survey respondents remained with partial or complete data. In a second online survey with security features in Qualtrics engaged, no IP addresses were associated with any duplicate submissions. To further protect data integrity and quality, we added items to detect inattentive or fraudulent respondents and applied a risk scoring system in which 23 survey respondents were high risk, 16 were moderate risk, and 289 of 464 (62.3%) were low or no risk and therefore considered eligible respondents. DISCUSSION: Technological safeguards, such as blocking repeat IP addresses and study design features to detect inattentive or fraudulent respondents, are strategies to support data integrity and quality in online survey research. For online data collection to make meaningful contributions to nursing research, it is important for nursing scientists to implement technological, study design, and methodological safeguards to protect data integrity and quality and for future research to focus on advancing data protection methodologies.

Modification and Psychometric Analyses of Stress and Coping Scales for the Extended Postpartum Period.

OBJECTIVE: To modify and psychometrically assess two scales that are used to measure stress and coping during the extended postpartum period. DESIGN: Instrument modification and psychometric assessment. SETTING: Online, community, and health care settings. PARTICIPANTS: Mothers with infants who were 2 to 22 months old: 20 in Phase 1 and 373 in Phase 2. METHODS: In Phase 1, participants from diverse backgrounds served as content experts to recommend modifications of items on two scales: Sources of Stress-Revised (SoS-R) and Postpartum Coping Scale (PCS). The results were 32-item modified versions of each scale. In Phase 2, we conducted a psychometric analysis of both revised scales using principal components analysis to identify dimensionality, Cronbach's alphas to estimate internal consistency reliability, and Pearson correlations to estimate validity of the SoS-R and PCS with the Perceived Stress Scale and the Brief COPE, respectively. RESULTS: We identified six components for the SoS-R: Overload, Changes After Pregnancy, Baby-Related Concerns, Working Mother Concerns, Low Support Resources, and Isolated Motherhood. The Cronbach's alpha for the SoS-R was .94. The SoS-R subscales demonstrated correlations with the Perceived Stress Scale that ranged from 0.55 to 0.30. We identified six components for the PCS: Self-Regulation, Spiritual Care, Self-Care, Use and Seek Support, Internal and External Resources, and Health Promotion. The Cronbach's alpha coefficients for the PCS ranged from .84 to .66. The highest correlations observed between the PCS subscales and the Brief COPE subscales ranged from 0.67 to 0.26. CONCLUSION: The SoS-R and PCS each include six components. Internal consistency reliability for all SoS-R subscales and four of six PCS subscales exceeded .70. The dimensions of each scale highlight areas of clinical and research concern.

Maternal Stressors and Coping Strategies During the Extended Postpartum Period: A Retrospective Analysis with Contemporary Implications.

Background: Despite recent emphasis on the "fourth trimester" and beyond, most knowledge of stressors affecting women is focused on the first 6 postpartum weeks. Our aim was to identify postpartum-specific stressors and coping over the extended postpartum period. Methods: We analyzed data from two surveys for a combined sample of 346 postpartum women. Principal components analysis of survey items on sources of stress was used to identify categories of postpartum-specific stressors. Content analysis was used to categorize text data on coping strategies. Results: Seven stressors were identified: Overload, Working mother concerns, Isolated motherhood, Limited supportive resources, Exhaustion, Parenting demands, and Changes in body and sexuality. Overload was the most frequent stressor (F = 49.32, p < 0.001) and was significantly higher at 9-12 months than at 5-8 months or at 13 months or more (F = 6.42, p = 0.002). Fulltime employment and having more than one child were associated with elevated scores on several stressors. Content analysis yielded seven coping strategies, such as Take time alone or with others, Manage emotions and thoughts, and Maintain a manageable workload. Five of the seven stressors were associated with at least one of the top five coping strategies; none was associated with Overload or Limited supportive resources. Conclusions: Women's predominant source of stress was from overload and was highest at 9 to 12 months postpartum. Community resources and public health policy and programming are needed to prepare and support women during the challenging first postpartum year.

Patterns and Correlates of Physical Symptoms among People with Peripheral Neuropathy.

Background: As the population ages and more people are affected by multiple chronic conditions, the prevalence of Peripheral Neuropathy (PN) has also rapidly increased. This swift rise in PN leaves clinicians and patients challenged by a lack of consistent diagnosis and treatment guidelines. Purpose: To assist those affected by PN, it is imperative to understand the breadth of symptoms, experiences, and factors related to the quality of life. The primary aims of this study are to (1) characterize the symptoms of PN in a nationwide sample; (2) discern differences in symptom clusters, given perceived causes of PN; and (3) identify significant physiological symptoms related to the quality of life for people with PN. Methods: An online survey of people in online PN support groups. Participants were recruited primarily via an open request sent to recipients of web-based communications from nationally recognized online PN support groups. Inclusion criteria were as follows: Self-reported diagnosis of PN, ability to read English or Spanish, residence in the U.S., and age ≥ 18 years. Results: A total of 608 individuals with PN were included in the analysis. This sample represents 49 U.S. states and the District of Colombia; 221 were male and 387 female. Their disease severity and etiology were similar to previously reported information on this population, with 53.3% of respondents suffering from PN without a known cause. Among known causes, diabetes was the most common (19.6%), followed by chemotherapy (6.9%) and autoimmune diseases (3.6%). Factors affecting the quality of life among people with PN included lower extremity mobility, upper extremity mobility, sleep disturbance, depressive symptoms, and patient activation.

