Prevalence of pressure ulcers in africa: A systematic review and meta-analysis.

BACKGROUND: A recent global review of pressure ulcers contained no studies from Africa. OBJECTIVE: To identify the prevalence and incidence of pressure ulcers in Africa. DATA SOURCES: Bibliographic databases, African specific databases, grey literature. STUDY ELIGIBILITY CRITERIA: Studies with prevalence or incidence data of pressure ulcers from Africa since the year 2000. PARTICIPANTS: Any age, including children, in any setting, specifically including hospital patients from any clinical area but not restricted to hospital settings. STUDY APPRAISAL AND SYNTHESIS METHODS: Hoy score for bias, Joanna Briggs Institute Critical Appraisal Instrument. METHOD: We followed the PRISMA guideline for systematic reviews. We searched Embase, Medline, Scopus, CINHAL, Google Scholar, specialist African databases and grey literature for studies reporting incidence or prevalence data. RESULTS: Nineteen studies met the inclusion criteria and were included in the study. Point prevalence rates varied from 3.4% to 18.6% for medical/surgical and other general hospital units with a pooled prevalence of 11%, for grades II-IV 5%. For spinal injury units the pooled prevalence was 44%. LIMITATIONS: restricted to English, French and Arabic. CONCLUSION: Prevalence of pressure ulcers in Africa reported here is similar to figures from a recent review of prevalence in Europe and two recent global reviews of hospitalised patients. Prevalence of pressure ulcers in spinal cord injury patients is similar to figures from a review of developing countries. The reporting of prevalence is lacking in detail in some studies. Studies using an observational design employing physical examination of patients showed higher prevalence than those relying on other methods such as medical notes or databases. IMPLICATIONS OF KEY FINDINGS: Further prevalence and incidence studies are needed in Africa. Reporting of such studies should ensure items in the "Checklist for Prevalence Studies" from Joanna Briggs Institute (or similar well regarded resources) are addressed and the PICOS model and PRISMA guidelines are employed. SYSTEMATIC REVIEW REGISTRATION NUMBER: Prospero registration number CRD42020180093.

Development of nurse education in Saudi Arabia, Jordan and Ghana: From undergraduate to doctoral programmes.

Doctoral programmes in nursing have a long history in the US where traditional research based PhDs and more clinically based doctoral programmes are common. In the rest of the world PhDs are better accepted though professional doctorates with a thesis component are common in the UK. In countries with newly established or planned doctoral programmes in nursing the research PhD seems the degree of choice. Here we discuss developments in Jordan, Saudi Arabia and Ghana. This study used official documents, strategic plans, curriculum developments and other documentary evidence from Saudi Arabia, Jordan and Ghana. We compared doctoral programmes and development with other countries by reference to the literature. We offer the example of public health and non-communicable diseases in particular as one area where doctorally trained nurses applying international standards in collaboration internationally may be of benefit.

Metabolic syndrome among type 2 diabetic patients in Sub-Saharan African countries: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Metabolic syndrome is one of the serious public health problems among type 2 diabetic patients. Despite a number of studies have been conducted, there is no overall estimation on the prevalence of metabolic syndrome among type 2 diabetic patients in Sub-Saharan African countries. Therefore, this study aimed to estimate the pooled prevalence of metabolic syndrome in patients with type 2 diabetes mellitus in Sub -Saharan African countries. METHODS: PubMed, Web of Science, African Journals Online, Google Scholar, Scopus, and Wiley Online Library databases from inception to April 27, 2020 were searched to identify relevant studies. The I2 statistic was used to check heterogeneity across the included studies. DerSimonian and Laird random-effects model was applied to estimate pooled effect size, and 95% confidence interval across studies. A funnel plot and Egger's regression test were used to determine the presence of publication bias. Sensitivity analysis was deployed to determine the effect of a single study on the overall estimation. All statistical analyses were done using STATA™ Version 14 software. RESULT: In this meta-analysis, a total of 23 studies with 6482 study participants were included. The estimated prevalence of metabolic syndrome in Sub-Saharan African countries was 59.62% (95% CI: 52.20, 67.03). Based on the subgroup analysis, the highest prevalence of metabolic syndrome (61.14%, 95% CI: 51.74, 70.53) was reported in Ethiopia. Additionally, the highest prevalence of metabolic syndrome was reported across studies using the diagnostic criteria of National Cholesterol Education Program Adult Treatment Panel III 64.8% (95% CI: 54.74, 74.86), followed by International Diabetic Federation (57.15%), and World health Organization (53.12%) definitions. CONCLUSION: Almost two out of three type 2 diabetic patients in Sub-Saharan African countries have metabolic syndrome, which implies that its prevalence is high in patients with type 2 diabetes mellitus. Therefore, policymakers need to design efficient strategies and guideline to reduce and control the burden of metabolic syndrome and its impact among diabetic population.

