The RAST-NP Pilot: Preparing New Graduate Nurse Practitioners for Emergent Procedures in Remote Settings Using a Novel Training Program.

With more new graduate primary care nurse practitioners (NPs) practicing in remote locales than ever before, their preparation for performing emergency procedural skills (EPSs) is critical for safe and effective care. Emergency procedural skills are not uniformly taught in primary care academic programs but are easily imparted via additional training and practice. The purpose of this project was to develop and pilot an expert panel-validated training program specifically for NPs bound for remote practice and to evaluate how the participants rated their self-efficacy in performing specific EPSs before and after completing the training, called the Remote Advanced Skills Training for NPs (RAST-NP). A diverse expert panel rated EPSs to determine skills to be included in a pilot training program. After achieving consensus on skills to be taught, a hybrid online-in-person curriculum was developed using standards from the International Nursing Association for Clinical Simulation and Learning. This training was conducted for more than 2 days and delivered to a class of 15 primary care NP students in their final year of education. All participants completed a pre- and postparticipation survey to assess their self-efficacy using a validated questionnaire, modified to address the EPSs taught. The participants reported higher confidence following training on all EPSs taught, as indicated by an increase in difference in mean scores from 1 to 6.15 on an 11-point scale. For each EPS, the difference was statistically significant by both a paired t test and a Whitney-Mann U test with probability of 0.01 or less. Results indicate that the methods utilized (i.e., psychomotor practice) increased confidence in NP students, and they also suggest that the amount of time spent practicing skills is associated with interval increases in confidence. A combination of didactic and psychomotor methods was uniformly effective at increasing confidence, and thereby self-efficacy, and higher success is associated with more time practicing the kinesthetic skills in situ.

Point of care ultrasound in pelvic health: scope of practice, education and governance for physiotherapists.

Pelvic health and pelvic floor dysfunction have wide-reaching implications across a range of patient groups. Placing ultrasound imaging into the hands of assessing and treating clinicians (i.e. point of care ultrasound, PoCUS) can provide a step change in clinical effectiveness and efficiency. Pelvic floor dysfunction is managed by one or more members of a multi-disciplinary team that includes physiotherapists. Physiotherapists' involvement includes diagnosis, patient education, identifying shared treatment goals, using rehabilitative strategies and empowering patients through self-management. Drawing upon existing publications in this area and applying framework principles, the authors propose a clinical and sonographic scope of practice for physiotherapists as part of supporting the consolidation and expansion of pelvic health PoCUS. Education and governance considerations are detailed to ensure the robust and safe use of this modality. Alongside empowering the use of ultrasound imaging by clinicians such as physiotherapists in the UK and internationally, we provide clarity to other members of the care pathway and ultrasound imaging professionals.

The effects of acculturation and environment on lifestyle behaviors in Korean immigrants: the mediating role of acculturative stress and body image discrepancy.

OBJECTIVES: Despite high rates of cardiometabolic diseases in Korean immigrants (KIs), little is known about cultural and environmental factors contributing to lifestyle behaviors. The purpose of this cross-sectional study was to examine the relationships among acculturation, environment, and lifestyle behaviors (dietary behavior, physical activity, and sedentary behavior) through culturally sensitive psychological mediators, body image discrepancy and acculturative stress in middle-aged KIs. DESIGN: A cross-sectional study was conducted. KIs aged 30-65 years were recruited online and at Korean community centers and churches in the Northeastern US Participants completed validated measures of dietary behavior (the Nutrition Subscale of the Health Promoting Lifestyle Profile (HPLP) II), physical activity (the International Physical Activity Questionnaire (IPAQ) - short form), and sedentary behavior (the Sedentary Behavior Questionnaire). Acculturative stress was measured by the Acculturative Stress Index and body image discrepancy was measured by the Stunkard Figure Rating Scale. Acculturation was defined as a latent variable measured by Korean and American orientation (Vancouver Index of Acculturation), age of immigration to the US, length of residency in the US, and English proficiency. Data were analyzed with structural equation modeling (SEM). RESULTS: The sample included 361 KIs (mean age = 41.77 ± 10.28 years, 48.1% female, and 46.4% overweight or obese). In the SEM model, acculturation had significant indirect effects on dietary behavior, physical activity, and sedentary behavior through body image discrepancy. Acculturative stress mediated the relationship between acculturation and sedentary behavior. Greater environmental support for physical activity and better healthy food accessibility were related to higher levels of physical activity and healthier dietary behavior, respectively. CONCLUSION: In our study, acculturation and environmental support for physical activity and healthy food simultaneously influenced KIs' lifestyle behaviors. Addressing an unhealthy body image and acculturative stress may be additional strategies for lifestyle intervention programs to prevent cardiometabolic diseases in KIs.