Development of a Diabetes-Focused Print Health Literacy Scale Using the Rapid Estimate of Adult Literacy in Medicine Model.

BACKGROUND: A diabetes mellitus (DM)-specific health literacy (HL) measure that focuses on both oral and print HL is needed in clinical and research settings. OBJECTIVE: The present study developed a psychometrically sound DM-specific HL instrument that measures oral and print HL. METHODS: We developed the measure in three steps. First, we reviewed clinical guidelines and conducted focus groups with experts to generate items. Next, we conducted a psychometric evaluation of the scale in three language versions (English, Spanish, and Korean). Lastly, we identified and removed items with potential cultural bias and duplicate functions to produce shorter versions of the scale, using item response theory (IRT). KEY RESULTS: We initially developed an 82-item DM-specific oral HL scale using the Rapid Estimate of Adult Literacy in Medicine (DM-REALM) model. To improve the clinical utility of the DM-REALM, we created shorter forms, a 40-item and 20-item version, and evaluated them by using IRT. All DM-REALM versions had high Cronbach alphas (.985, .974, and .945, respectively) and yielded sufficient convergent validity by positive correlations with existing functional HL scale (r = .49, p < .001), education (r = .14, p = .14 to r = .54, p < .001), and DM knowledge (r = .04, p = .70 to r = .36, p < .001). DM-REALM also demonstrated adequate sensitivity as an intervention evaluation tool that captures the changes induced by an intervention. CONCLUSIONS: All forms of the DM-REALM tool were reliable, valid, and clinically useful measures of HL in the context of DM care. Both researchers and clinicians can use this tool to assess DM-specific HL across multiple racial and ethnic populations. [HLRP: Health Literacy Research and Practice. 2020;4(4):e237-e249.] PLAIN LANGUAGE SUMMARY: This article reported the process and findings of a newly developed health literacy scale for people with diabetes mellitus using three different language versions. Both long and short versions of the scale demonstrated adequate validity and reliability.

Health Literacy and Outcomes of a Community-Based Self-Help Intervention: A Case of Korean Americans With Type 2 Diabetes.

BACKGROUND: Although scientific reports increasingly document the negative impact of inadequate health literacy on health-seeking behaviors, health literacy's effect on health outcomes in patients with diabetes is not entirely clear, owing to insufficient empirical studies, mixed findings, and insufficient longitudinal research. OBJECTIVE: The aim of this study was to empirically examine underlying mechanisms of health literacy's role in diabetes management among a group of Korean Americans with Type 2 diabetes mellitus. METHODS: Data from a randomized clinical trial of a health literacy-focused Type 2 diabetes self-management intervention conducted during 2012-2016 in the Korean American community were collected at baseline and at 3, 6, 9, and 12 months. A total of 250 Korean Americans with Type 2 diabetes participated (intervention, 120; control, 130). Participants were first-generation Korean American immigrants. Health literacy knowledge was measured with the original Rapid Estimate of Adult Literacy in Medicine and the diabetes mellitus-specific Rapid Estimate of Adult Literacy in Medicine. Functional health literacy was measured with the numeracy subscale of the Test of Functional Health Literacy in Adults and the Newest Vital Sign screening instrument, which also uses numeracy. Primary outcomes included glucose control and diabetes quality of life. Multivariate analyses included latent variable modeling. RESULTS: A series of path analyses identified self-efficacy and self-care skills as significant mediators between health literacy and glucose control and quality of life. Education and acculturation were the most significant correlates of health literacy. DISCUSSION: Despite inconsistent findings in the literature, this study indicates that health literacy may indirectly influence health outcomes through mediators such as self-care skills and self-efficacy. The study highlights the importance of health literacy, as well as underlying mechanisms with which health literacy influences processes and outcomes of diabetes self-management.

The Differential Role of Vitamin D in Type 2 Diabetes Management and Control in Minority Populations.