Nurses' knowledge and practice of pressure ulcer prevention and treatment: An observational study.

AIMS AND OBJECTIVES: To assess nurses' knowledge on pressure ulcer (PU) prevention and treatment in Jordan, and the frequency of and factors influencing nurses' implementation of PU prevention and treatment interventions. BACKGROUND: Highly educated and experienced nurses can provide effective PU care; however, previous studies highlighted poor knowledge and implementation of PU care. DESIGN: A correlational study examining nurses' knowledge of PU prevention and frequency of PU preventive actions in Jordanian hospitals. METHODS: Participants were 377 nurses and 318 patients from 11 hospitals. Data were collected to quantify the frequency of nurses' implementation of pressure ulcer prevention and treatment interventions for patients suffering from PUs and/or at risk of PU development using a self-reported cross-sectional survey and prospective 8-h observation. RESULTS: For observed PU prevention while type of hospital and number of beds in units were significant it is not known without further work if this is replicable. For observed PU treatment, linear regression analysis revealed significant negative beta values for more than 50 beds in clinical unit (ß = -2.49). CONCLUSION: The study addressed new factors, facilitating the provision of prevention and treatment strategies to PU development, including type of clinical institution and number of beds in clinical unit. RELEVANCE TO CLINICAL PRACTICE: There is a need to develop training programmes to improve insufficient nurses' knowledge and, thus, clinical practices on PU prevention and treatment. These programmes would assist both junior and senior nurses and other key stakeholders (e.g. hospital managers, policy-makers, and educators) to improve the performance of PU services, thus, minimising patient suffering.

Prevalence of pressure ulcers in long-term care: a global review.

OBJECTIVE: To identify and update the prevalence and incidence of pressure ulcers (PUs) in several countries, in people with long-term conditions resident in care homes or nursing homes. METHODS: We followed the PRISMA guideline for systematic reviews. However, due to funding constraints we do not claim this review to be systematic but it is a narrative review informed by PRISMA. Medline, Embase and CINHAL were searched for observational studies reporting incidence or prevalence data. Data reported relevant head-to-toe examination of PUs in residence in care or nursing homes. Internal and external validity of the included studies were assessed using the checklist devised by Hoy et al.1. RESULTS: Inclusion criteria was met by 17 studies and included in the study. Some studies gave a full breakdown by category, some only gave overall figures, and others excluded category I PUs. However, within those constraints certain patterns are clear. Prevalence rates varied from 3.4-32.4%. Large differences in prevalence in different countries were not explained by methodological differences. While some countries, such as Germany, the Netherlands and the US had robust data, other countries, such as the UK, had none. CONCLUSION: PUs are a common problem in long-term care. However, there are substantial differences between countries and many countries have no published data.

Evaluating clinical placements in Saudi Arabia with the CLES+T scale.

The clinical learning environment and supervision (CLES) tool has been enhanced with an additional sub-scale for measuring the quality of nurse teacher's involvement to form the CLES + T scale. It has been widely used in many countries to evaluate clinical placements. Here we report data from Saudi Arabia. The CLES + T was employed to measure satisfaction among student nurses concerning their clinical learning environment. Linear regression was used to determine relationships of various variables to the outcomes of total CLES + T score and those of its subscales. Students were generally satisfied with their placements. For female students the number of visits of the nurse tutor was positively associated with most subscales and with the total score. For males, who had fewer visits from a nurse tutor, there was no such association. Nurse tutor visits are positive in terms of clinical placement evaluation by female student nurses. Saudi nursing students are generally similar to students in other international studies in terms of their appraisal of clinical placements.

Pressure Ulcers Prevalence in the Acute Care Setting: A Systematic Review, 2000-2015.