Narrative Inquiry Into Nursing Care of Pregnant Women and Families in Specialized Fetal Diagnosis and Treatment Settings.

OBJECTIVE: To examine how nurses describe caring for women and families in specialized fetal diagnosis and treatment settings. DESIGN: We used narrative inquiry. SETTING: A secure online survey platform. PARTICIPANTS: We recruited 26 nurses from the Fetal Therapy Nurse Network as a subsample from a prior Delphi study on the essential structures, processes, outcomes, and challenges of nursing practice in the emerging field of fetal diagnosis and treatment. METHODS: We used narrative inquiry and Clandinin's three-dimensional space narrative analysis to interpret the stories provided by participants to illustrate their practice and the relationship between their practice and care quality and health outcomes. RESULTS: Participants described three primary types of fetal diagnoses and management scenarios: prenatal intervention (maternal-fetal surgery to treat a fetal anomaly), postnatal intervention (neonatal surgery), and perinatal palliative care (continuation of a pregnancy after a life-limiting fetal diagnosis). We identified three overarching themes related to nursing processes: A Sounding Board: Counseling the Pregnant Woman and Family, A Care Coordinator: Orchestrating a Complex Journey, and A Constant Presence: Being With the Pregnant Woman and Family. We also identified specific outcomes related to nursing care. CONCLUSION: We used narrative inquiry to expand on prior research and advance the conceptualization of a model of nursing practice in fetal diagnosis and treatment settings. Our results provide a basis to begin to test theories that connect nursing practice to care quality and outcomes in clinical practice settings. To comprehensively evaluate and enhance care as it evolves and expands, the immediate and long-term effects of nursing practice must be identified.

Development, Validation, and Implementation of a Guideline to Improve Clinical Event Debriefing at a Level-I Adult and Level-II Pediatric Trauma Center.

OBJECTIVE: Clinical event debriefing is recommended by the American Heart Association and the European Resuscitation Council, because debriefings improve team performance. The purpose here was to develop and validate tools needed to overcome barriers to debriefing in the emergency department. METHOD: This quality improvement project was conducted in 4 phases. Phase 1: Current evidence related to debriefing in the emergency department was reviewed and synthesized to inform an iterative process for drafting the debriefing guideline and instrument for documentation. Phase 2: Content Validity Index of the tools was evaluated by obtaining ratings of items' clarity and relevance from 5 national experts in 2 rounds of review. On the basis of experts' feedback, tools were revised, and a Facilitators' Guide was created. Phase 3: The validated debriefing tools were implemented. Phase 4: Debriefing facilitators completed a survey about their experience with using the new tools. RESULTS: The Content Validity Index of 71 debriefing tool items (guideline, instrument, Facilitators' Guide) was 0.93 and 0.96 for clarity and relevance, respectively. Of the 32 debriefings conducted during the first 8 weeks of implementation, 53% described patient safety concerns, and 97% described recommendations to improve performance. Most (94%) facilitators agreed that the guideline clarified debriefing requirements. CONCLUSION: The use of debriefing tools validated by computation of the Content Validity Index led to the identification of safety threats and recommendations to improve care processes. These tools can be used in ED settings to promote team learning and aid in identifying and resolving safety concerns.