Vitamin D deficiency is associated with incidence of type 2 diabetes (T2DM) as well as poor glycemic control among T2DM patients, yet comparative studies of its association among ethnic minority populations are scarce. Using baseline data from a behavioral intervention study of Korean Americans (KAs) with T2DM (N = 250 KAs) and the NHANES data set, we explored differential roles of vitamin D on HbA1C level or T2DM control in several racial groups. Significantly more KAs (55.2%) were vitamin D-deficient (U.S. average, 37.8%). Both common and unique correlates of vitamin D deficiency in minority populations were identified, including significant associations between Vitamin D and HbA1C in both non-diabetic and diabetic populations. Future studies are warranted to explain the causal mechanism of the effect of vitamin D and glycemic control as well as to examine contextual factors associated with vitamin D deficiency in certain minority groups.Clinical Trials Registry: Identifier NCT01264796.

Exploring the Relationship between Maternal Health Literacy, Parenting Self-Efficacy, and Early Parenting Practices among Low-Income Mothers with Infants.

OBJECTIVE: To explore the association of maternal health literacy (MHL), parenting self-efficacy and early parenting practices among low-income mothers with infants. DESIGN: A cross-sectional, descriptive correlational design. PARTICIPANTS: Low-income mothers (N=186) with infants. METHODS: Face-to-face interviews were conducted using English and Spanish versions of questionnaires by trained bilingual research assistants. The Newest Vital Sign (NVS) screening tool was used to measure MHL. RESULTS: Nearly three-quarters (72%) of mothers were rated as having low MHL. In the bivariate analysis, MHL was positively correlated with education, household income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children. The study findings demonstrate that parenting self-efficacy had a mediating effect on MHL and early parenting practices among mothers with infants. CONCLUSION: Results suggest that future research is needed to advance MHL in low-income mothers and to inform potential HL interventions for this target population.

Texas Nurse Staffing Trends Before and After Mandated Nurse Staffing Committees.

This article describes the evolution of mandated nurse staffing committees in Texas from 2002 to 2009 and presents a study that analyzed nurse staffing trends in Texas using a secondary analysis of hospital staffing data (N = 313 hospitals) from 2000 to 2012 obtained from the American Hospital Association Annual Survey. Nurse staffing patterns based on three staffing variables for registered nurses (RNs), licensed vocational nurses (LVNs), and total licensed nurses were identified: full-time equivalents per 1,000 adjusted patient days, productive hours per adjusted patient day, and RN skill mix. Similar to national trends between 2000 and 2012, most Texas hospitals experienced an increase in RN and total nurse staffing, decrease in LVN staffing, and an increase in RN skill mix. The magnitude of total nurse staffing changes in Texas (5% increase) was smaller than national trends (13.6% increase). Texas's small, rural, government hospitals and those with the highest preregulation staffing levels experienced the least change in staffing between 2000 and 2012: median change of 0 to .13 full-time equivalents per 1,000 adjusted patient days and median change in productive hours per patient day of 0 to .23. The varying effects of staffing committees in different organizational contexts should be considered in future staffing legislative proposals and other policy initiatives.

Unfinished nursing care, missed care, and implicitly rationed care: State of the science review.

OBJECTIVES: The purposes of this review of unfinished care were to: (1) compare conceptual definitions and frameworks associated with unfinished care and related synonyms (i.e. missed care, implicitly rationed care; and care left undone); (2) compare and contrast approaches to instrumentation; (3) describe prevalence and patterns; (4) identify antecedents and outcomes; and (5) describe mitigating interventions. METHODS: A literature search in CINAHL and MEDLINE identified 1828 articles; 54 met inclusion criteria. Search terms included: implicit ration*, miss* care, ration* care, task* undone, and unfinish*care. Analysis was performed in three phases: initial screening and sorting, comprehensive review for data extraction (first author), and confirmatory review to validate groupings, major themes, and interpretations (second author). RESULTS: Reviewed literature included 42 quantitative reports; 7 qualitative reports; 1 mixed method report; and 4 scientific reviews. With one exception, quantitative studies involved observational cross-sectional survey designs. A total of 22 primary samples were identified; 5 involved systematic sampling. The response rate was >60% in over half of the samples. Unfinished care was measured with 14 self-report instruments. Most nursing personnel (55-98%) reported leaving at least 1 task undone. Estimates increased with survey length, recall period, scope of response referent, and scope of resource scarcity considered. Patterns of unfinished care were consistent with the subordination of teaching and emotional support activities to those related to physiologic needs and organizational audits. Predictors of unfinished care included perceived team interactions, adequacy of resources, safety climate, and nurse staffing. Unfinished care is a predictor of: decreased nurse-reported care quality, decreased patient satisfaction; increased adverse events; increased turnover; decreased job and occupational satisfaction; and increased intent to leave. DISCUSSION & CONCLUSIONS: Unfinished care is a significant problem in acute care hospitals internationally. Prioritization strategies of nurses leave patients vulnerable to unmet educational, emotional, and psychological needs. Key limitations of the science include the threat of common method/source bias, a lack of transparency regarding the use of combined samples and secondary analysis, inconsistency in the reporting format for unfinished care prevalence, and a paucity of intervention studies.