Little is known about the prevalence of pressure ulcer (PrU) in acute care settings. The aim of this study is to determine the prevalence rate of PrU in acute care settings and to assess the methodological quality of the reviewed publications. The Cumulative Index to Nursing and Allied Health Literature, British Nursing Index, MEDLINE, and Cochrane Database of Systematic Reviews were searched using the keywords pressure ulcer or decubitus ulcer or bed sore or pressure sore or pressure injury, with prevalence and acute care, for studies published between January 2000 and December 2015. Nineteen publications met our criteria. These reported a prevalence range of between 7.8% and 54% for those using European Pressure Ulcer Advisory Panel methodology, 6% and 22% for those using National Pressure Ulcer Advisory Panel methodology, and 4.94% for the study that employed the Torrance system. The likely worldwide PrU prevalence rate range in acute care settings is between 6% and 18.5%. Prevalence rate varies between studies depending on the methodology of data collection. Moreover, the methodological quality of the included studies in the review was variable; therefore, it was difficult to compare the prevalence rate between the studies, settings, and countries.

The Acceptability of Iterative Reconstruction Algorithms in Head CT: An Assessment of Sinogram Affirmed Iterative Reconstruction (SAFIRE) vs. Filtered Back Projection (FBP) Using Phantoms.

BACKGROUND: Computed tomography (CT) is the primary imaging investigation for many neurologic conditions with a proportion of patients incurring cumulative doses. Iterative reconstruction (IR) allows dose optimization, but head CT presents unique image quality complexities and may lead to strong reader preferences. OBJECTIVES: This study evaluates the relationships between image quality metrics, image texture, and applied radiation dose within the context of IR head CT protocol optimization in the simulated patient setting. A secondary objective was to determine the influence of optimized protocols on diagnostic confidence using a custom phantom. METHODS AND SETTING: A three-phase phantom study was performed to characterize reconstruction methods at the local reference standard and a range of exposures. CT numbers and pixel noise were quantified supplemented by noise uniformity, noise power spectrum, contrast-to-noise ratio (CNR), high- and low-contrast resolution. Reviewers scored optimized protocol images based on established reporting criteria. RESULTS: Increasing strengths of IR resulted in lower pixel noise, lower noise variance, and increased CNR. At the reference standard, the image noise was reduced by 1.5 standard deviation and CNR increased by 2.0. Image quality was maintained at ≤24% relative dose reduction. With the exception of image sharpness, there were no significant differences between grading for IR and filtered back projection reconstructions. CONCLUSIONS: IR has the potential to influence pixel noise, CNR, and noise variance (image texture); however, systematically optimized IR protocols can maintain the image quality of filtered back projection. This work has guided local application and acceptance of lower dose head CT protocols.

Community Interventions for Health can support clinicians in advising patients to reduce tobacco use, improve dietary intake and increase physical activity.

AIMS AND OBJECTIVES: To increase clinical interventions to reduce modifiable risk factors for noncommunicable disease in low- and middle-income countries. BACKGROUND: Noncommunicable disease is the leading cause of death in the world and is common in low- and middle-income countries. Risk factors for noncommunicable disease are modifiable and health professionals are in an unique position to intervene and influence them. DESIGN: Clinical interventions were used as part of the Community Interventions for Health programme, a nonrandomised, controlled study undertaken in three communities - one each in China, India and Mexico. METHODS: All clinicians in intervention and control areas of the study were invited to complete surveys. A total of 2280 completed surveys at baseline and 2501 at follow-up. Culturally appropriate interventions to reduce tobacco use, improve dietary intake and increase physical activity were delivered in the intervention areas. RESULTS: Clinicians in the intervention group felt more prepared to advise smoking cessation and improvement of diet. They were more likely to test serum cholesterol and blood pressure, but less likely to take measurements of height, hip, waist and skin-fold thickness. There were more resources available to clinicians in the intervention group and they used counselling more and complementary medicine less than those in the control group. CONCLUSIONS: Community interventions which have been shown to have a positive effect in the community and workplace also change clinical practice. RELEVANCE TO CLINICAL PRACTICE: Community interventions make clinicians, including nurses, more likely to feel prepared to offer advice and more likely to use counselling. This would be expected to reduce risk factors in patients.

A comparison of the performance of the Braden Q and the Glamorgan paediatric pressure ulcer risk assessment scales in general and intensive care paediatric and neonatal units.