Instrument Context Relevance Evaluation, Translation, and Psychometric Testing of the Diabetes Eating Problem Survey-Revised (DEPS-R) among People with Type 1 Diabetes in China.

BACKGROUND: People with type 1 diabetes are susceptible to disordered eating behaviors. The American Diabetes Association recommends using the Diabetes Eating Problem Survey-Revised (DEPS-R) to screen them. There is no validated diabetes-specific screening measure in China. The objectives were to adapt DEPS-R into Mandarin Chinese and to test its psychometric properties among youths and adults with type 1 diabetes in China, respectively. METHODS: This study was conducted in two phases. Phase 1 included context relevance evaluation and instrument translation. Phase 2 was psychometric testing of reliability and construct validity among 89 youths (8~17 years old) and 61 adults with type 1 diabetes. RESULT: The Context Relevance Index and Translation Validity Index of this instrument were good. Strong internal consistency reliability correlations and convergent validity were demonstrated among youths and adults. DISCUSSION: The Chinese version of the DEPS-R is a valid and reliable tool for screening disordered eating behaviors in Chinese youths and adults with type 1 diabetes. The Context Relevance Index is advocated to evaluate the difference between the context in which an instrument was originally developed and the target context.

Combined innovations in public policy, the private sector and culture can drive sustainability transitions in food systems.

Global food system analyses call for an urgent transition to sustainable human diets but how this might be achieved within the current global food regime is poorly explored. Here we examine the factors that have fostered major dietary shifts across eight countries in the past 70 years. Guided by transition and food-regime theories, we draw on data from diverse disciplines, reviewing post-World War 2 shifts in consumption of three food commodities: farmed tilapia, milk and chicken. We show that large-scale shifts in commodity systems and diets have taken place when public-funded technological innovation is scaled-up by the private sector under supportive state and international policy regimes, highlighting pathways between commodity systems transformation and food-system transitions. Our analysis suggests that the desired sustainability transition will require public policy leadership and private-sector technological innovation alongside consumers who culturally value and can afford healthy, sustainable diets.

Modified Delphi Study on Nursing Practice and Science in Fetal Care.

OBJECTIVE: To identify essential structures, processes, outcomes, and challenges of nursing practice in fetal care and to identify research priorities for nurses in fetal care. DESIGN: We used a modified Delphi method to achieve consensus. SETTING: A secure online survey platform. PARTICIPANTS: The expert panel included nurses from the Fetal Therapy Nurse Network. In addition, a multidisciplinary research jury included members of the North American Fetal Therapy Network (NAFTNet). METHODS: We collected data in three consecutive rounds with online questionnaires that were e-mailed to panelists. We used content analysis to generate statements from an initial round of open-ended questions. Statements met consensus if 75% of the panelists ranked it as greater than or equal to 6 on a 1-to-7 Likert scale. RESULTS: The 48 nurse panelists and 11 multidisciplinary jury members described a range of nursing processes. Consensus was reached on 96 statements related to the structure, processes, outcomes, and research priorities of nurses in fetal care. CONCLUSION: The participants agreed that an expert fetal care nursing team is necessary to provide care to women and families during fetal diagnosis and treatment. Ideally, these nurses should coordinate care and provide direct clinical care (e.g., patient counseling) in outpatient prenatal settings and inpatient settings when fetal surgery is involved. Nurses should be supported to take on leadership roles in program development, research, quality improvement, and professional development with relevant professional organizations.

Cardiotoxicity in Hematopoietic Stem Cell Transplant: Keeping the Beat.