AIMS: To compare the predictive ability of two risk assessment scales used in children. BACKGROUND: There are several risk assessment scales (RASs) employed in paediatric settings but most have been modified from adult scales such as the Braden Q whereas the Glamorgan was an example of a scale designed for children. METHODS: Using incidence data from 513 paediatric hospital admissions, receiver operating characteristic (ROC) was employed to compare the two scales. The area under the curve (AUC) was the outcome of interest. RESULTS: The two scales were similar in this population in terms of area under the curve. Neonatal and paediatric intensive care were similar in terms of AUC for both scales but in general paediatric wards the Braden Q may be superior in predicting risk. CONCLUSION: Either scale could be used if the predictive ability was the outcome of interest. The scales appear to work well with neonatal, paediatric intensive care and general children's wards. However the Glamorgan scale is probably preferred by childrens' nurses as it is easy to use and designed for use in children. There is some suggestion that while the two scales are similar in intensive care, for general paediatrics the Braden Q may be the better scale.

Issues in data analysis.

NURSE RESEARCHER publishes a wide range of methodology papers, many of which aim to give guidance to early researchers. Here I comment on two papers. The first, Qualitative case study data analysis: an example from practice ( Houghton et al 2015 ) is clearly comprehendible by novice researchers. The second, Multiple imputation method for handling missing data: A case study of a secondary data analysis study ( Walani and Cleland 2015 ) is a rather different case. This is a useful paper but deals with a complex issue in quantitative data analysis. If you have looked at this paper and found it hard going then please read the following few paragraphs where I try to put this paper into context.

Successful up-scaled population interventions to reduce risk factors for non-communicable disease in adults: results from the International Community Interventions for Health (CIH) Project in China, India and Mexico.

BACKGROUND: Non-communicable disease (NCD) is increasing rapidly in low and middle-income countries (LMIC), and is associated with tobacco use, unhealthy diet and physical inactivity. There is little evidence for up-scaled interventions at the population level to reduce risk in LMIC. METHODS: The Community Interventions for Health (CIH) program was a population-scale community intervention study with comparator population group undertaken in communities in China, India, and Mexico, each with populations between 150,000-250,000. Culturally appropriate interventions were delivered over 18-24 months. Two independent cross-sectional surveys of a stratified sample of adults aged 18-64 years were conducted at baseline and follow-up. RESULTS: A total of 6,194 adults completed surveys at baseline, and 6,022 at follow-up. The proportion meeting physical activity recommendations decreased significantly in the control group (C) (44.1 to 30.2%), but not in the intervention group (I) (38.0 to 36.1%), p<0.001. Those eating ≥ 5 portions of fruit and vegetables daily decreased significantly in C (19.2 to 17.2%), but did not change in I (20.0 to 19.6%,), p=0.013. The proportion adding salt to food was unchanged in C (24.9 to 25.3%) and decreased in I (25.9 to 19.6%), p<0.001. Prevalence of obesity increased in C (8.3 to 11.2%), with no change in I (8.6 to 9.7%,) p=0.092. Concerning tobacco, for men the difference-in-difference analysis showed that the reduction in use was significantly greater in I compared to C (p=0.014). CONCLUSIONS: Up-scaling known health promoting interventions designed to reduce the incidence of NCD in whole communities in LMIC is feasible, and has measurable beneficial outcomes on risk factors for NCD, namely tobacco use, diet, and physical inactivity.

Reducing Health Risk Factors in Workplaces of Low and Middle-Income Countries.

OBJECTIVE: To reduce risk factors in workplace settings in low- and middle-income countries. DESIGN AND SAMPLE: Workplace interventions were utilized as part of the Community Interventions for Health program, a nonrandomized, controlled study undertaken in three communities in China, India, and Mexico. Exactly, 45 industrial, 82 health and 101 school workplace settings with a target population of 15,726. Two independent cross-sectional surveys of workers were conducted at baseline and follow-up, after 18-24 months of intervention activities. MEASURES: Culturally appropriate interventions to reduce tobacco use, increase physical activity, and improve dietary intake were delivered in the intervention areas. RESULTS: Exactly, 12,136 adults completed surveys at baseline, and 9,786 at follow-up. In the intervention group, the prevalence of tobacco use reduced significantly in men (-6.0%, p < .001) and the proportion eating five portions of fruit and vegetables daily increased (+6.9%, p < .001) compared with the control group. There were no significant differences between the groups for changes in physical activity or prevalence of overweight. CONCLUSIONS: Workplace interventions improved risk factors in China, India, and Mexico.