INTRODUCTION: The number of hematopoietic stem cell transplants (HSCTs) performed in the United States and worldwide is increasing. Cardiac events have been well described in HSCT, and the incidence and type of cardiac events have not changed over recent decades. PATIENTS AND METHODS: This study adds to the body of evidence in describing the incidence and type of cardiac events experienced by an allogeneic and autologous HSCT population at a single institution from 2012 to 2017. RESULTS: Sixty-five (9.8%) patients experienced cardiac events, including atrial arrhythmia (N = 39), acute heart failure (N = 9), acute coronary syndrome (N = 7), and new onset hypertension (N = 9), with a few instances of bradycardia, ventricular arrhythmia, pericardial effusion, and pericarditis. Our multivariable regression analysis identified age (older), creatinine (higher), and history of coronary artery disease to significantly correlate with risk of cardiac event (P = .005, P = .039, and P = .038, respectively). A subgroup analysis of those patients experiencing a cardiac event found pre-transplant atrial dilation by trans-thoracic echocardiogram to correlate with increased risk of atrial arrhythmia (33.8% vs. 9.7%; P = .03). Patients developing a CE had an increased risk of death within 1 year (11% vs. 32%; P < .001). CONCLUSION: We review our results in context of other important HSCT cardiac studies to illuminate the most relevant factors of medical history, laboratory data, and cardiac measurements that will identify patients at higher risk, allowing for intervention to improve HSCT outcomes.

Psychometric properties of the Danish Hospital Anxiety and Depression Scale in patients with cardiac disease: results from the DenHeart survey.

BACKGROUND: Anxiety and depression symptoms are common among cardiac patients. The Hospital Anxiety and Depression Scale (HADS) is frequently used to measure symptoms of anxiety and depression; however, no study on the validity and reliability of the scale in Danish cardiac patients has been done. The aim, therefore, was to evaluate the psychometric properties of HADS in a large sample of Danish patients with the four most common cardiac diagnoses: ischemic heart disease, arrhythmias, heart failure and heart valve disease. METHODS: The DenHeart study was designed as a national cross-sectional survey including the HADS, SF-12 and HeartQoL and combined with data from national registers. Psychometric evaluation included analyses of floor and ceiling effects, structural validity using both exploratory and confirmatory factor analysis and hypotheses testing of convergent and divergent validity by relating the HADS scores to the SF-12 and HeartQoL. Internal consistency reliability was evaluated by Cronbach's alpha, and differential item functioning by gender was examined using ordinal logistic regression. RESULTS: A total of 12,806 patients (response rate 51%) answered the HADS. Exploratory factor analysis supported the original two-factor structure of the HADS, while confirmatory factor analysis supported a three-factor structure consisting of the original depression subscale and two anxiety subscales as suggested in a previous study. There were floor effects on all items and ceiling effect on item 8. The hypotheses regarding convergent validity were confirmed but those regarding divergent validity for HADS-D were not. Internal consistency was good with a Cronbach's alpha of 0.87 for HADS-A and 0.82 for HADS-D. There were no indications of noticeable differential item functioning by gender for any items. CONCLUSIONS: The present study supported the evidence of convergent validity and high internal consistency for both HADS outcomes in a large sample of Danish patients with cardiac disease. There are, however, conflicting results regarding the factor structure of the scale consistent with previous research. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01926145.

Psychometric Evaluation of the Social Isolation Scale in Older Adults.

BACKGROUND AND OBJECTIVES: Social isolation is known to be detrimental to the health of older adults, yet there is no brief instrument to measure it. The objective was to describe the psychometric testing of a brief instrument constructed from theoretical underpinnings to measure social isolation in older adults. RESEARCH DESIGN AND METHODS: A sample of 9,245 participants, all aged 60 years and older, was obtained from 44 states in the United States. Summary descriptive statistics were calculated, followed by exploratory factor analysis using Geomin rotation and subsequently confirmatory factor analysis (CFA). After finding the best model, differential item functioning (DIF) was conducted using a multiple indicator multiple cause structural equation model to determine if item responses differed by gender or race after controlling for level of social isolation. Internal consistency was calculated and validity was assessed by correlating factor scores with 2 external measures. RESULTS: Exploratory factor analysis resulted in all items having statistically significant loadings. CFA showed the 2-factor model demonstrated excellent fit (CFI = 0.997, RMSEA = .038). The 2 factors were labeled connectedness and belongingness. After adjusting for demographic variables, no evidence suggested DIF. Internal consistency was good (alpha = .77) and the scale moderately correlated with the Social Network Index (r = .47). DISCUSSION AND IMPLICATIONS: The Social Isolation Scale has been shown to be an effective measure of social isolation in older adults. Using this concise instrument to quickly measure social isolation in a fast-paced health care environment would be beneficial to health care providers and patients.