An exploratory study to identify risk factors for the development of capecitabine-induced Palmar Plantar Erythrodysesthesia (PPE).

AIMS: To identify pre-treatment risk factors for the development of Palmar Plantar Erythrodysesthesia in participants receiving capecitabine monotherapy. Specifically the hypothesis that avoidance of activities that cause friction and pressure cause Palmar Plantar Erythrodysesthesia was tested. BACKGROUND: Previous literature showed contradictory evidence on the subject of predictors of chemotherapy-induced Palmar Plantar Erythrodysesthesia. There is a lack of empirical evidence to support the theory that Palmar Plantar Erythrodysesthesia is caused by damage to the microcapillaries due to everyday activities that cause friction or pressure to the hands or feet. DESIGN: Prospective epidemiological study of risk factors. METHODS: Prospective data collection. All patients prior to commencing capecitabine monotherapy between 11 June 2009-31 December 2010, were offered recruitment into the study and followed up for six cycles of treatment (n = 174). Data were collected during semi-structured interviews, from participants' diaries, physical examination of the hands and feet and review of notes. Data relating to activities that cause friction, pressure or heat were collected. Data were analysed using bivariate (chi-square and independent groups Student's t) tests where each independent variable was analysed against Palmar Plantar Erythrodysesthesia. RESULTS: The only variables that were associated with an increased risk of Palmar Plantar Erythrodysesthesia were a tendency to have warm hands and pre-existing inflammatory disease. CONCLUSIONS: This study gives no support for the hypothesis that avoidance of activities that cause friction and pressure cause Palmar Plantar Erythrodysesthesia.

High rates of child hypertension associated with obesity: a community survey in China, India and Mexico.

BACKGROUND: Hypertension is a significant risk factor for cardiovascular disease, and epidemiological evidence suggests that it is increasing in parallel with obesity in children and adolescents in low- and middle-income countries. AIM: To identify and determine the relationship between overweight, obesity and hypertension in a community sample of school children. METHODS: Anthropometric data were collected from 12,730 school children aged 12-18 years in China, India and Mexico as part of the Community Interventions for Health programme, an international study evaluating community interventions to reduce non-communicable disease by addressing the three main risk factors of tobacco use, unhealthy diets and physical inactivity. Logistic regression was used to examine the association of body mass index and gender and hypertension. RESULTS: Prevalence rates of hypertension were 5.2% in China, 10.1% in India and 14.1% in Mexico, and pre-hypertension rates in China, India and Mexico were 13.4%, 9.4% and 11.2%, respectively. Overweight and obesity prevalence rates varied by country and were 16.6% in China, 4.1% in India and 37.1% in Mexico. In all countries there was a significant association between overweight and obesity and rates of hypertension. Overweight children were 1.7-2.3 times more likely to be hypertensive and obese children 3.5-5.5 more likely to show hypertension than those of normal weight. CONCLUSIONS: Rates of hypertension and overweight and obesity are high in school children in China, India and Mexico, and increased bodyweight is a significant risk factor for hypertension.

Pressure ulcer prevention and treatment knowledge of Jordanian nurses.

AIMS: The aims of the study were to determine: (1) Jordanian nurses' level of knowledge of pressure ulcer prevention and treatment of hospitalized patients based on guidelines for pressure ulcer prevention and treatment. (2) Frequency of utilization of pressure ulcer prevention and treatment interventions in clinical practice. (3) Variables that are associated with nurses' utilization of pressure ulcer prevention and treatment interventions. BACKGROUND: Pressure ulcers are common and previous studies have shown education, knowledge and attitude affect implementation of interventions. METHODS: A cross-sectional survey design was used to collect data from 460 nurses between June 2010 and November 2010. We used a questionnaire, which was informed by earlier work and guidelines, to collect data about nurses' knowledge and practice of pressure ulcer prevention and treatment. RESULTS/FINDINGS: Knowledge and education show an association with implementation of prevention, and demographic variables do not. Similarly knowledge and type of hospital showed an association with implementing treatment. Of concern the use of "donuts" and massage are reported in use. CONCLUSION: Although pressure ulcer care is well known by nurses, inappropriate pressure ulcer interventions were reported in use.