Flexible employment policies, temporal control and health promoting practices: A qualitative study in two Australian worksites.

For four decades, theories of job demand-control have proposed that higher occupational status groups have lower health risks due to the stress accompanying jobs featuring high demands but high control. This research examines whether Flexible Work Arrangements (FWAs) can improve the health prospects of a range of workers by giving greater control over work time arrangements. Our setting is Australia, where FWAs were introduced in 2009. In line with these early studies alongside studies of work-life balance, we expected to observe that workers with access to control over daily work times could better control the activities outside of work that influence chronic disease. Using a practice sociology approach, we compared the accounts of twenty-eight workers in blue and white collar industries with differing degrees of work time flexibility. The findings do not contradict early theories describing occupational differences of job demand-control dynamics and their relationship to health risks. However, this study suggests that a) time demands and strains have increased for a broad sweep of workers since the 1980s, b) the greater control of higher occupational status groups has been eroded by the high performance movement, which has attracted less scrutiny than FWAs, and c) more workers are forced to adapt their daily lives, including their approach to health, to accommodate their job demands. Job insecurity further impedes preventative health practices adoption. What might appear to be worker-controlled flexibility can-under the pressures of job insecurity and performance expectations without time limits-transform into health-eroding unpredictability. The answer however is not greater flexibility in the absence of limits on the well-documented precursors of work stress: long hours, job insecurity and intensity-related exhaustion. While there have been welcome developments in job demand-control-health conceptualizations, they typically ignore the out-of-work temporal demands that workers face and which compound on-the-job demands. Redesign of the temporalities of working life within worksites need to be accompanied by society-level policies which address caring responsibilities, gender equality as well as broad labour market conditions.

Four Approaches for Determining Composite Scores for the Measurement of Transition in Cancer Scale.

BACKGROUND: We created the Measurement of Transitions in Cancer Scale to assess patients' perceptions of the extent of change they experience with cancer-related transitions and how well they feel they are managing these transitions. For some transitions, we found that the more change that was reported, the worse management was reported; however, the benchmark by which patients assess how well they have managed may vary with the extent of change. OBJECTIVES: The aim of the study was to identify approaches to combine reports of extent and management of change. METHODS: Among women with breast cancer, we explored relationships of composite measures (arithmetic and geometric means, subtractive and proportional need for improvement) with other indicators of well-being (symptoms, anxiety, depression, uncertainty, self-efficacy, knowledge of care options, medical communication competence). We examined statistical significance using false rate discovery for multiple tests on correlations with clinical outcomes. RESULTS: Greater extent and less management were significantly associated with higher total symptoms, anxiety, depression, uncertainty, and less self-efficacy in Personal Transitions, but not in Care Transitions. The arithmetic and geometric means had weak correlations with clinical outcomes, whereas the subtractive and proportional need for improvement had significant correlations with most clinical outcomes both in Personal and Care Transitions. The combined proportional need for improvement in Personal Transitions was significantly associated with total symptoms, anxiety, depression, uncertainty, and self-efficacy. The Care Transitions score was also significantly associated with total symptoms, anxiety, uncertainty, and self-efficacy. DISCUSSION: These approaches can be applied to other aspects of self-management that require assessment of the extent and management of an experience. The four approaches yield different results. We recommend the need for improvement composites to capture correlations with the clinical outcomes.