Health, lifestyle, belief and knowledge differences between two ethnic groups with specific reference to tobacco, diet and physical activity.

AIMS: To compare physical activity levels, body mass index, habitual diet, tobacco use and prevalence of non-communicable disease between the two ethnic groups and to identify predictors for differences between groups. BACKGROUND: Tobacco use, poor diet and physical inactivity are major lifestyle risk factors for chronic cardiovascular diseases, certain cancers, diabetes and chronic lung diseases. There are higher risk and incidence of these diseases in some ethnic groups, for example Asians have higher incidence of diabetes. DESIGN: Cross sectional survey. METHODS: Cross sectional survey of Asians of Indian descent and white British adults conducted between October-December 2009. Main outcome variables were lifestyle behaviours and BMI. Self-reported disease diagnosis was also collected. In a regression analysis, predictors of outcome variables were demographic variables and beliefs/attitudes/knowledge towards lifestyle behaviours. RESULTS/FINDINGS: Body mass index, tobacco use and non-communicable disease (except diabetes) were lower in Indians. Indians reported lower physical activity levels and greater salt use than Whites. Tobacco use was higher in Whites, but knowledge, attitudes and beliefs were similar between Whites and Indians. CONCLUSION: Health risk behaviour and morbidity are different between the two ethnic groups. Gender, age, educational level, beliefs, attitudes and knowledge do not explain these differences. Health promotion that aims to improve knowledge will probably not work and innovative methods are needed to improve health in high risk groups.

An evaluation of serum albumin and the sub-scores of the Waterlow score in pressure ulcer risk assessment.

BACKGROUND: From previous work serum albumin is predictive of pressure ulcers over and above the Waterlow score. However the sub-scores of the Waterlow score were not available, and the accuracy of calculation of the total score was poor. This study has used sub-scores and is an order of magnitude larger. OBJECTIVES: To compare serum albumin with Waterlow score as a predictive measure for pressure ulcers. DESIGN: Retrospective analysis of hospital information support system. SETTINGS: A district general hospital in Staffordshire. PARTICIPANTS: Adult non-elective in-patients. METHODS: Logistic regression and receiver operating characteristic. RESULTS: The sub-scores of the Waterlow score were explored. While they constitute a multi-dimensional dataset, many were not found relevant to pressure ulcer risk in this population (non-elective in-patients). Some sub-scores were not recorded correctly, and body mass index (BMI) was particularly badly reported. Age was found to be as predictive of pressure ulcer as the more complex Waterlow score. Serum albumin was at least as good as the Waterlow score in risk assessment of pressure ulcers. Matching patients with pressure ulcers to patients with none, who had identical Waterlow sub-scores, confirmed serum albumin as a robust predictive value in pressure ulcers. CONCLUSION: Risk assessing patients based on their age is as good as the more complex Waterlow score. Additional risk information can be gained from knowing the serum albumin value.

Conflict management styles used by nurse managers in the Sultanate of Oman.

AIM: The study aimed at investigating the conflict management styles used by nurse managers in the Sultanate of Oman. BACKGROUND: Conflict is inevitable in daily nursing work. Several styles are used to manage conflict situations. In previous studies conducted in Western countries, avoiding and compromising conflict management styles appear to be the first choices for the nurses. In Arab countries, no study to date has examined the conflict management styles used by nurse managers to compare with the results from studies conducted in Western countries. DESIGN: Survey. METHOD: A questionnaire was distributed to all nurse managers working in the three-management levels from nine referral hospitals in Sultanate of Oman, 271 were returned, a response rate of 86%. The results were analysed using spss version 16. RESULTS: Nurse managers in Oman used all five conflict management styles, with integrating style as the first choice followed in order by compromising, obliging, dominating and avoiding. These results differ from the results of the studies conducted on nurses in other countries. CONCLUSION: The results of this study have implications for people who work in the hospitals, whether practitioners or policy makers. Recommendations are offered to improve nurse managers' work environment. RELEVANCE TO CLINICAL PRACTICE: Conflict can affect patient care if handled badly. Poorly handled conflict results in lower staff morale and poorer retention, both adversely affect patient care.