Essential evidence-based introductory bioterrorism content for practicing nurses.

Bioterrorism content is too often absent from nursing education post-licensure. According to the Centers for Disease Control and Prevention (CDC), bioterrorism is defined as "the deliberate release of viruses, bacteria, or other germs (agents) used to cause illness or death in people, animals, or plants." The purpose of this scholarly work was to develop and pilot a curriculum on introductory bioterrorism concepts for practicing nurses. A literature search and a review of available resources elucidated pertinent content items on bioterrorism and its associated precautions for nurses. Next, two rounds of expert panel consisting of five members rated the identified content and provided comments to validate the curriculum's content. Based on the results, content items were expanded into a curriculum that was piloted as a four hour in person educational session and nurses in attendance were invited to participate in pre-test and post-test questions. They were also asked for their perceptions of the educational session's usefulness and influence on patient care in case of a bioterrorism event. All respondents strongly agreed that the information presented would be useful to them and would influence their patient care in a bioterrorism event. Further refinement, evaluation, and implementation of the developed curriculum are recommended.

Adolescent Preexposure Prophylaxis Administration: An Education Curriculum for Health Care Providers.

On May 15, 2018, the Federal Drug Administration amended the approval of preexposure prophylaxis (PrEP) to include minors (>35 kgs). Adolescent providers are now in need of access to a comprehensive education curriculum on the administration of PrEP to adolescents. This paper outlines such a curriculum with the goal of reaching adolescent providers unfamiliar with PrEP assessment, administration, and monitoring. A comprehensive adolescent PrEP curriculum was designed using a literature review. An expert panel of seven reviewed the curriculum for content validity. A pilot implementation of the curriculum was conducted with staff from eight school-based health clinics located in Upper Manhattan and the Bronx. A formal content-validated curriculum was established providing adolescent health care providers with the tools needed to administer PrEP in their clinical setting. Clinical providers can access our curriculum to aid in their administration of PrEP to an adolescent population.

The Development and Validation of an Acuity Tool in a Pediatric Outpatient Burn Clinic.

In outpatient settings, the role of nursing has shifted from episodic, reactive care to management of patients with higher acuity. In a pediatric outpatient clinic specializing in burn injuries, it became apparent that the lack of an acuity tool to measure patient complexity challenged efficient nurse staffing and patient satisfaction. In this quality improvement project, we developed a patient acuity tool to help determine nurse staffing, improve workload efficiencies, and improve the delivery of care.

Adapting an Evidence-Based Pediatric Acute Asthma Exacerbation Severity Assessment Tool for Pediatric Primary Care.

INTRODUCTION: The purposes of this project were (a) to examine criteria derived from evidence-based pediatric acute asthma exacerbation assessment tools, asthma scores, and the acute asthma prediction rule validated and used in the emergency department and (b) to adapt these criteria for pediatric primary care. METHOD: The three stages of the project included (a) identification of criteria in a literature review, (b) validation of the criteria by an expert panel, and (c) adaptation of the criteria in the design of an assessment tool. RESULTS: The criteria were validated and adapted in the design of The Pediatric Acute Asthma Exacerbation Severity Assessment and Disposition Decision-Making Tool for Pediatric Primary Care. DISCUSSION: The adaptation of criteria derived from the evidence and validated by an expert panel will inform and guide clinicians in assessing severity and support decision making in determining disposition of pediatric patients presenting with an acute asthma exacerbation in primary care.

Translation and validation of the Canadian diabetes risk assessment questionnaire in China.

OBJECTIVES: To adapt the Canadian Diabetes Risk Assessment Questionnaire for the Chinese population and to evaluate its psychometric properties. DESIGN AND SAMPLE: A cross-sectional study was conducted with a convenience sample of 194 individuals aged 35-74 years from October 2014 to April 2015. METHODS: The Canadian Diabetes Risk Assessment Questionnaire was adapted and translated for the Chinese population. Test-retest reliability was conducted to measure stability. Criterion and convergent validity of the adapted questionnaire were assessed using 2-hr 75 g oral glucose tolerance tests and the Finnish Diabetes Risk Scores, respectively. Sensitivity and specificity were evaluated to establish its predictive validity. RESULTS: The test-retest reliability was 0.988. Adequate validity of the adapted questionnaire was demonstrated by positive correlations found between the scores and 2-hr 75 g oral glucose tolerance tests (r = .343, p < .001) and with the Finnish Diabetes Risk Scores (r = .738, p < .001). The area under receiver operating characteristic curve was 0.705 (95% CI .632, .778), demonstrating moderate diagnostic value at a cutoff score of 30. The sensitivity was 73%, with a positive predictive value of 57% and negative predictive value of 78%. CONCLUSIONS: Our results provided evidence supporting the translation consistency, content validity, convergent validity, criterion validity, sensitivity, and specificity of the translated Canadian Diabetes Risk Assessment Questionnaire with minor modifications. This paper provides clinical, practical, and methodological information on how to adapt a diabetes risk calculator between cultures for public health nurses.

Social determinants of household food expenditure in Australia: the role of education, income, geography and time.

OBJECTIVE: To examine socio-economic status (SES) and time-related factors associated with less healthy food purchases in Australia. DESIGN: Data were from the 2009/10 Household Expenditure Survey (HES) conducted by the Australian Bureau of Statistics. Regression analysis was used to examine the associations between the proportion of the household food budget spent on various food types (processed and unprocessed foods, foods purchased from takeaways and restaurants) and SES and time constraint variables. SETTING: Australia, 2009-2010. SUBJECTS: Nationally representative sample of Australian households. RESULTS: Household income seems to be the most important correlate with food expenditure patterns once other SES indicators are controlled for. Time constraints appear to explain some, but not all, of the adjusted SES gradients in food expenditure. Comparing home food consumption categories (processed and unprocessed foods) with foods purchased away from home (takeaway and restaurant foods) shows that wealthier, more highly educated and least disadvantaged households spend relatively less of their total food budget on processed and unprocessed foods prepared at home and more on foods purchased away from home at restaurants. CONCLUSIONS: Simple SES gradients in dietary behaviour are influenced by correlations between different SES indicators and between SES and time constraints. Examining these factors separately obscures some of the possible causal effects of disadvantage on healthy eating. When formulating policy responses to unhealthy diets, policy makers should consider alternative sources of disadvantage, including time pressure.

Time and participation in workplace health promotion: Australian qualitative study.

Workplaces are considered promising settings for protecting and promoting the health and wellbeing of employees. To date, few workplaces, particularly small and medium sized enterprises (SME), or their workers, have adopted Workplace Health Promotion (WHP), raising questions as to why. We conducted interviews in 10 SME in the Australian Capital Territory (ACT) asking managers and workers to reflect on the reasons for their participation (or not) in WHP activities. We qualitatively explored factors that managers consider important when deciding whether to offer WHP and compared these to worker considerations regarding participation. Both workers and managers identified time constraints as a major barrier for participation in WHP activities. If WHP was implemented, time constraints arose mainly from: difficulties scheduling and synchronising activities to include most staff, even then casual staff were mostly excluded; and the duration of time required by employees to participate in the offered activities, and whether this was in paid (work) or unpaid (worker) time. Workers struggled to participate in WHP in their scheduled breaks and were reluctant to use time outside of work hours. We have developed a model illustrating the emerging tension between managers' and workers' needs for WHP participation. WHP participation will likely remain low until this tension, and associated financial implications, are widely acknowledged and addressed. Our research indicates that time should be considered more explicitly and thoughtfully in the workplace engagement and WHP design, to actively respond to constraints from activity duration, scheduling and synchronisation.